接纳承诺疗法的作用机制——基于元分析结构方程模型
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摘要
接纳承诺疗法(Acceptance and Commitment Therapy, ACT)被认为是行为治疗"第三浪潮"的重要代表。本研究使用元分析结构方程模型,考察ACT的作用机制。通过数据库检索与筛选,最终纳入文献50篇。结果发现:ACT所假设的心理灵活性、接纳、此时此刻、价值的中介作用都达到统计显著,认知解离这一中介变量并不显著;中介机制在网络化干预中仍然得到检验;相较之传统CBT, ACT在所假设的机制上有其区别于CBT的优势。后续临床研究应更全面地测量6大核心机制,关注对美好生活提升的影响,采用多点瞬时评价法,并尽可能使用更高级、更先进的统计方法检验其作用机制。
Following the Behavioral Therapy and the Cognitive-Behavioral Therapy(CBT), Acceptance and Commitment Therapy(ACT) is considered as one of the third wave of behavioral therapies. ACT is based on the relational frame theory, and its therapeutic model includes 6 components(i.e., acceptance, cognitive defusion,self-as-context, committed action, contact with the present moment, values) and psychological flexibility. What is the empirical evidence for these hypothesized components or mechanisms? In recent years, integrating meta-analysis and structural equation modeling, the meta-analytic structural equation model(MASEM) has made it possible to systematically examine the mechanisms of psychotherapy. Compared to the traditional single randomized controlled trial(RCT) studies, the MASEM combines multiple samples to increase statistical power and obtain more robust model estimates. The current study utilized two-stage structural equation modeling(TSSEM) to examine three aspects of the mechanisms of ACT, including:(1) the mediational effects of psychological flexibility and the 6 components,(2) the unique mechanisms of ACT compared to CBT, and(3)the generalizability of these mechanisms to internet-based ACT interventions.Studies were identified by searching Web of science, PsycARTICLES, PsycINFO, Pubmed, Elsevier,EBSCO, Wiley Online Library from the first available date until November, 2017. We used the search term Acceptance and Commitment Therapy combined with acceptance, cognitive defusion, self-as-context,committed action, contact with the present moment, values, or psychological flexibility. Selection criteria included:(1) adult sample(age > 18),(2) RCT or quasi-experimental design, which measured pre-post change with ACT interventions,(3) quantitative measures of psychological outcomes(clinical or non-clinical) before and after treatment, and(4) quantitative measures of mediational variables at pre and post treatment. Excluding criteria were(1) not having a control group,(2) mixed intervention studies, which integrated ACT with other interventions, or included the Acceptance component but not the complete ACT model, or used CBT with the Acceptance component, and(3) medication treatment as the control group. The metaSEM package in R was used for the TSSEM analysis to examine the mechanisms of ACT.The literature search resulted in 50 studies, involving issues such as pain disorder, personality disorder,depression, anxiety, substance abuse, and work-related burnout among healthy populations. Most studies examined psychological flexibility(k = 39), followed by contact with the present moment(k = 14), acceptance(k= 6), cognitive defusion(k = 9), and values(k = 5), whereas the studies of self-as-context(k = 1) and committed action(k = 1) were excluded from further MASEM analysis due to a low number of publications. Results indicated that(1) the mediational effects of psychological flexibility, acceptance, contact with the present moment, and values were significant, while the effects of cognitive defusion were not significant,(2) the mechanisms of ACT are evident in internet-based interventions, suggesting the generalizability of these mechanisms, and(3) compared to the traditional CBT, the hypothesized mechanisms of ACT have their unique advantages.Implications for future studies:(1) measure all 6 core mechanisms as comprehensively as possible;(2)focus more on the increase of wellbeing as opposed to improvement of symptoms;(3) use RCT based multiple measurements combined with the experience sampling method; and(4) apply more advanced statistical methods in addition to the traditional mediation statistics.
Following the Behavioral Therapy and the Cognitive-Behavioral Therapy(CBT), Acceptance and Commitment Therapy(ACT) is considered as one of the third wave of behavioral therapies. ACT is based on the relational frame theory, and its therapeutic model includes 6 components(i.e., acceptance, cognitive defusion,self-as-context, committed action, contact with the present moment, values) and psychological flexibility. What is the empirical evidence for these hypothesized components or mechanisms? In recent years, integrating meta-analysis and structural equation modeling, the meta-analytic structural equation model(MASEM) has made it possible to systematically examine the mechanisms of psychotherapy. Compared to the traditional single randomized controlled trial(RCT) studies, the MASEM combines multiple samples to increase statistical power and obtain more robust model estimates. The current study utilized two-stage structural equation modeling(TSSEM) to examine three aspects of the mechanisms of ACT, including:(1) the mediational effects of psychological flexibility and the 6 components,(2) the unique mechanisms of ACT compared to CBT, and(3)the generalizability of these mechanisms to internet-based ACT interventions.Studies were identified by searching Web of science, PsycARTICLES, PsycINFO, Pubmed, Elsevier,EBSCO, Wiley Online Library from the first available date until November, 2017. We used the search term Acceptance and Commitment Therapy combined with acceptance, cognitive defusion, self-as-context,committed action, contact with the present moment, values, or psychological flexibility. Selection criteria included:(1) adult sample(age > 18),(2) RCT or quasi-experimental design, which measured pre-post change with ACT interventions,(3) quantitative measures of psychological outcomes(clinical or non-clinical) before and after treatment, and(4) quantitative measures of mediational variables at pre and post treatment. Excluding criteria were(1) not having a control group,(2) mixed intervention studies, which integrated ACT with other interventions, or included the Acceptance component but not the complete ACT model, or used CBT with the Acceptance component, and(3) medication treatment as the control group. The metaSEM package in R was used for the TSSEM analysis to examine the mechanisms of ACT.The literature search resulted in 50 studies, involving issues such as pain disorder, personality disorder,depression, anxiety, substance abuse, and work-related burnout among healthy populations. Most studies examined psychological flexibility(k = 39), followed by contact with the present moment(k = 14), acceptance(k= 6), cognitive defusion(k = 9), and values(k = 5), whereas the studies of self-as-context(k = 1) and committed action(k = 1) were excluded from further MASEM analysis due to a low number of publications. Results indicated that(1) the mediational effects of psychological flexibility, acceptance, contact with the present moment, and values were significant, while the effects of cognitive defusion were not significant,(2) the mechanisms of ACT are evident in internet-based interventions, suggesting the generalizability of these mechanisms, and(3) compared to the traditional CBT, the hypothesized mechanisms of ACT have their unique advantages.Implications for future studies:(1) measure all 6 core mechanisms as comprehensively as possible;(2)focus more on the increase of wellbeing as opposed to improvement of symptoms;(3) use RCT based multiple measurements combined with the experience sampling method; and(4) apply more advanced statistical methods in addition to the traditional mediation statistics.
引文
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1纳入的元分析文献及特征编码,请见电子版的附表。
Alonso-Fernández,M.,López-López,A.,Losada,A.,González,J.L.,&Wetherell,J.L.(2013).Acceptance and commitment therapy and selective optimization with compensation for institutionalized older people with chronic pain:A pilot study.Pain Medicine,17(2),264-277.
Alsubaie,M.,Abbott,R.,Dunn,B.,Dickens,C.,Keil,T.F.,Henley,W.,&Kuyken,W.(2017).Mechanisms of action in mindfulness-based cognitive therapy(MBCT)and mindfulness-based stress reduction(MBSR)in people with physical and/or psychological conditions:A systematic review.Clinical Psychology Review,55,74-91.
Arch,J.J.,Eifert,G.H.,Davies,C.,Vilardaga,J.C.P.,Rose,R.D.,&Craske,M.G.(2012).Randomized clinical trial of cognitive behavioral therapy(CBT)versus acceptance and commitment therapy(ACT)for mixed anxiety disorders.Journal of Consulting and Clinical Psychology,80(5),750-765.
Assaz,D.A.,Roche,B.,Kanter,J.W.,&Oshiro,C.K.B.(2018).Cognitive defusion in acceptance and commitment therapy:What are the basic processes of change.The Psychological Record,68(4),405-418.
A-Tjak,J.G.L.,Davis,M.L.,Morina,N.,Powers,M.B.,Smits,J.A.J.,&Emmelkamp,P.M.G.(2015).Ameta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems.Psychotherapy and Psychosomatics,84(1),30-36.
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