Primenjena psihologija

Vol. 15, No. 4, pp. 473-506, 2022

Research Article

Guided Mindfulness-Acceptance Self-Help

Intervention for Dysphoric Students:

Preliminary Findings

Snežana Tovilović 1 , Zdenka Novović 1 , Ljiljana Mihić 1 and

Tanja Petrović 1

1 Department of Psychology, Faculty of Philosophy, University of Novi Sad, Serbia

ABSTRACT

The purpose of this pilot study was to test the efficacy of a novel self-help program

called Attention training (AT) based on the mindfulness-acceptance principles in a

sample of dysphoric students. We tried to determine if the program: a) contributed to

immediate and follow-up changes in the presumed components and mechanisms of

mindfulness-acceptance - psychological flexibility, attention control (switching and

updating), and rumination; b) was followed by a reduction in dysphoric symptoms; c) had

different effects depending on a different order of exercises within AT. The final sample

consists of 18 students from the University of Novi Sad, 19-29 years old with mild and

moderate depression (selected through pre-screening procedure). Data were collected

at 4 measurement occasions: before the first group meeting (pretest), right after

completion of all exercises (posttest), and two follow-ups - one and three months post-

treatment. AT consisted of 8 small-group, weekly meetings (up to 5 persons and < 90

minutes of overall therapist support). Participants listened to the audio-recorded

exercises that targeted the somatic, emotional, and cognitive domains. The sample was

randomly split into two groups with a different order of the emotional and cognitive

exercises. We found that AT, as a self-help intervention, can potentially lead to

improvements in the mindfulness components and mechanisms, even though an

increase in the depressive symptoms was noticed. Different explanations were provided

for such findings, including suggestions for further optimization of the program and

recommendations for further research.

Keywords:

self-help, attention training, mindfulness-acceptance, ruminations, dysphoric

symptoms

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UDC: 616.89-008-057.875:615.851

DOI: 10.19090/pp.v15i4.2396

Received: 08.03.2022.

Revised: 26.03.2022.

Accepted: 18.10.2022.

This is an open access article distributed

under the terms of the Creative Commons Attribution

License, which permits unrestricted use, distribution, and

reproduction in any medium, provided the original author

and source are credited.

 Corresponding author email: tovilovic@ff.uns.ac.rs

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Introduction

According to the WHO reports, depression contributes largely to the

overall burden of disease in a number of countries across the globe

(https://www.who.int/news-room/fact-sheets/detail/depression). Depression is

a heterogeneous mental condition symptom-wise and regarding its age at onset.

It can start in childhood, adolescence, or different adulthood periods (Zisook et

al., 2007). Earlier age at onset is associated with a number of clinical indicators

such as severity, chronicity, mental and physical co-morbidity, suicide risk, and

dysfunctionality (Zisook et al., 2007). Hence, early intervention might preclude

development of more serious, clinical types of depression. Addressing

depression in a timely manner is particularly important given the fact that the

rates of depression in young people, such as students, tend to be high (e.g.,

24.4%; Akhtar et al., 2020). A number of evidence-based therapies exist currently

that can ameliorate this condition. Within the past two decades so called third

wave of behavior and cognitive therapies have been popularized owing to their

scientific background and empirical support. For example, Mindfulness-based

cognitive therapy (MBCT; Segal et al., 2013) and Acceptance and commitment

therapy (ACT; Hayes et al., 1999) are examples of therapies that emphasize

mindfulness and acceptance, respectively. Both therapies are multi-component

interventions that require substantial resources in terms of education of

therapists, their availability, and affordability (Cavanagh et al., 2014). It has been

suggested that provision of mindfulness and acceptance interventions in a self-

help format (e.g., via books, audio-visual material) could be an effective way to

address the problem of insufficient resources (Cavanagh et al., 2014). Also,

research results suggest larger effects for guided (some contact with a therapist)

than unguided self-help interventions (e.g., Cavanagh et al., 2014; Gellately et al.,

2007). Hence, self-help seems an attractive option, especially for low- and

middle-income countries (Novović et al., 2019), and for those people whose

symptoms have not yet reached the alarming threshold. One challenge while

adopting any multi-component therapy to a self-help format is what

component(s) to select and in what order to provide these components in order

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to assure efficacy of the self-help format. Hence, the main focus of the current

study was creation of mindfulness-acceptance self-help intervention targeting

young people with mild to moderate depression symptoms. By reviewing what

is known currently about the components and mechanisms of mindfulness and

acceptance interventions, we wanted to select the components that were

deemed both suitable for self-help format and empirically supported so far.

Mindfulness/acceptance: definition and components

Mindfulness is defined as “paying attention in a particular way, on

purpose, non-judgmentally, to the present moment” (Kabat-Zinn, 1994, pp. 4).

This particular way of paying attention to the present moment is fostered

through various exercises including meditation, body scanning, and breathing

(Kabat-Zinn, 1994). In order to attain beneficial effects, a person doing

mindfulness exercise needs to bring another component into play, an attitude of

openness and acceptance even when facing uncomfortable internal events

(Bishop et al., 2004). The person learns to be a non-judgmental observer of inner

experiences rather than his/her own harsh critic (Kabat-Zinn, 1990). Mindfulness,

defined in this manner, is a crucial component of MBCT. During the initial stages

of this structured group therapy, individuals learn to observe their “automatic

pilot” i.e., a tendency to follow their wandering mind unquestionably and

respond automatically without considering a possibility that there is another,

more functional response (Segal et al., 2013). In order to switch from this

automatic to a new, so-called, “being” mode of functioning, during initial phases

of the treatment, MBCT participants are taught various exercises such as body

scan, yoga, breathing space, and acting mindfully during everyday activities

(Segal et al., 2013).

Mindfulness has been an integral part of ACT from its inception, even

though the creators of this therapeutic approach used different terminology to

describe it. Namely, the main goal of ACT is to build psychological flexibility (PF)

(Hayes et al., 1999; Hayes et al., 2004). PF is defined as “the ability to fully contact

the present moment and the psychological reactions it produces as a conscious

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person and to persist or change behavior in the situation in the service of chosen

values'' (Fletcher & Hayes, p. 319). According to Hayes et al. (1999), PF is a result of

activation of the following processes: acceptance, defusion, contact with the

present moment, self-as-context, values, and committed action. The first four

components are actually mindfulness components (Fletcher & Hayes, 2005).

Hence, mindfulness, according to ACT, encompasses the following abilities: to

observe internal events as passing objects in our awareness without a need to

struggle with them, to be willing to accept own experience as it is without a

need to change it, to focus attention to the present moment, and to change a

self- perspective (i.e., to free oneself from learned conceptualizations about the

self which are often highly evaluative) (Fletcher & Hayes, 2005). Different from

MBCT which is fairly structured and begins by teaching people how to focus

attention to the present moment through more formal mindfulness practice,

ACT relies more on shorter and less formal mindfulness exercises including an

abundant use of metaphors (Segal et al., 2013; Hayes et al., 2004). Additionally,

ACT is more flexible in terms of order of interventions and argues that

therapeutic work can start from any component constituting psychological

flexibility, depending on the actual client (Hayes et al., 2004). However, both

therapies have a solid evidence base for their efficacy in currently depressed

individuals (for meta-analytic reviews see Goldberg et al., 2019 and Gloster et al.,

2021).

Ruminations as a mechanism of action

One unresolved question in the literature is via which mechanisms the

different components of mindfulness-acceptance lead to better subjective well-

being (Shapiro et al., 2006; Wolkin, 2015). It seems that the proponents of MBCT

and ACT converge in their thinking about this issue. They seem to argue that

being caught in a web of one's own thinking leads to an unhealthy habit of our

mind called ruminations (Segal et al., 2013; Hayes & Smith, 2005). Hence, in

addition to fostering mindfulness-acceptance skills as a way of alleviation of

human suffering, MBCT and ACT rely on the assumption that they exert their

effects, at least partly, by decreasing depressive ruminations (Desrosiers et al.,

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2013; Perestelo-Perez et al., 2017; Ruiz et al., 2016; Segal et al., 2013; van der Velden

et al., 2015; Wolkin, 2015). Depressive ruminations represent a form of cognitive

overinvolvement i.e., a form of repetitive thinking about the possible causes and

consequences of one’s negative mood (Nolen-Hoeksema, 1991). The deleterious

effects of depressive ruminations on mood stem not so much from a focus on

the negative affect (Lyubomirsky & Nolen-Hoeksema, 1995), but from the

judgmental and evaluative nature of self-focused attention (Rude et al., 2007).

Components and mechanisms of the self-help program

MBCT and ACT served as the main forms of the mindfulness-acceptance

interventions from which we wanted to build a self-help program targeting

dysphoric students. Even though the descriptions of the main processes in these

two approaches differ, it seems that both emphasize, at least, the following

components of mindfulness-acceptance: attentional skills, body awareness,

emotional regulation (e.g., exposure, non-avoidance), and adopting a stance of

an impartial observer of one’s inner experiences as passing mental events (Hölzel

et al., 2011). According to some authors, building attentional skills is a starting

point which fuels and propagates other mindfulness-acceptance components

(Carmody, 2009; Chiesa & Malinowski, 2011; Hölzel et al., 2011). So, focusing

attention on a particular stimulus and re-focusing it when it wanders away could

be a prerequisite for further change. Also, research supports the view that

attentional skills are one important component of mindfulness (Brown & Ryan,

2003; Hölzel et al., 2011; Lutz et al., 2008; Malinowski, 2013; Verhaeghen, 2021). In

accordance with this literature and views, the initial phase in our self-help

program included exercises that required focusing attention on one’s body and

its sensations. Participants were asked to focus on their breath, then they were

guided to expand their awareness to include the whole body. Hence, this type

of exercise requires a combination of attentional faculties: ability to focus on a

particular object, ability to redirect attention once it wanders, and ability to

notice all internal experiences as they appear (Sumantry & Steward, 2021; Wolkin,

2015). Given the complexity of the attentional skills and the type of mindfulness

exercises our participants practiced, we expected to find effects on updating

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and switching (Huizinga et al., 2006; Miyake et al., 2000; Miyake & Friedman,

2012). Updating and switching represent those aspects of executive control

responsible for constant updating of working memory for relevant information

and shifting from one stimulus to the next (Miyake et al., 2000). Additional

components of the mindfulness-acceptance interventions that were included in

the self-help program included emotional regulation (acceptance, exposure) and

the cognitive component (decentering or defusion). Acceptance represents an

emotional regulation strategy and willingness to experience internal events, as

they appear and when they appear, without a need to avoid or modify them in

the service of valued life (Hayes et al., 1999). Others defined non-acceptance as

having negative reactions to negative emotions (Gratz & Roemer, 2004).

Decentering and defusion are the constructs developed within MBCT and ACT,

respectively. A common theme for these two constructs is the ability to observe

one's own thoughts as passing mental events which can free a person from an

unhealthy habit of identification with thought content (Hayes et al., 2004).

Although there is some agreement on what components constitute

mindfulness-acceptance, we still do not know much about their interaction, if

there is a particularly effective order of their implementation, generalizability,

cost-effectiveness, and optimization. Other than the suggestion that the first

step during practice should be cultivating attentional skills, it is an open question

what component should come next. Hence, we wanted to check whether the

order of exercises (emotion-focused followed by cognitive exercises, or vice

versa) matters in terms of the size of effects and sustainability of the effects. If

we knew in more detail how mindfulness works, we would be closer to targeted

interventions and could provide better training program optimization. This is

especially important when it comes to self-help programs, which are economical

forms of assistance that could be effective surrogates for longer-term programs.

Purpose of the study

In order to start answering some of these questions, we designed a

guided mindfulness-acceptance self-help program termed “Attention training”

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(AT). Even though the program included exercises focusing on the body,

emotions, and cognition, the term AT was used to highlight the importance of a

non-judgmental kind of attention while focusing on different domains (body,

emotions, or cognition). We examined whether significant changes could be

achieved with a minimum participation of trainers, in a sample of dysphoric

students. We explored if AT has positive effects on the processes of attention

(switching and updating) and psychological flexibility, on the one hand, and

ameliorating effects on ruminative thinking and the symptoms of depression, on

the other. Changes were explored immediately upon completion of the program

and at two follow-ups. In order to gain an insight into the question of whether

the order of different mindfulness-acceptance components matters, two groups

of students were recruited receiving a different order of exercises (body,

emotion, cognition vs. body, cognition, emotion). Finally, this study can be

considered a pilot study. It is a recommendation that this type of study is

conducted first, as an initial step, while testing the efficacy of new interventions

or while assessing a possibility for a successful implementation of a novel

program despite a small number of subjects (e.g., Leon et al., 2011; Tickle-Degnen,

2013).

Methods

Sample

The initial sample consisted of 22 participants, but after the exclusion of

those with incomplete data, 18 were kept for further analyses. All participants

were students from the University of Novi Sad, 19-29 old (

age = 22. 95;

= 3.06;

59% males) who were selected based on a pre-screening with the Patient Health

Questionnaire-9 (PHQ-9; Kroenke et al., 2001). The students were invited via

online posts that were shared across various social groups. The students that

scored over the cut-off 4 and under 15 (mild and moderate depression; Kroenke

et al., 2001) were invited for further evaluation. Two clinical psychologists

interviewed 60 preselected participants using the DIAMOND - a semi-structured

diagnostic interview for the DSM-5 psychiatric disorders (Tolin et al., 2013) to

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exclude those that had other disorders and suicidal ideation and tendencies. The

excluded participants were informed about other treatment options. This study

was approved by the Ethical Board of the Faculty of Philosophy, University of

Novi Sad. All participants signed informed consents and received feedback upon

completion of the study.

Materials

All instruments were administered 4 times: just before the first group

meeting (pretest), following completion of all exercises (retest), one- and three-

months post-treatment. A depression screening instrument was used during

recruitment, one month before the program commenced. Its subsequent

administrations followed the same timing as the rest of the instruments.

Mindfulness-acceptance scales:

The Acceptance and Action Questionnaire

(AAQ; Bond et al., 2011) is a

self-report measure of psychological inflexibility or the tendency to avoid

distressing internal experiences (e.g., thoughts, emotions, somatic symptoms),

and to become entangled with the web of own thoughts. We used an 8-item

version of the instrument because it was successfully used in previous research

with different Serbian populations - Cronbach α = .82 - .85 (Kovač, 2014; Lazić et

al., 2013; Stamenić, 2013). A higher score indicates greater inflexibility.

The Ruminative Thought Style Questionnaire

(RTSQ; Brinker & Dozois,

2009) is a 20-item measure describing positive, negative, and neutral facets of

global rumination. Respondents rated each statement on a 7-point Likert scale.

In the previous studies, the RTSQ demonstrated high internal consistency of .94

(Mihić et al., 2019).

Two cognitive control tasks, adapted from Miyake et al. (2000), measuring

switching (Local-global) and updating (Letter memory) were used (Purić, 2013):

In the

Local-global task

Navon figures, consisting of larger, global

geometric figures made of the same smaller ones, were presented in three

blocks. Figures in black and red were depicted in the first and second blocks,

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respectively. Participants were asked about the number of lines that constitute

a bigger shape in the first and a smaller one in the second block. In the third

block, red and black figures were presented interchangeably, and the task was

to indicate the number of lines in local or global shapes depending on the color.

The deterioration of performance in the third block in regard to the average of

the first two blocks represents the cost of switching. It is presented in seconds,

and lower results indicate poorer switching.

The

Letter memory task

consists of 12 lists of letters of different lengths

while the task was to reproduce the last four presented letters in each list. The

measure of updating is the proportion of correctly reproduced letters in all lists.

Better updating goes with higher results.

Depression - The Patient Health Questionnaire - 9 (PHQ-9; Kroenke et al., 2001)

The Patient Health Questionnaire - 9

(PHQ-9; Kroenke et al., 2001) is a 9-

item measure designed to assess the symptoms of depression according to

DSM-IV criteria. Respondents were asked to rate how often they were bothered

by each symptom over the past 2 weeks on a scale from 0 (

almost never

) to 3

(

almost every day

). Cronbach’s α in Kroenke et al.’s study was 0.89 (2001).

Procedure

The self-help program commenced one month following the initial

screening. The training consisted of 8 small-group weekly meetings (up to 5

persons and < 90 minutes of overall therapist support) during which participants

listened to the audio-recorded exercises. The program was delivered within one

month, after which participants were contacted one month and three months

for follow-ups. The sessions were followed by brief instructions related to

practice and potential obstacles during home-based training. There were three

sets of exercises that targeted somatic, emotional, and cognitive domains, and

each set was covered by two exercises. The final two exercises represented an

integration of previously practiced components. The sample was randomly split

into two groups in which the order of emotional and cognitive exercises was

reversed, while the somatic and integration parts were fixed as the first and last

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tasks, respectively. Therefore, we had an Emotion-first group (n = 8) (body-

emotion-cognition-integration order), and a Cognition-first group (n = 10) (body-

cognition-emotion-integration order) (Figure 1).

Figure 1. The order of exercise domains in the two groups.

The body awareness part

consisted of initial mindfulness exercises where

participants learned how to focus on their body, body sensations, and sensory

experiences of breathing. The idea was to develop an awareness of what is

happening to them in the present moment and to slowly return attention to their

body and breathing if their attention wandered.

The emotional part

consisted of emotional regulation exercises.

Participants were instructed to focus on their strong emotions and approach

them in a non-judgmental and accepting way. The goal of these exercises was

not to free a person from some emotions but to let them into the field of

consciousness without fighting and resisting, with a stance of openness and

interest.

The goal of exercises in

the cognitive part

was to observe thought

contents in a particular way. A person learned to treat his/her thoughts as

transient contents within a larger context of awareness, without attachment or

resistance (like leaves floating down a river).

The integrative part

included a combination of exposure to different

sensations, emotions, and thoughts that were present in the field of

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consciousness. Participants were encouraged to remain curious and open to

everything they experienced, whether it was a pleasant or an unpleasant

experience. The idea was to take that openness (mindfulness) and transfer it to

other situations in life.

Analyses

Five profile analyses were used to assess immediate and follow-up

changes due to our program on a set of dependent measures. The two groups

with different exercise orders represented an independent variable. Profile

analysis was chosen because it enabled us to test the following:

1. Whether psychological inflexibility, rumination, executive functioning,

and depression symptoms changed from one measurement occasion to

the next, independent of the groups. In profile analysis, this is known as

the “flatness hypothesis” (i.e., were the profiles flat or were there

differences from one time-point to the other). A significant multivariate

test of the within-subjects effect suggests that a profile was not flat.

2. Whether, on average, the two groups differed in their overall

achievements on each dependent measure, which is known as the “levels

hypothesis”. A significant between-subjects effect would suggest that

the groups differed.

3. Whether the groups had a similar or different pattern of changes on a

set of dependent measures over the course of the training and follow-

ups. This is known as the test of “parallelism”. A significant multivariate

effect of the time x group interaction would indicate that the profiles

were not parallel.

A rejection of the flatness hypothesis was followed by the t-tests with

Bonferroni correction to reveal if the differences between the first and the three

after-treatment measurements were significantly different and whether the

changes were sustained during follow-ups. A significant test of the parallelism

was followed by the tests of the simple main effects.

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Our data met all assumptions necessary for profile analysis. First of all,

there were more participants in the smallest cell than dependent variables, so

although the sample was small, we didn’t violate the recommended rule. As can

be seen in Table 1, skewness and kurtosis for all variables were within the

appropriate range (skewness between -2 to + 2 and kurtosis between -7 to + 7)

(Byrne, 2010; Hair et al., 2010). The skewness value for Switching was slightly

above the threshold, which can be considered a mild departure from normality.

None of the Box`s M tests was significant at

< .001 (Tabachnick & Fidell, 2007).

Results

Descriptive statistics

The two groups did not differ in their initial levels of depression,

ruminations, psychological flexibility, updating, switching, and overall home

practice after each session (Table 1). As can be seen, participants in both groups

experienced mild depressive symptoms at the beginning of the program. A table

of correlations among the measures across four measurements can be found in

Appendix A. As can be seen, the majority of variables displayed an expected

pattern of correlations given the previously cited literature. Also, increases in the

correlations were observed at three-month follow-up probably due to an

increase in the level of depression and its variability.

After the training, during debriefing, a majority of participants reported

that involvement in the program was a pleasant experience (95%) and that they

mostly did not experience a decrease in mood (73%). Out of those who

experienced mood worsening, only 1 participant attributed these changes to the

program. All participants declared that they would recommend the training to

their friends and acquaintances, and 83% accepted participating in a group

therapy that was offered after AT to those who were willing to continue their

self-exploration.

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Table 1

Descriptive statistics for two groups and the total sample: pretreatment values

Emotion

Cognition

Total

(16)

M (SD)

(

)

M(SD)

Depression

7.25

8.10

7.72

0.72

.48

1.15

1.43

(1.83)

(2.88)

(2.44)

Ruminations

72.50

71.30

71.83

0.14

.89

0.19

-1.13

(18.36)

(18.81)

(18.07)

Psy. inflexibility

31.25

29.70

30.39

0.38

.71

0.64

-0.66

(8.71)

(8.56)

(8.41)

Updating

.73

.65

.69

1.49

.16

-0.14

-0.59

(.09)

(.12)

(.11)

Switching

580.76

-576.23

-578.24

0.03

.97

-2.57

6.81

(362.31)

(200.97)

(274.32)

Home practice*

28.37

23.10

25.44

0.75

.47

1.32

(16.13)

(13.78)

(14.66)

Note.

* Home practice = overall time (hours) spent in home practice across the duration

of Attention training; Emotion = Emotion-first group; Cognition = Cognition-first group.

Did the participants improve on a set of dependent measures after

the treatment - flatness analysis?

In Table 2 one can see that all variables departed from the flatness

hypothesis suggesting that there were changes across different time points,

independently of the group effects (large effects). The profiles of these variables

across time are presented in Figures 2-6, solid lines. Their means are given in

Appendix B (rows titled Total C+E).

The tests of flatness were followed by the t-tests with Bonferroni

corrections (Appendix B), which suggested that from the pre-test to the post-

test, the participants’ scores on inflexibility and ruminations decreased (Cohen’s

= 0.84 and Cohen’s

= 0.91, respectively), whereas their scores on switching

and updating increased (Cohen’s

= 0.53 and Cohen’s

= 0.48, respectively).

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These changes remained at one-month and three-month follow-ups. On the

other hand, the depression scores increased at the post-test (Cohen ’s

= 1.78)

and remained such at the follow-ups.

Table 2

Results of profile analyses for all dependent variables

Flatness

Within-subjects effects

Levels

Between-subjects

effects

Parallelism

Main interaction

effects

(3,14)

Hott.

(1,16)

(3,14)

Inflexibility

6.62

.01

1.42

.59

2.66

.12

.14

2.34

.33

.67

.33

Rumination

4.71

.02

1.01

.50

1.97

.18

.11

4.73

.02

.50

Switching

7.55

.00

1.62

.62

0.03

.85

.00

0.17

.92

.97

.04

Updating

4.30

.02

0.92

.48

1.56

.23

.09

1.28

.41

.82

.18

Depression

14.94

.00

3.20

.76

6.64

.02

.29

1.40

.28

.77

.23

Did the two treatment groups differ in their overall levels of the

dependent measures?

From Table 2 (Levels column) and Appendix B (column Total 1-4) one can

see that the Cognition-first group had higher overall depression symptoms,

averaging across the four measurement occasions, compared to the Emotion-

first group (large effect). From Figure 6, it can also be seen that this difference

was mainly due to an additional rise of the symptoms in the Cognition-first group

after three months from the end of the program. There were no additional

differences between the two groups.

Is there a different pattern of changes across four measurements

between the two treatment groups?

The Time x Group interaction effect was significant only for ruminations

(Table 2, parallelism column). As can be seen in Figure 3, there was a different

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pattern of changes in ruminations over time between the two groups. The tests

of simple main effects revealed that within the Emotion-first group, at one-

month and three-month follow-ups there were significant drops in ruminations

compared to pre-test (mean differences =27.5 for both comparisons,

= 7.71

and

= 7.95 respectively, 95% [

]4.06-50.44, and [3.31-51.19], respectively,

.02 for both comparisons; Cohen’s

= 1.20). In the Cognition-first group, the levels

of rumination remained stable across the four time points.

Figure 2. Inflexibility means at 4 time-

points in groups with different order and

in the whole sample.

Figure 3. Rumination means at 4 time-

points in groups with different order and

in the whole sample.

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Figure 4. Updating means at 4 time-points

in groups with different order and in the

whole sample.

Figure 5. Switching means at 4 time-

points in groups with different order and

in the whole sample.

Figure 6. Depression means at 4 time-

points in groups with different order and

in the whole sample.

Discussion and conclusion

The aim of the present study was to test the efficacy of the novel self-

help Attention Training (AT) program based on the acceptance/mindfulness

principles. This program was created with an aim to help dysphoric students to

improve their attention and to accept their unpleasant thoughts and emotions

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in a non-judgmental way. We wanted to determine whether the program targets

and changes basic components and processes considered to underlie

mindfulness - psychological flexibility, rumination tendencies, and executive

functions (e.g., Hölzel et al., 2011; Levin et al., 2012; Lutz et al. 2008; Malinowski,

2013). We also followed these processes one and three months after finishing AT.

The second goal of our study was to explore whether the order of

different types of exercises mattered. Previous research suggested that directing

attention to the body is an important introductory component of attention

training (e.g., Verhaeghen, 2021; Hölzel et al., 2011), but we were interested in

seeing what happens next while practicing emotional and cognitive exercises in

a different order. In particular, we wanted to see if accepting emotions, as a first

step, can help one to deal better with ruminations and to become less entangled

in negative thinking. If, on the other hand, the reversed order would be more

effective, one could argue that decentering, defusion, and other cognitive

changes should take precedence over emotional regulation. Finally, we were

interested in the sustainability of the changes three months after the end of the

program.

Did the participants improve on a set of dependent measures

after the treatment?

Regarding our first question about efficacy, overall, our participants over

time demonstrated improvements on all dependent measures, with the

exception of the depression symptoms. They became more psychologically

flexible, less prone to ruminative thinking, and became more flexible in their

attentional capacities over the course of the program. These positive changes

were relatively stable showing that participants accepted the trained virtues of

regulating their inner contents, thoughts, and emotions. The changes observed

on psychological flexibility, ruminations, and attentional skills are in accordance

with other research findings (Hayes et al., 2006; Jain et al., 2007; Verhaeghen,

2021), suggesting that practicing mindfulness-acceptance in a self-help form can

increase acceptance, distancing from one’s own biased thinking, and attentional

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skills. There was a possibility that the improvement on attentional tasks, such as

Navon’s test, was a result of repeated testing rather than being a substantial

effect of the exercises that were practiced in AT. Because we did not have a

control group, we could not have excluded this possibility. On the other hand,

we observed that the pattern of changes may allow for additional explanations.

Namely, the largest change was between the pretest and posttest, which were

one month apart. The scores from the two follow-ups were relatively unchanged

compared to the second testing. One would expect greater improvements

during the follow-ups due to practice.

What happened with the depression symptoms? These symptoms

showed an increase over the course of the program and one and three months

after the program as measured by the PHQ-9. Different explanations can be

offered for this finding. One plausible explanation is that participants became

better at accepting and regulating their moods, which resulted in easier and

more honest reporting of inner states. According to the ACT theory, the

reduction of symptoms is not the basic goal and necessary effect of the applied

interventions, but the acceptance of one's sensations, emotions, and thoughts.

It is possible that the increase in the symptoms is an expression of increased

emotional acceptance and cognitive defusion instead of earlier emotional and

cognitive control. Some unpleasant feelings or symptoms may be present (non-

reduced), but their presence does not have a negative impact on general

improvement (Hayes et al., 2004).

The data that are in line with this explanation were obtained during

feedback from the participants. Namely, with only one exception, the

participants stated that the program was a useful experience for them, and 83%

expressed a desire to continue personal progress through an additional group

training program that was offered to them in the end. These findings could

reflect their openness to experience and acceptance, which includes even

unpleasant emotions. For example, in one study with individuals with panic

disorder, people who practiced acceptance, as opposed to suppression,

demonstrated a greater acceptance of unpleasant panic sensations and greater

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willingness to repeat the unpleasant situation of panic induction even though

the level of their panic symptoms remained unchanged and high (Levitt et al.,

2004). However, we can also speculate that some systematic factors, which

were not controlled in this study, had influenced the mood of students,

especially at two follow-ups which happened in the autumn (e.g., the beginning

of the semester, exam deadlines, the end of summer, etc.).

In contrast to the results of the PHQ-9, all participants, except one, did

not endorse that they felt more depressed when they were asked about their

mood during debriefing sessions right after the program. This contradicting

results from two self-reports about mood may be a consequence of the fact that

some symptoms as measured by the PHQ-9 (e.g., problems with concentration,

fatigue, sleep problems) could be an expression of students’ lifestyle rather than

depression symptoms (Novović et al., 2011; Janičić et al., 2019). Also, we should

take into consideration the possible adverse effects of mindfulness. Namely,

some authors previously reported mood worsening in some participants and

have suggested that we need to identify those individuals at risk of experiencing

adverse effects (Britton, 2019). In our study, we also had one reported case of

mood worsening attributed to the mindfulness-acceptance exercises.

Overall, our preliminary findings seem to suggest that the components

of AT training can have positive effects on the mindfulness-acceptance variables

and process, however, a better understanding of its effect on depression is

needed. Given inconsistent findings on two self-reports, future work on

optimization of this training should consider additional components that would

address even more emotional regulation. Also, more suitable instruments

targeting negative mood in the student population are recommended as well as

those tapping functionality, quality of life, and well-being.

Did the two treatment groups differ in their overall levels of the

dependent measures?

The two examined groups, Emotion-first, and Cognition-first groups did

not differ in their overall levels of psychological flexibility, ruminations, and

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attentional capacities, but only in their levels of depression (Figures 2-6). The

Cognition-first group, when considering all four measurement occasions,

demonstrated larger depression scores. It is noteworthy that in this group the

largest increase in the depressive symptoms was three months after the

program, which is probably attributed to some external factors not related to

the program. Unfortunately, we did not measure life events during and after the

training, and also we did not have a control group which could have served as a

baseline for comparison. Hence, future research, by addressing these limitations,

will be in a better position to explore whether the observed changes in

depressive symptoms in these types of programs result from a less avoidant

attitude towards emotions, whether they are prerequisites of change, or are

the results of life events unrelated to the self-help interventions. Even though

the only significant difference between the two groups was on the measure of

depression, one can see that the Emotion-first group performed better on all

mindfulness/ acceptance measures. If we had a larger sample size, these

differences could have become significant, and one could claim with more

certainty that emotional regulation (acceptance of negative emotions) should

precede cognitive interventions within the AT program intended for dysphoric

students. Also, the finding that the Emotion-first group over treatment

experienced greater decreases in ruminations compared to the Cognition-first

group might explain lower depression symptoms in this group.

Is there a different pattern of changes across four measurements

between the two treatment groups?

Finely, we revealed that there was a different pattern of changes at four

time points in the Emotion-first and Cognition-first groups regarding

ruminations. Although both profiles had a downward trend, only the Emotion-

first group really benefited from the training, especially at follow-ups, achieving

better improvement one and three months after the AT program. This result can

be seen as an indication of different change patterns or pathways of

improvement during AT. It seems that emotional change takes precedence: first

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emotional acceptance, then cognitive change. Combined, our results suggest

that practicing emotional regulation earlier in this treatment might have

contributed to the development of greater acceptance and less entanglement

with inner experiences through exposure and decreased reactivity to feelings. It

seems that thought patterns (the process of cognitive defusion) are more

susceptible to change if the barrier of emotional avoidance or emotional control

is removed.

Limitations

The major limitations of this study were a lack of a control group, a small

sample size, and unavailability of information regarding life events during the

training and follow-ups. Also, it would be useful to have a more detailed record

of daily practice which would include not only an overall estimate of daily

practice but what specific exercise was practiced in a given time period. We did

not have information about the amount of practice after the program ended. We

recognize that one important factor in maintaining the effects of the program is

the persistence of respondents in practicing the learned exercises, and it would

be important to monitor how long and how often program participants

continued to apply exercises after the program.

Strengths and directions for future research

This pilot study was the initial step in exploring AT as an efficient self-

help intervention for dysphoric students. It provided us with an insight into how

to optimize its delivery in terms of the order of interventions. One strength of

our study was a very careful selection of participants using a structured clinical

interview so that those with subthreshold depression symptoms could be

detected and invited to participate. It is known that such symptoms often go

unrecognized even though they can significantly affect the academic

achievement and quality of life of students. Also, we ruled out the possibility

that our findings were confounded by the effects of previous depressive

episodes and other comorbid diagnoses (e.g., personality pathology, psychosis,

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bipolar disorder). An additional strength of the study was the inclusion of one-

and three-month follow-ups which allowed us to gain a more detailed insight

into the maintenance of the achieved effects. We can also formulate

recommendations for further research. For example, how lasting are the changes,

and what factors contribute to their maintenance? The answer to this question

requires longer monitoring of study participants with control of factors that

could contribute to the permanence of the effects.

The next research question refers to the possibility of applying AT in

other problem areas and difficulties that are important for the student

population. In particular, can the program have positive effects on the reduction

of anxiety, which, in addition to depression, is a frequent disruptive factor in

students' academic achievement and life satisfaction? Is there a specific impact

on worry, somatic anxiety and social anxiety? The effect of the program on some

behavioral problems, such as procrastination and other patterns of avoidant

behavior typical of the student population, can also be examined. The question

is whether the pattern of change (emotional change first followed by cognitive

change) that we found in this study can generalize to other problem areas.

Future research should include and monitor not only the symptom reduction

measures, but also measures of subjective well-being, positive affectivity, and

general functionality. It is necessary to include control measures such as

significant life events, where it would be important to examine their possible

impact, but also whether the impact of adverse life events can be lessened

through the application of exercises learned during AT.

Funding

This research received no specific grant from any funding agency in the public,

commercial, or not-for-profit sectors.

Conflict of Interests

We have no conflicts of interest to disclose.

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Data availability statement

Data is available from the authors upon request.

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Appendix A

Table A1

Correlations among DVs at the pre-test

1. Psychological flexibility

2. Ruminations

.421

3. Depression

.165

.454

4. Updating

.046

-.243

-.285

5. Switching

-.260

-.317

.102

.117

Table A2

Correlations among DVs in the post-test

1. Psychological flexibility

2. Ruminations

.371

3. Depression

.351

.461

4. Updating

-.254

.068

.130

5. Switching

-.238

-.054

.056

.038

Table A3

Correlations among DVs in 1 month follow up

1. Psychological flexibility

2. Ruminations

.491*

3. Depression

.280

.246

4. Updating

.214

.021

.151

5. Switching

-.546*

-.240

.132

-.014

Note

. * – Correlation is significant at the 0.05 level (2-tailed).

Tovilović et al.

PP (2022) 15(4), 473-506

504

Table A4

Correlations among DVs in 1 month follow up

1. Psychological flexibility

2. Ruminations

.627**

3. Depression

.689**

.424

4. Updating

-.033

-.102

-.046

5. Switching

-.375

-.292

-.098

-.003

Note.

** – Correlation is significant at the 0.01 level (2-tailed).

PP (2022) 15(4), 473-506

Mindfulness-Acceptance Self-Help Intervention for

Dysphoric Students

505

Appendix B

Table B

Means, standard deviations, and pairwise comparisons of measurements at four time

points

Total and group Ms and SEs

at 4 measurements

Pairwise comparisons with

Bonferroni correction

Total

1-4

1-2

1-3

1-4

Inflexibility

TotalC+E

30.38

(8.41)

25.00

(7.88)

23.28

(7.11)

23.89

(8.50)

3.58

.01

4.72

.001

2.68

.10

Cognition

first

29.70

(8.56)

28.20

8.43

25.00

7.51

27.70

8.94

27.65

Emotion

first

31.25

8.71

21.00

5.15

21.12

6.38

19.12

5.11

23.12

Rumination

TotalC+E

71.83

(18.07)

54.44

(15.45)

55.17

(18.84)

53.50

(16.58)

2.92

.05

3.03

.04

3.33

.02

Cognition

first

71.30

(18.81)

55.40

(12.59)

63.10

(15.47)

60.10

(11.68)

62.48

Emotion

first

72.50

(18.36)

53.25

(19.32)

45.25

(18.76)

45.25

(18.76)

54.06

Switching

TotalC+E

-578.24

(274.31)

-424.53

(154.28)

-408.48

(181.58)

-383.66

(108.43)

3.83

.008

5.07

.001

3.87

.008

Cognition

first

-576.23

(200.07)

-415.56

(166.84)

-394.09

(126.28)

-383.79

(126.76)

-442.41

Emotion

first

-580.76

(362.31)

-435.77

(147.52)

-426.46

(242.70)

-383.50

(88.84)

-456.62

Updating

TotalC+E

.69

(.11)

.76

(.13)

.79

(.12)

.76

(.14)

1.91

.08

3.22

.005

1.92

.07

Cognition

first

.65

(.12)

.74

(.13)

.77

(.13)

.73

(.14)

.72

Emotion

first

.73

(.09)

.78

(.13)

.82

(.12)

.80

(.15)

.78

Depression

TotalC+E

7.72

(2.88)

12.33

(2.28)

10.78

(1.90)

12.56

(3.81)

5.48

.000

3.61

.01

5.23

.000

Tovilović et al.

PP (2022) 15(4), 473-506

506

Cognition

first

8.10

(2.88)

12.80

(2.74)

11.30

(2.26)

14.30

(4.37)

11.63

Emotion

first

7.25

(1.83)

11.75

(1.49)

10.12

(1.13)

10.37

(0.92)

9.87

Notes.

1 – pretest, 2 – posttest, 3 – one month follow-up, 4 – three months follow up.

TotalC+E = means for both groups at each time separately; Total1-4 = means of each group

separately for all time measurements.