Acceptance and Commitment Therapy for adults with visible differences: Advancing understanding and developing a self-guided intervention

Zucchelli, Fabio

Abstract

With the centrality of physical appearance in society, having an atypical appearance or ‘visible difference’ as the result of a health condition or injury can cause psychosocial challenges. While some adjust without need for psychological support, many affected individuals struggle with appearance-focused social anxiety, low self-esteem, depression and/or impaired quality of life. Acceptance and Commitment Therapy (ACT), an established transdiagnostic third-wave cognitive-behavioural approach aimed at cultivating psychological flexibility, holds conceptual promise as a method to help affected individuals develop more fulfilling lives unencumbered by appearance concerns. Despite published reports of real-world clinical use of ACT for people adversely affected by visible differences, prior to the research presented in this submission, barely any empirical studies had been published on the topic.
The five first-authored publications presented in this submission collectively sought to advance the empirical and theoretical understanding of how ACT can help individuals adversely affected by visible differences, with the applied goal of developing a testable ACT-based intervention. This work was framed by a pragmatic research paradigm, in which the research agenda is bound to its potential for beneficial social impact. Accordingly, my co-researchers and I progressed to develop a self-guided intervention aimed at maximising its reach to affected individuals. Owing to the methodological flexibility afforded by the pragmatic approach, I used a combination of qualitative and quantitative methods across the five studies, with each being selected based on the studies’ specific goals.
To build a theoretical foundation and provide direction for this work, I first conducted a narrative review of the relevant extant literature and laid out the conceptual rationale for ACT as an approach for the psychosocial difficulties associated with visible difference (paper 1). To better understand the subjective experience of ACT and to understand the clinical considerations of the population, in paper 2 I interviewed individuals with visible differences who had been through a specialist-delivered one-to-one ACT intervention. This study offered new insights into the interpersonal and intrapersonal processes involved in individual ACT therapy. By interpreting participants’ interview data through the lens of ACT theory and established body image models, my analysis also shaped a framework through which to examine the role of potential change processes in relation to appearance-focused behavioural outcomes.
In paper 3 I applied this framework to test two key processes of psychological inflexibility—experiential avoidance and cognitive defusion— as mediators of the relationship between individuals’ appearance evaluation and their behavioural coping strategies. The findings largely supported the hypothesis that these two psychological flexibility processes explain coping behaviours beyond negative appearance evaluations. With a view to developing a novel ACT intervention for the group, these findings offered the first empirical signal that exercises to cultivate acceptance and defusion (the inverse of experiential avoidance and fusion respectively) could disrupt unhelpful behavioural repertoires.
Led by published guidance on developing complex interventions, I adopted a combination of evidence-based, population-centred and modality-specific approaches to develop the intervention. The preceding papers each contributed to the evidence base underpinning the intervention. Owing to the growing ubiquity of smartphones and the increasing use of mobile health apps, I conceived the intervention as a mobile self-guided app, which informed the modality-specific considerations of development.
Following a population-centred approach, I presented stakeholders with the idea of an ACT-based mobile intervention, and when satisfied with its conceptual appeal, progressed to a formal research process in which we gained input from user representatives and specialist clinicians on the key considerations of mobile delivery and the intervention’s design. Using a range of qualitative data collection methods, we analysed the combined data and published the findings in paper 4. Stakeholders’ input offered vital orientation for the intervention’s further development, such as the need to design the intervention to safeguard users’ wellbeing, and preferences for relatable, interactive and actionable content.
Guided by stakeholders’ feedback, the evidence base and published guidance on designing mobile interventions, I then developed a low-cost prototype mobile intervention. In paper 5, I led a single group feasibility study to test the intervention’s proof-of-concept in a group of adults with a range of visible differences. This involved utilising mixed methods to collect data on participants’ programme usage and adherence, and the intervention’s acceptability, preliminary effectiveness and clinical safety. Overall findings established feasibility of the intervention, while also offering important direction for further modification into a full-scale native app. Since publishing paper 5, we have secured external funding to build and evaluate the intervention.
Alongside the five publications, this critical commentary presents the studies in terms of their scientific and real-world context, and their collective contribution to the scientific field of psychological intervention for individuals with visible differences. It also offers a critical examination of the five publications individually and collectively, as well as the surrounding extant literature.

• Thesis Type: Thesis
• Deposit Date: Apr 29, 2022
• Publicly Available Date: Aug 2, 2022
• Public URL: https://uwe-repository.worktribe.com/output/9430882
• Award Date: Aug 2, 2022