Acceptance- and Commitment-Based Interventions for Improving Psychological Flexibility: The Role of Social Factors
Keywords:
Acceptance and Commitment Therapy, psychological flexibility, social factors, social support, mental health stigma, qualitative researchAbstract
This study aimed to explain how recipients of Acceptance and Commitment Therapy perceived the role of social factors in the development and maintenance of psychological flexibility. An interpretive qualitative design using reflexive thematic analysis was employed. Participants were 24 adults living in Tehran who had completed at least eight sessions of an individual- or group-based Acceptance and Commitment Therapy intervention. Purposive maximum-variation sampling was used to obtain diversity in gender, age, marital status, educational attainment, employment status, presenting concerns, and intervention format. Data were collected through individual semi-structured interviews lasting between 45 and 75 minutes. The interview guide explored perceived changes after the intervention, the influence of family and interpersonal relationships, social norms, economic and occupational conditions, experiences of stigma, and factors facilitating or obstructing values-based action. Meaning saturation was reached after the twenty-first interview, and three additional interviews were conducted to confirm analytical sufficiency. Interviews were audio-recorded, transcribed verbatim, anonymized, and organized and coded using NVivo software. Credibility and dependability were enhanced through participant validation, peer review of coding decisions, constant comparison, reflexive memo writing, maximum-variation sampling, and maintenance of an analytical audit trail. Five main categories were generated: relational support and interpersonal safety as foundations for acceptance; social norms, stigma, and evaluative pressure; economic and occupational pressures restricting opportunities for flexibility; group processes and the therapeutic alliance as a social laboratory for flexibility; and social resources supporting committed action. Supportive relationships increased participants’ willingness to experience difficult thoughts and emotions without avoidance, whereas criticism, controlling relationships, mental health stigma, social comparison, gendered expectations, financial insecurity, and workplace demands impeded the everyday use of ACT skills. Group belonging, normalization of distress, observing peers’ progress, interpersonal accountability, and participation in value-consistent social activities were described as mechanisms that sustained behavioral change. Psychological flexibility emerged as a contextually embedded capacity rather than an exclusively intrapersonal attribute. ACT processes were more likely to generalize beyond therapy when participants experienced relational safety, accessible social resources, and realistic opportunities for values-based behavior. Integrating social-context assessment, culturally responsive metaphors, family or peer involvement, and attention to structural constraints may therefore strengthen the relevance, equity, and durability of acceptance- and commitment-based interventions.
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References
A-Tjak, J. G. L., Davis, M. L., Morina, N., Powers, M. B., Smits, J. A. J., & Emmelkamp, P. M. G. (2015). A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems. Psychotherapy and Psychosomatics, 84(1), 30–36. https://doi.org/10.1159/000365764
Braun, V., & Clarke, V. (2021). One size fits all? What counts as quality practice in reflexive thematic analysis? Qualitative Research in Psychology, 18(3), 328–352. https://doi.org/10.1080/14780887.2020.1769238
Fledderus, M., Bohlmeijer, E. T., Smit, F., & Westerhof, G. J. (2010). Mental health promotion as a new goal in public mental health care: A randomized controlled trial of an intervention enhancing psychological flexibility. American Journal of Public Health, 100(12), 2372–2378. https://doi.org/10.2105/AJPH.2010.196196
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
Grégoire, S., Lachance, L., Bouffard, T., & Dionne, F. (2018). The use of acceptance and commitment therapy to promote mental health and school engagement in university students: A multisite randomized controlled trial. Behavior Therapy, 49(3), 360–372. https://doi.org/10.1016/j.beth.2017.10.003
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour Research and Therapy, 44(1), 1–25. https://doi.org/10.1016/j.brat.2005.06.006
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.
Hennink, M. M., Kaiser, B. N., & Marconi, V. C. (2017). Code saturation versus meaning saturation: How many interviews are enough? Qualitative Health Research, 27(4), 591–608. https://doi.org/10.1177/1049732316665344
Holt-Lunstad, J. (2024). Social connection as a critical factor for mental and physical health: Evidence, trends, challenges, and future implications. World Psychiatry, 23(3), 312–332. https://doi.org/10.1002/wps.21224
Hsu, T., Adamowicz, J. L., & Thomas, E. B. K. (2023). The effect of acceptance and commitment therapy on the psychological flexibility and inflexibility of undergraduate students: A systematic review and three-level meta-analysis. Journal of Contextual Behavioral Science, 30, 169–180. https://doi.org/10.1016/j.jcbs.2023.10.006
Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30(7), 865–878. https://doi.org/10.1016/j.cpr.2010.03.001
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(4), 741–756. https://doi.org/10.1016/j.beth.2012.05.003
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Sage.
Luoma, J. B., Rossi, S. L., Sereda, Y., Pavlov, N., Toussova, O., Vetrova, M. V., Bendiks, S., Kiriazova, T., Krupitsky, E., Lioznov, D., Blokhina, E., Lodi, S., & Lunze, K. (2023). An acceptance-based, intersectional stigma coping intervention for people with HIV who inject drugs: A randomized clinical trial. The Lancet Regional Health–Europe, 28, 100611. https://doi.org/10.1016/j.lanepe.2023.100611
Macri, J. A., & Rogge, R. D. (2024). Examining domains of psychological flexibility and inflexibility as treatment mechanisms in acceptance and commitment therapy: A comprehensive systematic and meta-analytic review. Clinical Psychology Review, 110, 102432. https://doi.org/10.1016/j.cpr.2024.102432
Paliliunas, D., Belisle, J., & Dixon, M. R. (2018). A randomized control trial to evaluate the use of acceptance and commitment therapy to increase academic performance and psychological flexibility in graduate students. Behavior Analysis in Practice, 11(3), 241–253. https://doi.org/10.1007/s40617-018-0252-x
Perry, A., Gardener, C., Shieh, J., Hồ, Q. T., Doan, A., & Bhui, K. (2024). Investigating the acceptability of a culturally adapted acceptance and commitment therapy group for UK Vietnamese communities: A practice-based feasibility study. Transcultural Psychiatry, 61(4). https://doi.org/10.1177/13634615241228071
Prudenzi, A., Graham, C. D., Flaxman, P. E., Wilding, S., Day, F., & O’Connor, D. B. (2022). A workplace acceptance and commitment therapy intervention for improving healthcare staff psychological distress: A randomised controlled trial. PLOS ONE, 17(4), e0266357. https://doi.org/10.1371/journal.pone.0266357
Ruan, J., Cheng, H., Wu, L., Mak, Y. W., Zhang, X., Liang, J., Ma, H., Li, S., & Yeung, W. F. (2023). Perceptions and experiences of acceptance and commitment therapy among people with mental disorders: A qualitative systematic review. Journal of Contextual Behavioral Science, 30, 80–96. https://doi.org/10.1016/j.jcbs.2023.09.003
Tindle, R., Hemi, A., & Moustafa, A. A. (2022). Social support, psychological flexibility and coping mediate the association between COVID-19 related stress exposure and psychological distress. Scientific Reports, 12, 8688. https://doi.org/10.1038/s41598-022-12262-w
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research: A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349–357. https://doi.org/10.1093/intqhc/mzm042
Ye, B., Chen, X., Zhang, Y., & Yang, Q. (2022). Psychological flexibility and COVID-19 burnout in Chinese college students: A moderated mediation model. Journal of Contextual Behavioral Science, 24, 126–133. https://doi.org/10.1016/j.jcbs.2022.04.003
Zancan, R. K., Constantinopolos, L. B., Pankowski, B. E., Bellini, B. D., & Oliveira, M. S. (2023). Acceptance and commitment therapy for university students: A qualitative study. Psicologia: Teoria e Prática, 25(1), ePTPPE14535. https://doi.org/10.5935/1980-6906/ePTPPE14535.en
Zarling, A., Kim, J., Russell, D., & Cutrona, C. (2024). Increasing older adults’ social connectedness: Development and implementation of a web-assisted acceptance and commitment therapy–based intervention. JMIR Aging, 7, e47943. https://doi.org/10.2196/47943
