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Behavior Therapy 49 (2018) 360 – 372
www.elsevier.com/locate/bt

The Use of Acceptance and Commitment Therapy to Promote

Mental Health and School Engagement in University Students:
A Multisite Randomized Controlled Trial
Simon Grégoire
Lise Lachance
Thérèse Bouffard
Université du Québec à Montréal
Frédérick Dionne
Université du Québec à Trois-Rivières

results of this study suggest that an ACT-based intervention

The aim of this multisite randomized controlled trial was to offers a valuable way to promote mental health and school
determine whether an intervention based on Acceptance and engagement in postsecondary settings.
Commitment Therapy (ACT) was efficacious in improving
university students’ psychological flexibility, mental health,
Keywords: acceptance and commitment therapy; psychological
and school engagement. Students were recruited in four
flexibility; mental health; school engagement; university students
Canadian universities and randomly assigned to an interven-
tion (n = 72) or a wait-list control group (n = 72). Students in
the intervention group took part in four 2.5-hour workshops IN CANADA, A SIGNIFICANT number of college and
during a 4-week period and were asked to do exercises at university students experience mental health prob-
home (e.g., meditation, observation grids). Wait-list students lems. According to a survey conducted in 2016 within
received the intervention soon after the post measurements. 48 Canadian postsecondary institutions, 18.4% of
MANCOVAs and ANCOVAs revealed that students in the students were diagnosed or treated for anxiety within
intervention group showed greater psychological flexibility at the last 12 months and 14.7% were diagnosed or
postintervention than those in the control group. They also treated for depression. A sizeable proportion of
reported greater well-being and school engagement, and lower students reported feeling sad (24.8%), hopeless
stress, anxiety, and depression symptoms. Taken together, (23.4%), lonely (22.8%), exhausted (17.1%), and
under a tremendous amount of stress (14.4%;
American College Health Association, 2016). More
important, research suggests that the prevalence of
The authors received financial support from the Social Sciences
and Humanities Research Council (SSHRC) and the Fonds de anxiety and depression is slowly rising on campus
recherche du Québec – Société et culture (FRQSC) to conduct this (Center for Collegiate Mental Health, 2016) and that
study. They wish to thank both agencies for their generous funding postsecondary students are more likely to report
and are also grateful to psychologists Stéphanie Métivier, France
Landry, Dania Ramirez and Christine Smilga for their coordination mental illness symptoms than nonuniversity youth
of the study. The authors also thank the students who kindly agreed (42% compared with 17%; Ontario Ontario College
to participate. Health Association, 2009).
Address correspondence to Simon Grégoire, Ph.D., Département
d’éducation et pédagogie, Université du Québec à Montréal, C.P.
Mental health problems can have a profound
8888, Succursale Centre-ville, Montréal, Québec, H3C 3P8, Canada; influence on students’ quality of life and have a
e-mail: [email protected]. negative impact on their academic performance,
0005-7894/© 2018 Association for Behavioral and Cognitive Therapies.
school engagement, and graduation rate. In fact,
Published by Elsevier Ltd. All rights reserved. students report that stress (42.2%), anxiety (32.5%),
 act, mental health and school engagement 361

sleep difficulties (28.4%), and depression (20.9%) are one’s thoughts and feelings oppose taking valued
among the leading factors that affect their learning action (Levin, Pistorello, Seeley, & Hayes, 2014). To
and academic performance (American College Health foster psychological flexibility, ACT relies on six
Association, 2016). Moreover, students with mental interrelated and overlapping processes: acceptance
health problems have lower grade point averages and (i.e., willingness to open fully to unwanted experiences
lower rates of graduation than those not suffering such as difficult thoughts, memories, or emotions),
from such problems (Byrd & McKinney, 2012). contact with the present moment (i.e., being mindful
Many colleges and universities offer counselling and aware of one’s experiences), self as context
services to their students (MacKean, 2011), but the (i.e., maintaining perspective about oneself within
professionals who provide these services (e.g., psy- one’s experiences), cognitive defusion (i.e., being
chologists, social workers) are often understaffed and able to step back from unwanted experiences
overwhelmed by student demands (Jaworska, De without getting stuck in them), committed action
Somma, Fonseka, Heck, & MacQueen, 2016). In (i.e., engaging in actions that move toward important
a survey done within 93 counselling centers in aspects of life), and values (i.e., staying connected to
postsecondary institutions, the Center for Collegiate personal values or areas of life that are important).
Mental Health (2016) concluded that the demand for Meta-analyses show that ACT is efficacious in
counselling center services had significantly increased promoting both psychological flexibility and mental
over the last few years, outpacing the growth of health (A-Tjak et al., 2015; Öst, 2008, 2014; Powers,
institutional enrollment. Zum Vörde Sive Vörding, & Emmelkamp, 2009;
Taken together, these findings emphasize the Ruiz, 2012). The most recent meta-analysis included
importance of implementing programs aimed at 39 randomized controlled trials and a total of 1,821
helping postsecondary students to cope with issues patients with mental disorders or somatic health
of stress, anxiety, and depression. According to problems (A-Tjak et al., 2015). It shows that ACT
the Canadian Association of College and University outperformed control conditions on both primary
Student Services (MacKean, 2011), these programs (e.g., anxiety, depression) and secondary (e.g., quality
should be preventive, cost-effective, and easily acces- of life) outcome measures at posttreatment and
sible. They should also enable students to develop a follow-up assessments. The authors concluded that
range of skills that could help them maintain good ACT is more effective than treatment as usual or
mental health and sustain self-care. Following these placebo, and that it may be as effective as established
recommendations, our team developed an interven- psychological interventions in treating chronic pain,
tion in 2012 based on Acceptance and Commitment anxiety disorders, depression, and addiction.
Therapy (ACT; Hayes, Strosahl, & Wilson, 2012) to
promote mental health and school engagement act in postsecondary settings
among university students and help them cultivate Over the last 5 years, ACT has also been offered to
skills such as psychological flexibility (Grégoire, college and university students. According to Levin,
Lachance, Bouffard, Hontoy, & De Mondehare, Haeger, Pierce, and Twohig (2016), the transdiag-
2016). In the next section, ACT is briefly described as nostic nature of ACT is particularly well suited to
well as recent studies assessing its efficacy in college postsecondary settings. Although students may
and university institutions. We then describe the experience specific mental health disorders, many
multisite randomized controlled trial we have put of them struggle with problems (e.g., stress, relation-
forward to assess the effects of our intervention. ship issues, discrimination) that do not have any
specific diagnosis. Levin et al. (2016) claim that
what is act? ACT can be useful for a diversity of psychological
ACT is a transdiagnostic psychotherapeutic interven- problems that college and university students typi-
tion, based on a theoretical model called Relational cally experience and can help them increase their
Frame Theory (Hayes, Barnes-Holmes, & Roche, psychological flexibility.
2001). It is a “third wave” cognitive behavioral Some of the ACT interventions implemented in
therapy (CBT) that does not specifically target postsecondary settings were web-based. For example,
symptom reduction (e.g., anxiety, negative thoughts) Levin et al. (2016) offered a 4-week online interven-
but rather encourages participants to engage in tion to college students in the United States. The
values-based actions regardless of the presence or results of their randomized controlled trial show that,
absence of symptoms. The overall aim of ACT is to compared to those on the wait-list, participants
increase psychological flexibility, which is the ability receiving the ACT intervention improved on overall
to be mindful of experiences in the present moment, distress, general anxiety, social anxiety, depression,
in an accepting and nonjudgmental way, while academic concerns, and positive mental health.
behaving consistently with one’s values, even when Räsänen et al. (2016) offered a 7-week online
362 g r é g o i r e e t a l .

intervention to university students in Finland and college students and 16% of university students do
used a randomized controlled trial to measure its not complete their curriculum (Shaienks, Gluszynski,
efficacy. Those who took part in the intervention & Bayard, 2008), it becomes critical to have a better
reported more well-being and life satisfaction as well understanding of what can be done to enhance school
as lower stress and depression symptoms compared engagement in postsecondary institutions and im-
to the students in the wait-list control group. These prove both achievement and school completion rates.
benefits were maintained over a 12-month follow-up According to Fredricks et al. (2004), school engage-
period. ACT interventions in postsecondary settings ment is a multidimensional construct that draws on
have also been offered in self-help book (Muto, three dimensions. Behavioural engagement refers to
Hayes, & Jeffcoat, 2011), class (Moyer, Murrell, student conduct that is beneficial to psychosocial
Connally, & Steinberg, 2016), workshop formats adjustment and achievement at school. This dimen-
(Danitz & Orsillo, 2014; Danitz, Suvak, & Orsillo, sion can be divided into three main axes: positive
2016; Sandoz, Kellum, & Wilson, 2017), or through behaviors, involvement in school-related tasks, and
counselling services. For example, Grégoire et al. participation in social or extracurricular activities.
(2016) offered a 4-week intervention among univer- Emotional engagement refers to feelings, interests,
sity students enrolled in three different universities perceptions, and attitudes toward school. It
in Canada. The pretest-posttest switching-replication encompasses positive (e.g., happiness) and negative
design used to assess the intervention showed that (e.g., boredom) reactions to teachers, classmates,
it had a positive effect on students’ psychological academics, and school and is presumed to create ties
flexibility and mental health. to an institution and influence willingness to do
These results suggest that ACT interventions are the work. Cognitive engagement refers to student
effective at helping students deal with stress, anxiety, psychological investment in learning and the use of
or depression issues and represent a promising self-regulation strategies by students. It incorporates
avenue for promoting mental health in colleges and perceptions of competency, willingness to engage
universities campus. However, as pointed out by in effortful learning activities and establishing task-
others (Danitz et al., 2016; Räsänen et al., 2016), oriented goals. In a previous study, we showed that
more studies are needed to better understand the ACT could have a positive impact on university
impact of these interventions on mental health. To students’ level of school engagement (Grégoire et al.,
date, randomized controlled trials based on ACT for 2016). We believe that students who take part in
college and university populations are rare and the ACT were encouraged to take concrete steps to shape
studies are sometimes flawed with methodological their life in a more meaningful way, focus on their
limitations. For instance, psychological flexibility is most important values and were therefore more
often assessed with either the first or the second inclined to engage in their school endeavours.
version of the Acceptance and Action Questionnaire Although interesting, these results remain prelimi-
(AAQ; Bond et al., 2011; Hayes et al., 2004), the nary and need to be replicated with a broader sample
validity of which has been questioned by Gámez, and a more robust experimental research design.
Chmielewski, Kotov, Ruggero, and Watson (2011).
The authors argue that the number of items in the the current study
AAQ (n = 10) is insufficient to adequately measure all The aim of the present study is to extend previous
six underlying processes of ACT. Gámez et al. (2011) research by (a) conducting an ambitious random-
also contend that some of the items are too vague, ized controlled trial in four distinct universities,
ambiguous, or difficult to understand. Based on a (b) exploring the impact of an ACT intervention on
exploratory factor analysis, Wolgast (2014) found school engagement, a variable never considered
the items of the AAQ-II to be more strongly related before to our knowledge, and (c) measuring psycho-
to items designed to measure distress than items logical flexibility in a novel way to capture all six
designed to measure acceptance/ nonacceptance with ACT processes. More precisely, its goal was to
minimal references to functional outcomes. examine the effect of four workshops based on ACT
Additional studies are also needed to examine the on the psychological flexibility, mental health, and
impact of ACT interventions on academic variables school engagement of university students. Psycho-
such as school engagement. Evidence suggests that logical flexibility was used as a process outcome
school engagement is positively correlated to achieve- and four mental health indicators (stress, anxiety,
ment and perseverance among college and university depression, and well-being) were used as primary
students (Brault-Labbé, & Dubé, 2008; Casuso- outcomes. Although the reduction of psychological
Holgado et al., 2013) and helps to protect students symptoms is not the primary goal of ACT, stress,
from dropping out of school (Fredricks, Blumenfeld, anxiety, and depression indicators were chosen as
& Paris, 2004). Considering that in Canada, 25% of primary outcomes given that they are often targeted
 act, mental health and school engagement 363

Table 1
Participant Characteristics.
Groups Age Sex Degree Regime Sessions Sites
M (SD) (%) (%) (%) (%) (%)
Male Female Bachelor Master Doctorate Part-time Full-tine Fall 14 Winter 15 UQAM UdM UdS HEC
Intervention 32.55 23.6 76.4 54.2 34.7 11.1 26.4 73.6 50 50 27.8 34.7 15.3 22.2
(n = 72) (9.62)
Control 30.88 29.2 70.8 64.8 28.2 7 30 70 55.6 44.4 41.7 26.4 9.7 22.2
(n = 72) (8.78)
Note. M = Group mean; SD = Standard deviation; UQAM = Université du Québec à Montréal; UdM = Université de Montréal; UdS =
Université de Sherbrooke; HEC = Hautes Études Commerciales de Montréal.

in mental health studies conducted in postsecondary students are presented in Table 1. To be included in
settings (Conley, Durlak, & Dickson, 2013). School the study, participants had to be enrolled in one of
engagement was used as a secondary outcome the universities mentioned above and speak French.
variable. The workshops were free and students received no
The hypotheses of the study are the following: monetary compensation or other incentive for their
participation.
1. Students in the intervention group will report
higher psychological flexibility at the end of intervention
the workshops than students in the control Students took part in an intervention developed by
group. our team named KORSA (www.korsa.uqam.ca/en/).
2. Students in the intervention group will report In Swedish, KORSA means to cross over or to pass
fewer symptoms of stress, anxiety and depres- through. The intervention is presented to students as
sion and higher well-being at the end of the a way to go through their studies successfully while
workshops than students in the control group. maintaining a good quality of life. It comprises four
3. Students in the intervention group will report 2.5-hour workshops offered to groups of 8 to 15
higher school engagement at the end of the students during 4 consecutive weeks. The first
workshops than students in the control group. workshop focused on values and committed action
processes. Students were helped to clarify what
Method was important for them in various life domains
participants
(e.g., school, family) and to translate their personal
One hundred and forty-four (n = 144) students took values into concrete goals and actions. By the end of
part in this study during the fall semester of 2014 this workshop, they were encouraged to implement
and the winter semester of 2015. Students were small changes in their life that would move them
recruited from four universities in Canada (Université towards their values. The second workshop was
du Québec à Montréal = 34.7%; Université de based on acceptance and cognitive defusion processes.
Montréal = 30.6%; Université de Sherbrooke = Students were invited to look at difficult thoughts,
12.5%; Hautes Études Commerciales de Montréal = emotions, or sensations and see whether they were
22.2%). Most of them were women (73.6%) and trying to control or avoid these internal experiences.
were studying full time (71.8%). Their mean age was They were then asked to examine the workability of
31.72 1 (SD = 9.22) and about 60% of them were experiential avoidance strategies in the long term and
enrolled in a bachelor’s degree (59.4%). A third of the encouraged to adopt an alternative strategy, namely
students were completing a master’s degree (31.5%) acceptance. Through experiential exercises and
while a minority were doing a doctoral degree (9.1%). metaphors, participants were also helped to defuse
Almost half of the students were born in Canada difficult thoughts (e.g., “I’m a loser. I’ll never be able
(49.7%) while the rest were born in Europe (16.3%), to complete my bachelor’s degree.”) and encouraged
Africa (19%), South America (10.1%), or other to maintain their focus on their values while having
regions of the world (4.9%). Characteristics of the these thoughts. In the third workshop, students
learned different meditation practices to cultivate
1
The reasons why the mean age is above 30 are twofold. First, in the
mindfulness and help them get in touch with a sense
province of Quebec (where this study was conducted), students usually begin of self that is safe and continuous, and from which
university between 19 and 24 years old. Secondly, 40.6% of the students
who took part in this study were enrolled in graduate studies. Graduate
they can observe and accept changing experiences.
students are usually older. According to a report published by the The goal of the fourth workshop was to synthesize
Association of Universities and Colleges of Canada in 2010, 31% of
master’s students and 56% of PhD students were 30 years of age or older
all the learning done so far and ensure that it is
(Association of Universities and Colleges in Canada, 2011). transferred into the students’ daily life.
364 g r é g o i r e e t a l .

The intervention contains various ACT exercises, workshops aimed at helping them deal with stress and
such as the matrix developed by Polk and Schoendorff anxiety were to be offered within their university and
(2014) or the Bull’s Eye exercise (Harris & that they were invited to take part in an information
Hayes, 2009), and behavioral activation strategies session to learn more about it. During this session,
(Mazzucchelli, Kane, & Rees, 2010). It is based on general information was provided on the intervention
two documents: the trainer’s guide and the partici- goal and content as well as the current study. By the
pant’s guide. The former gives a detailed description end of this session, students who were willing to
of how each workshop should run. This guide has participate in the study were asked to complete the
been designed to standardize the workshops and pre-intervention questionnaire. They were then ran-
ensure that they are delivered on a consistent basis domly assigned by an independent researcher to the
from institution to institution and from one semester intervention or the wait-list control group with a
to the next. The participant’s guide is given to the computer algorithm (www.randomization.com/).
students at the beginning of the first workshop. It Students in the intervention group started their
contains exercises to do during the workshops or workshops 1 week later, while those in the wait-list
at home. In addition, throughout the intervention, control group started the same workshops immedi-
participants can obtain copies of the workshop ately after the intervention group completed the
overheads on a website, download various guided program. The postintervention questionnaire was
meditations for practicing at home, or find sugges- completed by all students the same week: those in the
tions for additional reading. For more information intervention group did it at the end of their fourth
regarding the intervention, the reader can consult the workshop, and those in the wait-list control group
supplementary material to this article. completed it online.
The KORSA workshops were administered by
two doctoral students in psychology (a male and a measures
female) already familiar with ACT and blind to the Process and outcomes variables were measured at
hypotheses of the study. These students had taken pre- and postintervention while demographic infor-
graduate classes on ACT and used the approach in mation was gathered only at pre-intervention. The
their internships. They were asked to give the Cronbach’s alpha values of all the scales are presented
workshops to one group under the supervision of in Table 2.
the first author of this study and to another group
under the supervision of an expert in group counsel- Process Measures
ling not involved in the current study. This procedure Psychological flexibility. Psychological flexibility
was implemented to ensure that the trainers led the was assessed with scales aimed at covering all six
workshops in accordance with ACT principles. ACT processes: (a) the short version of the Five Facet
Mindfulness Questionnaire (FFMQ; Bohlmeijer, Ten
research design Klooster, Fledderus, Veehof, & Baer, 2011) translated
To test the hypotheses, a multisite randomized and validated in French by Heeren, Douilliez,
controlled trial was used in each semester (in each Peschard, Debrauwere, and Philippot (2011); (b) the
research site) and was based on a 2 (intervention vs Multidimensional Experiential Avoidance Question-
wait-list control group) × 2 (pre, post) research design. naire (MEAQ; Gámez et al., 2011); and (c) a values
In the intervention group, students took part in the questionnaire developed for the purpose of this study.
KORSA workshops delivered at their university The FFMQ short version (24 items) was used to
during a 4-week period and were asked to do capture four of the psychological flexibility processes,
exercises at home between workshops (e.g., practice namely contact with the present moment (e.g., “It
meditation, complete observation grids). In the seems I’m running on automatic without much
control group, students were placed on a waiting awareness of what I’m doing”; inverse item),
list for 4 weeks and were then offered the KORSA cognitive defusion (e.g., “When I have distressing
workshops. thoughts or images, I just notice them and let them
go), self as context (e.g., “Usually when I have
procedure distressing thoughts or images, I can just notice them
Participants were recruited via emails sent through without reacting”), and acceptance (e.g., “I think
the counselling services’ mailing lists of the four some of my emotions are bad or inappropriate and I
universities mentioned above, an advertisement on shouldn’t feel them”; inverse item). Items of the
the university’s websites, and posters placed around FFMQ were measured on a 5-point Likert-type scale
the campuses. All students were targeted, not only ranging from 1 (never or very rarely true) to 5 (very
the ones seeking help from the counselling services often or always true). A global FFMQ score was
of their university. Students were informed that created based on the mean of all 24 items.
 act, mental health and school engagement 365

Table 2
Effects of Randomization on Student’s Psychological Flexibility, Mental Health and School Engagement at Postprogram.
Outcomes Intervention group Control group
measures
Pre Post Pre Post Pre Post MANCOVA ANCOVA
α α M SD M SD M SD M SD F df F df d (itt) d (pp)
Psychological 13.43*** 3.137
flexibility
FFMQ .83 .90 3.05 .34 3.09 .30 3.10 .34 3.04 .32 5.73* 1.143 .29 .47
MEAQ .82 .85 3.61 .63 3.95 .66 3.74 .63 3.71 .62 27.88*** 1.143 .58 .57
Values .89 .91 4.03 .96 4.52 .80 4.21 .97 4.22 1.05 16.95*** 1.143 .49 .47
questionnaire
Mental health 7.67*** 4.135
MSP-9 .79 .89 3.29 .48 2.94 .45 3.37 .59 3.27 .43 23.06*** 1.143 (-).46 (-).52
WBMMS .93 .95 3.10 .58 3.46 .51 3.15 .63 3.14 .59 28.93*** 1.143 .61 .81
GAD-7 .84 .89 16.63 4.98 13.89 4.43 17.87 4.65 17.29 4.92 21.45*** 1.143 (-).44 (-).45
PHQ-9 .85 .83 20.33 5.85 17.36 4.80 20.08 6.22 19.62 6.20 13.92*** 1.143 (-).41 (-).46
School
engagement
AES .91 .92 4.41 .88 4.66 .90 4.37 0.85 4.30 .94 14.54*** 1.143 .37 .46
Note. Analysis are based on intention-to-treat data using analysis of variance with the pre-intervention score as a covariate (ANCOVA); M =
Unajusted group; mean; SD = Standard deviation; α = Cronbach alpha; F = ANCOVA F-Values; df = Degrees of freedom; d(itt) = Effect size
(Cohen’s d) from intention-to-treat analyses; d(pp) = Effect size (Cohen’s d) from per protocol analyses; FFMQ = Short version of the Five
Facet Mindfulness Questionnaire; MEAQ = Multidimensional Experiential Avoidance Questionnaire; MSP-9 = Psychological Stress
Measure; WBMMS = Well-Being Manifestations Measure Scale; GAD-7 = General Anxiety Disorder questionnaire; PHQ-9 = Patient Health
Questionnaire; AES = Academic Engagement Scale; * p b .05. ** p b .01. *** p b .001.

Two subscales of the MEAQ (distress aversion and forward”). The values coherence subscale (5 items)
distress endurance) were used to capture the follow- measures to what extent the person is engaged in
ing psychological flexibility processes: acceptance actions that are coherent with his or her values
(e.g., “I wish I could get rid of all of my negative (e.g., “Day after day, I feel my actions are aligned
emotions”) and committed actions (e.g., “I am willing and coherent with my values”). The questionnaire
to suffer for the things that matter to me”). According was developed to tap into values and committed
to Gámez et al. (2011), these subscales have the most actions processes. Items were measured on a 6-point
content overlap with the AAQ-II. The distress Likert-type scale ranging from 1 (strongly disagree)
aversion subscale aimed at measuring whether or to 6 (strongly agree) and were averaged to calculate
not a person has negative attitudes towards his or her global scores. See footnotes for more information on
distress and if he or she accepts it or not, while the the validation of the values questionnaire. To assess
distress endurance subscale aimed at measuring the the construct validity of this novel scale, the items
willingness to behave effectively in the face of distress. were subjected to an exploratory factor analysis (EFA;
The guidelines provided by Brislin (1970) and maximum likelihood extraction) at pre-intervention.
Vallerand (1989) regarding translation and transcul- The Bartlett’s test of Sphericity, X 2 (45) = 561,43, p b
tural validation of psychometric tools were used to .001, and the Kaiser-Meyer-Olkin value (.84) sug-
translate in French the two subscales of the MEAQ. gested that the data were suitable for this type of
The items contained in these subscales were mea- analysis. EFA revealed two factors with eigenvalues
sured on a 6-point Likert-type scale ranging from 1 greater than 1, and the scree plot indicated a clear
(strongly disagree) to 6 (strongly agree). A global break after the third factor. To test this two-factor
MEAQ score was computed based on the mean solution, we used web-based parallel analysis
of all 25 items. Scores on the distress aversion (WPA) using a Monte Carlo simulation developed
subscale of the MEAQ were reversed. A high score by Watson (2000). This WPA provided similar results
indicates that a person tends to accept his or her and supported a two-factor solution explaining a total
distress. of 64.7% of the variance (Factor 1 = 50.0%,
The values questionnaire developed for this study eigenvalue = 5.00; Factor 2 = 14.7%, eigenvalue =
contains two subscales. The values clarity subscale 1.47). These factors were then extracted using oblimin
(5 items) measures to what extent a person knows rotation. Items that strongly loaded on Factor 1
his or her value (e.g., “I know exactly what my correspond to the values coherence subscale; those
strengths and qualities are and I want to put them that loaded on Factor 2 correspond to the values
366 g r é g o i r e e t a l .

clarity subscale. The correlation between both factors school perseverance (e.g., “Despite the difficulties, I
was .51. persevere in my studies”), enthusiasm towards studies
(e.g., “When I perform activities related to school, I’m
Primary Outcome Measures
full of energy”), and positive and negative aspects of
Mental health. Mental health was assessed with
school (e.g., “I accept the fact that my studies imply
four indicators: stress, psychological well-being,
both positive and negative aspects”). These subscales
anxiety, and depression. Stress was measured using
capture the three types of school engagement
the French version of the Psychological Stress Measure
(behavioral, emotional, and cognitive) described
(PSM-9; Lemyre & Lalande-Markon, 2009; Lemyre
above. Items of the AES were scored on a 6-point
& Tessier, 1988). It comprises nine items asking
Likert-type scale ranging from 1 (strongly disagree)
participants to evaluate how often over the last week
to 6 (strongly agree). A global AES score was created
they had experienced various manifestations of stress
based on the mean of all 14 items. High scores reflect
(e.g., “I feel rushed; I do not seem to have enough
greater school engagement.
time”) using a 5-point Likert scale ranging from 1
(never) to 5 (always). High scores on the PSM-9 attrition
(average of all items) reflect more stress.
The power analysis was designed to compare the
Psychological well-being was measured using the
mean change between groups in psychological
24-item Well-Being Manifestations Measure Scale
flexibility (H1), mental health indicators (H2),
(WBMMS) originally developed in French by
and school engagement (H3) over the intervention
Massé et al. (1998). Here again, participants were
period using analyses of covariance (ANCOVAs)
asked to evaluate how often during the last week
controlling for these measures at baseline. The
they had experienced different manifestations of
analysis was conducted using an alpha of .05, a
well-being (e.g., “I felt good, at peace with myself”)
power of .80, and a large effect size (f = .40). The
using a 5-point Likert scale ranging from 1 (never)
desired total sample size was 84. Assuming an
to 5 (always). High scores on the WBMMS (average
attrition rate of 21% based on the systematic
of all items) reflect more psychological well-being.
review conducted by Öst (2014) on the efficacy of
Anxiety and depression were measured with the
ACT interventions, it was decided to recruit at least
French version of the General Anxiety Disorder
101 participants for the study.
Questionnaire (GAD-7; Micoulaud-Franchi et al.,
A total of one hundred and sixty students (n = 160)
2016; Spitzer, Kroenke, Williams, & Löwe, 2006)
took part in the information sessions that were held in
and the French version of the Patient Health
universities and sixteen of them (n = 16) decided not
Questionnaire (PHQ-9; Carballeira et al., 2007;
to participate in the workshops after these sessions.
Kroenke & Spitzer, 2002), respectively. The GAD-7
One hundred and forty-four (n = 144) were randomly
is a brief scale (7 items) aimed at assessing general
assigned to either the intervention group (n = 72) or
anxiety disorder symptoms while the PHQ-9 is a
the control group (n = 72). In the intervention group,
9-item scale used to detect depression symptoms.
sixty-eight (n = 68) students attended to the first
Participants were asked how often during the last
workshop and fifty-seven of them (n = 57) completed
week they were bothered by anxiety (e.g., not being
more than three workshops (75% of the intervention)
able to stop or control worrying) and depression
and filled out the postintervention questionnaire. In
symptoms (e.g., feeling down, depressed, or hope-
the control group, forty (n = 42) students completed
less). Both scales were scored on a 4-point Likert-type
the postintervention questionnaire. Within the inter-
scale ranging from 1 (never) to 4 (almost every day)
vention group, dropout occurred when students did
and were based on the sum of all their respective
not attend a minimum of three workshops or did not
items. Both the GAD-7 and PHQ-9 endorse a 4-point
complete the postintervention questionnaire. Within
Likert-type scale that range from 0 to 3. In the current
the control group, dropout occurred when students
study, a 1-to-4 scale was chosen to ensure coherence
failed to complete the postintervention questionnaire.
with the rest of the response scales used in the
Therefore, the attrition rate in this trial is 21% (1 –
questionnaire. Scores on the GAD-7 range from 7 to
(57/72)) in the intervention group and 42% (1 – (42/
28 while those on the PHQ-9 range from 9 to 36.
72)) in the control group (see Figure 1 for more
High scores on these scales reflect greater symptom
details).
severity.
Secondary Outcome Measure data analysis
School engagement. School engagement was Hypotheses 1, 2, and 3 were tested using multivariate
measured with the French version of the Academic analysis of covariance (MANCOVA) and univariate
Engagement Scale (AES; Brault-Labbé & Dubé, analysis of covariance (ANCOVA) models in which
2008), which contains 14 items and three subscales: we examined the effect of randomization on mean
 act, mental health and school engagement 367

FIGURE 1 Participants Flow Throughout the Randomized Controlled trial.

levels of all outcomes measures at postintervention conditions (Del Re, Maisel, Blodgett, & Finney,
controlling for these measures at baseline. Analysis of 2013). Based on Morris (2008) recommendations,
covariance is associated with greater statistical power effect sizes were reported using Cohen’s d and calcu-
than ANOVA to detect change in randomized designs lated with the Carlson and Schmidt (1999) method.
(Van Breukelen, 2006). MANCOVAs and ANCO- According to Cohen (1988), a between-group effect
VAs were conducted according to the intention-to- size of .20 is considered small, .50 moderate, and
treat principles using the last-observation-carried- above .80 large.
forward method (Twisk & de Vente, 2002) on the
conservative assumption that students who did not Results
complete the workshops experienced no significant preliminary analysis
change. The analyses were also repeated for those The normality of the data was tested using the
students who completed more than three workshops. Kolmogorov-Smirnov and Shapiro-Wilk tests. The
It has been argued that the use of both the intention- homogeneity of variance-covariance matrices was
to-treat and per protocol principles help “bracket” assessed with Box’s M test. The presence of outliers
the likely effects of an intervention under different was also checked (.001 level) using both univariate
368 g r é g o i r e e t a l .

(z scores) and multivariate (Mahalanobis distance) out revealed no significant difference on any of these
approaches. No assumption violations or outliers measures.
were detected. Little’s missing completely at random
test (MCAR; Little, 1988) was conducted to see the effects of the intervention on
whether missing data for the process and outcome psychological flexibility, mental
measures at pre- and postintervention were missing health and school engagement
in a random way. The results of the test were not According to our hypotheses, we expected that
significant (chi-square = 153.72, df = 142, p = .23), students in the intervention group would report
suggesting the data were missing in a random greater psychological flexibility (H1), mental health
manner. Therefore, the missing data at both times (H2), and school engagement (H3) at the end of the
of measurement were imputed using the expectation- workshops than those in the control group. To test
maximization (EM) algorithm (Dempster, Laird, & these hypotheses, we first ran MANCOVAs to
Rubin, 1977). explore the effect of the intervention on mean levels
As previously mentioned, students were assessed at of all psychological flexibility and mental health
baseline (pre-intervention) prior to randomization. outcomes measures at postintervention controlling
To ensure equivalence between the intervention for these measures at baseline. Assumption testing
and control groups following randomization in all was conducted to check for normality, homogeneity
research sites, groups were compared on demo- of variance-covariance matrices, and univariate and
graphic variables using the procedure suggested by multivariate outliers, with no serious violations
Roeser et al. (2013). First, chi-square statistics and noted. The multivariate analysis revealed a significant
cross-tabulations with adjusted standardized resid- group effect for psychological flexibility, F (3, 137) =
uals served to examine the comparability of the 13.43, p = .000, and mental health, F(4, 135) = 7.67
groups (intervention vs control) with respect to sex, p = .000. A series of univariate ANCOVAs was then
school degree, study regime and semester in each conducted to examine the effect of the intervention on
research site. The results showed that the groups each outcome and process measure at postinterven-
were not significantly different in all sites with respect tion controlling for these measures at baseline.
to these sociodemographic variables. Next, analysis ANCOVAs results revealed that students in the
of variance (ANOVA) used to examine if the age intervention group reported greater psychological
of students differed according to their group and flexibility at postintervention than those in the control
the research sites showed no difference for group, group (see Table 2). Their scores on the FFMQ,
F(1, 141) = 1.17, p = .28. However, Tukey b post-hoc MEAQ, and values questionnaire were significantly
test showed that students from UdS were significantly higher than those of students in the control group.
older than those from the other universities, F (3, Students in the intervention group also reported
139) = 6.20, p = .001. greater mental health at postintervention than those
Group equivalence on all process and outcome in the control group. Their scores on the WBMMS
measures at baseline was also assessed using univar- (psychological well-being) were higher after control-
iate ANOVAs with study conditions (intervention vs ling for baseline measures and their scores on
control group), research sites (UQAM, UdM, UdS, the PSM-9 (stress), GAD-7 (anxiety), and PHQ-9
HEC), and their interaction as the between-subject (depression) were lower. These students also showed
factors. Results showed no main effects of these greater school engagement at postintervention than
factors on any of the process and outcome measures. those in the control group.
Thus, considering that the intervention and the MANCOVAs and ANCOVAs were repeated with
control groups were generally similar in sociodemo- students who completed 75% of the workshops. As
graphic characteristics and baseline measures, groups the per protocol and intention-to-treat analyses led to
were combined across sites. similar pattern of results, only the latter are presented
Additional analyses examined if students who in Table 2.
completed 75% of the workshops (n = 57) differed
from those who dropped out (n = 15). Chi-square Discussion
statistics and cross-tabulations with adjusted stan- In this study, we developed workshops based on
dardized residuals revealed no significant difference ACT for university students and measured their
with regard to research site, study conditions, sex, effects on psychological flexibility, stress, anxiety,
school degree, study regime, and semester. An depression, well-being, and school engagement.
ANOVA also showed no age difference between Compared to those in the control group, students
groups. The ANOVAs conducted on process and who took part in the intervention group scored
outcome measures at baseline between students who higher at the post-program on all psychological
adhere to the intervention and those who dropped flexibility measures used in this study, and these
 act, mental health and school engagement 369

effects were moderate. This is an encouraging result students’ on- and off-task in an instructional setting
as the primary goal of ACT is to promote psycho- (see Fredricks et al., 2011, for a list of instruments
logical flexibility. Studies have shown that psycho- aimed at measuring school engagement).
logical flexibility is the cornerstone of healthy Based on the CONSORT recommendations
personal and social functioning and that this valuable (Moher et al., 2010), both the intention-to-treat
ability helps people adapt to all kinds of situational and per protocol principles were used in this study
demands and prevents the development of various to allow the readers to correctly interpret the effect
mental health problems (Kashdan & Rottenberg, of the intervention. In fact, it has been argued that
2010). Postsecondary students experience various each method allows to answer different yet related
difficulties (e.g., academic overload, pressure to research questions, and that both have their pros and
succeed, competition with peers, financial burdens, cons (Gupta, 2011). While the intention-to-treat
concern for the future, relationship conflicts; method allows us to explore what happens to
MacKean, 2011). Dealing with these difficulties participants who were allocated to an intervention,
with more psychological flexibility—by being aware the per protocol gives information on what happens to
of thoughts and emotions related to these difficulties those who completed the intervention without any
without trying to avoid them, for instance—may help major deviations from the study protocol. The latter is
students pursue a rich and meaningful life. They may usually considered preferable as it helps preserve the
also be in a better position to tolerate distress, develop integrity of the randomization process and provides a
an open and compassionate attitude towards emo- more realistic estimate of average treatment effect in
tions, thoughts and sensations, and organize their life the “real world” as it is normal for participants to
around meaningful academic and professional goals. drop out of an intervention or not adhere to it. The per
Students who took part in the KORSA workshops protocol analyses, on the other hand, provide
also reported higher well-being at postprogram and information on the true efficacy of an intervention
lower stress, anxiety, and depression symptoms than when used as directed (Del Re et al., 2013). In this
those in the control group. These results are consistent study, both types of analyses led to similar results,
with those reported by others (Danitz & Orsillo, although the effect sizes were generally smaller in the
2014; Danitz et al., 2016; Levin, Pistorello, Seeley, & intention-to-treat analyses (see Table 2). This is not
Hayes, 2013; Moyer et al., 2016; Muto et al., 2011; surprising since the intention-to-treat method usually
Räsänen et al., 2016) and suggest that ACT is leads to more conservative conclusions regarding the
an effective way to promote mental health among efficacy of the intervention because of dilution due to
postsecondary students and reduce their distress noncompliance (Gupta, 2011). The fact that both
symptoms. The fact that the strongest effect of the methods provided similar patterns of results is
intervention was on students’ well-being (d = .61vs encouraging. It has been argued that when the
.81) is worth mentioning. Indeed, the aim of ACT is intention-to-treat and per protocols analyses come to
not so much to reduce people’s distress symptoms, essentially the same conclusions, confidence in the
but to help them build a more meaningful life that study results is increased (Gupta, 2011).
provides well-being, vitality, and coherence, regard- Strengths of this study include assessing an inter-
less of the presence or absence of symptoms. vention using a multisite randomized controlled trial
The intervention also had a positive impact on and including variables that have not received much
school engagement and suggests that ACT may help attention so far in the ACT literature (e.g., school
reduce the risk of dropping out. This is an interesting engagement). Psychological flexibility was also
result as a growing number of researchers, educators, assessed by combining three questionnaires, which
and policymakers recognized that student engage- allow covering all six ACT processes and avoid the
ment is an important key to address low achieve- limits of the AAQ-I and II (Gámez et al., 2011).
ment, student boredom, and high dropout rates Although the questionnaires we used provided us
(Fredricks et al., 2004). Obviously, these results need with more fine-grained analyses, they were created
to be interpreted with caution as school engagement from different conceptual backgrounds and may
was measured with a self-report questionnaire that have failed to correctly map the ACT processes. Since
may have been biased by social desirability. In the launch of this study, significant progress has been
subsequent studies, it would be useful to examine if made regarding the assessment of psychological
the results of this research can be replicated with other flexibility. Indeed, Rolffs, Rogge, and Wilson
types of school engagement indicators such as teacher (2016) published the Multidimensional Psychologi-
report questionnaires or observation measures. cal Flexibility Inventory (MPFI), a comprehensive
Teacher report questionnaires involve teacher ratings scale aimed at assessing flexibility processes (those
of individual student engagement while observation mentioned above) and inflexibility processes (lack of
measures rely on an independent observer assessing contact with the present moment, lack of contact
370 g r é g o i r e e t a l .

with values, inaction, self-as-context, fusion, experi- their stress, anxiety, and depression symptoms. We
ential avoidance). This promising scale may allow believe these transdiagnostic interventions should
researchers to examine the benefits of ACT interven- be disseminated within university campuses, com-
tions on psychological flexibility more precisely and bined with other initiatives aimed at developing and
to better understand their mechanisms of actions. promoting healthy lifestyles, and integrated into
Despite its strengths, the current study is limited systemic efforts to prevent problems. The results of
by different factors. First, as we did not compare the this trial also extend previous studies and suggest
intervention with another treatment, we cannot be that besides their positive impact on mental health,
certain that it was the intervention per se that ACT interventions also help increase school engage-
produced the observed effects. It would have been ment among university students. These are prelimi-
preferable to use an active rather than a passive nary but interesting results and efforts should be put
control group as comparison to control for nonspe- forward to pursue this line of research by using
cific effects (e.g., group social support processes). various types of school engagement indicators.
Second, no follow-up was included in the study as we Regarding the KORSA intervention presented in
did not have the resources to do so. This means we this paper, both the trainer’s guide and the partici-
cannot be certain that the observed effects were pant’s guide should be published to allow practi-
maintained over time. In future, studies using long- tioners to use these documents and help researchers
term follow-up or intensive longitudinal designs and pursue the evaluation of the workshops.
multiple times of measurement would be especially Conflict of Interest Statement
valuable to explore how variables such as stress or The authors declare that there are no conflicts of interest.
psychological flexibility evolve across time. Smart-
phone applications could be used to make ecological
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