Opioid use disorder (OUD) and chronic pain (CP) are commonly comorbid health conditions that cause significant disability, distress, and mortality. Treatment for these conditions is impacted by drop out and presence of other psychiatric conditions. Acceptance and Commitment Therapy is an effective intervention to treat chronic pain and substance use disorders, however this intervention has not been systematically evaluated for treatment of comorbid OUD and CP, especially in a racially and economically marginalized population. In this paper we describe development of such an ACT manual, using an intervention mapping approach. While the manual pays close attention to opioid use and chronic pain, it includes transdiagnostic principles that target overall psychological well-being including a deep emphasis on expanding valued living. We incorporated trauma informed care, cultural humility, and harm reduction principles in the development of nine ACT skills that are easy to understand and scalable. The treatment manual centers economically and racially marginalized patients who are traditionally underrepresented in psychological research. This manual is currently being evaluated in clinical trial NCT05039554 with funding from the NIH HEAL project #RM1DA055437. The treatment manual and handouts are freely available for use and included.

Loneliness-the discrepancy between actual and desired levels of social connection-is a pervasive public health concern. Research suggests that many men report loneliness and desire more intimate relationships. The Interpersonal Process Model of Intimacy posits that intimacy, the meaningful connection between two individuals, is a critical variable in preventing loneliness and develops through a bidirectional process of vulnerable self-disclosure, responsiveness, and perceived partner responsiveness. This manuscript applies the Interpersonal Process Model of Intimacy, as interpreted from a contextual behavior science lens, to contextualize the existing research on masculinity and men's social relationships to inform future research and clinical practice. We review the research on men's engagement in different components of the model (vulnerable self-disclosure, responsiveness, perceived partner responsiveness), emphasizing how masculinity inform men's behavior. Research indicates that men often do not engage in behaviors essential to a contextual behavioral model of intimacy (e.g., vulnerable emotions, distress, or asking for help) because such behaviors are inconsistent with masculinity. Research also indicates men often do not acknowledge others' disclosures or respond with judgment or confusion. Men may also perceive responsiveness as stressful due to social proscriptions regarding receiving help. We discuss implications for research and clinical interventions to ameliorate men's loneliness.

Functional Analytic Psychotherapy (FAP) is an efficacious but complex treatment. Despite a solid empirical foundation, research on the treatment is limited. While five process-focused rules guide the treatment, developers made an early statement that they believed only the first rule of FAP, watching for the occurrence of daily life problems occurring in the therapy session, was needed to guide treatment effectively. The current study was designed to assess this claim through the use of a FAP analog procedure in hopes of increasing the accessibility of the treatment and thus facilitating implementation efforts. In this study, 81 undergraduate participants engaged in a closeness-generating class in which they were randomized into two groups. In the experimental condition, research assistants had access to a self-report measure regularly used to inform clinicians about potential daily life problems that may occur in the therapy room. No such information was available to the research assistants in the control condition. Findings indicated that while fear of intimacy, a core construct in FAP, decreased on average following the procedure, the experimental condition had no impact on this change. Further, when research assistants had access to the daily life problem information, participants found them less effective at responding to disclosures. These findings suggest the importance of a nuanced case conceptualization, the limitations of the first rule of FAP, and the strengths and limitations of the use of an analog paradigm to study FAP.

Young adult sexual minority men are at heightened risk for psychological distress (i.e., depression and anxiety). Mounting evidence suggests the adverse consequences of distal stigma, and existing frameworks (the Minority Stress Theory and Psychological Mediation Framework) posit that distal minority stress may impact psychological distress through minority stress-specific processes, such as internalized homonegativity, as well as general psychological vulnerability factors, such as emotion dysregulation. There is a lack of research examining this process integrating both frameworks and understanding potential resilience factors such as mindfulness and self-compassion and where they may assert impact. Using structural equation modeling, the current study investigated the relationship between distal minority stress, measured by heterosexist discrimination, and psychological distress (i.e., depression and anxiety) through a serial indirect effect via internalized homonegativity and emotion dysregulation, while including internalized homonegativity and emotion dysregulation for their unique indirect effects separately, among young adult sexual minority men ( = 307). Further, the study explored mindfulness and self-compassion as potential moderators in subsequent models. Results indicate that two significant paths explain the association between heterosexist discrimination and psychological distress, including through internalized homonegativity and emotion dysregulation as a serial indirect path, as well as through internalized homonegativity alone. Both mindfulness and self-compassion emerged as protective factors in the "upstream" part of the model, particularly in the effect of heterosexist discrimination on internalized homonegativity. Contrary to expectation, both mindfulness and self-compassion had a strengthening impact on the positive association between internalized homonegativity and emotion dysregulation. Findings support the conceptualization of emotion dysregulation as a "downstream" effect of minority stress, as well as adapting and utilizing mindfulness and self-compassion to alleviate the impact of distal minority stress. Additional longitudinal research, particularly rigorously designed clinical trials, is needed to further evaluate such intervention programs.

Functional Analytic Psychotherapy (FAP) is a type of psychotherapy often described as "process-based" because treatment targets are idiographically defined, and intervention strategies are specified in behavioral principles. Recently, refinements have been made to the idea of process-based therapy (PBT) that incorporates an extended evolutionary meta-model (EEMM). The present discussion articulates how FAP fits into current conceptualizations of engaging in PBT. I argue that embracing a PBT approach to treatment can enhance therapeutic outcomes by expanding the conceptualization of clinically relevant behaviors to be viewed as a series of interrelated processes. EEMM dimensions are explored as clinically relevant behaviors, and established FAP intervention strategies for some of these dimensions are discussed. This expanded conceptualization of FAP is applied to a case example before future directions for FAP are discussed in the context of a process based approach to treatment.

This article is part of a special issue in the devoted to process-based therapy (PBT) or a process-based approach to therapy and the role it plays in harmonizing existing evidence-based treatments. In the present discussion, we focus on acceptance and commitment therapy (ACT) and how it fits into the PBT framework. We describe how viewing ACT through a PBT framework and its organizing rubric-the extended evolutionary meta-model (EEMM)-provides fertile ground to expand the ACT and psychological flexibility models, transforming ACT into a more inclusive and flexible version of itself and giving clinicians wider berth with respect to delivering ACT. The PBT approach allows ACT to incorporate therapeutic elements that are not traditionally part of the framework, including include cognitive reappraisal, interpersonal therapy dynamics, physiological downregulation, and the principle of nonattachment. Importantly, ACT maintains its foundational principles throughout this integration. We provide a case example of how to use PBT methods to conceptualize an ACT case, to illustrate PBT-infused ACT in practice. Finally, we outline possible future directions for ACT as it continues to evolve inside of PBT.

Perspective taking is important for effective interpersonal functioning. According to Relational Frame Theory (RFT), perspective taking is underpinned by deictic relational framing. It has been proposed that individuals with Borderline Personality Disorder (BPD) may have deficits in perspective taking. A mixed experimental design ( = 112) was used to assess whether individuals with a diagnosis of BPD displayed impaired perspective taking on a computerised RFT deictic relational task (DRT) and a self-report measure, compared to a control sample. There was no significant difference between groups on the computerised DRT. Within the clinical group, overall distress and relational distress were not found to be significantly associated with DRT performance or self-reported perspective taking. However, those with BPD self-reported significantly worse perspective taking ability compared to the control sample. This finding indicates a discrepancy between perceived perspective taking ability and direct perspective taking performance in persons with BPD.

Rising rates of mental health problems in undergraduate students is a critical public health issue. There is evidence supporting the efficacy of acceptance and commitment therapy (ACT) in decreasing psychological symptoms in undergraduates, which is thought to be facilitated through increases in psychological flexibility (PF) and decreases in psychological inflexibility (PIF). However, little is known about the effect of ACT on these processes in undergraduates. We conducted a systematic review and three-level meta-analysis examining this effect in 20 studies, which provided 56 effect sizes. A combined sample of 1,750 undergraduates yielded a small-to-medium overall effect ( = .38, = .09, < .001, 95% CI: [0.20, 0.56]). This effect did not depend on control group type, intervention modality, number of sessions, the questionnaire used, whether PF or PIF was measured, or participant age. However, there was a significant mean effect only in studies with a specific clinical target, but not in those without one. Furthermore, the higher the percentage of female participants, the lower the reported effect size. Results suggested that ACT may increase PF and decrease PIF in undergraduates and highlighted various conceptual and measurement issues. Study protocol and materials were preregistered (https://osf.io/un6ce/).

Mindfulness skills are a component of many modern cognitive-behavioral therapies that are used to treat a wide range of disorders, including psychotic disorders. While habitual (i.e., trait) mindfulness is associated with clinical outcomes, the effects of momentary (i.e., state) mindfulness are unclear. This is due in part to previous studies using cross-sectional designs relying on trait self-report questionnaires. Although such approaches are invaluable, they lack temporal specificity to evaluate momentary changes and effects of mindfulness. To address these limitations, the current study used ecological momentary assessment (EMA) to evaluate state levels of two mindfulness skills, acceptance and monitoring, and their association with state fluctuations in symptoms. Participants included individuals with affective and non-affective psychotic disorders (PD; = 49) and healthy controls (CN; = 53) who completed six days of EMA. Results indicated that the PD group endorsed lower state acceptance than CN; however, the groups did not significantly differ in monitoring. Further, greater state mindfulness skills in both acceptance and monitoring were associated with greater positive affect, reduced negative affect, and reduced negative symptoms. However, participants with a predominantly affective psychosis presentation showed differential effects compared to those with non-affective presentations. These findings suggest that mindfulness training for people with psychotic disorders may benefit from focusing on improving acceptance in order to improve emotional experience and build on existing monitoring skills. Further, mindfulness based psychosocial interventions may offer a novel means of treating negative symptoms in people with PD, which are currently stalled and largely unresponsive to other treatments.

While the adaptation of evidence-based psychosocial support tailors the intervention components to the targeted context, minimizing the associated costs of developing new interventions for low-income contexts, the acceptability of such adapted interventions is important for augmenting successful implementation and sustainability. Given that psychosocial support to persons living with HIV is mostly rendered by healthcare providers, their acceptance of adapted interventions before implementation is crucial. This study explored healthcare providers' acceptance of an adapted mindfulness and acceptance-based intervention supporting adolescents with HIV. Ten healthcare providers at two urban clinics in Kampala, Uganda attended a three-day training on using the adapted intervention and gave feedback on its appropriateness during in-depth interviews conducted thereafter. Semi-structured interviews were based on the Theoretical Framework of Acceptability and findings were analyzed abductively within the seven components of the framework. Overall, the adapted intervention was perceived to be acceptable and appropriate for use with adolescents. Benefits included the intervention offering support beyond a focus on adherence to drugs, refocusing adolescents on aspects in their lives that matter most, and being easy to integrate into providers' work processes. Providers however expressed concern about the time the intervention requires and the possibility of increasing their workload. These findings will support further adaptation and implementation.

Misophonia is characterized by decreased tolerance of ordinary human-generated trigger sounds and associated visual stimuli (e.g., chewing, sniffing, lip smacking), coupled with intense affective reactions. The disorder often begins during childhood or adolescence and is associated with impairment and distress in numerous life domains. Research has begun to examine the underlying psychological mechanisms of misophonia in adults, but studies in youth are limited. Trait mindfulness (i.e., nonjudgmental and nonavoidant present-moment awareness) and cognitive emotion regulation (i.e., cognitive processing, or responding to, emotionally arousing situations) are two proposed mechanisms that may underpin pediatric misophonia and associated functional impairment. In the present exploratory cross-sectional study, we examined trait mindfulness and cognitive emotion regulation and their relations with misophonia features and adaptive functioning in 102 youth with misophonia ( = 13.7; = 2.5; range = 8-17). More severe misophonia was significantly associated with decreased levels of both trait mindfulness and adaptive functioning across domains, in addition to deficits in certain facets of cognitive emotion regulation, particularly self-blame. Neither trait mindfulness nor facets of cognitive emotion regulation moderated the association between misophonia severity and adaptive functioning across domains, with the notable exception that difficulties with adaptive functioning in peer relationships was attenuated in those high in mindfulness. Findings suggest that trait mindfulness- and to a lesser extent cognitive emotion regulation- may be potentially relevant processes in pediatric misophonia. However, more research is needed to uncover the precise nature of these processes to aid future characterization and intervention efforts, especially in light of equivocal findings in the present study.

HIV disproportionately affects young Black men who have sex with men (YBMSM) in the Southern United States. Pre-exposure prophylaxis (PrEP) is an efficacious, biomedical approach to prevent HIV. While Mississippi (MS) has among the highest rates of new HIV infections, it also ranks among the top three states for unmet PrEP need. Thus, increasing engagement in PrEP care for YBMSM in MS is imperative. A potential method to improve psychological flexibility and promote PrEP uptake, explored by this study, is the incorporation of Acceptance and Commitment Therapy (ACT) into PrEP interventions. ACT is an evidence-based intervention used to treat a wide range of mental and physical illnesses.

Refugees are vulnerable to developing mental health problems. The unprecedented appearance and rapid spread of COVID-19 exacerbated this vulnerability, especially in low-income countries where refugees survive on humanitarian aid and live in congested settlements. These appalling living conditions are a stressor, making adherence to COVID-19 control measures impractical and an additional psychological strain for refugees. The present study examined how psychological inflexibility is associated with adherence to COVID-19 control measures. A sample of 352 refugees from Kampala City and Bidibidi settlements were recruited. Refugees with high levels of psychological inflexibility reported higher PTSD symptom severity and low adherence to COVID-19 control measures. Moreover, PTSD severity mediated the association between psychological inflexibility and adherence, while avoidance coping moderated both direct and indirect effects. Interventions for reducing psychological inflexibility and avoidance coping may be essential in boosting adherence to measures relevant to the current and future status of the pandemic, along with other crises that refugees face.

This paper describes the iterative development of an evidence-based behavioral intervention for individuals with cancer at risk for opioid use disorder, using the National Institutes of Health Stage Model for Behavioral Intervention Development. Adult patients with cancer from an outpatient palliative care clinic at an academic cancer center, with moderate to high risk of opioid misuse, were enrolled in a treatment development study that aimed to increase psychological flexibility. In this intervention, psychological flexibility is the posited mechanism of change for reduction of opioid use disorder risk. Patients completed baseline (pre-intervention) assessments, a six-session behavioral intervention based in Acceptance and Commitment Therapy, post-intervention assessments, and a semi-structured exit interview. Ten patients with moderate to high risk of opioid misuse completed the intervention. Patients rated the intervention as highly acceptable and were generally highly satisfied. Patients reported finding the coping skills helpful (e.g., mindfulness, cognitive defusion) and reported a preference for more sessions. These treatment development efforts have implications for the development and design of acceptance- and mindfulness-based, targeted interventions for individuals with cancer, receiving palliative care and at risk for opioid use disorder. Specifically, this six-session behavioral intervention to increase psychological flexibility was acceptable to patients and ready to be studied in a pilot RCT.

Depression is a common, serious complication during the postpartum period. Predictors of postpartum depression characterize who is at-risk for persistent symptoms. This study explored how psychological inflexibility affects depressive symptoms at 4 and 12 weeks postpartum.

In light of the adverse mental health impacts of the COVID-19 pandemic for parents of preschool-aged children, it is important to identify modifiable protective factors that can inform interventions for parents who continue to struggle. The present study examined prospective and concurrent associations of parental psychological flexibility (acceptance, defusion, and committed action) with measures of parental stress and depression symptoms in an international sample of parents of preschoolers assessed at three time points over the first two years of the COVID-19 pandemic: The start of the pandemic (T1) as well as the end of the first (T2) and second (T3) year of the pandemic. Consistent with hypotheses, the three measures of parent psychological flexibility (assessed at T2) prospectively predicted parenting stress levels one year later (T3) ( < .05). Defusion and Committed Action also prospectively predicted lower levels of depression symptoms one year later [ < .05]. Comparable concurrent analyses of data of parents who provided data at T1 and T2 (N = 79) are also presented with acceptance and defusion negatively associated with parental stress (p < .001) and defusion negatively associated with depression (p < .05). This study contributes longitudinal evidence for the value of psychological flexibility for parents and suggests that Acceptance and Commitment Therapy interventions may help to support parental mental health during sustained periods of stress such as the COVID-19 pandemic.

Distress tolerance, or the ability to tolerate physically and emotionally aversive experiences, is a target of psychological intervention in contextual behavioral science. It has been conceptualized as a self-reported ability, as well as a behavioral tendency, and operationalized with a wide variability of questionnaires and behavioral tasks. The current study aimed to investigate whether behavioral tasks and self-report assessments of distress tolerance measure the same underlying dimension, two correlated dimensions, or whether method factors accounted for covariation above and beyond a general content dimension. A university student sample ( = 288) completed behavioral tasks associated with distress tolerance and self-report distress tolerance measures. Confirmatory factor analysis indicated that behavioral and self-report assessments of distress tolerance do not comprise a single dimension of distress tolerance, or two correlated dimensions of self-report or behavioral distress tolerance. Results also failed to support a bifactor conceptualization with a general distress tolerance dimension and domain-specific method dimensions for behavioral and self-report assessments. Findings suggest that more precision and attention to contextual factors are required in the operationalization and conceptualization of distress tolerance.

Patients with advanced gastrointestinal cancer often experience high symptom burden, which is associated with heightened distress in both patients and their family caregivers. Few interventions have been tested to jointly address patient and caregiver symptoms in advanced gastrointestinal cancer. In a randomized pilot trial, telephone-based, dyadic acceptance and commitment therapy (ACT) was found to be feasible in this population. The present secondary analyses examined the impact of this intervention on patient and caregiver physical and psychological symptoms. Patients and caregivers ( = 40 dyads) were recruited from clinics in Indianapolis, Indiana and randomized to either six weeks of telephone-based ACT or education/support, an attention control condition. Outcomes were assessed at baseline and at 2 weeks and 3 months post-intervention. Study group differences in outcomes were not statistically significant. However, when examining within-group change, only ACT patients experienced moderate reductions in pain severity and interference at 2 weeks post-intervention (effect size [ES]=-0.47; -0.51) as well as moderate reductions in depressive symptoms at 2 weeks (ES=-0.42) and 3 months (ES=-0.41) post-intervention. ACT caregivers experienced moderate reductions in sleep disturbance (ES=-0.56; -0.49) and cognitive concerns (ES=-0.61; -0.85) across follow-ups. Additionally, caregivers in both conditions experienced moderate reductions in fatigue (ES=-0.38 to -0.70) and anxiety (ES=-0.40 to -0.49) across follow-ups. Findings suggest that ACT may improve certain symptoms in dyads coping with advanced gastrointestinal cancer and warrant replication in a larger trial.

Maladaptive eating patterns and behaviors are frequently documented in relation to obesity onset and management. To better understand these occurrences, it is important to examine psychological processes that may be guiding these patterns and behaviors. The current study examined the role of psychological inflexibility on emotional eating, food cravings, and disordered eating symptoms among 161 participants (60.9% female, = 31.58, = 10.71) who attended a baseline appointment for a larger randomized-controlled trial for individuals with elevated anxiety sensitivity and obesity. Three separate two-step hierarchal regressions were conducted. Results indicated that greater levels of psychological inflexibility were associated with greater levels of emotional eating, food cravings, and disordered eating symptoms. These findings suggest that promoting psychological flexibility may be a key factor in promoting positive changes in eating behaviors among individuals seeking treatment for comorbid affective vulnerabilities and weight-related behaviors.

Acceptance and Commitment Therapy (ACT) is a third-wave behavioral and cognitive therapy that increases psychological flexibility through mindfulness, acceptance, and value-driven behavior change. ACT has been successfully used to inform a variety of health interventions. Using non-therapists to deliver ACT-based behavioral health interventions offers an opportunity to provide cost efficient and integrated care, particularly among underserved populations experiencing barriers to mental health care, such as inadequate insurance, mental health stigma, and provider shortages. This systematic review aims to: 1) identify ACT-informed behavioral health interventions delivered by laypeople and 2) review the specific characteristics of each intervention including number and duration of sessions, delivery modality, interventionist training, and intervention outcomes.