Rector, K., Vilardaga, R., Lansky, L., Lu, Kellie, Bennet, C.L., Ladner, R.E., Kientz, J.A. (2016). Design and Real World Evaluation of Eyes-Free Yoga: An Exer- game for Blind & Low Vision Exercise. Transaccions on Accessible Computing. Read more

People who are blind or low vision may have a harder time participating in exercise due to inaccessibility or lack of encouragement. To address this, we developed Eyes-Free Yoga using the Microsoft Kinect that acts as a yoga instructor and has personalized auditory feedback based on skeletal tracking. We conducted two different studies on two different versions of Eyes-Free Yoga: 1) Controlled study with 16 people who are blind or low vision to evaluate the feasibility of a proof-of-concept, 2) 8-week in-home deployment study with four people who are blind or low vision, with a fully functioning exergame containing four full workouts and motivational techniques. We found that participants preferred the personalized feedback for yoga postures during the laboratory study. Therefore, the personalized feedback was used as a means to build the core components of the system used in the deployment study and was included in both study conditions. From the deployment study, we found that the participants practiced Yoga consistently throughout the 8-week period (Average hours = 17; Average days of practice = 24), almost reaching American Heart Association recommended exercise guidelines. On average, motivational techniques increased participant’s user experi- ence and their frequency and exercise time. The findings of this work have implications for eyes-free exer- game design, including engaging domain experts, piloting with inexperienced users, using musical meta- phors, and designing for in-home use cases.

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McDonell, M.G., Leickly, E., McPherson, S., Skalisky, J., Srebnik, D., Angelo, F. A., Vilardaga, R., Nepon, J.R., Roll, J.M., & Ries, R. (In Press). A randomized controlled trial of ethyl glucuronide-based contingency management for outpatients with co-occurring alcohol use disorders and serious mental illness. American Journal of Psychiatry. Read more

Objective: To determine if a contingency management (CM) intervention targeting alcohol use using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives included determining if CM was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior.
Method: Seventy-nine participants (37% female, 44% non-white) with serious mental illnesses and alcohol dependence who completed a 4-week observation period were randomized to treatment-as-usual and 12-weeks of CM for alcohol abstinence and addiction treatment attendance, or treatment-as-usual and reinforcement only for study participation. Urine alcohol and drug test and self-report outcomes were assessed during the 4-week observation, 12-week intervention, and 3-month follow-up periods.
Results: CM participants were 3.1 times (95% CI: 2.2, 4.5) more likely to submit an alcohol- negative urine test during the 12-week intervention period attaining nearly 3 weeks of additional alcohol abstinence relative to controls. Those who received CM had significantly lower mean EtG levels, and reported less drinking and fewer episodes of heavy drinking, relative to controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up. The CM group was also 2.3 times more likely to submit stimulant-negative drug tests and 2.6 times more likely to submit smoking-negative breath samples, relative to controls.
Conclusions: This is the first randomized controlled trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of CM for alcohol dependence in seriously mentally ill outpatients.

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Karkar, R. Zia, J., Vilardaga, R., Mishra, S.R., Fogarty, J., Munson, S.A. & Kientz, J.A. (2016). A Framework for self-experimentation in personalized health. Journal of the American Medical Informatics Association, 23(3):440-448. doi: 10.1093/jamia/ocv150; PMID: 26644399.Read more

Highlight: Using mobile technology to guide people through self-experimentation to investigate health questions is a feasible and promising approach to advancing personalized health

Objective: To describe an interdisciplinary and methodological framework for applying single case study designs to self-experimentation in personalized health. We examine our framework’s applicability to various health conditions and present an initial case study with irritable bowel syndrome (IBS).

Methods and Materials: An in-depth literature review was performed to develop the framework and to identify absolute and desired health condition requirements for the application of this framework. We developed mobile application prototypes, storyboards, and process flows of our framework using IBS as our case study. We conducted three focus groups and an online survey using a human-centered design approach for assessing our framework’s feasibility.

Results:  All six focus group participants had a positive view about our framework and volunteered to participate in future studies. Most stated they would trust the results because it was their own data being analyzed. They were most concerned about confounds, non-meaningful measures, and erroneous assumptions on the timing of trigger effects. Survey respondents (N = 60) were more likely to be adherent to an 8 versus 12-day study length even if it meant lower confidence results.

Discussion: Implementation of our self-experimentation framework in a mobile application appears to be feasible for people with IBS. This framework can likely be applied to other health conditions. Considerations include the learning curve for teaching self-experimentation to non-experts and the challenges involved in operationalizing and customizing study designs.

Conclusion: Using mobile technology to guide people through self-experimentation to investigate health questions is a feasible and promising approach to advancing personalized health.

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Vilardaga, R., Rizo, J., Kientz, J., McDonell, M.G., Ries, R., Sobel, K. (2016). User experience evaluation of a smoking cessation app in people with Serious Mental Illness, Nicotine & Tobacco Research, 18(5):1032-1038. doi: 10.1093/ntr/ntv256; PMCID: PMC4900234.Read More

Highlight: An user experience evaluation of QuitPal provides guidance and recommendations to tailor smoking cessation apps for individuals with chronic mental illness

Introduction: Smoking rates among people with serious mental illness are 3 to 4 times higher than the general population, yet currently there are no smoking cessation apps specifically designed to address this need. We report the results of a User Experience (UX) evaluation of a National Cancer Institute smoking cessation app, QuitPal, and provide user centered design data that can be used to tailor smoking cessation apps for this population.

Methods: 240 hours of field experience with QuitPal, 10 hours of recorded interviews and task performances, usage logs and a self-reported usability scale, informed the results of our study. Participants were five individuals recruited from a community mental health clinic with a reported serious mental illness history. Performance, self-reports, usage logs and interview data were triangulated to identify critical usability errors and user experience (UX) themes emerging from this population.

Results: Data suggests QuitPal has below average levels of usability, elevated time on task performances and required considerable amounts of guidance. User experience themes provided critical information to tailor smoking cessation apps for this population, such as the importance of breaking down “cessation” into smaller steps and use of a reward system.

Conclusions: This is the first study to examine the UX of a smoking cessation app among people with serious mental illness. Data from this study will inform future research efforts to expand the effectiveness and reach of smoking cessation apps for this highly nicotine dependent yet under-served population.

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Villatte, J.L., Vilardaga, R., Villatte, M., Plumb Vilardaga, J.C., Atkins, D.C., Hayes, S.C. (2016). Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomess, Behaviour Research and Therapy, 77:52-61. doi: 10.1016/j.brat.2015.12.001; PMCID: PMC4752868 Read more

Highlight: Activation and Openness components of Acceptance and Commitment Therapy demonstrate differential improvements in psychiatric symptoms and quality of life with comparable high levels of acceptability, completion and patient satisfaction.

A modular, transdiagnostic approach to treatment design and implementation may increase the public health impact of evidence-based psychosocial interventions. Such an approach relies on algorithms for selecting and implementing treatment components intended to have a specific therapeutic effect, yet there is little evidence for how components function independent of their treatment packages when employed in clinical service settings. This study aimed to demonstrate the specificity of treatment effects for two components of Acceptance and Commitment Therapy (ACT), a promising candidate for modularization. A randomized, nonconcurrent, multiple-baseline across participants design was used to examine component effects on treatment processes and outcomes in 15 adults seeking mental health treatment. The ACT OPEN module targeted acceptance and cognitive defusion; the ACT ENGAGED module targeted values-based activation and persistence. According to Tau-U analyses, both modules produced significant improvements in psychiatric symptoms, quality of life, and targeted therapeutic processes. ACT ENGAGED demonstrated greater improvements in quality of life and values\based activation. ACT OPEN showed greater improvements in symptom severity, acceptance, and defusion. Both modules improved awareness and non-reactivity, which were mutually targeted, though using distinct intervention procedures. Both interventions demonstrated high treatment acceptability, completion, and patient satisfaction. Treatment effects were maintained at 3-month follow up. ACT components should be considered for inclusion in a modular approach to implementing evidence-based psychosocial interventions for adults.

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Pistorello, J., Hayes, S. C., Seeley, J., Biglan, T., Long, D. M., Levin, M. E., Kosty, D., Lillis, J., Villatte, J., MacLane, C., Vilardaga, R., Daflos, S., Hammonds, S., Locklear, A. & Hanna, E. (2016). ACT-based first year experience seminars. Chapter to appear in J. Block-Lerner & L. Cardaciotto (Eds.), The mindfulness-informed educator: Building acceptance & psychological flexibility in higher education. New York: Routledge.Read more

Highlight: An Acceptance and Commitment Training designed to prevent suicidality in college students is acceptable, especially amongst highly distressed students, and leads to increased levels of values-based motivation


Levin, M.E., Luoma, J.B., Vilardaga, R., Lillis, J., Nobles, R., & Hayes, S.C. (In Press) Examining the role of psychological in flexibility, perspective taking and empathic concern in generalized prejudice. Journal of Applied Social Psychology.Read more

Highlight: Strong associations between deficits in flexible connectedness and generalized prejudice amongst college students

Research to-date on generalized prejudice has focused primarily on personality factors. Further work is needed identifying manipulable variables that directly inform anti-prejudice interventions. The current study examined three such variables: empathic concern, perspective taking, and psychological inflexibility/flexibility with prejudiced thoughts, as a test of the flexible connectedness model. A sample of 604 undergraduate students completed online surveys. A model indicated prejudice measures loaded onto a latent variable of generalized prejudice. In a second model, psychological inflexibility, flexibility, empathic concern and perspective taking were all significant, independent predictors of generalized prejudice. Psychological inflexibility also predicted prejudice above and beyond personality and general inflexibility variables. Results suggest the three components of the flexible connectedness model may be important targets for prejudice interventions.

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Zeng, E.Y., Vilardaga, R., Heffner, J.L., Mull, K.E. & Bricker, J.B. (2015). Predictors of utilization of a novel smoking cessation smartphone app. Telemedicine and e-Health.Read more

Highlight: Smoking cessation apps’ effectiveness could be enhanced by focusing on increasing engagement of women, those with lower education, heavy smokers, and those with current depressive symptoms

Background: Understanding the characteristics of high and low utilizers of smartphone apps for smoking cessation would inform development of more engaging and effective apps, yet no studies to date have addressed this critical question. Introduction: Informed by prior research on predictors of cessation website utilization, this study examines the degree to which baseline demographic factors (gender, age and education), smoking-related factors (smoking level and friends’ smoking), and psychological factors (depression and anxiety) are predictive of utilization of a smartphone app for smoking cessation called “SmartQuit.” Methods: Data came from 98 participants randomized to SmartQuit as part of a pilot trial from March to May 2013. We used negative binomial count regressions to examine the relationship between user characteristics and utilization of the app over an 8-week treatment period. Results: Lower education (RR = .492; p = .021), heavier smoking (RR = .613; p = .033), and depression (RR = .958; p = .017) prospectively predicted lower app utilization. Women (RR = .320; p = .022), those with lower education (RR = .490; p = .013), and heavier smokers (RR = .420; p = .039) had lower utilization of app features known to predict smoking cessation. Discussion: Many of the predictors of utilization of smoking cessation apps are the same as those of cessation websites. Conclusions: App-delivered smoking cessation treatment effectiveness could be enhanced by focusing on increasing engagement of women, those with lower education, heavy smokers, and those with current depressive symptoms.

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Lowe, J.M., McDonell, M.G., Leickly, E., Angelo, F.A., Vilardaga, R., McPherson, S., Srebnik, D., Roll, J. & Ries, R. (2015). Determining ethyl glucuronide cut-off when detecting self-reported alcohol use in addiction treatment patients. Alcoholism: Clinical and Experimental Research.Read more

Highlight: Lowe et al FigureEthyl glucoronide levels of 200 ng/ml are an appropiate cut-off level for detection of 24-hours alcohol use among addiction treatment patients

Background: Ethyl glucuronide (EtG) is an alcohol biomarker with potential utility as a clinical research and alcohol treatment outcome. Debate exists regarding the appropriate cutoff level for determining alcohol use, particularly with the EtG immunoassay. This study determined the EtG immunoassay cutoff levels that most closely correspond to self-reported drinking in alcohol-dependent outpatients. Methods: Eighty adults with alcohol dependence and mental illness, taking part in an alcohol treatment study, provided urine samples 3 times per week for up to 16 weeks (1,589 samples). Self-reported drinking during 120 hours prior to each sample collection was assessed. Receiver operating characteristic analyses were conducted to assess the ability of the EtG immunoassay to detect self-reported alcohol use across 24- to 120-hour time periods. Sensitivity and specificity of EtG immunoassay cutoff levels was compared in 100 ng/ml increments (100 to 500 ng/ml) across 24 to 120 hours. Results: Over half (57%) of the 1,589 samples indicated recent alcohol consumption. The EtG immunoassay closely corresponded to self-reported drinking from 24 (AUC = 0.90, 95% CI: 0.88,0.92) to 120 hours (AUC = 0.88, 95% CI: 0.87, 0.90). When cutoff levels were compared across 24 to 120 hours, 100 ng/ml had the highest sensitivity (0.93 to 0.78) and lowest specificity (0.67 to 0.85). Relative to 100 ng/ml, the 200 ng/ml cutoff demonstrated a reduction in sensitivity (0.89 to 0.67), but improved specificity (0.78 to 0.94). The 300, 400, and 500 ng/ml cutoffs demonstrated the lowest sensitivity (0.86 to 0.33) and highest specificity (0.86 to 0.97) over 24 to 120 hours. Conclusions: For detecting alcohol use for >24 hours, the 200 ng/ml cutoff level is recommended for use as a research and clinical outcome.

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Leickly, E., McDonell, M.G., Vilardaga, R., Angelo, F. A., Lowe, J. M., McPherson, S., Srebnik, D., Roll, J.M., & Ries, R. (2015). High levels of agreement between clinic-based ethyl glucuronide (EtG) immunoassays and laboratory-based mass spectrometry. The American Journal of Drug and Alcohol Abuse. doi:10.3109/00952990.2015.1011743 Read more

Highlight: High levels of agreement between clinic-based EtG immunoassays and laboratory based mass spectomerry suggest EtG may be a useful clinical monitoring tool for alcohol use in community based addiction treatment settings

Background: Immunoassay urine drug screening cups that detect use for two or more days are commonly used in addiction treatment settings. Until recently, there has been no comparable immunoassay test for alcohol use in these settings. Objectives: The aim of this study was to assess the agreement of a commercially available ethyl glucuronide immunoassay (EtG-I) test conducted at an outpatient addiction clinic and lab-based EtG mass spectrometry (EtG-MS) conducted at a drug testing laboratory at three cut-off levels. High agreement between these two measures would support the usefulness of EtG-I as a clinical tool for monitoring alcohol use. Methods: Forty adults with co-occurring alcohol dependence and serious mental illnesses submitted 1068 urine samples over a 16-week alcohol treatment study. All samples were tested using EtG-I on a benchtop analyzer and 149 were randomly selected for EtG-MS analysis at a local laboratory. Agreement was defined as the number of samples where EtG-I and EtG-MS were both above or below a specific cut-off level. Agreement was calculated at low cut-off levels (100 and 250 ng/ml), as well as at a higher cut-off level (500 ng/ml) recommended by most by commercial drug testing laboratories. Results: Agreement between EtG-I and EtG-MS was high across all cut-off levels (90.6% at 100 ng/ml, and 96.6% at 250 and 500 ng/ml). Conclusions: EtG immunoassays conducted at low cut-off levels in point-of-care testing settings have high agreement with lab-based EtG-MS. EtG-I can be considered a useful clinical monitoring tool for alcohol use in community-based addiction treatment settings.

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Jones, H., Mercer, L., Wyszynski, C.M., Heffner, J.L., Vilardaga, R., & Bricker, J. B. (2015). Web-Based Acceptance and Commitment Therapy Smoking Cessation Treatment for Smokers With Depressive Symptoms. Journal of Dual Diagnosis, 11(1):56-62. Read more

Highlight: Web-based Acceptance of Commitment Therapy for people who smoke and have depressive symptoms might offer higher levels of receptivity and efficacy than standard web-based treatments

Objective: Smokers with depressive symptoms have more difficulty quitting smoking than the general population of smokers. The present study examines a web-based treatment using acceptance and commitment therapy (ACT) for smokerswith depressive symptoms. The study aimed to determine participant receptivity to the intervention and its effects on smoking cessation, acceptance of internal cues, and depressive symptoms. Methods: Smokers who had positive screening results for depressive symptoms at baseline (n = 94) were selected from a randomized controlled trial (N = 222) comparing web-based ACT for smoking cessation ( with Forty-five participants (48%) completed the three-month follow-up. Results: Compared to, WebQuit participants spent significantly more time on site (p = .001) and had higher acceptance of physical cravings (p = .033). While not significant,WebQuit participants were more engaged and satisfied with their program and were more accepting of internal cues overall. There was preliminary evidence that WebQuit participants had higher quit rates (20% versus 12%) and lower depressive symptoms at follow-up (45% versus 56%) than those in Conclusions: This was the first study of web-based ACT for smoking cessation among smokers with depressive symptoms, with promising evidence of receptivity, efficacy, impact on a theory-based change process, and possible secondary effects on depression. A fully powered trial of the ACT intervention specifically for depressed smokers is needed. This was part of a clinical trial registered as NCT#01166334 at

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Heffner, J.L., Vilardaga, R., Mercer, L.D., Kientz, J.A., & Bricker, J.B. (2015). Feature-level Analysis of a Novel Smartphone Application for Smoking Cessation. The American Journal of Drug and Alcohol Abuse, 41(1):68{73. doi: 10.3109/00952990.2014.977486, PMID: 25397860 Read more

Highlight: Viewing a quit plan and tracking the act of letting “urges to smoke pass” was associated with higher levels of quitting in an exploratory analysis of features of a smoking cessation app

Background: Currently, there are over 400 smoking cessation smartphone apps available, downloaded an estimated 780,000 times per month. No prior studies have examined how individuals engage with specific features of cessation apps and whether use of these features is associated with quitting. Objectives: Using data from a pilot trial of a novel smoking cessation app, we examined: (i) the 10 most-used app features, and (ii) prospective associations between feature usage and quitting. Methods: Participants (n = 76) were from the experimental arm of a randomized, controlled pilot trial of an app for smoking cessation called ‘‘SmartQuit,’’ which includes elements of both Acceptance and Commitment Therapy (ACT) and traditional cognitive behavioral therapy (CBT). Utilization data were automatically tracked during the 8-week treatment phase. Thirty-day point prevalence smoking abstinence was assessed at 60-day follow-up. Results: The most-used features – quit plan, tracking, progress, and sharing – were mostly CBT. Only two of the 10 most-used features were prospectively associated with quitting: viewing the quit plan (p = 0.03) and tracking practice of letting urges pass (p = 0.03). Tracking ACT skill practice was used by fewer participants (n = 43) but was associated with cessation (p = 0.01). Conclusions: In this exploratory analysis without control for multiple comparisons, viewing a quit plan (CBT) as well as tracking practice of letting urges pass (ACT) were both appealing to app users and associated with successful quitting. Aside from these features, there was little overlap between a feature’s popularity and its prospective association with quitting. Tests of causal associations between feature usage and smoking cessation are now needed.

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Theoretical contributions and Reviews

Karkar, R., Fogarty, J., Kientz, J.A., Munson, S.A., Vilardaga, R., & Zia, J. (2015). Opportunities and Challenges for Self-Experimentation in Self-Tracking. In Adjunct Proceedings of the 2015 ACM International Joint Conference on Pervasive and Ubiquitous Computing and Proceedings of the 2015 ACM International Symposium on Wearable Computers (pp. 991-996). New York, NY, USA: ACM. Read more

Highlight: An user experience evaluation of QuitPal provides guidance and recommendations to tailor smoking cessation apps for individuals with chronic mental illness

Personal informatics applications support capture and access of data related to an increasing variety of dimensions of everyday life. However, such applications often fail to effectively support diagnostic self-tracking, wherein people seek to answer a specific question about themselves. Current approaches are therefore difficult, tedious, and error-prone. This workshop paper discusses our ongoing efforts to develop methods for self-experimentation in self-tracking. We examine how self-experimentation situates within existing models of personal informatics processes, discuss our current focus on personal food triggers in patients suffering from Irritable Bowel Syndrome, and highlight open challenges for self-experimentation more broadly.

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Vilardaga, R. & Codd, T. (2015). Perspectives on the nature of being, becoming and reality in contextual behavioral science. Journal of Contextual Behavioral Science, 4(4):213-214. doi:10.1016/j.jcbs.2015.07.002 Read more

Highlight: Introduction to special issue discussing perspectives and controversies around the concept of ontology in contextual behavioral science


Yadavaia, J., Hayes, S. C., & Vilardaga, R. (2014). Using acceptance and commitment therapy to increase self-compassion: A randomized controlled trial. Journal of Contextual Behavioral Science, 3(4):248-257. doi:10.1016/j.jcbs.2014.09.002 Read more

Highlight: Acceptance and Commitment Therapy increases levels of self-compassion and might be of more benefit to those with greater trauma history

Self-compassion has been shown to be related to several types of psychopathology,including traumatic stress, and has been shown to improve in response to various kinds of interventions. Current conceptualizations of self-compassion fit well with the psychological flexibility model, which underlies acceptance and commitment therapy (ACT). However, there has been no research on ACT interventions specifically aimed at self-compassion. This randomized trial therefore compared a 6-hour ACT-based workshop targeting self-compassion to a wait-list control. From pretreatment to 2-month follow-up, ACT was significantly superior to the control condition in self-compassion, general psychological distress, and anxiety. Process analyses revealed psychological flexibility to be a significant mediator of changes in self-compassion, general psychological distress, depression, anxiety, and stress. Exploratory moderation analyses revealed the intervention to be of more benefit in terms of depression, anxiety, and stress to those with greater trauma history.

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Bricker, J.B., Mull, K., Kientz, J., Vilardaga, R., Mercer, L. D., Akioka, K., & Heffner, J.L. (2014). Randomized, controlled pilot trial of a smartphone app for smoking cessation using acceptance and commitment therapy. Drug & Alcohol Dependence, 143:87-94. doi:10.1016/j.drugalcdep.2014.07.006, PMID:25085225. Read more

Highlight: Acceptance and Commitment Therapy is feasible to deliver by smartphone application and shows higher engagement and promising quit rates compared to an application that follows US Clinical Practice Guidelines

Background: There is a dual need for (1) innovative theory-based smartphone applications for smokingcessation and (2) controlled trials to evaluate their efficacy. Accordingly, this study tested the feasibility,acceptability, preliminary efficacy, and mechanism of behavioral change of an innovative smartphone-delivered acceptance and commitment therapy (ACT) application for smoking cessation vs. an applicationfollowing US Clinical Practice Guidelines. Method: Adult participants were recruited nationally into the double-blind randomized controlled pilottrial (n = 196) that compared smartphone-delivered ACT for smoking cessation application (SmartQuit) with the National Cancer Institute’s application for smoking cessation (QuitGuide). Results: We recruited 196 participants in two months. SmartQuit participants opened their applicationan average of 37.2 times, as compared to 15.2 times for QuitGuide participants (p < 0.001). The overall quit rates were 13% in SmartQuit vs. 8% in QuitGuide (OR = 2.7; 95% CI = 0.8–10.3). Consistent with ACT’s theory of change, among those scoring low (below the median) on acceptance of cravings at baseline (n = 88), the quit rates were 15% in SmartQuit vs. 8% in QuitGuide (OR = 2.9; 95% CI = 0.6–20.7). Conclusions: ACT is feasible to deliver by smartphone application and shows higher engagement and promising quit rates compared to an application that follows US Clinical Practice Guidelines. As results were limited by the pilot design (e.g., small sample), a full-scale efficacy trial is now needed.

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Vilardaga, R., Heffner, J.L., Mercer, L.D., & Bricker, J. (2014). Do counselor techniques predict quitting during smoking cessation treatment? A component analysis of telephone-delivered acceptance and commitment therapy. Behaviour Research and Therapy, 61:89-95. doi:10.1016/j.brat.2014.07.008, PMID:25156397, PMCID:PMC4172522. Read more

Highlight: Counselor techniques designed to increase individuals’ awareness and openness to experience reduced the odds of smoking at the next session in a telephone clinical trial of Acceptance and Commitment Therapy

No studies to date have examined the effect of counselor techniques on smoking cessation over the course of treatment. To address this gap, we examined the degree to which the use of specific Acceptance and Commitment Therapy (ACT) counseling techniques in a given session predicted smoking cessation reported at the next session. The data came from the ACT arm of a randomized controlled trial of a telephone-delivered smoking cessation intervention. Trained raters coded 139 counseling sessions across 44 participants. The openness, awareness and activation components of the ACT model were rated for each telephone counseling session. Multilevel logistic regression models were used to estimate the predictive relationship between each component during any given telephone session and smoking cessation at the following telephone session. For every 1-unit increase in counselors’ use of openness and awareness techniques there were 42% and 52% decreases in the odds of smoking at the next counseling session, respectively. However, there was no significant predictive relationship between counselors’ use of activation techniques and smoking cessation. Overall, results highlight the theoretical and clinical value of examining therapists’ techniques as predictors of outcome during the course of treatment.

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Levin, M.E., Luoma, J.B., Lillis, J., Hayes, S.C., & Vilardaga, R. (2014). The acceptance and action questionnaire stigma (AAQ-S): Developing a measure of psychological flexibility with stigmatizing thoughts. Journal of Contextual Behavioral Science, 3(1):21–26. doi: 10.1016/j.jcbs.2013.11.003 Read more

Highlight: The Acceptance and Action Questionnaire – Stigma, is a valid and reliable measure of psychological flexibility with stigmatizing thoughts

The current study sought to develop and test the Acceptance and Action Questionnaire – Stigma(AAQ-S), a measure of psychological flexibility with stigmatizing thoughts. A sample of 604 undergraduate students completed an online survey, which included an initial pool of 43 AAQ-S items as well as measures related to psychological flexibility and stigma. Expert judge ratings and factor analysis were used to identify and refine two distinct subscales; psychological flexibility and psychological inflexibility relating to stigmatizing thoughts. Analyses indicated that the AAQ-S psychological flexibility and inflexibility subscales, as well as a combined total score, correlate with other measures of psychological flexibility and stigma in expected ways, and are more predictive of stigma than a general measure of psychological flexibility. Overall, the results suggest that the AAQ-S could be a useful measure in conducting future estigma research.

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Theoretical contributions and Reviews

Vilardaga, R., Bricker, J., & McDonell, M. (2014). The promise of mobile technologies and single case designs for the study of individuals in their natural environment. Journal of Contextual Behavioral Science, 3(2):148-153. doi:10.1016/j.jcbs.2014.03.003 Read more

Highlight: A review of the opportunities and implications of combining single case designs, mobile technology and novel analytic methods for the experimental study of individuals in their natural environment

Mobile technologies are growing rapidly around the world to broad demographics of society. These technologies hold great promise for their integration with Single Case Designs (SCDs) and the study of individuals in their natural environment. This paper discusses the theoretical, methodological and analytic implications of these tools for the advancement of the contextual behavioral etiology of behavioral disorders, and their remediation. We hope this paper will highlight the scientific advantages of combining mobile technologies and SCDs and encourage their adoption among CBS scientists.

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Roth, W., Vilardaga, R., Wolfe, N., Bricker, J., & McDonell, M. (2014). Practical considerations in the design and development of smartphone apps for behavior change. Journal of Contextual Behavioral Science, 3(4):269-272. doi: 10.1016/j.jcbs.2014.08.006 Read more

Highlight: Guidance and recommendations about the design and development process of smartphone applications for behavior change from both academia and the technology industry

The fast adoption of smartphone applications (apps) by behavioral scientists pose a new host of opportunities as well as knowledge and interdisciplinary challenges. Therefore, this brief report will discuss the lessons we have learned during the development and testing of smartphone apps for behavior change, and provide the reader with guidance and recommendations about this design and development process. We hope that the guidance and perspectives presented in this brief report will empower behavioral scientists to test the efficacy of smartphone apps for behavior change, further advance the contextual behavioral etiology of behavioral disorders and help move the field towards personalized behavior change technologies.

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Vilardaga, R., McDonell, M.G., Leickly, E., & Ries, R. (2014). Ecological momentary assessments in psychosis: A contextual behavioral approach to studying mindfulness and acceptance. In B. Gaudiano (Ed.), Incorporating Acceptance and Mindfulness into the Treatment of Psychosis: Current Trends and Future Directions. Oxford University Press: New York. Read more

Highlight: A review of ecological momentary assessments in psychosis to study mindfulness and acceptance

The purpose of this chapter is to explore the role of assessment from a contextual behavioral science (CBS) perspective. We argue that a more contextual assessment of environmental and behavioral variables is key for the treatment of severe psychopathology. In line with one of the premises of the CBS approach, the development of rules of generalization with precision, scope and depth, we argue that the ecological momentary assessment method (EMA) improves the precision of standard assessment strategies, which will help us understand the contextual behavioral etiology of these disorders. This chapter also presents a brief description of the development of acceptance and mindfulness-based EMA items, discusses the integration of behavioral science and computer science to enhance assessments in this population, and finally illustrates the advantages of the EMA method in a patient diagnosed with paranoid schizophrenia.

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Vilardaga, R. (2014). Technical, practical and analytic innovations in single case designs for contextual behavioral scientists. Journal of Contextual Behavioral Science, 3(2):136-137. Read more

Highlight: Introduction to special issue about the technical, practical and analytic innovations in single case designs for behavioral scientsts


Vilardaga, R., Hayes, S. C., Atkins, D. C., Bresee, C., & Kambiz, A. (2013). Comparing experiential acceptance and cognitive reappraisal as predictors of functional outcome in individuals with serious mental illness. Behaviour Research and Therapy, 51(8):425–433. doi: Read more

Highlight: The use of experiential acceptance skills amongst individuals facing psychotic and stressful experiences might lead to higher levels of quality of life and positive affect

Background: Two psychological regulation strategies to cope with psychotic symptoms proposed by the cognitive behavioral tradition were examined in this study: cognitive reappraisal and experiential acceptance. Although cognitive behavior therapy for psychosis has increasing empirical support, little is known about the role of these two strategies using methods of known ecological validity. Methods: Intensive longitudinal data was gathered from 25 individuals diagnosed with a psychiatric disorder with psychotic features. During the course of six days we measured contextual factors, psychotic and stressful events, psychological regulation strategies and functional outcome. Results: Positive psychotic symptoms and stressful events had negative associations with quality of life and affect, whereas experiential acceptance had positive associations with them. Cognitive reappraisal had inconsistent associations with quality of life and no association with affect. Social interactions and engagement in activities had a positive association with quality of life. Results were supported by additional and exploratory analyses. Conclusions: Across measures of functional outcome, experiential acceptance appears to be an effective coping strategy for individuals facing psychotic and stressful experiences, whereas cognitive reappraisal does not. In order to inform treatment development efforts, results suggest the need to further investigate the role of these psychological regulation strategies using ecologically valid methods.

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McDonell, M., McPherson, S., Vilardaga, R., Srebnik, D., Angelo, F. N., Leickly, E., Saxon, A. J., Roll, J., & Ries, R. (2013). Preliminary findings: Contingency management targeting psychostimulant use results in secondary decreases in smoking for severely mentally ill adults. The American Journal on Addictions, 23(4):407–410. doi: 10.1111/j.1521-0391.2013.12114.x Read more

Highlight: Contingency management targetting psycho-stimulant use, results in secondary decreases in smoking amongst adults with serious mental disorders

Background: Treatments for drug addiction and smoking in severely mentally ill (SMI) adults are needed. Objectives: To investigate the effect of a contingency management (CM) intervention targeting psycho‐stimulant on cigarette smoking. Methods: 126 stimulant dependent SMI smokers were assigned to CM or a non‐contingent control condition. Rates of smoking‐negative (<3 ppm) carbon monoxide breath‐samples were compared. Results: Individuals who received CM targeting psycho‐stimulants were 79% more likely to submit a smoking‐negative breath‐sample relative to controls. Conclusions and Scientific Significance: This study provides initial evidence that a behavioral treatment for drug use results in reductions in cigarette smoking in SMI adults.


Vilardaga, R., Estévez, A., Levin, M.E., & Hayes, S.C. (2012). Deictic Relational Responding, Empathy and Experiential Avoidance as Predictors of Social Anhedonia in College Students. The Psychological Record, 62,409-432. Read more

Highlight: Deficits in perspective taking, emphatic concern and psychological flexibility are associated with social anhedonia, a precursor of psychosis

Social anhedonia has been linked to the development and exacerbation of psychosis. The present study explored the hypothesis that scores in social anhedonia are related to deictic relational responding, empathic concern, and experiential avoidance, as suggested by relational frame theory and acceptance and commitment therapy. College students (N = 110) from a Spanish university completed self-report measures of social anhedonia, empathy, and experiential avoidance. Deictic relational responding was measured by performance on a behavioral task. Sequential multiple regression indicated that deictic relational responding, empathy, andexperiential avoidance have a large relationship size with social anhedonia, accounting for 26% of the total variance, and minimal overlap among each other. These data support the utility of these processes as predictors of social anhedonia, suggesting new psychological targets for its prevention and treatment. The implication of these processes for the development of psychosis should be explored.

Theoretical Contributions and Reviews

Levin, M.E., Hayes, S.C., & Vilardaga, R. (2012). Acceptance and Commitment Therapy: Applying a iterative translational research strategy in behavior analysis. In G. Madden, G.P. Handley, & W. Dube (Eds.). APA Handbook of Behavior Analysis (Vol.2). Washington, DC. American Psychological Association. Read more

Highlight: A description of Acceptance and Commitment Therapy and its iterative translational research strategy

Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is a behavior-analytic model of intervention and behavior change. ACT is grounded in a post-Skinnerian account of language and cognition, relational frame theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), that codeveloped with ACT. ACT and RFT are linked to an elaboration and extension of the traditional behavioranalytic model of how best to build and extend psychological knowledge, which we have termed a contextual behavioral science (CBS) approach (Hayes, Levin, Plumb, Boulanger, & Pistorello, in press; Vilardaga, Hayes, Levin, & Muto, 2009). In this chapter, we describe the ACT model and enough of the underlying theoretical underpinnings and scientific strategy to place data on its impact and change process in the proper context. We link CBS to the challenges faced by an inductive approach in translation and system building.

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Vilardaga, R. (2012). Estigma y Prejuicios. In C. Luciano and M. Páez (Eds.), Terapia de Aceptación y Compromiso: Libro de casos (pp. 251-267). Madrid: Pirámide. Read more

Highlight: Theoretical account of stigma and prejudice from a contextual behavioral perspective

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Villatte, M., Vilardaga, R., & Monestès, J.L. (2012). How the self relates to others when perspective taking is impaired. In L.McHugh, & I. Stewart (Eds.). The Self and Perspective Taking. Oakland: New Harbinger Publications. Read more

Highlight: The consequences of an impaired perspective taking ability are discussed in the area of psychosis


Vilardaga, R., Luoma, J.B., Hayes, S.C., Pistorello, J., Levin, M., Hildebrandt, M.J., Kohlenberg, B., Roget, N. & Bond, F.W. (2011). Burnout among the Addiction Counseling Workforce: The Differential Roles of Mindfulness and Values-based Processes and Worksite Factors. Journal of Substance Abuse Treatment, 40, 323-335. Read more

Highlight: Experiential avoidance, cognitive fusion, and values commitment strongly predict burnout among addiction counselors

Although work-site factors have been shown to be a consistent predictor of burnout, the importance of mindfulness and values-based processes among addiction counselors has been little examined. In this study, we explored how strongly experiential avoidance, cognitive fusion, and values commitment related to burnout after controlling for well-established work-site factors (job control, coworker support, supervisor support, salary, workload, and tenure). We conducted a cross-sectional survey among 699 addiction counselors working for urban substance abuse treatment providers in six states of the United States. Results corroborated the importance of work-site factors for burnout reduction in this specific population, but we found that mindfulness and values-based processes had a stronger and more consistent relationship with burnout as compared with work-site factors. We conclude that interventions that target experiential avoidance, cognitive fusion, and values commitment may provide a possible new direction for the reduction of burnout among addiction counselors.

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Theoretical Contributions and Reviews

Vilardaga, R.& Hayes, S.C. (2011). A Contextual Behavioral Approach to Pathological Altruism. In B. Oakley, A. Knafo, G. Madhavan, & D.S. Wilson (Eds.). Pathological Altruism (pp. 25-37). New York: Oxford University Press. Read more

Highlight: A theoretical account of pathological altruism from a contextual behavioral perspective

In the same way that the process of natural evolution selects features of the human species, the cultural environment selects for patterns of behaviors during the lifetime of an individual or a group. One particular form of human behavior, language, is of great survival value. But language also amplifies the way we experience both the positive and negative aspects of the world. Verbal processes can reinforce behaviors that are damaging for individuals and groups. Some verbal behaviors that may play a role in pathological altruism are experiential avoidance, a conceptualized self, perspective-taking, and values-based action. Acceptance and commitment therapy and Relational Frame Theory lay forth a scientific framework and provide tools to modify such behaviors, which points to their potential utility to reduce pathological altruism.


Plumb, J. & Vilardaga, R. (2010). Assessing Treatment Integrity in Acceptance and Commitment Therapy: Strategies and Suggestions. International Journal of Behavioral Consultation and Therapy, 3, 263-295. Read more

Highlight: Strategies and suggestions to assess treatment integrity in Acceptance and Commitment Therapy and specific examples from two complete coding manuals

In this paper, we briefly review the current literature on treatment integrity and discuss the relevance of this procedure for detecting, measuring and ensuring that the proposed mechanisms of change in cognitive behavior therapy, in this case of acceptance and commitment therapy (ACT; S.C. Hayes, Strosahl, & Wilson, 1999), take place. We discuss aspects such as how to develop an integrity coding system that takes into account the nuances of the ACT model, critical factors when deciding the different processes to include in the coding manual, and suggestions for how to operationalize the distinction between adherence and competence from an ACT perspective. In addition, we also provide more specific guidance about issues as how to select the segments to be coded, the training of those who will code the intervention, and the interrater reliability process. Finally, we provide the reader with a complete example of a treatment integrity coding manual that was specifically adapted for a randomized controlled trial in the treatment of obsessive compulsive disorder (Twohig et al., 2010a). The aim of the current paper is to provide some essential tools for ACT researchers to develop treatment integrity protocols so that they are more encouraged to adopt such methods in their studies.

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Vilardaga, R. & Hayes, S.C. (2010). Acceptance and Commitment Therapy and the Therapeutic Relationship Stance. European Psychotherapy, 9, 117-140. Read more

Highlight: A new theoretical model to conceptualize the therapeutic relationship and a tool for clinicians to foster flexible connectedness

This paper characterizes the ACT therapeutic relationship stance in the context of the findings of the common factors literature and the relationship between therapeutic alliance and outcomes. We describe some foundational aspects of the ACT model (its philosophical set of assumptions, its scientific theory of language and cognition, and its operating system of clinical intervention) and how they form the ACT therapeutic relationship stance. We also provide a possible theoretical model of the therapeutic relationship and a specific exercise to foster it that can be used by clinicians. Overall, we hold the therapeutic relationship as an important component of the therapeutic process and we argue that the ACT model, as a contextual behavioral science strategic approach (VILARDAGA, HAYES, LEVIN, & MUTO, 2009) provides a clearer understanding of the impact of the therapeutic relationship on outcomes, together with a clearer rationale to both improve the therapeutic relationship and research it.


Vilardaga, R., Hayes, S.C., Levin, M. & Muto, T. (2009). Creating a strategy for progress: A contextual behavioral science approach. The Behavior Analyst, 32, 105-133. Read more

Highlight: A proposal for a contextual behavioral science approach with emphasis in the following pivotal features: theory, flexible language systems for applied workers and methodological diversity

Behavior analysis is a field dedicated to the development and application of behavioral principles to the understanding and modification of the psychological actions of organisms. As such, behavior analysis was committed from the beginning to a comprehensive account of behavior, stretching from animal learning to complex human behavior. Despite that lofty goal, basic behavior analysis is having a generally harder time finding academic support, and applied behavior analysis has narrowed its focus. In the present paper we argue that both of these trends relate to the challenge of human language and cognition, and that developments within clinical behavior analysis and the analysis of derived relational responding are providing a way forward. To take full advantage of these developments, however, we argue that behavior analysts need to articulate their unique approach to theory, to develop more flexible language systems for applied workers, and to expand their methodological flexibility. This approach, which we term contextual behavioral science, is meant as an evolutionary step that will allow behavior analysis to better capture the center of modern psychological concerns in both the basic and applied areas. Clinical behavior analysis is showing a way forward for behavior analysis to regain its vision as a comprehensive approach to behavior.

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Vilardaga, R. (2009). A Relational Frame Theory account of empathy. International Journal of Behavioral Consultation and Therapy, 5, 178-184. Read more

Highlight: A Relational Frame Theory account of how empathy has implications for individual’s overall well being and functioning

The current paper proposes a Relational Frame Theory (RFT, Hayes, Barnes-Holmes, & Roche, 2001a) conceptualization of empathy and perspective taking that follows previous literature outlining a relationship between those phenomena and general functioning. Deictic framing, a relational operant investigated by RFT researchers, constitutes the behavioral core of perspective taking and empathic concern towards other individuals. Given (a) the recent evidence supporting the importance of deictic framing in the areas of child development and autism and (b) the reported success of several studies in implementing perspective-taking procedures, it is reasonable to conclude that deictic framing is a psychological process that can play an important role in the development of new interventions that can be extended to the adult population and to other human phenomena, such as social coordination, helping behaviors, stigma/prejudice reduction, and clinical problems.

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Vilardaga, R. & Hayes, S.C. (2009). Experiential avoidance and superstition: Considering concepts in context. Philosophy, Psychiatry, & Pyschology, 15, 269-271. Read more

Highlight: A reply to a critique by Garcia-Montes (2008) in which we defend Acceptance and Commitment Therapy’s use of the technical term experiential avoidance


Hayes, S.C., Yadavaia, J.E., Boulanger, J., Vilardaga, R., Plumb, J., Fletcher, L., Bunting, K., Levin, M., Hildebrandt, M. & Waltz, T. (2007). Applied extensions of behavior principles: Applied behavioral concepts and behavioral theories. In D. Woods & J. Kanter (Eds.), Understanding behavior disorders (pp.47-80). Reno, NV: Context Press. Read more

Highlight: Review of Acceptance and Commitment Therapy as an extension of behavior analysis applied to clinical behavioral disorders

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Vilardaga, R., Hayes, S.C., & Schelin, L. (2007). Philosophical, theoretical and empirical foundations of Acceptance and Commitment Therapy. Anuario de Psicología, 38, 117-128. Read more

Highlight: Review of Acceptance and Commitment Therapy describing its philosophical, theoretical and empirical foundations

This article has two main purposes. The first one is to present the philosophical, theoretical, and empirical underpinnings of Acceptance and Commitment Therapy (ACT). The second is to outline the importance of philosophy and theory in order to build an empirical clinical psychology that copes progressively with the needs of the field. To accomplish these purposes, we have structured the article in three distinct sections. In the first one, we will explore the philosophical assumptions of ACT, known as Functional Contextualism. In the second section, we will offer a brief history of the applied and theoretical tradition of ACT, Behavior Analysis, and Relational Frame Theory (RFT), a modern account of human language and cognition. Finally, we will present some clinical outcomes that, although preliminary, exemplify the broad range of health problems and psychological disorders for which the ACT model has shown to have positive results. Overall we will offer a unified version of the ACT/RFT model that interconnects its multiple dimensions.


Lichtenstein, F. & Vilardaga, R. (2003). Pasos hacia la aproximación entre psicología y cibernética: La obra de Santiago Montserrat (1910-1994). Revista de Historia de la Psicología, 25, 753-764. Read more

Highlight: Historiographical study of Santiago Montserrat, leading Spanish psychiatrist who introduced cibernetics in Spain during the 1950’s

The goal of our essay is to go deeply into the historical relevance on the Catalan Psychology and Psychiatry fields that Dr. Santiago Montserrat Esteve had (1910-1994). Despite the fact that he is such a contemporary figure in his field, his work is partially known, which is why we consider that it deserves a better detailed examination. To underline some main historical facts we are going to focus on two of them. First, the introduction of the Cybernetics in Spain and the General System Theory under the epistemological and clinical views. Secondly, to recognize his influence on some current outstanding psychiatrists who were trained by him, in both clinical and academic senses within the Catalan Psychology and Psychiatry fields. Actually, due to the difficulty we faced in finding enough information about the public track of this character, we have used some interviews conducted by the authors of this essay with professionals who had the chance to collaborate with Dr. Montserrat on several projects, which is why they all are considered to be a vital source of information about this work, as well as the social and historical context this was developed.


Belchi, I., Vilardaga, R., Bados, A. (2002). Cognitive behavioral treatment of a person with adjustment disorder waiting for a lung transplant. Cuadernos de Medicina Psicosomática y Psiquiatría de Enlace, 62/63, 215-232. Read more

Highlight: Case study of a person with adjustment disorder waiting for a lung transplant that receives cognitive behavioral treatment

There are not much controlled studies about the therapeutic outcome of psychological treatment with people waiting lung transplant who suffer from psychological complains. In this article we present the case of a person who has on the waiting list for lungs transplant with an adjustment disorder with anxiety and depressed mood. She needed to reduce her anxiety levels to be ready for the transplant. After the evaluation, cognitive-behavioral intervention was carried out to achieve these objectives. Seven and a half months after starting the intervention, the patient was transplanted. The obtained measures show that the aims of the intervention were reached. A clinical assessment of the case show the maintenance of the client’s quality of life.


Romeo, M., Domínguez, X., Espinal, I., Röper, Ch. & Vilardaga, R. (1997). Study of the behavior of visitors to Barcelona Zoo. In The XXII International Colloquium of Economic Psychology, IAREP, II (pp. 1067-1078), Valencia: Promolibro. Read more

Highlight: Study of visitors to Barcelona Zoo suggests the internal arrangement of animals in the zoo could be improved using marketing principles