Journal of Contextual Behavioral Science 27 (2023) 98–106

Contents lists available at ScienceDirect

Journal of Contextual Behavioral Science

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

ACT-based self-help for perceived stress and its mental health implications
without therapist support: A randomized controlled trial
M. Eklund a, C. Kiritsis a, F. Livheim b, A. Ghaderi a, *
a
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
b
Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

A R T I C L E I N F O A B S T R A C T

Keywords: Access to interventions that effectively reduce stress is limited and often costly. Lack of time, and stigma might
Acceptance and commitment therapy also be significant barriers. This study examined the effectiveness of an Acceptance and Commitment Therapy
Mindfulness (ACT)-based self-help book without therapist support for adults with moderate levels of stress, without psy­
Psychological flexibility
chiatric diagnoses. Participants were recruited primarily through the website of the book and posts in various
Pure Self-help, Stress
social media channels. Participants (n = 133) were randomly assigned to an intervention group (n = 67) or a
wait-list group (n = 66). Both the primary outcome measure (stress) and the secondary outcome measures (e.g.,
quality of life, worry, depressive symptoms and burnout symptoms) were measured before and after the inter­
vention, and at 6-months follow-up. Compared to the wait-list group, the improvement was significantly larger in
the intervention group at the end of intervention for stress (Cohen’s d = 1.00), worry (d = 0.69), and all three
subscales of the burnout questionnaire (d = 0.59 to 0.73). The corresponding effect on depressive symptoms was
medium (d = 0.51). We did not find any robust evidence of mediation of outcome through psychological flex­
ibility or mindfulness, but number of pages read, number of mindfulness exercises performed, and perceived
helpfulness of the weekly assignments significantly predicted change in stress. At the 6-month follow-up, the
gains in the intervention group remained as the results were virtually identical to those at the end of inter­
vention. Our findings provide additional support for the efficacy of an ACT-based pure self-help to reduce stress
among adults with moderate level of stress, without psychiatric diagnoses.

Stress is a major concern in most modern societies, with high prev­
alence and significant negative health outcomes (Fink, 2016). There are
many definitions of stress. According to Cohen and colleagues, “Psy­
chological stress occurs when an individual perceives that environmental
demands tax or exceed his or her adaptive capacity” (Cohen et al., 1995).
The individual’s perception of stress is thus a key component in the
experience of stress, as measured by for example the Perceived Stress
Scale (Cohen et al., 1983) based on the transactional model of stress
(Lazarus, 1966).
It is also common to divide stress into two types, “acute stress” that is
short-term and can be helpful, and “chronic stress” that lasts for a longer
period and may harm health. It is well known that long-term stress may
lead to both mental and physiological illness (Ekman, Arnetz, & Red,
2013) as it increases the risk of depression, post-traumatic stress disor­
der, anxiety disorder, cardiovascular diseases, type-2 diabetes, and
abdominal obesity (e.g., Chetty et al., 2014; Hackett & Steptoe, 2017;
Scott et al., 2012). Nearly everyone has an experience of stress related to
either relationships, work, or other demanding situations (Singer et al.,
2007; Wersebe et al., 2018). Most adults spend a significant amount of
their time at work, consequently, the workplace may contribute to a
significant portion of the total stress a person experiences during a day
(Richardson & Rothstein, 2008). Work-related stress is a sizable finan­
cial burden on society and a rising problem (Hassard et al., 2018).
However, stress may also be related to other contexts and situations, and
several other factors such a lack of time, low access to treatment, or
stigma may hinder the individual from seeking help to alleviate the
negative consequences of perceived stress. Therefore, wide availability
of an intervention for handling stress in general might be a significant
contribution to public health.
There are several psychological treatments for subjectively perceived
stress. These treatments either focus on changing the context, or the
individual’s approach to the response (e.g., Awa et al., 2010; Hofer et al.,
2018). Stress inoculation training (SIT), multi-modal rehabilitation,
mindfulness-based interventions, cognitive behavioral therapy (CBT)

* Corresponding author. Ata Ghaderi Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, 171 77, Stockholm, Sweden.
E-mail address: ata.ghaderi@ki.se (A. Ghaderi).

https://doi.org/10.1016/j.jcbs.2023.01.003
Received 13 May 2022; Received in revised form 5 January 2023; Accepted 13 January 2023
Available online 16 January 2023
2212-1447/© 2023 The Authors. Published by Elsevier Inc. on behalf of Association for Contextual Behavioral Science. This is an open access article under the CC
BY license (http://creativecommons.org/licenses/by/4.0/).
M. Eklund et al. Journal of Contextual Behavioral Science 27 (2023) 98–106

and acceptance and commitment therapy (ACT) are common examples quizzes should predict changes in the primary outcome from baseline to
of psychological interventions for stress (Flaxman & Bond, 2010; Hofer the end of intervention. Finally, we examined potential iatrogenic ef­
et al., 2018; Regehr et al., 2013). ACT has shown promising results in a fects of the intervention and participant satisfaction.
wide range of psychosocial and psychiatric problems, such as stress,
drug abuse, chronic pain, anxiety, depression, self-injurious behavior, 1. Methods
and obsessive-compulsive disorder (e.g., A-Tjak et al., 2015; Gloster
et al., 2020). Although some meta-analyses and reviews indicate 1.1. Participants
promising results for CBT, ACT and mindfulness-based interventions for
stress and its mental health implications (e.g., Regehr et al., 2013), ac­ The inclusion criteria were to be at least 18 years old and to report at
cess to psychological treatments is still limited. Studies on ACT-based least mild levels of perceived stress, defined as a score of at least 15 on
self-help are also emerging with promising results (e.g., Selvi et al., the Depression Anxiety Stress Scales (DASS; Lovibond & Lovibond,
2021; Wersebe et al., 2018). Recently, Hofer et al. (2018) reported good 1995). However, the majority of participants scored much higher, and
outcome of an ACT-based pure self-help intervention regarding stress (i. the mean DASS score of those included was 21.92 (SD = 4.71). Exclusion
e., a large between group effect size for stress at the end of the inter­ criteria were: Indications of major depression (a score above nine on the
vention). Bibliotherapy for various psychiatric conditions and psycho­ Patient Health Questionnaire-9, PHQ-9; Kroenke et al., 2001), suicidal
logical problems has shown promising outcomes, and increases access to intent (based on item 9 on the PHQ-9), having an established current
psychological treatment (e.g., Fanner & Urquhart, 2008). In terms of the psychiatric diagnosis (i.e., a formal diagnosis established by a profes­
level of therapist support, some overviews suggest that guided self-help sional within the Swedish Health Care System), having already read the
is more efficient than pure self-help (Heber et al., 2017; Lilienfeld et al., self-help book used in this study, or concurrent psychotherapy. The
2015). On the other hand, pure self-help might also be a viable option rationale for exclusion of those with major depression, suicidal intent, or
given its ease of access and flexibility in terms of time of use, as other established current psychiatric diagnoses was lack of solid data on
demonstrated in some previous randomized controlled trials (Hofer the safety of pure self-help for those with stress and comorbid condi­
et al., 2018; Jeffcoat & Hayes, 2012). As the only published study of tions, and to follow the ethical guidelines in research where the safety of
ACT-based pure self-help for stress is the one by Hofer et al. (2018), patients/participants is a crucial aspect. In total, 133 adults were
more studies are needed to investigate its effect across different cultures, included in the study, of which the majority reported moderate stress (i.
languages, and samples with various characteristics. e., with a score of 19 or above on the DASS). The characteristics of the
ACT includes six core processes; acceptance, defusion, self as sample are shown in Table 1.
context, committed actions, values and being present (Levin et al., 2012)
and aims to increase psychological flexibility (French et al., 2017; 1.2. Procedures
Jiménez, 2012). The now on-going process-based therapy movement
highlights the need for increased understanding of the different unique Between February and middle of March 2019, participants were
effects in common psychological treatments, in order to evolve more recruited through several different channels; primarily the website of
flexible treatments tailored to the clients’ idiographic needs (Hofmann the book (http://www.tidattleva.se) and posts in suitable Facebook
& Hayes, 2019). Some studies have examined the mediating role of groups. Individuals who declared interest for participation were
psychological flexibility in the treatment of various conditions such as screened for inclusion through an online platform (BASS4) at Karolinska
anxiety, depression, stress, and pain, with promising results (e.g., Bond Institutet based on PHP/Clojure and the MySQL database with a strong
& Bunce, 2000; Flaxman & Bond, 2010; Fledderus et al., 2013; Lloyd protocol for encryption and authentication as well as strong key ex­
et al., 2013; Muto et al., 2011; Wicksell et al., 2010). However, in ACT, change and cipher, in addition to meeting all the requirements for safety
mindfulness is defined as a separate process, seen as an interface of back-ups, malware protection, data separation control, etc., which make
processes in psychological flexibility (Munoz-Martinez et al., 2017), and it suitable for handling sensitive data in research and to ensure
several studies support the effectiveness of mindfulness-based in­
terventions for conditions such as stress, generalized anxiety disorder Table 1
and depression (Grossman et al., 2004; Janssen et al., 2018; Wells et al., The characteristics of participants in ACT self-help (n = 63), and the wait-list
2010). To contribute to the understanding of processes that might be control condition (n = 60).
related to outcome, mindfulness and psychological flexibility were ACT Self-Help Wait-List Control
investigated as a mediators of outcome in the current study. In addition,
Mean age (SD) 43.0 (8.96) 39.6 (8.21)
we investigated whether variables related to adherence to the treatment
Sex: n (%)
and perception of the treatment were related to change in outcome from Women 56 (89%) 50 (84%)
baseline to the end of the intervention. Men 7 (11%) 5 (8%)
The current study is a constructive replication (Lykken, 1968, 1991) Other/unknown 0 (0%) 5 (8%)
Relationship status: n (%)
of the study by Hofer et al. (2018) and aims to evaluate the efficacy of
Single 7 (11%) 6 (10%)
ACT-based pure self-help, using the book “Tid att leva (Time to live)” Married 26 (41%) 26 (44%)
(Livheim et al., 2017) for adults with moderate levels of perceived stress Domestic partner 23 (37%) 20 (33%)
without concurrent psychiatric diagnoses. Divorced 6 (10%) 3 (5%)
Our first hypothesis was that the intervention group consisting of Widowed 1 (1%) 0 (0%)
Other/unknown 0 (0%) 5 (8%)
adults with at least mild to moderate levels of stress would report
Highest level of education: n (%)
significantly lower levels of perceived stress, measured by the Perceived Upper secondary school 9 (14%) 2 (3.5%)
Stress Scale (primary outcome), at the end of the intervention compared Vocational education 4 (7.0%) 3 (5.0%)
to a wait-list group. Our second hypothesis was that psychological University 43 (68%) 48 (80%)
flexibility measured by the Acceptance and Action Questionnaire-II and/ Postgraduate studies 7 (11%) 2 (3.5%)
Other/unknown 0 (0%) 5 (8.0%)
or mindfulness measured by the Mindful Attention Awareness Scale, Occupation
would mediate the effect of the intervention on the primary outcome. Working 55 (87%) 44 (73%)
Third, we hypothesized that number of pages read, number of restor­ Studying 2 (3%) 6 (10%)
ative activities, number of physical activities, mindfulness training, Other/unknowna 6 (10%) 10 (17%)
perceived helpfulness of the weekly assignments and understanding of a
Parental leave, long term sick-listed/on disability pension, retired or
the treatment components measured by number of correctly answered unemployed.

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confidentiality. All participants provided informed consent prior to technical problems. Participants could contact the research staff through
participation through BASS4. Eligible participants were then randomly e-mail if they had any questions during the intervention. No aspects of
assigned with equal likelihood (1:1) to one of the two conditions (ACT the book or content were discussed during such contacts. Follow up took
versus wait-list (WL): Fig. 1), which was accomplished using a place between September 2019 and February 2020.
randomization list from Research Randomizer (www.random.org). The study was approved by the Swedish Ethical Review Authority
Participants were informed of their assigned condition by e-mail sent (Dnr. 2018/2391-31 and 2019-007702), and pre-registered on Clin­
from the platform, in which participants in the wait-list group were also icaltrials.gov (NCT03826732).
informed that they would receive the same intervention as the inter­
vention group as soon as the intervention group had completed the trial.
1.3. Intervention
Applicants who were excluded from participation were informed and
received tailored information about the cause of exclusion (e.g.,
The ACT-based self-help book “Time to live” (Livheim et al., 2017)
depressive symptomatology) and where and how to seek professional
consists of ten chapters. Chapter 1 focuses on psychoeducation, early
help if needed.
signs of stress and how to schedule restorative activities. Chapter 2 fo­
The intervention group received the ACT-based self-help book “Time
cuses on physical exercise, the importance of taking short breaks,
to live” (In original Swedish: “Tid att leva”: Livheim et al., 2017) without
mindfulness, and sleep. Chapter 3 focuses on values and introduces the
therapist support. There is also an English version of this book, entitled
concept of committed action. Chapter 4 focuses on finding a balance in
The mindfulness and acceptance workbook for stress reduction (Livheim
life and on problem solving. Chapter 5 focuses on acceptance and the
et al., 2018). Each week, for a duration of ten weeks, the participants
distinction between natural and unnecessary suffering. Chapter 6 fo­
read a chapter in the book and answered a few questions on an online
cuses on the cost of avoidance and how to use acceptance and mind­
platform. Both groups answered the same questions except for questions
fulness to deal with obstacles. Chapter 7 focuses on communication,
regarding the intervention itself, which were only answered by those in
including how to be assertive and how to ask for help. Chapter 8 focuses
the intervention group. No feedback was given to the participants at any
on how to be mindful in everyday life. Chapter 9 focuses on
time, but automated prompts were e-mailed to participants who did not
self-compassion. Chapter 10 focuses on values, goals, milestones, and
respond to the weekly questions in time. Participants who did not
the importance of everyday actions. In every chapter, the reader is
respond after the automated prompts during the initial phase of the
encouraged to engage in physical exercise regularly. Each chapter also
intervention were contacted to determine whether they were facing any
includes an assignment that relates to the topic of that chapter. For

Fig. 1. Flowchart of the participants.

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M. Eklund et al. Journal of Contextual Behavioral Science 27 (2023) 98–106

example, in Chapter 1 the assignment is to choose one to three restor­ Table 2

ative activities to do for the next week. The main differences between The Main Content of the Intervention/Book in each Chapter and Examples of
the Swedish and English versions of the book are that the English version Exercises/Assignments.
has 9 instead of 10 chapters, it is about 10 pages shorter, and some Chapter Main content Exercises/Assignments
examples have been changed to better fit an international context 1. The first step What stress is. The difference 1. Read the next chapter.
(Livheim et al., 2018). An overview of the content of the intervention toward a less between short-term and long- 2. Pick one to three
and weekly assignments in “Information and reference removed to stressful life. term stress. Typical signs of restorative activities for the
enable double blind review” are presented in Table 2. stress. Checking stress levels coming week and put them
by doing The Perceived Stress in your calendar and follow
Scale (10-item version). One through doing them.
1.4. Measures important key to dealing with
stress is restoration and doing
The primary outcome was perceived stress. This was assessed with recharging activities.
the Perceived Stress Scale-14 (PSS-14; Cohen et al., 1983) at five time 2. Effective ways Short summary of key points (Both one and two above
to deal with from last chapter, this is done done subsequently in
points: baseline, week three, week five, week 10 (post-treatment) and at stress. subsequently in chapters chapters 2–10). To pick and
6-month follow-up. PSS-14 has shown adequate reliability and validity 2–10. Sleep, short breaks, schedule exercise, short
(Cohen et al., 1983). The internal consistency of the PSS-14 in the cur­ exercise, and mindfulness as breaks, and enough sleep. Do
rent study was 0.85. Secondary outcomes included quality of life, effective ways to deal with two mindfulness exercises
stress. (provided online).
measured by the Brunnsviken Brief Quality of Life Inventory (BBQ;
3. What makes Identifying values. Exercise Same as previous two
Lindner et al., 2016), anxiety assessed by the General Anxiety Disorder-7 your life visiting your 90th birthday. chapters. Pick a value and do
(GAD-7; Spitzer et al., 2006), depressive symptoms and suicidal intent, meaningful? Explore your values by one or two concrete
assessed by the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., making a Life Compass. The behaviors associated with
2001), and work engagement and burnout symptoms measured by the difference between values that value.
and goals.
Shirom-Melamed Burnout Measure (SMBM; Shirom & Melamed, 2006). 4. Change what is Identifying external stressors Same as previous chapters.
The SMBM consists of three subscales: emotional exhaustion, physical not working. and doing a structured Follow through testing a plan
fatigue, and cognitive weariness. The secondary outcomes were assessed problem-solving exercise. from problem solving.
at three time points: baseline, week 10 (post-treatment) and at 6-month 5. Willingness to Acceptance, what it is, and Same as previous chapters.
face the what it is not. Differentiating Try new ways of accepting/
follow-up. All the measures possess good psychometric properties (BBQ;
inevitable. between “natural stress” and open up when meeting
Lindner et al., 2016, GAD-7; Spitzer et al., 2006, PHQ-9; Kroenke et al., “unnecessary stress”. The challenges the coming week.
2001, SMBM; Shirom & Melamed, 2006). latter is created by reacting to
Two ACT-specific measures were also included as mediators; psy­ life’s hurdles in unhelpful
chological flexibility and mindfulness, measured by the Acceptance and ways (e.g., struggle),
6. Wisely How comparing ourselves to Same as previous chapters.
Action Questionnaire-II (AAQ-II; Bond et al., 2011), and by the Mindful navigating others can cause stress. Actively challenge
Attention Awareness Scale (MAAS; Brown & Ryan, 2003). These were storms in life. How avoiding or ineffective behaviors when
assessed at five time points: baseline, week three, week five, week 10 overachieving can cause wanting to avoid or
(post-treatment) and at 6-month follow-up. The Swedish 6-item version stress and suffering. overachieve.
Hanging on to values, accept/
of AAQ-II has shown good psychometric properties (SAAQ; Lundgren &
open up to emotions, and act
Parling, 2017), as has MAAS (Black et al., 2012; Brown & Ryan, 2003). wisely.
The participants’ satisfaction with the intervention was assessed 7. Healthy The importance of calm and Same as previous chapters.
week 10 (post-treatment) and at 6-month follow-up with the Client relationships. clear communication. Actively try out a new
Satisfaction Questionnaire-8 (CSQ-8; Attkisson & Zwick, 1982). CSQ-8 Effective communication communication technique.
techniques (e.g., the I-
has similar or sometimes even better psychometric properties message). Saying no. Asking
compared to the original 18-item version (Attkisson & Zwick, 1982). for help as a key to reducing
The participants’ expectation of the intervention was assessed at base­ stress.
line with the Credibility/Expectancy Questionnaire (CEQ; Devilly & 8. Mindfulness – How mindfulness can help Same as previous chapters.
focus on here reduce stress. To integrate Try out two mindfulness
Borkovec, 2000). It consists of two factors, credibility and expectancy,
and now. being here and now into exercises (provided online),
with high internal consistency and good test-retest reliability (CEQ; everyday life. To accept that and practice mindfulness in
Devilly & Borkovec, 2000). Iatrogenic events were assessed at week 10 mind wanders and gently daily life.
(post-treatment) and at 6-month follow-up with the Negative Effects bringing back attention to
Questionnaire (NEQ; Rozental et al., 2019; Rozental et al., 2016). The here and now.
9. Being a good Life will partly contain Same as previous chapters.
internal consistency of the NEQ is high (.95) (Rozental et al., 2016).
friend to challenges, and everybody Plan and try out self-
All participants were, on a weekly basis, asked to do a quiz about the yourself. suffers. Learning self- compassionate actions.
contents of the week’s chapter, and to respond to the following ques­ compassion and practice
tions: A) How many pages have you read during the week? B) How being kind to oneself in
actions.
helpful did you find this week’s assignment on a scale from 1 to 10,
10. Life from now Checking stress levels by
where 1 means “Not helpful at all” and 10 means “Very helpful”? C) How on. doing PSS-10 again. Setting
many restorative activities have you done during the week? D) How SMART goals connected to
many times have you exercised during the week? and E) How many values for the coming year.
mindfulness exercises have you done during the week? Quizzes con­ Summary of all strategies in
the book and a prompt to
sisted of 6–10 multiple choice questions related to the content of each
continue to use what was
chapter (Supplement A). deemed as effective.

1.5. Data analysis

Data were analyzed using Statistical Package for the Social Sciences
(SPSS) for Macintosh, version 26. The alpha level for statistical signifi­
cance was set at 0.05. Power analyses indicated that 128 participants

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would be sufficient to obtain a power of .80 across analyses, assuming an Table 3

alpha level of 0.05 (Cohen, 1988), and the same effect size as in the Mean (M) and the Standard Error (SE) of the Main and Secondary Outcomes of
previous study of ACT-based self-help for stress (Hofer et al., 2018). the ACT Self-Help Group (ACT, n = 63), and the Wait-list Control Condition (WL,
Chi-square tests and t-tests were used to examine potential differ­ n = 60) at Baseline, and Post-treatment, as well as Overall Effect of Time,
ences between the intervention group and the wait-list group regarding Condition, and Time*Condition Interaction.
demographics or outcome measures at baseline. Potential change in the Baseline Post-treatment
outcome variables between the groups and across time were investi­ ACT WL ACT WL Effect
gated using Generalized Linear Mixed Models (GLMM). The GLMM has sizea
several merits compared to ANOVA as multilevel analyses are inherently PSS-14 29.68 28.84 20.49 28.95 1.00
intention to treat, and repeated measures can be nested into partici­ (0.90) (0.97) (1.12) (1.05)
pants. Moreover, in the GLMM, relevant distributions and links can also Time: F (1, 199) = 29.42, p < .001, Condition: F (1, 199) = 10.72, p < .001,
be specified dependent on the actual nature of data. Interaction: F (1, 199) = 30.92, p < .001
AAQ-2 22.52 (.90) 21.49 (.96) 19.76 22.77 d = -0.38
For the mediation analyses, the SPSS add-on PROCESS macro using (1.02) (1.01)
bootstrapping was used (Hayes, 2013; Preacher & Hayes, 2004). The Time: F (1, 199) = 1.68, p = .196, Condition: F (1, 199) = .621, p = .432, Interaction: F
statistical significance of the mediators was estimated by calculating (1, 199) = 12.56, p < .001
bias-corrected 95% confidence intervals around mean-centered OLS BBQ 49.10 49.47 56.38 50.17 d = 0.34
(2.06) (2.20) (2.37) (2.31)
regression coefficients by bootstrapping. The change in the primary
Time: F (1, 199) = 8.28, p = .004, Condition: F (1, 199) = 1.05, p = .31. Interaction: F
outcome measure from baseline to post-treatment was used as the (1, 199) = 5.65, p = .018
dependent variable. Early change in the mediators was obtained across GAD-7 7.52 (.47) 7.11 (.50) 4.52 (.58) 7.53 (.54) d = 0.69
different time spans early in the intervention: from baseline to week Time: F (1, 199) = 9.189, p = .003, Condition: F (1, 199) = 4.45, p = .035, Interaction:
three, from baseline to week five, and from week three to week five. F (1, 199) = 16.17, p = .001
MAAS 3.38 (.09) 3.33 (.09) 4.18 (.10) 3.41 (.10) d = 1.00
Finally, linear regression analysis was used to assess the relationship Time: F (1, 199) = 44.02, p = .001, Condition: F (1, 199) = 12.69, p = .001,
between the adherence and change in the primary outcome measure Interaction: F (1, 199) = 29.30, p = .001
PSS-14 (i.e., perceived stress). The cut-off for small, medium and large PHQ-9 7.59 (.50) 7.49 (.53) 4.62 (.60) 6.96 (.57) d = .51
effect sizes based on Cohen’s d was set at 0.2, 0.5, and 0.8, respectively. Time: F (1, 199) = 17.60, p = .001, Condition: F (1, 199) = 2.65, p = .11, Interaction: F
(1, 199) = 9.65, p = .002
SMBM- 2.84 (.12) 3.06 (.12) 3.56 (.14) 2.94 (.12) d = 0.59
2. Results P
Time: F (1, 199) = 11.77, p = .001, Condition: F (1, 199) = 1.607, p = .21, Interaction:
2.1. Drop-out F (1, 199) = 23.48, p = .001
SMBM- 2.81 (.11) 2.81 (.12) 3.53 (.13) 2.91 (.13) d = 0.61
C
Of the 133 randomized participants, four in the intervention group time effect: F (1, 199) = 24.77, p = .001, Condition: F (1, 199) = 3.91, p = .05,
and 11 in the wait-list group did not complete the full baseline assess­ Interaction: F (1, 199) = 13.94, p = .001
ment battery. Briefly after providing baseline data, two participants in SMBM- 3.28 (.13) 3.13 (.15) 3.93 (.15) 3.08 (.15) d = 0.73
the intervention group and three in the wait-list group decided to E
Time effect: F (1, 199) = 8.52, p = .004, Condition: F (1, 199) = 8.30, p = .004,
terminate their participation. At post-treatment, 39 (58%) in the inter­
Interaction: F (1, 199) = 11.77, p = 001
vention group and 46 (70%) in the wait-list group completed the as­
a
sessments. At 6-month follow-up, 39 participants (58%) in the Effect size (Cohen’s d) of the difference between the conditions at post-
intervention group completed the assessment. The drop-out group was treatment. Self-rated levels of stress measured by the Perceived Stress Scale-14
not significantly different from those who provided data at post- (PSS-14), psychological flexibility measured by the Acceptance and Action
Questionnaire-II (AAQ-II)), quality of life measured by Brunnsviken Brief
treatment on any of the demographics or baseline outcome measures.
Quality of Life (BBQ), worry and anxiety measured by General Anxiety Disorder-
At baseline, there were no statistically significant differences between
7 (GAD-7), mindfulness measured by the Mindful Attention Awareness Scale
the conditions for any of the demographic or outcome variables. (MAAS), depressive symptoms and suicidal intent measured by the Patient
Health Questionnaire-9 (PHQ-9), the physical fatigue subscale of the Shirom-
2.2. Main outcomes Melamed Burnout Measure (SMBM-P), the cognitive weariness subscale of the
Shirom-Melamed Burnout Measure (SMBM-C), the emotional exhaustion sub­
For the primary outcome (i.e., perceived stress, measured by the PSS- scale of the Shirom-Melamed Burnout Measure (SMBM-E).
14), we found a significant overall effect of Time (baseline to week 10,
post-treatment), and Condition, as well as a significant interaction be­ repeatedly and treated as mediators of outcome. The means and stan­
tween Time and Condition (Table 3). The interaction effect reflects a dard deviations of both mediators in each condition from baseline to
marked decrease in the level of perceived stress in the intervention week three and week five are presented in Table 4.
group from baseline to week 10 (post-treatment) compared to virtually As shown in Table 4, data from AAQ-II were only available for 42
no change in the wait-list group. The magnitude of the effect between participants in the intervention group, and 23 in the wait-list group for
the conditions at week 10 (post-treatment) was large (Cohens’ d = 1.00)
favouring the intervention group. The difference between the conditions
at week 10 (post-treatment) for the secondary outcome’s anxiety (GAD- Table 4
7), depression (PHQ-9), and burnout (all three sub-scales in SMBM) was Mean and standard deviation (SD) of ratings on acceptance and actions ques­
in the moderate range, while the effect size in quality of life (BBQ) was tionnaire (AAQ) and mindfulness attention awareness scale (MAAS) across
small (Table 3). A significant Time*Condition interaction emerged for measurements in the intervention (ACT) versus the wait-list control condition.
all the secondary outcomes. For the two ACT-specific measures we found AAQ MAAS
a large effect size for mindfulness (MAAS) as well as a significant Intervention Wait-List Intervention Wait-List
interaction effect, while the effect size for psychological flexibility Group n = 42 Control n = Group n = 41 Control n =
(AAQ-2) was small and no significant interaction emerged (Table 3). Mean (SD) 23 Mean (SD) 23
Mean (SD) Mean (SD)

2.3. Mediation Baseline 23.36 (6.77) 20.57 (4.84) 3.36 (0.66) 3.39 (0.61)
Week 3 23.43 (7.60) 21.39 (6.27) 3.44 (0.58) 3.63 (0.59)
Week 5 22.29 (6.90) 20.00 (4.81) 3.67 (0.59) 3.91 (0.55)
In terms of mediation, the AAQ-II and the MAAS were rated

102
M. Eklund et al.
all occasions (baseline, week three and week five). No significant
changes in the AAQ-II were found in any of the conditions across time
(from baseline to week three and week five). A larger number of par­
ticipants provided data on week three on AAQ-II in both conditions (52
in the intervention group and 27 in the wait-list group), compared to
week five (44 versus 26). Separate analyses of the change in the AAQ-II
from baseline to week three, or from baseline to week five, did not yield
any significant differences in any of the conditions.
For the MAAS, data were available from 51 to 44 participants in the
intervention group and 27–26 in the wait-list group from baseline to
week three and five, respectively. The change in MAAS from baseline to
week three was not significant in any of the conditions. However, the
week five ratings of the MAAS were significantly higher than those re­
ported at baseline (F (1, 68) = 33.81, p < .001). Unexpectedly, the
magnitude of change from baseline to week three in the intervention
group (from 3.38 (SD = 0.67) to 3.71 (SD = 0.59), d = 0.56) was slightly
smaller to that in the wait-list group (from 3.40 (SD = 0.60) to 3.89 (SD
= 0.45), d = 0.99). At a conservative level, the pre-requisites for a true
and meaningful mediation analysis, according to Kazdin (2007) were
not met. Nevertheless, a boot-strapped mediation analysis of the main
outcome (PSS-14) with changes in the MAAS from baseline to week five
as mediator was performed with the conditions as independent variable.
The change in the MAAS did not emerge as a significant mediator of the
PSS-14.
2.4. Prediction of outcome
To investigate whether the number of pages read, number of
restorative activities, number of physical activities, mindfulness
training, perceived helpfulness of the weekly assignments, or number of
correct answers to the quizzes predicted changes in the primary outcome
(perceived stress) from baseline to week 10 (post-treatment), we per­
formed a series of linear regression analyses. Number of pages read
significantly predicted change in perceived stress (Table 5). The more
pages the participants read the larger the change in perceived stress
from baseline to week 10 (post-treatment). For each page read the stress
was reduced by 0.047 units. The mean number of pages read by the
participants was 178.3 (SD = 95.7), and the total number of pages were
319.
Mindfulness training, perceived helpfulness of weekly assignments,
and number of quizzes done and correctly responded to during the
intervention also predicted change in perceived stress from baseline to
week 10 (post-treatment). On the other hand, number of restorative
activities, or physical activities did not emerge as significant predictors.
If the critical p-value in the prediction analyses was corrected by the
number of regression analyses, then only perceived helpfulness of ex­
ercises, and number of correct answers to the quizzes would remain as
significant predictors of change in the main outcome.
2.5. Potential iatrogenic effects
Regarding possible iatrogenic events, 86 of the 360 reported nega­
tive effects were attributed to the treatment, measured by the Negative
Effects Questionnaire (NEQ) at week 10 (post-treatment). At the 6-
month follow-up, the number dropped to 73 negative effects. Only a
Table 5
Regression Analyses of the Predictors of Change in the Main Outcome Variable
(Perceived Stress) from Baseline to week 10 (post-treatment).
B SE for B Beta t p
Number of pages read 0.047 0.019 0.38 2.48
Number of restorative activities 0.077 0.061 0.21 1.25
Number of physical activities 0.073 0.091 0.13 0.80
Mindfulness training 0.234 0.110 0.33 2.13
Perceived helpfulness of exercises 0.226 0.060 0.53 3.80
Number of correct answers to quizzes 0.082 0.024 0.49 3.38
Journal of Contextual Behavioral Science 27 (2023) 98–106
negligible portion of the reported negative effects, both at week 10
(post-treatment) and at 6-month follow-up, were reported to have actual
negative impact on the participants’ self-perceived well-being. They
included doubts about the intervention quality, more symptoms, and
feelings of hopelessness (See Supplement B for further information).
Participants’ perceived satisfaction with the intervention was measured
with Client Satisfaction Questionnaire-8 (CSQ-8) and showed an average
of 15.44 points (out of 32) at week 10 (post-treatment) and 15.10 (out of
32) at the 6-month follow-up. The CSQ-8 revealed that the participants
were least satisfied with the quality of the intervention. In the credibility
part of the CEQ, the participants rated the logical appearance of the
intervention, and their certainty to recommend the intervention as high
(M = 7 out of 8). The mean prospective rating of perceived successful­
ness of the intervention was also rated fairly high (M = 6 out of 8), while
the expectation for symptom reduction was rated 55% of 100%.
2.6. The main outcomes at 6-month follow-up
At the 6-month follow-up, the results for the primary and secondary
outcomes as well as the two ACT-specific measures were virtually
identical to those at week 10 (post-treatment) with one exception.
Participants reported a significant deterioration on GAD-7 (F (1, 78) =
6.62, p = .01). The magnitude of this effect was d = − 0.28 (see Sup­
plement C).
3. Discussion
This study is a constructive replication (Lykken, 1968, 1991) of an
ACT-based pure self-help intervention for stress by Hofer et al. (2018).
To our knowledge, the study by Hofer et al. (2018) is the only published
study of the effectiveness of an ACT-based pure self-help intervention for
stress despite its high prevalence and negative consequences. Our study
confirms the main finding in Hofer et al. (2018), by showing a large
reduction in stress (Cohen’s d = 1.00) among adults with moderate
levels of stress, without concurrent psychiatric diagnoses. This indicates
that an easily accessible, timesaving, and non-expensive intervention
without any therapist support can be of future interest in handling the
rising problem of stress. Our result on burnout and depressive symptoms
is also in line with those of Hofer et al. (2018), revealing moderate ef­
fects on physical fatigue (d = 0.59). cognitive weariness (d = 0.61) and
emotional fatigue (d = 0.73) in SMBM as well as for depressive symp­
toms (d = 0.51). We also found a significantly larger improvement of
worry in the intervention group compared to the wait-list group (d =
0.69). Results were maintained at 6-month follow-up, except for a sig­
nificant deterioration of GAD-7 (d = − 0.28). Speculatively, later dete­
rioration in anxiety during the follow-up may reflect the lack of
momentum gained by engaging in a book that offers a new perspective,
and weekly assignments during the active phase of the trial, or openness
to have the worries that most people may encounter. It may also reflect a
reduction in mindfulness at 6-month follow-up compared to the end of
the intervention.
At 6-month follow-up, the participants’ total satisfaction with the
intervention (M = 15.10 on the CSQ-8) were lower than what’s usually
found in evaluations of face-to-face psychological treatments (M = 27)
(Nguyen et al., 1983), something that also may have impact on the
GAD-7 results at the 6-month follow up. In summary, the book "Time to
live" (Livheim et al., 2017) showed a good and lasting effect on moderate
level stress, although the participants expressed some doubts about the
quality of the intervention. At baseline, according to the CEQ, the par­
ticipants considered the intervention to have high credibility in terms of
reducing stress-related symptoms as well as being logical (M = 7 out of
.02
.22 8). This should also be considered in light of the fact that most other
.43 studies examining self-help for stress and burnout offer some therapist
.04 support, and/or web-based discussion forums for participants (e.g.,
.001 Muto et al., 2011). Our results are in line with previously mentioned
.002
self-help interventions with the advantage of being potentially easier to
103
M. Eklund et al.
access, lowering the threshold for participants to try psychological
treatment, providing a large effect on the main outcome compared to no
treatment, and no cost to practitioners to provide support or guidance.
Something else to discuss in context of self-help interventions is our
sample constitution. Our sample consists mainly of women, similar to
other studies (e.g., Jeffcoat & Hayes, 2012). Women seem to be over­
represented as readers of self-help literature (Thelwall & Kousha, 2017;
Wilson & Cash, 2000). In addition, educated women are more likely to
take care of their health (United States Department of State Bureau of
International Information Programs, 2012), and have a habit of pro­
cessing textual material. To reach other target groups such as men or a
more ethnically diverse group of participants, other platforms, or more
directed recruitment strategies such as ads that target these groups
might be a viable option. In addition, it might be necessary to culturally
adapt the content to other racial/ethnic groups or genders.
In addition to exploring the efficacy of ACT for different problems
and conditions, the processes that lead to the outcome have been an
important area of focus within research on ACT, and a central factor in
this context is the role of psychological flexibility (PF). In our study
neither AAQ-2 nor MAAS emerged as a significant mediator of our pri­
mary outcome measure. We chose a conservative approach, following
the recommendations of Kazdin (2007), including the importance of
timeline in terms of change in the mediator occurring at an early stage of
treatment. In contrast to studies where PF has been shown to mediate
the outcome (Bond & Bunce, 2000; Flaxman & Bond, 2010; Lloyd et al.,
2013; Muto et al., 2011), we failed to find such an effect. This might be a
consequence of applying a conservative approach in our study. Although
we found a significant and small change in the AAQ-2 (d = 0.38) and a
significant large effect in the MAAS (d = 1.00) from baseline to
post-treatment, the change in these variables in the initial phases of the
intervention were negligible. It has been suggested that some of the ACT
processes might exert their effect in a longer term than within the
timeframe of the intervention. To truly study this hypothesis, closed
follow-ups are needed which is beyond the scope of the current study.
Whilst the effect size for mindfulness (baseline to post-treatment) is
large in our study, Hofer et al. (2018) reported small effects for
“describing” and “awareness” and no significant effect for other
measured mindfulness skills. Hofer et al. (2018) used the instrument
Kentucky Inventory of Mindfulness Skills (KIMS) while we used MAAS to
measure mindfulness, which may partly explain the differences in our
outcomes.
In terms of moderators, number of pages read by the participants
significantly predicted the outcome on the PSS-14. Surprisingly though,
neither the number of restorative activities nor number of physical ac­
tivities moderated the outcome. Physical activity has a well-researched
and documented effect on negative mood although the role of its specific
properties (e.g., duration, intensity and mode of physical exercises) for
the outcome needs further research (Chan et al., 2019). Although
potentially low sensitivity of the measures, or a ceiling effect might also
be possible alternative explanations for lack of significant findings, our
results may reflect the fact that the book’s focus is ACT-based in­
terventions, not physical exercise. On the other hand, mindfulness
training predicted change in the PSS-14. Whilst we couldn’t establish the
state of mindfulness as a mediator for reduced self-perceived stress, we
can conclude that mindfulness training seems to moderate the main
outcome (PSS-14).
Perceived helpfulness of weekly assignments, and number of correct
answers to quizzes were related to more reduction in PSS-14 from
baseline to post-treatment in contrast to the findings of Hofer et al.
(2018). In addition, we found that number of pages read, and number of
mindfulness exercises performed significantly predicted change in the
main outcome variable. These observations are valuable in improving
the design of future interventions based on a pure self-help format.
104
Journal of Contextual Behavioral Science 27 (2023) 98–106
3.1. Limitations
The generalizability of the study is limited as the sample consisted of
predominantly highly educated middle-aged women. If these charac­
teristics are applied to the general population, our sample may at best be
representative for users of self-help books beyond intervention trials.
Reliance on self-report is generally viewed as a limitation in inter­
vention studies, but the experience of stress is probably best evaluated
through self-report. The drop-out is significant, but not dramatically
larger than in other pure self-help studies. Nevertheless, drop-out limits
the generalizability of outcome. Our exclusion criteria may also be a
limitation, as comorbidity is a common condition, and exclusion of those
with major depression, suicidal intent or other psychiatric disorders
limits the generalizability of the results. However, safety of the partic­
ipants is a priority. Future studies should include participants with such
comorbidities if systematic monitoring and potential immediate inter­
vention is available within the research study, and throughout the
follow-up period.
3.2. Future research
Stress and related mental health problems are not uncommon among
men, or ethnic minorities. In fact, minority stress adds to other sources of
stress, and future studies should aim to include these groups to obtain a
more representative sample of the population. In addition, studies that
specifically target these groups should be conducted, given the lower
propensity of seeking professional help among some minority groups,
and men. In summary, we suggest that future studies put in more efforts
in recruiting a more diverse sample, e.g., through broadening the
recruitment channels and approaches or through directed recruitment.
To investigate the increased reach of pure self-help interventions, we
also encourage researchers to study the possible effects of availability of
a digital version of the book within an app which may apply to other
target groups. Survey and qualitative investigation among those who are
difficult to reach for such intervention might also be reasonable ap­
proaches to learn about barriers and potential solutions for increased
reach. Future study should also continue to apply a conservative
approach in the study of mediators, as done in the current study, to push
the field forward. Understanding drop-out in studies of pure self-help is
another important future task. It might be valuable to a priori plan to
conduct a brief qualitative follow-up interview of study drop-outs to
understand the reasons for drop-out in future studies.
Take home message
The outcomes of ACT-based pure self-help intervention for stress are
promising. It is a non-expensive, flexible, and easily accessible inter­
vention and thus of future interest in the on-going global battle against
society’s raising stress and its mental health implications.
Funding
The cost for ethical applications and books delivered to the partici­
pants was paid by the authors of the self-help book (Fredrik Livheim,
Daniel Ek and Björn Hedensjö). Otherwise, this research did not receive
any specific grant from funding agencies in the public, commercial or
not-for profit sectors.
Data sharing
Data will be made available upon reasonable request. Please contact
the corresponding author.
Declaration of competing interest
ME and CK report no conflict of interest. FL receives royalties from
M. Eklund et al.
his books on acceptance and commitment therapy (ACT), and income
from training professionals in ACT. Therefore, he had no substantial role
in drafting the ethical application, recruitment, randomization, data
analyses, or the first draft of the manuscript. AG receives royalties from
two books on eating disorders, occasional fees for workshops and su­
pervision with focus on CBT treatment of eating disorders, and consul­
tancy fees from the Swedish Agency for Health Technology Assessment
and Assessment of Social Services.
Acknowledgements
This work used the BASS4 platform from the eHealth Core Facility at
Karolinska Institutet, which is supported by the Strategic Research Area
Healthcare Science (SFO–V). The cost for ethical applications and books
delivered to the participants was paid by the authors of the self-help
book (Fredrik Livheim, Daniel Ek and Björn Hedensjö). Otherwise, this
research did not receive any specific grant from funding agencies in the
public, commercial or not-for profit sectors.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jcbs.2023.01.003.
References
A-Tjak, J. G., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A., & Emmelkamp, P. M.
(2015). A meta-analysis of the efficacy of acceptance and commitment therapy for
clinically relevant mental and physical health problems. Psychotherapy and
Psychosomatics, 84, 30–36. https://doi.org/10.1159/000365764
Attkisson, C. C., & Zwick, R. (1982). The client satisfaction questionnaire: Psychometric
properties and correlations with service utilization and psychotherapy outcome.
Evaluation and Program Planning, 5, 233–237. https://doi.org/10.1016/0149-7189
(82)90074-X
Awa, W. L., Plaumann, M., & Walter, U. (2010). Burnout prevention: A review of
intervention programs. Patient Education and Counseling, 78, 184–190. https://doi.
org/10.1016/j.pec.2009.04.008
Black, D. S., Sussman, S., Johnson, C. A., & Milam, J. (2012). Psychometric assessment of
the mindful attention awareness scale (MAAS) among Chinese adolescents.
Assessment, 19, 42–52. https://doi.org/10.1177/1073191111415365
Bond, F. W., & Bunce, D. (2000). Mediators of change in emotion-focused and problem-
focused worksite stress management interventions. Journal of Occupational Health
Psychology, 5, 156–163. https://doi.org/10.1037/1076-8998.5.1.156
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., …
Zettle, R. D. (2011). Preliminary psychometric properties of the acceptance and
action questionnaire-II: A revised measure of psychological inflexibility and
experiential avoidance. Behavior Therapy, 42, 676–688. https://doi.org/10.1016/j.
beth.2011.03.007
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its
role in psychological well-being. Journal of Personality and Social Psychology, 84,
822–848. https://doi.org/10.1037/0022-3514.84.4.822
Chan, J., Liu, G., Liang, D., Deng, K., Wu, J., & Yan, J. H. (2019). Special issue -
therapeutic benefits of physical activity for mood: A systematic review on the effects
of exercise intensity, duration, and modality. Journal of Psychology, 153, 102–125.
https://doi.org/10.1080/00223980.2018.1470487
Chetty, S., Friedman, A. R., Taravosh-Lahn, K., Kirby, E. D., Mirescu, C., Guo, F.,
Krupik, D., Nicholas, A., Geraghty, A., Krishnamurthy, A., Tsai, M-K.,
Covarrubias, D., Wong, A., Francis, D., Sapolsky, R. M., Palmer, T. D., Pleasure, D., &
Kaufer, D. (2014). Stress and glucocorticoids promote oligodendrogenesis in the
adult hippocampus. Molecular Psychiatry, 19, 1275–1283. https://doi.org/10.1038/
mp.2013.190
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Lawrence
Erlbaum Associates.
Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress.
Journal of Health and Social Behavior, 24, 385–396. https://doi.org/10.2307/
2136404
Cohen, S., Kessler, R. C., & Gordon, L. U. (1995). Strategies for measuring stress in studies of
psychiatric and physical disorders. Measuring stress: A guide for health and social
scientists (Vol. 28, pp. 3–26). New York, NY: Oxford University Press.
Devilly, G. J., & Borkovec, T. D. (2000). Psychometric properties of the credibility/
expectancy questionnaire. Journal of Behavior Therapy and Experimental Psychiatry,
31, 73–86. https://doi.org/10.1016/s0005-7916(00)00012-4
Ekman, R., Arnetz, B. B., & Red. (2013). Stress: Gen, individ, samhälle. (3 uppl. Liber.
Fanner, D., & Urquhart, C. (2008). Bibliotherapy for mental health service users Part 1: A
systematic review. Health Information and Libraries Journal, 25(4), 237–252. https://
doi.org/10.1111/j.1471-1842.2008.00821.x
105
Journal of Contextual Behavioral Science 27 (2023) 98–106
Flaxman, P. E., & Bond, F. W. (2010). A randomised worksite comparison of acceptance
and commitment therapy and stress inoculation training. Behaviour Research and
Therapy, 48, 816–820. https://doi.org/10.1016/j.brat.2010.05.004
Fledderus, M., Bohlmeijer, E. T., Fox, J.-P., Schreurs, K. M. G., & Spinhoven, P. (2013).
The role of psychological flexibility in a self-help acceptance and commitment
therapy intervention for psychological distress in a randomized controlled trial.
Behaviour Research and Therapy, 51, 142–151. https://doi.org/10.1016/j.
brat.2012.11.007
French, K., Golijani-Moghaddam, N., & Schröder, T. (2017). What is the evidence for the
efficacy of self-help acceptance and commitment therapy? A systematic review and
meta-analysis. Journal of Contextual Behavioral Science, 6, 360–374. https://doi.org/
10.1016/j.jcbs.2017.08.002
Gloster, A. T., Walder, N., Levin, M. E., Twohig, M. P., & Karekla, M. (2020). The
empirical status of acceptance and commitment therapy: A review of meta-analyses.
Journal of Contextual Behavioral Science, 18, 181–192. https://doi.org/10.1016/j.
jcbs.2020.09.009
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress
reduction and health benefits. Journal of Psychosomatic Research, 57, 35–43. https://
doi.org/10.1016/S0022-3999(03)00573-7
Hackett, R. A., & Steptoe, A. (2017). Type 2 diabetes mellitus and psychological stress. A
modifiable risk factor. Nature Reviews Endocrinology, 13, 547–560. https://doi.org/
10.1038/nrendo.2017.64
Hassard, J., Teoh, K. R. H., Visockaite, G., Dewe, P., & Cox, T. (2018). The cost of work-
related stress to society: A systematic review. Journal of Occupational Health
Psychology, 23, 1–17. https://doi.org/10.1037/ocp0000069
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis:
A regression-based approach. The Guilford Press.
Heber, E., Ebert, D. D., Lehr, D., Cuijpers, P., Berking, M., Nobis, S., & Riper, H. (2017).
The benefit of web- and computer-based interventions for stress: A systematic review
and meta-analysis. Journal of Medical Internet Research, 19(2), e32. https://doi.org/
10.2196/jmir.5774
Hofer, P. D., Waadt, M., Aschwanden, R., Milidou, M., Acker, J., Meyer, A. H., …
Gloster, A. T. (2018). Self-help for stress and burnout without therapist contact: An
online randomised controlled trial. Work & Stress, 32, 189–208. https://doi.org/
10.1080/02678373.2017.1402389
Hofmann, S. G., & Hayes, S. C. (2019). The future of intervention science: Process-based
therapy. Clinical Psychological Science, 7, 37–50. https://doi.org/10.1177/
2167702618772296
Janssen, M., Heerkens, Y., Kuijer, W., van der Heijden, B., & Engels, J. (2018). Effects of
mindfulness-based stress reduction on employees’ mental health: A systematic
review. PLoS One, 13(1), Article e0191332. https://doi.org/10.1371/journal.
pone.0191332
Jeffcoat, T., & Hayes, S. C. (2012). A randomized trial of ACT bibliotherapy on the
mental health of K-12 teachers and staff. Behaviour Research and Therapy, 50,
571–579. https://doi.org/10.1016/j.brat.2012.05.008
Jiménez, F. J. (2012). Acceptance and commitment therapy versus traditional cognitive
behavioural therapy. A systematic review and meta-analysis of current empirical
evidence. International Journal of Psychology and Psychotherapy, 12, 333–358.
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research.
Annual Review of Clinical Psychology, 3, 1–27. https://doi.org/10.1146/annurev.
clinpsy.3.022806.091432
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief
depression severity measure. Journal of General Internal Medicine, 16, 606–613.
https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Lazarus, R. S. (1966). Psychological stress and the coping process. McGraw-Hill.
Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treatment
components suggested by the psychological flexibility model: A meta-analysis of
laboratory-based component studies. Behavior Therapy, 43, 741–756. https://doi.
org/10.1016/j.beth.2012.05.003
Lilienfeld, S. O., Lynn, S. J., Lohr, J. M., & Red. (2015). Science and pseudoscience in
clinical psychology (2nd ed.). The Guilford Press.
Lindner, P., Frykheden, O., Forsström, D., Andersson, E., Ljótsson, B., Hedman, E.,
Andersson, G., & Carlbring, P. (2016). The Brunnsviken brief quality of life scale
(BBQ): Development and psychometric evaluation. Cognitive Behaviour Therapy, 45,
182–195. https://doi.org/10.1080/16506073.2016.1143526
Livheim, F., Bond, F. W., Ek, D., & Hedensjo, B. S. (2018). The mindfulness and acceptance
workbook for stress reduction: Using acceptance and commitment therapy to manage
stress, build resilience, and create the life you want. New Harbinger Publications.
Livheim, F., Ek, D., & Hedensjö, B. (2017). Tid att leva: Ett tioveckors program för
stresshantering med ACT och medveten närvaro. Natur & Kultur.
Lloyd, J., Bond, F. W., & Flaxman, P. E. (2013). The value of psychological flexibility:
Examining psychological mechanisms underpinning a cognitive behavioural therapy
intervention for burnout. Work & Stress, 27, 181–199. https://doi.org/10.1080/
02678373.2013.782157
Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the depression anxiety stress scales.
The Psychology Foundation of Australia.
Lundgren, T., & Parling, T. (2017). Swedish acceptance and action questionnaire (SAAQ):
A psychometric evaluation. Cognitive Behaviour Therapy, 46, 315–326. https://doi.
org/10.1080/16506073.2016.1250228
Lykken, D. T. (1968). Statistical significance in psychological research. Psychological
Bulletin, 70(3, Pt.1), 151–159. https://doi.org/10.1037/h0026141
Lykken, D. (1991). What’s wrong with psychology anyway?. In D. Cichetti, & W. Grove
(Eds.), Thinking clearly about psychology: Essays in honor of Paul E. Meehl (Vol. 1, pp.
3–39) Minneapolis, MN US: University of Minnesota Press. Matters of public interest.
Munoz-Martinez, A., Monroy-Cifuentes, A., & Torres-Sanchez, L. (2017). Mindfulness:
Process, skill or strategy? A behavioral-analytic and functional-contextualistic
M. Eklund et al.
analysis. Psicologia USP, 28(2), 298–303. https://doi.org/10.1590/0103-
656420160038
Muto, T., Hayes, S. C., & Jeffcoat, T. (2011). The effectiveness of acceptance and
commitment therapy bibliotherapy for enhancing the psychological health of
Japanese college students living abroad. Behavior Therapy, 42, 323–335. https://doi.
org/10.1016/j.beth.2010.08.009
Nguyen, T. D., Attkisson, C. C., & Stegner, B. L. (1983). Assessment of patient
satisfaction: Development and refinement of a service evaluation questionnaire.
Evaluation and Program Planning, 6, 299–313. https://doi.org/10.1016/0149-7189
(83)90010-1
Preacher, K. J., & Hayes, A. F. (2004). SPSS and SAS procedures for estimating indirect
effects in simple mediation models. Behavior Research Methods Instruments &
Computers, 36, 717–731. https://doi.org/10.3758/BF03206553
Regehr, C., Glancy, D., & Pitts, A. (2013). Interventions to reduce stress in university
students: A review and meta-analysis. Journal of Affective Disorders, 148, 1–11.
https://doi.org/10.1016/j.jad.2012.11.026
Richardson, K. M., & Rothstein, H. R. (2008). Effects of occupational stress management
intervention programs: A meta-analysis. Journal of Occupational Health Psychology,
13, 69–93. https://doi.org/10.1037/1076-8998.13.1.69
Rozental, A., Kottorp, A., Boettcher, J., Andersson, G., & Carlbring, P. (2016). Negative
effects of psychological treatments: An exploratory factor analysis of the negative
effects questionnaire for monitoring and reporting adverse and unwanted events.
PLoS One, 11(6), Article e0157503. https://doi.org/10.1371/journal.pone.0157503
Rozental, A., Kottorp, A., Forsström, D., Månsson, K., Boettcher, J., Andersson, G.,
Furmark, T., & Carlbring, P. (2019). The negative effects questionnaire:
Psychometric properties of an instrument for assessing negative effects in
psychological treatments. Behavioural and Cognitive Psychotherapy, 47, 559–572.
https://doi.org/10.1017/S1352465819000018
Scott, K. A., Melhorn, S. J., & Sakai, R. R. (2012). Effects of chronic social stress on
obesity. Current Obesity Reports, 1, 16–25. https://doi.org/10.1007/s13679-011-
0006-3
Selvi, K., Parling, T., Ljótsson, B., Welch, E., & Ghaderi, A. (2021). Two randomized
controlled trials of the efficacy of acceptance and commitment therapy-based
106
Journal of Contextual Behavioral Science 27 (2023) 98–106
educational course for body shape dissatisfaction. Scandinavian Journal of Psychology,
62, 249–258. https://doi.org/10.1111/sjop.12684
Shirom, A., & Melamed, S. (2006). A comparison of the construct validity of two burnout
measures in two groups of professionals. International Journal of Stress Management,
13, 176–200. https://doi.org/10.1037/1072-5245.13.2.176
Singer, G. H. S., Ethridge, B. L., & Aldana, S. I. (2007). Primary and secondary effects of
parenting and stress management interventions for parents of children with
developmental disabilities: A meta-analysis. Mental Retardation and Developmental
Disabilities Research Reviews, 13, 357–369. https://doi.org/10.1002/mrdd.20175
Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for
assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166,
1092–1097. https://doi.org/10.1001/archinte.166.10.1092
Thelwall, M., & Kousha, K. (2017). Goodreads: A social network site for book readers.
Journal of the Association for Information Science and Technology, 68, 972–983.
https://doi.org/10.1002/asi.23733
Wells, A., Welford, M., King, P., Papageorgiou, C., Wisely, J., & Mendel, E. (2010). A pilot
randomized trial of metacognitive therapy vs applied relaxation in the treatment of
adults with generalized anxiety disorder. Behaviour Research and Therapy, 48,
429–434. https://doi.org/10.1016/j.brat.2009.11.013
Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between
stress, well-being, and psychological flexibility during an acceptance and
commitment therapy self-help intervention. International Journal of Clinical and
Health Psychology, 18, 60–68. https://doi.org/10.1016/j.ijchp.2017.09.002
Wicksell, R. K., Olsson, G. L., & Hayes, S. C. (2010). Psychological flexibility as a
mediator of improvement in acceptance and commitment therapy for patients with
chronic pain following whiplash. European Journal of Pain, 14(10), 1059.e1–1059.
e11. https://doi.org/10.1016/j.ejpain.2010.05.001
Wilson, D. M., & Cash, T. F. (2000). Who reads self-help books? Personality and Individual
Differences, 29(1), 119–129. https://doi.org/10.1016/S0191-8869(99)00182-8
United States Department of State Bureau of International Information Programs (2012).
Global Women’s issues: Women in the world today. Retrieved from https://collec
tion.bccampus.ca/textbooks/global-womens-issues-women-in-the-world-today-e
xtended-version-gpa-publications-140http://open.bccampus.ca/find-open-textboo
ks/?uuid=47e557eb-f65f-4586-b08f-ae4600504177.