From an ACT perspective, many of the psychological factors related to weight control that were discussed previously can be grouped into three categories:

• Persistence in the face of difficult emotions and thoughts or distress tolerance
• Cognitive rigidity
• Motivational factors

Persistence: Individuals who have difficulty maintaining weight loss typically report or have been found to eat in response to stress and other negative affective states, such as hopelessness, helplessness, anger, anxiety, or boredom. From an ACT perspective, this can be seen as a problem with persistence or distress tolerance. The ACT theory of psychopathology suggests that attempts to change or eliminate unwanted private experiences (experiential avoidance) result in a narrow set of behavioral responses. In this case, the presence of uncomfortable or undesirable emotions consistently occasions eating for comfort. The problem is that the short-term effects of reducing negative affect have little or no impact on an individual’s long-term ability to face discomfort and lead a healthy, vital life. Each instance strengthens the relationship between uncomfortable emotion and avoidance. In a sense, the individual becomes less able to deal with uncomfortable emotions over time and eating is required more and more as a coping response.

Rigidity: Individuals who have difficulty maintaining weight loss typically report or have been found to adhere to rigid thinking patterns and rigid control of eating behaviors. Unsuccessful maintainers frequently adhere to dichotomous “all or nothing” thinking, viewing a minor misstep as a total failure or discounting any gains that fall short of some imagined ideal as meaningless. These individuals are prone to alternating between total restriction of desirable foods and a complete lack of weight controls all together. From and ACT perspective, this can be viewed as cognitive fusion. Cognitive fusion refers to situations in which behavior is excessively regulated by verbal rules and is insensitive to direct experiences. Individuals may be responding to verbal formulations, such as, “I had cake therefore I blew it, so what’s the point” or, “I only lost 15 pounds. I’ll never get to where I want to be.” These private events are experienced as literal truth, not as experiences that can be noticed while not being believed nor disbelieved. Individuals respond as though this is a true state of affairs and engage in behaviors that are inconsistent with a healthy, vital life.

Motivational factors: Individuals who have difficulty maintaining weight loss typically report attempting to lose weight in response to pressure from friends, family members, or health professionals as opposed to personal reasons, such as caring for oneself, wanting to be more healthy, or less activity restriction. From an ACT perspective, this can be seen as a form of rule-governance called pliance. Pliance occurs when individuals engage in behaviors in an attempt to please others or “be good” (Hayes, Strosahl et al., 1999). When this function dominates over direct, personal experiences of what works, problems can occur. These externally based contingencies are often not enough to maintain behavior outside the presence of the contextual variables (e.g. family member telling them they are doing a good job). Given the lifelong nature of maintaining weight, it is unlikely that excessive pliance could be a successful long-term behavioral approach. From an ACT perspective, individuals do not need to engage in behaviors consistent with weight maintenance in order to be praised by others; they can do them as an expression of chosen personal values (also called augmenting) and doing what works in regard to those values (also called tracking). In this respect, weight maintenance behaviors are less rigid and are more likely to be tied to the direct contingencies necessary for success.

Motivation, then, can be viewed primarily as a values issue. People are often not connected to their values. It is possible that there is frequently a disparity between what people want in their lives and what they are actually doing. This disparity can be painful to contact, thus relegating the issue of values to the background. Acceptance and defusion can help create a context where this disparity can be noticed without attachment to the painful private events that can accompany this connection. From an ACT perspective, then, values work involves goal setting/ attainment and the willingness to say/ know what is truly wanted. This involves the ability to recognize and be in contact with the disparity between what is desired and what is currently being done.

The ability to cope with stress has been associated with weight maintenance. Individuals who were described as having poor coping skills, or a poor ability to manage internal or external demands that are appraised as stressful, have been show to regain weight when confronted with stressful life events (S. Byrne, Cooper, & Fairburn, 2003; Gormally & Rardin, 1981; Gormally, Rardin, & Black, 1980; Grilo, Shiffman, & Wing, 1989). People who regain lost weight tend to eat in response to the presence of negative emotional states or use food to regulate their mood; a phenomenon often referred to as emotional eating (S. Byrne et al., 2003; Ganley, 1989). Obese people who have difficulty losing or keeping off weight have been shown to use food as a source of comfort and satisfaction (Castelnuovo-Tedesco & Schiebel, 1975), eat after difficult interpersonal situations (Hockley, 1979), and eat in response to hopelessness, helplessness, anger, anxiety, or boredom (Hudson & Williams, 1981; Rotmann & Becker, 1970). Motivational factors have also been associated with weight maintenance. Successful weight maintainers have been found to be motivated to lose weight for more personal reasons as opposed to pressures from family, friends, or medical professionals (Ogden, 2000). It appears that when a person is intrinsically motivated, and weight loss is tied to meaningful outcomes other than just losing weight, patients tend to be more successful in keeping weight off. Self-efficacy has been also been associated with weight maintenance. Self-efficacy can be described as a belief in one’s capability to produce desired outcomes in one’s life. Related, individuals who respond to overeating episodes passively tend to regain weight more than those who respond actively (Jeffery et al., 1984). The key difference seems to be that active responders somehow do not get stuck when confronted with adversity. Rigid versus flexible control of eating behavior has been associated with weight regain. Rigid control is characterized by dichotomous ‘all or nothing’ thinking and alternating periods of severe restriction and no weight control efforts. Flexible control is characterized by a ‘more or less’ approach, a long-term outlook, and the inclusion of desired foods at moderate amounts (Westenhoefer, 2001). Despite the literature findings, potentially important psychological variables are rarely targeted in clinical trials of comprehensive weight loss programs or program components. Many interventions lack a psychological component altogether (for a review, see Avenell et al., 2004).

Outcome Studies: Weight Maintenance

• Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58-69.

• Forman, E. M., Butryn, M. L., Hoffman, K. L., & Herbert, J. D. (2009). An open trial of an acceptance-based behavioral intervention for weight loss. Cognitive and Behavioral Practice, 16(2), 223-235.

• Tapper, K., Shaw, C., Ilsley, J., Hill, A. J., Bond, F. W., & Moore, L. (2009). Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52, 396–404.

• Niemeier, H. M., Leahey, T., Palm Reed, K., Brown, R. A., & Wing, R. R. (2012). An acceptance-based behavioral intervention for weight loss: A pilot study. Behavior Therapy, 43, 427-435.

• Katterman, S. N., Goldstein, S. P., Butryn, M. L., Forman, E. M., & Lowe, M. R. (2014). Efficacy of an acceptance-based behavioral intervention for weight gain prevention in young adult women. Journal of Contextual Behavioral Science, 3, 45-50.

• Nourian, L., & Aghaei, A. (2015). Effectiveness of Acceptance and Commitment Therapy on the body mass index in women afflicted with obesity. Iranian Journal of Psychiatric Nursing, 3, 11-20.

• Berman, M., Morton, S., & Hegel, M. (2016). Uncontrolled pilot study of an acceptance and commitment therapy and health at every size intervention for obese, depressed women: Accept yourself. Psychotherapy, 53(4), 462-467.

• Bradley, L. E., Forman, E. M., Kerrigan, S. G., Goldstein, S. P., Butryn, M. L., Thomas, J. G., ... & Sarwer, D. B. (2017). Project HELP: a remotely delivered behavioral intervention for weight regain after bariatric surgery. Obesity surgery, 27(3), 586-598.

Micro/Component Studies: Weight Maintenance

• Lillis, J. (2008). Acceptance and Commitment Therapy for the treatment of obesity-related stigma and sustained weight loss. Unpublished doctoral dissertation. University of Nevada, Reno.

• Lillis, J., Thomas, J., Niemeier, H., & Wing, R. (2017). Exploring process variables through which acceptance-based behavioral interventions may improve weight loss maintenance. Journal of Contextual Behavioral Science, 6(4), 398-403.

• Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Brandsma, L. L., & Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study. Behaviour Research and Therapy, 45, 2372-2386.

98 participants with chocolate cravings were exposed to a CBT-based protocol and an ACT-based protocol or no instructions and required to carry chocolate with them of for two days. Those more impacted by food related cues ate less and had fewer cravings in the ACT condition.

• Sairanen, E., Lappalainen, R., Lapveteläinen, A., & Karhunen, L. (2012). Perceptions, motives, and psychological flexibility associated with weight management. Journal of Obesity & Weight Loss Therapy, 2(135).

• Weineland, S., Arvidsson, D., Kakoulidis, T., & Dahl, J. (2012). Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obesity Research & Clinical Practice, 6(1), e21-e30.

• Forman, E. M., Hoffman, K. L., Juarascio, A. S., Butryn, M. L., & Herbert, J. D. (2013). Comparison of acceptance-based and standard cognitive-based coping strategies for craving sweets in overweight and obese women. Eating Behaviors, 14, 64-68.

• Sairanen, E., Lappalainen, R., Lapveteläinen, A., Tolvanen, A., & Karhunen, L. (2014). Flexibility in weight management. Eating behaviors, 15(2), 218-224.

• Sairanen, E., Tolvanen, A., Karhunen, L., Kolehmainen, M., Järvelä, E., Rantala, S., Peuhkuri, K., Korpela, R., & Lappalainen, R. (2015). Psychological Flexibility and Mindfulness Explain Intuitive Eating in Overweight Adults. Behavior Modification, 39(4), 557-579.

Measurement Development: Weight Maintenance

• Lillis, J., & Hayes, S. C. (2008). Measuring avoidance and inflexibility in weight related problems. International Journal of Behavior Consultation and Therapy, 4(4), 348-354.

• Lillis, J., Luoma, J. B., Levin, M. E., & Hayes, S. C. (2010). Measuring Weight Self‐stigma: The Weight Self‐stigma Questionnaire. Obesity, 18(5), 971-976.

• Sandoz, E. K., Wilson, K. G., Merwin, R, M. & Kellum, K. K. (2013). Assessment of body image flexibility: The Body Image-Acceptance and Action Questionnaire. Journal of Contextual Behavioral Science, 2, 39-48.

• Palmeira, L., Cunha, M., Pinto-Gouveia, J., Carvalho, S., & Lillis, J. (2016). New developments in the assessment of weight-related experiential avoidance (AAQW-Revised). Journal of Contextual Behavioral Science, 5(3), 193-200.

Psychological Flexibility and Weight Maintenance

• Ciarrochi, J., Sahdra, B., Marshall, S., Parker, P., & Horwath, C. (2014). Psychological flexibility is not a single dimension: The distinctive flexibility profiles of underweight, overweight, and obese people. Journal of Contextual Behavioral Science, 3, 236-247.

Physical Activity and Weight Maintenance

• Mutikainen, S., Föhr, T., Karhunen, L., Kolehmainen, M., Kainulainen, H., Lappalainen, R., & Kujala, U. (2015). Predictors of increase in physical activity during a 6-month follow-up period among overweight and physically inactive healthy young adults. Journal of Exercise Science and Fitness, 13 (2), 63-71. 

Body Image and Weight Maintenance

• Pearson, A. N., Follette, V. M. & Hayes, S. C. (2012). A pilot study of Acceptance and Commitment Therapy (ACT) as a workshop intervention for body dissatisfaction and disordered eating attitudes. Cognitive and Behavioral Practice, 19(1), 181-197.

• Rafiee, M., Sedrpoushan, N., & Abedi. M. R. (2014). The effect of Acceptance and Commitment Therapy on reducing anxiety symptoms and body image dissatisfaction in obese women. Journal of Social Issues & Humanities, 2 (1), 187-190.

• Timko, C. A., Juarascio, A. S., Martin, L. M., Faherty, A., & Kalodner, C. (2014). Body image avoidance: An under-explored yet important factor in the relationship between body image dissatisfaction and disordered eating. Journal of Contextual Behavioral Science, 3(3), 203-211.

• Webb, J. B. (2015). Body image flexibility contributes to explaining the link between body dissatisfaction and body appreciation in White college-bound females. Journal of Contextual Behavioral Science, 4, 176-183.

Obesity has been referred to as a dangerous epidemic and one of the most important public health challenges of the 21st century. The sharp increase in obesity has contributed to increases in related conditions, causing a sizeable economic cost burden for health providers and funding agencies. The 2002 estimated U.S. cost burden for obesity was $92.6 billion (Finkelstein, Fiebelkorn, & Wang, 2003).

It has been shown that marketplace food portions have increased in size since the 1970’s(Young & Nestle, 2002). People have been eating out more (K. Ball, Brown, & Crawford, 2002), food industry marketing has increased, and larger numbers of new products are being introduced (Gallo, 1990). Most Americans are sedentary. Technological advances have led to an increase in use of computers, cars, elevators, and televisions, with subsequent decreases in athletic activities including walking and bicycling.

Obese people also face discrimination resulting in external consequences. A recent review of the literature found evidence of obesity discrimination at every stage of the employment cycle (Roehling, 1999). Negative attitudes regarding obesity are widespread, socially acceptable, and develop as early as three years of age (Falkner et al., 1999; Puhl & Brownell, 2003a).

Well controlled, comprehensive weight loss programs often achieve substantial weight loss results with low rates of attrition. However weight maintenance has been a significant problem in the literature. Typically, half the weight lost is regained in the first year following treatment, and by 3-5 years posttreatment, 80% of patients have returned to or exceeded their pretreatment weight (Perri, 1998; Wadden et al., 1989; Wing, 1998).

Outcome Studies: Coping with Cancer

• Páez, M., Luciano, M. C., & Gutiérrez, O. (2007). Tratamiento psicológico para el afrontamiento del cáncer de mama. Estudio comparativo entre estrategias de aceptación y de control cognitivo. [Psychological treatment for breast cancer. Comparison between acceptance based and cognitive control based strategies] Psicooncología, 4, 75–95.

• Branstetter, A. D., Wilson, K. G., Hildebrandt, M., & Mutch, D. (2004). Improving psychological adjustment among cancer patients: ACT and CBT. Paper presented at the Association for Advancement of Behavior Therapy, New Orleans.

  Large randomized trial showing that ACT is more helpful than traditional CBT in dealing with end stage cancer and works through a different process. Amazing data.

Case Studies: Coping with Cancer

• Montesinos, F., Hernández, B., & Luciano, C. (2001). Application of Acceptance and Commitment Therapy (ACT) in cancer patients. Análisis y Modificación de Conducta, 27, 113, 503-524.

Outcome Studies: Chronic Pain

• Greco, L. A., Blomquist, K. K., Acra, S., & Moulton, D. (2006). Acceptance and Commitment Therapy for Adolescents with Functional Abdominal Pain: Results of a Pilot Investigation. Manuscript submitted for publication.
• Wicksell, R. K., Melin, L., Lekander, M., & Olsson, G. L. (2009). Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial. Pain, 141(3), 248-257.

• Vowles, K. E., Wetherell, J. L., & Sorrell, J. T. (2009). Targeting acceptance, mindfulness, and values-based action in chronic pain: Findings of two preliminary trials of an outpatient group-based intervention. Cognitive and Behavioral Practice, 16, 49-58.

• Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology, 76, 397-407.

• Wicksell, R.K., Ahlqvist, J., Bring, A., Melin, L. & Olsson, G.L. (2008). Can exposure and acceptance strategies improve functioning and life satisfaction in people with chronic pain and whiplash-associated disorders (WAD)? A randomized controlled trial. Cognitive Behaviour Therapy
  

  Included people (adults) with longstanding pain due to whiplash (WAD). A 10-session protocol was compared with a wait list control group, and found significant improvements following treatment in functioning and life satisfaction, as well as in psychological flexibility (as measured with PIPS).

• McCracken, L. M., MacKichan, F., & Eccleston, C. (2007). Contextual cognitive-behavioral therapy for severely disabled chronic pain sufferers: Effectiveness and clinically significant change. European Journal of Pain, 11, 314-322.

• Wicksell R.K, Melin, L. & Olsson, G.L. (2007). Exposure and acceptance in the rehabilitation of children and adolescents with chronic pain.European Journal of Pain, 11, 267-274.
  

  Open trial with 14 adolescents. Good outcomes that continue to improve through follow up.

• McCracken, L. M., Vowles, K. E., & Eccleston, C. (2005). Acceptance-based treatment for persons with complex, long standing chronic pain: A preliminary analysis of treatment outcome in comparison to a waiting phase. Behaviour Research and Therapy, 43, 1335-1346.
  

  108 chronic pain patients with a long history of treatment are followed through an ACT-based 3-4 week residential treatment program. Measures improved from initial assessment to pre-treatment on average only 3% (average of 3.9 month wait), but improved on average 34% following treatment. 81% of these gains were retained through a 3 month follow up. Changes in acceptance predicted positive changes in depression, pain related anxiety, physical disability, psychosocial disability, and the ability to stand. Positive outcomes were also seen in a timed walk, decreased medical visits, daily rest due to pain, pain intensity, and decreased pain medication use.

• Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and Commitment Therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785-802.
  

  A small randomized controlled trial shows that a four hour ACT intervention reduced sick day usage by 91% over the next six months compared to treatment as usual in a group of chronic pain patients at risk for going on to permanent disability.

Mediation Analyses

• Wicksell, R. K., Olsson, G. L., Hayes, S. C. (2010). Psychological flexibility as a mediator of improvement in acceptance and commitment therapy for patients with chronic pain following whiplash. European Journal of Pain. 

Case Studies: Chronic Pain

• Kleen, M., & Jaspers, J. P. C. (2007). Women should not be allowed to run. Acceptance and commitment therapy (ACT) with a pain disorder. Translated from: Vrouwen horen niet hard te lopen. Acceptance and commitment therapy (ACT) bij een pijnstoornis. Gedragstherapie, 40, 7-26.

• Wicksell, R. K., Dahl, J., Magnusson, B., & Olsson, G. L. (2005). Using Acceptance and Commitment Therapy in the rehabilitation of an adolescent female with chronic pain: A case example. Cognitive and Behavioral Practice, 12, 415-423. Shows dramatic improvement with a 14 year old chronic pain patient using a values focused ACT protocol.

• Luciano, C., Visdómine, J.C., Gutiérrez, O., & Montesinos, F. (2001). ACT (Acceptance and Commitment Therapy) and chronic pain. Análisis y Modificación de Conducta, 27, 113, 473-502.
  

  Describes the use of ACT in the treatment of chronic pain and shows resulting data. Case study.

Micro/Component Studies: Chronic Pain

• Vowles, K., McNeil, D.W., Bates, M., Gallimore, P. & McCall, C. (2007). Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain. Behavior Therapy, 38, 412-425.

• A number of other micro/component studies have examined the impact of brief ACT interventions on performance in pain inducing preparations and are listed here.

Correlational Studies: Chronic Pain

• McCracken, L. M., & Zhao-O'Brien, J. (2010). General psychological acceptance and chronic pain: There is more to accept than pain itself. European Journal of Pain, 14, 170-175.
• McCracken, L. M., & Vowles, K. E. (2008). A prospective analysis of acceptance and values in patients with chronic pain. Health Psychology, 27, 215-220.

• Vowles, K. E., McCracken, L. M., & Eccleston, C. (2008). Patient functioning and catastrophizing in chronic pain: The mediating effects of acceptance. Health Psychology, 27, S136-S143.

• Wicksell, R. K., Renofalt, J., Olsson, G. L., Bond, F. W., & Melin, L. (2008). Avoidance and cognitive fusion - Central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS). European Journal of Pain, 12, 491-500.

• McCracken, L. M., Gauntlett-Gilbert, J., & Vowles, K. E. (2007). The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability. Pain, 131, 63-69.

• McCracken, L. M., & Vowles, K. E. (2007). Psychological flexibility and traditional pain management strategies in relation to patient functioning with chronic pain: An examination of a revised instrument.Journal of Pain, 8, 339-349.

• McCracken, L. M., Vowles, K. E., & Gauntlett-Gilbert, J. (2007). A prospective investigation of acceptance and control-oriented coping with chronic pain. Journal of Behavioral Medicine, 30, 339-349.

• Vowles, K. E., McCracken, L. M., & Eccleston, C. (2007). Processes of behavior change in interdisciplinary treatment of chronic pain: Contributions of pain intensity, catastrophizing, and acceptance.European Journal of Pain, 11, 779-787.

• McCracken, L. M. (2006). Toward a fully functional, flexible, and defused approach to pain in young people. Cognitive and Behavioral Practice, 13, 182-184.

• McCracken, L. M., & Eccleston, C. (2006). A comparison of the relative utility of coping and acceptance-based measures in a sample of chronic pain sufferers. European Journal of Pain, 10(1), 23-29.

• McCracken, L. M., & Yang, S. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain, 123, 137-145.

• McCracken, L. M. (2005). Social context and acceptance of chronic pain: The role of solicitous and punishing responses. Pain, 113, 155-159.

• McCracken, L. M., & Eccleston, C. (2005). A prospective study of acceptance of pain and patient functioning with chronic pain. Pain, 118, 164-169.

• McCracken, L. M. , Vowles, K. E., & Eccleston, C. (2004). Acceptance of chronic pain: Component analysis and a revised assessment method.Pain, 107, 159-166.

• McCracken, L. M. & Eccleston, C. (2003). Coping or acceptance: What to do about chronic pain. Pain, 105, 197-204.

• Viane, I., Crombez, G., Eccleston, C., Poppe, C., Devulder, J., Van Houdenhove, B., & De Corte, W.(2003). Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain, 106(1/2), 65-73.

• McCracken, L. M., Spertus, I. L. , Janeck, A. S., Sinclair, D., & Wetzel, F. T. (1999). Behavioral dimensions of adjustment in persons with chronic pain: Pain-related anxiety and acceptance. Pain, 80, 283-289.

• McCracken, L. M. (1999). Behavioral constituents of chronic pain acceptance: Results from factor analysis of the Chronic Pain Acceptance Questionnaire. Journal of Back & Musculoskeletal Rehabilitation, 13, 93-100.

• McCracken, L. M. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain, 74, 21-27.
  

  This study is based on a pain related early version of the AAQ. Greater acceptance of pain was associated with reports of lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily uptime, and better work status. A relatively low correlation between acceptance and pain intensity showed that acceptance is not simply a function of having a low level of pain. Regression analyses showed that acceptance of pain predicted better adjustment on all other measures of patient function, independent of perceived pain intensity. This work is replicated, refined and extended in McCracken, L. M. & Eccleston, C. (2003). Coping or acceptance: What to do about chronic pain. Pain, 105, 197-204. and McCracken, L. M. , Vowles, K. E., & Eccleston, C. (2004). Acceptance of chronic pain: Component analysis and a revised assessment method. Pain, 107, 159-166.

Outcome Studies: Epilepsy

• Lundgren, T., Dahl, J., Yardi, N., & Melin, J. (2008). Acceptance and Commitment Therapy and Yoga for drug refractory epilepsy: A randomized controlled trial. Epilepsy and Behavior, 13, 102-108.

• Lundgren, A. T., Dahl, J., Melin, L., & Kies, B. (2006). Evaluation of Acceptance and Commitment Therapy for drug refractory epilepsy: A randomized controlled trial in South Africa. Epilepsia, 47, 2173-2179.
  

  RCT with 27 drug resistant epileptics comparing 9 hours of ACT – individual and group -- to supportive therapy. Reduction of seizures to near zero level; maintenance for a year. Quality of life improves continuously through the follow up. Mediational analyses fit the ACT model and are described in more detail in Lundgren, T., Dahl, J., & Hayes, S. C. (2008). Evaluation of mediators of change in the treatment of epilepsy with Acceptance and Commitment Therapy. Journal of Behavior Medicine, 31(3), 225-235.

• Lundgren, A. T. (2004). Development and evaluation of an integrative health model in the treatment of epilepsy: Two randomized controlled trials investigating the effects of a short term ACT intervention, yoga, and attention control therapy in India and South Africa. Unpublished thesis, University of Uppsala, Uppsala, Sweden.
  

  Two small RCTs (N = 18; and N = 28) comparing a three session ACT protocol (two individual; one group) to two other conditions. As compared to yoga, significantly reduced seizures in the ACT condition; as compared to attention control, significantly reduced seizures and experiential avoidance, and significantly increased quality of life in the ACT condition at a one year follow up.

Outcome Studies: Diabetes Management

• Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336-343.
  

  RCT showing that ACT + patient education is significantly better than patient education alone in producing good self-management and better blood glucose levels in lower SES patients with Type II diabetes. Effects at follow up are mediated by changes in self-management and greater psychological flexibility with regard to diabetes related thoughts and feelings.

Outcome Studies: High-Risk Sexual Behavior

• Metzler, C. W., Biglan, A., Noell, J., Ary, D., & Ochs, L. (2000). A randomized controlled trial of a behavioral intervention to reduce high-risk sexual behavior among adolescents in STD clinics. Behavior Therapy, 31, 27-54.
  

  Components from ACT were included as component of a successful program to reduce high risk sexual behavior in adolescents.

Case Studies: Athletic Performance

• Gardner, F. L. & Moore, Z.E. (2004). A mindfulness-acceptance-commitment based approach to athletic performance enhancement: Theoretical considerations. Behavior Therapy, 35, 707-724.
  

  Case study. An ACT protocol with an emphasis on mindfulness helps with sports outcomes.

Case Studies: Erectile Dysfunction

• Montesinos, F. (2003). ACT, sexual desire orientation and erectile dysfunction. A case study. Analisis y Modificación de Conducta, 29, 291-320.
  

  A successful application of ACT to a 30-year-old male with difficulties in accepting his bisexual orientation and with an erectile dysfunction is presented.

Outcome Studies: Smoking

• Bricker, J. B., Mann, S. L., Marek, P. M., Liu, J. M., Peterson, A. V. (2010). Telephone-delivered acceptance and commitment therapy for adult smoking cessation: A feasibility study. Nicotine & Tobacco Research, 12, 454-458.

• Hernandez-Lopez, M., Luciano, M. C, Bricker, J., B., Roales-Nieto, J. G., & Montesinos, F. (2009). Acceptance and commitment therapy for smoking cessation: A preliminary study of its effectiveness in comparison with cognitive behavioral therapy. Psychology of Addictive Behaviors, 23, 723-730.

• Brown, R. A., Palm, K. M., Strong, D. R., Lejuez, C. W., Kahler, C. W., Zvolensky, M. J., Hayes, S. C., Wilson, K. G., & Gifford, E. V. (2008). Distress tolerance treatment for early-lapse smokers: Rationale, program description, and preliminary findings. Behavior Modification, 32(3), 302-332.

• Rosenqvist, D. & Sand, J. (2006). Mindfulness based smoking cessation for groups - an explorative study. Thesis at the Lund University, Sweden.

  6 acceptance and mindfulness group sessions during 35 days including individual homework assignments. 8 of 10 participants completed the program. At 1 mo follow up 50 percent (of 8 completers) were non-smokers, and the rest showed a decrease in smoking at a rate between 45 and 75 percent. Increase of the acceptance aspect of mindfulness was correlated with non-smoking.

• Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M.., Rasmussen-Hall, M. L., & Palm, K. M. (2004). Acceptance theory-based treatment for smoking cessation: An initial trial of Acceptance and Commitment Therapy. Behavior Therapy, 35, 689-705.

  Medium sized randomized controlled trial comparing ACT to nicotine replacement therapy (NRT) as a method of smoking cessation. Quit rates were similar at post but at a one-year follow-up the two groups differed significantly. The ACT group had maintained their gains (35% quit rates) while the NRT quit rates had fallen (less than 10%). Mediational analyses shows that ACT works through acceptance and response flexibility.

Outcome Studies: Stress and Burnout

• Blackledge, J. T., & Hayes, S. C. (2006). Using Acceptance and Commitment Training in the Support of Parents of Children Diagnosed with Autism. Child & Family Behavior Therapy, 28(1), 1-18.

  Pre – post study shows that ACT workshop helps parents cope with the stress of raising autistic children.

• Luoma, J. B., Hayes, S. C., Twohig, M. P., Roget, N., Fisher, G., Padilla, M., Bissett, R., & Kohlenberg, B. (2007). Augmenting continuing education with psychologically focused group consultation: Effects on adoption of group drug counseling. Psychotherapy: Theory, Research, Practice, Training, 44(4), 463-469.

As small study examining whether a group consultation including elements of Acceptance and Commitment Therapy improved adoption compared to a standard 1-day continuing education workshop on Group Drug Counseling (GDC). The group consultation appeared to result in greater adoption as well as greater sense of personal accomplishment ( a burnout subscale). 

• Blackledge, J. T., & Hayes, S. C. (2006). Using Acceptance and Commitment Training in the Support of Parents of Children Diagnosed with Autism. Child & Family Behavior Therapy, 28(1), 1-18.

  Pre – post study shows that ACT workshop helps parents cope with the stress of raising autistic children.

• Hayes, S. C., Bissett, R., Roget, N., Padilla, M., Kohlenberg, B. S., Fisher, G., Masuda, A., Pistorello, J., Rye, A. K., Berry, K. & Niccolls, R. (2004). The impact of acceptance and commitment training and multicultural training on the stigmatizing attitudes and professional burnout of substance abuse counselors. Behavior Therapy, 35, 821-835.

  A medium sized randomized controlled trial that found that a one day ACT workshop produces greater decreases in stigmatization of clients by therapists and greater decreases in therapist burnout than an educational control and (or some comparisons) than multicultural training. Mediational analyses fit the model.

• Bond, F. W. & Bunce, D. (2000). Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology, 5, 156-163.

  Randomized controlled trial. Shows that ACT is more effective than a previously empirically supported behavioral approach to reducing worksite stress and anxiety, and that both are better than a wait list control.

Correlational Studies: Stress and Burnout

• Bond, F.W., Flaxman, P.E., & Bunce, D. (2008). The influence of psychological flexibility on work redesign: Mediated moderation of a work reorganization intervention. Journal of Applied Psychology, 93, 645-654.

• Bond, F. W., & Flaxman, P. E. (2006). The Ability of Psychological Flexibility and Job Control to Predict Learning, Job Performance, and Mental Health. Journal of Organizational Behavior Management, 26, 113-130.

• Donaldson, E. & Bond, F.W. (2004). Psychological acceptance and emotional intelligence in relation to workplace well-being. British Journal of Guidance and Counselling, 32, 187-203.

  Study compared experiential avoidance (as measures by the AAQ) and emotional intelligence in terms of their ability to predict general mental health, physical well-being, and job satisfaction in workers (controlling for the effects of job control since this work organisation variable is consistently associated with occupational health and performance). Results from 290 United Kingdom workers showed that emotional intelligence did not significantly predict any of the well-being outcomes, after accounting for acceptance and job control. Acceptance predicted general mental health and physical well-being but not job satisfaction, Job control was associated with job satisfaction, only. Not controlling one’s thoughts and feelings (as advocated by acceptance) may have greater benefits for mental well-being than attempting consciously to regulate them (as emotional intelligence suggests).

• Bond, F. W. & Bunce, D. (2003). The role of acceptance and job control in mental health, job satisfaction, and work performance. Journal of Applied Psychology, 88, 1057-1067.

  Shows that AAQ predicts positive work outcomes (mental health, satisfaction, performance) even one year later, especially in combination with job control. Re-factors the AAQ and shows that a two factor solution can work on a slightly different 16 item version.

Outcome Studies: Weight Maintenance

• Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58-69.

Micro/Component Studies: Weight Maintenance Outcome Studies: Weight Maintenance

• Lillis, J. (2008). Acceptance and Commitment Therapy for the treatment of obesity-related stigma and sustained weight loss. Unpublished doctoral dissertation. University of Nevada, Reno.

Micro/Component Studies: Weight Maintenance

• Forman, E.M., Hoffman, K.L., McGrath, K.B., Herbert, J.D., Brandsma, L.L. & Lowe, M.R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study. Behaviour Research and Therapy, 45, 2372-2386.

  98 participants with chocolate cravings were exposed to a CBT-based protocol and an ACT-based protocol or no instructions and required to carry chocolate with them of for two days. Those more impacted by food related cues ate less and had fewer cravings in the ACT condition.

Measurement Development: Weight Maintenance

• Lillis, J., & Hayes, S. C. (2008). Measuring avoidance and inflexibility in weight related problems. International Journal of Behavior Consultation and Therapy, 4(4), 348-354.