Acceptance and Commitment Therapy Based Psychoeducation Group for Test Anxiety: A Case Study of Senior High School Students

Yayın Tarihi: 20.02.2020 Abstract The purpose of this study was to investigate the effectiveness of Acceptance and Commitment Therapy (ACT) based psycho-educational group on test anxiety of high school students. The participants were six senior high school students with high level of test anxiety and all of the participants were female. They were selected by multi-stage sampling method. Psycho-educational group was designed to include six processes of psychological flexibility/inflexibility, that is the core concept of ACT; and it lasted six weeks by 90 minutes per week. Participants were interviewed before and after the psychoeducation group. The content analysis was applied and the findings of ACT-based psychoeducation program revealed that participants’ test anxiety and psychological inflexibility level as well as how they handle the problem have changed as a result of this psycho-educational group process. The participants also stated that their definition of test anxiety problem have changed after the group process. Implications and suggestions for future research and


Introduction
Currently, schools, exams and tests are some of the most important components of student life (Mcllroy & Bunting, 2002). Tests are among the most common evaluation methods to measure student achievement. The high competition in education has increased the pressure on students and increased the level of test anxiety. Test anxiety is described as an undesirable feeling full of physiological and behavior indication and comes out in an evaluative testing condition (Dusek, 1980). Another current definition is provided by Akinsola and Nwajei (2013) that examination, by itself, causes anxiety in students especially when they attach high importance to the exam and they consider it as difficult; and also they do not have enough preparation for it.
Test anxiety is a common problem for people at all education levels (Gibson, 2014). Even though the literature states that test anxiety begins even in childhood, when children face any evaluative process, it is also an enduring problem for college students (Akinsola & Nwajei, 2013;Dodeen, 2009) and continues during their education years until adulthood (Gibson, 2014). In his current research, Cassady (2010) stated that test anxiety is typical for nearly 40% students in school settings. The literature is very rich in terms of the test anxiety research of different countries. Although the type of exam changes, the consequences do not; that is, test anxiety influences students' academic performance in a negative way (Brooks, Alshafei & Taylor, 2015;Cassady, 2010;Eum & Rice, 2011;Hembree, 1988;Sarason, 1980;Zeidner, 1998).
Test anxiety includes three components: cognitive, affective and behavioral (Zeidner, 1998). The cognitive side includes worrisome thoughts about exams, concentration problems and making recall difficult; the affective side is related to emotions such as a heightened state of emotional arousal, fear, panic and mistrust; and the behavioral side compromises bodily reactions such as the sensations of tachycardia, heart palpitations, shallow breathing, numbness of tingling in hands/feet or upset stomach during a test-anxiety-provoking event. The behavioral symptoms also include avoidant behaviors typically associated with test anxiety such as avoiding talking/thinking about the test, and avoiding studying by procrastinating. Moreover, test anxiety can emerge when an evaluative process is approaching. It can be felt before, during or after the exam (Cassady, 2004). Therefore, it is considered a situation-specific concept varying from person to person (Spielberger & Vagg, 1995). No matter which of the three components is active, test anxiety creates distress for the test taker because the symptoms can distract the person while taking an important test.
Educational systems determine the overall course of events in education. In systems where racing is encouraged and great importance is attached to the exams, test anxiety can become a highly critical point to be considered. Turkey is among the countries where exams are given considerable importance, particularly the university entrance exam. In 2017, more than 2 million senior students entered the nationwide university entrance exam (Student Selection and Placement Center [SSPC], 2016). However, the overall quota of the universities and colleges was approximately 910,000. Thus, senior high school students in Turkey face a highly competitive environment. Kavakci, Semiz, Kartal, Dikici and Kugu (2014) mentioned that 48% of senior high school students preparing for their university entrance exam had high test anxiety. In this regard, test anxiety of issue for high school students has been studied extensively in the Turkish literature (Boyacioglu & Kucuk, 2011;Güler, 2012;Kavakci et al., 2014;Yildirim, 2007). However, most of this research in Turkey is based on correlational studies (Güler, 2012;Yildirim & Ergene, 2003).
The test anxiety phenomenon has been studied and investigated from various psychological approaches and models, including the Self-regulation Model (Carver & Scheier, 1981), Cognitive-Attentional Models (Sarason, 1980), Self-worth Model (Covington, 1984), and Information Processing Model (Naveh-Benjamin, McKeachie, Lin, & Holinger, 1981). Despite the prevalence of various therapeutic interventions and models, there are still significant shortcomings in the treatment of test anxiety. This gap can be filled with the view of postmodern approaches which provide different explanations to deal with the problems. One of the well-grounded post-modern approach is Acceptance and Commitment Therapy (ACT), a novel treatment developed mainly to prove that all human beings suffer (Hayes, Strosahl & Wilson, 1999). With its different view for problem solutions, which is mainly focused on accepting the problem rather than trying to get rid of it, ACT offers an unfamiliar procedure in dealing with test anxiety problem. The solution includes accepting the problem instead of fighting against it and staying with the problem rather than escaping unwanted thoughts. Because ACT argues that the suffering results not from thoughts, feelings, memories, or some physical sensations, but from the responses to these internal events (Turrell & Bell, 2016).
Acceptance and Commitment Therapy is a third-wave behavior therapy that was developed over three decades ago and is rooted in the philosophical tradition of functional contextualism (Hayes, Hayes, Reese & Sarbin, 1993) and based on the Relational Frame Theory (RFT). RFT asserts that there is a strong relationship between language and cognition (Hayes, Barnes-Holmes & Roche, 2001). Functional contextualism emphasizes psychological pragmatism and is considered an extension of Skinner's radical behaviorism (Hayes et al., 1993). From a functional contextualist perspective, the key point is to predict and influence behavior in a context (Turrell & Bell, 2016). All actions can only be understood in their entirety with reference to their context (Hayes, Levin, Plumb-Vilardaga, Villatte & Pistorello, 2013). In this regard, functional contextualists focus on understanding the function of a behavior (either overt or covert) which may differ depending on the contextual situation. Therefore, the overall goal of functional contextualism is the prediction and influence of a behavior that is either overt motor or covert private, with precision, scope, and depth (Hayes, 2004).
The overall goal of ACT is to increase psychological flexibility, which is described as the process of contacting to the present moment, thoughts and feelings it contains, without defense, fully, as a conscious human being and depending on what the situation affords, persisting or changing one's behavior in the service of chosen values (Hayes, Luoma, Bond, Masuda, & Lillis, 2006;Hayes, Strosahl, & Wilson, 1999). Psychological flexibility which is a positive psychological skill is explained through six basic processes. Conversely, psychological inflexibility that is considered as a negative psychological skill is also conceptualized through six processes. ACT clarifies human behavior trough six basic features and claims that the main reason of human suffering and maladaptive behavior is the psychological inflexibility (Bond et al., 2011;Hayes, Strosahl, & Wilson, 2012). In this regard, to obtain a better understanding of the relationship between psychological flexibility/inflexibility and psychopathology, it is necessary to clarify these core processes.

Acceptance vs. Experiential Avoidance
From an ACT perspective, acceptance refers to a behavioral willingness for engaging distressing tasks with an open, receptive and non-judgmental attitude with respect to both internal private and external experiences (Hayes et al., 2012). Accepting something does not necessarily mean liking or approving it. For example, one may accept thoughts and feelings about an unpleasant experience without liking or approving it. In other words, one can notice and accept a particular experience without any firm attempt to change (Wilson, 2008). Experiential avoidance, which is considered the primary source of psychological suffering from an ACT perspective (Villatte, Villatte & Hayes, 2016), and Hayes et al. (2012, p. 72) desribes it as: "occurs when one is unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions, thoughts, memories, behavioral predispositions) and takes steps to alter the form, frequency, or situational sensitivity of these experiences even though doing so is not immediately necessary".

Defusion vs Fusion
It is crystal clear that humans are intensely verbal (Hayes et al., 2012). While humans sometimes can control what they verbalize in the outer world, which is called public speech, they cannot have the same control over what they think in their internal world, which is called private speech. In this context, defusion refers to making contact with verbal products in terms of what they are, not what they say they are; fusion, on the other hand, refers to taking verbal products literally and acting upon them (Wilson, 2008). In this regard, one should separate his/her thoughts from their referents in order to succeed at defusion (Hayes & Smith, 2005).

Present-Moment Awareness vs Inflexible Attention to Present Moment
ACT promotes a non-judgmental contact with the present moment, considering the fact that the only time any psychological or environmental events occur is in the present moment (Hayes et al., 2012). Present-moment awareness involves being here and now, fully conscious of both one's internal private world and the external material experiences, and flexibly noticing and paying attention to those experiences (Harris, 2008). Considering also that the six processes in the ACT model are interrelated, someone fusing with thoughts and experientially avoiding internal experiences would have a lesser present-moment awareness (Wilson, 2008).

Self-as-Context vs Attachment to the Conceptualized Self (Self as Content)
From a contextual behavioral perspective, the self has three aspects (Hayes et al., 2012). The conceptualized self attributes characteristics to the self, such as "I am old" or "I am depressed". Psychological distress arises when one takes these self-descriptions literally (Hayes et al., 1999) due to strong identification with the content (Wilson, 2008). The second sense of selfthe self as processis the ongoing self-awareness that is described as the continuous knowledge of one's own experiences in the present moment (Hayes & Smith, 2005). The third onethe self as observer or the self as contextis the self that is aware of all the experiences, including thoughts, emotions, and bodily sensations (Wilson, 2008). Therefore, the self-as-context component emphasizes the importance of seeing ourselves more than our current struggles or characteristics (self as content).

Values
Valued living is one of the most important aspects of the ACT model. Values are understood in different ways according to various psychological approaches (Wilson, 2008). In ACT, values are not considered as goals, feelings, thoughts, ideas, or outcomes, but as freely chosen life directions (Hayes & Smith, 2005). Values could serve as a stable and consistent compass in one's life that motivate even during the most adverse or painful situations (Hayes et al., 2012). In this regard, a lack of clear values may cause many problematic behaviors and psychological inflexibility.

Committed Action vs Inaction, Avoidance Persistence and Impulsivity
ACT is mainly considered a behavioral therapy rooted in behaviorism and functional contextualism (Hayes et al., 2012). Therefore, one should be committed to take steps or actions in the service of one's chosen values, in order to develop greater psychological flexibility (Hayes & Smith, 2005).
In conclusion, a person who is psychologically inflexible usually tries to avoid undesired private events and unable to stay in the here and now mindfully. Additionally, a psychologically inflexible person is someone who is unable to defuse from his/her thoughts and does not have clear values. Finally, it is very difficult for a psychologically inflexible person to take steps towards his/her values.
ACT was found to be effective with a wide range of problems and populations, including but not limited to adults, adolescents, and children, and with various psychological problems such as depression, anxiety, and chronic pain (Cullen, 2008). The number of randomized controlled trials (RCT) in ACT has considerably increased, given the broad range of issues involved (Biglan, Hayes & Pistorello, 2008). There are randomized controlled trials, including workplace stress management (Bond & Bunce, 2000), anxiety and depression (Hancock et al., 2016;Sirous, Moloud, Esmaeili, & Maryam, 2016), chronic pain (Ghomian & Shairi, 2014;McCracken, Sato, & Taylor, 2013) and substance abuse (Stotts et al., 2012). However, test anxiety has not been sufficiently studied in the ACT literature. The RCT study of Brown, Forman, Herbert, Hoffman, Yuen and Goetter (2011) with 16 university students was found promising in which the effectiveness of cognitive therapy (CT) and acceptance-based behavior therapy (ABBT) was compared. The results of this pilot study reveleaed that those who received ABBT experienced improvements on test performance whereas those received CT exhibited reduced performance on test. Moreover, Saeed, Ahmad, Farah and Mehdi (2016) also conducted an experimental study with 60 male high school students to test the effectiveness of ACT on test anxiety. Their study also revealed that students' test anxiety, who receieved eight sessions of ACT intervention, significantly decreased in comparison to control group.
There are other studies where ACT and cognitive behavior therapy (CBT) were compared in order to investigate some forms of anxiety. Herbert et al. (2018) compared the effectiveness of traditional CBT (tCBT) and ACT in treatment of social anxiety disorder. They found that those who received tCBT evidenced greater improvements in self-reported social anxiety and overall functioning in comparison to the participants who received ACT. In another randomized controlled trial, Kocovski, Fleming, Hawley, Huta and Anthony (2013) similarly investigated the effectiveness of mindfulness and acceptance-based group therapy (MAGT) versus cognitive behavioral group therapy (CBGT). The results of this study indicated that both MAGT and CGBT were more effective than the control group but not significantly different from one another on social anxiety. Additionally, being evaluated by others might be a common component in understanding both test anxiety and other anxiety related issues. England et al. (2012) examined the effectiveness of acceptance-based exposure treatment for public speaking anxiety (PSA) compared to standard habituation-based exposure with clinical population. One of the major findings of the study indicated that participants in both groups demonstrated significant cognitive improvement on public speaking, confidence and social skills. PSA was also studied by Block (2002) with college students from both ACT and CBT perspective. The study mainly revealed that both ACT and CBT group treatment were effective in reducing the PSA for college students. Performance anxiety as a phenomenon was also studied with various populations including music performance anxiety (Juncos et al., 2017) and sport performance anxiety (Scott-Hamilton, Schutte & Brown, 2016).
The transdiagnostic nature of ACT helps individuals to promote greater flexibility rather than focusing on specific symptom or pathology with regard to six core interrelated processes aforementioned earlier (Dindo, Van Liew & Arch, 2017). This very flexible nature of ACT makes it practical for adolescence who are in transition stage in which they seek more autonomy (Turrell & Bell, 2016) of ego development. ACT in a group context can also be a good fit for high school students who experience high levels of test anxiety, considering that the group process may be able to reveal their experiential avoidances and fused thoughts. From this point of view, we asked the following research question: How do the students' perceptions about test anxiety and psychological flexibility differ as a result of an ACT-based psychoeducation group process? In addition, the following hypothesis was tested based on the research question: The participants' statements and perceptions will be more psychologically flexible after the group process.

Methodology Design
Multiple case study design (Creswell, 2007) was implemented as a qualitative research method. Case studies help us to understand the contextual cues and conditions of each case based on a certain phenomenon (Yin, 2017). Types of qualitative case studies are determined based on the number of cases, such as whether it is only one case, or multiple cases, a group or a program (Creswell, Hanson, Plano Clark, & Morales, 2007). In this study, a psychoeducational group counseling process based on Acceptance and Commitment therapy was implemented and there were multiple cases based on a certain phenomenon. The main issue in this current study was the senior high school students' test anxiety in conjunction with their psychological inflexibility level.

Participants
The data were collected from a public high school in Bolu, Turkey. The participants were recruited from the same high school via purposive sampling among 215 senior high school students who had high test anxiety score; and a total of six senior high school students (n=6) participated in a group process based on the Acceptance and Commitment Therapy approach. All participants were female and between 17 and 19 years of age.

Data Collection Instruments
In selecting the cases of this multiple case study, Cognitive Test Anxiety Scale-Revised (CTAR) (Cassady & Finch, 2015) was utilized. The scale consists of 25 items on a four-point Likert-type scale, ranging from 1 (not at all like me) to 4 (very much like me). The CTAR was previously adapted into Turkish by Bozkurt, Ekitli, Thomas, and Cassady (2017). The Turkish adaptation study was carried out with high school students. The exploratory factor analysis results indicated that the scale has a unidimensional factor; in addition, two items were omitted as a result of the analysis due to cultural factors. The internal consistency of the scale was found to be high (Cronbach's alpha = .93).
The participants were interviewed with a semi-structured questionnaire which was created by the researchers and was based on the six core process of ACT (Hayes, Strosahl & Wilson, 2012) with the emphasis on critical developmental periods of adolescents (Turrell & Bell, 2016). The interview questions were based on test anxiety in the light of the core concepts of Acceptance and Commitment Therapy (e.g., "If we were videotaping you as someone experiencing test anxiety, what would we see on the video?" and "What are you feeling now about the university entrance exam?"). Researchers directed the same ten interview questions as pre-interview and post-interview. Additionally, the post-interview interview included questions about group process evaluation (e.g., "What have you gained in coping with test anxiety at the end of the group process?" and "Which activities were the most useful for you?" Each interview lasted 10-15 minutes.

Procedure
The present study was aimed to explore the effectiveness of an ACT-based group counseling process for senior high school students with high test anxiety based on a six-week ACT group protocol. We completed the literature review and the design of the ACT group protocol in the fall of 2016. The selection of participants, group intervention and data analysis were conducted in the spring of 2017, considering the fact that senior high school students face test anxiety because of the approaching national university entrance exam at the end of the spring semester, which was held two months later after the intervention had finished. Moreover, the ethical procedure was completed with the permission of the Human Subjects Ethics Committee and Ministry of National Education, as well as with the consent of parents.
The group counseling sessions (See Table 1) were conducted once a week, and each session lasted 90 minutes. We started the sessions in March 2017 and ended them in the first week of May 2017. Each session began with a short mindfulness exercise along with the activities related to the aim of the session. It was also essential to emphasize that each session was supported by metaphors, as ACT is well known for metaphor use.
The theoretical planning, preparation of group protocol and all analyses were conducted together by the researchers. However, the group counseling processes were led by one of the researchers. As the first step in the whole procedure, researchers conducted a psychoeducational seminar on the various components of test anxiety with all senior high school students at the school. At the end of the seminar, the Cognitive Test Anxiety Scale-Revised (CTAR) was applied in order to determine the students' test anxiety level. Among 215 participants, 80 filled out all the scale. In the next step, based on CTAR scores, 16 students were invited to be interviewed due to their high level of test anxiety. As a result of the content analysis of the interviews, 10 students were excluded either because of non-eligibility for the group counseling process or because of personal unwillingness. Thus, only six students met the criteria to attend the ACT-based group counseling process.
A six-week test-anxiety group protocol was created based on the six core processes of ACT (Table 1). In the first session, the participants met the leader to discuss the general rules to be followed throughout the entire group process. The participants were asked to state their expectations and fears regarding this group process. Values, one of the core processes of the ACT group protocol, were discussed with the help of metaphors, followed by the introduction phase. In the second session, the acceptance and willingness processes were explained in relation to participants' current test anxiety. Participants were invited to attend experiential activities in order to internalize the importance of acceptance and willingness. The third session began with a reminder of the cost of control and lack of acceptance, and willingness exercises. Furthermore, participants were introduced to ACT's self-as-context process. They discussed and experienced the self-as-context concept through related metaphors in order to explore the relationship between their test anxiety and themselves.
The fourth session for the most part included activities related to two core concepts of ACT: defusion and committed action. The leader helped participants become familiar with the basics of defusion from thoughts and committed actions in the service of chosen values. In the fifth session, participants were provided with different experiential exercises, including values, defusion, acceptance and willingness, along with self-compassion activities. The last session ended with the overall evaluation of the ACT core processes in relation to participants' test anxiety.

Data Analysis
The data was analyzed by the content analysis of both pretreatment interviews and posttreatment interviews which were audio-recorded and transcribed. To maintain confidentiality, participants were named from P1 to P6. The transcriptions were analyzed separately and carefully by the researchers. As a result of independent analysis, the codes and themes were determined by mutual agreement. Main themes were structured followed by the coding units as a result of the transcriptions. Lastly, outstanding quotations were reported. In terms of validity of the study, member checking and multiple data sources were used as suggested by Creswell (2007). Each participant was asked to check their categorical distinctions after the termination of the group procedure based on their own transcriptions. Furthermore, reliability of the content analysis was adapted by several ways as suggested by Krippendorff (2004) such as intercoder reliability and accuracy. Intercoder reliability was ensured in this study considering the fact that two researchers transcribed and conducted the whole data set separately. (BME) Overall evaluation of the six core processes of ACT in relation to test anxiety. Participation certificates and "Happiness Trap" as a present for each participant.

Findings
Regarding the aim of this qualitative study, we explored the opinions of high school students with high test anxiety about an ACT-based group counseling process in reducing the symptoms of test anxiety and psychological inflexibility. The participants filled out CTAR to be included in the study. The semi-structured interviews were conducted with students based on the high results gathered from CTAR. The interviews were transcribed and content analysis was applied.
The results of content analysis obtained from the semi-structured interviews revealed some important themes consisted with ACT perspective along with several codes. The obtained experiences of the participants can be divided into four main themes or categories: (1) perception of the exam, (2) present-moment awareness and mindfulness skills, (3) cognitive defusion skills and strategies, and (4) experiential avoidance and acceptance.

Perception about the exam
To start with, perceptions about the exam were raised repeatedly during interviews. While some participants expressed their test anxiety with fear and reactive responses, they also considered the exam as an obstacle on their way to higher education. In contrast, their test anxiety definition has changed dramatically towards a more value-directed perception, which is ACTconsistent behavior. This is reflected in the quotations below:

Present-moment awareness and mindfulness skills
Since one of the most core processes of ACT is present-moment awareness and mindfulness, many detailed data were gathered in this context through the interviews both in the preinterview and post-interview. The participants explicitly revealed the symptoms of presentmoment awareness and mindfulness even during the interviews. As illustrated by the statements below, there is a clear distinction between pre-interview and post-interview interviews of the participants.

"I feel tension in my stomach when I think about the exam" (P6-pre-interview)
The statement of another participant (P2) also revealed similar symptoms: "… I feel stressed and I feel that my body releases adrenaline. I truly feel my heart beats" (P2-pre-interview) However, the same participants showed signs of more mindfulness skills in the post interview:

"When I think of the exam, I am noticing that I am getting excited a little bit, and I feel tension on my shoulders in the evenings. That is it" (P6-post-interview)
"I still feel a little bit stressed but not as much as before. I think I got used to it and the more we talked about the exam, the more it became a normal life event" (P2-post-interview)

Cognitive defusion skills and strategies
As a third wave of cognitive behavioral therapy, ACT strongly emphasizes the cognitive component of behavior. In this regard, it is very important to teach cognitive defusion skills as a way of putting a distance between the self and the mind. It was discovered that participants knew nothing about cognitive defusion skills prior to the intervention. However, the postinterview interviews indicated that most of the participants learned new cognitive defusion strategies. To determine whether or not participants learned cognitive defusion skills, they were asked the following question: "How much do you think you can defuse yourself from these negative thoughts?" Some answers are noted below: "I am trying to do other things; for example, I am spending time with my family, I am playing games with my siblings, I am reading books so that I find myself in the stories of the book. I can get rid of anxious thoughts by doing other things" (P4-pre-interview) As stated in the pre-interview response, P4 was not familiar with cognitive defusion skills. It is obvious that the very same participant learned those cognitive defusion skills, as reflected in the following quotation: "When these kinds of negative thoughts appear, I am now able to look at them at a distance" (P4-post-interview)

Experiential avoidance and acceptance
While experiential avoidance reflects the psychological inflexibility in the ACT model, acceptance corresponds to psychological flexibility. In this sense, most of the participants reported strategies such as over-controlling their anxiety and negative thoughts, suppressing thoughts by trying not to think about the exam and other ineffective strategies while dealing with test anxiety. Here are some examples of experiential avoidance from pre-interviews: "I am trying not to think about the exam. I find myself eating too much and sometimes sleeping too much in order to deal with test anxiety. I do not like myself experiencing test anxiety that much" (P4-pre-interview) "I am noticing now that the negative thoughts are here with me. Therefore, I am just observing them without fighting. After some time, they disappear by themselves. I have realized that I also get very tired if I try to control them" (P4post-interview) Overall evaluation of the group process also showed that most of the participants have gained awareness of their undesired private events. Participants emphazised that they no longer want to fight with other anxious thoughts as well because they were mostly perceived as an exhausting process and making them tired. Most of participants also stated that their friends or family members should also benefit from the skills gained from this present group. One of the most significant findings of the study was that all participants found some ACT metaphors, such "passengers on the bus, clouds in the sky and self-compassion exercises," very effective and vivid in understanding the core process of psychological flexibility.

Discussion
Acceptance and Commitment Therapy is a promising approach as supported in different studies. There are now more than two hundred randomized controlled trials using ACT as their main theoretical approach. The main purpose of the current study was also to investigate the effectiveness of an ACT-based test anxiety group for senior high school students, given that test anxiety has not been sufficiently studied in ACT literature and Turkish literature lacks ACT based research. The present study was based on a qualitative design including multiple case study. The results of the qualitative analysis supported the hypothesis of the study. The participants' statements and perceptions before and after the treatment indicated by selected quotations showed that there were significant differences in terms of handling the test anxiety problem after the group treatment. The results of the qualitative phase also showed that participants started to use more psychologically flexible language. This finding implies that they were able to internalize the core process of ACT as a result of the group process.
ACT has been providing promising results with a great number of samples. Even though most of the experimental research has been conducted with adults (Öst, 2014), introducing ACT concepts in various problem areas including test anxiety are found effective. To illustrate, Brown et al. (2011) conducted an experimental study with college students on test anxiety. Even though the sample was different from the present study, the results were in line with the current findings in terms of using ACT concepts in dealing with test anxiety in a group process. In addition, Boone and Manning (2012) found that a ten-session ACT group protocol with depressed and anxious college students was effective. Moreover Eifert, Forsyth, Arch, Espejo, Keller and Langer (2009) studied three anxious participants who went through 12 weeks of ACT treatment; their findings also supported the effectiveness of ACT treatments, with results of positive pre-to-post treatment changes in ACT-relevant process measures. That is, the concept of test anxiety can be a perennial and pervasive issue for high school students. Therefore, one of the main implications of the study is that the students experiencing test anxiety may gain further applicable life skills by becoming more psychologically flexible.
The findings of the current study were in line with the existing literature. The experimental study conducted by Sohrabi, Mohammadi and Delavar (2013) showed that high school students decreased their test anxiety level through the mindfulness strategies. Although the sample did not exactly match, a notable finding of a 12-week experimental study including ACT was that psycho-education about acceptance and valued living to decrease the focus of anxious language of past experiences was effective. That is, in line with the findings of this study, psycho-education groups can be effective to teach how to use ACT in handling the problems. Similarly, Hooper and McHugh (2013) found that teaching how to use cognitive defusion decreased the frequency of experiential avoidance.
This qualitative study can be considered as a valuable research to make ACT concepts familiar with the students. When students' pre and post interviews were analyzed, it was discovered that their use of words and anxiety level changed. Surprisingly, how they gave importance to the test anxiety changed into a way full of awareness and defusion. It is also important to mention that participants learnt how to live together with test anxiety rather than spending energy to get rid of it. This finding was striking simply because it could lead to further true experimental studies following as a continuum of this primary pilot study with Turkish sample.
There are possible limitations to be considered in the present study. First, the results cannot be generalized to the whole high school student population because the sample included senior students of only one school and the small sample size prevents to make generalizations about the population of high school students in Turkey. Also, it should be noted that all participants were female; therefore, the results cannot give information about the situation for male students. There is also a need to consider self-report data gathered in the study. The participants might be affected by several reasons while filling out the measurements and could not reflect their actual response. Therefore, it is crucial to mention that the results were interpreted by considering that their responses were actual honest responses. Moreover, the study was conducted with only female students who voluntarily participated in an ACT-based test-anxiety group. Therefore, the results should be discussed cautiously in terms of gender. Another limitation of the study was the lack of a follow-up session. Although this study may answer important questions about the test anxiety of high school students, other related questions may remain unanswered. Since this study was not a true experimental design, it is not possible to have causal conclusions. Some further suggestions should also be provided: First, male students should also be included in the study. In addition, a true experimental design can be used to compare experimental and control groups in order to obtain a better understanding the effect of the ACT group protocol. College and high school counseling centers may benefit from ACT group protocols in dealing with various problems, since ACT is applicable in many different areas.