An Acceptance and Commitment Therapy Prototype Mobile Program for Individuals With a Visible Difference: Mixed Methods Feasibility Study

Abstract

Background Mobile apps may offer a valuable platform for delivering evidence-based psychological interventions for individuals with atypical appearances, or visible differences, who experience psychosocial appearance concerns such as appearance-based social anxiety and body dissatisfaction. Before this study, researchers and stakeholders collaboratively designed an app prototype based on acceptance and commitment therapy (ACT), an evidence-based form of cognitive behavioral therapy that uses strategies such as mindfulness, clarification of personal values, and value-based goal setting. The intervention also included social skills training, an established approach for increasing individuals’ confidence in managing social interactions, which evoke appearance-based anxiety for many. Objective In this study, the authors aim to evaluate the feasibility of an ACT-based app prototype via the primary objectives of user engagement and acceptability and the secondary feasibility objective of clinical safety and preliminary effectiveness. Methods To address the feasibility objectives, the authors used a single-group intervention design with mixed methods in a group of 36 participants who have a range of visible differences. The authors collected quantitative data via measures of program use, satisfaction ratings, and changes over 3 time points spanning 12 weeks in outcomes, including selected ACT process measures (experiential avoidance, cognitive defusion, and valued action), scales of appearance concerns (appearance-based life disengagement, appearance-fixing behaviors, appearance self-evaluation, and fear of negative appearance evaluation), and clinical well-being (depression and anxiety). Semistructured exit interviews with a subsample of 12 participants provided qualitative data to give a more in-depth understanding of participants’ views and experiences of the program. Results In terms of user engagement, adherence rates over 6 sessions aligned with the upper boundary of those reported across mobile mental health apps, with over one-third of participants completing all sessions over 12 weeks, during which a steady decline in adherence was observed. Time spent on sessions matched design intentions, and engagement frequencies highlighted semiregular mindfulness practice, mixed use of value-based goal setting, and high engagement with social skills training. The findings indicate a good overall level of program acceptability via satisfaction ratings, and qualitative interview findings offer positive feedback as well as valuable directions for revisions. Overall, testing for clinical safety and potential effectiveness showed encouraging changes over time, including favorable changes in appearance-related life disengagement, appearance-fixing behaviors, and selected ACT measures. No iatrogenic effects were indicated for depression or anxiety. Conclusions An ACT-based mobile program for individuals struggling with visible differences shows promising proof of concept in addressing appearance concerns, although further revisions and development are required before further development and more rigorous evaluation.

Body image and appearance distress among military veterans and civilians with an injury-related visible difference: A comparison study

“…These include developing mindfulness to de-identify from thoughts (cognitive defusion) and open-up to painful emotions (experiential acceptance) and helping individuals to clarify their values to inform their actions via goal setting (committed action). Psychologists across Europe have noted the utility of ACT for patients with visible differences (41,42), and there is some empirical research of its effectiveness and suitability in new interventions (Zucchelli et al, 2022). In both groups, engagement in meaningful activities predicted higher body esteem, which is congruent with findings related to BI psychological flexibility; engaging in meaningful activities consistent with one's values and needs arguably equates to the process of committed action (acting towards goals guided by values) that fosters psychological flexibility (45).…”

Peer-Recommended Coping Strategies for Individuals Living With Alopecia Areata

“…These findings were expanded upon by a 2020 study in which Rajoo et al evaluated facilitators and barriers to PA at different stages of individual adjustment. Zucchelli et al (2022) evaluated the appeal and efficacy of an acceptance and commitment therapy-based mobile app amongst individuals with cosmetic health conditions, suggesting value for some individuals. An earlier study by Willemsen et al (2011) supported the use of hypnotherapy as well.…”

A Mixed-Methods Analysis of Mobile ACT Responses From Two Cohorts

“…High attrition rates are common among mHealth interventions ( 19 ). Zucchelli et al noted 53% of participants completed four out of six app-delivered 30-min ACT sessions in a study focused on alleviating psychosocial appearance concerns of those with atypical appearances via ACT ( 20 ). However, 60% of participants reported finding the interventions helpful, 88.6% said they were easy to understand, and exit interviews revealed daily reminders were important in encouraging app usage ( 20 ).…”

“…Zucchelli et al noted 53% of participants completed four out of six app-delivered 30-min ACT sessions in a study focused on alleviating psychosocial appearance concerns of those with atypical appearances via ACT ( 20 ). However, 60% of participants reported finding the interventions helpful, 88.6% said they were easy to understand, and exit interviews revealed daily reminders were important in encouraging app usage ( 20 ). Nevertheless, there is limited research on how best to characterize engagement among mHealth ACT interventions, and more work is needed to understand what predicts greater engagement with digital health interventions.…”