Journal of Contextual Behavioral Science: Marge A. Sierra, Eliana Ortiz

Journal of Contextual Behavioral Science 28 (2023) 127–138
Contents lists available at ScienceDirect
Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs
Feasibility and effect of a self-help online acceptance and commitment

therapy program focused on repetitive negative thinking for Colombian
young women
Marge A. Sierra *, Eliana Ortiz
Universidad Católica de Colombia, Colombia
A R T I C L E I N F O A B S T R A C T
Keywords: Online psychological interventions (OPI) are evidence-based programs that provide mental health treatment over
Acceptance and commitment therapy the internet. Meta-analytic data suggests that OPI’s effectively treat emotional symptomatology. RNT-focused
Online psychological intervention ACT consider psychological inflexibility and RNT as trans-diagnostic process that significantly predict
Repetitive negative thinking
emotional symptomatology. The present study analyzed the effect of a self-help OPI which contents have pre
Emotional symptomatology
Repeated measures design
viously shown content validity, user feasibility and effectivity. This is an open trial design with repeated mea
sures of emotional symptomatology and behavioral change processes. Bayesian analysis of variance for repeated
measures was conducted with JASP for each variable, Bayes Factors (BF10) determined how much the evidence
favored OPI effect. Effect sizes, reliable and significant change and moderation analyses were also conducted. 18
cisgender women around 30 years old mostly heterosexual, single and unemployed finished the OPI. There is
decisive evidence for OPI effect on emotional symptomatology and behavioral change processes (experiential
avoidance, cognitive fusion and RNT). There is also anecdotal evidence for the moderating role of the number of
hierarchical RNT triggers (abstract private events), their type and intimate partner relationship distress as well as
anecdotal evidence against the moderating role of being a psychologist. Results need to be considered in the
context of the study limitations and future research should explore the program’s feasibility and effect in other
populations and cultures. However, the program is feasible and efficacious for the treatment of emotional
symptomatology at least for young cisgender women in Colombia.
Online Psychological Interventions (OPI; Peñate et al., 2014; Perle severity of emotional symptomatology (Nolen-Hoeksema, 1991, 2000;
et al., 2011; Sierra et al., 2018; Sierra & Ortiz, 2022a) are Nolen-Hoeksema et al., 2008; Segerstrom et al., 2000; Sorg et al., 2012).
evidence-based self-help programs designed for mental health treatment It consists of repetitive thoughts which contents are deemed negative,
through information and communication technologies. OPIs typically aversive, intrusive, and difficult to control or avoid (Ehring & Watkins,
feature psycho-education about the target diagnosis or problem, an 2008; McLaughlin & Nolen-Hoeksema, 2011; Segerstrom et al., 2000;
evaluation process and explicit intervention components (Andersson & Watkins, 2008; Watkins et al., 2005) RNT is also an experiential
Cuijpers, 2009; Nelson et al., 2011; Peñate et al., 2014; Sierra & Ortiz, avoidance strategy (Ruiz, Luciano, et al., 2020) that easily becomes
2022a; Titov, 2007). Most of the existing third-wave OPI’s are adapted predominant as it: tends to be a generalized reaction to fear, unattained
from acceptance-based interventions (Brown et al., 2016; Cavanagh goals, and values incoherence, prolongs negative affect by focusing on
et al., 2014; Kelson et al., 2019; Spijkerman et al., 2016; Twomey et al., the content of the unwanted the private events, and often leads to
2017). Existing meta-analytic data suggest that these OPI’s effectively engaging in additional experiential avoidance strategies (Caselli et al.,
treat emotional symptomatology, finding medium to high effect sizes 2013; Newman & Llera, 2011; Nolen-Hoeksema et al., 2007; Ruiz et al.,
and relatively low attrition rates (Brown et al., 2016; Cavanagh et al., 2016a; Wells, 2009).
2014; Sierra et al., 2018; Sierra & Ortiz, 2022a; Spijkerman et al., 2016) RNT-focused ACT (Ruiz et al., 2016a, 2018) is an ongoing research
Repetitive negative thinking (RNT) is a trans diagnostic process that line within the Acceptance and commitment therapy (ACT; Hayes et al.,
includes rumination and worry and significantly predicts the onset and 2011; Wilson & Luciano, 2002) framework and as such considers
* Corresponding author. Avenida Caracas 46-40, Bogotá, D.C., Colombia.

E-mail address: masierra34@ucatolica.edu.co (M.A. Sierra).
https://doi.org/10.1016/j.jcbs.2023.03.010
Received 20 September 2022; Received in revised form 21 February 2023; Accepted 10 March 2023
Available online 15 March 2023
2212-1447/© 2023 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
M.A. Sierra and E. Ortiz Journal of Contextual Behavioral Science 28 (2023) 127–138
psychological inflexibility is a trans-diagnostic process at the core of participants outcomes after the OPI. c) Confirming the theorized medi
psychopathology and consists of a functional class of behavior in which ating role of psychological inflexibility components in emotional
ongoing private experiences dominate responding over chosen values symptomatology scores, supporting its role as behavioral change
(Bond et al., 2011; Luciano et al., 2021; Törneke et al., 2016). There is mechanisms for the OPI. d) Assess the feasibility of the OPI according to
evidence of the predictive role of psychological inflexibility for the the user’s self-reported clarity, utility and satisfaction scores. To this
development of symptomatology (Faustino, 2020; Faustino et al., 2021; date no studies have assessed the effect of this or any other OPI based on
Hayes et al., 2012; Kashdan & Rottenberg, 2010; Levin et al., 2014; RNT-Focused ACT over emotional symptomatology or psychological
Tyndall et al., 2018). ACT aims to promote psychological flexibility, the inflexibility. However, this research is important and necessary towards
ability to nonjudgmentally become aware of ongoing private experi contributing to establish OPIs as legitimate, effective and feasible al
ences while orienting the present ongoing behavior towards valued ternatives to traditional psychotherapy as encouraged by Kazdin
ends. (2014a; 2014b).
RNT-focused ACT is particularly based upon the growing evidence The program’s contents have been previously evaluated by experts
that values and RNT triggers are organized as hierarchical networks of and users showing feasibility and adequate content validity (Sierra &
positive and negative reinforcers (Gil et al., 2012, 2014; Gil-Luciano Ruiz, 2022). The OPI contents were also tested on a different setting
et al., 2019). Thus, the rationale behind focusing on RNT is being able to (face to face workshops) for preventing and reducing emotional symp
identify and target the most abstract triggers of RNT or “Big Ones” toms in novice clinical psychology trainees (Dereix-Calonge et al.,
within the hierarchical network as achieving transformation of functions 2019). Results show that the contents of the program were efficacious in
at this level of the hierarchical network would make the other subor reducing emotional symptoms (d = .75), depression (d = 0.79), and RNT
dinated RNT triggers that are usually more concrete and specific lose (d = 0.62). Subgroup analyses with participants showing higher levels of
sense, strength, importance and influence over the person’s life (Ruiz emotional symptoms evidenced statistically significant reductions in
et al., 2016a, 2018, 2019, 2020a, 2020b; Dougher et al., 1994, 2007; Gil emotional symptoms (d = .97 to 2.52). 73.33% of participants shown
et al., 2012, 2014; Gil-Luciano et al., 2019; Rodríguez-Valverde et al., reliable change in emotional symptoms, while 66.67% shown a clini
2009; Villarroel et al., 2021). Focusing on RNT is also especially cally significant improvement.
important considering it’s deemed as the most predominant response in
presence of aversive private events (Ehring & Watkins, 2008; Newman & 1. Method
Llera, 2011; Ruiz, Luciano, et al., 2020). The efficacy of brief,
RNT-focused ACT interventions has been tested through several 1.1. Design
single-case experimental designs (Ruiz et al., 2016a, 2018, 2019, 2020a,
2020b; Salazar et al., 2020) and randomized controlled trials (Bernal- This is an open trial (Nezu & Nezu, 2007) that follows a repeated
Manrique et al., 2020; Dereix-Calonge et al., 2019), finding very large measures design (Morley, 2017; Price et al., 2017) assessing emotional
effect sizes for decreasing emotional symptomatology and RNT over symptomatology and behavioral change processes across specific mile
diverse samples and populations. stones during the OPI. As expected for open trials, there was a single
On the other hand, it has been documented that the strict biosecurity experimental condition, no control group and no randomization. The
measures adopted by most countries in the world in the wake of the trial complies with national and international standards of research with
COVID-19 pandemic can have a negative effect over the mental health of human participants (see ethical considerations section) and total
the general population (Giallonardo et al., 2020; Henssler et al., 2020; transparency is ensured by providing all pertinent files as complemen
Serafini et al., 2020; Wang et al., 2021). It is also is estimated that at tary to this paper.1
least half of people who have been infected with COVID-19 report some
type of psychological distress (Mazza et al., 2020; Panchal et al., 2020; 1.2. Participants
Qiu et al., 2020; Wang, Hu, et al., 2020; Wang, Pan, et al., 2020; Wang
et al., 2020). Additionally, the already high prevalence of psychological The present study offered the participants recruited on Sierra and
disorders and scarce mental health coverage for the most vulnerable Ortiz (2022b) that voluntarily consented and responded to a mental
populations have been leading evidence-based therapies to the explo health survey the opportunity to participate on the OPI. In order to do so
ration of alternative delivery modes for psychological therapy in order they would need to have over 25 points on the total score of the main
to reduce the mental health burden at a global level (APA, 2006; Kazdin, outcome measure, be able to read and write and have a permanent
2014b). Information and communication technologies offer that exact internet connection. Exclusion criteria were screened according to the
possibility through what is known as “telehealth” (the use of said tools to participants responses to the virtual survey used on Sierra and Ortiz
facilitate access to assessment, diagnosis, intervention and follow-up) (2022b) and included: self-reported history of psychotic or eating dis
(Eysenbach, 2001; Nickelson, 1998; Peñate, 2012). Kazdin (2014a) orders, recent suicide plans or attempts, current use of psychoactive
considered this the following step after gathering enough evidence in substances and current mental health treatment (psychological, phar
favor of a certain evidence-based therapy, further research should aim to macological or both). 44 young people initially shown interest and
demonstrate that delivering that therapy using telehealth strategies is provided their consent to be contacted, among them only 26 (59.09%)
feasible and has an equivalent effect compared to traditional psycho were considered enrolled since they actually created their account and
therapy. Also, the effect found would need to be mediated by the password. However, 16 (36.36%) did not start any of the activities at all,
behavioral change mechanisms or trans-diagnostic processes proposed representing attrition rates consistent with the “Law of attrition”
at the theoretical level and already documented in its traditional (Eysenbach, 2005) but higher than expected (19–23%). 10 (22.72%)
application (Kashdan & Rottenberg, 2010; Kazdin, 2014a, 2014b; dropped the program at different points in time and in the end only 18
Wangelin et al., 2016). (40.9%) finished the OPI.
Considering the latter, the present study aims to conduct the initial
feasibility and efficacy analysis of a self-help OPI program by specif 1.3. Instruments
ically: a) Assessing how much evidence favors the alternative hypothesis
(i.e. the OPI is effective and decreases emotional symptomatology and Depression Anxiety and Stress Scale (DASS-21; Original: Antony
psychological inflexibility components scores across time) over the null
hypothesis (i.e. the OPI does not have an effect and therefore there is no
significant differences between the scores across time) b) Identifying 1
Data available on https://data.mendeley.com/datasets/34ycrjtkzt/draft?
moderating variables that explain the existing variability among a=c4a597b0-f5cc-4f97-98a2-6f59e69358c1.
128
et al., 1998; Colombian Version: Ruiz, García-Martín, et al., 2017): Ones”, experiential avoidance strategies, valued directions, and possible
DASS-21 is a psychometric instrument with three subscales that evalu committed actions. b) Help the participants identify the ineffectiveness
ates the presence and severity of depression, anxiety and stress symp of their previous coping strategies. c) Proposing an alternative behav
toms during the last week. It has 21 items with a four-point Likert-type ioral pattern on three steps involving disengaging from RNT, remem
scale (0 = It has not happened to me; 3 = It has happened to me a lot, or bering their values and acting towards them.
most of the time). DASS-21 has a hierarchical factor structure (Lovibond Module II “Developing an observation point for thoughts” aims to
& Lovibond, 1995) and its total summative score can be used as a train the participants to identify how RNT starts, how it works and how
trans-diagnostic emotional symptomatology outcome with a clinical to disengage from it. This module focuses on defusion and illustrates
cut-off score of 25 (Ruiz et al., 2018, 2020, 2020a, 2020b; Ruiz, Luciano, pervasive aspects of human thinking, emphasizing that the participants
et al., 2020; 2020). Its Cronbach’s alpha is α = 0.83 for the general are free to decide how to relate to their private events. These activities
population in Colombia (Ruiz, García-Martín, et al., 2017). also showed the participants that being mindful of what is important and
Acceptance and Action Questionnaire (AAQ-II; Original: Bond useful for them in the present moment can help them disengage from
et al., 2011; Validation Colombia: Ruiz, Suárez-Falcón, et al., 2016): RNT and advance towards their values.
AAQ-II is a psychometric instrument to assess experiential avoidance, an Module III “Focusing on what really matters” seeks to help the par
inflexible behavioral pattern that consists of systematically attempting ticipants clarify their values. This module includes activities that show
to escape, avoid or postpone the experience of discomfort triggered by the long-term consequences of their previous coping strategies and how
certain verbal and contextual events (Boulanger et al., 2010; Chawla & the proposed alternatives can actually help them advance towards the
Ostafin, 2007; Cookson et al., 2019; Hayes et al., 1996; Hayes et al., meaningful life they want. Other activities propose establishing concrete
2011). It consists of 7 items that score on a seven-point Likert-type scale and realistic goals related to their values and planning on ways to
(1 = Never true; 7 = Always true). Its Cronbach’s alpha is α = 0.91 for overcome potential barriers that will surely arise as they try to progress.
the general population in Colombia (Ruiz, Suárez-Falcón, et al., 2016).
Cognitive Fusion Questionnaire (CFQ; Gillanders et al., 2014; 1.5. Procedure
Validation Colombia: Ruiz, Suárez-Falcón, et al., 2017): CFQ is a psy
chometric instrument to assess cognitive fusion, an inflexible behavioral Participants who met inclusion criteria were contacted and informed
pattern under control of the emotional and discriminative functions that about the terms and conditions of the study and informed consent was
certain verbal events might have (Bardeen & Fergus, 2016; Cookson obtained. Their participation on Sierra and Ortiz (2022b) was the first
et al., 2019; Dionne, Ngô, & Blais, 2014; Hayes et al., 2011; Hayes et al., baseline point and their evaluation at the time of consenting for the OPI
2001; Wilson & Luciano; 2002). In other words, cognitive fusion consists was the second point. These two points were averaged to represent a
of taking literally, over analyzing and acting according to thoughts and single average baseline score.
verbal rules that lead to inflexible behaviors such as experiential Next, the participants created their password for the OPI website and
avoidance. It consists of 7 items that score on a seven-point Likert-type were able to navigate autonomously the tutorial page and the activities
scale (1 = Never true; 7 = Always true). Its Cronbach’s alpha is α = 0.93 available in Module I. Only after finishing all of the activities the
for the general population in Colombia (Ruiz, Suárez-Falcón, et al., participant was able to notify completion and request the release of the
2017). next module. Weekly synchronic feedback and support sessions (1 h)
Perseverative Thinking Questionnaire (PTQ; Ehring et al., 2011): with the first author were scheduled to discuss their answers and
PTQ is a psychometric instrument to evaluate repetitive negative progress on the program activities. These sessions could be re-scheduled
thinking, an inflexible behavioral pattern characterized by the repetitive according to the participant’s need extending their participation on the
occurrence of verbal events featuring contents that are deemed as OPI. Repeated measures of the instruments were virtually obtained
negative, aversive, intrusive, and difficult to control or avoid (Ehring & weekly regardless of the participant’s progress.
Watkins, 2008; McLaughlin & Nolen-Hoeksema, 2011; Segerstrom et al., Module I, Module II and Module III time points featured on the
2000; Watkins, 2008; Watkins et al., 2005). It consists of 15 items that present study were different for every participant. Module I scores
score on a five-point Likert-type scale (0 = Never; 4 = Almost always). represent the repeated measures collected when the last activity of
According to preliminary data, its Cronbach’s alpha is α = 0.96 for the Module I was discussed synchronically. Likewise, Module II scores
general population in Colombia. consisted of the last repeated measures obtained after providing syn
User Quality Survey (UQS; Sierra & Ruiz, 2022): Clarity, utility and chronic feedback regarding Module II activities. On the other hand,
satisfaction regarding the OPI contents were evaluated with the same Module III scores represent the repeated measures given at the final
kind of custom instrument used for the program content validity study synchronic session that closed their participation on the OPI. Partici
(Sierra & Ruiz, 2022). The instrument consisted of a 5-point Likert-type pants also responded virtually to every psychometric instrument at
scale (5 = completely agree; 1 = completely disagree). The item for Clarity short-term (one month) and mid-term (three months) follow-up after the
stated “The contents of the program have been clear and easy to un end of the OPI. The obtained data allowed to analyze the permanence of
derstand”, the one for Utility was “The contents of the program have the OPI effect over time.
been useful in my daily life” and the one for Satisfaction was “I am Ethical Considerations: Informed consent fully complied with na
satisfied with the contents of the program”. tional (Law 1090 of 2006, 2006, Statutory Law 1266 of 2008, Statutory
Law 1581 of 2012) and international (APA, 2013, 2019; BACB, 2014;
1.4. Intervention World Medical Association, 2013) ethical standards. The document
explained what is an open trial, its procedures and scope, as well as the
Disentangled, Aware, and Committed (DAC; Sierra & Ruiz, 2018; participation conditions and inclusion criteria and the possibility of
Sierra & Ruiz, 2022) is a self-help OPI based on previously tested withdrawing at any time, without any repercussions and warranting the
trans-diagnostic RNT-focused ACT protocols. DAC has three modules protection of their personal data.
including: 15 videos, 9 audios, and 15 written activities and experiential On the other hand, DAC adheres to all applicable norms in Colom
exercises. DAC is designed to last four weeks allowing the participant to bian territory (Law 1090 of 2006, 2006, Statutory Law 1266 of 2008,
complete one module weekly and have an extra week to catch up or go Statutory Law 1581 of 2012), particularly Resolution 2654 of 2019,
back, although duration depends on the pace and detail the participant 2019 by which provisions and parameters are established for the exer
chooses to take. cise of telehealth. Additionally, the web platform hosting the program
Module I “Knowing the problem and finding solutions” has three had an SSL certificate that warrants the informatic security of the users
goals: a) assessing the participant’s hierarchical triggers for RNT or “Big through a 128-bit encrypted connection that prevents the attack of
129
hackers and viruses. In addition, there was a username and password indexes for DASS-21. A change of 9 points is required to get RC. There is
system set-up to access the intervention area of the program. Every CSC if the participant shows RC, and their score is closer to the
possible measure to ensure the security, privacy and protection of the nonclinical average rather than to the clinical one. Ruiz et al. (2018) also
participants’ personal, clinical and contact data were taken into account established that the cutoff point for CSC is 22/23 (i.e., 22 being closer to
in compliance with the ethical guidelines for OPIs proposed by APA the nonclinical average and 23 being closer to the clinical average).
(2013). Descriptive statistical analyses were conducted for the UQS re
sponses and Aiken’s V (Aiken, 1980, 1985) and its 95% confidence in
1.6. Data analysis tervals (CI) were also computed for the user’s Clarity, Utility and
Satisfaction. Aiken’s V may range between 0 and 1, with 1 indicating a
Alternative data analysis that adequately fit the objectives of the perfect agreement among participants. The latter was computed with
studies are recommended by the ACBS taskforce (Hayes et al., 2021), in the Microsoft Excel calculator provided by Cordón (2017), based on
the case of single case experimental designs Bayesian statistics offer Merino-Soto and Livia-Segovia (2009). As Charter (2003) suggests V
certain advantages in contrast to frequentist approaches. Bayesian sta values beyond 0.70 should be statistically significant and that signifi
tistics not only allow the evaluation of the existing evidence in favor of cance can be tested assessing whether or not 95% CI includes values
the null hypothesis, but also to accurately discriminate between below 0.70. This guideline was adopted to consider participant’s
“absence of evidence” and “evidence of absence” (Dienes, 2014; Keysers agreement over the program’s quality.
et al., 2020). This approach also permits accounting for prior knowledge To confirm the role of psychological inflexibility components as
in order to conduct more informative tests (Gronau et al., 2020; Lee & mechanisms of behavioral change that explain the intervention effect, a
Vanpaemel, 2018) and monitor the changes on the evidence as available parallel multiple mediation analysis was conducted via the Boot
data continues to grow (Rouder, 2014). Most studies analyzing the effect strapping method with bias correction for repeated measures using the
of RNT-focused ACT (Ruiz et al., 2016a, 2018, 2019, 2020a; Salazar MEMORE package designed by Montoya and Hayes (2017) for SPSS. The
et al., 2020) have followed single case experimental designs and used analysis was based on the immediate effect of the intervention (Aver
Bayesian statistics to test their hypothesis and assess the available evi aged Baseline vs. Module III/Post). Indirect effects were analyzed by
dence. The repeated measures design featured on the present study is mediating variable and the percentage of contribution to the total effect
inspired by the latter studies and although it’s not identical Bayesian was calculated in order to clarify and quantify their explanatory role in
statistics are still deemed appropriate and robust enough to draw valid, the intervention effect. Finally, in order to identify and contextualize the
generalizable and updateable inferences that a frequentist approach reasons that might explain the variability between the OPI overall effect
would not allow specially with a such a small sample size. among participants showing better results than others, moderation an
A Bayesian analysis of variance for repeated measures (Bayesian RM- alyses were conducted using JASP’s “Between Subject Factors” option
ANOVA; Goss-Sampson, 2020; Van den Bergh et al., 2020; Van Doorn within the RM-ANOVA conducted for DASS-T scores.
et al., 2020) was conducted with the JASP software for each variable
specifying a multivariate Cauchy prior for the effects and comparing the 2. Results
observed data with a null model. In order to meet the assumptions for
the Bayesian RM-ANOVA preliminary descriptive analyses were Descriptive: The 18 participants had a mean age of 29.72 (SD = 5.77)
computed to identify outliers and Winsorize (Ghosh & Vogt, 2012; years old and were all cisgender women that did not belonged to any
Kennedy et al., 1992; Kwak & Kim, 2017) by replacing the old value vulnerable populations or ethnic communities. Half of these women
with the next higher or lower score on the variable according to the case. (50%) were professionals in psychology, the majority of them were
Shapiro – Wilk tests and Model Averaged Q-Q Plots were assessed heterosexual (77%), single (66.66%), unemployed (44.44%), living on
finding the data was distributed normally enough for most of the vari an urban area (83.33%) and assigned to the medium low tier (50%) of
ables and points in time. Levene tests for homogeneity of variances were socioeconomic classification used in Colombia (National Administrative
omitted as every point in time under comparison has exactly the same Department of Statistics i.e. DANE, 2022).
sample size (n = 18). Post-hoc comparisons between the first and second None of them used any psychoactive substances, had a history of
baseline points given by another Bayesian RM-ANOVA were assessed to psychotic disorders or had either planned or tried to commit suicide
identify significant differences that would indicate there is a pre-existing recently. Additionally, neither of them was receiving any kind of mental
tendency on the data. health treatment. Clinical variables had baseline mean scores of 11.55
Bayes Factors (BF10) and its error were assessed to determine how (SD =3.53) for depression, 8.11 (SD =4.30) for anxiety, 12.44 (SD
much the evidence favors intervention effect (Rouder et al., 2012). The =2.51) for stress and 32.11 (SD =5.80) for general emotional symp
posterior odds have been corrected for multiple testing by fixing to 0.5 tomatology. On the other hand, psychological inflexibility variables had
the prior probability that the null hypothesis holds across all compari baseline mean scores of 33.33 (SD =5.38) for experiential avoidance,
sons (Westfall et al., 1997). This allowed Posterior odds given by 36.13 (SD =5.61) for cognitive fusion and 40.38 (SD = 6.98) for RNT
post-hoc comparisons to be considered as corrected BF10 and evaluated (See more in Table 1).
to determine how strong is the evidence in favor of intervention’s im Clarity, Utility and Satisfaction: Participants rated the Clarity
mediate, short-term and mid-term effect as well as if there are further (Mean =4.72; SD =0.95), Utility (Mean =4.77; SD =0.94) and Satis
reductions after Module-I, II and III for each variable. Bayes Factors were faction (Mean =4.83; SD =0.38) with the program contents with mean
interpreted using the heuristic guide provided by Goss-Sampson (2020) scores higher than 4 out of 5 points. On the other hand, coefficient V for
considering values above 1 as informative of evidence in favor of the Clarity was V =0.93 (95% CI [0.84, 0.96]), for Utility V =0.94 (95% CI
alternative hypothesis and values below 1 as indicative of evidence in [0.86, 0.97]) and for Satisfaction V =0.96 (95% CI [0.88, 0.98]), indi
favor of the null hypothesis (see Goss-Sampson, 2020, p. 40 for the cating significant agreement between the participant’s evaluation of the
details). program quality.
Effect sizes (Cohen, 1988) were computed and then interpreted using Assumption Checks: Box and whiskers plots were generated with
Sawilowsky’s (2009) new rules of thumb: 0.1–0.2 very small; 0.2–0.5 SPSS to identify the presence of outliers. When identified, outliers were
small, 0.5–0.8 medium; 0.8–1.2 large; 1.2–2.0 very large and >2.0 huge. Winsorized, normality tests were conducted after the correction and
Jacobson and Truax’s (1992) indices of reliable (RC) and clinically homogeneity tests were skipped.
significant change (CSC) were also calculated for DASS-21 to assess the Most variables were normally distributed according to the Shapiro-
clinical impact of the intervention. Ruiz, García-Martín, et al. (2017), Wilk test, except for: a) depression at the end of the Module-III, short-
had already established reliable and clinically significant change term and mid-term follow up, b) anxiety at the end of Module-I, Module-
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Table 1
Descriptive statistics for sample characterization.
Sociodemographic Clinical History
Variable Category Freq % Variable Category Freq %
Sexual Orientation Heterosexual 14 77.77 Neurodivergence Yes 1 5.55

Homosexual 2 11.11 No 17 94.44
Bisexual 1 5.55 History of Depression Yes 5 27.77
Asexual 1 5.55 No 13 72.22
Marital Status Single 12 66.66 History of Anxiety Yes 6 33.33
Married 3 16.66 No 12 66.66
Free/Civil Union 2 11.11 History of Eating Disorders Yes 1 5.55
Divorced 1 5.55 No 17 94.44
Socioeconomic Classification Low 7 38.88 Have you wished to be dead? Yes 8 44.44
Medium Low 9 50 No 10 55.55
Medium High 2 11.11 Have you wanted to hurt yourself? Yes 6 33.33
Residence Zone Urban 15 83.33 No 12 66.66
Rural 3 16.66 Have you thought about suicide? Yes 8 44.44
Employment Status Unemployed 8 44.44 No 10 55.55
Formal 6 33.33 Have you tried to commit suicide before? Yes 3 16.66
Informal 4 22.22 No 15 83.33
Occupation Architect 1 5.55 Continuous Variables
Foreign Languages Teacher 1 5.55 Variable Mean SD
Health Administration Technician 1 5.55 Sessions/Weeks 5.61 1.61

Interior Design and Decoration Technician 1 5.55 Age 29.72 5.77
Lawyer 1 5.55 Weekly Working Hours 22.77 23.79
Organizational Psychology Technician 1 5.55
Psychologist 9 50
Spanish Language Teacher PG 1 5.55
Systems Engineer 1 5.55
Veterinary 1 5.55
II, Module-III, short-term and mid-term follow-up, c) stress at mid-term Averaged Q-Q Plots (see JASP files) generated for the analysis show that
follow-up, d) general emotional distress at short and mid-term follow- the data is not in gross violation of normality and therefore Bayesian
up, e) experiential avoidance at short-term follow-up, However, Model RM-ANOVAs can be conducted. (see Table 2)
Table 2
Descriptive statistics and normality tests for clinical variables at every point in time.
Variable Mean SD Shapiro-Wilk P-value S–W Variable Mean SD Shapiro-Wilk P-value S–W
Emotional Symptomatology Psychological Inflexibility
DASS-D_BL01 10.77 4.44 .883 .030 AAQ_BL01 32.05 7.05 .931 .200
DASS-D_BL02 12.33 3.81 .956 .529 AAQ_BL02 34.61 5.04 .967 .733
DASS-D_BLMn 11.55 3.53 .962 .635 AAQ_BLMn 33.33 5.38 .951 .448
DASS-D_M01 7.72 3.44 .942 .309 AAQ_M01 29.66 7.08 .906 .074
DASS-D_M02 4.22 3.24 .932 .213 AAQ_M02 23.83 9.23 .967 .734
DASS-D_M03 2.22 2.01 .834 .005 AAQ_M03 17.88 8.31 .905 .071
DASS-D_FUP01 2.72 2.39 .876 .022 AAQ_FUP01 16.72 7.72 .885 .031
DASS-D_FUP02 3.38 3.71 .777 <.001 AAQ_FUP02 16.83 8.15 .922 .138
DASS-A_BL01 7.94 4.31 .938 .269 CFQ_BL01 35.72 6.53 .974 .870
DASS-A_BL02 8.27 4.80 .973 .850 CFQ_BL02 36.55 6.72 .967 .733
DASS-A_BLMn 8.11 4.30 .955 .511 CFQ_BLMn 36.13 5.61 .965 .694
DASS-A_M01 4.77 4.23 .873 .020 CFQ_M01 34.33 6.18 .934 .224
DASS-A_M02 1.88 1.71 .820 .003 CFQ_M02 24.50 8.03 .971 .810
DASS-A_M03 0.55 0.85 .640 <.001 CFQ_M03 17.44 7.92 .892 .042
DASS-A_FUP01 1.22 1.11 .857 .011 CFQ_FUP01 15.94 7.23 .936 .248
DASS-A_FUP02 2.66 3.63 .735 <.001 CFQ_FUP02 16.72 7.94 .913 .095
DASS-S_BL01 11.27 2.96 .953 .475 PTQ_BL01 41.00 9.12 .971 .815
DASS-S_BL02 13.61 2.95 .962 .640 PTQ_BL02 39.77 6.40 .922 .139
DASS-S_BLMn 12.44 2.51 .963 .664 PTQ_BLMn 40.38 6.98 .953 .479
DASS-S_M01 10.00 4.05 .954 .500 PTQ_M01 40.55 7.80 .916 .108
DASS-S_M02 6.00 3.19 .953 .475 PTQ_M02 25.55 11.69 .947 .375
DASS-S_M03 3.72 2.78 .935 .236 PTQ_M03 17.61 11.30 .919 .126
DASS-S_FUP01 3.00 2.49 .903 .066 PTQ_FUP01 15.44 11.04 .909 .083
DASS-S_FUP02 5.33 4.80 .896 .048 PTQ_FUP02 16.55 10.26 .949 .405
DASS-T_BL01 30.00 7.55 .973 .859
DASS-T_BL02 34.22 6.77 .972 .834
DASS-T_BLMn 32.11 5.80 .927 .174
DASS-T_M01 21.72 8.17 .951 .448
DASS-T_M02 12.38 6.69 .930 .194
DASS-T_M03 6.00 3.86 .905 .070
DASS-T_FUP01 5.38 2.61 .882 .028
DASS-T_FUP02 11.05 10.44 .847 .007
NaN* All values are identical.
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Post-hoc comparisons were evaluated for differences between the processes that have previously been documented as predictive of
first and second baseline points. There was anecdotal evidence in favor emotional symptomatology and that the skills acquired by the partici
of the presence of differences for stress (BF10=1.873; error% =0.001), pants are still being practiced up to three months later. (See Table 4).
indicating that there may be a pre-existing trend in the data. There was For experiential avoidance there were very large effect sizes at the
also decisive evidence in favor of the presence of differences in the immediate (d =1.51; 95% CI =, 82–2.19), short-term (d =1.70; 95% CI
cognitive fusion scores (BF10=945; error% = 8.127e − 11), indicating =, 96–2.42) and mid-term (d =1.49; 95% CI =, 80–2.16) respectively.
that there is a trend for this variable. The rest of the variables tested For cognitive fusion, there were very large immediate (d =1.85; 95% CI
shown no significant differences between baseline points according to =1.07–2.62) and mid-term (d =1.79; 95% CI =1.02–2.53) effect sizes
the post-hoc comparisons. and a huge effect size for short-term follow-up (d =2.06; 95% CI
To mitigate the differences found in the variables at the first and =1.22–2.88). Finally, for repetitive negative thinking there were very
second baseline points and to perform Bayesian RM- ANOVAs, the first large effect sizes immediately (d = 1.95; 95% CI = 1.15–2.75), short-
and second baseline points were averaged and that average score term (d = 1.95; 95% CI = 1.14–2.74) and mid-term (d = 1.86; 95%
became the only baseline point that represented the pre-treatment phase CI = 1.08–2.63).
for the rest of the analyses The total effect of the intervention is partially mediated (63%) by the
Emotional Symptomatology: In general, there is decisive evidence of psychological inflexibility components evaluated. Its direct effect on
the overall, immediate, short- and mid-term effect of the OPI on emotional symptomatology decreases, but remains significant when
emotional symptomatology general and specific scores. The only mediating variables are included. All indirect effects were significant
exception was found for anxiety symptoms at the mid-term, follow up. and according to Cohen’s (1988) rules of interpretation, the coefficient
Nevertheless, there was very strong evidence in favor of the effect of the of determination (R2 = 0.38) obtained indicates a substantial mediation
intervention indicating that the intervention was effective for the of the intervention effect. Experiential avoidance, cognitive fusion and
treatment of anxiety and that its effect tends to remain up to three repetitive negative thinking explained 25%, 20% and 18% of the total
months later (See Table 3). According to the RC and CSC indices 100% of effect respectively (See Table 5.).
the participants were classified as recovered at the end of the OPI and Moderating role of the number of “Big Ones”: There is moderate
short-term follow-up. Three months later, 15 participants (83.33%) evidence (BF10=3.24) for the interaction between the OPI effect and the
were classified as recovered, but the rest did not obtain RC or did not number of abstract hierarchic RNT triggers. The latter indicates this
show CSC. might be a moderating variable and there is also anecdotal evidence
For depression, immediate (d =2.68; 95% CI =1.66–3.68) and short- (BF10 = 1.35) for the indirect effect of the number of hierarchic RNT
term (d =2.65; 95% CI =1.64–3.64) huge effect sizes were found, while triggers or “Big ones” over emotional symptomatology outcomes.
there was a very large effect size in the mid-term (d =1.81; 95% CI Descriptive plots show that participants with multiple triggers tend to
=1.04–2.56). For anxiety, there were very large effect sizes for imme have a slower reduction of symptomatology and wider variability
diate (d =1.82; 95% CI =1.04–2.57) and short-term follow-up (d =1.63; among their improvements. Some of them shown sub-clinical relapse (i.
95% CI =0.91–2.34), while a large mid-term effect was found (d =1.11; e symptomatology increases below 25) at last follow-up, most of them
95% CI =0.51–1.70). For stress, huge effect sizes were found for im
mediate (d =2.58; 95% CI =1.59–3.55) and short-term follow-up (d Table 5
=2.71; 95% CI =1.69–3.72), while a very large effect was found in the Standardized regression coefficients for mediation analysis.
mid-term (d =1.23; 95% CI =0.60–1.84). Finally, in the case of general
Standardized Regression β σ 95% CI p
emotional symptomatology, the effect sizes were huge at immediate (d Coefficients
=4.19; 95% CI =2.71–5.66) and short-term follow-up (d =4.12; 95% CI
Total Effect 26,11 1,46 23,01–29,20
=2.66–5.56), and very large at mid-term (d =1.76; 95% CI =
<,000
Direct Effect 19,74 3,62 11,75–27,72 <,000
1.00–2.49). Indirect Effects β σ 95% CI %
Psychological inflexibility as behavioral change process: There is Explained
decisive evidence in favor of the overall, immediate, short- and mid- Experiential Avoidance 6,75 11,78 − 11,03–29,34 25
term effect of the intervention on experiential avoidance, cognitive Cognitive Fusion − 5,23 19 − 23,40–63,67 20
RNT 4,87 13,21 − 32,51–24,26 18
fusion and repetitive negative thinking. This implies that the interven
tion is generating a behavioral change through the trans-diagnostic
Table 3
Bayes factors for the effect of intervention on emotional symptomatology at different time points.
Type of Effect Depression Anxiety Stress Emotional Symptomatology
BF10 error% BF10 error% BF10 error% BF10 error%
General 1.200e+20 .379 4.567e+12 .416 8.090e +15 .479 1.398e+25 .427
Immediate 1.278e +6 1.997e − 11 7517974 4.204e − 7 752896646 4.986e − 9 8.873e +8 3.444e − 13
Short-term 1.103e +6 2.564e − 11 2109850 1.213e − 8 1.513e +6 1.424e − 11 6.732e +8 3.594e − 13
Mid-term 7286598 2.957e − 7 41990 3.996e − 6 104158 2.125e − 5 5.055.049 2.624e − 9
Table 4
Bayes factors for the effect of the intervention on behavioral change processes at different times.
Type of Effect Experiential Avoidance Cognitive Fusion RNT
BF10 error% BF10 error% BF10 error%
General 1.687e +15 .537 1.091e +22 .526 1.822e +21 .394
Immediate 894.648 9.186e − 8 9757.342 3.779e − 9 18859.102 2.168e − 9
Short-term 3340.983 1.456e − 10 36571.645 9.253e − 10 18345.825 2.236e − 9
Mid-term 743.977 1.148e − 7 6220.119 1.021e − 7 10375.723 3.667e − 9
132
were unemployed. Other participants experienced clinical relapse (i.e is slower to achieve and harder to keep for participants who report
symptomatology increases above 25) at the last follow up due to indi additional RNT triggers related to social experiences. (See Fig. 2)
vidual differences. (See Fig. 1) Moderating role of intimate partner relationship distress: There is
Moderating role of “Big Ones” type: To analyze the nature of RNT strong evidence (BF10=12.57) in favor of the interaction between OPI
triggers a broad classification of the “Big Ones” was conducted using two effect and self-reported intimate partner relationship distress. Moderate
categories: failure-type triggers (related to work, study or economic evidence (BF10 = 3.75) was also found for the indirect effect of experi
sustainability) and social-type triggers (related to family, friends or encing intimate partner relationship distress on emotional symptom
intimate partner relationships). There is anecdotal evidence atology outcomes. According to descriptive analysis when participants
(BF10=1.31) for the interaction of trigger types with the OPI effect as experience intimate partner relationship distress slower reductions of
well as anecdotal evidence (BF10 = 2.31) in favor of the indirect effect of emotional symptomatology are noticeable and even clinical relapse at
trigger types on emotional symptomatology outcomes. All participants the last follow up. Importantly, two of the participants that self-reported
had a failure-type trigger but only some of them reported an additional distress were on abusive relationships during the OPI and continued to
social-type trigger. Descriptive analysis suggest that behavioral change have them at last follow up potentially explaining the documented
Fig. 1. Descriptive raincloud plot for the moderating role of the number of “Big Ones”.
Fig. 2. Descriptive raincloud plot for the moderating role of “Big Ones” type.
Fig. 3. Descriptive raincloud plot for the moderating role of intimate partner relationship distress.
133
relapse.(See Fig. 3) mediate the effect as they concurrently decrease over the OPI and
Moderating role of being a psychologist: Considering that half of the explain at least 63% of the documented behavioral change. This effect is
participants were professionals in psychology and understanding how it maintained for most participants across the majority of variables
could limit the generalizability of the results moderation analysis were showing even further decreases one and three months after finishing the
conducted to evaluate potential differences between them and other OPI, with exceptions addressed through moderation analyses. On the
participants. In contrast with this argument, there is at least anecdotal other hand, the participants deemed the program as highly clear, useful
evidence in favor of the null hypothesis (BF10 = 0.43) (i.e. psychology and satisfactory with significant agreement between them.
professionals had no significant differences on emotional symptom The effect sizes calculated for this study are quite similar to those
atology outcomes). Descriptive plots evidence a slower behavioral found by previous empirical and meta-analytical studies analyzing the
change and wider variability among the psychologists’ scores at the end effect of RNT-focused ACT and trans-diagnostic acceptance based OPIs
of Module I but a rather similar performance to the non-psychologist (see Table 6). The current OPI’s immediate effect is superior to all other
participants across Modules II and III and a similar tendency to clin effect sizes documented but its effect at the last follow-up was actually
ical and sub-clinical relapse. (See Fig. 4) smaller than most of the compared studies. The latter might be due to
the influence of the discussed moderating variables and the current
3. Discussion study’s limitations addressed below. Nonetheless, the Bayesian analyses
conducted were coherent with previous findings indicating there is
The preliminary findings previously discussed for the current sample substantial evidence in favor of the effect of RNT-focused ACT over
of Colombian cisgender women show there is decisive evidence for the emotional symptomatology and psychological flexibility components,
immediate effect of DAC delivered as an OPI on depression, anxiety, specifically RNT which has also been proven to mediate behavioral
stress, emotional symptomatology, experiential avoidance, cognitive change and intervention effect (Ruiz et al., 2016a, 2018, 2019, 2020a;
fusion and RNT, suggesting the last three are change mechanisms that Salazar et al., 2020).
Fig. 4. Descriptive raincloud plot for the moderating role of being a psychologist.
Table 6
Comparison between this study’s effect size and other research findings.
Study Symptomatology Effect Size AAQ-II/AFQ-Y Effect Size CFQ Effect Size RNT Effect Size
POST LFUP POST LFUP POST LFUP POST LFUP
Current 4.19 1.76 1.51 1.49 1.85 1.79 1.95 1.86

RNT-Focused ACT
Bernal-Manrique et al. (2020) 1.24 N/A .98 N/A N/A N/A 2.61 N/A
Dereix-Calonge et al. (2019) 2.52 N/A N/A N/A N/A N/A 1.0 N/A
Ruiz, Riaño-Hernández, et al. (2016) .99 1.62 .97 2.09 .85 2.23 N/A N/A
Ruiz et al. (2018) 1.93 2.44 .98 1.32 1.52 2.01 1.87 2.51
Ruiz et al. (2019) 1.17 N/A N/A N/A 2.54 N/A 3.19 N/A
Ruiz, Luciano, et al. (2020) 2.16 3.34 2.06 3.46 2.32 3.90 3.27 4.52
Ruiz, Peña-Vargas, et al. (2020) 1.50 2.42 1.38 2.32 1.79 2.73 1.48 2.26
Salazar et al. (2020) 2.57 2.12 3.74 2.12 N/A N/A N/A 3.14
Trans-diagnostic acceptance based OPIs
Flett et al. (2020) .01 .01 N/A N/A N/A N/A N/A N/A
Kladnitski et al. (2020) 1.18 N/A N/A N/A N/A N/A N/A N/A
Levin et al. (2013) .28 N/A .40 N/A N/A N/A N/A N/A
Levin et al. (2016) .11 .14 .05 .08 N/A N/A N/A N/A
Levin et al. (2020) 2.63 3.62 2.35 1.6 N/A N/A N/A N/A
Viskovich and Pakenham (2019) .36 N/A 0 N/A N/A N/A N/A N/A
Meta-analytic data for acceptance based OPIs
Brown et al. (2016) .73 N/A N/A N/A N/A N/A N/A N/A
Cavanagh et al. (2014) - .37 N/A .49 N/A N/A N/A N/A N/A
Sierra et al. (2018) .60 N/A N/A N/A N/A N/A N/A N/A
Sierra and Ortiz (2022a) 1.30 2.4 1.23 1.81 N/A N/A N/A N/A
Spijkerman et al. (2016) .29 N/A N/A N/A N/A N/A N/A N/A
LFUP = Last Follow-up; N/A = Not available.
134
These findings imply that RNT-Focused ACT is wise to focus on potential barriers towards mental health access. It is especially recom
identifying and transforming the functions of abstract private events mended to work with healthcare professionals such as doctors and
deemed hierarchical triggers of RNT, previous studies (Ruiz et al., nurses considering that their role during the COVID-19 pandemic led to
2016a, 2018, 2019, 2020a; Salazar et al., 2020) also support the hy their mental health being more affected than that of the general popu
pothesis that doing so renders other concrete triggers meaningless, lation and COVID-19 patients themselves (Chew et al., 2020; Tan et al.,
limiting their ability to influence the client’s behavior. The latter is 2020).
documented in the present study through the RNT instrument which Future research needs to explore further the program’s feasibility
shows a significant and systematic decrease across time and explain 18% and effect not only for young cisgender men but also for transgender
of the concurrent emotional symptomatology alleviation evidenced by women, men and non-binary people whom actually are in a higher risk
most participants. The latter would mean that even though RNT is often for emotional symptomology and suicide risk (Guz et al., 2021; Rimes
regarded as part of the experiential avoidance functional class (Bond et al., 2019). Translations and cultural adaptations of DAC for its
et al., 2011; Luciano et al., 2021; Törneke et al., 2016), special attention application as OPI or any other format are needed to further establish its
to RNT-triggers and their organization is important towards clinical validity and effectiveness across different cultures. Modifications of DAC
assessment and intervention due to the evidence of it trans-diagnostic specifically designed for populations at risk such as: low income, un
role as a functional unit that generates behavioral change and influence employed, marginalized or victimized people among others are also
intervention effect. welcome. It is also imperative to design and validate an instrument that
On the other hand, the present findings also contribute evidence in users and professionals can use to evaluate OPI quality. This instrument
favor of the role of experiential avoidance and cognitive fusion as trans- might include a virtual platform usability component but should also
diagnostic processes or behavioral change mechanisms that not only include clarity, usefulness, satisfaction and other relevant components
predict emotional symptomatology (Faustino, 2020; Faustino et al., that allow the assessment of the OPIs overall quality beyond the virtual
2021; Hayes et al., 2012; Kashdan & Rottenberg, 2010; Levin et al., platform performance.
2014; Sierra & Ortiz, 2022b; Tyndall et al., 2018) but also explain how In conclusion DAC is a feasible and efficacious OPI program that
ACT interventions reduce symptomatology as a result of psychological significantly reduces emotional symptomatology (i.e. depression, anxi
inflexibility decreasing and the client engaging in more flexible and ety and stress), experiential avoidance, cognitive fusion and RNT at least
values coherent behavior (Ruiz et al., 2016a, 2018, 2019, 2020a; Salazar for young cisgender women in Colombia.
et al., 2020).
However, results need to be considered understanding the following Funding
limitations. First, there is only two baseline points that have been
averaged to mitigate pre-existing tendencies identified on stress and This study was funded through the Bicentennial Doctoral Scholarship
cognitive fusion. This is methodologically problematic as ideally there for Excellence No. BB 2019 01 program sponsored by the Royalties Fund
would need to be a stable baseline without any detectable tendency in for Science, Technology and Innovation of the Colombian Government.
order to proceed with intervention. However, making participants with
moderate symptomatology wait and send additional repeated measures Declaration of competing interest
to get a longer baseline is far from any ethical standard in psychological
practice. Hopefully others can replicate the study without such con The authors declare they do not have any conflict of interest.
straints and better methodological quality. Second, moderation analysis
regarding the “Big Ones” was conducted inferring the RNT triggers from Acknowledgments
the clinical data provided by the participants rather than arising from a
process of trigger clarification (Gil-Luciano et al., 2019; Ruiz et al., None.
2018, 2020a, 2020b). Future instances of this program or any other
RNT-focused one might benefit from including a session or module Appendix A. Supplementary data
specifically for that process allowing the participants to figure them
selves who is their “Big One”. Third, this study did not assess valued Supplementary data to this article can be found online at https://doi.
action or functional improvements known to be an important outcome org/10.1016/j.jcbs.2023.03.010.
in the context of ACT as they evidence change in behavioral patterns.
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Journal of Contextual Behavioral Science: Marge A. Sierra, Eliana Ortiz

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Journal of Contextual Behavioral Science 28 (2023) 127–138

Contents lists available at ScienceDirect

Journal of Contextual Behavioral Science

Feasibility and effect of a self-help online acceptance and commitment

* Corresponding author. Avenida Caracas 46-40, Bogotá, D.C., Colombia.

Variable Category Freq % Variable Category Freq %

Sexual Orientation Heterosexual 14 77.77 Neurodivergence Yes 1 5.55

Occupation Architect 1 5.55 Continuous Variables

Foreign Languages Teacher 1 5.55 Variable Mean SD

Health Administration Technician 1 5.55 Sessions/Weeks 5.61 1.61

Emotional Symptomatology Psychological Inflexibility

NaN* All values are identical.

BF10 error% BF10 error% BF10 error% BF10 error%

BF10 error% BF10 error% BF10 error%

POST LFUP POST LFUP POST LFUP POST LFUP

Current 4.19 1.76 1.51 1.49 1.85 1.79 1.95 1.86

LFUP = Last Follow-up; N/A = Not available.

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