Journal of Contextual Behavioral Science 8 (2018) 29–35

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

Empirical research

Improving flexible parenting with Acceptance and Commitment Therapy: A T

case study
⁎
Juan M. Flujas-Contrerasa, Inmaculada Gómezb,
a
University of Almeria. Department Building C, Room 1.31, La Cañada de San Urbano, 04120, Almeria, Andalusia, Spain
b
University of Almeria, College of Enginneering, Room 0.50, La Cañada de San Urbano, 04120, Almeria, Andalusia, Spain

A R T I C LE I N FO A B S T R A C T

Keywords: This paper describes a case study of Acceptance and Commitment Therapy applied to the problems in a mother's
Acceptance and Commitment Therapy interaction with her family. Acceptance and Commitment Therapy is implemented using metaphors and ex-
Adolescent ercises in seven clinical sessions with the mother. Psychological flexibility, experiential avoidance, behavior
Emotion regulation control, acceptance of private events and coherence of valued actions were assessed. The Valued Living
Parenting
Questionnaire was also used. The results show a decrease in control and avoidance behavior. Both mother and
Psychological flexibility
son's acceptance and valued actions increased at the end of the treatment and were maintained at follow-up. The
treatment established a flexible behavioral repertoire not only by the mother, who received direct intervention,
but was also in her son's behavior. The effects of her treatment are reflected in her son, suggesting two-way
psychological flexibility between mother and son.

1. Introduction
Acceptance and Commitment Therapy (ACT) (Hayes, Strosahl, &
Wilson, 2012) is a third-wave contextual therapy which attempts to
induce acceptance of uncomfortable thoughts, psychological flexibility
and change in behavior, moving toward values. Therefore, ACT does
not attempt to change or eliminate private events or symptoms, but
aims to generate acceptance and orient the client toward important
personal values. Psychological flexibility, the ability to act in ac-
cordance with one's values regardless of inner experiences, is the cen-
tral construct of good psychological functioning. It is composed of six
interrelated and connected core processes: (i) acceptance, as the oppo-
site of experiential avoidance and control, an active willingness to come
into contact with private events without making any attempt to change
their frequency or form; (ii) cognitive defusion, which alters the psy-
chological function of private events, changing the way one interacts
with them, (iii) present moment, defined as the ability to be in non-
judgmental contact with psychological and environmental events in the
present; (iv) self as context, a process in which one is aware of the flow
of private events without becoming fused to them; (v) values, important
chosen qualities which cannot be possessed but are present in actions;
and (vi) committed action, the final aim of ACT, to encourage effective
action linked to values (Hayes et al., 2012; Hayes, Luoma, Bond,
Masuda, & Lillis, 2006; Páez, Gutiérrez, Valdivia, & Luciano, 2006).
ACT effectiveness has been demonstrated in family contexts, in which
parents are included in the intervention. Thus in child abuse, it has
lessened maltreatment and improved family interaction quality
(Gómez, Hódar, Barranco, & Martínez, 2012), in adolescent anorexia
nervosa with successful results in reduction of eating disorder symp-
toms and changes in acceptance (Timko, Zucker, Herbert, Rodriguez, &
Merwin, 2015), and in autism, where it achieved better adjustment to
parenting problems (Blackledge & Hayes, 2006; Conner & White, 2014;
Jones, Hastings, Totsika, Keane, & Rhule, 2014). An online ACT group
protocol reduced traumatic barriers in parents of children with lifetime
illnesses (Rayner et al., 2016). However, these studies have not ex-
amined the indirect effects of intervention in children or adolescents
with their parents. Brown, Whittingham, Boyd, McKinlay, and Sofronoff
(2014) found that in a group of parents of children with acquired brain
injury, ACT significantly improved children's emotional symptoms and
parental over-activity, as well as parent-child interaction.
The role of parenting styles and development of psychopathology
have been related as risk and protective factors in adolescent life style,
healthy eating and physical activity habits (Berge, Wall, Loth, &
Neumark-Sztainer, 2010; Martínez, López, Moral, & de la Torre, 2014;
Newland, 2015; Rodrigo et al., 2004), depression (Iglesias & Triñanes,
2009), self-esteem (Alcazar & Parada, 2014), psychopathic traits
(López, Romero, & Villar, 2012), substance abuse problems (Calafat,
Garcia, Juan, Becoña, & Fernández, 2014; Matejevic, Jovanovic, &
Lazarevic, 2014), bullying (León, Felipe, Polo, & Fajardo, 2015;
Prodócimo, Cerezo, & Arense, 2014), stress (de la Torre, Casanova,

⁎
Corresponding author.
E-mail addresses: jfc397@ual.es (J.M. Flujas-Contreras), igomez@ual.es (I. Gómez).

https://doi.org/10.1016/j.jcbs.2018.02.006
Received 5 May 2017; Received in revised form 21 February 2018; Accepted 28 February 2018
2212-1447/ © 2018 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
J.M. Flujas-Contreras, I. Gómez Journal of Contextual Behavioral Science 8 (2018) 29–35

García, Carpio, & Cerezo, 2011) emotional problems (Samuelson, mother's problems in interacting with her family. Our aim was to pro-
Wilson, Padrón, Lee, & Gavron, 2016), aggression and impulsivity vide a guide for family-related ACT interventions, and specifically, to
(Calvete & Gámez, 2014; García & Carpio, 2015), among others. In promote parental flexibility. It was also attempted to provide a vision of
general, maladaptive parenting styles are related to worse psychoe- functional assessment and intervention supported by empirical data.
motional development and wellbeing in childhood and adolescence.
Parenting styles may also be a mediator in adolescent self-destruc-
2. Method
tive behavior and suicide attempts. Several studies have found that
acceptance and affective parenting styles are negatively correlated with
2.1. Patient
psychopathic personality traits (López et al., 2012), just as ambivalent
and controlling parenting styles increase risk of self-destructive beha-
María (M.), the subject of this case study, was a 43-year-old, re-
viors (Burešová, Bartošová, & Čerňák, 2015). Perception of a weaker
cently divorced, upper-middle class Spanish woman. She was mother of
emotional bond, parental control, rejection and weaker family cohesion
two, a 16-year-old boy (Pablo) and a girl, 20. M. sought help at the
increase the probability of suicide ideation and attempts (Cruz, Narciso,
Clinical Research Unit of the University because Pablo (P.) had at-
Muñoz, Pereira, & Sampaio, 2013; Lipschitz, Yen, Weinstock, & Spirito,
tempted suicide two weeks before, attributed to an adolescent percep-
2012). Likewise, family conflicts are a risk factor for developing
tion of parental rejection, loneliness and a feeling of being distanced
avoidance strategies in emotional regulation (Biglan et al., 2015).
from his family. M. reported that P. showed experiential avoidance
The psychological function of parents’ emotions, thoughts and
strategies in peer and family relationships, emotional regulation,
feelings (private events) is important in understanding their relation-
school, etc. She felt that she should be in control of her and her chil-
ship with their children from a contextual perspective. In particular,
dren's lives, but such strategies were increasing her avoidance in her
knowing the development and maintenance of their behavioral re-
family and socioemotional contexts.
pertoire, such as the role of their reaction to the literal content of
A functional assessment showed that M.’s emotional regulation
thoughts (cognitive fusion) in their acts as parents, could lead them to
strategies in her relationships with her children (e.g., parenting diffi-
experiential avoidance in their attempts to deal with distress. Finally, if
culties, family relationships) and in other personal areas (i.e., peer re-
experiential avoidance is maintained, it can be manifested in mala-
lationships, suppressing activities) were based on avoidance and con-
daptive parenting behaviors (Cheron, Ehrenreich, & Pincus, 2009;
trol behaviors. Fig. 1 shows a functional assessment of her behavior, a
Coyne & Wilson, 2004; Whittingham, 2014). In a longitudinal study,
specific analysis of the variables which impact on the patient's behavior
Williams, Ciarrochi, and Heaven (2012) explored the relationship be-
in a three-term contingency (antecedent-behavior-consequence)
tween parenting styles and psychological flexibility in adolescents, and
(Valero & Ferro, 2015). Specifically, M. was avoiding relationships and
found that authoritarian, intrusive, controlling and cold parenting
activities with her children due to the psychological functions of
styles had a negative influence on adolescent psychological flexibility.
thoughts and feelings about experiences with her ex-husband. More-
A study by Brown, Whittingham, and Sofronoff (2015) positively cor-
over, she tried to control her negative feelings and thoughts about her
related experiential avoidance with an ineffective parenting style.
children's behavior, so she was controlled by the literal content of her
Parenting interventions in this context should therefore incorporate
thoughts.
acceptance strategies in facing their discomfort with their child's be-
havior and defusion strategies to offset maladaptive parenting beha-
viors (Coyne & Wilson, 2004; Greco & Eifert, 2004; Simon & Verboon, 2.2. Assessment
2016; Wahler, Rowinski, & Williams, 2008).
This paper describes a case study in which ACT was applied to a To find out the coherence of importance and behavior with values,
the Spanish version of the Valued Living Questionnaire (Wilson &

Fig. 1. Maria's functional assessment.

30
J.M. Flujas-Contreras, I. Gómez Journal of Contextual Behavioral Science 8 (2018) 29–35

Table 1 Table 2
Behaviors and verbalizations appearing on clinical sessions. Metaphors and experiences used during therapy.
Examples of behavior/verbalizationsa Components Session

Fussed thoughts – “I want to be a model for my son” with successive P S A D V C Metaphors and exercises 1 2 3 4 5 6 7 8 F
comparisons with the father. X X X Numbers exercise X X X X X X X X
– “I want to be a good mother and have a good family” X X X X White elephant metaphor X X X X X X X
“Family is supreme” following a sociocultural construction X X Bicycle metaphor X X
of perfect family. X X X Garden metaphor X X X X X X X
– “My son needs to have illusions”. X Mud in the glass metaphor X X X
– “I am realistic with my limitations” to keep her coherence X X X Climbing a Mountain X X X X
with avoidance behavior. metaphor
– “I am a failure as a mother” “I feel weak” “ X X X X X Passengers on a Bus X X X X X
Avoidance – Avoid friend relationship and meetings in areas close to exercise
ex-husband. X X X X Epitaph exercise X
– Take medicine. X X X X X Hug thoughts exercise X
– Go to other city. X X X X X Physicalizing exercise X
– Sign up for a personal growth course. relax X X X X Bubble in the road X
– Delete family photos “It has been like a cleaning” metaphor
Acceptance – “Now we are a family, but different” X X X X Fight with thoughts cards X
– “I have to go with Pablo to his cycling training even if it X X X X X Dyke metaphor X X
hurts me” X X X X Sick person in hospital X
– “I've had a bad time but I'm putting up for my children” refer metaphor
to a specific situation. “I have learned to keep walking with X X X X X Feed the tiger metaphors X X
my discomfort”. X X X X Polygraph metaphor X X X
– Explain the conflict with her ex-husband to her friends and X X X Radio metaphor X X X X X
therapist. She doesn’t avoid this conversation. X X X Paint a room exercise X
– Give independence to her son. X X X X Go for a walk with mind X
Valued action – Meet new friends and expand her personal relationships. exercise
– Visit her family more frequently (sisters). X Mule in the well metaphor X X
– Involved in Pablo's hobbies: learning about technologies. X X X Shops street exercise X
– Go to the beach with her children and take a walk with Pablo X X Pebble in shoe X
at night.
Note: P: present moment; S: self as context; A: acceptance; D: defusion;V: va-
a
Verbalizations are expressed between quotation marks. lues; C: commitment acction.

Luciano, 2002) was applied at the beginning of treatment. Values are
defined as a special class of reinforcement which are more like a di-
rection for action than goals. The importance of values and coherence
between actions and personal values are scored on a 10-point Likert
scale. The Questionnaire has a Cronbach's alpha of .77 (Wilson, Sandoz,
Kitchens, & Roberts, 2010). The Valued Living Questionnaire was
completed by the patient at admission.
The Psychological Flexibility Sheet (Hayes et al., 2012) is a clinical
observational scale for six processes in psychological flexibility: present
moment, self as context, acceptance, cognitive defusion, values and
committed action. It consists of 25 items scored on a 10-point Likert-
type scale. This form was completed at the beginning and at the end of
treatment by the co-therapist based on the patient's report.
An observational behavioral record sheet was kept for her and her
son, including her behavioral repertoire of experiential avoidance and
behavior control, acceptance of thoughts and feelings and frequency of
coherence of actions and personal values, during all the clinical and
video-recorded sessions (later the behavioral record sheet was checked
against the video recordings) by the co-therapist and supervised by the
therapist. Experiential avoidance was recorded as expressions and be-
havior related to escape or avoidance of some thoughts, feeling or
emotions (private events) with negative functions. Behavior control was
recorded as efforts to manage, change or eliminate unpleasant private
events. However, scoring of acceptance of thoughts and feelings was
related to willingness to contact unpleasant private events, i.e. without
making any attempt to change their frequency or form. Finally, we re-
corded coherence of actions and personal values as ongoing actions di-
rected at important personal areas. These behavioral repertoires were
chosen because they are directly related to the aim of the therapy. The
relative frequency of there repertories is recorded each time that M.
performed a clinical relevant behavior during session, referred (verba-
lized) these repertories to some aspect of their life, or the use of a me-
taphor or exercise used in session. The relative frequency of P's behavior
was recorded based on behavioral repertories of experiential avoidance,
control, acceptance and values-related actions reported orally by M.
2.3. Treatment
Based on M.’s functional assessment, ACT was chosen for direct
intervention in experiential avoidance behavior and cognitive fusion of
thoughts and feelings, focusing on reduction of avoidance, increasing
acceptance of emotions, feelings and sensations (private events) and
commitment to behavior change (Table 1), in seven bi-weekly two-hour
clinical sessions for four months, and a follow-up session two months
later. All clinical sessions were videotaped.
The intervention was performed in all clinical sessions by the
therapist. The co-therapist observed, from an observational room
through a mirror, behaviors and verbalizations and registered it in the
instruments described above. Both were experienced ACT practitioners,
family and parenting interventions.
As an idiographic therapy, ACT components, not a session-by-ses-
sion protocol, were followed. The aims of intervention in M. were to: a)
promote a psychologically flexible perspective of the mother role. That
is, to promote her ability to be in contact with unpleasant private events
while interacting with her son, and b) increase valued actions, mainly
in the family. Indirect aims for P. were to: a) promote acceptance of his
emotions and regulate them with psychological flexibility, and b) in-
crease valued actions. We hypothesized that M.’s psychological barrier
functions (behavioral pattern that could impede achievement) were
based on P.’s behavior, so we expected direct intervention with the
mother to spread to the family context, particularly P's emotional and
behavioral regulation.
ACT metaphors and exercises (Wilson & Luciano, 2002) used to
achieve these goals (see Table 2) were presented during treatment when
clinically relevant behavior appeared, so the use of metaphors or ex-
ercises depended on the patient's behavior. After establishing the
therapeutic relationship and the context of therapy, the first step in
treatment was creative hopelessness, that is, coming into touch with
and becoming aware of the strategies regulating her emotions, or ra-
ther, control and avoidance behaviors that were distancing her from her
personal values. Sessions 2 and 3 were directed at clarifying values and

31
J.M. Flujas-Contreras, I. Gómez
identifying barriers involved in her relationship with her family. Some
intervention techniques employed for creative hopelessness were the
“mule in the well” metaphor, the “finger in the dike” metaphor and
“fight with thoughts cards”.
M's main self-regulation strategy for managing her (and her chil-
dren's) emotions, thoughts and feelings was control, which was main-
tained by her self-coherence. To promote open willingness of non-
judgmental awareness and embrace experience of thoughts, emotions
and feelings, we used several metaphors, like “the lie detector”, “the
radio”, “the numbers” or the “white elephant”, when M.’s clinical be-
havior was relevant (aimed at controlling everything, exhaustive plans
for changing something and the need to feel under control require
acting in the direction of values). Then M. understood the paradox of
remembering a thought when she is trying to forget it, and generalized
it by herself. Making M. aware that control and experiential avoidance
are leading her away from her values was a relevant moment in
therapy, which the patient would remember several different times
during it.
Sessions 4–7 were mainly directed at valued actions and commit-
ment as the fundamental pillars of treatment. At the beginning, values
were well clarified, mainly concerning family and emotional relation-
ships, but the strategies were wrong. The “garden metaphor” (Wilson &
Luciano, 2002) was the main treatment technique used in this case to
clarify and organise values hierarchically and define their direction.
This metaphor was used several times during therapy, not only for
values (flowers) but also for barriers and unpleasant private events
(weeds). At the same time, other metaphors, such as “Pebble in shoe” or
“Sick person in hospital” were employed to promote action in spite of
emotional distress. The “Shops on the street” (Wilson & Luciano, 2002)
exercise is described below with explanations that were not made ex-
plicit to the patient in parentheses:
Therapist: “Imagine that you are in a street full of shops (co-
ordination with private events, trying to be aware of her flow of
thoughts) and you are going to catch a train (refers to values). These
shops are very interesting and entice you. Are you going to let them and
go into the shop? Or just look at the windows?”
Maria: “So far, I've gone into the shop.”
T: “It's like the radio (referring to the metaphor) or your feelings,
your thoughts about controlling your children, your feelings of guilt.
You go into the shop and miss the train” (Meaning that while she is
fused to her thoughts she is moving away from her values).
M: “Now I see it (observe her private events, that is, taking per-
spective between her thoughts and her behavior). I look at it and it
hurts me.”
T: “What do you see through the window? Can you describe it?
What colour is it? What shape is it? How does it move?”
M: It's my insecurity (e.g.) … [some description of that thought/
feeling] (this is part of a defusion technique aimed at breaking the link
between thoughts and behavior, taking perspective and giving private
events some physical characteristics) […repeat this exercise in other
shop windows coordinating with other private events]
T: “Sometimes we hide the window (refer to attempts to avoid
private events), but it doesn’t matter if you don’t look at it…”
M: “No, because it's still there.”
T: “Sometimes we try not to look at the window, but the feelings are
still there.”
M: “Yes, but I don’t understand how he can live this way (referring
to P.)”
T: “But can you live with that?”
M: “Yes, because it is in my values…” (She is making sense of her
behavior with acceptance because of her values.)
Aiming at psychological flexibility and acceptance of private events,
the therapist attempted to alter the context in which her thoughts,
emotions and feelings occurred, that is, break with attachment to the
literal content of thoughts. The “go for a walk with your mind” exercise,
for example, or “passengers on a bus” were used for this.
32
Journal of Contextual Behavioral Science 8 (2018) 29–35
Fig. 2. M.’s psychological flexibility scores from Psychological Flexibility Sheet.
Taking perspective to differentiate self from own thoughts, emo-
tions or sensations was another goal. Finally, in Session 9 (follow-up),
M. reported some behavioral achievements concerning values related to
her children and reduction of experiential avoidance related to her ex-
husband and his context (see Table 1). M. also reported some im-
provements in her son toward stronger psychological flexibility.
3. Results
Fig. 2 shows the Values Questionnaire, in which little discrepancy
was observed between importance and consistence. The area of stron-
gest discrepancy was marriage/couples/intimate relations (with 8
points). With regard to the discrepancy between values, M. proposed
some short-term valued actions, mainly concerning family and care of
children. These actions consisted of sharing hobbies with P. (tech-
nology, music), going to cycling training with P., sharing time with the
family, and learning an adequate parenting style (use of reinforcement,
punishment, overprotection, etc.). For personal growth, she proposed
meeting with her friends again, returning to her neighbourhood, con-
tinuing to progress at work, and others.
Fig. 3 shows how M. improved in each component of psychological
flexibility assessed using the Psychological Flexibility Sheet. We found
higher scores on all the components, but the acceptance and cognitive
defusion scores showed the widest difference between pre-test and post-
test, from .6 to 9.3 and from .8 to 8.4, respectively. We found moderate-
to-high effects in committed action (from 1.6 to 8), values (from 3.8 to
8.8) and self as context (from 2.25 to 7.25). The smallest difference was
in the present moment score, from 1.6 to 5.6 points.
Fig. 4 shows that Maria's reports of private event control behavior
decreased from the first (94.44%) to the last session (11.11%). The
opposite occurred with acceptance behavior, i.e., being open to nega-
tive thoughts, which improved from 5.56% to 88.8% in the last session.
Acceptance scores were maintained at the four-month follow-up. Fig. 5
shows Maria's reports of actions approaching values increased from
18.75% to 70% at the end of treatment and this was maintained at
follow-up. Avoidance behavior decreased from 81.25% to 30% (see
examples in Table 1).
Furthermore, Pablo's progress as reported by Maria (Fig. 6) shows
acceptance behavior growing from 0% to 66.6% and control of private
events decreasing from 100% to 33.3%. Fig. 7 shows how avoidance
behavior decreased from 85.7% to 23% at the end and action toward
values increased from 14.2% to 76%. Both are maintained at the four-
mouth follow-up.
J.M. Flujas-Contreras, I. Gómez Journal of Contextual Behavioral Science 8 (2018) 29–35

Baseline Treatment Follow-up

100

90

80

70

PERCENTAGE OF BEHAVIORS
60

50

40

30

20

10

0
1 2 3 4 5 6 7 8 9
SESSION

Avoidance Valued acts

Fig. 5. M.’s expressions of her avoidance and values acts behavioral repertoire.
Fig. 3. Values questionnaire scores.
Baseline Treatment Follow-up
100
Baseline Treatment Follow-up
100
90
90
80
80
70
PERCENTAGE OF BEHAVIORS

70
PERCENTAGE OF BEHAVIORS

60
60
50
50
40
40
30
30
20
20
10
10
0
0 1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9 SESSION
SESSION
Control Acceptance
Control Acceptance
Fig. 6. M's expressions of P.’s control and acceptance behavioral repertoire.
Fig. 4. M.’s expressions of her control and acceptance behavioral repertoire.

In view of the above, it may be concluded that an ACT treatment

4. Discussion
Maria (M) progressed positively and consistently with the treat-
ment, which generated acceptance of negative emotions, thoughts and
feelings at the same time she began acting in the direction of her values.
Her parenting style qualitatively improved, enriching her relationship
with her children, as she stimulated and took an active part in Pablo's
hobbies. She was able to provide educational guidance (making ap-
propriate rules, enforcing limits, establishing secure attachment, etc.),
has got back in touch with old friends, and has even started a new
relationship, while accepting discomfort and doubt.
directed at improving the mother's psychological flexibility was asso-
ciated with positive effects in her son's behavioral functioning. This is
coherent with the literature, which suggests two-way psychological
flexibility between parents and children (Biglan et al., 2015). Based on
his mother's report, Pablo has improved in school (passing all subjects),
has renewed friendships beyond their previous context (limited to
hobbies), spends time with his mother and sister, helps with housework,
and eats with his mother. He has started to take his relationship with his
father into perspective (relations with his father are good, and he has
learned how to place limits and conditions, etc.) and he has improved in
emotional regulation (talks about his discomfort with his mother, seeks

33
J.M. Flujas-Contreras, I. Gómez
Baseline Treatment
100
90
80
70
PERCENTAGE OF BEHAVIORS
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8
SESSION
Avoidance Valued acts
Fig. 7. M's expressions of P.’s avoidance and values acts behavioral repertoire.
solutions and acts sensibly when his father disappoints him). Other
studies that apply ACT in parents of children with health or psycholo-
gical problems have demonstrated two-way development of flexible
strategies even when the treatment was applied only in parents, al-
though in a small sample (Brown et al., 2014; Rayner et al., 2016).
Psychological inflexibility and experiential avoidance may be
manifested in maladaptive parenting behaviors that affect the child's
psychoemotional development (Cheron et al., 2009; Coyne & Wilson,
2004; Whittingham, 2014). A study by Brassell et al. (2016) found that
the parent's general psychological flexibility was associated with
adaptive parenting practices, eventually lessening internalization and
externalization problems in children. Psychological flexibility has been
found to be a protective factor in affective disorders (Kashdan &
Rottenberg, 2010), chronic pain (McCracken & Gutiérrez, 2011;
McCracken & Velleman, 2010), working context (Bond & Flaxman,
2006; Bond, Flaxman, & Bunce, 2008), substance abuse (Luoma, Drake,
& Kohlenberg, 2011) and eating disorders (Masuda, Hill, Tully, &
Garcia, 2015), and therefore, additional research in psychological
flexibility in parents as preventive intervention for children and youth
is important.
This study has some limitations, like the absence of validated scales
for assessing avoidance behavior beyond clinical evaluation during the
sessions and pre-post treatment, a longer baseline stage to provide a
stable response pattern and direct continuous assessment of P's beha-
vior. The ratings completed by the co-therapist could be biased, a blind
assessor could improve the validity of results. In addition, the limita-
tions of the design itself: no control group and limited generalizability.
Other case studies should be done to generalize the results.
Nevertheless, this case may be used as a guide for ACT parenting
intervention, taking into account the importance of idiographic func-
tional assessment and framing metaphors and exercises around the
patient's behavior. The treatment established a flexible behavioral re-
pertoire not only in the mother, who received direct intervention, but
was also generalized to the family context. This case study provides
additional evidence in the same direction as other research in con-
textual therapy for parents (Ben-Porath, 2010; Biglan, 1989; Blackledge
& Hayes, 2006; Coyne & Wilson, 2004; Gauntlett-Gilbert, Connell,
Clinch, & McCracken, 2013; Gómez et al., 2012; Simon & Verboon,
2016; Wicksell, Kanstrup, Kemani, Holmström, & Olsson, 2015)
Journal of Contextual Behavioral Science 8 (2018) 29–35
Follow-up Compliance with ethical standards
Funding: This study was not funded.
Ethical approval: All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
Informed consent: Informed consent was obtained from all in-
dividual participants included in the study.
Conflict of interest
No conflict of interest is declared by the authors.
Submission declaration and verification
The present manuscript has not been published previously and it is
not under consideration for publication other scientific journals but
Journal of Contextual Behavioral Science.
9
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