Intervention and mediation effects of target processes in a randomized controlled trial of Acceptance and Commitment Therapy for anxious cancer survivors in community oncology clinics

doi:10.1016/j.brat.2022.104103

Behaviour Research and Therapy

Volume 153, June 2022, 104103

https://doi.org/10.1016/j.brat.2022.104103 Get rights and content

Abstract

Objective

Acceptance and Commitment Therapy (ACT) is a promising psycho-oncological intervention, but its mechanisms in real-world settings are not fully understood. This study examined core theorized ACT and broader ACT-consistent target processes as mediators of ACT versus minimally-enhanced usual care within a randomized trial for anxious cancer survivors in a community oncology setting.

Method

Two core theorized ACT target processes (experiential avoidance and values-aligned behavior, each measured with two instruments) and two broader ACT-consistent target processes (emotional approach coping and self-compassion) were analyzed at pre- and post-intervention as mediators of general anxiety symptoms, cancer-related trauma symptoms, and fear of cancer recurrence (N = 134).

Results

ACT led to greater increases on emotional approach coping (ps ≤ .001) and one measure of values-aligned behavior (ps ≤ .031), and marginal or greater improvement on self-compassion (ps ≤ .055), but not other core ACT target processes. Self-compassion and emotional approach coping mediated ACT's effects on cancer-related trauma symptoms (ps ≤ .037). Additionally, self-compassion, emotional approach coping, and values-aligned behavior marginally mediated fear of recurrence and general anxiety symptoms improvement (ps ≤ .088).

Conclusion

ACT reduced cancer survivors’ anxiety-related symptoms, and especially cancer-related trauma symptoms, most consistently by promoting self-compassion and emotional approach coping.

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Section snippets

Participants

To be eligible for the Valued Living RCT, participants were required to: 1) have completed primary cancer treatment within 1.5–24 months of study enrollment; 2) have no current evidence of cancer for solid tumor cancers, or be in remission or asymptomatic after initial treatment for hematologic malignancies; 3) self-report elevated anxiety about cancer and elevated general anxiety and/or depressive symptoms on multiple screeners¹

Change in target processes

There was significant overall improvement in all target processes (Supplemental Table 2). ACT and MEUC participants did not differ significantly in Pre-Post change on the two experiential avoidance measures (Table 1 a paths). Comparing the two values-aligned behavior measures, ACT improved more on the Bullseye, but not on the VLQ. By contrast, ACT led to significantly greater improvement than MEUC on the self-compassion and emotional approach coping measures.

Change in outcome variables

Overall across condition, each of

Discussion

This study examined longitudinal change and mediation effects of core theorized ACT and broader ACT-consistent target processes in a community oncology clinic-based RCT of ACT versus MEUC for anxious cancer survivors. Regarding condition differences, ACT participants showed significantly greater improvement than MEUC participants on one measure of values-aligned behavior but not on either measure of experiential avoidance. ACT participants also improved more than MEUC on two broader

Conclusion

We have examined core theorized ACT and broader ACT-consistent target processes in an ACT RCT for anxious cancer survivors embedded within community oncology care clinics. Values-aligned behavior as measured by one instrument (but not another) was a marginal partial mediator of fear of cancer recurrence and general anxiety symptom improvement. The two broader ACT-consistent target processes (self-compassion and emotional approach coping) were significant partial mediators of cancer-related

Funding

The Valued Living study, which provided the dataset analyzed in this manuscript, was supported by an American Cancer Society Research Scholar Grant (PI: Arch, RSG-15-020-01–CPPB). Dr. Arch also receives unrelated research funding from AstraZeneca.

CRediT authorship contribution statement

Joel N. Fishbein: Conceptualization, Methodology, Software, Formal analysis, Writing – original draft, Writing – review & editing, Visualization. Charles M. Judd: Conceptualization, Methodology, Formal analysis, Writing – review & editing, Supervision. Sarah Genung: Data curation, Writing – review & editing, Project administration. Annette L. Stanton: Methodology, Writing – review & editing. Joanna J. Arch: Conceptualization, Methodology, Investigation, Writing – review & editing, Supervision,

References (48)

J.J. Arch et al.
Longitudinal treatment mediation of traditional cognitive behavioral therapy and acceptance and commitment therapy for anxiety disorders
Behaviour Research and Therapy
(2012)
C. Benoy et al.
Treatment sensitivity: Its importance in the measurement of psychological flexibility
Journal of Contextual Behavioral Science
(2019)
E.J. Bluett et al.
Acceptance and commitment therapy for anxiety and OCD spectrum disorders: An empirical review
Journal of Anxiety Disorders
(2014)
F.W. Bond et al.
Preliminary psychometric properties of the acceptance and action questionnaire-II: A revised measure of psychological inflexibility and experiential avoidance
Behavior Therapy
(2011)
A.T. Gloster et al.
Increasing valued behaviors precedes reduction in suffering: Findings from a randomized controlled trial using ACT
Behaviour Research and Therapy
(2017)
S.C. Hayes et al.
Report of the ACBS Task Force on the strategies and tactics of contextual behavioral science research
Journal of Contextual Behavioral Science
(2021)
S.G. Hofmann et al.
Beyond linear mediation: Toward a dynamic network approach to study treatment processes
Clinical Psychology Review
(2020)
T. Lundgren et al.
The bull’s-eye values Survey: A psychometric evaluation
Cognitive and Behavioral Practice
(2012)
C.W. Ong et al.
The role of psychological inflexibility and self-compassion in acceptance and commitment therapy for clinical perfectionism
Journal of Contextual Behavioral Science
(2019)
C.W. Ong et al.
A review of AAQ variants and other context-specific measures of psychological flexibility
Journal of Contextual Behavioral Science
(2019)

C.W. Ong et al.

A psychometric comparison of psychological inflexibility measures: Discriminant validity and item performance

Journal of Contextual Behavioral Science

(2020)

N.J. Petrelli

A community cancer center program: Getting to the next level

Journal of the American College of Surgeons

(2010)

E.D. Reilly et al.

A systematic review of values measures in acceptance and commitment therapy research

Journal of Contextual Behavioral Science

(2019)

I. Tyndall et al.

The Acceptance and Action Questionnaire-II (AAQ-II) as a measure of experiential avoidance: Concerns over discriminant validity

Journal of Contextual Behavioral Science

(2019)

M. Wolgast

What does the Acceptance and Action Questionnaire (AAQ-II) really measure?

Behavior Therapy

(2014)

J.J. Arch et al.

Presence and predictors of anxiety disorder onset following cancer diagnosis among anxious cancer survivors

Supportive Care in Cancer

(2020)

J.J. Arch et al.

An Acceptance and Commitment Therapy (ACT) group intervention for cancer survivors experiencing anxiety at re-entry

Psycho-Oncology

(2016)

J.J. Arch et al.

Randomized trial of an Acceptance and Commitment Therapy intervention for anxious cancer survivors in community clinics: Outcomes and moderators

Journal of Clinical and Consulting Psychology

(2021)

K. Barrett et al.

A systematic review of values-based psychometric tools within Acceptance and Commitment Therapy (ACT)

Psychological Record

(2019)

T. Deshields et al.

Psychosocial staffing at National Comprehensive Cancer Network member institutions: Data from leading cancer centers

Psycho-Oncology

(2016)

W. Gámez et al.

The Brief experiential avoidance Questionnaire: Development and initial validation

Psychological Assessment

(2014)

K.A. Goldsmith et al.

Tutorial: The practical application of longitudinal structural equation mediation models in clinical trials

Psychological Methods

(2018)

A.L. Hawkes et al.

Effects of a telephone-delivered multiple health behavior change intervention (CanChange) on health and behavioral outcomes in survivors of colorectal cancer: A randomized controlled trial

Journal of Clinical Oncology

(2013)

S.A. Hayes-Skelton et al.

Experiential avoidance

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Self-compassion and emotional approach coping (i.e., coping with stressors by actively acknowledging, processing, and expressing one's emotions), two broader ACT-consistent processes, as well as values-aligned behavior were significant or marginal partial mediators of anxiety symptoms in cancer survivors. Interestingly, experiential avoidance was not a significant mediator (Fishbein et al., 2022). Other studies suggest that self-compassion plays a critical role as a mediator of the intervention effects of ACT (Ong et al., 2021).
Acceptance and Commitment Therapy (ACT) is a promising approach in psycho-oncology that has led to an increasing number of studies and reviews. This systematic umbrella review provides a comprehensive overview of the results of existing systematic reviews and meta-analyses to investigate the trans-symptomatic (i.e., psychological and physical symptoms) efficacy of ACT in the context of cancer. The study addresses both physical and psychological outcomes, aiming to identify existing research gaps and delineate potential focal points for future studies exploring the application of ACT in psycho-oncological settings.
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Participants

Change in target processes

Change in outcome variables

Behaviour Research and Therapy

Journal of Contextual Behavioral Science

Journal of Anxiety Disorders

Behavior Therapy

Behaviour Research and Therapy

Journal of Contextual Behavioral Science

Clinical Psychology Review

Cognitive and Behavioral Practice

Journal of Contextual Behavioral Science

Journal of Contextual Behavioral Science

Journal of Contextual Behavioral Science

Journal of the American College of Surgeons

Journal of Contextual Behavioral Science

Journal of Contextual Behavioral Science

Behavior Therapy

Supportive Care in Cancer

Psycho-Oncology

Journal of Clinical and Consulting Psychology

Psychological Record

Psycho-Oncology

Psychological Assessment

Psychological Methods

Journal of Clinical Oncology