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Thesis advisor: David L. Blustein / This study aimed to illuminate a piece of complexity behind vocational identity development in emerging adulthood. While identity development involves changes across various areas within one’s life, the establishment of a vocational identity is thought to be among the most vital and daunting tasks to manage during the transition from adolescence to adulthood (e.g., Erikson, 1959). For those fortunate enough to experience positive developments in this aspect of their identity, a plethora of positive life- and career outcomes are associated with them (Diemer & Blustein, 2007; Hirschi, 2011a; Hirschi, 2011c; Klotz et al., 2014; Luyckx et al., 2010). While this form of identity development is historically understood to be among the most challenging, evolving changes in “macrostructural conditions” (i.e., technological innovation and AI) have further complicated things, leading some to feel discouraged from taking an “active engagement in the exploratory process,” likely followed by a delay in making an occupational choice (Mortimer, 2002, p. 442). Despite the prominent role that establishing a vocational identity has in a young person’s maturation process (Erikson, 1959), this phenomenon has yet to be introduced and examined in a modern career development theory, and more specifically, within psychology of working theory (PWT; Duffy et al., 2016). The current study postulates that both original and new PWT career variables: economic constraints, marginalization, work volition, career adaptability, and psychological flexibility, interact and contribute to the overall development of an emerging adult’s vocational identity. The purpose of the present study was to demarcate how specific paths of PWT (Duffy et al., 2016) were connected to vocational identity development for those within emerging adulthood (ranging in ages 18-25). Broadly, it was hypothesized that work volition and career adaptability would predict vocational identity development and that these relationships would be moderated by psychological flexibility. Additional exploratory models, which placed psychological flexibility in two other locations, were also assessed. These relationships were examined by surveying 283 emerging adults via an online survey tool. These participants responded to questions about their vocational identity, levels of psychological flexibility, work volition, career adaptability, experiences of macro-level barriers, and demographic characteristics. Data were analyzed using hierarchical linear regression. Findings revealed that the primary hypothesized model describing work volition and career adaptability to predict vocational identity was an excellent fit to the data. Additionally, the model results indicate that psychological flexibility did not moderate these relationships. However, it does play a significant role in overall vocational identity development, career adaptability, and work volition independent of other variables. Among demographic variables, SES differences were found within the sample. These results are discussed and grounded in their unique contribution to the existing literature on vocational identity development, psychological flexibility, and career development. Theoretical, policy, and practical implications are discussed. Future directions and limitations of the study are also considered. / Thesis (PhD) — Boston College, 2022. / Submitted to: Boston College. Lynch School of Education. / Discipline: Counseling, Developmental and Educational Psychology.

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Il presente elaborato ha come tema il ruolo dello psicologo clinico nella riabilitazione cardiologica, con una particolare attenzione alle sfide poste nel sostenere e facilitare il cambiamento dello stile di vita del paziente affetto da cardiopatia ischemica. La tesi si articola in tre sezioni, ognuna delle quali comprende un’introduzione teorica, con spunti sia di natura clinica che riferimenti al contesto della riabilitazione, e un contributo empirico che intende fornire una prospettiva innovativa al campo di riferimento. Il primo capitolo si apre con una breve descrizione della cardiopatia ischemica e dei fenomeni ad essa clinicamente legati. Queste informazioni introduttive si riveleranno preziose nello svolgersi dei capitoli successivi, in quanto consentono di approfondire il contesto della riabilitazione cardiologica, i suoi principali obiettivi e il razionale alla base dell'intervento clinico proposto. A questo proposito, verrà sottolineata la centralità dell’esercizio fisico come outcome funzionale della riabilitazione. In linea con questo affondo teorico, il primo contributo empirico è volto a indagare la relazione tra ridotta capacità di esercizio e sintomatologia ansiosa e depressiva, e a valutare la direzione di questa associazione attraverso un Cross-Lagged Panel Design che ha incluso 212 pazienti afferenti all’Unità di Riabilitazione Cardiovascolare dell’Ospedale S. Luca di Milano. I risultati sono discussi alla luce del ruolo che lo psicologo può svolgere per massimizzare il beneficio che il paziente può ottenere dalla riabilitazione, anche nei termini di capacità d’esercizio. Questo tema, accennato nella discussione del primo studio, viene ampliato nel secondo capitolo. Il secondo capitolo introduce infatti il modello dell’Acceptance and Commitment Therapy (ACT), riferimento teorico che costituisce l’ossatura dell’intervento presentato nella terza parte dell’elaborato. In particolare viene approfondito il ruolo della flessibilità psicologica, che rappresenta il cuore clinico del modello ACT, in quanto meccanismo primario di azione terapeutica. Per quanto esistano diversi strumenti per misurare questo costrutto, nessuno di essi è stato pensato e validato per il contesto cardiovascolare. La sezione empirica del secondo capitolo si riferisce allo sviluppo di un nuovo questionario per la misurazione della flessibilità psicologica adatto al contesto in esame - il CVD-AAQ, ovvero CardioVascular Disease Acceptance and Action Questionnaire - di cui vengono valutate le proprietà psicometriche. Lo studio si è avvalso di un secondo campione di 275 pazienti, arruolati nella medesima Unità Operativa. Il CVD-AAQ viene proposto e descritto in quanto misura di outcome dello studio presentato nella terza e ultima parte dell’elaborato. 8 Il terzo capitolo presenta lo studio ACTonHEART, un trial clinico randomizzato finalizzato a valutare l’efficacia e la fattibilità di un protocollo di intervento basato sull’ACT, cui scopo è migliorare il benessere e sostenere il cambiamento dello stile di vita dei pazienti ischemici in riabilitazione, aumentandone la flessibilità psicologica. Novantadue pazienti sono stati arruolati e allocati al gruppo sperimentale (N= 59) e di controllo (N= 33), seguendo uno schema di randomizzazione sbilanciata 2:1. Il gruppo di controllo ha svolto la sola riabilitazione, quello sperimentale in aggiunta ha partecipato all’intervento di gruppo ACTonHEART, il cui manuale è presentato integralmente in forma manualizzata. Il protocollo ha una durata di sei ore, suddivise in tre sedute, ognuna delle quali è incentrata su un principio clinico dell’ACT e affronta un aspetto diverso del cambiamento dello stile di vita richiesto al paziente ischemico in un’ottica di prevenzione secondaria. Gli outcome dell’ACTonHEART sono i seguenti: Body Mass Index, flessibilità psicologica e benessere. Ognuno di essi è stato misurato in tre occasioni: prima della riabilitazione (t0), al suo termine (t1) e in un follow-up a sei mesi (t2). Considerata la presenza di tre misurazioni e il fatto che solo i pazienti assegnati al gruppo sperimentale hanno partecipato a un trattamento di gruppo, da un punto di vista metodologico l’ACTonHEART si configura come un Partially Nested Design a tre livelli, un disegno di ricerca la cui struttura verrà brevemente descritta in una sezione dedicata. Per valutare l’efficacia del trattamento è stata infine svolta un’analisi multilivello, i cui risultati sono presentati e discussi nella sezione finale dell’elaborato. / The thematic core of the present paper consists in the role of clinical psychology in cardiac rehabilitation, with a specific focus on the challenges faced when supporting the changes in lifestyle required to patients suffering from ischemic heart disease. This thesis is divided into three broad sections. Every section includes a theoretical introduction, describing both clinical and rehabilitation state-of-the art practices and research results, and an empirical contribution aiming to provide an innovative perspective on the topics considered. The first chapter includes a brief description of ischemic heart disease and its clinically related phenomena. This introductory information will prove valuable in the subsequent chapters, as it deepens the context of cardiovascular rehabilitation, describing its main goals and the rationale behind its mode of intervention, as well as the centrality of exercise capacity as functional outcome. Starting from this theoretical background, the first empirical contribution aims at investigating the relationship between reduced exercise capacity and symptoms of anxiety and depression. The direction of this association will be evaluated through a Cross-Lagged Panel Design that included 212 patients recruited in the Cardiovascular Rehabilitation Unit of S. Luca Hospital in Milan. Results are discussed in light of the role the psychologist plays in order to maximize the impact the rehabilitation has on the patient, even in terms of exercise capacity. This theme, introduced in the discussion of the first study, is further explored in the second chapter. The second chapter introduces Acceptance and Commitment Therapy (ACT), the theoretical framework of ACTonHEART, which is the intervention presented in the third part of the thesis. In particular, psychological flexibility will be discussed as the primary mechanism of therapeutic action proposed by the ACT model. While there are several tools to measure this construct, none of them have been validated for the cardiovascular context. The empirical section of the second chapter presents a disease-specific new questionnaire for measuring the psychological flexibility, the Cardiovascular Disease Acceptance and Action Questionnaire (CVD-AAQ), whose psychometric properties are evaluated. The validation study examined a second sample of 275 patients enrolled in the same hospital. The CVD-AAQ will be used as a measure of outcome for the intervention presented in the third and last part of the elaborate. The third chapter presents the ACTonHEART study, a RCT aimed at evaluating the effectiveness and feasibility of an ACT-based intervention protocol, whose purpose is to improve well-being and support the change in lifestyle of ischemic patients, through an increase in psychological flexibility. 10 Ninety-two patients were enrolled and randomized, following an unbalanced randomization ratio of 2:1, to the experimental group (N= 59) and the control group (N= 33). The control group was administered Treatment-as-Usual (TAU), while experimental subjects participated in the ACTonHEART group intervention in addition to the cardiac rehabilitation process. In this section the ACTonHEART protocol will be entirely presented in its manualized form. The ACTonHEART protocol consists in three sessions for a total of six hours. Each session focuses on an ACT clinical principle and addresses a different aspect of the lifestyle changes asked to the ischemic patient for secondary prevention. The outcomes considered for the ACTonHEART are the following: Body Mass Index, Psychological Flexibility and Well-Being. Participants were assessed at baseline (t0), at the end of the rehabilitation period (t1), and at a six-month follow-up (t2). The ACTonHEART is a Partially nested Design with three levels, a research methodology whose structure will be briefly outlined in this section. An appropriate multilevel analysis was carried out to evaluate the effectiveness of the intervention, whose results are presented and discussed in the final section of the thesis.

Depression är vanligt förekommande världen över och läkarstudenter är en utsatt grupp. Under läkarprogrammet ökar dessutom den psykiska ohälsan bland studenterna. Förmågan till psykologisk flexibilitet, innefattande defusion, acceptans, jag-som-kontext, flexibel uppmärksamhet i nuet, värden och ändamålsenligt handlande, har visat sig ha samband med ohälsa. Training for Awareness, Resilience and Action (TARA) har skapats i USA som metod för att i grupp behandla depression hos tonåringar. Under 2018 erbjöds TARA till en grupp läkarstudenter i Umeå och denna kvalitativa studie innefattade semistrukturerade intervjuer två år efter avslutad behandling. Deltagarna var fem av dessa studenter och intervjuerna fokuserade på deras upplevelser av TARA samt vilka metoder de fortsatt att använda. Åldern på deltagarna var 21-32 år vid intervjutillfället. En tematisk analys användes för att analysera materialet från intervjuerna. Resultatet visade att deltagarna upplevde att de fick flera olika verktyg att använda sig av för att hantera sin psykiska ohälsa. Främst var andningsövningar och att uppmärksamma det som hände inom dem som beskrevs som det viktigaste. Deltagarnas beskrivningar av deras erfarenheter visar att de övat upp sin förmåga till defusion, acceptans, flexibel uppmärksamhet i nuet, värden och ändamålsenligt handlande under TARA. Beskrivningar av jag-som-kontext gick inte att hitta i materialet. Studiens utformning, kvalitativa intervjuer, och urvalet av deltagare har minskat möjligheten till generalisering. Dock kan resultatet förstås som att TARA kan hjälpa till att öka upplevelsen av psykologisk flexibilitet, vilket i förlängningen kan minska symtomen på depression. / Depression is common worldwide and medical students are a vulnerable group and during the medical education mental illness increases. The ability for psychological flexibility, including diffusion, acceptance, Self-as-context, flexible contact with the present, values ​​and appropriate action, has been shown to be associated with ill health. Training for Awareness, Resilience and Action (TARA) has been created in the United States as a method of treating depression in group in adolescents. In 2018, TARA was offered to a group of medical students in Umeå and this qualitative study included semi-structured interviews with five of these students about their experiences of TARA and what methods they are using. The interviews were conducted two years after their participation in TARA. The participants attended the second and forth semester of their education when TARA occurred. The age of the participants was 21-32 years at the time of the interview. A thematic analysis was used to analyze the material from the interviews. The results showed that the participants felt that they were given several different tools to use to manage their mental illness. Mainly breathing exercises and paying attention to what was happening within them was described as the most important. The participants' descriptions of their experiences show that they practiced their ability for defusion, acceptance, flexible contact with the present, values ​​and appropriate action during TARA. Descriptions of Self-as-context couldn’t be found in the material. The design of the study, qualitative interviews, and the selection of participants have reduced the possibility of generalization. However, the result can be understood as that TARA can help to increase the experience of psychological flexibility, which in the long run can reduce the symptoms of depression.

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Affective intra-individual variability (IIV) and affective psychological flexibility (PF) are both types of within-person variability. Affective IIV is defined as the range of emotions experienced by an individual assessed at multiple time points. PF is defined as the ability to vary one’s responses in a contextually dependent manner in order to appropriately meet situational demands. Currently, there are no comparisons between affective IIV and PF demonstrating how these constructs might be uniquely different from each other. The current study proposed to examine affective IIV and PF in order to establish discriminant and convergent validity, and stability data for each construct. The National Study of Daily Experiences (NSDE) waves 1 and 2, an 8-day daily diary portion of the Midlife Development in the United States (MIDUS I) and MIDUS II surveys was used for this study (n =793 adults completed both waves of the NSDE). Affective IIV was related to higher mean NA and neuroticism, and lower perceived control. Affective PF was related to lower mean NA, neuroticism, and higher mean PA and perceived control. Higher affective IIV was associated with more psychological distress when assessed concurrently at both waves and predicted more psychological distress and physical ill-health 10 years later. Higher affective PF was related to less psychological distress and physical ill-health when assessed concurrently at wave 1 and less psychological distress and physical ill-health 10 years later. When situational context is included in the calculation of emotional variability, changes in emotional response may represent emotional complexity and increased control rather than emotional lability and are related to better psychological and physical outcomes.

It is increasingly clear that pain and emotions are closely interconnected. Pain does not only cause psychological distress, but psychological distress also amplifies pain through neurological mechanisms. Treatment of both chronic and acute pain would benefit from acknowledging the psychological mechanisms of pain neurophysiology. Psychological acceptance predicts increased pain tolerance and decreased pain intensity and discomfort in experimentally induced pain and improved physical and psychosocial functioning for persons with chronic pain. The overall aim of this thesis was to evaluate acceptance-based interventions for persons suffering from pain. In Study I the effect of a manualised ACT-based self-help intervention for adults with chronic pain was evaluated in an RCT (n=90). The results showed improvements in satisfaction with life, physical functioning and pain intensity for the ACT group. Both the ACT and the control group improved regarding depression and anxiety. In Study II the mediating effect of acceptance for treatment change was evaluated, using data from Study I (n=64). The results showed indirect effects of treatment via acceptance for physical functioning but not for satisfaction with life. In Studies III and IV, instruments to measure psychological flexibility in relation to pain were developed for children with cancer, and their parents respectively, using factor analysis. The results showed that a two-factor solution for the child scale (n=61) and a three-factor solution for the parent scale (n=243), best represented the data. In Study V, an acceptance-based intervention was preliminarily evaluated in a single-subject study (n=5) for children reporting pain during cancer treatment. The intervention consisted of an approximately 15-minute long pain exposure exercise. All participants reported reduced discomfort of pain, and three of the participants reported reduced pain intensity. The results suggest that a manualised ACT-based self-help intervention is a valuable addition to the treatment repertoire for persons with chronic pain and that acceptance may mediate the effect of treatment on physical functioning. Furthermore, instruments to measure acceptance in the context of acute pain in children with cancer are now available, although further validation is needed. Lastly, the results indicate that an acceptance-based intervention may help children undergoing cancer treatment to cope with pain.