Psychological flexibility in depression relapse prevention: processes of change and positive mental health in group-based ACT for residual symptoms
Open accessAbstract
Relapse rates following a depressive episode are high, with limited treatments available aimed at reducing such risk. Acceptance and commitment therapy (ACT) is a cognitive-behavioral approach that has gained increased empirical support in treatment of depression, and thus represents an alternative in relapse prevention. Psychological flexibility (PF) plays an important role in mental health according to the model on which ACT is based. This study aimed to investigate the role of PF and its subprocesses in reducing residual symptoms of depression and in improving positive mental health following an 8-week group-based ACT treatment. Adult participants (75.7 % female) with a history of depression, but currently exhibiting residual symptoms (N = 106) completed measures before and after intervention, and at 6 and 12-month follow-up. A growth curve model showed that positive mental health increased over 12-months. Multilevel mediation modeling revealed that PF significantly mediated these changes as well as the reduction of depressive symptoms, and that processes of acceptance, cognitive defusion, values and committed action, in turn, mediated increased PF.
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Lower level of self-as-context is associated with more likely being troubled by negative emotions and experiences in daily life.
“which was also consistent with previous studies (Godbee and Kangas, 2020; Østergaard et al., 2020), suggesting that the lower the level of self-as-context, the more likely the person is going to be troubled by various negative emotions and experiences in daily life.”
From Measuring self-as-context in Chinese college students: Validity and reliability of the Chinese version of self-as-context scale (C-SACS) (2022) · cites this paper as Østergaard et al., 2020
The Introduction (page unavailable) describes self-as-context as creating distance from negative self-identities and cites preliminary findings suggesting it supports mental health. It does not establish that people with lower self-as-context are more likely to be troubled by negative emotions and experiences in daily life. The Discussion (page unavailable) says the study did not measure self-as-context specifically. (LLM, conf=0.84)
Experimental — accuracy not yet measuredIn adults in remission, ACT was associated with lower residual depression after 12 months, mediated by increases in cognitive defusion and psychological flexibility; MBCT increased decentering and predicted lower residual depression after 6 months; MBCT and CBT improved decentering and reduced relapse over 24 months.
“In a recent study with adults experiencing remission, ACT was associated with lower residual depression after 12 months and this was mediated by increases in cognitive defusion and psychological flexibility (40.77 ± 11.9 years)78.”
From Decentering as a core component in the psychological treatment and prevention of youth anxiety and depression: a narrative review and insight report (2021) · cites this paper as [78]
Split into 3 atoms — 2 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredIn adults seeking treatment for anxiety and depression, self-rated decentering increases following CBT, mindfulness-based interventions, and acceptance-based therapies.
“In adults seeking treatment for anxiety and depression, medium-large increases in self-rated decentering are reported following CBT (d = 0.7–0.82) (~43 years)52,73, mindfulness-based interventions (d = 0.6–1.01) (34.49–53.30 years)26,52,74–76 and acceptance-based therapies (d = 0.32–1.85) (37.00–46.40 years)73,77–80.”
From Decentering as a core component in the psychological treatment and prevention of youth anxiety and depression: a narrative review and insight report (2021) · cites this paper as [78]
The Results (Overall Outcomes; page unavailable) report improved cognitive fusion and mindfulness measures after group-based ACT, but do not report self-rated decentering. Searches for “decentering” and the claimed effect-size range found no decentering measure or result in our copy; the paper also does not establish the claimed pattern across CBT, mindfulness-based interventions, and acceptance-based therapies. (LLM, conf=0.76)
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Santoft, F., Salomonsson, S., Hesser, H., Lindsäter, E., Ljótsson, B., Lekander, M., Kecklund, G., Öst, L.-G., & Hedman-Lagerlöf, E. (2019) · Behavior Therapy · doi:10.1016/j.beth.2018.08.005 · Cited by 31 · see citing works
Fergus, T. A. (2015) · Journal of Clinical Psychology · doi:10.1002/jclp.22194 · Cited by 29 · see citing works
Aasen, H. (2001) · NORA - Norwegian Open Research Archives · Cited by 28 · see citing works
Dalrymple, K. L., Morgan, T. A., Lipschitz, J. M., Martinez, J. H., Tepe, E., & Zimmerman, M. (2014) · Behavior Modification · doi:10.1177/0145445513518422 · Cited by 22 · see citing works
Relationships among stress, experiential avoidance and depression in psychiatric patients
Rueda, B., & Valls, E. (2016) · The Spanish Journal of Psychology · doi:10.1017/sjp.2016.32 · Cited by 16 · see citing works
Østergaard, T., Lundgren, T., Rosendahl, I. K., Zettle, R. D., Jonassen, R., Harmer, C. J., Stiles, T. C., Landrø, N. I., & Haaland, V. Ø. (2019) · Frontiers in Psychology · doi:10.3389/fpsyg.2019.01995 · Cited by 11 · see citing works
Østergaard, T., Lundgren, T., Zettle, R., Jonassen, R., Harmer, C. J., Stiles, T. C., Landrø, N. I., & Haaland, V. Ø. (2018) · Trials · doi:10.1186/s13063-018-2515-9 · Cited by 10 · see citing works
Norwegian Acceptance and Action Questionnaire (NAAQ): A psychometric evaluation.
Østergaard, T., Lundgren, T., Zettle, R. D., Landrø, N. I., & Haaland, V. Ø. (2020) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2019.12.002 · Cited by 10 · see citing works
Self-citationMental health among people with psoriasis undergoing patient education in climate therapy
Langeland, E., Robinson, H. S., Moum, T., Larsen, M. H., & Wahl, A. K. (2013) · Scandinavian Journal of Psychology · doi:10.1111/sjop.12073 · Cited by 8 · see citing works
Acceptance and Commitment Theory of Depression
Zettle, R. D. (2015) · Wiley eBooks · doi:10.1002/9781119114482.ch7 · Cited by 8 · see citing works
Acceptance and Mindfulness-Based Interventions
Zettle, R. D., & Gird, S. R. (2016) · doi:10.1093/oxfordhb/9780199973965.013.37 · Cited by 2 · see citing works
Flagged first, then by citations
4 of the 103 references couldn’t be matched to a known paper.
Research works printed but not linked: 1
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Cited by
Sorted by citations
The impact of caring for family members with mental illnesses on the caregiver: a scoping review
Phillips, R., Durkin, M. A., Engward, H., Cable, G., & Iancu, M. (2022) · Health Promotion International · doi:10.1093/heapro/daac049 · Cited by 129 · see citing works
Bennett, M. P., Knight, R., Patel, S., So, T., Dunning, D., Barnhofer, T., Smith, P., Kuyken, W., Ford, T., & Dalgleish, T. (2021) · Translational Psychiatry · doi:10.1038/s41398-021-01397-5 · Cited by 81 · see citing works
Zeifman, R. J., Wagner, A. C., Monson, C. M., & Carhart-Harris, R. L. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.04.105 · Cited by 65 · see citing works
Sloshower, J., Zeifman, R. J., Guss, J., Krause, R., Safi-Aghdam, H., Pathania, S., Pittman, B., & D’Souza, D. C. (2024) · Scientific Reports · doi:10.1038/s41598-024-58318-x · Cited by 65 · see citing works
Dubey, N., Podder, P., & Pandey, D. (2020) · Frontiers in Psychology · doi:10.3389/fpsyg.2020.589365 · Cited by 56 · see citing works
Effect of acceptance and commitment therapy for depressive disorders: a meta-analysis
Zhao, B. T., Wang, Q., Wang, L., Chen, J., Yin, T., Zhang, J., Cheng, X., & Hou, R. H. (2023) · Annals of General Psychiatry · doi:10.1186/s12991-023-00462-1 · Cited by 32 · see citing works
“Depression from an ACT perspective is seen as a consequence of psychological inflexibility, when individuals struggle with inner content such as thoughts and feelings which subsequently limits their ability to cope with emotional stress [30].”
BackgroundBricker, J. B., Levin, M., Lappalainen, R., Mull, K., Sullivan, B., & Santiago-Torres, M. (2021) · JMIR mHealth and uHealth · doi:10.2196/32847 · Cited by 28 · see citing works
“Acceptance has been identified as a core mediator in ACT-based interventions across a wide variety of content areas [16-18].”
BackgroundLindner, C., Kotta, I., Marschalkó, E. E., Szabó, K., Kálcza-Jánosi, K., & Retelsdorf, J. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19095098 · Cited by 29 · see citing works
“Promoting psychological flexibility enables people to shift their focus from symptoms to underlying processes, increasing their mental health [83].”
BackgroundMa, J., Ji, L., & Lu, G. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1050227 · Cited by 16 · see citing works
(2021) · doi:10.1093/oxfordhb/9780197550076.013.9 · Cited by 15 · see citing works
Brandon, S., Pallotti, C., & Jog, M. (2020) · Journal of Contemporary Psychotherapy · doi:10.1007/s10879-020-09468-2 · Cited by 16 · see citing works
“Moreover, studies have indicated potential for ACT in preventing behavioral health concerns in high risk populations and promoting well-being (Dindo et al. 2018; Grègoire et al. 2018; Ostergaard et al. 2020).”
BackgroundMechanisms of change in an Internet-Based ACT study for depression in China
Zhao, C., Ren, Z., Jiang, G., & Zhang, L. (2022) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2022.03.004 · Cited by 14 · see citing works
Fang, S., Huang, M., & Wang, Y. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.1051661 · Cited by 12 · see citing works
“, 2020), and people with depression and anxiety (Østergaard et al., 2020).”
BackgroundResultJo, D., Yang, Y., & Yang, E. (2024) · Cognitive Therapy and Research · doi:10.1007/s10608-024-10534-5 · Cited by 12 · see citing works
“These components might adequately capture how individuals engage with their values and act meaningfully, thereby influencing their men - tal health considerably (Michelson et al., 2011; Østergaard et al., 2020).”
Zhao, Z., Zhao, C., Ren, Z., Shi, C., & Lai, L. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100585 · Cited by 10 · see citing works
Monteiro, F., Pereira, M., Canavarro, M. C., & Fonseca, A. (2021) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2021.701107 · Cited by 8 · see citing works
“Previous studies with acceptance-based interventions in general adult population samples have shown that the enhancement of psychological flexibility mediated the effects of the intervention on positive mental health (37, 38).”
ResultA Systematic Review and Taxonomy of Neuroticism Interventions for the General PublicPreprint
Wright, A. J., Haehner, P., Hopwood, C. J., & Bleidorn, W. (2024) · doi:10.31234/osf.io/jy3eb · Cited by 8 · see citing works
Tunç, E., & Orak, O. S. (2024) · Nurse Education Today · doi:10.1016/j.nedt.2024.106230 · Cited by 7 · see citing works
Kong, Q., Yan, S., Huang, K., Han, B., Han, R., Jiao, Y., Yang, H., Pu, Y., Li, S., & Jia, Y. (2025) · Psychiatry Research · doi:10.1016/j.psychres.2025.116701 · Cited by 6 · see citing works
Taha, S. M., & Elhay, E. S. A. (2022) · Assiut Scientific Nursing Journal · doi:10.21608/asnj.2022.112602.1287 · Cited by 7 · see citing works
“Rumination of unpleasant emotions and related thoughts is an example of psychological inflexibility which has a significant role in the initiation, maintenance, and recurrence of depression (Østergaard et al., 2020).”
BackgroundA Systematic Review and Taxonomy of Neuroticism Interventions for the General Public
Wright, A. J., Haehner, P., Hopwood, C. J., & Bleidorn, W. (2026) · Personality Science · doi:10.1177/27000710261421531 · Cited by 5 · see citing works
Shan, D., Li, S., Xu, R., Huang, J., Wang, Y., Zheng, Y., Huang, S., Song, Y., Han, J., Suto, S., et al. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1096903 · Cited by 5 · see citing works
The Impact of a Creativity Camp Intervention on Depression and Well-Being in Adolescents
Cullen, K. R., DiMaggio-Potter, M. E., Klimes‐Dougan, B., Bernstein, G. A., Koutstaal, W., Reigstad, K. M., Padilla, L. E., Mueller, B. A., Wu, P., Schneck, D. D., et al. (2024) · Child Psychiatry & Human Development · doi:10.1007/s10578-024-01766-3 · Cited by 6 · see citing works
“Standard treatments focus on alleviating symptoms rather than promoting strengths, such as flexibility and resilience in facing life’s challenges [4].”
Jeong, N., Kim, E., & Chun, J. (2024) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2024.100842 · Cited by 4 · see citing works
Wang, C., Zheng, Y., Wang, X., Wang, M., & Yang, X. (2025) · Western Journal of Nursing Research · doi:10.1177/01939459251336042 · Cited by 4 · see citing works
“28,29 According to the psychological flexibility model, psychological flexibility (acceptance, mindfulness) may help patients to open up to unwanted experiences (eg, diabetes symptoms) and not struggle with them when to do this serves one’s goals, which may reduce their depressive symptoms and in…”
Lim, E., Shin, J.-E., & Park, S. (2023) · BMC Public Health · doi:10.1186/s12889-023-15180-2 · Cited by 4 · see citing works
“symptoms, and treatment of COVID-19, the less likely they are to have problems with their mental health [45].”
BackgroundTrait Acceptance Buffers Aggressive Tendency by the Regulation of Anger during Social Exclusion
He, C., Mao, J., Yang, Q., Yuan, J., & Yang, J. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph192214666 · Cited by 5 · see citing works
“It was thought that the acceptance strategy applied through the use of Acceptance and Commitment Therapy (ACT) can improve psychological flexibility [16,42,43], leading to the creation of broader and more flexible behavior options that could aid people in changing or eradicating negative or unwanted events [16,44,45],…”
MethodPenubarthi, S., Reddy, M. V., Donthu, R. K., Guhan, N., Ravindra, A. G., & Bhongir, A. V. (2025) · Indian Journal of Psychological Medicine · doi:10.1177/02537176251363856 · Cited by 2 · see citing works
“Additionally, heterogeneity may be attributed to clinical differences, such as variations in TBI severity, the use studies for each of the secondary outcomes, publication bias was not assessed.”
Williams, J. M., Heath, C., Leightley, D., Murphy, D., & Dymond, S. (2025) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2025.100956 · Cited by 2 · see citing works
Sosic-Vasic, Z., Bergmann, M., & Kroener, J. (2026) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2025.1673223 · Cited by 1 · see citing works
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Padır, M. A., Vangölü, M. S., & MUTLU, Ş. (2023) · Elektronik Sosyal Bilimler Dergisi · doi:10.17755/esosder.1359777 · Cited by 2 · see citing works
Inflexibility, Reactions to Retirement, and Mental Health in Elite Competitors: A Mediation Analysis
Zimmerman, J., Bounds, E. M., Daoust, N., Rowatt, W. C., & Schnitker, S. A. (2024) · Journal for Advancing Sport Psychology in Research · doi:10.55743/000023 · Cited by 1 · see citing works
Grand manuel de psychologie positive
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“…ACT are gradual and cumulative (Hinton & Gaynor, 2010; Stockton et al., 2019), whereas reductions in mood and depressive symptoms often exhibit a lag effect, with robust and sustained improvements typically emerging over a period of time after the end of the intervention (Østergaard et al., 2020).”
Novel Psychological Interventions in the Treatment of Unipolar Major Depression
Patierno, C., Carrozzino, D., & Cosci, F. (2026) · Advances in experimental medicine and biology · doi:10.1007/978-981-95-6872-7_30
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- Authors
- Østergaard, T., Lundgren, T., Zettle, R. D., Landrø, N. I., & Haaland, V. Ø.
- Affiliations
- University of Oslo (NO)
- Karolinska Institutet (SE)
- Wichita State University (US)
- Corresponding author
- Østergaard, Tom
- Lundgren, Tobias
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2020-03-27
- Volume
- 11
- Pages
- 528-528
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC7119364
- OpenAlex
- W3013642457
- Cited by
- 45
- References
- 103
- Citations by year
- 2026: 6 · 2025: 6 · 2024: 11 · 2023: 7 · 2022: 8 · 2021: 5 · 2020: 2
- FWCI
- 2.20
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Holmes Museum Of Anthropology (Wichita State University) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Duo Research Archive (University of Oslo) (submittedVersion, cc-by)
- Funders
- Helse Sør-Øst RHF
- Norges Forskningsråd
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- psychological flexibility, depression relapse prevention, acceptance and commitment therapy, residual depressive symptoms, positive mental health, group therapy, acceptance, cognitive defusion, change processes
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