Psychological Services In the public domain

2016, Vol. 13, No. 2, 156 –161 http://dx.doi.org/10.1037/ser0000062

The Efficacy of Focused Acceptance and Commitment Therapy

in VA Primary Care

Natalie G. Glover Patrick D. Sylvers

VA Puget Sound Health Care System, Seattle, Washington VA Puget Sound Health Care System, Seattle, Washington, and
University of Washington

Erika M. Shearer and Mary-Catherine Kane Peter C. Clasen

VA Puget Sound Health Care System, Seattle, Washington Stanford University School of Medicine

Amee J. Epler and Jennifer C. Plumb-Vilardaga Jordan T. Bonow

VA Puget Sound Health Care System, Seattle, Washington VA Sierra Nevada Health Care System, Reno, Nevada

Matthew Jakupcak
VA Puget Sound Health Care System, Seattle, Washington, and University of Washington

Focused Acceptance & Commitment Therapy (FACT) is a brief intervention based on traditional
Acceptance and Commitment Therapy (ACT). Although there is a growing body of research on the
efficacy of ACT for a variety of populations and disorders, there is little research to date on the use of
FACT in group settings. This project is 1 of the first of its kind, as it examines data on psychological
flexibility, health and mental health status, and symptom reduction from a 4-week FACT group.
Participants in this study were 51 patients who attended this group as part of routine clinical care in a VA
integrated primary care and mental health setting. They completed pre- and posttreatment measures of
well-being, depression, anxiety, stress, psychological flexibility, and perceptions of physical and mental
health functioning. Pre- to posttreatment analyses of variance demonstrated large effects for quality of
life, F(1, 51) ⫽ 21.29, p ⬍ .001, ␩2 ⫽ 0.30, moderate effects for depressive symptoms, F(1, 51) ⫽ 11.47,
p ⬍ .001, ␩2 ⫽ 0.08, and perceptions of mental health functioning (MCS scale), F(1, 51) ⫽ 9.67, p ⫽
.003, ␩2 ⫽ 0.11, and small effects for perceptions of perceived stress, F(1, 51) ⫽ 4.08, p ⫽ .04, ␩2 ⫽
0.03, and physical health functioning (PCS scale), F(1, 51) ⫽ 6.60, p ⫽ .01, ␩2 ⫽ 0.08. There was a
statistical trend for reductions in anxiety, F(1, 51) ⫽ 3.29, p ⫽ .07, ␩2 ⫽ 0.01, and a nonsignificant effect
for psychological flexibility, F(1, 51) ⫽ 2.05, p ⫽ .16, ␩2 ⫽ 0.04. These data provide initial support for
the implementation of a group-based FACT protocol within a VA primary care setting and help to lay
a foundation for further, more controlled studies on Group FACT in future research.

Keywords: Acceptance and Commitment Therapy, efficacy, focused, primary care, VA

Integrating behavioral health interventions into primary care leads
to better patient outcomes, reduces provider burden, lowers health
care costs, and mitigates stigma associated with mental health services
(Kathol, deGruy, & Rollman, 2014). Despite these clear benefits,
patients and providers in the United States underutilize integrated
behavioral health services (Melchert, 2015). This underutilization is
attributable, in part, to a dearth of behavioral interventions that fit into
the existing primary care setting.
Primary care is characterized by a high volume of patients who
present with a wide variety of physical and psychosocial com-

Editor’s Note. This article is part of a special issue on Public Mental
Health Innovations.
Natalie G. Glover, Mental Health Service, VA Puget Sound Health Care
System, Seattle, Washington; Patrick D. Sylvers, Mental Health Service,
VA Puget Sound Health Care System and Department of Psychiatry and
Behavioral Sciences, University of Washington; Erika M. Shearer and
Mary-Catherine Kane, Mental Health Service, VA Puget Sound Health
Care System; Peter C. Clasen, Department of Psychiatry and Behavioral
Sciences, Stanford University School of Medicine; Amee J. Epler and
Jennifer C. Plumb-Vilardaga, Mental Health Service, VA Puget Sound
Health Care System; Jordan T. Bonow, VA Sierra Nevada Health Care
System, Reno, Nevada; Matthew Jakupcak, Mental Health Service, VA
Puget Sound Health Care System and Department of Psychiatry and
Behavioral Sciences, University of Washington.
We thank Stacey Cherup-Leslie, Michael Earley, Alison Ilem, Laura McIn-
tire, and Erin Tansill for their assistance in facilitating the Life Paths group
within primary care mental health integration at VA Puget Sound.
Correspondence concerning this article should be addressed to Natalie
G. Glover, VA Puget Sound: American Lake Division, 9600 Veterans
Drive SW, Tacoma, WA 98493. E-mail: natalie.glover@va.gov

156
 ACCEPTANCE AND COMMITMENT THERAPY IN PRIMARY CARE
plaints. To address the needs of this population, behavioral inter-
ventions in this setting must maximize impact through brief,
group-based, trans-diagnostic treatments: in other words, interven-
tions that rapidly provide services to a high volume of patients
with a wide variety of presenting concerns. These interventions
must also adopt a stepped-care perspective: Brief treatments will
not resolve all concerns for all patients, however they help all
patients to become acclimated to services, to develop treatment
goals, and to acquire resources for pursuing additional care, if
necessary.
Focused Acceptance and Commitment Therapy (Strosahl, Rob-
inson, & Gustavsson, 2012), or FACT, represents a promising
evidence-based behavioral intervention that meets the needs of the
primary care setting. FACT is an abridged version of Acceptance
and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson,
1999, 2011), a trans-diagnostic approach to psychotherapy that
views psychological rigidity as a ubiquitous phenomenon under-
lying psychopathology and behavioral problems. Using experien-
tial exercises, mindfulness practice, and values clarification, ACT
promotes psychological flexibility (i.e., a measure of acceptance)
and overall health. ACT has yielded positive outcomes for numer-
ous conditions (see Hayes, Luoma, Bond, Masuda, & Lillis, 2006,
for a recent meta-analysis), including mental health and chronic
medical conditions. FACT distills the core methods of ACT into a
protocol that is delivered in two to four sessions, compared with
the typical 12-week ACT paradigm, while providing similar out-
comes for patients (Strosahl, Hayes, Bergan, & Romano, 1998)
and there is growing evidence that brief ACT interventions are
effective when delivered in the group therapy milieu (Butryn,
Forman, Hoffman, Shaw, & Juarascio, 2011; Goodwin, Forman,
Herbert, Butryn, & Ledley, 2012; Kohtala, Lappalainen, Savonen,
Timo, & Tolvanen, 2015). For these reasons, FACT represents a
useful behavioral intervention for the primary care setting.
Despite these advantages, we are not aware of research demon-
strating effectiveness of FACT in primary care, particularly in a
Veteran population. Such data are critical to supporting the imple-
mentation and dissemination of promising behavioral interventions
(like FACT) into integrated primary care settings. This project is
one of the first of its kind, as it examines outcomes related to
changes in core ACT mechanisms (e.g., psychological flexibility),
health and mental health status, and symptom reduction (e.g.,
depression and anxiety) from a 4-week FACT group facilitated in
an integrated VA primary care setting. This research was imple-
mented as a quality improvement (QI) project1 within an estab-
lished, integrated primary care behavioral health program.
Hypotheses
We made the following predictions for outcomes associated
with participation in a primary care– based FACT group:
1. Patients will demonstrate statistically and clinically sig-
nificant improvements in patient-reported quality of life,
as well as their perceptions of their physical and mental
health functioning.
2. Patients will demonstrate statistically and clinically sig-
nificant reductions in patient-reported depression, anxi-
ety, and stress.
157
3. Patients will demonstrate statistically significant gains in
patient-reported psychological flexibility, a theoretical
target for ACT-based therapies.
Method
Participants
Participants included 51 patients who attended the FACT group
as part of routine clinical care in a VA integrated primary care and
mental health setting. Patients in this setting typically present with
mild to moderate mental health concerns and are either referred to
treatment within the integrated primary care setting or referred to
specialty mental health for more intensive, traditional mental
health treatment options. Within the integrated primary care set-
ting, treatment options include brief, 1- to 4-session psychoeduca-
tional classes (e.g., pain, stress, depression, chronic medical con-
ditions, sleep, anger, etc.) and group therapy; brief, 2- to 6-session
individual therapy; initiation of medication by primary care pro-
viders with telephone follow-up by mental health RNs; or a com-
bination of these services. Participants were referred by integrated
primary care mental health clinical staff who recommended the
FACT group based on patients’ presenting problems, treatment
goals, and interests. Participant mean age was 53.23 years (SD ⫽
12.81), 86.27% (n ⫽ 44) were men and 13.7% (n ⫽ 7) were
women, and 64% (n ⫽ 32) identified as Caucasian, 28% (n ⫽ 14)
African American, 2% (n ⫽ 1) Asian American, and 6% (n ⫽ 3)
Native American. Diagnoses of participants included both Unspec-
ified Depressive and Anxiety disorders, Major Depressive Disor-
der, Adjustment Disorders, and Posttraumatic Stress Disorder with
group sizes ranging from two to 12 patients.
Protocol
The FACT group in this protocol consisted of four 90-min,
weekly group sessions: Finding Leverage, Promoting Awareness,
Promoting Openness, and Promoting Engagement. The protocol
was developed by seven of our nine authors. The sessions were
structured based on strategies described in Strosahl, Robinson, and
Gustavsson (2012), and included elements of both experiential
ACT exercises and group discussion. The initial session, Finding
Leverage, involved informed consent, introduced values-based
living, introduced mindfulness, and introduced the ACT concept of
creative hopelessness (that is, identified the concept of a life
without pain as hopeless). The second session, Promoting Aware-
ness, focused on values clarification and identifying experiential
avoidance as a barrier to psychological flexibility. The third ses-
sion, Promoting Openness, focused on cognitive defusion exer-
cises. Cognitive defusion is defined as a process by which an
individual comes to acknowledge his or her thoughts as thoughts,
1
Traditional outcome research in the primary care setting leverages
randomized, clinical trial (RCT) designs; however, the results of these
studies may not always generalize to “real-world” settings because of their
high level of control, frequent exclusion of patients with comorbid condi-
tions, inflexibility with respect to a highly adaptive setting, costliness, and
randomization of patients (Peek, Cohen, & deGruy, 2014). Among alter-
natives to RCTs are quality improvement (QI) projects, which are ideally
both theory-driven and generalizable (Neuhauser & Diaz, 2007).
158 GLOVER ET AL.
so that those thoughts can be responded to in terms of their
workability in the individual’s life, as opposed to their literal truth
(Luoma, Hayes, & Walser, 2007). The final session, Promoting
Engagement, focused on committing to valued behaviors and
promoting a willingness to experience painful thoughts and emo-
tions in service of values. The group was originally led by four of
the protocol developers who trained future group facilitators.
Training included weekly discussions of ACT concepts, review of
relevant activities and metaphors, and observing and cofacilitating
group sessions.
Measures
Participants completed pre- (beginning of first group) and post-
(end of fourth group) treatment self-report assessment measures.
Measures included the WHO-5 Well Being Index (WBI-5; World
Health Organization, 1998), the Depression Anxiety and Stress
Scale 21 (DASS-21; Lovibond & Lovibond, 1995), the Accep-
tance and Action Questionnaire II (AAQ-II; Bond et al., 2011), and
the SF-12 Health Survey, Version 2 (SF-12v2; Ware, Kosinski, &
Keller, 1996).
The WBI-5 is a five-item, Likert-type self-report questionnaire
intended to measure overall subjective well-being and quality of
life. Each item is measured on a six-point Likert-type scale ranging
from 0 (not present) to 5 (constantly present). Studies have found
that the WBI-5 demonstrates reasonable sensitivity and specificity
in identifying depression and anxiety (87% [78 –94] and 70%
[65–75], respectively, coefficient ⌲ ⫽ 0.36 [0.29 –0.44]; cutoff
point ⱕ9; Lowe et al., 2004) as well as good internal consistency
(Cronbach’s alpha ⫽ .95 [0.91–0.99]; Heun, Burkart, Maier, &
Bech, 1999).
The DASS-21 is a 21-item, Likert-type self-report questionnaire
intended to measure subjective depression, anxiety, and stress.
Each item is measured on a 4-point Likert-type scale ranging from
0 (did not apply to me at all) to 3 (applied to me very much, or
most of the time). Studies have found that the DASS-21 demon-
strated construct validity in primary care (e.g., Gloster et al., 2008)
and depressed clinical samples (e.g., Page, Hooke, & Morrison,
2007). The DASS-21 demonstrated adequate internal consistency
in this sample (Cronbach’s alpha pretreatment ⫽ 0.89; posttreat-
ment ⫽ 0.94).
The AAQ-II is a 7-item, Likert-type self-report questionnaire
designed to measure psychological flexibility and experiential
avoidance (two theoretical mechanisms of action proposed by
ACT theorists). The AAQ-II is a relatively recent measure, and
studies have found that it demonstrates adequate psychometric
properties. From a total sample of 2,816 participants, Cronbach’s
alpha pretreatment is 0.88, and posttreatment is 0.91. The 3- and
12-month test–retest reliabilities are .81 and .79, respectively.
AAQ-II scores concurrently, longitudinally, and incrementally
predict a range of outcomes, including mental health, and also
demonstrate appropriate discriminant validity (Bond et al., 2011).
The SF-12v2 is a 12-item, mixed-method (3-, 5-, and 6-point
Likert-type scales, as well as binary response items) self-report
questionnaire designed to broadly measure patient perceptions of
physical and mental health functioning. Several studies have found
that the SF-12v2 serves as a valid indicator of current health status
(e.g., Larson, 2002). Moreover, studies have found that the SF-
Table 1
Descriptive Statistics for Study Measures
Pretreatment Posttreatment
Measure M (SD) M (SD)
DASS21
Depression Scale 19.97 (10.34) 15.27 (9.51)
Anxiety Scale 13.30 (8.70) 11.40 (9.48)
Stress Scale 19.73 (9.69) 17.19 (9.68)
SF12v2
Physical Composite Score 35.48 (8.73) 38.06 (8.80)
Mental Health Composite Score 35.87 (9.17) 40.41 (8.64)
AAQ-II 27.43 (8.94) 26.84 (8.99)
WBI-5 8.60 (4.16) 12.81 (5.34)
Note. N ⫽ 51. DASS21 ⫽ Depression Anxiety Stress Scale 21;
SF12v2 ⫽ SF-12 Health Survey, Version 2; AAQ-II ⫽ Acceptance and
Action Questionnaire II; WBI-5 ⫽ WHO Five Well Being Index.
12v2 provides comparable sensitivity to the longer SF-36 (e.g.,
Jenkinson et al., 1997).
Data Analysis
Table 1 displays descriptive statistics for the sample. All pre-
and posttreatment measures displayed adequate normality to sup-
port the assumptions of OLS regression (SPSS skewness scores
within ⫾ 1.0). When regressed on AAQ-II outcomes, we found a
significant effect of age and ethnicity on AAQ-II outcomes (F ⫽
16.39, p ⬍ .01 and F ⫽ 12.89, p ⫽ .01, respectively) and, as such,
were included as covariates in analyses evaluating AAQ-II out-
comes; however, we did not find significant effects of age or
ethnicity when regressed on other outcome measures (all p ⬎ .2).
We did not find significant effects of gender when regressed on
any of the outcome measures (all p ⬎ .2).
Results
Hypothesis 1
We used repeated-measures ANOVA to test whether quality of
life, as measured by the WBI-5, improved over the course of
treatment. Effect sizes for all analyses were calculated as “classi-
cal” ␩2 (cf., Pierce, Block, & Aguinis, 2004) using the formula
SSfactor/SStotal. Results indicated a large effect on quality of life
(F(1, 51) ⫽ 21.29, p ⬍ .001, ␩2 ⫽ 0.30) from pre- to posttreat-
ment. In terms of clinically significant change (Jacobson & Truax,
1991), 19 (37.25%) participants demonstrated clinically significant
improvements in perceived quality of life, whereas 3 (5.88%)
participants demonstrated clinically significant exacerbations.
We used repeated-measures MANOVA to test whether the
participants’ perception of their overall physical and mental health
functioning, as measured by the SF-12v2, improved over the
course of treatment. Results demonstrated a moderate effect of
treatment on participant perceptions of mental health functioning
(Mental Health Composite Scores [MCS] scale), F(1, 51) ⫽ 9.67,
p ⫽ .003, ␩2 ⫽ 0.11, and a small effect on perceptions of physical
health functioning (Physical Health Composite Scores [PCS] scale,
F(1, 51) ⫽ 6.60, p ⫽ .01, ␩2 ⫽ 0.08.
 ACCEPTANCE AND COMMITMENT THERAPY IN PRIMARY CARE
Hypothesis 2
We used repeated-measures MANOVA to test whether the
intervention led to significant reductions in patient-reported de-
pression, anxiety, and stress, as measured by the DASS-21. To
account for shared variance among DASS-21 subscales, all
changes in scale scores were tested within the same analysis.
Results revealed a small effect of treatment on perceived stress,
F(1, 51) ⫽ 4.08, p ⫽ .04, ␩2 ⫽ 0.03, a moderate effect of treatment
on depressive symptoms, F(1, 51) ⫽ 11.47, p ⬍ .001, ␩2 ⫽ 0.08,
and a possible statistical trend for reductions in anxiety, F(1, 51) ⫽
3.29, p ⫽ .07, ␩2 ⫽ 0.01. Of note, it is possible that the lattermost
finding does not constitute a statistical trend, but rather a redun-
dancy error attributable to overlapping scales.
In terms of reliable change (Jacobson & Truax, 1991), 15
participants demonstrated reductions in DASS-21 Stress, 19 in
DASS-21 Depression, and 10 in DASS-21 Anxiety. Reliable ex-
acerbation of symptoms occurred in four participants in DASS-21
Stress, four participants in DASS-21 Depression, and three partic-
ipants in DASS-21 Anxiety. In terms of clinically significant
change, 15 participants fell in the asymptomatic range for
DASS-21 Depression, 26 for DASS-21 Stress, and 21 for
DASS-21 Anxiety.
Hypothesis 3
We used repeated-measures ANCOVA, with age and ethnicity
as covariates, to test whether the intervention led to increases in
psychological flexibility, as measured by the AAQ-II. Results
indicated a nonsignificant effect of treatment on psychological
flexibility, F(1, 51) ⫽ 2.05, p ⫽ .16, ␩2 ⫽ 0.04.
Patient care 6 to 18 months after participation in the FACT
group was assessed, and it was found that 53.8% did not seek
additional services, 25% followed up with additional groups or
monthly individual treatment in the integrated primary care clinic,
13.5% continued with psychiatric services only, and 7.7% were
referred to specialty mental health services.
Discussion
To our knowledge, this is the first study to evaluate the effec-
tiveness of FACT in a primary care setting within a VA health care
system. Results indicate that a brief (four session), group-based
iteration of FACT delivered in this setting is associated with
enhanced quality of life, reduced stress, and decreased depressive
symptoms. Results also showed a trend toward decreased anxiety
symptoms. Inconsistent with hypotheses, these changes were not
associated with corresponding changes in acceptance/psychologi-
cal flexibility.
These findings are consistent with literature assessing the effec-
tiveness of longer ACT protocols (i.e., 12 weeks) with respect to
enhanced quality of life (A-Tjak et al., 2015), reduced stress
(Daltry, 2015), and reduced anxiety and depressive symptoms
(Smout, Hayes, Atkins, Klausen, & Duguid, 2012). These findings
are also consistent with extant research showing that shorter-term
treatment may lead to outcomes just as great as those achieved by
longer-term treatment (Molenaar et al., 2011). Moreover, there is
a substantial body of research supporting the phenomenon of rapid
clinical change occurring within the first two to four treatment
159
sessions (Doane, Feeny, & Zoellner, 2010), which is associated
with long-term functional improvements as well as reduced rates
of relapse (Aderka, Nickerson, Boe, & Hoffman, 2012). Thus, our
findings indicate that FACT leads to statistical and clinically
meaningful psychological improvement in a brief, group-based
format in primary care. Our results also support the usefulness of
FACT groups (Strosahl et al., 2012), serving as a meaningful
addition to the literature already supporting the effectiveness of
brief ACT interventions (Butryn et al., 2011; Goodwin et al., 2012;
Kohtala et al., 2015).
Of particular importance, given the applied nature of the current
research, is the clinical significance of the findings. With respect to
clinically significant change (Jacobson & Truax, 1991), 29% of the
patients demonstrated decreased stress, 37% demonstrated de-
creased depression, and 19% demonstrated decreased anxiety, as
assessed by the DASS-21. By comparison, a relatively small
proportion of patients reported elevated symptoms after treatment:
7% reported increased stress, 7% reported increased depression,
and 6% reported increased anxiety. It is unclear whether these
increased scores reflect clinical worsening or some level of ex-
pected symptom variability as patients increase awareness of psy-
chological problems in the early phases of treatment. Indeed, some
ACT studies show a delayed pattern of improvement, which may
in part be attributable to this focus on increased awareness of
psychological distress (e.g., Luoma, Kohlenberg, Hayes, &
Fletcher, 2012). With respect to remission of symptoms, following
participation in FACT, 29% of participants fell within the asymp-
tomatic range for depression, 50% for stress, and 40% for anxiety.
These results provide further support for the capacity of the FACT
protocol to lead to meaningful, positive change in participants’
symptomatology. With regard to meaningful change, of particular
importance for the integrated primary care setting is the trajectory
of care for patients— essentially the effectiveness of primary group
treatment at reducing needs for specialty mental health services
(e.g., mental health clinic, PTSD-focused clinic, etc.). These out-
comes are in line with patient care-related goals of integrated
primary care clinics.
It is important to note that this brief, group-based implementa-
tion of FACT in a primary care setting was not associated with
significant changes in patient-reported psychological flexibility.
Although the ACT model suggests psychological flexibility rep-
resents a mediating mechanism, not all research examining ACT
outcomes supports this claim (Niles et al., 2014). Therefore,
changes in psychological flexibility may not be necessary for
patients to benefit from interventions like FACT. It may also be
that significant and sustainable levels of change in psychological
flexibility are borne over a longer period of time and that the brief
nature of this intervention and assessment window did not suffi-
ciently capture these effects (Luoma et al., 2012). Future research
is required to monitor the long-term outcomes of patients who
engage in FACT in the primary care setting. Such long-term
monitoring would also be beneficial in demonstrating sustainment
of the short-term clinical improvements from FACT documented
by the present research. This would be particularly important in
ruling out alternative explanations for short-term improvements
including transient processes such as regression to the mean or
temporary reduction in distress accompanying initiation of treat-
ment. Of note, the Five Facet Mindfulness Questionnaire (FFMQ;
Baer, Smith, Hopkins, Krietmeyer, & Toney, 2006) is a widely
160 GLOVER ET AL.
used measure of mindfulness and self-compassion that may also
prove very useful in ACT and FACT research, specifically in terms
of capturing progress related to psychological flexibility.
Current findings should be considered within the context of a
number of limitations. First, this study did not include a control
group and randomization, therefore it is not possible to determine
whether FACT participation caused changes in the measured out-
comes. Nevertheless, this study offers critical preliminary data
(with respect to both clinical outcomes and feasibility) to support
more rigorous effectiveness trials. Second, though ACT is known
for its transdiagnostic efficacy (Strosahl et al., 2012), it may have
proven useful to track participants’ diagnoses, to explore whether
they moderated the reported outcomes. Third, the study did not
attempt to assess the process of change. Research examining more
traditional ACT protocols has revealed evidence to support that
ACT works through generally recognized processes of change
(e.g., cognitive defusion, use of acceptance strategies, and willing-
ness to engage in value-driven behavior regardless of unpleasant
thoughts and emotions; Ruiz, 2012); however, the process of
change may differ with respect to a more time-limited FACT
protocol in a group setting. Future work is critical to examine this
hypothesis. Finally, as mentioned earlier, the use of follow-up
data/long-term monitoring would have been useful in demonstrat-
ing sustainment, if any, of short-term clinical improvements
gained following participation in the FACT group.
Despite these limitations, the current study provides preliminary
evidence for the efficacy of a FACT group protocol in a VA
primary care setting. Moreover, the brief, group-based, and trans-
diagnostic nature of the intervention employed in this study rep-
resents an ideal fit for the needs of modern primary care. For these
reasons, FACT represents a promising intervention that can ad-
vance the goals of integrated primary care.
References
Aderka, I. M., Nickerson, A., Bøe, H. J., & Hofmann, S. G. (2012). Sudden
gains during psychological treatments of anxiety and depression: A
meta-analysis. Journal of Consulting and Clinical Psychology, 80, 93–
101. http://dx.doi.org/10.1037/a0026455
A-Tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., &
Emmelkamp, P. M. (2015). A meta-analysis of the efficacy of accep-
tance and commitment therapy for clinically relevant mental and phys-
ical health problems. Psychotherapy and Psychosomatics, 84, 30 –36.
http://dx.doi.org/10.1159/000365764
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006).
Using self-report assessment methods to explore facets of mindfulness.
Assessment, 13, 27– 45. http://dx.doi.org/10.1177/1073191105283504
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N.,
Orcutt, H. K., . . . Zettle, R. D. (2011). Preliminary psychometric
properties of the Acceptance and Action Questionnaire-II: A revised
measure of psychological inflexibility and experiential avoidance. Be-
havior Therapy, 42, 676 – 688. http://dx.doi.org/10.1016/j.beth.2011.03
.007
Butryn, M. L., Forman, E., Hoffman, K., Shaw, J., & Juarascio, A. (2011).
A pilot study of acceptance and commitment therapy for promotion of
physical activity. Journal of Physical Activity & Health, 8, 516 –522.
Daltry, R. M. (2015). A case study: An ACT stress management group in
a university counseling center. Journal of College Student Psychother-
apy, 29, 36 – 43. http://dx.doi.org/10.1080/87568225.2015.976076
Doane, L. S., Feeny, N. C., & Zoellner, L. A. (2010). A preliminary
investigation of sudden gains in exposure therapy for PTSD. Behaviour
Research and Therapy, 48, 555–560. http://dx.doi.org/10.1016/j.brat
.2010.02.002
Gloster, A. T., Rhoades, H. M., Novy, D., Klotsche, J., Senior, A., Kunik,
M., . . . Stanley, M. A. (2008). Psychometric properties of the Depres-
sion Anxiety and Stress Scale-21 in older primary care patients. Journal
of Affective Disorders, 110, 248 –259. http://dx.doi.org/10.1016/j.jad
.2008.01.023
Goodwin, C. L., Forman, E. M., Herbert, J. D., Butryn, M. L., & Ledley,
G. S. (2012). A pilot study examining the initial effectiveness of a brief
acceptance-based behavior therapy for modifying diet and physical
activity among cardiac patients. Behavior Modification, 36, 199 –217.
http://dx.doi.org/10.1177/0145445511427770
Hayes, S. C. J., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006).
Acceptance and commitment therapy: Model, processes and outcomes.
Behaviour Research and Therapy, 44, 1–25. http://dx.doi.org/10.1016/j
.brat.2005.06.006
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and
commitment therapy: An experiential approach to behavior change.
New York, NY: Guilford Press.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and
Commitment Therapy: The process and practice of mindful change (2nd
ed.). New York, NY: Guilford Press.
Heun, R., Burkart, M., Maier, W., & Bech, P. (1999). Internal and external
validity of the WHO Well-Being Scale in the elderly general population.
Acta Psychiatrica Scandinavica, 99, 171–178. http://dx.doi.org/10.1111/
j.1600-0447.1999.tb00973.x
Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical
approach to defining meaningful change in psychotherapy research.
Journal of Consulting and Clinical Psychology, 59, 12–19. http://dx.doi
.org/10.1037/0022-006X.59.1.12
Jenkinson, C., Layte, R., Jenkinson, D., Lawrence, K., Petersen, S., Paice,
C., & Stradling, J. (1997). A shorter form health survey: Can the SF-12
replicate results from the SF-36 in longitudinal studies? Journal of
Public Health Medicine, 19, 179 –186. http://dx.doi.org/10.1093/
oxfordjournals.pubmed.a024606
Kathol, R. G., Degruy, F., & Rollman, B. L. (2014). Value-based finan-
cially sustainable behavioral health components in patient-centered med-
ical homes. Annals of Family Medicine, 12, 172–175. http://dx.doi.org/
10.1370/afm.1619
Kohtala, A., Lappalainen, R., Savonen, L., Timo, E., & Tolvanen, A.
(2015). A four-session acceptance and commitment therapy based in-
tervention for depressive symptoms delivered by masters degree level
psychology students: A preliminary study. Behavioural and Cognitive
Psychotherapy, 43, 360 –373. http://dx.doi.org/10.1017/S135246
5813000969
Larson, C. O. (2002). Use of the SF-12 instrument for measuring the health
of homeless persons. Health Services Research, 37, 733–750. http://dx
.doi.org/10.1111/1475-6773.00046
Lovibond, P. F., & Lovibond, S. H. (1995). The structure of negative
emotional states: Comparison of the Depression Anxiety Stress Scales
(DASS) with the Beck Depression and Anxiety Inventories. Behaviour
Research and Therapy, 33, 335–343. http://dx.doi.org/10.1016/0005-
7967(94)00075-U
Löwe, B., Gräfe, K., Zipfel, S., Witte, S., Loerch, B., & Herzog, W. (2004).
Diagnosing ICD-10 depressive episodes: Superior criterion validity of
the Patient Health Questionnaire. Psychotherapy and Psychosomatics,
73, 386 –390. http://dx.doi.org/10.1159/000080393
Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An
Acceptance & Commitment Therapy skills-training manual for thera-
pists. Oakland, CA: New Harbinger.
Luoma, J. B., Kohlenberg, B. S., Hayes, S. C., & Fletcher, L. (2012). Slow
and steady wins the race: A randomized clinical trial of acceptance and
commitment therapy targeting shame in substance use disorders. Journal
 ACCEPTANCE AND COMMITMENT THERAPY IN PRIMARY CARE
of Consulting and Clinical Psychology, 80, 43–53. http://dx.doi.org/10
.1037/a0026070
Melchert, T. P. (2015). Integrating behavioral health care into primary
health care. Washington, DC: American Psychological Association.
http://dx.doi.org/10.1037/14441-014
Molenaar, P. J., Boom, Y., Peen, J., Schoevers, R. A., Van, R., & Dekker,
J. J. (2011). Is there a dose-effect relationship between the number of
psychotherapy sessions and improvement of social functioning? British
Journal of Clinical Psychology, 50, 268 –282. http://dx.doi.org/10.1348/
014466510X516975
Neuhauser, D., & Diaz, M. (2007). Quality improvement research: Are
randomised trials necessary? Quality & Safety in Health Care, 16,
77– 80. http://dx.doi.org/10.1136/qshc.2006.021584
Niles, A. N., Burklund, L. J., Arch, J. J., Lieberman, M. D., Saxbe, D., &
Craske, M. G. (2014). Cognitive mediators of treatment for social
anxiety disorder: Comparing acceptance and commitment therapy and
cognitive-behavioral therapy. Behavior Therapy, 45, 664 – 677. http://dx
.doi.org/10.1016/j.beth.2014.04.006
Page, A. C., Hooke, G. R., & Morrison, D. L. (2007). Psychometric
properties of the Depression Anxiety Stress Scales (DASS) in depressed
clinical samples. British Journal of Clinical Psychology, 46, 283–297.
http://dx.doi.org/10.1348/014466506X158996
Peek, C. J., Cohen, D. J., & deGruy, F. V., III. (2014). Research and
evaluation in the transformation of primary care. American Psychologist,
69, 430 – 442. http://dx.doi.org/10.1037/a0036223
Pierce, C. A., Block, C. A., & Aguinis, H. (2004). Cautionary note on
reproting eta-squared values from multifactor ANOVA designs. Educa-
161
tional and Psychological Measurement, 64, 916 –924. http://dx.doi.org/
10.1177/0013164404264848
Ruiz, F. J. (2012). Acceptance and commitment therapy versus traditional
cognitive behavioral therapy: A systematic review and meta-analysis of
current empirical evidence. International Journal of Psychology & Psy-
chological Therapy, 12, 333–357.
Smout, M. F., Hayes, L., Atkins, P. W. B., Klausen, J., & Duguid, J. E.
(2012). The empirically supported status of acceptance and commitment
therapy: An update. Clinical Psychologist, 16, 97–109. http://dx.doi.org/
10.1111/j.1742-9552.2012.00051.x
Strosahl, K., Hayes, S. C., Bergan, J., & Romano, P. (1998). Assessing the
field effectiveness of Acceptance and Commitment Therapy: An exam-
ple of the manipulated training research method. Behavior Therapy, 29,
35– 63. http://dx.doi.org/10.1016/S0005-7894(98)80017-8
Strosahl, K., Robinson, P., & Gustavsson, T. (2012). Brief interventions for
radical change: Principles & practice of focused acceptance & com-
mitment therapy. Oakland, CA: New Harbinger Publications.
Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-item short-form
health survey: Construction of scales and preliminary tests of reliability
and validity. Medical Care, 34, 220 –233. http://dx.doi.org/10.1097/
00005650-199603000-00003
World Health Organization. (1998). Info package: Mastering depression in
primary care, version 2.2. Frederiksborg, Denmark: WHO, Regional
Office for Europe, Psychiatric Research Unit.
Received May 22, 2015
Revision received September 6, 2015
Accepted September 14, 2015 䡲