Journal of Contextual Behavioral Science 3 (2014) 248–257

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Using acceptance and commitment therapy to increase

self-compassion: A randomized controlled trial
James E. Yadavaia a,n, Steven C. Hayes b, Roger Vilardaga c,1
a
Department of Psychology, 296 University of Nevada, Reno, Reno, NV 89557-0062, USA
b
Department of Psychology, 298 University of Nevada, Reno, Reno, NV 89557-0062, USA
c
University of Washington, Department of Psychiatry and Behavioral Sciences, University of Washington at Harborview Medical Center, Box 359911,
325 Ninth Ave., Seattle, WA 98104-2499, USA

art ic l e i nf o a b s t r a c t

Article history: Self-compassion has been shown to be related to several types of psychopathology, including traumatic
Received 1 December 2013 stress, and has been shown to improve in response to various kinds of interventions. Current
Received in revised form conceptualizations of self-compassion fit well with the psychological flexibility model, which underlies
31 August 2014
acceptance and commitment therapy (ACT). However, there has been no research on ACT interventions
Accepted 30 September 2014
specifically aimed at self-compassion. This randomized trial therefore compared a 6-hour ACT-based
workshop targeting self-compassion to a wait-list control. From pretreatment to 2-month follow-up, ACT
Keywords: was significantly superior to the control condition in self-compassion, general psychological distress, and
Self-compassion anxiety. Process analyses revealed psychological flexibility to be a significant mediator of changes in self-
Acceptance and commitment therapy
compassion, general psychological distress, depression, anxiety, and stress. Exploratory moderation
Psychological flexibility
analyses revealed the intervention to be of more benefit in terms of depression, anxiety, and stress to
General psychological distress
Mediation those with greater trauma history.
Moderation Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science

1. Introduction psychological disorders in response to stressful life events, such

as exposure to trauma (Cox, MacPherson, Enns, & McWilliams, 2004;
The concept of self-compassion has been put forth as a healthy Sharhabani-Arzy, Amir, & Swisa, 2005; Thompson & Waltz, 2008).
alternative to both self-criticism and high self-esteem and has Interventions of various lengths and formats, from mindfulness-
been conceptualized as consisting of self-kindness, mindfulness, based stress reduction programs to very brief rationales, have been
and common humanity (Neff, 2003b). Self-kindness involves shown to increase self-compassion, as measured by Neff's Self-
extending understanding, patience, and benevolence to the self, Compassion Scale (SCS; Neff, 2003a; for a review of research using
especially in difficult times; Common humanity refers to a sense in the SCS, see Neff, 2012). One study showed that an 8-week mindful
which one is connected to others in and even through one's self-compassion course based on Neff's conceptualization improved
suffering, as suffering is in fact common to all human beings; And self-compassion, mindfulness, compassion towards others, life satis-
mindfulness involves holding painful experiences in awareness faction, avoidance, depression, anxiety, and stress significantly more
(that is, not denying or distracting from them) but at a distance so than a wait-list control, with all improvements maintained at
that one does not become overly identified with them. The 6-month follow-up (Neff & Germer, 2013).
relevance of self-compassion has been supported by recent Some authors have suggested that acceptance and commit-
research showing that self-compassion correlates negatively with ment therapy (ACT; Hayes, Strosahl, & Wilson, 2012) overlaps with
depression, anxiety, worry, rumination, and PTSD avoidance Neff's conceptualization of self-compassion considerably and that
symptoms (Neff, 2003a; Neff, Rude, & Kirkpatrick, 2007; Raes, Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche,
2010; Thompson & Waltz, 2008). In addition, self-criticism and 2001), the basic science of language and cognition behind ACT,
low self-compassion play a role in the development of may be relevant to self-compassion as well (Neff & Tirch, 2013).
While research on ACT has not extensively examined self-compas-
sion, ACT's process of change, psychological flexibility, which is
n
Corresponding author. Present address: VA Long Beach Healthcare System, measured by the Acceptance and Action Questionnaire-II (AAQ-II;
5901 E. 7th Street (06/116B), Long Beach, CA 90822, USA. Tel.: þ 1 775 453 3703. Bond et al., 2011), correlates with the SCS at r ¼ .65 (Neff,
E-mail addresses: [email protected] (J.E. Yadavaia),
[email protected] (S.C. Hayes), [email protected] (R. Vilardaga).
unpublished data cited in Neff & Tirch, 2013).
1
Roger Vilardaga's writing was supported by the National Institute On Drug Psychological flexibility from an ACT perspective has 6 different
Abuse under Award Number K99DA037276. dimensions. It consists of (1) deliteralizing language and cognition

http://dx.doi.org/10.1016/j.jcbs.2014.09.002
2212-1447/Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science
 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257 249

(defusion), (2) openly and willingly experiencing emotions and model and its underlying theory of language and cognition, RFT,
bodily sensations (acceptance), (3) flexibly and voluntarily attend- we designed an ACT intervention aimed at:
ing to what is present (present moment awareness), (4) having a
sense of self as the perspective from which life is experienced, as (1) Weakening fusion with self-criticism and self-conceptualizations.
distinguished from one's identity or self-image (self-as-context), A defused stance is adaptive in that it involves flexibility in
(5) flexible yet persistent self-directed behavior (committed terms of the extent to which self-criticisms and self-
action), and (6) freely chosen qualities of action that make conceptualizations govern behavior. For example, defusion
behavior intrinsically reinforcing (values). frees individuals from pursuing lives centered around disprov-
There are parallels and similarities between the concepts of ing self-criticisms through rigid perfectionism, but it also
psychological flexibility and self-compassion. First, from an ACT allows individuals to recognize areas of weakness so as to
perspective, Neff's central concept of self-kindness may be closely empower personal growth.
linked to self-acceptance. The opposite of experiential acceptance, (2) Strengthening deictic framing repertoires, which are involved in
experiential avoidance, is viewed within ACT to include excessive cultivating self-perspective-taking and self-as-context. Deictic
evaluation of one's experiences as bad or wrong and is therefore framing is involved in perspective-taking and compassion.
highly self-invalidating. Acceptance of one's painful experiences, Because these processes are usually thought of in terms of
and of oneself when one is hurting, can thus be a stance of what one does with respect to others (e.g., “putting oneself in
profound self-kindness. Further, contacting pain openly is neces- another's shoes”), the idea of applying them to the self may
sary for extending understanding to oneself, a coping skill that is seem odd. However, through self-conceptualizations as
included in Neff's definition of self-kindness. “good,” “bad,” “okay,” “broken,” etc., self-as-content/self-as-
Second, from an RFT point of view, extending such self- object becomes more salient. Thus, defusion from self-as-
understanding involves deictic relational frames (or perspective content and the cultivation of self-as-context are central to
taking), which are defined as frames “that specify a relation in the self-empathy involved in self-compassion.
terms of the perspective of the speaker” (Hayes et al., 2001, p. 38). (3) Constructing and enacting a value of self-kindness through
These very same deictic frames are involved in a sense of common acceptance and self-acceptance. Just as compassion towards
humanity (an aspect central to self-compassion), since they allow others may be conceptualized as empathy plus kindness
one to see that both the self and others have moment to moment (Lazarus, 1991), self-compassion may be conceptualized as
perspectives that can bear witness to difficult experiences. As self-perspective-taking plus a value of self-kindness. One
perspective taking is strengthened, RFT argues that a larger way to enact such a value is to embrace the suffering parts
common consciousness emerges that is extended across time, of the self with love and acceptance rather than avoiding
place, and person. thoughts and feelings linked to them.
Third, Neff's self-compassion conceptualization and ACT both
emphasize mindfulness, which from an ACT perspective consists Consistent with ACT's theoretical model and with previous ACT
of defusion, acceptance, contact with the present moment, and research, we hypothesize that the ACT intervention will lead to
self-as-context (Fletcher & Hayes, 2005). Defusion is important for improvements in self-compassion and general psychopathology.
self-compassion because it allows self-criticisms to pass through Likewise, we hypothesize that such improvements will be
the mind without having to be believed, proven wrong, or mediated by increases in psychological flexibility. Given previous
otherwise engaged—a stance that is likely more workable than research indicating the role of self-compassion among victims of
an agenda of cognitive change. Defusion from self-criticism is trauma, an exploratory aim of this study was to examine whether
particularly well-suited to self-critics because instructions to be the ACT intervention was more efficacious for individuals with a
less self-critical will likely be taken as criticisms, and will history of trauma.
strengthen the self-critical repertoire. Self-as-context, or the
observing self, is a sense of self that emerges from defusion from
self-conceptualizations. Unlike self-esteem, which depends on 3. Method
positive self-evaluations, self-as-context cannot be threatened by
failures and is therefore consummately stable. 3.1. Participants

Participants were undergraduates (N ¼73) 18 years of age and

2. The present study older enrolled in psychology classes at the University of Nevada,
Reno. So that the intervention could be tested on those for whom
In summary, (1) research suggests that lack of self-compassion it would be most relevant, and to avoid ceiling effects, participants
might play a role in general psychopathology and in individual's were screened for low self-compassion, which was defined as a
response to trauma, (2) there has been a recent emergence in the score on the SCS below the mean score for undergraduates in the
literature of self-compassion as a treatment target, and (3) ACT original validation sample, 18.25. For similar reasons, participants
and Neff's conceptualization of self-compassion share a number of were also screened for high psychological distress, as indicated by
conceptual commonalities. a score on the General Health Questionnaire (GHQ; Goldberg,
Despite the clear applicability of ACT to self-compassion work, 1972) of 10 or higher, which indicates the presence of a current
and the relevance of self-compassion with regards to psycho- DSM-IV Axis I disorder with a sensitivity of 78% and a specificity of
pathology, no study to date has examined the effectiveness of an 60% in this approximate age group (Baksheev, Robinson, Cosgrave,
ACT protocol targeted at self-compassion. In addition, the con- Baker, & Yung, 2011). Participants completed the screening instru-
ceptual overlaps between the psychological flexibility model and ments and all subsequent measures on SurveyMonkey (http://
self-compassion beg the question of whether psychological flex- www.surveymonkey.com/) after signing up through a research
ibility may account for changes in self-compassion. sign up system maintained by the Psychology Department.
Therefore, this study aims to test the efficacy of an ACT Those who qualified for the study were invited by email and/or
approach to self-compassion, test the mediational role of psycho- by phone by the first author to attend a 20-minute informed
logical flexibility, and explore the moderating role of trauma consent meeting where the study was described. Each participant
history on the efficacy of the intervention. Drawing from the ACT who consented was then assigned to either the ACT workshop or
250 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257

waitlist condition via a random number generator (http://stattrek. The General Health Questionnaire (GHQ; Goldberg, 1972) is a
com/statistics/random-number-generator.aspx). Participants in 12-item Likert self-report scale that measures general psychologi-
the ACT condition were scheduled to attend a workshop to occur cal distress by assessing the extent to which certain experiences
within 11 weeks of the date they gave consent. Three workshops have been present recently, such as “thinking of yourself as a
were given for ACT participants, and therefore the participants worthless person” or “feeling reasonably happy, all things con-
were grouped into 3 cohorts. Waitlist participants were then sidered.” The GHQ has been used extensively as a screening
grouped into 3 corresponding cohorts according to when they instrument for psychopathology among young people (Tait,
consented. For example, the earliest consenters were asked to Hulse, & Robertson, 2002). Internal consistency is good in
complete the assessments during the same weeks as were the ACT college-aged individuals (Cronbach's α ¼.84; Winefield, Goldney,
participants receiving the first workshop, and so on. Participant Winefield, & Tiggemann, 1989) and was good at pretreatment in
flow is shown in Fig. 1. the current study (α ¼.87).
The Depression Anxiety and Stress Scales-21 (DASS-21;
Lovibond & Lovibond, 1995) are 3 7-item self-report scales
3.2. Measures and assessment schedule measuring the severity of depression, anxiety, and stress over
the past week. Items are presented together in a 21-item ques-
In addition to a variety of demographic variables (see Table 1) tionnaire and are rated on a 0–3 scale. Internal consistency has
the following measures were taken. previously been shown to be good (α for each scale 4.87; Antony,
Bieling, Cox, Enns, & Swinson, 1998), and was acceptable to good at
pretreatment in the present study (αs for depression, anxiety, and
3.2.1. Outcome measures stress¼.86, .76, and .84, respectively). Sample items include, “I felt
The Self-Compassion Scale (SCS; Neff, 2003a) measures self- downhearted and blue,” (Depression), “I felt I was close to panic,”
compassion through 26 self-report items rated on a 5-point Likert (Anxiety), and “I tended to over-react to situations,” (Stress).
scale ranging from almost never to almost always. The SCS has good
internal reliability, both in its validation study (α ¼.92) and in the
present study (α ¼ .90). The SCS yields an overall score and consists 3.2.2. Process measure
of six subscales: Self-Kindness (e.g., “When I'm going through a The Acceptance and Action Questionnaire-II (AAQ-II; Bond
very hard time, I give myself the caring and tenderness I need.), et al., 2011) is a measure of psychological flexibility. The AAQ-II's
Self-Judgment, Common Humanity (e.g., When I feel inadequate in 7 self-report items are rated on a 7-point Likert scale ranging from
some way, I try to remind myself that feelings of inadequacy are never true to always true. Item ratings are added together, and
shared by most people.”), Isolation, Mindfulness (e.g., “When I fail higher scores indicate higher levels of psychological inflexibility.
at something important to me I try to keep things in perspective”), The AAQ-II is more internally consistent than the original AAQ
and Over-Identification. (Hayes et al., 2004) with an α ¼.84 in its validation study and

Fig. 1. Participant flow.

 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257 251

Table 1
Participant characteristics.

ACT Waitlist Total

(N ¼ 30) (N ¼ 43) (N ¼ 73)

% N % N % N

Female 70 21 77 33 74 54
Asian/Pacific Islander 17 5 16 7 16 12
African-American/Black 7 2 7 3 7 5
Hispanic/Latino 10 3 14 6 12 9
Native American 0 0 2 1 1 1
White/Non-Hispanic 77 23 72 31 74 54
Bisexual 3 1 2 1 3 2
Heterosexual 97 29 86 37 89 65
Gay 0 0 7 3 4 3
Lesbian 0 0 0 0 0 0
Questioning 0 0 2 1 3 2
Pansexual 0 0 2 1 1 1

Mean SD Mean SD Mean SD

Age 19.90 4.05 20.83 4.61 13.69 2.66

Grade point average (GPA) 3.42 .51 3.31 .48 16.49 4.84
Stressful life events (SLESQ-R) 1.93 1.78 1.86 1.57 1.89 1.66
Self-compassion (SCS) at Screening 13.91 2.83 13.54 2.57 13.69 2.66
Psychological distress (GHQ) at screening 16.80 5.06 16.28 4.73 16.49 4.84

Table 2
Stressful life events assessed by SLESQ-R.

Life-threatening illness
Life-threatening accident
Robbery or mugging in which physical force or a weapon was used against you
Death of an immediate family member, romantic partner, or very close friend because of accident, homicide, or suicide
Being physically forced to have intercourse or to have oral or anal sex against your wishes, or when you were helpless (e.g. when intoxicated)
Other than the above experiences, being touched in private body parts, being made to touch someone else's body, or experiencing someone try to make you have sex
against your wishes
Being slapped repeatedly, beaten, or otherwise attacked or harmed as a child by a parent, caregiver, or other person
Being kicked, beaten, slapped around, or otherwise physically harmed as an adult
Being repeatedly ridiculed, put down, ignored, or told you were no good by a parent, romantic partner, or family member
Other than the above experiences, being threatened with a knife or gun
Being present when another person was killed, seriously injured, or sexually or physically assaulted
Being in any other situation where you were seriously injured or your life was in danger (e.g. military combat, living in a war zone)
Being in any other situation that was extremely frightening or horrifying, or one in which you felt extremely helpless

α ¼.87 in the present study. The AAQ-II correlates very highly with after the intervention (“post”), and 8–9 weeks after the interven-
the AAQ-I (r ¼.97), which has mediated ACT treatment effects in tion (“follow-up”). Two measures were taken at screening (the
many outcome studies (Hayes, Luoma, Bond, Masuda, & Lillis, GHQ and SCS). Participants were compensated for assessment
2006). Items include, “My painful experiences and memories make completion with research credits and a lottery for gift cards, which
it difficult for me to live a life that I would value,” and “I'm afraid of were funded though indirect funds of the second author's research
my feelings.” lab and through personal funds of the first author.

3.3. Intervention
3.2.3. Moderator measure
The Stressful Life Events Screening Questionnaire-Revised
The protocol for the 6-hour workshop was based on the
(SLESQ-R; Green, Chung, Daroowalla, Kaltman, & DeBenedictis,
manual used by Lillis, Hayes, and Bunting (2009) but was adapted
2006) is a self-report instrument designed to screen for a history
significantly to focus on self-compassion (see Yadavaia, 2013 for
of events that could qualify as Criterion A stressors for PTSD. Each
the complete protocol). The present workshop focused on weak-
of its 13 items contains a yes-no question regarding history of a
ening fusion with self-criticism and self-conceptualizations, build-
particular type of stressful event (see Table 2 for a list of these
ing self-perspective-taking and self-as-context, and strengthening
events). Follow-up questions for each item assess the age at which
a value of self-kindness through acceptance and self-acceptance.
the stressor occurred as well as other details, but since the purpose
To foster defusion from self-criticisms, the unworkability of
was to assess whether participants had been exposed to poten-
attempts to suppress or change self-critical thoughts was high-
tially traumatic stressors, these were not used in the present study.
lighted, for example using the Chocolate Cake Exercise (Hayes,
Strosahl, & Wilson, 1999, pp. 124–125). Defused acceptance of self-
3.2.4. Assessment schedule critical thoughts was then presented as an alternative, as partici-
With the exception of demographic measures and the mod- pants were asked to imagine writing their thoughts on leaves
erator measure (the SLESQ-R), taken only at baseline, all measures flowing down a stream and to watch for times when they
were taken one week before the intervention (“pre”), 1–2 weeks fuse with thinking and lose the image of the stream. Defusion
252 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257

from self-as-content was also instigated by comparing self- 4.2. Distributional assumptions
conceptualizations to documentaries, in that both are based on “real
footage” but are still merely content about something. That is, in the Before conducting formal statistical analyses, underlying dis-
same way that a documentary about Africa is not Africa, our stories tributional assumptions were examined, particularly skewness,
about ourselves are not us (Harris, 2008, pp. 155–156). kurtosis, outliers, and homogeneity of variance. Data from each
Experiential exercises were included to cultivate self-compassion condition at each time point were required to exhibit skewness
through perspective taking and contact with self-as-context. For between  2.00 and 2.00 and kurtosis between 4.00 and 4.00.
example, participants were led in an eyes-closed exercise called the Only the Anxiety subscale of the DASS failed to meet criteria, but
Child Exercise (Walser & Westrup, 2007, pp. 186–190), in which did so after 2 outliers were removed from follow-up. A summary
participants are guided to imagine themselves as they were as small of the means and standard deviations of all outcome and process
children walking through their childhood homes, asking their variables are shown in Table 3.
parents for what they would most want from them psychologically.
Then, participants are guided to imagine their adult selves meeting
4.3. Outcomes
their childhood selves, giving them what they feel the child needs or
could benefit from, thus enacting a value of self-kindness.
4.3.1. Analytic strategy
The protocol then focused more on self-kindness as a value,
Although hierarchical linear modeling (HLM) was explored as a
with acceptance of one's experience presented as a way to enact a
method of data analysis, in virtually all cases modeling time
value of self-kindness. In the Stand and Declare Exercise, partici-
categorically rather than as a linear covariate provided a better
pants made public commitments to act in concert with their
fit as determined by a comparison of nested models using
values, such as showing oneself greater kindness in difficult times.
restricted log-likelihoods, and thus a mixed model repeated
measures (MMRM) analysis was used. MMRM is a mixed regres-
sion model that retains most of the advantages of HLM for an
3.3.1. Personnel intent-to-treat analysis (Raudenbush & Bryk, 2002) in using all
Each workshop was led by 2 clinical psychology doctoral available data from all subjects and taking into account the
students (from a total group of 3) who had received at least obtained outcome and missingness, thus reducing the problem
3 semesters of practicum training in ACT and at least 1 year of of missing data. Although treatment occurred in groups, the
experience using ACT with individual clients. The first author analysis was not fully nested since the comparison condition
served as co-leader for all workshops. contained no nesting variable at that level.
Several simpler and restrictive covariance assumptions were
tested (compound symmetry, compound symmetry heteroge-
3.3.2. Adherence neous, Toeplitz) and the simplest model was used that was not
All workshops were audio recorded using MP3 recorders. significantly different than the unspecified covariance structure as
Clinical psychology graduate students with a minimum of 1 year determined by comparison of nested models through the
of practicum training in ACT rated each workshop using an restricted log-likelihood.
adherence manual adapted from Plumb and Vilardaga (2010) that Denominator degrees of freedom for the fixed effects test
assessed coverage of the 6 ACT flexibility processes and the statistics was based on the Sattherthwaite approximation. Effect
absence of ACT-inconsistent approaches, e.g. cognitive disputation. sizes (converted to Cohen's d), were be derived from the F-test
Overall scores for each workshop were computed by averaging the statistic for the regression coefficients using the formula
pffiffiffiffiffiffiffiffiffiffi
individual item ratings, which could range from 1 to 5. To evaluate d ¼ 2 F=df (with df constrained to be no larger than the number
inter-rater reliability of the adherence instrument, 1 of the 3 work- of participants), which is suggested for repeated measures and
shops was randomly selected to be rated by 2 of the adherence multilevel designs (Rosenthal & Rosnow, 1991; Verbeke &
raters. The raters' responses were never more than 1 point apart, Molenberghs, 2000). Effect sizes for within group contrasts were
and they agreed precisely 76% of the time. Overall adherence calculated by the formula [Mdiff/√{V(1)þV(2)2 Cov(1,2)}] where
scores for the 3 workshops were high in all cases (4.59, 4.69, and V¼variance, Cov¼covariance, and numbers refer to the measure-
4.86; M¼ 4.71, SD ¼ .14), indicating that the intervention was ment occasions compared (Wackerly, Mendenhall, & Scheaffer, 2008,
delivered skillfully and in depth. p. 271). Effect sizes are discussed using the cutoffs suggested by
Cohen (1988).

4. Results 4.3.2. Self-compassion

An MMRM analysis with a heterogeneous compound symmetry
4.1. Participant characteristics covariance structure best fit the data from the SCS and revealed a
significant effect for treatment condition (po .001) and time
A total of 532 participants were screened, of which 225 (p o.001), and a significant and medium time-by-condition inter-
qualified; approximately 85 attended the informed consent ses- action [F(2, 102.61) ¼10.18, p o.001, effect size ¼ .74]. The interac-
sion (38%). Of these, 78 (92%) agreed to participate, and 73 (86%) tion reflected the differences in magnitude of improvement
actually did so (as defined by supplying at least 1 assessment between conditions. More specifically, the waitlist participants
point). The ACT group was smaller (n ¼34) than the waitlist group showed a small significant improvement from pre to post (p ¼.03,
(n ¼44) because of the unblocked randomization procedure, which effect size¼.35) and from pre to follow-up [Estimate¼ 1.52,
could not ensure equivalence of group size. There was no differ- SE¼.49, t (109.56) ¼3.08, p o.01, 95% CI:.54, 2.49, effect size ¼ .48],
ence on any screening measure or demographic variable (gender, while ACT participants exhibited a significant large improvement
racial/ethnic background, sexual orientation, or grade point aver- from pre to post (p o.001, effect size ¼1.15) and from pre to
age) between the two conditions, except that that ACT participants follow-up [Estimate¼ 4.82, SE¼.59, t (109.37) ¼ 8.21, p o.001, 95%
were significantly younger than waitlist control participants CI: 3.66, 5.99, effect size ¼1.54]. The pre to follow-up changes were
(p ¼.04), although the means differed by less than 1 year. See significantly different between the two conditions [Estimate¼
Table 1 for details on participant characteristics.  3.31, SE ¼.77, t (109.45) ¼  4.32, p o.001, 95% CI:  4.83,
 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257 253

Table 3
Means, standard deviations, and between-condition comparisons of outcome and process variables at each time point.

Pre Post Follow-up

Mean SD N Mean SD N Mean SD N

Self-compassion (SCS)
ACT 14.64 3.72 30 17.95 2.95 28 19.28 2.92 28
Control 13.87 3.00 43 14.98 3.31 39 15.26 3.96 40
P for between-group t .33 .00 .00

General psychological distress (GHQ)

ACT 14.63 6.56 30 9.96 4.37 28 7.68 4.59 28
Control 15.35 5.12 43 15.05 5.92 39 11.88 5.07 40
P for between-group t .60 .00 .00

Depression (DASS-D)
ACT 11.53 9.69 30 7.50 7.42 28 6.00 7.16 28
Control 12.84 8.00 43 14.09 12.30 39 11.28 9.18 40
P for between-group t .53 .01 .01

Anxiety (DASS-A)
ACT 10.47 7.84 30 7.36 8.02 28 6.64 7.46 28
Control 8.09 6.73 43 9.54 9.85 39 8.25 7.57 40
P for between-group t .17 .34 .39

Stress (DASS-S)
ACT 15.33 10.13 30 12.90 8.26 28 10.43 9.05 28
Control 15.98 8.27 43 17.18 10.45 39 14.98 8.31 40
P for between-group t .76 .08 .04

Psychological flexibility (AAQ-II)

ACT 25.40 9.41 30 20.86 7.61 28 17.61 7.93 28
Control 26.23 8.29 43 24.65 10.29 39 23.87 9.44 40
P for between-group t .69 .10 .01

Note: All comparisons were independent samples 2-tailed t-tests. SCS¼ Self-Compassion Scale; GHQ ¼ General Health Questionnaire; DASS ¼Depression Anxiety and Stress
Scales; AAQ-II ¼Acceptance and Action Questionnaire-II.

effect for treatment condition (p o.001), time (p o.001), and a

significant and small time-by-condition interaction [F(2, 106.80) ¼
3.69, p ¼.03, effect size ¼ .45]. The interaction reflected the
between-condition differences in the degree to which participants
improved. More specifically, while the waitlist participants
showed no improvement from pre to post (p ¼.77) and showed a
significant medium improvement from pre to follow-up [Estimate¼
 3.54, SE¼1.06, t (108.29)¼  3.34, po.01, 95% CI:  5.64,  1.44,
effect size¼.52], those in the ACT condition showed a significant
medium improvement from pre to post (po.001, effect size¼.67)
and large and significant improvement from pre to follow-up
[Estimate¼ 7.06, SE¼1.27, t (108.08)¼  5.56, po.001, 95% CI:
 9.57,  4.54, effect size¼1.03]. The pre to follow-up changes were
significantly different between the two conditions [Estimate¼3.52,
SE¼1.65, t (108.17)¼ 2.13, p¼ .04, 95% CI:.24, 6.80, effect size¼.52, a
medium effect].

4.3.4. Depression
An MMRM analysis with a Toeplitz covariance structure best fit
the data for the DASS-D and revealed a significant effect for
treatment condition (p ¼.01) and time (p ¼.03), and a significant
and small time-by-condition interaction [F(2, 87.45)¼ 3.11,
p¼ .0498, effect size¼ .41]. The interaction reflected the fact that
Fig. 2. Changes in SCS by condition.
participants in the waitlist condition showed no improvement
from pre to post (p ¼.41) or from pre to follow-up (p ¼.34), while
1.79, effect size ¼ 1.06, a large effect]. Fig. 2 displays changes in ACT participants showed a significant small improvement from
the SCS across time points for each condition. pre to post (p ¼.01, effect size ¼ .48) and a significant medium
improvement from pre to follow-up [Estimate¼  5.72, SE¼ 2.09,
t (63.18) ¼  2.73, p¼ .01, 95% CI:  9.91,  1.54, effect size ¼.51].
4.3.3. General psychological distress Although pre to post changes were significantly different between
An MMRM analysis with a heterogeneous compound symmetry the two treatment conditions [Estimate¼ 5.50, SE¼2.21, t (133.02)¼
covariance structure best fit the data and revealed a significant 2.49, p¼ .01, 95% CI: 1.13, 9.86, effect size¼ .61, a medium effect], the
254 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257

pre to follow-up changes were not significantly different between 4.4.2. Self-compassion
conditions (p¼.15). Pre to post changes in psychological flexibility (AAQ-II) sig-
nificantly mediated (p o.05) pre to follow-up changes in self-
compassion as measured by the SCS (bootstrapped point
4.3.5. Anxiety estimate¼ 2.51, SE ¼.86, 95% CI: .07, 2.01). The significantly better
For DASS-A scores, an MMRM analysis with an unstructured impact of the intervention on SCS pre to follow-up changes,
covariance structure best fit the data and revealed no effect for t(63) ¼3.72, p o.01, was reduced but continued to be significant
treatment condition (p ¼.48), a significant effect for time (p ¼.04), after including the mediator, t(63) ¼3.03, p o.01 (proportion of
and a significant and medium time-by-condition interaction [F(2, effect mediated¼ 28.1%).
67.21) ¼7.48, p o.01, effect size ¼ .67]. The interaction reflected the
fact that the waitlist participants showed a significant and small 4.4.3. General psychological distress
deterioration from pre to post (p ¼.04, effect size ¼ .34) and no Pre to post changes in psychological flexibility significantly
change from pre to follow-up (p ¼.92), while ACT participants mediated (po.05) pre to follow-up changes in general psychological
showed a significant medium improvement from pre to post distress as measured by the GHQ (bootstrapped point estimate¼
(p ¼.01, effect size ¼.53) and from pre to follow-up [Estimate¼  1.78, SE¼1.10, 95% CI:  4.74,  .21). The significantly better impact
5.17, SE ¼1.48, t (71.37) ¼  3.48, p o.01, 95% CI:  8.12,  2.21, of the workshop on GHQ pre to follow-up changes, t(63)¼ 2.01,
effect size ¼.66]. The pre to follow-up changes were significantly p¼.049, was no longer significant after including the mediator,
different between the two conditions [Estimate¼5.29, SE ¼1.92, t(63)¼  1.14, p¼.26 (proportion of effect mediated¼46.9%).
t (70.47) ¼2.76, p ¼.01, 95% CI: 1.46, 9.11, effect size ¼.68, a medium
effect]. 4.4.4. Depression
Pre to post changes in psychological flexibility significantly
mediated (p o.05) pre to follow-up DASS-D changes (boot-
4.3.6. Stress strapped point estimate ¼ 2.89, SE¼ 1.79; 95% CI:  7.70,  .34).
For the DASS-S, an MMRM analysis with a heterogeneous Although the decrease in DASS-D scores from pre to follow-up was
compound symmetry covariance structure fit the data best and non-significant, t(63) ¼  1.79, p¼ .08, it was reduced after adjust-
revealed a marginally significant effect for treatment condition ing for the mediator, t(63) ¼  .80, p¼ .43 (proportion of difference
(p ¼.06), a significant effect for time (p ¼.02), and no significant mediated¼59.9%).
time-by-condition interaction (p ¼.13). The waitlist participants
showed no change from pre to post (p¼ .42) or from pre to follow- 4.4.5. Anxiety
up (p¼ .50). Those in the ACT condition also showed no change Pre to post AAQ-II changes significantly mediated (p o.05) pre
from pre to post (p ¼.16) but showed a significant medium to follow-up DASS-A change scores (bootstrapped point
improvement from pre to follow-up [Estimate¼ 5.25, SE ¼1.74, estimate¼  1.78, SE¼1.27, 95% CI:  6.02,  .26). The significantly
t (111.53)¼  3.02, po .01, 95% CI:  8.70,  1.80, effect size ¼.56]. better pre to follow-up DASS-A change scores observed in the ACT
Evaluation of the difference in the pre to follow-up changes condition, t(63) ¼ 2.40, p¼ .02, became non-significant after
between conditions revealed a non-significant trend towards a including the mediator, t(63) ¼  1.59, p¼ .12 (proportion of effect
small effect in favor of the ACT participants [Estimate¼ 4.25, mediated¼37.7%).
SE¼ 2.27, t (111.64) ¼1.88, p ¼.06, 95% CI: .24, 8.75, effect
size¼ .46]. 4.4.6. Stress
Pre to post changes in AAQ-II significantly mediated (po.05) pre
to follow-up changes in stress as measured by the DASS-S (boot-
4.4. Mediation analyses strapped point estimate¼  2.09, SE¼ 1.52, 95% CI: 7.04,  .09).
The non-significant trend towards superiority of the ACT condition
4.4.1. Analytic strategy in terms of pre to follow-up DASS-S change scores, t(63)¼  1.86,
The functional role of psychological flexibility (AAQ-II) in p¼.07, disappeared after including the mediator in the analysis,
producing effects on the outcome measures was examined by t(63)¼  1.09, p¼ .28 (proportion of effect mediated¼ 44%).
mediation analysis. Testing the significance of the “a” and “b” cross
product is recognized as perhaps the best all-around available 4.5. Moderation analyses
method to test mediation (MacKinnon, Lockwood, Hoffman, West,
& Sheets, 2002). A nonparametric method using bootstrapped 4.5.1. Analytic strategy
samples developed by Preacher and Hayes (2004, 2008) was used To evaluate whether the workshop was differentially effective
in the current study to test the statistical significance of the cross for individuals according to trauma history, the SLESQ-R (taken at
product of the coefficients. In the present set of analyses, para- pretreatment) was evaluated as a moderator of the effect of
meter estimates were based on 3000 bootstrap samples. The bias treatment condition on outcomes. Following the recommenda-
corrected and accelerated 95% confidence intervals were then tions of Hayes (2013), linear regression was used to construct a
examined. These confidence intervals are similar to the 2.5 and model with the following predictors of outcome variables: SLESQ-
97.5 percentile scores of the obtained distribution of the cross R, treatment condition, and the interaction (i.e., product) of SLESQ-
products over the k samples, but with z-score based corrections for R and treatment condition. If the coefficient for the interaction
bias due to the underlying distribution (Preacher & Hayes, 2004, term in a given analysis is significant, SLESQ-R may be regarded as
2008). If the confidence intervals do not contain zero, the point a moderator of that outcome. Significant interactions were then
estimate was considered significant at the level indicated. In each probed by examining the conditional effects of condition on
mediational analysis, all time points were included, and therefore outcome at the 25th, 50th, and 75th percentiles of the SLESQ-R.
participants who missed 1 or more assessments were excluded So that coefficients may be interpretable within the range of
(N ¼ 8 of 73). Pre to follow-up changes in the outcome variable the data, both SLESQ-R and condition were mean centered prior to
were entered as outcomes, and pre to post changes in the process analysis (Hayes, Glynn, & Huge, 2012). Data for both pre and
variable (AAQ-II) were entered as mediators. follow-up could only be collected from 93% of participants (68 of
 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257 255

73), meaning that 7% of pre to follow-up change data were 4.5.3. General psychological distress
missing. Because listwise deletion and single imputation may bias The SLESQ-R did not significantly moderate the effect of treat-
results in datasets with more than 5% missing data (Graham, 2009; ment condition on pre to follow-up GHQ change scores (coefficient of
Schafer, 1999), multiple imputation (Rubin, 1987) was used in interaction term¼  .41, SE¼1.12, 95% CI:  2.64, 1.83). As noted by
these analyses. Multiple imputation is a Monte Carlo technique for the confidence interval, this moderation effect clearly included 0,
handling missing data, in which multiple complete datasets are suggesting a null effect.
constructed by imputing missing data points with values gener-
ated based on individuals' scores on other variables. Each of the 4.5.4. Depression
imputed datasets is then analyzed using standard techniques, and The SLESQ-R was a significant moderator of the impact of
pooled estimates and confidence intervals for the coefficients of treatment condition on the change in DASS-D scores from pre to
interest are constructed (Croy & Novins, 2005; Graham, 2009; follow-up (coefficient of interaction term¼  3.11, SE ¼1.55, 95%
Schafer, 1999). The statistical package mi from R statistics (R-3..1; CI: 6.20,  .02). Visual inspection (Fig. 3) confirmed this pattern.
R Core Team, 2013) was used to carry out this procedure Follow-up analyses based on a non-imputed dataset revealed that
(Su, Gelman, Hill, & Yajima, 2011). Using bootstrapping, 30 8.2% of the total variance in DASS-D change scores was uniquely
imputed datasets were generated, and missing data were imputed attributable to the interaction [F(1,64) ¼6.18, p¼ .02]. Probing the
based on values for all other variables in the dataset. Confidence interaction revealed that among those scoring low in depression
intervals constructed for each coefficient were used to evaluate (25th percentile) on the SLESQ-R, the effect of condition on DASS-D
statistical significance, and these statistics were complemented pre to follow-up change scores was non-significant (p¼.46). How-
with visual inspection of plots of the interaction using the car ever, among those scoring moderate (50th percentile) or high (75th
package in R (Fox & Weisberg, 2011). Because statistical proce- percentile), DASS-D pre to follow-up change scores for the ACT
dures have not yet been developed to incorporate multiple treatment group were significantly better than those of the waitlist
imputation into additional dismantling analyses, such as the control (conditional effects of  5.11 and  9.04 respectively, ps both
probing of interactions, these analyses were performed on a o.05). Thus, ACT was helpful with depression for the more trauma-
non-imputed data set in which missingness was handled through tized participants.
listwise deletion.
4.5.5. Anxiety
The SLESQ-R significantly moderated the relationship between
treatment condition and DASS-A pre to follow-up change scores
4.5.2. Self-compassion (coefficient of interaction term¼  2.63, SE¼ 1.16, 95% CI:  4.94,
The SLESQ-R did not significantly moderate the effect of  .32; see Fig. 3). Analyses based on a non-imputed dataset
treatment condition on pre to follow-up SCS change scores showed that 9.5% of the total variance in DASS-A change scores
(coefficient of interaction term¼ .73, SE¼.43, 95% CI: .14, 1.59). was uniquely attributable to the interaction [F(1,64) ¼ 7.55,
However, confidence intervals and visual inspection (see Fig. 3) po .01]. Probing the interaction showed that among participants
suggest a stronger association between the ACT intervention and scoring low on the SLESQ-R, there was no significant effect of
self-compassion for those with higher scores in the SLEQ-R, condition on pre to follow-up DASS-A change scores (p ¼ .59). By
suggesting a moderation trend. contrast, among those scoring moderate or high, DASS-A change
scores were significantly better in the ACT group (conditional

Fig. 3. Visual inspection of moderation analyses.

Note: Each figure provides a scatter plot between the outcome and the ACT intervention, with a linear regression line indicated in dashes. Within each figure, and from left to
right, each panel indicates the association between the outcome and the ACT intervention at each level of trauma history (1st, 2nd , 3rd and 4th quartiles). As shown in the
each figure, as trauma history increases, the association between the outcome and the ACT intervention increased in the expected direction for each outcome. Trauma
History¼ SLESQ-R; Self-Compassion ¼SCS; Depression¼Depression subscale of the DASS; Anxiety ¼Anxiety subscale of the DASS; and Stress¼ Stress subscale of the DASS.
256 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257

effects of  5.09 and  8.40, respectively, ps both o.01). Thus, ACT intervention tested here was functionally an ACT-based workshop,
was helpful with anxiety for the more traumatized participants. and that with limited modification, ACT is a successful treatment
for improving self-compassion.
4.5.6. Stress
The SLESQ-R did not significantly moderate the impact of 5.2. Moderating role of trauma history
treatment condition on DASS-S pre to follow-up changes (coeffi-
cient of interaction term¼ 2.85; SE¼1.51; 95% CI:  5.86, .016; Exploratory analyses and visual inspection suggested that the
90% CI:  5.38,  .33). As shown in Fig. 3 and the interaction's workshop had a greater effect on self-compassion, depression,
confidence interval, a finer grain analysis and visual inspection of anxiety, and stress among those endorsing more types of stressful
this association suggest a moderation trend. Additional analysis life events, including a history of trauma. However, there was no
also showed that 7.2% of the total variance in DASS-S change evidence of moderation for the general psychological distress
scores in a non-imputed dataset could be uniquely attributed to outcome. Given the conceptual overlap between general psycho-
the interaction [F(1, 64) ¼ 5.41, p ¼.02]. Probing the interaction logical distress and depression, anxiety, and stress, it is puzzling
showed that among participants scoring low on the SLESQ-R, the that trauma history did not moderate the effects on general
effect of condition on DASS-S pre to follow-up changes was not psychological distress. Still, these findings show that the workshop
significant (p ¼.58). However, among those scoring moderate or was more efficacious overall among those who were in greater
high, DASS-S changes were significantly better for ACT participants need of it, an interpretation that comports with other research
(conditional effects of  5.16 and  8.75, respectively, ps both showing ACT to be more beneficial for those higher in distress and
o.05). Thus, ACT was helpful with stress for the more traumatized experiential avoidance (e.g., Muto, Hayes, & Jeffcoat, 2011). Given
participants. the significant correlation between stressful life events and psy-
chological flexibility in this study (r ¼.24, p o.05, 2-tailed; see
Yadavaia, 2013), it may be that the workshop was more effective
5. Discussion among the more traumatized participants at least partly because
they were higher in experiential avoidance.
Given recent emphasis in the literature highlighting the rela-
tionship between low self-compassion and high levels of psycho- 5.3. Limitations
pathology, the present study was designed to test the efficacy of an
ACT approach to self-compassion as compared to a waitlist control, First, the use of a waitlist rather than active control group does
and to examine its additional impact on general psychopathology. not allow the discrimination of placebo or demand effects from
ACT's underlying process of change, psychological flexibility, was treatment effects. Second, the sample used in this study could
examined as a mediator of treatment effects, and exploratory limit its generalizability. As undergraduates in psychology classes,
analyses were conducted to evaluate the role of participants' the participants were younger and higher in intellectual ability,
history of trauma on treatment outcomes. socioeconomic status, and psychological mindedness than the
general population. It could be argued that some of the concepts
5.1. Efficacy of ACT intervention and mediation by psychological contained in the protocol could be too subtle and sophisticated for
flexibility individuals of lower ability levels. However, evidence against the
seriousness of this concern is provided by reports of the successful
The study showed that the ACT intervention led to large application of ACT in intellectually disabled (Brown & Hooper,
increases in self-compassion as compared to the waitlist control 2009; Pankey, 2008) and brain-injured individuals (Sylvester,
at post-treatment and two months after the intervention. The ACT 2011). In addition, the fact that the sample was not treatment-
intervention also led to moderate to large reductions in general seeking could limit the generalizability of these findings to a
psychological distress at two months, and as compared to the clinical population because, for example, treatment-seeking indi-
waitlist condition. Symptoms of depression were significantly viduals may be even more distressed than the participants in this
reduced in the ACT group after the intervention and at two months study. Finally, the use of the AAQ-II as a process of measure of
follow-up. Although improvements post-treatment were greater psychological flexibility has been questioned in some studies and
in the ACT condition than in the control condition, this difference supported by others. Some authors have argued that the AAQ-II is
disappeared after 2 months. Conversely, symptoms of anxiety simply a measure of psychological distress (Wolgast, 2014), while
improved in the ACT condition at each measurement occasion— others have shown that it explains additional variance above and
improvements which were superior as compared to the waitlist beyond traditional measures of affect (Gloster, Klotsche, Chaker,
condition. For the last outcome, stress, the ACT intervention led to Hummel, & Hoyer, 2011).
moderate reductions over time, but between group differences
only reached a trend, which could be due to insufficient power to 5.4. Future directions and clinical implications
detect small effects. Finally, psychological flexibility mediated the
effect of the intervention on all outcomes, accounting for 28.1– The mediational analyses in this study were important in that
59.9% of the effects of the ACT intervention. they provided information as to the process by which the inter-
Overall, these outcomes are consistent with our theoretical vention brought about change, in this case psychological flexibility.
rationale, suggesting that this brief intervention was efficacious to However, because the AAQ-II measures several facets of psycho-
improve self-compassion and symptoms of psychopathology, and logical flexibility, and because the intervention targeted several of
that these improvements were mediated by the hypothesized the 6 ACT processes, it is difficult to know which components of
process of change. Differences between group conditions in out- the intervention impacted which processes and were most bene-
come and process measures were generally medium to large and ficial. One way to examine processes of change with greater
always in favor of the ACT intervention. Particularly notable is the precision is to use laboratory analog studies to evaluate brief
large effect size obtained on the self-compassion outcome (1.06), interventions that specifically target basic processes of interest
which is comparable to that produced by a much longer interven- (see Levin, Hildebrandt, Lillis, & Hayes, 2012 for a meta-analysis of
tion from within the self-compassion tradition (effect size ¼1.67, such studies in the area of psychological flexibility). Another way
Neff & Germer, 2013). Taken together, these findings show that the is to use ecological momentary assessments and mobile
 J.E. Yadavaia et al. / Journal of Contextual Behavioral Science 3 (2014) 248–257 257

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