Applications and Adaptations of Acceptance and Commitment Therapy (ACT) for Adolescents.

Blackledge, J., & Hayes, S. (2006). Using Acceptance and Commitment Training in the Support of Parents of Children diagnosed with Autism. Child and Family Behavior Therapy, 28(1), 1-18. doi: 10.1300/J019v28n01_01

Blackledge and Hayes (2006) investigated the effectiveness of a 2-day (14 hour) group format Acceptance and Commitment Therapy (ACT) intervention on the depression and distress of parents and caregivers of children with a autism diagnosis. The intervention was presented as a supportive and collective experience to assist parents and caregivers with better methods to cope with the difficulties and stress associated with supporting an autistic child. The authors aimed to evaluate the effectiveness of the ACT intervention with participants being recruited from 3 differing geographical regions in an intent to attain the common mainstream of parents in this particular situation. The study consisted of self-report instruments measuring therapeutic mechanisms of change and outcomes in depression, distress, and perceived control over their children’s behaviour. ACT-specific concepts were measured using the Acceptance and Action Questionnaire-9-item version (AAQ), which measures experiential avoidance, cognitive fusion, and complications in acting in the presence of adverse private events, and the Automatic Thoughts Questionnaire (ATQ-B), which measures the frequency of automatic negative accounts an individual has. The psychological needs of parents and caregivers of children diagnosed with autism is largely ignored. The focus of this study was on the decrease of distress and depression levels of these parents post-treatment and attempted to reassess the treatment gains 3 months after the completion of treatment. Limitations of this study included the small trial which involved only 20 participants, thus the study could not control for social support or expectancy. Furthermore, the process measures utilised in the study were not optimal, in addition to many of the participants not being highly distressed despite the intervention analysing the effects of this training on the levels of distress experienced. Due to the very general processes measures that were applied in the study it was unknown whether there was improvement from parents and caregivers in accepting difficult emotions and defusing from aversive cognitions. The study found that the use of ACT with parents and caregivers of children diagnosed with autism is effective in reducing the processes measures of experiential avoidance and cognitive fusion. The study additionally provides evidence that ACT can be effective in this population in adjusting to the difficulties associated with raising their children. Given that parents and caregivers often have high rates of depressive and anxiety disorders, this study is beneficial in looking at the support and care needed to raise autistic children and provides evidence that ACT may improve the psychological situation faced by these parents and caregivers (Breslaud & Davis, 1986). Results from this study indicate that the creation of an ACT family-based treatment for both parents and autistic children may be of value.

Murrell, A., & Scherbarth, A. (2011). State of the research & literature address: ACT with children, adolescents and parents. The International Journal of Behavioral Consultation and Therapy, 7(1), 15-22. doi: 10.1037/h0101005

Murrell and Scherbarth (2011) present a review of empirical and theoretical work on the use of Acceptance and Commitment Therapy (ACT) with youth and parents. Personal communication, online databases, and ACT-related websites were utilised to accumulate information regarding published and unpublished work. The authors aimed to summarise the state of ACT work that has been administered with children, adolescents, and their parents and to provide further questions and recommendations for ACT researchers. Published articles were identified using the PsychInfo database, with search terms including ‘ACT’, or ‘Acceptance’, and ‘child’, ‘adolesc’, or ‘parent’. Unpublished work was found in published articles or the research labs link or directly from important researchers in the domain of ACT with youth. The review only included articles that were written in English. The research, which involves ACT in the population of youth and parents, focuses on individual problems in children and adolescents, such as anxiety disorders and chronic pain, and parents, such as impaired parenting. Limitations involve the issue of treatment measures, which should reflect the acceptance and valuing components of ACT and not solely traditional measures of symptomatology. Additionally, although many treatment protocols included measures of functionality, some did not, and it seems that there is no standardized measures of valuing for children. Furthermore, most study designs were case studies and uncontrolled group-design studies, however, when comparing gold-standard for treatment studies larger samples and controlled designs are crucial. In support of previous research, it was concluded that ACT appears beneficial in parents in regards to aiding therapeutic progress in youth. This review adds to the limited literature available on ACT work conducted with children, adolescents, and their parents. Additionally, the authors provide recommendations that will be valuable to future researchers and the community of ACT.

Swain, J., Hancock, K., Dixon, A., Koo, S., & Bowan, J. (2013). Acceptance and Commitment Therapy for anxious children and adolescents: Study protocol for a randomised controlled trial. Trials, 14(140),  1-12. doi:  10.1186/1745-6215-14-140.

The paper involved describing and evaluating a protocol for Acceptance and Commitment Therapy (ACT) for children and adolescents with a diagnosis of anxiety disorder. The aim is to determine the effectiveness of a manualized ACT group-therapy programme in the treatment of anxiety disorders in the population of youth. Additionally the authors aim to identify which mechanisms of change regarding the ACT intervention are crucial to changes in outcome measures for the adolescent participants. The randomised controlled trial will involve the randomisation of patients to ACT, Cognitive Behavior Therapy (CBT) or a waitlist control. Participants in the ACT or CBT groups will receive 10 one and a half hour group-therapy sessions each week, whilst participants in the control group will receive CBT after 10 weeks. Repeated measured are to be taken immediately after the completion of therapy and three months post therapy. The authors scope of the study is to add to the paucity of research regarding the efficacy of ACT in youth with anxiety. Limitations are not definite with the trial not yet being completed, however, there is suggestion that difficulties may arise concerning recruitment and retention of participants, particularly adolescents. The authors conclude that to date this will not only be the largest trial of ACT in the treatment of youth, but will also be the first randomised controlled trial which examines the effectiveness of ACT in youth with a diagnosis of anxiety disorder. This study will be of value by adding to the current research and literature and also has the potential to provide extensive data on the effectiveness of ACT for anxiety disorders and the mechanisms involved in the process of change. Furthermore, this study may provide methods for parents to help their children and give useful information when selecting treatments in contemporary clinical practice.

Swain, J., Hancock, K., Hainsworth, C., & Bowman, J. (2013). Acceptance and Commitment Therapy in the treatment of anxiety: A systematic review. Clinical Psychology Review, 33(8), 965-978. doi: 10.1016/j.cpr.2013.07.002

Swain, Hancock, Hainsworth and Bowman (2013) conducted a broad systematic review to examine the effectiveness of  Acceptance and Commitment Therapy (ACT) in the treatment of anxiety. Databases, such as PsychoInfo, PsychArticles, and Medline, were utilised for published data up to October 2012. Proquest database was used to identify unpublished literature, such as dissertations and theses. Furthermore, reference lists were analysed and citation searches conducted. The study aimed to evaluate the empirical research for ACT in the treatment of anxiety, including both published and unpublished literature, and to assess the utility of ACT in the treatment of anxiety. Data was extracted from studies that met the inclusion criteria which involved ACT intervention studies which applied a minimum of two of ACT’s core processes; studies specifically aimed at treating anxiety disorder, problem anxiety or anxiety symptoms; outcome measures arranged to determine reduction of anxiety symptoms or remission and of established psychometric quality; and articles prepared in English. A method of quality assessment termed Psychotherapy Outcome Study Methodology Rating Form (POMRF) was utilised to review the articles which examines 22 individual methodological elements. The scope of the study involves applying ACT specifically to anxiety disorders and treating anxious symptoms. The study focuses on outcomes that include reductions in clinician-rated and self-report anxiety measures and investigating whether the diagnostic criteria is achieved for a given anxiety disorder. Results are tentative due to the limited number and quality of eligible studies. Due to the relationship between effect sizes and POMRF scores being unknown, no analysis of this relationship was able to be conducted. The POMRF assessment of methodological rigour identified that the majority of studies demonstrated various fundamental design errors, such as no control comparison. Most disorders were examined by only a small number of studies and used various outcome assessment tools therefore making comparisons challenging. Additionally, it was difficult to compare the effectiveness of ACT to other psychological treatments due to studies being often underpowered to identify the differences, or between-group analyses not being stated. Furthermore, typical in this domain of research, problems were found in the variety of therapeutic terminology used, diversity in treatment modalities, and some studies being found to be statistically insignificant. The review, which used a broad inclusion criteria and literature to maximise findings and reduce publication bias, provides preliminary evidence for ACT in the treatment of anxiety in clinical and nonclinical populations. Furthermore, ACT demonstrated statistically significant results in individual and group configurations. This review has been advantageous in adding to the current literature by providing preliminary support for the utility of ACT as an alternative intervention in the treatment of anxiety. However, additional research is required to examine the effectiveness of ACT in relation to specific anxiety disorders and underrepresented populations, such as youth and the elderly.

Pahnke, J., Lundgren, T., Hursti, T., & Hirvikoski, T. (2014). Outcomes of an Acceptance and Commitment Therapy-based skills training group for students with high-functioning autism spectrum disorder: A quasi-experimental pilot study. Autism, 18(8), 953-964. doi: 10.1177/1362361313501091

Using a quasi-experimental design, this study investigated the feasibility and outcomes of a 6-week Acceptance and Commitment Therapy (ACT) training programme for a group of young adults with high-functioning autism. The study aimed to evaluate whether an ACT model, which has been modified in ways that make it feasible to use with individuals with autism spectrum disorder (ASD), reduces stress and emotional distress, and increases psychological flexibility in individuals with ASD. The intervention endeavoured to use acceptance and mindfulness skills, and behaviour change procedures to support individuals with ASD deal with difficult emotions, cognitions and body sensations. Additionally, the intervention aimed to break experiential avoidance patterns, and assist in identifying valuable life directions and then act accordingly. Furthermore, it was proposed that the intervention would support individuals with ASD to acquire skills that would aid them to cope with uncomfortable mental events and sensory inputs and use goal-directed behaviours. The study recruited participants that had been diagnosed with ASD within a special school environment to increase the ecological validity of the intervention. The intervention measured participant characteristics and the outcome of the intervention were measured by the Stress Survey Schedule, the Strengths and Difficulties Questionnaires (SDQ), and the Beck Youth Inventories (BYI). The Stress Survey Schedule and the SDQ were teacher- and self-rated, whereas the BYI was only self-rated. Using the 6-week ACT training programme, the study focused on decreasing levels of stress, hyperactivity, emotional distress and increasing prosocial behaviour, and psychological flexibility. The main limitations identified were the small sample size and low statistical power, which consequently limited the analyses of potential effects of background factors, such as gender, IQ, age, and co-morbidity, on the treatment results. The ACT programme resulted in a decrease of reported student and teacher stress and increases in self-reported prosocial behaviour. Thus, it was concluded that the ACT training programme has the potential to be an effective treatment which is feasible in a special school environment and has the capability to be useful in reducing stress and psychiatric symptoms in young adults with ASD. The results of this research are crucial in the development and implementation of ACT-based treatment programmes for young individuals with ASD. To test the validity of the intervention larger studies and replications of the programme would be beneficial and in various environments.

Halliburton, A., & Cooper, L. (2015). Applications and adaptations of Acceptance and Commitment therapy (ACT) for adolescents. Journal of Contextual Behavioral Science, 4(1), 1-11. doi: 10.1016/j.jcbs.2015.01.002

The authors of this review concentrate on Acceptance and Commitment Therapy (ACT) and its relevance and applicability for professionals who work with adolescents. The aim was to investigate the similarities and differences between a traditional cognitive-behavioral therapy (tCBT) approach and an ACT approach and determine which of the two approaches would be the most effective for adolescents. The review consisted of ten studies that utilized many or all of the ACT components, such as mindfulness, acceptance, and defusion, in the population of adolescents between the ages of 11 and 17. These studies were collected from a range of journals and disciplines. The review focuses on recognising developmental adaptations and consideration that have been accumulated from a range of cognitive-behavioral approaches and that can consequently aid in the use of ACT in adolescents. Limitations involved the small sample sizes and single case designs that were utilised in many of the studies used in the review. Additionally, several studies acknowledged using self-report surveys, which can be unreliable and subject to social desirability, and symptom measures, that were not adequately adapted for the adolescent population. The authors concluded that there is some support in using ACT and ACT techniques in the adolescent population. However, it is noted that the translation of ACT protocols used with adults to adolescent needs to be treated with caution in regard to the methodology and assessments used. Furthermore, methodological problems in studies have limited conclusions on the effectiveness of ACT compared with tCBT and additional empirically supported therapies. This review provides service providers with valuable information regarding treating adolescents with new and existing therapies that may be effective and beneficial for this population. It should be acknowledged that further research on a more diverse sample of adolescents will help professionals identify which types of adolescents that ACT could be a favourable therapy option for.

Livheim, F., Hayes, L., Ghaderi, A., Magnusdottir, T., Hogfeldt, A., Rowse, J., … Tengstrom, A. (2015). The effectiveness of Acceptance and Commitment Therapy for adolescent mental health: Swedish and Australian pilot outcomes. Journal of Child and Family Studies, 24(4), 1016-1030. doi: 10.1007/s10826-014-9912-9

The high and increasing prevalence of mental health conditions, particularly depression and anxiety, among adolescents calls for further research to identify effective prevention interventions (Calear & Christensen, 2010). Livheim et al., (2015) investigated the effectiveness of a group intervention based on Acceptance and Commitment Therapy (ACT) in two pilot studies conducted in Australian and Swedish school settings. The aim of the study was to evaluate the effectiveness of the brief intervention, which was based on the principles of ACT, on depressive symptomology in the Australian study and stress in the Swedish study. Both studies were conducted with adolescents in real-world conditions in normal school environments. 66 participants were enrolled in the manualized 8-week program in the Australian study, which involved a scheduled comparison, with random allocation for girls and a replication for boys. 32 participants were enrolled in the Swedish study which was 6-weeks, due to the shorter school terms, and was a randomized controlled design. The Australian study focused on the effectiveness of an ACT-intervention based on the fundamental variable of depression and associated symptoms, whereas the Swedish study concentrated on the effectiveness of an ACT-intervention on self-perceived stress and related symptoms. Limitations of the study included the lack of long-term follow-up to confirm the results; the relatively small sample size and limited age-range and gender variability, which consequently made it challenging to generalise results; and all participants were volunteers. It should additionally be acknowledged that the data was all self-reported questionnaires, thus the authors suggest future research should include further objective measures, such as attendance at school. The Australian study demonstrated a significant reduction in depressive symptoms and psychological inflexibility for adolescents in comparison to a control group who received standard care. The Swedish study found a significant reduction in levels of stress and anxiety in addition to increased mindfulness skills. Therefore, the authors suggest that the ACT intervention may be beneficial for reducing stress and depressive symptoms in adolescents. The present study contributes to the literature supporting an ACT-intervention in adolescents with mental health issues and emphasises the need for additional prevention programmes. Given that depression, anxiety and stress are common issues among adolescents, future research that compares an ACT intervention to attention control or credible alternatives in effectiveness trials would be of value to this domain of research and provide further support for an ACT intervention.

Wicksell, R., Kanstrup, M., Kemani, M., Holmstrom, L., & Olsson, G. (2015). Acceptance and Commitment Therapy for children and adolescents with physical health concerns. Current Opinion in Psychology, 2, 1-5. doi: 10.1016/j.copsyc.2014.12.029

The article provides an overview of the research conducted on Acceptance and Commitment Therapy (ACT) for youth whom have physical concerns such as pain, acquired brain injuries, cystic fibrosis, and sickle cell disease.The authors aimed to identify whether ACT is effective at improving or retaining functioning in youth with physical concerns, and if this is maintained in the presence of longstanding symptoms and associated distress. Papers for this review were either from an ongoing systematic review in regards to ACT and pain, or through complementary searches in PubMed and PsychInfo. Measures of outcome and process variables of children included Chronic Pain Acceptance Questionnaire (CPAWQ) and the psychological Inflexibility in Pain Scale. Measures to assess parental processes included the Parent Psychological Flexibility Questionnaire (PPFQ) and the adapted parent version of CPAQ. The paper focuses on the treatment effects of ACT in developing guidelines to match specific interventions to individuals, maximising their effectiveness. The main limitation was the minimal studies that have been conducted regarding ACT in youth with physical concerns. Additionally, majority of the studies conducted involved individuals suffering from chronic undefined pain and the methodological quality largely varied. Thus no conclusions could be drawn concerning how ACT works and for whom.In conclusion, ACT appears to be promising in the treatment of youths with physical concerns and ACT-oriented interventions may enhance the effects of medical interventions. However, it is emphasised that more research is required to evaluate ACT. This paper is valuable in determining the utility of an ACT approach in the treatment of a specific population and therefore provides beneficial supplementary information for the research of ACT.

Swain, J., Hancock, K., Dixon, A., & Bowman, J. (2015). Acceptance and Commitment Therapy for children: A systematic review of intervention studies. Journal of Contextual Behavioral Science, 4(2), 73-85. doi:10.1016/j.jcbs.2015.02.001

A systematic review was completed by Swain, Hancock, Dixon and Bowman (2015) examining published and unpublished research regarding Acceptance and Commitment Therapy (ACT) interventions for children. With the increasing number of available studies, the aim of this systematic review was to examine the evidence for ACT in the treatment of children and produce support for future evidence-based clinical decision-making in this domain. Furthermore, the authors intended to deliver an integrated synthesis of the literature by including an analysis of the findings and an evaluation of the methodological accuracy of included studies. The authors utilised an extensive inclusion criteria in order to maximise review breadth. Quality assessment was administered using the 22-item “Psychotherapy outcome study methodology rating form” (POMRF), which has been recognised as a critical step in progressing the field (Gaudiano, 2009). POMRF measures methodological items such as research design and therapist training, and assigns each study an overall score between 0 and 44 with higher scores demonstrating greater methodological rigour. The prevalence of research focused on quality of life outcomes, symptoms, and psychological flexibility on measures reported by parents, clinicians and patients. The research also concerned the maintenance of the treatment gains at a follow-up assessment after the commencement of the treatment. The authors acknowledge that limitations of the intervention studies may include author bias, which cannot be ruled out due to the majority of the studies being administered by a group of affiliated researchers. This is also associated with therapist allegiance and experience and skill, which both inadvertently may result in study outcomes being distorted by preferences towards a treatment or theory, and treatment gains related to the experience of the therapist (Luborsky, Singer, & Luborsky, 1975). Another limitation is the lack of measurement in quality of life (QOL) outcomes, which has been suggested to reflect the clinical significance of changes and effectiveness of ACT. The review concludes that the emerging evidence indicates ACT is effective in the treatment of children across an extensive range of issues. However, the authors emphasise the need of larger scale methodological trials from an extensive research group, research on various age groups, and ACT treatment delivered through group or family-based formats to further strengthen these findings. This review provides evidence that for clinicians ACT may be regarded as a feasible therapeutic option when working with children. Furthermore,  it is proposed that ACT may be used with individuals with intellectual disabilities, such as autism.

Leoni, M., Corti, S., Cavagnola, R., Healy, O., & Noone, S. (2016). How Acceptance and Commitment Therapy changed the perspective on support provision for staff working with intellectual disability. Advances in Mental Health and Intellectual Disabilities, 10(1), 59-73. doi: 10.1108/AMHID-09-2015-0046

The authors acknowledge that a career in mental health can be emotionally and psychologically demanding increasing the risk of burnouts and psychological distress, however, it is acknowledged that such a profession can also be rewarding and satisfying. The article examines the effects of interventions for professionals working with individuals with intellectual disabilities, with a particular focus on the efficacy of Acceptance and Commitment Therapy (ACT) training. The paper aims to develop and facilitate an improved understanding of distressing processes, and methods to implement positive resources to promote well-being. Appropriate theoretical models and literature associated with stress reduction were examined from a Cognitive Behaviour Therapy (CBT) approach with a specific focus on ACT. The paper focused on the wellbeing and behaviour of professionals whom support individuals with intellectual disabilities, in addition to ACT and various third wave generation behavioural approaches. The paper acknowledges limitations including when staff behaviour becomes controlled by cognitions, thus it is difficult to develop a reliable measure to access these thoughts and the level of fusion. Additionally, small sample sizes in the interventions and a need to increase replication studies to investigate the impact of ACT on specific intellectual disability settings (i.e. gender, age, type and frequency of therapy) are noted. Furthermore, it is acknowledged that it may be challenging to state exactly whether changes in stress levels are a result of exclusively ACT or a combination of ACT and ABA training, as ACT training contains elements of ABA (Bethay, Wilson, Schnetzer, & Nassar, 2013). The research provides evidence that ACT-based interventions appear promising in improving the well-being of professionals working with intellectual disabilities in addition to reducing the risk of burnout and increasing psychological flexibility. Brief ACT workshops were also confirmed to be efficient in reducing occupational stress and increase feelings of efficacy.This research is of value as it provides evidence that the implementation of ACT interventions can be effective and beneficial for both staff and the individuals with intellectual disabilities that they support.

Villatte, JL., Vilardaga, R., Villatte, M., Vilardaga, JC., Atkins, DC., & Hayes, SC. (2016). Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes. Behaviour Research and Therapy, 77, 52-61. doi: 10.1016/j.brat.2015.12.001

The authors emphasise the impact of selecting and implementing components of Acceptance and Commitment Therapy (ACT), a promising candidate for modularization. ACT open consists primarily of procedures focusing on the acceptance and cognitive defusion processes of the psychological flexibility model, which aim to decrease the occurrence of detrimental responses to cognitions, sensations and feelings. ACT engaged consists of procedures which identify the values and action processes of the psychological flexibility model and intends to increase motivation and meaningful behaviour. The study aims to investigate the functional relationships between ACT intervention components, processes, and results which consequently will aid in the development of a modular, transdiagnostic treatment specifically for the adult population. 15 adults who met the inclusion criteria, which involved meeting clinical case status on the Brief symptom Inventory and being aged 18 years or over, were included in the study. 7 participants were allocated to ACT open and 8 participants allocated to ACT engaged. The results of the treatment measures were based on the severity of psychological symptoms and the quality of life. The study focused on evaluating the specific effects of each ACT component (ACT open and ACT engaged) on the treatment process and outcomes when employed in clinical service settings. A limitation identified included the small sample size (N=15), which indicates that the study should be replicated in a larger sample across various therapists, treatment settings, and participants. Both ACT open and ACT engaged established broad symptom improvements; increases in quality of life; high treatment acceptability and completion rates; and satisfaction from participants. Treatment effects were also maintained at a 3-month follow up. Therefore, it is suggested that ACT components could be included in a modular method to completing evidence-based psychosocial interventions for the adult population. The results of the study are of value at a clinical and community level as they highlight the differences of implementation in both components of the ACT intervention and show the effectiveness of the ACT process with adults seeking mental health treatment.

Ong, C., Lee, E., & Twohig, M. (2018). A meta-analysis of dropout rates in acceptance and commitment therapy. Behaviour Research and Therapy, 104, 14-33. doi: 10.1016/j.brat.2018.02.004

The article looks at the overall acceptability of Acceptance and Commitment Therapy (ACT) and how it measures to that of other empirically supported treatments. The authors administered a meta-analysis to investigate the rate of individuals that drop out of ACT interventions. The aims of the study involved examining dropout rates in ACT across a wide variety of psychological and behavioural issues, comparing dropout rates in ACT to those in other psychological interventions, and determining moderators, such as client characteristics and therapy variables, of dropout in ACT. For studies to be included in the meta-analysis, which was conducted following the PRISMA guidelines, they had to meet a specific criteria including: random assignment to treatment condition; inclusion of at least one comparison condition; participants having a psychological diagnosis, behavioural issue, or physical diagnosis; therapy being conducted face-to-face; in line with the ACT protocol; and be published in English. The authors used the Psychotherapy Outcome Study Methodology Rating Scale to analyse results from 68 studies. The review focused on the dropout rate, which is a crucial aspect of treatment utility, of clients who participate in ACT. As the meta-analysis solely focused on randomized controlled trials, the generalizability of the results to other settings was consequently limited. Due to insufficient data the authors acknowledge that analyses regarding moderating variables, that may be associated to dropout, were unable to be conducted. Additionally, dropout rates based on overall attrition were only investigated as a result of the limited data and may be higher than reported. The studies involved did not use the same scales to analyse the data which complicates the analysis of results. In addition to comparable effectiveness of ACT to other treatment, ACT demonstrates comparable dropout rates. Higher-level clinicians/therapists were associated with increased dropout rates in addition to “therapist experience” being identified as a factor that can significantly influence dropout rates. This study reveals that there is no significant differences in dropout rates in regard to ACT and other interventions, therefore ACT has the ability to be effective for a range of psychological and behavioural health concerns. However, it should be acknowledged that studies which resulted in high dropout rates may not have been published and therefore results of this meta-analysis may be skewed.

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Acceptance and Commitment Therapy (ACT) is a newer psychotherapy that has produced plenty of clinical and research interest and increased in popularity in recent years. After investigating research regarding the behaviourally based and broadly applicable model, it can be concluded that ACT is successful in treating a vast variety of psychological problems, such as depression and anxiety, psychopathology, and physical health concerns. Additionally, although ACT was originally developed in the domain of clinical psychology, ACT has demonstrated potential in aiding individuals’ health behaviour change. A dominant finding in the reviewed articles was that interventions based on ACT have demonstrated significant improvements in differing populations in regard to the levels of depression and psychological flexibility. The core principles and processes of ACT have been identified as being applicable in individuals who do not have psychological or physical impairments themselves but are tending to individuals with a range of issues, such as physical concerns and intellectual disabilities. ACT has been found to mitigate psychological distress and reduce levels of depression in these caregivers. Furthermore, there is an abundance of research which have demonstrated that ACT is a feasible and effective treatment option in many populations even when compared to other empirically supported and established therapies such as cognitive-behavioral therapy (CBT). It was acknowledge that evidence does not exist for ACT to be used above CBT, however, both treatments were found equally effective in treating anxiety in the population of children.

The articles reviewed did not provide any contradictory research results.

The results of the review suggests that the ACT model can have a positive impact and cause significant improvements on individuals when applied by trained professionals. This can be associated to long-term implications involving client satisfaction and precision in client-therapist communication. It is also to be acknowledged that the review found clinical expertise to be associated with improved outcomes of ACT. Furthermore, the research indicated that due to the focus that ACT has regarding acceptance, self, and emotions the model is attractive to many nonbehaviorual and skilled clinicians, suggesting that the limited number of concepts of ACT can still have a board clinical appeal (Strosahl, Hayes, Bergan, & Romano, 1998). Some of the outcomes identified went beyond alterations in symptoms to outcomes of major systems importance, such as the interest from government and care organisations regarding the brief time period which has an evident impact on cost effectiveness in health care delivery systems. Another implication was that the sample sizes for previous studies has been small and populations diverse, thus conclusions need to be taken with caution. In one particular study the participants resided in the identical school area which limited the generalizability of the results. Most of the studies, which seem to support many critical aspects of ACT, represent smaller pilot studies with methodological limitations.

Although research involving randomized clinical trials and controlled time series investigating ACT is growing, for ACT to continue to advance in the future and to clarify the efficacy of its research some issues need to be addressed (Strosahl et al., 1998). Most studies of ACT thus far have been conducted with the adult population, therefore the results of its effectiveness when applied to adolescents and children is restricted. It would be valuable for ACT to be applied in a diverse population in order to investigate its promising trans-diagnostic and robust effects. Furthermore, increasing efforts are required to replicate previous findings utilising independent and larger samples, this is important when examining the robustness of the preliminary effects previously reported. Additional research involving controlled experimental studies which examine processes crucial in ACT, such as self and values, will aid to supplement and further support the results from larger efficacy trials (Gaudiano, 2011). It has been proposed that traditional symptom measures may be unsuccessful in identifying hypothesised ACT-specific change processes and influence null results. Future research in regard to developing more reliable and valid measures for processes and outcomes in ACT is recommended. Additionally, including more objective, behavioural task-based measure will aid self-reported measures.

The articles reviewed demonstrated that ACT interventions were successful in treating individuals with physical health concerns and autism spectrum disorder (ASD) in addition to individuals that aided in their care. It has been proposed that 33% of adults with an ASD diagnosis additionally have a physical disability, however, there is limited research on ACT in the comorbidity of physical health concerns and ASD (Rydezewska et al., 2018). Due to the high comorbidity it would be of benefit for future research into an effective intervention to treat this population.

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