Author’s Accepted Manuscript

Acceptance and commitment training focused on

repetitive negative thinking for clinical psychology
trainees: A randomized controlled trial

Iduar Dereix, Francisco J. Ruiz, Marco A. Sierra,

Andrés Peña-Vargas, Eduar S. Ramírez
www.elsevier.com/locate/jcbs

PII: S2212-1447(18)30330-2
DOI: https://doi.org/10.1016/j.jcbs.2019.02.005
Reference: JCBS296
To appear in: Journal of Contextual Behavioral Science
Received date: 11 December 2018
Revised date: 31 January 2019
Accepted date: 20 February 2019
Cite this article as: Iduar Dereix, Francisco J. Ruiz, Marco A. Sierra, Andrés
Peña-Vargas and Eduar S. Ramírez, Acceptance and commitment training
focused on repetitive negative thinking for clinical psychology trainees: A
randomized controlled trial, Journal of Contextual Behavioral Science,
https://doi.org/10.1016/j.jcbs.2019.02.005
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 ACT focused on RNT 1

Acceptance and commitment training focused on repetitive negative thinking for clinical

psychology trainees: A randomized controlled trial

Iduar Dereix, Francisco J. Ruiz*, Marco A. Sierra, Andrés Peña-Vargas, Eduar S. Ramírez

Fundación Universitaria Konrad Lorenz

[email protected]

[email protected]

[email protected]

[email protected]

[email protected]

*
Correspondence address: Fundación Universitaria Konrad Lorenz, Carrera 9 bis, Nº 62-43,

Bogotá (Cundinamarca, Colombia): Tel.: (+57 1) 347 23 11 ext. 185

Abstract
This parallel randomized controlled trial evaluated the effect of Acceptance and Commitment

Training (ACT) focused on disrupting repetitive negative thinking (RNT) versus a waitlist

control (WLC) in clinical psychology trainees. Ninety-four undergraduate, clinical psychology

trainees of a Colombian university were invited to participate in the study. Eighty-five trainees

agreed to participate and were allocated by means of simple randomization to a group, 6-session
 ACT focused on RNT 2

RNT-focused ACT intervention or the WLC. The ACT training was based on an online program

for emotional disorders. The primary outcomes were measures of emotional symptoms and

valued living, whereas process measures were RNT-related measures. All participants completed

the study. At posttreatment, repeated measures ANOVA showed that the training was efficacious

in reducing emotional symptoms (d = 0.75), depression (d = 0.79), the frequency of behaviors

obstructing valued living (d = 0.51), RNT focused on clinical practice (d = 0.89), and general

RNT (d = 0.62). Larger effect sizes were obtained by participants showing high levels of

emotional symptoms (d = 0.75 to 2.52), with 73.33% of participants obtaining a reliable change

in emotional symptoms, and 66.67% a clinically significant change versus 7.14% for both

indicators in the WLC condition. The training effects were longitudinally mediated by the

reduction of RNT focused on clinical practice at two-thirds of the program. An easy-to-

implement RNT-focused ACT training is effective in reducing emotional symptoms and

promoting valued living in clinical psychology trainees.

Keywords: Acceptance and commitment therapy; Repetitive negative thinking; Clinical

psychology trainees; Emotional symptoms; Values.

1. Introduction

Recent research has shown that professionals in mental health usually suffer from high

levels of emotional symptoms and burnout (e.g., McCormack, MacIntyre, O’Shea, Herring, &

Campbell, 2018; Simionato & Simpson, 2018). Among this type of professionals, trainees often

experience the highest rates of emotional symptoms (Cartwright & Gardner, 2016; Simionato &
 ACT focused on RNT 3

Simpson, 2018). This might be due to the wide range of stressors usually faced by trainees,

which include feelings of incompetence when obtaining unsatisfactory outcomes, having

different opinions from their supervisors, realizing discrepancies between their expectations and

the real clinical practice, frequent switching between different roles, and additional academic

workload (e.g., Cushway, 1992; Cushway & Tyler, 1996; Hill, Sullivan, Knox, & Schlosser,

2007; Kuyken, Peters, Power, Lavender, & Rabe-Hesketh, 2000; Truell, 2001). Indeed, there is

empirical evidence that novice clinical psychology trainees show a higher increase of emotional

symptoms during the first two months of practice than a student control cohort (Ruiz, Dereix, &

Sierra, submitted).

Some studies have explored the psychological factors involved in emotional symptoms

and burnout among mental health professionals. Vilardaga et al. (2011) found that experiential

avoidance, cognitive fusion, and valued living predicted burnout better than work-site factors

among addiction counselors. Similar results were found by Kroska, Calarge, O’Hara, Deumic,

and Dindo (2017) in medical students. Specifically, high levels of experiential avoidance

significantly predicted depression symptoms, emotional exhaustion and depersonalization,

whereas low levels predicted greater personal accomplishment. The inverse pattern of results

was found for values-based behavior: low levels were associated with emotional difficulties, and

high levels with accomplishment. Lastly, Dereix, Ruiz, Cardona-Betancourt, and Flórez

(submitted) showed that repetitive negative thinking (RNT; Ehring & Watkins, 2008) focused on

the clinical practice was a better longitudinal predictor than general RNT and experiential

avoidance of the increase of emotional symptoms experienced by novice clinical psychology

trainees.
 ACT focused on RNT 4

The above-mentioned findings suggest that mindfulness and acceptance-based trainings

might be effective in reducing stress in mental health professionals. Indeed, Rudaz, Twohig,

Ong, and Levin (2017) found 24 studies that analyzed the effect of this type of interventions

including mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1991), mindfulness-based

cognitive therapy (MCBT; Segal, Williams, & Teasdale, 2002), mindful self-compassion (MSC;

Germer & Neff, 2013), and acceptance and commitment therapy (ACT; Hayes, Strosahl, &

Wilson, 1999) in mental health professionals. The authors concluded that there is: (a) some

preliminary support for MBSR in reducing stress, but mixed evidence for burnout and

psychological well-being; (b) MBCT did not show consistent improvements in stress and well-

being; (c) MSC showed no consistent effects on stress; and (d) ACT showed consistent results in

reducing stress, but was not consistent for burnout and psychological well-being. Among the

studies, those testing the effect of ACT trainings used more rigorous methodology. Overall, the

conducted studies have shown some positive preliminary evidence, but further studies with better

methodology and larger sample sizes are required. Of the 24 studies reviewed by Rudaz et al.,

only 9 tested the effect of mindfulness and acceptance-based interventions on clinical

psychology trainees. The results of these studies were promising, but some mixed effects were

found. Importantly, most of the studies showed significant methodological limitations.

The empirical evidence showing the pernicious role of ACT processes (i.e., experiential

avoidance, cognitive fusion, and values-based behaviors; Kroska et al., 2017; Vilardaga et al.,

2011) and RNT (Dereix et al., submitted) in mental health professionals might indicate a way to

improve the psychological trainings designed for them. In this respect, in the last few years, brief

RNT-focused ACT interventions have been developed that have shown to be highly effective in
 ACT focused on RNT 5

emotional disorders (Ruiz et al., 2018; Ruiz, Riaño-Hernández, Suárez-Falcón, & Luciano,

2016).

The RNT-focused ACT interventions were designed by following several analyses based

on relational frame theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), a functional

contextual approach to human language and cognition. These analyses emphasized six relevant

points (Gil-Luciano, Calderón-Hurtado, Tovar, Sebastián, & Ruiz, 2019; Luciano, 2017; Ruiz et

al., 2016; Törneke, Luciano, Barnes-Holmes, & Bond, 2016). Firstly, Ruiz et al. (2016)

suggested that RNT in the form of worry and rumination is a predominant experiential avoidance

strategy because it is the first reaction when the individual undergoes aversive private

experiences. Secondly, RNT tends to prolong and amplify negative affect because it is focused

on negative content (Newman & Llera, 2011; Wells, 2009). Thirdly, the extension of negative

affect provoked by the engagement in prolonged RNT usually leads to engaging in additional

experiential avoidance strategies that are more effective in reducing discomfort (e.g., Caselli et

al., 2013; Nolen-Hoeksema, Stice, Wade, & Bohon, 2007; Wells, 2009). Fourthly, the previous

engagement in RNT tends to extend the relational networks (or the cognitive contents) involved

in the aversive thoughts, which makes experiencing the same or related thoughts that trigger

RNT more probable. Fifthly, the individual develops an inflexible pattern of behavior when

repeating the previous cycle in response to aversive private experiences, which precludes

engagement in values-based behaviors. Lastly, triggers for RNT are usually organized in

hierarchical networks (Gil-Luciano et al., 2019; Luciano, 2017; Ruiz et al., 2016), such that the

triggers at the top of the hierarchy symbolically contain the triggers at lower levels of the

network. According to the previous analysis, the RNT-focused ACT protocols aim to dismantle
 ACT focused on RNT 6

unconstructive RNT patterns in response to the trigger at the top of the hierarchical network of

triggers.

The current study aims to analyze the effect of an RNT-focused ACT protocol in

emotional symptoms and valued living in novice clinical psychology trainees. Due to the

expected variability in the participants, we expected that, for participants with low levels of

emotional symptoms, the intervention would lead to the prevention of the symptom increase that

is often seen in novice trainees and, for participants with high levels of emotional symptoms, to

their reduction. A randomized controlled trial (RCT) was conducted to compare the effect of the

ACT protocol versus a waitlist control (WLC). The RNT-focused ACT training was based on an

online program for emotional disorders (Sierra & Ruiz, submitted) and was implemented in 6

one-hour group sessions. We expected that participants in the RNT-focused ACT group would

show less emotional symptoms and higher valued living at posttreatment than the WLC group.

Additionally, we expected that changes in RNT focused on the clinical practice at the two thirds

of the program would mediate the effect of the intervention on emotional symptoms and valued

living. The CONSORT statement (Moher et al., 2010) was followed to guide the reporting of this

RCT.

2. Method

2.1.Participants

Eligible participants were undergraduates in Psychology at the beginning of their clinical

training. Ninety-four clinical psychology trainees of a Colombian university were invited to

participate in this study. All potential participants were undergraduates enrolled in the 9th

semester (out of 10) in which they develop their clinical practice. Unlike other countries (e.g.,

USA), Colombian laws permit undergraduates in Psychology to receive training in clinical

 ACT focused on RNT 7

psychology and to attend to clients under the guidance of a supervisor. The potential participants

were at the beginning of their clinical practice in the Center of Clinical Psychology of the

university. This center offers inexpensive psychological treatment to the community. All

therapists are students who are individually supervised by a clinical psychologist once a week for

1.5 hours. The students can treat up to 5 patients during the semester.

After explaining the aims of the study, 85 clinical psychology trainees (90.43% of the

trainees approached) agreed to participate in the study and signed the informed consent. No

exclusion criteria were adopted in this study. The mean age of the participants was 23.38 (SD =

2.87; range = 20-33), 79% were women, and most of them were single (87.4%). Participants

were compensated with 20,000 Colombian pesos (approximately 6 US dollars) for completing

the study at the end of the semester.

As we could not select the number of participants a priori according to a power analysis

(i.e., we approached every clinical psychology trainee of the center in a semester), we conducted

a sensitivity analysis with G*Power 3.1.9.2 (Faul, Erdfelder, Lang, & Buchner, 2007). In this

analysis, we computed the minimum effect size that would be identified as statistically

significant with an 80% probability with an alpha error probability of .05 in the option

“ANOVA: Repeated measures, between factors.” We entered 85 in the total sample size, 2 in the

number of groups, 2 in the number of measurements, and 0.5 in the correlation between repeated

measures (this correlation was based on the data from the study by Dereix, Ruiz, Cardona-

Betancourt, et al., submitted, which had a sample and timing of basically the same characteristics

as in this study). According to this analysis, this study was well suited to detect medium effect

sizes (d = 0.53).

2.2.Research design
 ACT focused on RNT 8

A parallel, two-arm RCT was conducted. Simple randomization was conducted following

a 1:1 ratio with the assistance of the web-based tool Research Randomizer (Urbaniak & Plous,

2013). Participants were randomly allocated to the RNT-focused ACT training (N = 43) or to the

WLC (N = 42). The second author generated the random allocation sequence, whereas the first,

fourth and fifth authors enrolled the participants. An assistant, who was not involved in the

recruitment and the application of the intervention, assigned participants to the interventions.

The ACT training was an adaptation of the web-based RNT-focused ACT intervention

for emotional disorders presented by Sierra and Ruiz (submitted). Dependent variables were

divided into primary outcome and process outcomes. The primary outcomes were measures of

emotional symptoms and valued living, whereas process outcomes were measures of general

RNT and RNT focused on the clinical practice. We selected the variable RNT focused on the

clinical practice to analyze its potential role as mediator of the training effects because: (a) the

main goal of the intervention was to disrupt dysfunctional patterns of RNT, and (b) the PTQ-

CPT was shown to be a good longitudinal predictor of emotional symptoms in a study with

clinical psychology trainees with similar characteristics (Dereix, Ruiz, Cardona-Betancourt, et

al., submitted). Thus, we hypothesized that participants who reduced more RNT focused on the

clinical practice at the end of Module 2 of the training (see below) would show greater

intervention effects at posttreatment.

2.3.Outcome measures

Depression Anxiety and Stress Scales – 21

(DASS-21; Lovibond & Lovibond, 1995; Spanish version by Daza, Novy, Stanley, &

Averill, 2002). The DASS-21 is a 21-item, 4-point Likert-type scale (3 = applied to me very

much. or most of the time; 0 = did not apply to me at all) consisting of sentences describing
 ACT focused on RNT 9

negative emotional states experienced during the last week. It contains three subscales

(Depression, Anxiety, and Stress) and has shown good internal consistency and convergent and

discriminant validity. The DASS-21 has good psychometric properties (alpha of .93 in the total

scale) in Colombian samples and a factor structure consisting of three correlated factors

corresponding to the above-mentioned subscales and a general, second-order factor (Ruiz,

García-Martín, Suárez-Falcón, & Odriozola-González, 2017). The hierarchical structure of the

DASS-21 allows obtaining a global score on emotional symptoms by summing all items. Mean

scores on the DASS-total for a nonclinical sample of 894 participants was 19.36 (SD = 12.48),

whereas for a sample of 245 clinical participants, it was 26.87 (SD = 14.53). In this study, the

DASS-21 obtained an alpha of .93 for the total scale. With respect to the subscales, the alphas

were .89, .77, and .84, for Depression, Anxiety, and Stress, respectively.

Valuing Questionnaire

(VQ; Smout, Davies, Burns, & Christie, 2014). The VQ is a 10-item, 7-point Likert (6 =

completely true; 0 = not at all true) self-report instrument designed to assess general valued

living during the past week. The VQ has two subscales: Progress (i.e., enactment of values,

including clear awareness of what is personally important and perseverance) and Obstruction

(i.e., disruption of valued living due to avoidance of unwanted experience and distraction from

values). The Spanish version has shown good psychometric properties. Mean scores obtained on

the VQ in Colombia for general population were 19.5 (SD = 6.43) for Progress and 11.7 (SD =

6.88) for Obstruction, whereas mean scores for a clinical sample (N = 235) were 17.23 (SD =

6.63) and 15.42 (SD = 7.12), respectively. In this study, the VQ obtained alphas of .84 and .90

for Progress and Obstruction, respectively.

2.4.Process outcomes
 ACT focused on RNT 10

Perseverative Thinking Questionnaire

(PTQ; Ehring et al., 2011). The PTQ is a 15-item, 5-point Likert (4 = almost always; 0 =

never) self-report instrument that was designed to evaluate the tendency to engage in RNT when

facing negative experiences or problems in general (i.e., it is a content-independent self-report).

The PTQ has shown excellent internal consistency, high test-retest reliability, and convergent

and predictive validity. As there is no Spanish translation of the PTQ, we back-translated it by

following the guidelines by Muñiz, Elosua, and Hambleton (2013). Preliminary data from our

laboratory indicate that the PTQ possesses excellent internal consistency in Colombia (mean

Cronbach’s alpha of .96) and a one-factor structure. In this study, the PTQ obtained an alpha of

.96.

Perseverative Thinking Questionnaire for Clinical Psychology Trainees

(PTQ-CPT; Dereix, Ruiz, Suárez-Falcón, & Flórez, in press). The PTQ-CPT is a 9-item,

5-point Likert (4 = almost always; 0 = never) self-report instrument that was designed to evaluate

the tendency of clinical psychology trainees to engage in RNT concerning issues of the clinical

practice. It was based on the PTQ and, as such, it is also a content-independent self-report of

RNT. Dereix, Ruiz, Suárez-Falcón, et al. showed that the PTQ-CPT possesses excellent internal

consistency (alpha of .93) and a one-factor structure. In this study, the PTQ-CPT obtained an

alpha of .91.

2.5.RNT-focused ACT

The RNT-focused ACT program (Sierra & Ruiz, submitted) consists of 3 modules with

an approximate duration of 2 hours each (i.e., 6 hours in total) that are designed for application

through a website. Each module consists of several videos, audio files, and exercises. The

program was designed for the treatment of emotional disorders. Three hypothetical characters
 ACT focused on RNT 11

facing a hard time in their lives are introduced in the program to illustrate the concepts of the

RNT-focused ACT interventions implemented in previous studies in vis a vis therapy (Ruiz et

al., 2016, 2018). In order to maintain the transdiagnostic nature of the intervention, none of the

characters shows specific symptomatology; contrarily, the examples are focused on how they

relate to their own thoughts and emotions and what choice they are making at every moment

(i.e., engaging in RNT and other experiential avoidance strategies or in valued behaviors).

The first module of the intervention is entitled “Knowing the problem and finding

solutions” and has the following objectives: (a) Introducing the rationale of the intervention, (b)

Identifying the hierarchy of triggers for RNT and core aspects of the RNT process, (c)

Identifying experiential avoidance strategies that are a consequence of the RNT process, (d)

Introducing and identifying values, (e) Introducing and identifying valued actions, (f)

Introducing learning to choose between engaging in RNT or in valued actions as the alternative,

and (g) Differentiating experientially the engagement in RNT process from the experience of

defusing from thoughts.

The second module is entitled “Developing an observation point of your thoughts.” It has

the following aims: (a) Illustrating and identifying the RNT process in greater detail, (b)

Introducing and practicing the difference between judging and engaging in RNT in response to

external events versus taking a nonjudgmental stance towards them, (c) Illustrating how private

events are influenced by the context and that engaging in RNT can be under voluntary control,

(d) Practicing the skill of noticing the flow of thoughts and focusing attention on a valued

behavior, and (e) Promoting a transcendental and coherent perspective of the self.

Lastly, the third module is entitled “Focusing on what really matters” and has the

following objectives: (a) Illustrating that values can change and evolve throughout time in the
 ACT focused on RNT 12

context of a transcendent self, (b) Exploring the long-term consequences of rigidly engaging in

RNT versus behaving with flexibility towards one’s own values, (c) Establishing goals and

objectives that permit advancing towards one’s own values, (d) Exploring time management and

establishing specific daily activities towards values, (e) Identifying the psychological barriers to

advancing toward values and establishing an agenda for several days focused on advancing

towards previously defined goals, and (f) Summarizing the main contents of the program.

A more detailed description of the program can be seen in Sierra and Ruiz (submitted).

2.6.Procedure

The procedure of this study was approved by the institutional Ethics Committee and it

was conducted between August and October, 2018. The study was presented to potential

participants in the first week of the semester (first week of August) during a general induction to

the procedures of the Center of Clinical Psychology. They were told that the aim of the study

was to analyze the efficacy of a brief ACT training in the emotional adaptation of clinical

psychology trainees to their roles. Also, the presentation emphasized that the training would

provide them with (a) a different, experiential way of approaching ACT, and (b) tools that they

might find helpful during their clinical practice. Participants who signed the informed consent

were given a questionnaire package including the measures mentioned above and a form for

basic sociodemographic information.

The training began two weeks after the recruitment session. It was conducted in 6 weekly

sessions that lasted approximately 1 hour. To increase adherence to the training, the sessions

were conducted after the weekly mandatory trainings in assessment and/or intervention

organized by the Center of Clinical Psychology. These trainings had an approximate duration of

2 hours. When this training ended, the participants in the ACT condition were asked to take a 10-
 ACT focused on RNT 13

minute break and to come back to the room to participate in the session. We emphasized that

participation was voluntary.

Although the RNT-focused ACT intervention was designed to be web-based applied, the

sessions of this study were conducted vis a vis to: (a) prevent access of participants of the WLC

condition to the program (i.e., if web-based applied, we could not guarantee that participants of

the WLC condition would not have followed the program, as all participants worked together in

the same center and shared the computer room for most part of the working day), and (b)

enhance adherence to the program by conducting the sessions in convenient space times (i.e., we

took advantage of the fact that clinical psychology trainees were asked to refrain from

programming clinical sessions during a period of 3 hours to attend to the mandatory trainings).

The sessions were conducted in groups of approximately 15 participants and were led by

two psychologists who were previously trained in the application of the training by the second

author. The psychologists only had a facilitator role because all sessions consisted of viewing

videos, hearing audio files, and responding individually to some exercises. Interaction between

the participants during the sessions was minimal.

All outcome and process measures were administered at pretreatment and posttreatment.

The PTQ-CPT was also administered after finishing Module 2 (i.e., at the beginning of the fifth

session) to analyze the potential longitudinal mediator role of the training effect. Participants in

the RNT-focused ACT condition were considered completers if they attended at least 4 sessions

(i.e., two thirds of the training). The posttreatment measures were administered one week after

finishing the training (approximately two months after the pretreatment measurement, i.e., first

week of October 2018). The participants in the WLC condition began the training afterwards.

2.7.Data analysis
 ACT focused on RNT 14

Prior to conducting the data analyses, all variables were explored for accuracy of data

entry and missing values. Missing data points in the items of the scales were estimated using the

participant’s mean score for the specific scale. No missing data were found after conducting this

estimation. Afterwards, we inspected raw data graphically and identified the outliers, which were

replaced with the next highest value by following the Winsor method (Guttman, 1973). Less than

4% of the data were modified during outlier correction.

Data analyses were conducted with the free software JASP 0.9.1.0 (https://jasp-stats.org/)

and with SPSS 25©. First, independent sample t-tests were conducted to explore the equivalence

of both conditions at pretreatment. Secondly, repeated measures analysis of variance (RM

ANOVA) were computed to analyze the effects of the factors Time (Pretreatment and

Posttreatment) and Condition (RNT-focused ACT training vs. WLC) on all dependent variables.

The effect size for pre-post designs suggested by Morris (2008) was computed on the online

calculator http://www.psychometrica.de/effect_size.html#interpretation (Lenhard & Lenhard,

2016). This effect size is a variation of Cohen’s d which controls for differences of the

conditions at pretreatment and its results can be interpreted as small (d = .20 to .49), medium (d

= .50 to .79), and large (above d = .80) (Cohen, 1988).

As the inclusion of psychologically healthy participants in this type of studies tends to

dilute the intervention outcomes (e.g., Bunce, 1997), we reran the analyses with only the

participants with high levels of emotional symptoms (percentile 65th in the current study in the

DASS-Total score, which corresponded with a score higher than 20). Also, we computed the

reliable change index (RCI) and clinically significant change (CSC) according to the guidelines

provided by Jacobson and Truax (1991) with the data presented for the DASS-Total. The RCI

indicates whether a participant has shown a change score on a psychometric instrument that
 ACT focused on RNT 15

exceeds the reasonably expected change due to measurement error alone. CSC ocurrs when the

participant shows an RCI and his/her score in the instrument that is closer to the nonclinical

average than to the clinical average. Chi-squared tests were conducted to analyze possible

statistically significant differences in the frequency of RCI and CSC between conditions.

Cohen’s ds were obtained from the chi-square value according to the formula presented by

Rosenthal and DiMatteo (2001).

To analyze the potential longitudinal mediating role of RNT focused on the clinical

practice (i.e., PTQ-CPT scores) in the training effects, six independent, simple mediation

analyses were conducted with the nonparametric bootstrapping procedure to estimate direct and

indirect effects using PROCESS 3.1 (Hayes, 2018). In all mediation analyses, condition (i.e.,

ACT vs. WLC) acted as the predictor variable. RNT focused on the clinical practice (i.e., PTQ-

CPT scores) at the end of Module 2 (i.e., the beginning of the fifth session) was entered as the

putative mediator. The outcome measures at posttreatment served as criterion variables (Y).

Lastly, to control for pretreatment scores on the outcome variabes and the mediator variable,

scores in the same type of outcome entered as Y were included as covariates as well as the scores

on the mediator variable (i.e., PTQ-CPT scores). The total effect (c) of type of treatment (X) on

outcome variables (Y) was modeled through two pathways: the direct pathway and the indirect

one. The direct effect (c’) runs from the type of treatment to outcomes without passing through

RNT focused on the clinical practice. The indirect pathway runs from the type of treatment to

outcomes through RNT focused on the clinical practice at the end of Module 2 (ab). Mediation

analysis is mainly based on estimating the indirect pathway (ab) (Hayes & Rockwood, 2017).

Indirect effects were deemed significant if the 95% bias corrected (BC) bootstrap confidence

intervals (CI) for those effects based on 20,000 bootstrapped samples did not include zero. The
 ACT focused on RNT 16

partially standardized indirect effect (abps) was computed as an indicator of the effect size of

mediation. This effect size can be interpreted as the number of standard deviations by which the

outcome is expected to change (increase or decrease) as result of the indirect process analyzed

(Preacher & Kelley, 2011). In simple mediation models, abps has shown satisfactory bias level

(Miočević, O’Rourke, MacKinnon, & Brown, 2018).

3. Results

Figure 1 shows participants’ flow throughout the study. All participants in the ACT

condition attended at least 4 sessions and, thus, were considered as completers. No data were lost

at posttreatment.

3.1.Equivalence of conditions at pretreatment

Table 1 shows the mean scores of each condition at pretreatment. Overall, the scores of

the ACT condition were slightly higher in emotional symptoms and RNT measures, but the

independent sample t-test did not reveal statistically significant differences between conditions

(DASS-Total: t(83) = 1.258, p = .212; Depression: t(83) = 0.238, p = .813; Anxiety: t(83) =

1.360, p = .178; Stress: t(83) = 0.155, p = .877; VQ-Progress: t(83) = -0.086, p = .932; VQ-

Obstruction: t(83) = 0.849, p = .398; PTQ-CPT: t(83) = 1.288, p = .201; PTQ: t(83) = 1.172, p =

.245).

3.2.Pre-post differences in the overall sample

Table 1 also shows that participants in the ACT condition showed a slight decrease in

DASS-Total, Depression, and Anxiety scores, whereas the WLC showed increases in all these

variables. Regarding the Stress scores, the ACT condition showed less increase of these

symptoms at posttreatment than the WLC. The RM ANOVA showed statistically significant
 ACT focused on RNT 17

interaction effects between the factors Time and Condition for the DASS-Total, F(1) = 10.35, p

= .002, and the DASS-Depression, F(1) = 20.77, p < .001, which indicates that participants in the

WLC condition showed a higher increase of symptoms than participants in the ACT condition.

However, there were no statistically significant interaction effects between Time and Condition

for Anxiety, F(1) = 2.76, p = .10, or Stress, F(1) = 1.79, p = .19. The effect sizes were dcorr =

0.75, 0.79, 0.42, and 0.36 for DASS-Total, Depression, Anxiety, and Stress, respectively.

With respect to valued living, the ACT condition showed an increase of progress toward

values (i.e., VQ-Progress scores) and a decrease in obstruction in valued living (VQ-

Obstruction). The WLC condition showed the inverse pattern of pre-post change. The RM

ANOVA showed a statistically significant interaction effect between the factors Time and

Condition for VQ-Obstruction, F(1) = 9.79, p = .002. However, there was no statistically

significant interaction effect between Time and Condition for VQ-Progress, F(1) = 1.45, p =

.231. The effect sizes were dcorr = 0.34 and 0.51 for VQ-Progress and VQ-Obstruction,

respectively.

Participants in the ACT condition showed decreases in RNT focused on the clinical

practice (i.e., PTQ-CPT scores) and general RNT (i.e., PTQ scores), whereas participants in the

WLC showed increases in these variables. We conducted paired t-tests with the ACT condition

to analyze whether the changes in RNT measures were statistically significant. The results

showed that participants in the ACT condition showed a decrease of scores in both the PTQ-

CPT, t(42) = 3.76, p < .001, and the PTQ, t(42) =2.93, p = .005. The RM ANOVA showed

statistically significant interaction effects between the factors Time and Condition for the PTQ-

CPT, F(1) = 11.60, p = .001, and the PTQ, F(1) = 7.01, p = .01. The effect sizes were dcorr = 0.89

and 0.62 for PTQ-CPT and PTQ, respectively.

 ACT focused on RNT 18

3.3.Pre-post differences in participants with high levels of emotional symptoms

Table 2 shows the mean scores of participants with high scores on the DASS-Total at

pretreatment. The ACT condition showed a decrease of scores in all indicators of emotional

symptoms, whereas the WLC condition showed increases. Regarding valued living, the ACT

condition showed an increase in the VQ-Progress and a decrease in VQ-Obstruction, whereas the

opposite pattern was observed for the WLC. Lastly, the ACT condition showed decreases both in

RNT focused on the clinical practice and general RNT, whereas the WLC condition experienced

increases in both indicators. The RM ANOVA revealed statistically significant interaction effects

between Time and Condition for the DASS-Total, F(1) = 14.99, p < .001, dcorr = 2.52; DASS-

Depression, F(1) = 11.91, p = .002, dcorr = 1.21; DASS-Anxiety, F(1) = 5.60, p = .025, dcorr =

1.30; VQ-Progress, F(1) = 5.06, p = .033, dcorr = 1.10;, and VQ-Obstruction, F(1) = 6.12, p =

.020, dcorr = 0.88. The interaction effect for Time and Condition reached marginally significant

levels of the PTQ, F(1) = 4.14, p = .052, dcorr = 1.00. We conducted paired t-tests with the ACT

condition to analyze whether the changes in RNT measures were statistically significant. The

results showed that participants in the ACT condition showed a statistically significant decrease

of scores in the PTQ, t(14) = 2.19, p = .046, but not in the PTQ-CPT, t(14) = 1.57, p = .14.

Table 3 shows the percentages of RCI and CSC for each condition in participants with

high levels of emotional symptoms. In the ACT condition, 11 of the 15 participants showed RCI

(73.33%), and 10 participants (66.67%) showed CSC. These results contrasted with only 1 out of

the 14 participants (7.14%) showing RCI and CSC in the WLC condition. The chi-squared tests

showed that a higher percentage of participants in the ACT condition obtained reliable changes

and clinically significant changes: RCI (2(1) = 13.08, p < .001, d = 1.81) and CSC (2(1) =

10.90, p < .001, d = 1.55). Only 6.67% of the participants in the ACT condition showed
 ACT focused on RNT 19

deterioration of emotional symptoms at posttreatment, whereas 28.57% of participants in the

WLC condition showed deterioration. This seems to indicate that the training did not show harm

or unintended effects.

3.4.Mediation analyses

The mediation analyses conducted with emotional symptoms as dependent variables

showed that RNT focused on the clinical practice (i.e., PTQ-CPT scores) at the end of Module 2

acted as mediator of the condition effect in all cases. Specifically, the indirect effects of

condition on DASS-Total, DASS-Depression, DASS-Anxiety, and DASS-Stress were 3.787 (SE

= 1.410, 95% BC CI [1.342, 6.806]), 0.882 (SE = 0.436, 95% BC CI [.181, 1.884]), 0.909 (SE =

0.462, 95% BC CI [.174, 1.960]), 1.424 (SE = 0.601, 95% BC CI [.329, 2.678]), respectively.

The abps for the same analyses were 0.289 (SE = 0.101, 95% CI [.108, .502]), 0.187 (SE = 0.090,

95% CI [.040, .388]), 0.909 (SE = 0.462, 95% BC CI [.174, 1.960]), and of 1.424 (SE = 0.601,

95% BC CI [.329, 2.678]).

The mediation analyses conducted with valued living scores as dependent variables

showed that RNT focused on the clinical practice at the end of Module 2 acted as mediator of the

condition effect only in VQ-Obstruction. With respect to scores on the VQ-Progress, the indirect

effect of condition on VQ-Progress scores was not statistically significant, with an estimate of -

0.522 (SE = 0.421, 95% BC CI [-1.523, .112]). The abps for this analysis was -0.089 (SE = 0.073,

95% CI [-.264, .019]). Regarding the scores on the VQ-Obstruction, the indirect effect of

condition on VQ-Obstruction scores was statistically significant (path ab), with an estimate of

1.399 (SE = 0.630, 95% BC CI [0.372, 2.835]). The abps was 0.188 (SE = 0.085, 95% CI [.050,

.380]).
 ACT focused on RNT 20

4. Discussion
Mindfulness and acceptance-based trainings have been tested for fostering self-care and

reducing stress in clinical psychology trainees. Specifically, Rudaz et al. (2017) found 9 studies

that tested the effect of this type of interventions on clinical psychology trainees. Overall, the

results were promising, but some mixed effects were found and most of the studies showed

significant methodological limitations.

The current RCT aimed to analyze the effect of a 6-session, group-based, RNT-focused

ACT training versus a waitlist control in emotional symptoms and valued living of clinical

psychology trainees (N = 85). The training was an adaptation of the web-based RNT-focused

ACT intervention for emotional disorders presented by Sierra and Ruiz (submitted), and its

application required minimal training. The ACT training obtained statistically significant effects

at posttreatment on overall emotional symptoms, depression, and obstruction in valued living,

with medium to large effect sizes. Changes in process measures were also statistically

significant, especially for RNT focused on the clinical practice, which showed a large effect size.

Overall, the participants in the WLC condition showed increases of emotional symptoms

throughout the study that were consistent with a previous study with trainees with similar

characteristics (Ruiz, Dereix, et al., submitted).

The effect of the RNT-focused ACT training was greater with participants with high

scores on emotional symptoms. Specifically, the intervention led to statistically significant and

large effect sizes in overall emotional symptoms (d = 2.52), depression (d = 1.21), anxiety (d =

1.30), and values (d = 1.10 and 0.88 for the Progress and Obstruction subscales, respectively).

There were statistically significant differences between conditions in the ratios of reliable change

(ACT: 73.33%, WLC: 7.14%) and clinically significant change (ACT: 66.67%, WLC: 7.14%). It

is worth noting that participants with high scores on emotional symptoms showed increases of
 ACT focused on RNT 21

emotional symptoms and decreases of valued living in the WLC condition, with 28.57% of them

showing a deterioration of emotional symptoms throughout the study. This implies that the

presence of emotional symptoms in trainees does not seem to be a transitory experience and that

implementing RNT-focused ACT trainings might be especially beneficial for this type of

trainees.

The mediation analyses conducted with the whole sample showed that the reduction of

RNT focused on the clinical practice at the end of Module 2 was a statistically significant

mediator of the intervention effect in reducing emotional symptoms and behaviors obstructing

valued living. This is the first mediation analysis of RNT-focused ACT interventions and, as

such, it provides preliminary evidence that this type of intervention works through its main

hypothesized process of change. Further analysis should test whether this finding holds for RNT-

focused ACT interventions implemented in clinical participants and explore other potential

mediators such as measures of experiential avoidance, cognitive fusion or psychological

flexibility.

Some strengths and limitations of the current study are worth mentioning. With respect to

the strengths, the current study is one of the few RCTs conducted with clinical psychology

trainees and mental health professionals (Rudaz et al., 2017). Specifically, the systematic review

conducted by Rudaz et al. identified 9 studies that analyzed the effect of mindfulness and

acceptance-based interventions for clinical psychology trainees. Only one of the studies was an

RCT (Smeets, Neff, Alberts, & Peters, 2014), two were nonrandomized trials (Shapiro, Brown,

& Biegel, 2007; Stafford-Brown & Pakenham, 2012), and the remaining ones were open trials.

Also, the current RCT is the most statistically powered (i.e., largest sample size) of the studies

conducted with clinical psychology trainees. The latter factor is important, given that
 ACT focused on RNT 22

interventions with trainees might be more of a preventive nature, and effect sizes in this type of

studies tend to be smaller than in clinical participants (e.g., Stice, Shaw, Bohon, Marti, & Rohde,

2009). Specifically, this study was well suited to identify medium effect sizes. An additional

strength of the current study is the longitudinal mediation analysis conducted. To our knowledge,

this is the first study with clinical psychology trainees that analyzes the longitudinal mediators of

the intervention effects. Lastly, another strength of this study is that the implementation of the

intervention required minimal training, which facilitates its diffusion. Additional studies might

analyze the effect of the RNT-focused ACT training applied through website, which it is the

original way of applying this intervention (Sierra & Ruiz, submitted).

Regarding the limitations of the study, firstly, the sample of this study consisted of

undergraduate clinical psychology trainees. However, in a good number of countries, training in

clinical psychology is only permitted at postgraduate level, which hinders the generalizability of

the results of this study. Further studies might replicate the results of this study with clinical

psychology trainees at postgraduate level. Secondly, the sample was recruited from only one

university, which also affects the generalizability of the results. Thirdly, no follow-up data was

collected; therefore, we have no evidence of the long-term effects of the RNT-focused ACT

training. Collecting follow-up data in this study was not possible because of the lack of time:

participants were in clinical training for only one additional month. This caused the need to apply

the ACT training to the WLC condition immediately after obtaining the posttreatment data. Also,

raising conclusions from the collection of follow-up data only for the ACT condition at the end

of the semester would be problematic because the number of stressors at the end of the semester

is high and, in the absence of a control condition, the data would be difficult to interpret.

Accordingly, further studies should analyze the long-term effect of the RNT-focused ACT
 ACT focused on RNT 23

training. Lastly, the training was compared to a WLC condition. Although WLC conditions are

thought to control for hope and expectancies for change, they cannot control for the potentially

beneficial effect of unspecific factors such as attention and support (Knock, Janis, & Wedig,

2008). Further studies might analyze the effect of the RNT-focused ACT training versus a

nondirective supportive intervention.

In conclusion, this study adds empirical evidence of the efficacy of an easy-to-apply,

RNT-focused ACT training in decreasing emotional symptoms and improving valued living

through the putative process of change. Further studies might adapt the intervention more tightly

to the stressors faced by trainees and analyze its effect in a web-based format.

Declarations of interest: none

The authors of the manuscript entitled “Acceptance and commitment training focused on repetitive
negative thinking for clinical psychology trainees: A randomized controlled trial” declare that there are no
conflicts of interest.
 ACT focused on RNT 24

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 ACT focused on RNT 31

Table 1 Descriptive Data at Pretreatment and Posttreatment, Results of the Repeated Measures

ANOVA, and Controlled d Effect Size

RNT-focused ACT Wait-list Condition Between-group

differences
Pre Post Pre Post
M M M M F Controlled
(SD) (SD) (SD) (SD) d
Primary outcomes
DASS-Total: 19.16 16.88 16.21 22.02 10.35** 0.75
Emotional symptoms (11.72) (10.56) (9.78) (15.00)
DASS – Depression 4.91 3.02 4.67 6.45 20.77** 0.79
(4.52) (2.86) (4.80) (5.58)
DASS – Anxiety 5.77 5.12 4.62 5.62 2.76 0.42
(3.86) (4.08) (3.93) (5.82)
DASS – Stress 7.12 8.37 6.98 9.71 1.78 0.36
(3.91) (4.89) (4.40) (5.38)
VQ: Valued living – 20.19 20.60 20.29 18.90 1.64 0.34
Progress (5.49) (5.98) (5.21) (5.70)
VQ: Values living – 10.49 10.12 9.14 12.50 9.99** 0.51
Obstruction (7.77) (7.18) (6.80) (7.60)
Process outcomes
PTQ-CPT: RNT in 15.44 11.42 13.50 15.67 11.60** 0.89
clinical practice (6.87) (7.95) (7.03) (10.81)
PTQ: General RNT 24.44 19.19 21.45 23.48 7.01** 0.62
(13.10) (11.68) (10.21) (14.91)
Note. DASS = Depression, Anxiety, and Stress Scales-21; PTQ = Perseverative Thinking Questionnaire; PTQ-CPT
= Perseverative Thinking Questionnaire – Clinical Psychology Trainees; VQ = Valuing Questionnaire.
*p < .05. **p ≤ .01.
 ACT focused on RNT 32

Table 2 Descriptive Data at Pretreatment and Posttreatment, Results of the Repeated Measures
ANOVA, and Controlled d Effect Size for Participants with DASS-Total Scores Higher than 20
at Pretreatment
RNT-focused ACT Wait-list Condition Between-group
differences
Pre Post Pre Post
M M M M F Controlled
(SD) (SD) (SD) (SD) d
Primary outcomes
DASS-Total: 32.47 21.33 27.71 32.93 14.99** 2.52
Emotional symptoms (7.75) (10.42) (4.63) (13.46)
DASS – Depression 9.53 4.73 9.14 9.86 11.91** 1.21
(3.96) (3.06) (5.08) (5.16)
DASS – Anxiety 9.67 6.60 8.57 9.57 5.60* 1.30
(3.13) (3.89) (3.05) (6.38)
DASS – Stress 11.00 9.60 11.57 13.43 2.75 0.97
(2.90) (5.41) (3.72) (4.26)
VQ: Valued living – 18.27 20.40 18.79 16.43 5.06* 1.10
Progress (3.94) (5.93) (4.10) (4.93)
VQ: Values living – 16.60 13.80 13.93 16.36 6.12* 0.88
Obstruction (5.96) (6.05) (5.58) (6.23)
Process outcomes
PTQ-CPT: RNT in 18.13 15.33 18.00 20.36 2.85 0.75
clinical practice (6.30) (7.92) (7.39) (7.39)
PTQ: General RNT 33.27 25.27 28.00 30.14 4.14a 1.00
(11.92) (10.57) (7.56) (12.23)
Note. ap = .052. DASS = Depression, Anxiety, and Stress Scales-21; PTQ = Perseverative Thinking Questionnaire;
PTQ-CPT = Perseverative Thinking Questionnaire – Clinical Psychology Trainees; VQ = Valuing Questionnaire.
*p < .05. **p < .01.
 ACT focused on RNT 33

Table 3 Percentages of reliable change and clinically significant change in DASS-Total score in

participants with DASS-Total > 20 at pretreatment

Improved No change Deteriorated

Reliable Change
ACT 73.33% 20.00% 6.67%
WLC 7.14% 64.29% 28.57%
Clinically Significant Change
ACT 66.67% 26.67% 6.67%
WLC 7.14% 64.29% 28.57%
Note. ACT = Acceptance and commitment therapy; WLC = Waitlist control
 ACT focused on RNT 34

Figure 1. Participants’ flow throughout the study.

 ACT focused on RNT 35

Highlights

 Clinical psychology trainees usually show high levels of emotional symptoms.

 Clinical trial of RNT-focused ACT versus a waitlist control.

 85 trainees were randomly allocated to the experimental conditions.

 The intervention reduced emotional symptoms and behaviors obstructing values.

 Large effect sizes were found in participants with high level of emotional symptoms.