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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.
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 (
M
age = 22. 95;
SD
= 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
p
< .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
t
(16)
p
Sk
Ku
M (SD)
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
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
d
= 0.84 and Cohen’s
d
= 0.91, respectively), whereas their scores on switching
and updating increased (Cohen’s
d
= 0.53 and Cohen’s
d
= 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
d
= 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
F
(3,14)
p
Hott.
T
η
2
F
(1,16)
p
η
2
F
(3,14)
p
W.
Λ
η
2
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
.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,
SE
= 7.71
and
SE
= 7.95 respectively, 95% [
CI
]4.06-50.44, and [3.31-51.19], respectively,
p
=
.02 for both comparisons; Cohen’s
d
= 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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Mindfulness-Acceptance Self-Help Intervention for
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Appendix A
Table A1
Correlations among DVs at the pre-test
1
2
3
4
5
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
2
3
4
5
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
2
3
4
5
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
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Table A4
Correlations among DVs in 1 month follow up
1
2
3
4
5
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).
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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
1
2
3
4
t
p
t
p
t
p
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
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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.