Tinnitus is a highly prevalent health condition creating moderate or severe interference on mood, sleep and daily functioning for a group of those affected. The aims of this thesis were 1) to explore the role of acceptance and psychological flexibility in understanding tinnitus interference both experimentally and with a longitudinal design 2) to evaluate the immediate and long-term outcomes of an acceptance based behaviour therapy (Acceptance and Commitment Therapy; ACT) in the treatment of people with tinnitus and, 3) to investigate the relationship between treatment outcome and processes assumed to be the active ingredients of treatment (acceptance and cognitive defusion). Study I (n=47) was an experiment comparing the impact of acceptance to that of thought suppression or a neutral instruction on the ability to maintain attention on an imagery task. Results indicated that participants could benefit from an acceptance strategy when performing the task. Study II (n=47) was a longitudinal trial studying the mediating role of acceptance on the relationship between tinnitus interference at baseline and tinnitus interference, anxiety, life quality, and depression at a seven-month follow-up. Full mediation was found for life quality and depression, and partial mediation for tinnitus interference. Study IV (n=64) was a randomised controlled trial evaluating the immediate and long-term effects of ACT in comparison to those of Tinnitus Retraining Therapy (TRT) and to a wait list control. Results showed that ACT had large immediate effects on tinnitus interference in comparison to wait list, and medium long-term effects in comparison to TRT. Results were also seen on secondary outcome. Self-reported tinnitus acceptance significantly mediated the immediate outcome of ACT. Study III (n=24) was a process study where the video recorded sessions of ACT from study IV were observed and rated with regard to client behaviour. Results showed that in-session acceptance and defusion behaviours rated early in therapy were predictors of sustained positive treatment effects of ACT. These associations continued to be substantial even when controlling for the prior improvement in outcome. This whereas prior symptom change could not predict process variables rated late in therapy. Participants in all trials were chronic tinnitus patients, mainly from different departments of audiology. These findings implicate that 1) acceptance and psychological flexibility may contribute to the understanding of tinnitus interference 2) ACT can reduce tinnitus interference in a group of normal hearing tinnitus patients and 3) acceptance and cognitive defusion are important processes in ACT, related to outcome. / Tinnitus är ett mycket vanligt hälsoproblem där en grupp av de drabbade upplever påtagliga besvär såsom påverkan på sömn, välbefinnande och funktionsnivå. Denna avhandlings syften var att 1) utforska den roll acceptans och psykologisk flexibilitet har för förståelsen av tinnitusbesvär såväl experimentellt som med en longitudinell design 2) utvärdera de omedelbara och långsiktiga effekterna av en acceptansinriktad beteendeterapi (Acceptance and Commitment Therapy; ACT) vid behandling av personer med tinnitus samt 3) undersöka relationen mellan behandlingsutfall och processer som antas utgöra behandlingens aktiva komponenter (acceptans och kognitiv defusion). Studie I (n=47) var ett experiment där man jämförde förmågan att bibehålla uppmärksamheten på en mental bild vid tre olika betingelser: acceptans, tankesuppression eller en neutral betingelse. Resultaten indikerade att deltagarna som slumpats till acceptans var hjälpta av denna strategi i genomförandet av uppgiften. Studie II (n=47) var en självrapportstudie med longitudinell design där det undersöktes om acceptans fungerade som en mediator i sambandet mellan tinnitusbesvär i baslinjen och livskvalitet, depression, ångest och tinnitusbesvär vid en uppföljning efter sju månader. För variablerna livskvalitet och depression visade resultaten en fullständig mediation och för tinnitusbesvär en partiell mediation. Studie IV (n=64) var en randomiserad kontrollerad prövning av de omedelbara och långsiktiga effekterna av ACT i jämförelse med Tinnitus Retraining Therapy (TRT) och en väntelistekontrollgrupp. Resultaten visade att ACT hade en stor omedelbar effekt på tinnitusbesvär i jämförelse med väntelistan och en medelstor effekt i jämförelse med TRT. Även sekundära utfallsmått visade på effekter. Utfallet i ACT medierades av självrapporterad acceptans av tinnitus. Studie III (n=24) studerade processer i ACT-behandlingen genom observation och skattning av klientbeteenden under de videoinspelade sessionerna. Resultaten visade att klienternas acceptans- och defusionbeteende under sessioner tidigt i terapin predicerade det långsiktiga utfallet i behandlingen. Dessa samband kvarstod även när man kontrollerade för symtomförbättring fram till den skattade sessionen. Detta medan tidigare symtomförbättring inte predicerade klientbeteende senare i behandling. Deltagare i samtliga studier var patienter med kronisk tinnitus, huvudsakligen rekryterade från reguljär hörselvård. Resultaten från dessa studier indikerar att 1) acceptans och psykologisk flexibilitet kan bidra till förståelsen av tinnitusbesvär 2) ACT kan minska tinnitusbesvär hos en grupp normalhörande patienter 3) acceptans och kognitiv defusion är viktiga processer i ACT vilka är relaterade till behandlingutfallet.

The psychological aspects of sports is crucial for performance and important for sustaining good mental health. Despite this, efforts to improve those aspects are surprisingly rare and partly due to stigmatization of help-seeking together with lack of time and economic resources. However, in recent decades much research on internet-based interventions have been conducted. Also, a growing body of empirical support for the Mindfulness-Acceptance-Commitment approach (MAC) related to enhancement in performance and mental health in sports has emerged. This study was the first to explore the effects of internet-based MAC, which was conducted with the digital self-care programme ACTSPORT with or without feedback. Of 193 participants (aged 18 - 71, from 40 different sports on a variety of levels) who were randomly assigned to feedback, non-feedback and waitlist group, 125 completed the study. The results showed that participants who completed ACTSPORT with feedback experienced significantly enhanced performance, reduced performance anxiety and improved mental health, which included higher quality of life and less symptoms of depression. These improvements were predicted by significant improvements in acceptance and dispositional mindfulness. A larger effect was found for participants with feedback which indicated that some support is preferable. In conclusion, the present study indicate that internet-based interventions in sport may be  effective, time-saving, cost-effective, flexible and available means for both enhancement in performance and aspects of mental health. / De psykologiska faktorerna inom idrott är avgörande för prestation och viktiga för att upprätthålla god mental hälsa. Trots detta är ansträngningar för att förbättra dessa faktorer förvånansvärt sällsynta. Det beror bland annat på att det råder ett stigma kring att söka hjälp samt brist på tid och ekonomiska resurser. De senaste decennierna har det genomförts en stor mängd forskning på internetbaserade interventioner. Dessutom har Mindfulness-Acceptance-Commitment approach (MAC) fått en ökad mängd empiriskt stöd gällande förbättring i prestation och mental hälsa inom idrott. Föreliggande studie är den första i sitt slag att undersöka effekten av internetbaserad MAC, vilken genomfördes med det digitala självhjälpsprogrammet ACTSPORT med eller utan feedback. Av 193 deltagare (ålder 18 - 71, i 40 olika sporter på alla nivåer) som randomiserades till tre grupper med feedback, utan feedback eller väntelista, fullföljde 125 deltagare studien. Resultaten visade att deltagare som fullföljde ACTSPORT med feedback upplevde signifikant förbättrad prestation, minskad prestationsångest såväl som förbättrad mental hälsa vilket inkluderade högre livskvalité och minskade depressionssymtom. Detta visade sig kunna prediceras av signifikanta förbättringar i acceptans och dispositionell mindfulness. En större effekt sågs för deltagarna i gruppen med feedback vilket indikerade att ett visst stöd är fördelaktigt. Slutsatser från studien är att internetbaserade interventioner inom idrott kan vara effektiva, tidsbesparande, kostnadseffektiva, flexibla och tillgängliga medel för att både öka prestation och aspekter av mental hälsa.

Pathologische Sorgen sind ungenau definiert. Für die Behandlungsplanung bleiben wichtige Fragen offen: Welche Merkmale sind für die Unterscheidung zwischen behandlungsbedürftigen und nicht behandlungsbedürftigen Sorgen relevant? Welche Art von Sorgen muss wie behandelt werden? Und: Welche Art von Sorgen gilt es eher zu akzeptieren? Wir machen praxisnahe Vorschläge dafür, wie Sorgen mittels einer einfachen Heuristik auch vom Patienten selbst als «pathologisch» identifiziert werden können. Im Sinne eines therapeutischen Arbeitsmodells ergeben sich differentielle Bearbeitungsstrategien, je nachdem, ob es sich um wichtige oder weniger wichtige, auf lösbare oder unlösbare Probleme bezogene sowie angemessene oder überzogene Sorgen handelt. Das vorgestellte Arbeitsblatt zu den Sorgen soll vor allem die wahrgenommene Kontrolle des Patienten stärken und die Psychoedukation zur Generalisierten Angststörung erleichtern. / Pathological worries have not yet been clearly defined. As a consequence, practically relevant questions remain open: Which characteristics distinguish worries relevant for treatment from those which are not? What kind of worries has to be treated in which way? And: What kind of worries is rather to be accepted? We propose a simple rationale which helps the therapist and the patient to identify pathological worries. According to this working model, different treatment strategies result depending on whether worries are central or not, whether they relate to a problem which can be solved or not, and whether they seem proportionate or exaggerated. The presented worksheet is meant to strengthen the perceived control of the patient and to help facilitate psychoeducation for generalised anxiety disorder. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Systematic Review: Healthcare professionals work in highly emotive environments and are considered to be at high risk of developing burnout due to the nature of their roles. There has been increased interest in applying mindfulness-based interventions for stress reduction in healthcare professionals. Previous reviews have tended to include a heterogeneous mix of patients, healthcare students and healthcare professionals. The inherent differences in these roles limits the conclusions that can be drawn regarding the effectiveness of mindfulness-based interventions for healthcare professionals. The current review aimed to address this gap in knowledge by reviewing mindfulness-based interventions specifically for healthcare professionals. Eight studies were included in the review. It was concluded that despite some methodological weaknesses there was promising evidence of the effectiveness of mindfulness-based interventions in reducing stress and improving well-being particularly when baseline levels of stress were high. The evidence in support of reducing burnout was less conclusive. Future studies employing larger samples using active controls and longitudinal designs will provide valuable information on the long-term efficacy of these interventions. Empirical Research Study: Several studies have identified psychological adjustment as one of the most important factors correlating with psychological distress and quality of life in people with cancer. Identifying ways to promote positive adjustment to cancer is an important goal in helping to alleviate distress and improve quality of life for this client group. This can be facilitated by identifying robust predictors of distress. Previous studies have identified a number of useful predictors, such as coping styles and psychological adjustment styles. The current study aimed to explore the predictive power of two newer constructs aligned to mindfulness-based processes: self-compassion and cognitive fusion - in determining adjustment to cancer. 114 adults with various cancer diagnoses completed the Mini Mental Adjustment to Cancer Scale, Brief COPE, the Self-Compassion Scale, Cognitive Fusion Questionnaire; and two outcome measures: the Hospital Anxiety and Depression Scale and the Functional Analysis of Cancer Therapy – General. Hierarchical multiple regression was used to explore relationships between predictor variables: mental adjustment, coping style, self-compassion and cognitive fusion, and outcome variables: distress and quality of life. Results showed that a known predictor, emotional avoidance coping and the newer construct, cognitive fusion were significant predictors of distress over and above other known predictors. Emotional avoidance coping was the only significant predictor of quality of life over and above known predictors and the newer constructs under examination. Self-compassion did not account for any significant incremental variance in distress or quality of life after controlling for other known predictors. The results of this study indicate that interventions focused on reducing cognitive fusion and emotional avoidance are warranted and potentially beneficial in reducing distress in this population.

Elite freestyle snowboarders often expose themselves to large risks while performing their sport. A natural response to risk is fear, and it is the aim of this study to explore how elite freestyle snowboarders experience and cope with emotions of fear in conjunction with performing their sport. When examining these mechanisms, Acceptance and Commitment Therapy (ACT) will be used as the theoretical framework. The aim is to try to determine if the riders accept or avoid situations, thoughts and emotions of fear. Data was collected through semi-structured interviews with seven elite freestyle snowboarders (six men and one woman). The content of the interviews where processed with theory driven thematic analysis and inductive thematic analysis. The analysis revealed eight themes related to the athletes’ experience of fear: (1) Sources of fear, (2) Fear inducing events and situations, (3) Physiological responses, (4) Cognitive changes, (5) Action tendencies, (6) Fear appraisal, (7) Fear and risk and (8) Fear as a problem. In the analysis of the participants’ coping strategies for fear two themes emerged: Coping strategies not related to ACT and ACT-related coping strategies. It can be concluded from this study that elite freestyle snowboarders at times experience fear when exposed to high risk of injury, and can interpret this experience both as a negative and positive for well-being and performance. Participants use a range of coping strategies for fear; some which are in line with traditional sport psychology with an avoidance approach. Despite no previous ACT training, some participants have developed an accepting approach to relate to fear. The complexity of ACT as a theoretical framework is also demonstrated in this study due to the difficulties in categorizing the distinction between processes and orientations of strategies.

It is widely accepted in the literature that adverse experiences in childhood, such as abuse and emotional invalidation, pose a major risk factor for the development of psychopathology later in life. What is less known, however, is what processes mediate these associations. This study investigated whether psychological inflexibility – that is, cognitive fusion and experiential avoidance - play a role in mediating these relationships. Although abuse and experiential avoidance have featured prominently in the literature, emotional invalidation and cognitive fusion have been comparatively neglected. 518 adults currently experiencing self-reported psychological distress were recruited from online mental health support forums. They completed questionnaires measuring experiences of abuse and maternal/paternal emotional invalidation in childhood and current levels of cognitive fusion, experiential avoidance and psychopathology in an online survey. Given the interpersonal nature of the childhood experiences, and the impact these may have on attachment relationships, participants were also asked to complete a measure of adult attachment. Regression and path analyses indicated that whilst childhood abuse had a direct impact on adult psychopathology, experiences of maternal and paternal emotional invalidation had indirect relationships with psychopathology via cognitive fusion and experiential avoidance. In terms of predicting current levels of psychopathology, cognitive fusion made the most significant contribution, both directly, and indirectly via experiential avoidance. No reliable predictive relationships were observed between adult attachment and any other variable. The results add novel findings to the literature regarding the role of childhood emotional invalidation and cognitive fusion in the development and/or maintenance of distress. They suggest that clinical interventions aimed at cognitive defusion may be of particular benefit to people currently experiencing psychological distress and, perhaps, those with a history of emotional invalidation. However, the cross-sectional nature of this study limits the causal conclusions that can be made and future research should consider the use of longitudinal designs to extend these findings.

Background: In recent years Acceptance and Commitment Therapy (ACT) has gained increasing status as a promising approach to treating chronic pain physical functioning and psychological well-being. The basic premise of ACT as applied to chronic pain is that while pain hurts, it is the struggle with pain that causes suffering. This approach aims to restore effective and adaptive functioning for an individual within a context of continuing pain so that the individual can live a more vital and meaningful life. There is a growing empirical support for the effectiveness of ACT however research has relied on self-reported quantitative outcomes, focused on addressing changes in pain intensity and the physical and psychological impact of chronic pain. There appears to be a gap in the literature on the exploration of the experience of attending an ACT programme for chronic pain from the patient’s perspective. Aim: This study sought to explore the experience of attending an ACT programme for chronic pain within an outpatient NHS hospital setting. Furthermore the study sought to explore the modulating factors influencing clients learning and understanding of the construct of acceptance from the perspective of the participants. Additionally, the experience of attending a group based ACT intervention was explored. Methodology: A qualitative methodology was chosen for the project. The study used a purposive sample of twelve participants, who had all attended the Luton & Dunstable Hospital ACT 8 week outpatient programme for chronic pain. The participants were interviewed through the use of a semi structured interviews, and the transcripts were transcribed and then analysed using Thematic Analysis. Identified themes were further organised using the tool of Thematic Network Analysis. Results: Three global themes emerged from the analysis of the data. The first global theme encompassed the participant’s pre-programme expectations and this theme highlighted the participant’s feelings of hope and hopelessness prior to attending the programme. The second global theme demonstrated the on-going process of living with chronic pain and highlighted the benefits and barriers to adopting and ACT based approach to chronic pain. Finally the third global theme addressed the experience of a group based intervention and included the positive and negative aspects of this experience for the participants. Clinical Implications & Conclusion: Based on the results of this study a number of clinical implications were highlighted in relation to the future development of ACT programmes for chronic pain. These included suggestions in relation to engaging participants in such programmes. Notably, timing issues, validation of physical symptoms, and consideration of the potential barriers to acceptance and understanding of the benefits of adopting and ACT group based pain management approach were discussed.

Background: Research in psychological adjustment to multiple sclerosis (MS) suggests that the way individuals appraise their condition can have an impact upon their psychological well-being and adjustment to their condition. Such research has influenced the development of Cognitive Behavioural Therapy (CBT) interventions in this population. In recent years, Acceptance and Commitment Therapy (ACT) has gathered increasing interest in relation to chronic health conditions. ACT does not target the content of thought, but rather focuses on the contexts in which thought occurs (i.e. how individuals relate to their experiences). Aim and Primary Hypothesis: A cross sectional design was used to compare the extent to which cognitive appraisals and ACT constructs (‘acceptance’ and ‘cognitive fusion’), mediate the relationship between physical symptoms of MS and psychological adjustment outcomes. It was hypothesised that in comparison to cognitive appraisals, ACT constructs would serve as stronger mediators of the relationship between physical symptoms of MS and outcome measures. This study also piloted a newly adapted measure of MS related acceptance, the Multiple Sclerosis Acceptance Questionnaire (MSAQ). Method and Results: Participants (N = 133) completed self-report measures of: MS symptom severity, various cognitive constructs (cognitive appraisals and ACT constructs), symptoms of psychological distress, and satisfaction with life. Multiple mediation analysis was then used to compare competing mediational hypotheses. In comparison to all measures of cognitive appraisals, the ACT constructs tended to be stronger mediators of the relationship between symptoms and outcome measures (both psychological distress, and satisfaction with life). There was also some evidence for appraisals of personal control mediating the relationship between symptoms of MS and psychological distress. Conclusions: This research suggests that ACT constructs may be relevant to the process of psychological adjustment to MS, and that ACT based interventions may be worthy of investigation in this population. The newly adapted MSAQ also shows preliminary promise as a measure of MS related acceptance.

The term emerging adulthood was coined during the 21st century to describe human development between adolescence and adulthood, during the ages of 18-25 (Arnett, 2000). During this stage, individuals can explore life areas. Emerging adults beginning college have a unique opportunity to form their identities and develop value systems (Hauser & Greene, 1991). With increasing autonomy, college students have possibilities for positive development and risk; values may be imperative in that differentiation. Furthermore, value systems are believed to play a major role in decision-making (Schwartz, 1992). Parents are influential in values development (Simpson, 2001; Steinberg & Sheffield Morris, 2001). During emerging adulthood, individuals have opportunities to notice discrepancies between their parents’ value system and society. Thus, emerging adults evaluate and choose personal values, which may or may not be similar to those of their parents, peers, or broader culture. Findings from this study indicate female caregivers’ parenting styles and closeness of the parent-child relationship have significant direct effects on the degree to which values are freely chosen. Specifically, Authoritarian parenting style (β = -.43 B = -1.70, p < .001), Authoritative parenting style (β = .12, B = .53, p < .001), and Emotional Support (β = .30, B = 6.80, p < .001) significantly predicted the degree to which values are intrinsically chosen. Only one significant relationship was found for male caregivers; there was a significant positive relationship between the authoritative parenting style and quality of the parent-child relationship (β = .64, B = .10, p < .001).

The present study used a basic behavioral paradigm derived from Relational Frame Theory (RFT), a contemporary behavioral account of language and cognition, to validate principle-based definitions of the cognitive interventions of defusion and reappraisal. Ninety-one participants first underwent an RFT learning paradigm that established symbolically generalized avoidance. Participants were then randomized to a defusion, reappraisal, or control condition. The main outcomes were equivalence responding—indicative of the trained relational network and analogous to the content of cognition—and avoidance—analogous to the behavioral impact of cognition. Defusion and reappraisal significantly reduced avoidance responding, providing support for the hypothesis that these interventions target the behavior of relational framing. Mediation analyses, conducted on an exploratory basis, revealed differences between the mechanisms of defusion and reappraisal and provided preliminary support for the classification of these interventions as a functional context intervention and a relational context intervention, respectively.