Buscar en
International Journal of Clinical and Health Psychology
Toda la web
Inicio International Journal of Clinical and Health Psychology The link between stress, well-being, and psychological flexibility during an Acc...
Journal Information
Vol. 18. Issue 1.
Pages 60-68 (January - April 2018)
Visits
6800
Vol. 18. Issue 1.
Pages 60-68 (January - April 2018)
Original article
Open Access
The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention
Relación entre estrés, bienestar y flexibilidad psicológica durante una intervención de autoayuda de Terapia de Aceptación y Compromiso
Visits
...
Hanna Wersebe, Roselind Lieb, Andrea H. Meyer, Patrizia Hofer, Andrew T. Gloster
Corresponding author
andrew.gloster@unibas.ch

Corresponding author. University of Basel, Department of Psychology, Division of Clinical Psychology and Intervention Science, Missionsstrasse 62A, 4055 Basel, Switzerland.
University of Basel, Switzerland
Article information
Abstract
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Tables (2)
Table 1. Descriptive statistics of measures of well-being and psychological flexibility.
Table 2. Association between an increase in psychological flexibility during the intervention and changes in stress and well-being during or after the intervention.
Show moreShow less
Abstract

Background/Objective: Prolonged stress can overwhelm coping resources, leading people to seek mental health care. Acceptance and commitment therapy (ACT) is an intervention that enhances well-being and reduces distress, assumedly by means of increasing psychological flexibility (PF). We examined the association between a total increase in PF during an intervention and decreases in stress and increases in well-being during and after the intervention. Method: The intervention was a randomized controlled trial of an ACT-based self-help intervention. Participants were 91 individuals reporting elevated levels of work-related stress. Measurements were completed at preintervention, postintervention, and 3-month follow-up. Results: Structural equation models revealed that the total increase in PF during the intervention was negatively associated with a decrease in stress (b=-0.63, SE=0.14, p<.001) and positively associated with an increase in well-being during the intervention (b=0.48, SE=0.11, p<.001), but not with a decrease in stress (b=0.03, SE=0.27, p>.05) and well-being (b=-0.04, SE=0.39, p>.05) following the intervention. Conclusions: Our study provides empirical support for decreasing stress and promoting well-being through ACT and emphasizes the potential of PF in promoting well-being.

Keywords:
Acceptance and commitment therapy
Well-being
Psychological flexibility
Stress
Experiment
Resumen

Antecedentes/Objetivo: El estrés prolongado puede inhibir los recursos de adaptación, llevando a las personas a solicitar servicios de salud mental. La Terapia de Aceptación y Compromiso (ACT) es una intervención que fomenta el bienestar y reduce la ansiedad, presuntamente mediante el aumento de la flexibilidad psicológica (PF). Examinamos la asociación entre un aumento total en PF durante una intervención y el descenso del estrés y el aumento del bienestar durante y después de la intervención. Método: En un ensayo aleatorio controlado de una intervención de autoayuda con base en ACT participaron 91 individuos con niveles elevados de estrés laboral. Completaron mediciones pre, post y seguimiento a tres meses. Resultados: Modelos de ecuaciones estructurales revelaron que el aumento total en PF durante la intervención está negativamente asociado a la reducción del estrés (b=-0,63, SE=0,14, p<0,001) y positivamente asociado con el aumento del bienestar durante la intervención (b=0,48, SE=0,11, p<0,001), pero no con el descenso del estrés (b=0,03, SE=0,27, p>0,05) y el bienestar (b=-0,04, SE=0,39, p>0,05) después de la intervención. Conclusiones: Se proporciona base empírica de la reducción del estrés y el fomento del bienestar mediante ACT, enfatizando el potencial de PF para fomentar el bienestar.

Palabras clave:
terapia de aceptación y compromiso
bienestar
flexibilidad psicológica
estrés
estudio ex post facto
Full Text

Nearly everyone experiences stress in daily life, such as work deadlines, family arguments or being late for an appointment. These stressors can have a strong impact on well-being (Almeida, 2005; Schönfeld, Brailovskaia, Bieda, Zhang, & Margraf, 2016; Thoits, 2010). One particular deleterious type of stress is related to work. People who work may experience a substantial level of work-related stress (Eurofound, 2005). In one U.S. report, 40% of all professionals stated that their job is very or extremely stressful (American Psychological Association Center for Organizational Excellence, 2014). Work-related stress is associated with increased absenteeism and reduced efficiency at work and large costs for society (Henderson, Glozier, & Elliott, 2005; Kalia, 2002; Sultan-Taïeb, Chastang, Mansouri, & Niedhammer, 2013). Further, prolonged stress can lead to stress related disorders, which is subject to the Eleventh Revision of International Classification of Diseases and Related Health Problems (ICD-11) (Keeley et al., 2016; Maercker et al., 2013). Also it has been associated with a range of adverse health outcomes, such as anxiety and depression (Fawzy & Hamed, 2017; Herr et al., 2017; Melchior et al., 2007; Tennant, 2001), coronary disease (e.g. Li, Zhang, Loerbroks, Angerer, & Siegrist, 2014), and sleep problems (e.g. Faber & Schlarb, 2016).

Challenges of prolonged stress may at times exceed a person's capacity to cope effectively, and this is when mental health care may be sought. However, traditionally, the focus in mental health care has been on treating mental disorders and symptoms rather than promoting well-being (Seligman & Csikszentmihalyi, 2000). It has been recognized that mental health is more than simply the absence of mental illness. For instance, it has been addressed in the two-continua model of mental health that states that positive mental health or well-being is related to, but different from mental illness (Keyes, 2005). Well-being can be broken down into emotional, social, and psychological well-being (Diener, Napa Scollon, & Lucas, 2009; Diener, Suh, Lucas, & Smith, 1999; Ryff, 1989). Emotional well-being refers to feelings of happiness and (life) satisfaction. Psychological well-being refers to living a rich life, in which one's abilities are taken into account. Social well-being refers to the feeling that one values and is valued by the society in which one lives.

Prior studies with population-based samples investigating the interdependence of well-being and psychopathology (Keyes, 2007; Lamers, Westerhof, Glas, & Bohlmeijer, 2015; Trompetter, de Kleine, & Bohlmeijer, 2016) showed that well-being protects against mental illness through components such as positive relationships with others, autonomy, and environmental mastery. Two such studies showed that well-being over time buffers against mental illness and disease later in life (Grant, Guille, & Sen, 2013; Lamers et al., 2015). The latter showed that a decrease in psychopathology was linked to improved well-being, and a decrease in well-being was linked to higher levels of psychopathological symptoms. Another study indicated that low well-being was strongly associated with depression 10 years later (Wood & Joseph, 2010), and another found that changes of levels of well-being were related to the prevalence and incidence of mental illness in a 10-year time span (Keyes, Dhingra, & Simoes, 2010). In sum, findings consistently support the two-continua model and indicate the relevance of well-being for mental health care.

The two-continua model and existing studies about the impact of well-being indicate the need for interventions that explicitly promote well-being (Hayes, Strosahl, & Wilson, 1999, 2012; Keyes, 2007). Acceptance and Commitment Therapy (ACT) is a cognitive behavioral therapy, which may fit well with mental health promotion, and one of the central goals of ACT is to increase psychological flexibility (PF). PF is the ability to adapt to a variety of different situational demands when doing so is useful for living a meaningful life, and it is thought to be an important mechanism of change during ACT interventions (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Acceptance and mindfulness are core processes of PF (Baer et al., 2008; Carmody & Baer, 2008; Soysa & Wilcomb, 2015). Another crucial focus is valued action and behavior change processes. Pursuing one's values has been found to be related to well-being and functioning, for instance, in mental health professionals (Veage et al., 2014), students (Sagiv & Schwartz, 2000), and (treatment-resistant) patients (Gloster, Sonntag, et al., 2015; Wersebe et al., 2016). Research has demonstrated that ACT is effective in promoting well-being (e.g., Bohlmeijer, Fledderus, Rokx, & Pieterse, 2011; Bohlmeijer, Lamers, & Fledderus, 2015; Fledderus, Bohlmeijer, Smit, & Westerhof, 2010). Though not always linear, results of an ACT effectiveness trial indicate that well-being improved in the ACT group compared to the control group from preintervention to postintervention and follow-up (Fledderus et al., 2010). Studies that examined guided self-help over the Internet aiming at increasing positive mental health found that over the course of therapy, participants reported significant improvements in all three aspects of well-being (e.g., Bohlmeijer et al., 2015; Fledderus, Bohlmeijer, Pieterse, & Schreurs, 2012). These findings indicate that change processes in acceptance and valued action are beneficial for an engaged and meaningful life (Hayes et al., 1999, 2012). Taken together, there are solid indications for the association of PF, and its increase through ACT, and well-being.

Enhancing PF has also been shown to be effective in reducing stress (e.g., Brinkborg, Michanek, Hesser, & Berglund, 2011; Dahl, Wilson, & Nilsson, 2004; Flaxman & Bond, 2010). Results in the treatment of social workers, for instance, show that stress decreased in an intervention group compared to a control group and that pre- to posttreatment changes in PF were linked to these decreases in stress (Brinkborg et al., 2011). One study's finding showed pre–post reductions in distress following an ACT intervention (Flaxman & Bond, 2010). Importantly, an increase in PF following the intervention resulted in reduced distress among working individuals. Research indicates that participants not only decreased in their stress levels but also in sick leave utilization (Dahl et al., 2004). In short, individuals with symptoms of work stress might especially benefit from ACT, as this intervention changes the focus from symptom reduction to engagement in acceptance and mindfulness (Carmody & Baer, 2008; Soysa & Wilcomb, 2015) and valued behaviors (Clarke, Kingston, James, Bolderston, & Remington, 2014; Gloster, Sonntag, et al., 2015)—core PF processes.

The purpose of the present study was to examine an increase in PF and its association with decreases in stress and increases in well-being during and following a self-help intervention based on ACT. In this study, a sample of individuals with heterogeneous occupations and with at least moderate levels of stress read an ACT self-help book. We hypothesized that a change in PF during the intervention (i.e., preintervention to postintervention) would be associated with (1) decreases in stress during the intervention (i.e., pre-intervention to post-intervention), and after the intervention (i.e., postintervention to followup), and (2) increases in well-being during (i.e., preintervention to postintervention), and after (i.e., postintervention to followup) the intervention.

MethodDesign and procedure

Data were collected in an online randomized controlled trial comparing an ACT group to a waiting list (WL) control group for individuals with at least moderate levels of stress (Hofer et al., 2017). Participants were randomized to immediate intervention or one of two WL groups. Participants in the immediate intervention received a self-help book with weekly reading assignments and weekly assessments. The WL groups differed with respect to the presence (WL+) versus absence (WL−) of a weekly measurement of PF during their intervention. Participants in the WL− group were not contacted during the waiting period or the intervention. For this study, data of the participants in the WL− group were used only after they received treatment. After the waiting period, participants in the WL groups received the self-help book. Follow-up for all participants took place 3 months after the 6-week-intervention. The study was approved by the local ethics committee and full informed consent was secured from all participants.

Participants

Participants were recruited via a newsletter of a German health insurance company sent to members nationwide who were eligible for inclusion if they had an elevated score of 17 or more on the Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983). This value was chosen as it marks the mean of a normative adult population (Cohen & Janicki-Deverts, 2012) and has been used in several other studies (e.g., Brinkborg et al., 2011). This cut-off value assured that participants had a moderate or greater stress level. Individuals who were currently in psychotherapy treatment or showed clinically significant suicidal intent as indicated by a score greater than 1 on Item 9 of the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996) were excluded. For the present study, the immediate intervention group and the WL+ were used, as participants in these groups filled out the weekly measure of PF relevant for the present study. In total, 133 participants were included in the study, of which 92 filled out the weekly measure on PF. We included 91 in our analysis (due to missing data).

Intervention

Participants received the self-help book Burnout: mit Akzeptanz und Achtsamkeit den Teufelskreis durchbrechen (Burnout: Break the Vicious Cycle with Acceptance and Mindfulness; Waadt & Acker, 2013a). The intervention was delivered with no therapist contact. The book consists of 11 chapters and presents processes and techniques stemming from ACT. After each chapter participants were asked to complete practical exercises. Audio instructions for ACT processes were available for download on the book's website (Waadt & Acker, 2013b). To complete the book in 6 weeks, chapters were assigned in sections.

Measures

Participants completed measures at preintervention, postintervention, and follow-up. The ACT group (immediate intervention) and the WL+ group also completed weekly measurements during the intervention to assess PF. All questionnaires were administered online.

Mental Health Continuum—Short Form (MHC-SF; Keyes, 2005). The MHC-SF is a 14-item questionnaire that measures well-being scaling from 1 (never) to 6 (every day). Respondents rated their emotional well-being (3 items), social well-being (5 items), and psychological well-being (6 items) over the last month. For each aspect of well-being a mean score across the individual items was computed. Higher scores indicate greater well-being (Keyes, 2005; Lamers, Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011). The MHC-SF has demonstrated good psychometric properties across various age groups and nations (Lamers et al., 2011; Westerhof & Keyes, 2010).

Perceived Stress Scale (PSS; Cohen et al., 1983). The PSS is a 10-item self-report measure of perceived stress in certain situations. Higher scores indicate higher perceived stress levels (0–40 points). The PSS has shown good validity and reliability (Cohen et al., 1983).

Open and Engagement State Questionnaire (OESQ; Benoy, Knitter, Doering, Knellwolf, & Gloster, 2017). The OESQ is a one-dimensional measure that captures PF across 4 items considerating all six processes of ACT (acceptance, defusion, present moment, self-as-context, values and committed action), referring to its core processes, referring to its core processes. Higher scores indicate higher PF (0–4 points). A study on the psychometric properties of the OESQ in patients with panic disorder with agoraphobia and individuals with burnout indicated good internal consistency (Cronbach's (α=.87) (Benoy et al., 2017).

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 22.0 and Mplus version 6.12 (Muthén & Muthén, 2010). Hypotheses were tested with structural equation models, specifically latent growth curve models (LGMs; Heck & Thomas, 2015) (see Figure 1). LGMs are suitable for analyzing the nested structure of repeated measures data within a person and take advantage of the statistical power of analyzing multiple time points (Muthén & Curran, 1997). LGMs can incorporate incomplete cases in the analyses by using full-information maximum-likelihood estimation. Growth is described here using two parameters from the LGM, the intercept and the slope. The intercept is the score at a set time point—in this case the first week after preintervention. The linear slope is the average growth rate between repeated measurements of PF between pre- and postintervention. To test our assumptions that an increase in PF between preintervention and postintervention would be associated with pre–post decreases in stress and increases in well-being, we correlated the slope coefficient of PF from the LGM with the difference scores of stress and well-being. We used a correlation approach because PF was concurrently measured with stress or well-being between pre- and postintervention. To test our hypothesis that an increase in PF between pre- and postintervention would be associated with decreases in stress and increases in well-being between postintervention and follow-up, we regressed difference scores of well-being and stress on the slope coefficient of PF. The α level for statistical significance for all analyses was set to .05.

Figure 1.

Structural Equation Model.

(0.15MB).
ResultsDescriptive statistics

Descriptive statistics of all measures involved in the analyses at preintervention, postintervention, and follow-up are shown in Table 1. Well-being and PF increased over time while stress decreased.

Table 1.

Descriptive statistics of measures of well-being and psychological flexibility.

Measure  BaselinePostFollow-up
  n  M  SD  n  M  SD  n  M  SD 
Stressa  91  25.77  4.95  77  19.78  6.61  76  17.51  6.29 
Overall well-beingb  91  2.10  1.04  82  2.62  1.13  76  2.89  1.05 
Emotional well-beingb  91  2.24  1.16  81  2.72  1.22  76  3.16  1.14 
Social well-beingb  91  1.76  1.75  81  2.29  1.23  76  2.45  1.17 
Psychological well-beingb  91  2.28  1.12  81  2.80  1.20  76  3.08  1.14 
Psychological flexibilityc  91  14.91  6.71  74  23.34  8.82  71  23.80  8.72 
a

Measured with the Perceived Stress Scale.

b

Measured with the Mental Health Continuum—Short Form.

c

Measured with the Open and Engagement State Questionnaire.

Sample characteristics

Participants were largely female (72%), with an average age of 42.4 years (SD=9.6) and ranging from 23-60 years. Participants were all Caucasian with the vast majority being German (97%), and the remaining Austrian and Hungarian. The social class distribution was as follows: 6.6% originated from the lowest, 30.8 from the lower middle, 56% from the middle and 6.6% from the upper middle social class. Further, 67% of the participants had an upper secondary education, 27.5% a higher education, 3.3% an other education while 2.2% had no education.

Is an increase in PF associated with a decrease in stress and an increase in well-being?

During the intervention. LGMs indicated that an increase in PF during the intervention was significantly negatively related to a decrease in stress and positively related to an increase in overall well-being as well as all three of its components: emotional, social, and psychological well-being during the intervention (Table 2). Estimates were highest for the association of PF with stress and overall well-being. Of the well-being subscales, emotional and psychological well-being resulted in higher estimates compared to social well-being.

Table 2.

Association between an increase in psychological flexibility during the intervention and changes in stress and well-being during or after the intervention.

Measure  Estimate  SE  p value 
Change during the intervention
Stress  −0.63  0.14  .00 
Overall well-being  0.48  0.11  .00 
Emotional well-being  0.45  0.13  .00 
Social well-being  0.29  0.13  .02 
Psychological well-being  0.36  0.12  .00 
Change after the intervention
Stress  0.03  0.27  .91 
Overall well-being  -0.04  0.39  .91 
Emotional well-being  -0.13  0.33  .70 
Social well-being  -0.12  0.42  .78 
Psychological well-being  -0.13  0.33  .70 

Note. Reported estimates are based on standardized values.

After the intervention. An increase in PF during the intervention was not significantly associated with a decrease in stress and increase in well-being including all three subcomponents (emotional, social and psychological well-being) after the intervention (Table 2). Estimates for the association of PF with stress and overall well-being, including the subscales, were very small. As sex and age are not associated with both predictor (PF) and outcome (stress/well-being), the analyses were not controlled for sex and age (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2001).

Discussion

The aim of this study was to investigate the association of an increase in PF with stress and well-being for individuals with at least a moderate level of stress. To the best of our knowledge, this is the first study to examine whether an increase in PF during an intervention is related to decreases in stress and increases in well-being after the intervention. As hypothesized, we found that a total increase in PF during the intervention was related to a decrease in stress and an increase in well-being during the intervention, but not after the intervention. These findings are in line with earlier research in the treatment of stress among social workers (Brinkborg et al., 2011), which found that changes in PF during an intervention were linked with decreases in stress during the intervention. Prolonged high levels of stress typically involve serious disruptions in daily life, and studies have suggested that ACT alters responses to stress in a way that leads to a reduction of stress (Bond & Bunce, 2003; Frögéli, Djordjevic, Rudman, & Livheim, 2016; Lloyd, Bond, & Flaxman, 2013). A group intervention study of individuals with psychological distress found that increases in PF during the intervention were related to increased well-being at postintervention (Fledderus et al., 2010). Our findings indicate that individuals with symptoms of stress benefit from a structured self-help intervention such as ours, which promoted changes in PF.

Well-being has crucial implications for the individual, society, and the economy and importantly, our findings imply that PF is linked to well-being. Evidence suggests that well-being is clearly connected to health care utilization, psychosocial adaptation and functioning, and work productivity (Chida & Steptoe, 2008; Keyes, 2004; Keyes & Grzywacz, 2005) and that ACT interventions are positively related to enhanced well-being (Bohlmeijer et al., 2015; Fledderus et al., 2010; Livheim et al., 2014; Räsänen, Lappalainen, Muotka, Tolvanen, & Lappalainen, 2016).

A total increase in PF during the intervention was not associated with decreases in stress and increases in well-being after the intervention. Thus, people's increase in PF during the intervention was not related to their decreases in stress and increases in well-being after the intervention. This is partly opposed to earlier findings (e.g., Fledderus et al., 2010), that found increases of PF during the intervention (i.e. baseline to post treatment) were linked to improved well-being at follow-up. One study (Brinkborg et al., 2011) has examined the relationship between PF and improvements in stress and well-being during the intervention. To our knowledge, however, it has not previously been tested whether increases in PF during the intervention are linked to decreases in stress and increases in well-being after the intervention. Hence, our findings extend earlier research.

This study needs to be interpreted with several limitations taken into account. First, this study relied on self-reported measurements. These are prone to biases inherent in this assessment approach. Analyses of information stemming from other sources (e.g., experience sampling, friends and family or employers) may have resulted in different findings as self-report measures may not capture stress and well-being in their full complexity. A combination of self-report measures with physiological measures may deliver further insights. Second, the study sample was limited to individuals with symptoms of moderate to elevated levels of stress from the general population. Therefore findings cannot be extrapolated to individuals of low or (very) high stress. Third, participants were recruited through a newsletter of a health insurance company, which may have led to selection bias. Thus, participants were likely motivated and believed in the treatment approach as well its efficacy. Nevertheless, recruiting with the newsletter of the health insurance company is at the same time a strength as it allowed to sample nationwide. This is unique in a study in individuals with elevated levels of stress and more representative of the general population than recruiting in one particular company. However, identity of the participants was not revealed to the health insurance company. It may be possible that individuals are less willing to read a self-help book or may react differently if offered, for instance, by the employer. Further, it remains unknown whether the change process in PF with stress and well-being are similar in clinical populations, for example. As this is the first time that bivariate analyses of PF with stress and well-being were executed based on a self-help intervention, we cannot draw any conclusion whether strengths of associations are different in face-to-face therapy or guided self-help.

These limitations notwithstanding, our study shows that individuals with elevated stress levels at baseline reported an increase in PF, which was associated with a decrease in stress and an increase in well-being during an ACT intervention. Further, our results are of clinical importance, as self-help interventions are easily accessible, inexpensive (Ebert et al., 2016; Marks & Cavanagh, 2009), and can evidently promote crucial processes of change in stress and well-being. Further strengths of the study are the sample of individuals with heterogeneous occupations and that it is interconnected with studies designed to examine PF across different levels of analysis, including genetic research, in which PF has been linked with genetic polymorphisms (Gloster, Gerlach, et al., 2015). We have extended the existing body of literature by explicitly investigating the link between changes in PF, stress, and well-being and thus integrating research on PF, stress, and well-being.

More research on the temporal relationship between PF and stress and well-being is certainly needed. Future research should investigate if the association of changes between PF and stress and well-being is different in face to face therapy or guided self-help. Future work should also, for instance, extend the number of measurements of the outcome (e.g., after each week or session). This would enable a more fine-grained analysis of when relevant changes occur and how these changes are associated with each other. This is important as the reduction of stress and promotion of well-being could help deter more serious problems from developing. Our longitudinal analysis emphasized the potential of PF in promoting well-being and creating substantial changes in participants’ lives and thus provides support for the theory that PF and well-being are strongly linked (Ciarrochi & Kashdan, 2013; Hayes, 2013).

Funding

The work was supported in part by the Swiss National Science Foundation (FNSNF) under Grant no. 100014_149524/1 & PP00P1_163716/1.

References
[Almeida, 2005]
D.M. Almeida.
Resilience and Vulnerability to Daily Stressors Assessed via Diary Methods.
Current Directions in Psychological Science, 14 (2005), pp. 64-68
[American Psychological Association Center for Organizational Excellence, 2014]
American Psychological Association Center for Organizational Excellence.
2014 Work and well-being survey.
[Baer et al., 2008]
R.A. Baer, G.T. Smith, E. Lykins, D. Button, J. Krietemeyer, S. Sauer, E. Walsh, J.M.G. Williams.
Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples.
Assessment, 15 (2008), pp. 329-342
[Beck et al., 1996]
A.T. Beck, R.A. Steer, G.K. Brown.
Manual for the Beck Depression Inventory-II.
Psychological Corporation, (1996),
[Benoy et al., 2017]
C. Benoy, B. Knitter, S. Doering, L. Knellwolf, A.T. Gloster.
Assessing Psychological Flexibility: Validation Of The Open and Engagement State Questionnaire.
(2017),
Manuscript submitted for publication
[Bohlmeijer et al., 2011]
E.T. Bohlmeijer, M. Fledderus, T.A.J. Rokx, M.E. Pieterse.
Efficacy of an early intervention based on acceptance and commitment therapy for adults with depressive symptomatology: Evaluation in a randomized controlled trial.
Behaviour Research and Therapy, 49 (2011), pp. 62-67
[Bohlmeijer et al., 2015]
E.T. Bohlmeijer, S.M.A. Lamers, M. Fledderus.
Flourishing in people with depressive symptomatology increases with Acceptance and Commitment Therapy. Post-hoc analyses of a randomized controlled trial.
Behaviour Research and Therapy, 65 (2015), pp. 101-106
[Bond and Bunce, 2003]
F.W. Bond, D. Bunce.
The role of acceptance and job control in mental health, job satisfaction, and work performance.
The Journal of Applied Psychology, 88 (2003), pp. 1057-1067
[Brinkborg et al., 2011]
H. Brinkborg, J. Michanek, H. Hesser, G. Berglund.
Acceptance and commitment therapy for the treatment of stress among social workers: A randomized controlled trial.
Behaviour Research and Therapy, 49 (2011), pp. 389-398
[Carmody and Baer, 2008]
J. Carmody, R.A. Baer.
Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program.
Journal of Behavioral Medicine, 31 (2008), pp. 23-33
[Chida and Steptoe, 2008]
Y. Chida, A. Steptoe.
Positive psychological well-being and mortality: A quantitative review of prospective observational studies.
Psychosomatic Medicine, 70 (2008), pp. 741-756
[Ciarrochi and Kashdan, 2013]
J. Ciarrochi, T.B. Kashdan.
The foundations of flourishing.
Mindfulness, acceptance and positive psychology, pp. 1-29
[Clarke et al., 2014]
S. Clarke, J. Kingston, K. James, H. Bolderston, B. Remington.
Acceptance and commitment therapy group for treatment-resistant Participants: A randomised controlled trial.
Journal of Contextual Behavioral Science, (2014),
[Cohen and Janicki-Deverts, 2012]
S. Cohen, D. Janicki-Deverts.
Who's Stressed? Distributions of Psychological Stress in the United States in Probability Samples from 1983, 2006, and 2009.
Journal of Applied Social Psychology, 42 (2012), pp. 1320-1334
[Cohen et al., 1983]
S. Cohen, T. Kamarck, R. Mermelstein.
A global measure of perceived stress.
Journal of Health and Social Behavior, 24 (1983), pp. 385-396
[Dahl et al., 2004]
J. Dahl, K.G. Wilson, A. Nilsson.
Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial.
Behavior Therapy, 35 (2004), pp. 785-801
[Diener et al., 2009]
E. Diener, C. Napa Scollon, R.E. Lucas.
The evolving concept of subjective well-being: The multifaceted nature of happiness.
Assessing Well-Being, 15 (2009), pp. 67-100
[Diener et al., 1999]
E. Diener, M.E. Suh, E.R. Lucas, L.H. Smith.
Subjective Well-Being: Three Decades of Sucess.
Psychological Bulletin, 25 (1999), pp. 270-302
[Ebert et al., 2016]
D.D. Ebert, E. Heber, M. Berking, H. Riper, P. Cuijpers, B. Funk, D. Lehr.
Self-guided internet-based and mobile-based stress management for employees: Results of a randomised controlled trial.
Occupational and Environmental Medicine, (2016),
oemed-2015
[Eurofound, 2005]
Eurofound.
Fourth European Working Conditions Survey.
European Foundation for the Improvement of Living and Working Conditions, (2005),
[Faber and Schlarb, 2016]
J. Faber, A.A. Schlarb.
The Relation of Sleep, Distress, and Coping Strategies—What Male and Female Students Can Learn from Each Other?.
Health, 8 (2016), pp. 1356-1367
[Fawzy and Hamed, 2017]
M. Fawzy, S.A. Hamed.
Psychological stress among medical students in Assiut University, Egypt.
Psychiatry Research, 255 (2017), pp. 186-194
[Flaxman and Bond, 2010]
P.E. Flaxman, F.W. Bond.
A randomised worksite comparison of acceptance and commitment therapy and stress inoculation training.
Behaviour Research and Therapy, 48 (2010), pp. 816-820
[Fledderus et al., 2012]
M. Fledderus, E.T. Bohlmeijer, M.E. Pieterse, K.M.G. Schreurs.
Acceptance and commitment therapy as guided self-help for psychological distress and positive mental health: A randomized controlled trial.
Psychological Medicine, 42 (2012), pp. 485-495
[Fledderus et al., 2010]
M. Fledderus, E.T. Bohlmeijer, F. Smit, G.J. Westerhof.
Mental health promotion as a new goal in public mental health care: A randomized controlled trial of an intervention enhancing psychological flexibility.
American Journal of Public Health, 100 (2010), pp. 2372
[Frögéli et al., 2016]
E. Frögéli, A. Djordjevic, A. Rudman, F. Livheim.
A randomized controlled pilot trial of acceptance and commitment training (ACT) for preventing stress-related ill health among future nurses.
Anxiety, Stress, & Coping, 29 (2016), pp. 1-17
[Gloster et al., 2015a]
A.T. Gloster, A.L. Gerlach, A. Hamm, M. Höfler, G.W. Alpers, T. Kircher, A. Ströle, T. Lang, H.U. Wittchen, J. Deckert, A. Reif.
5HTT is associated with the phenotype psychological flexibility: Results from a randomized clinical trial.
European Archives of Psychiatry and Clinical Neuroscience, 265 (2015), pp. 399-406
[Gloster et al., 2015b]
A.T. Gloster, R. Sonntag, J. Hoyer, A.H. Meyer, S. Heinze, A. Stroehle, G. Eifert, H.-U. Wittchen.
Treating Treatment-Resistant Patients with Panic Disorder and Agoraphobia Using Psychotherapy: A Randomized Controlled Switching Trial.
Psychotherapy and Psychosomatics, 84 (2015), pp. 100-109
[Grant et al., 2013]
F. Grant, C. Guille, S. Sen.
Well-Being and the Risk of Depression under Stress.
[Hayes, 2013]
S.C. Hayes.
The genuine conversation.
Mindfulness, acceptance and positive psychology, pp. 303-322
[Hayes et al., 2006]
S.C. Hayes, J.B. Luoma, F.W. Bond, A. Masuda, J. Lillis.
Acceptance and commitment therapy: Model, processes and outcomes.
Behaviour Research and Therapy, 44 (2006), pp. 1-25
[Hayes et al., 1999]
S.C. Hayes, K. Strosahl, K.G. Wilson.
Acceptance and commitment therapy: An experiental approach to behavior change.
Guilford Press, (1999),
[Hayes et al., 2012]
S.C. Hayes, K. Strosahl, K.G. Wilson.
Acceptance and commitment therapy: An experiental approach to behavior change.
Guilford Press, (2012),
[Heck and Thomas, 2015]
R. Heck, S.L. Thomas.
An Introduction to Multilevel Modeling Techniques: MLM and SEM Approaches Using Mplus.
Routledge, (2015),
[Henderson et al., 2005]
M. Henderson, N. Glozier, K.H. Elliott.
Long term sickness absence: Is caused by common conditions and needs managing.
British Medical Journal, 330 (2005), pp. 802-803
[Herr et al., 2017]
R.M. Herr, J. Li, A. Loerbroks, P. Angerer, J. Siegrist, J.E. Fischer.
Effects and mediators of psychosocial work characteristics on somatic symptoms six years later: Prospective findings from the Mannheim Industrial Cohort Studies (MICS).
Journal of Psychosomatic Research, 98 (2017), pp. 27-33
[Hofer et al., 2017]
P. Hofer, M. Waadt, R. Aschwanden, M. Milidou, J. Acker, A.H. Meyer, R. Lieb, A.T. Gloster.
The effectiveness of an ACT Self-help Intervention for Stress and Burnout without Therapist Contact: An Online Randomized Controlled Trial.
(2017),
Manuscript submitted for publication
[Kalia, 2002]
M. Kalia.
Assessing the economic impact of stress-The modern day hidden epidemic.
Metabolism, 51 (2002), pp. 49-53
[Keeley et al., 2016]
J.W. Keeley, G.M. Reed, M.C. Roberts, S.C. Evans, R. Robles, C. Matsumoto, C.R. Brewin, M. Cloitre, A. Perkonigg, C. Rousseau, O. Gureje, P. Lovell, P. Sharon, A. Maercker.
Disorders specifically associated with stress: A case-controlled field study for ICD-11 mental and behavioural disorders.
International Journal of Clinical and Health Psychology, 16 (2016), pp. 109-127
[Keyes, 2004]
C.L.M. Keyes.
The nexus of cardiovascular disease and depression revisited: The complete mental health perspective and the moderating role of age and gender.
Aging & Mental Health, 8 (2004), pp. 266-274
[Keyes, 2005]
C.L.M. Keyes.
Mental illness and/or mental health? Investigating axioms of the complete state model of health.
Journal of Consulting and Clinical Psychology, 73 (2005), pp. 539-548
[Keyes, 2007]
C.L.M. Keyes.
Promoting and protecting mental health as flourishing: A complementary strategy for improving national mental health.
The American Psychologist, 62 (2007), pp. 95-108
[Keyes et al., 2010]
C.L.M. Keyes, S.S. Dhingra, E.J. Simoes.
Change in level of positive mental health as a predictor of future risk of mental illness.
American Journal of Public Health, 100 (2010), pp. 2366-2371
[Keyes and Grzywacz, 2005]
C.L.M. Keyes, J.G. Grzywacz.
Health as a complete state: The added value in work performance and healthcare costs.
Journal of Occupational and Environmental Medicine/American College of Occupational and Environmental Medicine, 47 (2005), pp. 523-532
[Kraemer et al., 2001]
H.C. Kraemer, E. Stice, A. Kazdin, D. Offord, D. Kupfer.
How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors.
American Journal of Psychiatry, 158 (2001), pp. 848-856
[Lamers et al., 2011]
S.M.A. Lamers, G.J. Westerhof, E.T. Bohlmeijer, P.M. ten Klooster, C.L.M. Keyes.
Evaluating the psychometric properties of the Mental Health Continuum-Short Form (MHC-SF).
Journal of Clinical Psychology, 67 (2011), pp. 99-110
[Lamers et al., 2015]
S.M.A. Lamers, G.J. Westerhof, C.A.W. Glas, E.T. Bohlmeijer.
The bidirectional relation between positive mental health and psychopathology in a longitudinal representative panel study.
The Journal of Positive Psychology, 10 (2015), pp. 1-8
[Li et al., 2014]
J. Li, M. Zhang, A. Loerbroks, P. Angerer, J. Siegrist.
Work stress and the risk of recurrent coronary heart disease events: A systematic review and meta-analysis.
International Journal of Occupational Medicine and Environmental Health, 28 (2014), pp. 8-19
[Livheim et al., 2014]
F. Livheim, L. Hayes, A. Ghaderi, T. Magnusdottir, A. Högfeldt, J. Rowse, S. Turner, S.C. Hayes, A. Tengström.
The Effectiveness of Acceptance and Commitment Therapy for Adolescent Mental Health: Swedish and Australian Pilot Outcomes.
Journal of Child and Family Studies, (2014), pp. 1-15
[Lloyd et al., 2013]
J. Lloyd, F.W. Bond, P.E. Flaxman.
The value of psychological flexibility: Examining psychological mechanisms underpinning a cognitive behavioural therapy intervention for burnout.
Work & Stress, 27 (2013), pp. 181-199
[Maercker et al., 2013]
A. Maercker, C.R. Brewin, R.A. Bryant, M. Cloitre, G.M. Reed, M. Van Ommeren, A. Humayun, L.M. Jones, A. Kagee, A.E. Llosa, C. Rousseau, D.J. Somasundaram, R. Souza, Y. Suzuki, I. Weissbecker, S. Wessely, M.B. First, S. Saxena.
Proposals for mental disorders specifi cally associated with stress in the International Classification of Diseases-11.
Lancet, 381 (2013), pp. 1683-1685
[Marks and Cavanagh, 2009]
I. Marks, K. Cavanagh.
Computer-aided psychological treatments: Evolving issues.
Annual Review of Clinical Psychology, 5 (2009), pp. 121-141
[Melchior et al., 2007]
M. Melchior, A. Caspi, B.J. Milne, A. Danese, R. Poulton, T.E. Moffitt.
Work stress precipitates depression and anxiety in young, working women and men.
Psychological Medicine, 37 (2007), pp. 1119-1129
[Muthén and Curran, 1997]
B.O. Muthén, P.J. Curran.
General longitudinal modeling of individual differences in experimental designs: A latent variable framework for analysis and power estimation.
Psychological Methods, 2 (1997), pp. 371-402
[Muthén and Muthén, 2010]
L.K. Muthén, B.O. Muthén.
Mplus user's guide.
6th ed., Muthén & Muthén, (2010),
[Räsänen et al., 2016]
P. Räsänen, P. Lappalainen, J. Muotka, A. Tolvanen, R. Lappalainen.
An online guided ACT intervention for enhancing the psychological wellbeing of university students: A randomized controlled clinical trial.
Behaviour Research and Therapy, 78 (2016), pp. 30-42
[Ryff, 1989]
C.D. Ryff.
Happiness is everything, or is it? Explorations on the meaning of psychological well-being.
Journal of Personality and Social Psychology, 57 (1989), pp. 1069-1081
[Sagiv and Schwartz, 2000]
L. Sagiv, S.H. Schwartz.
Value priorities and subjective well-being: Direct relations and congruity effects.
European Journal of Social Psychology, 30 (2000), pp. 177-198
[Schönfeld et al., 2016]
P. Schönfeld, J. Brailovskaia, A. Bieda, X.C. Zhang, J. Margraf.
The effects of daily stress on positive and negative mental health: Mediation through self-efficacy.
International Journal of Clinical and Health Psychology, 16 (2016), pp. 1-10
[Seligman and Csikszentmihalyi, 2000]
M.E.P. Seligman, M. Csikszentmihalyi.
Positive psychology: An introduction.
American Psychologist, 55 (2000), pp. 5-14
[Soysa and Wilcomb, 2015]
C.K. Soysa, C.J. Wilcomb.
Mindfulness, self-compassion, self-efficacy, and gender as predictors of depression, anxiety, stress, and well-being.
Mindfulness, 6 (2015), pp. 217-226
[Sultan-Taïeb et al., 2013]
H. Sultan-Taïeb, J.-F. Chastang, M. Mansouri, I. Niedhammer.
The annual costs of cardiovascular diseases and mental disorders attributable to job strain in France.
BMC Public Health, 13 (2013), pp. 748
[Tennant, 2001]
C. Tennant.
Work-related stress and depressive disorders.
Journal of Psychosomatic Research, 51 (2001), pp. 697-704
[Thoits, 2010]
P.A. Thoits.
Stress and Health: Major Findings and Policy Implications.
Journal of Health and Social Behavior, 51 (2010), pp. S41-S53
[Trompetter et al., 2016]
H.R. Trompetter, E. de Kleine, E.T. Bohlmeijer.
Why Does Positive Mental Health Buffer Against Psychopathology? An Exploratory Study on Self-Compassion as a Resilience Mechanism and Adaptive Emotion Regulation Strategy.
Cognitive Therapy and Research, (2016), pp. 1-10
[Veage et al., 2014]
S. Veage, J. Ciarrochi, F.P. Deane, R. Andresen, L.G. Oades, T.P. Crowe.
Value congruence, importance and success and in the workplace: Links with well-being and burnout amongst mental health practitioners.
Journal of Contextual Behavioral Science, 3 (2014), pp. 258-264
[Waadt and Acker, 2013a]
M. Waadt, J. Acker.
Burnout: mit Akzeptanz und Achtsamkeit den Teufelskreis durchbrechen.
Hans Huber, (2013),
[Waadt and Acker, 2013b]
M. Waadt, J. Acker.
Downloadbereich ACT gegen Burnout.
[Wersebe et al., 2016]
H. Wersebe, R. Lieb, A.H. Meyer, J. Hoyer, H.-U. Wittchen, A.T. Gloster.
Changes of valued behaviors and functioning during an Acceptance and Commitment Therapy Intervention.
Journal of Contextual Behavioral Science, (2016), pp. 1-8
[Westerhof and Keyes, 2010]
G.J. Westerhof, C.L.M. Keyes.
Mental Illness and Mental Health: The Two Continua Model Across the Lifespan.
Journal of Adult Development, 17 (2010), pp. 110-119
[Wood and Joseph, 2010]
A.M. Wood, S. Joseph.
The absence of positive psychological (eudemonic) well-being as a risk factor for depression: A ten year cohort study.
Journal of Affective Disorders, 122 (2010), pp. 213-217
Copyright © 2017. Asociación Española de Psicología Conductual
Article options
Tools