based on the conceptualization presented above we have developed a treatment manual in the form of self - help text material .
several components are included with the emphasis on building skills to foster flexibility , cognitively and behaviorally , in relation to the adverse situation of having a child diagnosed with a severe illness .
the treatment manual consists of eight modules , and the participant works with one at a time .
however , the content of the modules extend into each other throughout the program , for example , relaxation skills will be covered and trained beyond module 2 .
overview of treatment components and content in module 1 the participant is introduced to the program and treatment outline .
he or she is provided with psychoeducation regarding reactions to adverse events and symptoms of traumatic stress .
furthermore , he or she is introduced to the conceptualization outlined above and treatment components .
the concepts of rumination and avoidance are introduced , and the participants are instructed to register this type of behavior when it happens . in module 2 ,
the training is a short version of applied relaxation ( st , 1987 ) developed by lisspers and almn ( 2009 ) . in module 3 , the participant is introduced to the dark side of language and thinking .
participants are taught to identify instances of  getting stuck  in rumination and cognitive avoidance .
they are introduced to detached mindfulness ( wells , 2008 ) and defusion ( hayes et al . , 1999 ) .
this includes detecting oneself when  stuck  or  caught up  in negative thinking , and the individuals are instructed to detach from this thinking through exercises .
an example of such an exercise could be  the leaves in the stream exercise  were the individual is instructed to visualize a stream passing by and to place thoughts that come to mind on leaves in the stream and watch them pass by .
these types of exercises are intended to foster flexibility in thinking and prevent instances of abstract and unproductive repetitive thought . in module 4 ,
the participants are introduced to the concepts of rules and assumptions and how they may affect behavior .
participants are instructed to assess the function of their behavior , that is , to map its consequences .
if participants notice that a certain behavior as a response to certain rules or assumptions has negative consequences , they are instructed to use detached mindfulness and defusion strategies in such situations and experiment with new behaviors , that is , behavior experiments ( farmer & chapman , 2008 ) . in module 5 ,
participants are introduced to the concepts of willingness and acceptance ( hayes et al . , 1999 ) .
the distinction is made between clean and dirty discomfort in the context of having a child with cancer .
clean discomfort is thoughts and emotions that show up related to their child 's disease expected under such circumstances .
however , engaging in a struggle with these thoughts and feelings , that is , trying to get rid of them , often result in dirty discomfort . through metaphors and exercises participants
are instructed to open up to and accept their clean discomfort in the service of flexibility .
the main exercises in this section consist of writing assignments where the participants are instructed to open up to and express their clean discomfort .
module 6 includes writing assignments framed in the context of perspective taking ( lange et al . , 2003 ) .
for example , participants are instructed to imagine a friend being in the same situation as they currently are in , and to write a letter to this friend , expressing what they would like to say to this friend .
participants are introduced to the concepts of values , goals , and valued action ( hayes et al . , 1999 ) .
they are taught that values are freely chosen and that they are a matter of what they want to hold as important in their lives .
furthermore , participants are instructed to generate tangible goals consistent with their values and to practice valued action , that is , acting toward goals consistent with their chosen values . in module 8 , participants are given a prcis of the program and are instructed to generate a maintenance plan .
this section also covers general self - care strategies such as basic sleep hygiene , exercise , and good eating habits .
in the pilot phase of an ongoing randomized controlled trial ( rct ) , we investigated the preliminary efficacy and feasibility of the intervention with a mother of a child on cancer treatment .
data from pre- , post- , and follow - up assessments of the primary outcome variables ptss , depression , and quality of life are reported .
in addition , data on variables that we hypothesize to influence change in the outcome variables , namely , rumination as a response to trauma - related intrusions and the opposite of experiential avoidance , namely , acceptance and action in presence of difficult thoughts and emotions , are reported .
maria was a 38-year - old mother of a 4-year - old girl diagnosed with acute lymphoblastic leukemia 3 months prior to the intervention start .
maria lived together with the girl 's father , and they had another daughter aged 9 . at the time of the intervention maria was receiving higher education .
she lived 150 km from the pediatric oncology center where her daughter received her treatment and the location of the research group . at the time of the intervention maria 's daughter was on chemotherapy with 4 to 5 days
she had a history of an episode of depression and occasional panic attacks ( around 6 years ago ) for which she had received successful drug therapy .
the guided self - help treatment material consisted of approximately 100 written pages in eight chapters / modules as outlined in the introduction and table 1 , and a cd with exercises .
the material was developed by the first author , a licensed psychologist and phd student , under the supervision of an experienced licensed psychologist , licensed psychotherapist , and phd .
it was designed to enable the participant to work with the material independently by reading and conducting homework assignments and then receive feedback via e - mail or telephone from a clinical psychologist . the ptsd checklist 
civilian ( pcl - c : weathers , litz , herman , huska , & keane , 1993 ) was used to assess ptss .
it includes 17 items keyed to a specific trauma , in this case the child 's cancer disease , and the items correspond to the b ( reexperiencing ) , c ( avoidance ) , and d ( hyper - arousal ) criteria of ptsd in the 4 edition of the diagnostic and statistical manual of mental disorders ( dsm - iv - tr : 
 american psychiatric association , 2000 ) .
the montgomery sberg depression rating scale  self assessment ( madrs - s : svanborg & sberg , 1994 ) was used to assess symptoms of depression .
the quality of life inventory ( qoli : frisch , cornell , villanueva , & retzlaff , 1992 ) was used to assess quality of life .
the acceptance and action questionnaire  parents of children with cancer ( aaq - pcc ) developed by our research group as a modification of the original acceptance and action questionnaire - ii ( bond et al . , 2011 ) was used as a measure of behavioral acceptance and action in the presence of difficult thoughts and emotions .
rumination was assessed with the rumination subscale of the responses to intrusions questionnaire ( riq : clohessy & ehlers , 1999 ; murray , ehlers , & mayou , 2002 ; steil & ehlers , 2000 ) .
maria was recruited by a nurse at the pediatric oncology center where her daughter received her treatment . after providing written informed consent maria and the first author met at the center for an initial interview . at the end of this interview
maria received the instruments to be completed before the intervention that she answered and returned to the first author in a prepaid envelope .
it was agreed that maria and the first author would have weekly contacts , weeks when maria was at the center the contacts took place in vivo , and weeks when she was at home , contacts took place via telephone .
maria worked with the material for 10 weeks which resulted in three in - vivo meetings lasting 2 hours in total and six conversations via telephone lasting 3 hours in total .
maria e - mailed reports on homework assignments to the first author and received the new module at in vivo meetings or via posted mail .
after finishing work with the last module maria received and returned the assessments to be completed after intervention via posted mail .
maria was invited to complete follow - up assessments 3 months after the intervention but failed to do so because of time restraints .
instead she provided follow - up assessments 6 months after the intervention according to the same procedure .
the procedure and study protocol was approved by the local regional ethics committee . to determine the clinical significance and reliability of change subsequent to intervention we used statistical methods suggested by jacobson and traux ( 1991 ) .
clinical significance is suggested when either ( 1 ) the level of functioning subsequent to intervention falls within the range of a nonclinical population , where range is defined as within two standard deviations of the mean of that population , or ( 2 ) the level of functioning subsequent to intervention places the individual closer to the mean of the nonclinical population than the mean of the clinical population , which correspond to the ( 2 ) and ( 3 ) criteria suggested by jacobson and truax ( 1991 ) .
( 1 ) was used when the distributions were nonoverlapping and ( 2 ) when distributions were overlapping .
when distributions were overlapping , the reliable change index ( rc ) proposed by jacobson , follette , and revenstorf ( 1984 ) was utilized to ensure that change was reliable .
see table 2 for an overview of results from pre- , post- , and follow - up assessments . at the preassessment maria 's scores indicated that she experienced a high level of ptss , moderate depression , and impaired quality of life .
responses on the aaq - pcc indicated that she used acceptance strategies to some extent but had difficulties handling distressing thoughts and emotions .
in the initial contact , maria described high levels of tension and stress and a predominant fear that her child would die .
she reported suffering from headaches , neck and shoulder pain , and what she referred to as  stress - stomach  resembling symptoms of irritable bowel syndrome .
furthermore , she described mood swings and that she often felt very irritated and had frequent outbursts of anger .
she ruminated about why this had happened to her family , what the purpose was , worried about being abandoned and left alone , and that nobody would care for her .
she identified verbal rules that affected her behavior negatively , such as  i must not lose control  and
 others can not see me sad ,  and was encouraged to practice detached mindfulness when these rules came into mind and to reduce avoidant behavior triggered by such thinking and instead engage in valued behavior and activities .
maria appreciated the writing assignments and put forth the value of practicing self - compassion .
scores for maria at pre- , post- and follow - up - assessment compared to clinical and nonclinical norms note .
civilian ; qoli = quality of life inventory ; madrs - s = montgomery sberg depression rating scale  self assessment ; aaq - pcc = acceptance and action scale  parents of children with cancer ; na = not available . 

the intervention maria stated that she found the relaxation training and detached mindfulness components most useful .
she reported that she did n't feel as tense anymore and that she was confident in her new strategy when faced with new stressors .
she reported that she had more distance to her own thoughts and not being caught up in them as much as before .
her postassessments indicated a low level of ptss , mild depression , and good quality of life , all representing clinical significant and reliable change from the preintervention assessment .
in addition , responses on the riq subscale indicated reductions in ruminative thinking whereas responses on the aaq - pcc indicated increased acceptance and action .
these results were maintained at the 6-month follow up except for quality of life which was reduced , no longer representing clinically significant and reliable change from the preassessment .
maria was a 38-year - old mother of a 4-year - old girl diagnosed with acute lymphoblastic leukemia 3 months prior to the intervention start .
maria lived together with the girl 's father , and they had another daughter aged 9 . at the time of the intervention maria was receiving higher education .
she lived 150 km from the pediatric oncology center where her daughter received her treatment and the location of the research group . at the time of the intervention maria 's daughter was on chemotherapy with 4 to 5 days
she had a history of an episode of depression and occasional panic attacks ( around 6 years ago ) for which she had received successful drug therapy .
the guided self - help treatment material consisted of approximately 100 written pages in eight chapters / modules as outlined in the introduction and table 1 , and a cd with exercises .
the material was developed by the first author , a licensed psychologist and phd student , under the supervision of an experienced licensed psychologist , licensed psychotherapist , and phd .
it was designed to enable the participant to work with the material independently by reading and conducting homework assignments and then receive feedback via e - mail or telephone from a clinical psychologist . the ptsd checklist 
civilian ( pcl - c : weathers , litz , herman , huska , & keane , 1993 ) was used to assess ptss .
it includes 17 items keyed to a specific trauma , in this case the child 's cancer disease , and the items correspond to the b ( reexperiencing ) , c ( avoidance ) , and d ( hyper - arousal ) criteria of ptsd in the 4 edition of the diagnostic and statistical manual of mental disorders ( dsm - iv - tr : 
 american psychiatric association , 2000 ) .
the montgomery sberg depression rating scale  self assessment ( madrs - s : svanborg & sberg , 1994 ) was used to assess symptoms of depression .
the quality of life inventory ( qoli : frisch , cornell , villanueva , & retzlaff , 1992 ) was used to assess quality of life . the acceptance and action questionnaire  parents of children with cancer ( aaq - pcc ) developed by our research group as a modification of the original acceptance and action questionnaire - ii ( bond et al . , 2011 )
was used as a measure of behavioral acceptance and action in the presence of difficult thoughts and emotions .
rumination was assessed with the rumination subscale of the responses to intrusions questionnaire ( riq : clohessy & ehlers , 1999 ; murray , ehlers , & mayou , 2002 ; steil & ehlers , 2000 ) .
maria was recruited by a nurse at the pediatric oncology center where her daughter received her treatment . after providing written informed consent maria and the first author met at the center for an initial interview . at the end of this interview
maria received the instruments to be completed before the intervention that she answered and returned to the first author in a prepaid envelope .
it was agreed that maria and the first author would have weekly contacts , weeks when maria was at the center the contacts took place in vivo , and weeks when she was at home , contacts took place via telephone .
maria worked with the material for 10 weeks which resulted in three in - vivo meetings lasting 2 hours in total and six conversations via telephone lasting 3 hours in total .
maria e - mailed reports on homework assignments to the first author and received the new module at in vivo meetings or via posted mail . after finishing work with the last module maria received and returned the assessments to be completed after intervention via posted mail .
maria was invited to complete follow - up assessments 3 months after the intervention but failed to do so because of time restraints . instead she provided follow - up assessments 6 months after the intervention according to the same procedure .
the procedure and study protocol was approved by the local regional ethics committee . to determine the clinical significance and reliability of change subsequent to intervention we used statistical methods suggested by jacobson and traux ( 1991 ) .
clinical significance is suggested when either ( 1 ) the level of functioning subsequent to intervention falls within the range of a nonclinical population , where range is defined as within two standard deviations of the mean of that population , or ( 2 ) the level of functioning subsequent to intervention places the individual closer to the mean of the nonclinical population than the mean of the clinical population , which correspond to the ( 2 ) and ( 3 ) criteria suggested by jacobson and truax ( 1991 ) .
( 1 ) was used when the distributions were nonoverlapping and ( 2 ) when distributions were overlapping .
when distributions were overlapping , the reliable change index ( rc ) proposed by jacobson , follette , and revenstorf ( 1984 ) was utilized to ensure that change was reliable . see table 2 for an overview of results from pre- , post- , and follow - up assessments . at the preassessment maria 's scores indicated that she experienced a high level of ptss , moderate depression , and impaired quality of life .
responses on the aaq - pcc indicated that she used acceptance strategies to some extent but had difficulties handling distressing thoughts and emotions . in the initial contact , maria described high levels of tension and stress and a predominant fear that her child would die .
she reported suffering from headaches , neck and shoulder pain , and what she referred to as  stress - stomach  resembling symptoms of irritable bowel syndrome .
furthermore , she described mood swings and that she often felt very irritated and had frequent outbursts of anger .
she ruminated about why this had happened to her family , what the purpose was , worried about being abandoned and left alone , and that nobody would care for her .
she identified verbal rules that affected her behavior negatively , such as  i must not lose control  and
 others can not see me sad ,  and was encouraged to practice detached mindfulness when these rules came into mind and to reduce avoidant behavior triggered by such thinking and instead engage in valued behavior and activities .
maria appreciated the writing assignments and put forth the value of practicing self - compassion .
scores for maria at pre- , post- and follow - up - assessment compared to clinical and nonclinical norms note .
civilian ; qoli = quality of life inventory ; madrs - s = montgomery sberg depression rating scale  self assessment ; aaq - pcc = acceptance and action scale  parents of children with cancer ; na = not available . 

the intervention maria stated that she found the relaxation training and detached mindfulness components most useful .
she reported that she did n't feel as tense anymore and that she was confident in her new strategy when faced with new stressors .
she reported that she had more distance to her own thoughts and not being caught up in them as much as before .
her postassessments indicated a low level of ptss , mild depression , and good quality of life , all representing clinical significant and reliable change from the preintervention assessment .
in addition , responses on the riq subscale indicated reductions in ruminative thinking whereas responses on the aaq - pcc indicated increased acceptance and action .
these results were maintained at the 6-month follow up except for quality of life which was reduced , no longer representing clinically significant and reliable change from the preassessment .
the guided self - help treatment material consisted of approximately 100 written pages in eight chapters / modules as outlined in the introduction and table 1 , and a cd with exercises .
the material was developed by the first author , a licensed psychologist and phd student , under the supervision of an experienced licensed psychologist , licensed psychotherapist , and phd .
it was designed to enable the participant to work with the material independently by reading and conducting homework assignments and then receive feedback via e - mail or telephone from a clinical psychologist .
the ptsd checklist  civilian ( pcl - c : weathers , litz , herman , huska , & keane , 1993 ) was used to assess ptss .
it includes 17 items keyed to a specific trauma , in this case the child 's cancer disease , and the items correspond to the b ( reexperiencing ) , c ( avoidance ) , and d ( hyper - arousal ) criteria of ptsd in the 4 edition of the diagnostic and statistical manual of mental disorders ( dsm - iv - tr : 
 american psychiatric association , 2000 ) .
the montgomery sberg depression rating scale  self assessment ( madrs - s : svanborg & sberg , 1994 ) was used to assess symptoms of depression .
the quality of life inventory ( qoli : frisch , cornell , villanueva , & retzlaff , 1992 ) was used to assess quality of life .
the acceptance and action questionnaire  parents of children with cancer ( aaq - pcc ) developed by our research group as a modification of the original acceptance and action questionnaire - ii ( bond et al . , 2011 ) was used as a measure of behavioral acceptance and action in the presence of difficult thoughts and emotions .
rumination was assessed with the rumination subscale of the responses to intrusions questionnaire ( riq : clohessy & ehlers , 1999 ; murray , ehlers , & mayou , 2002 ; steil & ehlers , 2000 ) .
maria was recruited by a nurse at the pediatric oncology center where her daughter received her treatment . after providing written informed consent maria and the first author met at the center for an initial interview . at the end of this interview
maria received the instruments to be completed before the intervention that she answered and returned to the first author in a prepaid envelope .
it was agreed that maria and the first author would have weekly contacts , weeks when maria was at the center the contacts took place in vivo , and weeks when she was at home , contacts took place via telephone .
maria worked with the material for 10 weeks which resulted in three in - vivo meetings lasting 2 hours in total and six conversations via telephone lasting 3 hours in total .
maria e - mailed reports on homework assignments to the first author and received the new module at in vivo meetings or via posted mail . after finishing work with the last module maria received and returned the assessments to be completed after intervention via posted mail .
maria was invited to complete follow - up assessments 3 months after the intervention but failed to do so because of time restraints .
instead she provided follow - up assessments 6 months after the intervention according to the same procedure .
to determine the clinical significance and reliability of change subsequent to intervention we used statistical methods suggested by jacobson and traux ( 1991 ) .
clinical significance is suggested when either ( 1 ) the level of functioning subsequent to intervention falls within the range of a nonclinical population , where range is defined as within two standard deviations of the mean of that population , or ( 2 ) the level of functioning subsequent to intervention places the individual closer to the mean of the nonclinical population than the mean of the clinical population , which correspond to the ( 2 ) and ( 3 ) criteria suggested by jacobson and truax ( 1991 ) .
( 1 ) was used when the distributions were nonoverlapping and ( 2 ) when distributions were overlapping .
when distributions were overlapping , the reliable change index ( rc ) proposed by jacobson , follette , and revenstorf ( 1984 ) was utilized to ensure that change was reliable .
see table 2 for an overview of results from pre- , post- , and follow - up assessments . at the preassessment maria 's scores
indicated that she experienced a high level of ptss , moderate depression , and impaired quality of life .
responses on the aaq - pcc indicated that she used acceptance strategies to some extent but had difficulties handling distressing thoughts and emotions . in the initial contact ,
maria described high levels of tension and stress and a predominant fear that her child would die .
she reported suffering from headaches , neck and shoulder pain , and what she referred to as  stress - stomach  resembling symptoms of irritable bowel syndrome .
furthermore , she described mood swings and that she often felt very irritated and had frequent outbursts of anger .
she ruminated about why this had happened to her family , what the purpose was , worried about being abandoned and left alone , and that nobody would care for her .
she identified verbal rules that affected her behavior negatively , such as  i must not lose control  and
 others can not see me sad ,  and was encouraged to practice detached mindfulness when these rules came into mind and to reduce avoidant behavior triggered by such thinking and instead engage in valued behavior and activities .
maria appreciated the writing assignments and put forth the value of practicing self - compassion .
scores for maria at pre- , post- and follow - up - assessment compared to clinical and nonclinical norms note .
civilian ; qoli = quality of life inventory ; madrs - s = montgomery sberg depression rating scale  self assessment ; aaq - pcc = acceptance and action scale  parents of children with cancer ; na = not available . 

the intervention maria stated that she found the relaxation training and detached mindfulness components most useful .
she reported that she did n't feel as tense anymore and that she was confident in her new strategy when faced with new stressors .
she reported that she had more distance to her own thoughts and not being caught up in them as much as before .
her postassessments indicated a low level of ptss , mild depression , and good quality of life , all representing clinical significant and reliable change from the preintervention assessment .
in addition , responses on the riq subscale indicated reductions in ruminative thinking whereas responses on the aaq - pcc indicated increased acceptance and action .
these results were maintained at the 6-month follow up except for quality of life which was reduced , no longer representing clinically significant and reliable change from the preassessment .
in this article we presented a conceptualization regarding the understanding of traumatic stress in parents of children with cancer and strategies to alleviate such distress and to promote adaptation . in our conceptual model the constructs experiential avoidance and rumination are hypothesized to play important roles in negatively influencing constructive coping and adjustment .
these constructs are operationalized in behavioral terms and are potentially modifiable through intervention . to our knowledge
such a conceptualization guided by theory informing intervention strategies has not been outlined before in the context of parents of pediatric oncology patients .
however , future empirical research is needed to illuminate whether these constructs have predictive value in the understanding of traumatic stress and general adjustment among parents of children with cancer .
we have suggested that strategies such as relaxation training , detached mindfulness and defusion , acceptance , behavioral experiments , and valued action could be viable options when working with parents of children with cancer . in line with this
we have developed a treatment package in the form of self - help text material that parents can work with in adjunction to support via e - mail or telephone .
this article also reports findings from a case study in which we demonstrate the application and feasibility of this approach .
the results indicate clinically significant and reliable change in the outcome variables ptss , depression , and quality of life , and the intervention was well received .
maria exhibited reductions in rumination and increases in acceptance and action in the presence of distressing thoughts and feelings .
it would have been more stringent to use several baseline assessments and continue assessment during intervention in a single - subject design ( barlow , nock , & hersen , 2009 ) .
furthermore , norms for aaq - pcc and riq are lacking which prevented calculations of clinically significant and reliable change for these variables .
however , when considering these shortcomings it should be taken into consideration that this , to the best of our knowledge , is the first , albeit preliminary and explorative , report of a remote intervention targeting ptss in parents of children with cancer . awaiting more rigorous evidence
we hope that the current conceptual outline and case study may serve as inspiration for research initiatives and routine clinical practice in the field of pediatric psychology ( drotar , 2009 ) .
the current conceptualization and treatment strategies were developed for parents of children with cancer experiencing high levels of traumatic stress .
the intervention is rather comprehensive and time - consuming and in contrast to the assertion that interventions for this population need to be brief ( kazak et al . , 2006 ) .
however , research indicates that parental ptss as a response to a child 's serious illness is related to earlier stressful events ( pder et al . , 2008 ) and to a previous need of psychosocial care ( bronner et al . , 2010 ) .
it therefore seems plausible that some parents of children with cancer are in need of intensive and specialized treatment approaches , and that these should be integrated as options in routine care , if proven effective in more rigorous research designs .
awaiting such evidence this article may serve as inspiration for professionals in the field of psychosocial pediatric oncology . even though anecdotal ,
the findings show that it may be possible to work with parents of children on cancer treatment in a remote fashion that allude to possibilities of meeting these parents need for psychosocial support despite the limitations that their current situation impose .
furthermore , according to this article it may be possible to integrate intervention strategies such as detached mindfulness , defusion , and values clarification when working with parents of children on cancer treatment . as in the case of maria , focusing on helping parents to reduce repetitive ruminative thinking and experiential avoidance may help them to focus on aspects where they do have control that can have empowering consequences .
we are not aware of any studies of the applicability and efficacy of such components in this population but they may show to be of value in this strained group . we are currently running a rct investigating the efficacy of the herein presented treatment approach in parents recruited 2 months after their child 's cancer diagnosis . in the trial , this material is used in an internet - administered guided self - help format with therapist support via e - email .
if results from this trial are positive we hope that this conceptualization and the sequent remote intervention will allow more parents in a very straining situation the access to flexible and effective help .
 being a parent of a child diagnosed with cancer poses an enormous stressor . 
 indeed , several parents have difficulties adjusting to such a situation and react with symptoms of traumatic stress , depression , and reduced quality of life . however , there is little conceptual work on behavioral mechanisms that contribute to suboptimal adaptation in these parents . 
 the authors present a conceptualization in which experiential avoidance and rumination are suggested to contribute to increased levels of traumatic stress and suboptimal adaption . 
 based on this conceptualization , a recently developed intervention for parents of children with cancer , in the form of guided self - help , is presented . 
 finally , the authors present a successful case study as an example of the application of this intervention . clinical implications and suggestions for future research 
 are discussed . 
Intervention Components
CASE STUDY
Maria
Material
Assessments
Procedure
Statistical Analyses
Results
DISCUSSION