Empirical ResearchAcceptance and commitment therapy and subjective wellbeing: A systematic review and meta-analyses of randomised controlled trials in adults
Introduction
Developing interventions that aim to promote mental health has increasingly been recognised as a global priority (World Health Organisation, 2013). In the UK and internationally, this agenda has been reflected in the burgeoning number of public policy, legislation, programmes and interventions which aim to enhance the mental health of individuals and their communities (e.g. Department of Health, 2014, New Economics Foundation, 2011; Office for National Statistics, 2019). Conceptually, mental health promotion broadens the focus of researchers' and clinicians' attention towards improving indicators of wellbeing and health, in addition to more narrowly focused efforts to alleviate psychological distress or ‘illness’. The ‘dual-factor model of mental health’ (Westerhof & Keyes, 2010) proposes that mental health and mental illness exist on distinct, yet related, dimensions. A growing body of research evidence attests to the possibility that positive mental health (i.e. elevated subjective wellbeing; SWB) ‘buffers’ against mental and physical illness (Grant, Guille, & Sen, 2013; Keyes, Dhingra, & Simoes, 2010; Steptoe, Docray & Wardle, 2009). As such, SWB has been highlighted as an important outcome for clinicians and researchers involved in delivery and evaluating psychological interventions respectively (Diener, Diener, & Tamir, 2004; Trompetter, de Kleine, & Bohlmeijer, 2017; White, Imperiale, & Perera, 2016). SWB has been defined broadly as “a person's cognitive and affective evaluations of his or her life” (Diener, Oishi, & Lucas, 2002, p. 63), and has been proposed to consist of hedonic and eudaimonic aspects (Keyes, Scmotkin & Ryff, 2002; Waterman, 1993). Hedonia relates to satisfaction with life, and an emotional equilibrium between positive affect (e.g. happiness) and negative affect (Diener, Emmons, Larsen, & Griffin, 1985; Diener, Suh, Lucas, & Smith, 1999; Larsen & Prizmic, 2008). Eudaimonia concerns optimal, psychological functioning and fulfilment of one's own potential (i.e. “self-acceptance”, “environmental mastery”, “positive social relationships”, and “purpose in life”) (Ryff & Keyes, 1995, p. 720). There exists a wealth of validated, self-report wellbeing measures for which underlying conceptualizations may be divided into hedonic and eudaimonic traditions (for a comprehensive review of measures see Cooke, Melchert, & Connor, 2016). Increasingly, measures have been developed to capture both of these aspects of wellbeing. For example, Keyes (2002) argues that emotional (i.e. hedonic), psychological and social (both eudaimonic) components constitute the core aspects of wellbeing. Furthermore, it is suggested that individuals may be classified as “flourishing”, “languishing”, or in “moderate mental health” depending on their levels of SWB as assessed by the Mental Health Continuum (MHC-Short-Form/Long Form; Keyes, 2002). This theoretical understanding of wellbeing aligns closely with the World Health Organisation's (WHO) definition of mental health: “a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community” (2001, p.1). Acceptance and commitment therapy (ACT) is a transdiagnostic intervention, which focuses on personal growth, and the cultivation of wellbeing through enhanced value-based living (Harris, 2011; Hayes, 2004). Underpinned by functional contextualism, ACT moves away from reductionist approaches to therapy that aim to correct the content of “dysfunctional” or “pathological” cognitions and behaviours; instead focusing on the context in which psychological and behavioural events occur. In ACT, psychological suffering is considered to be caused by a lack of “psychological flexibility”, which has been defined as “the ability to fully contact the present moment and the thoughts and feelings it contains without defence, and, depending upon what the situation affords, persisting in or changing behaviour in the pursuit of goals and values” (Bond et al., 2011, p.678). In order to enhance psychological flexibility, ACT draws on six therapeutic processes: acceptance (embracing internal experiences without altering their form or frequency); cognitive defusion (achieving psychological distance from internal experiences); being present (ongoing, non-judgemental contact with psychological and environmental events as they occur); self-as-context (observing or noticing ones' inner/outer world, and flexible perspective taking); values (choosing valued life directions); and committed action (acting in service of one's chosen values). Whilst ACT does not view symptom reduction itself as a primary goal, this can be a “fortuitous by-product” of enhanced psychological flexibility (Harris, 2007, p.2). Further, ACT takes a non-pathologising stance towards human distress, emphasising instead that distress is an inherent aspect of the human condition (McCracken & Vowles, 2014; Ramsey-Wade, 2015). Reflecting an evidence-based practice focus on measuring the efficacy of interventions in terms of symptom reduction, a large proportion of ACT studies have focused on “disorders” and condition-specific outcomes (e.g. Beilby, Bymes, & Yaruss, 2012; Bohlmeijer, Fledderus, & Rokx, 2011; Lappalainen et al., 2014). A number of systematic reviews and meta-analysis have been conducted (Powers, Vording, & Emmelkamp, 2009; Swain, Hancock, Hainsworth, & Bowman, 2013; A-Tjak et al., 2015). Research has demonstrated ACT's efficacy in relation to anxiety and depression (e.g. Forman, Herbert, Moitra, Yeomans, & Geller, 2007) and a range of mental health difficulties (e.g. Gratz & Gunderson, 2006; Hayes, 2004) and physical health conditions (e.g. Dahl, Wilson, & Nilsson, 2004). Yet there have been recent calls for research efforts to focus on transdiagnostic outcomes such as SWB (Fledderus, Bohlmeijer, Smit, & Westerhof, 2010; French, Golijani-Moghaddam, & Schröder, 2017; Trompetter, Bohlmeijer, Lamers, & Schreurs, 2016). In the current review, the authors sought to address an important gap within the literature base, by synthesising and critically appraising the research findings of randomised controlled trials (RCTs) of face-to-face and guided ACT interventions (i.e. an ACT intervention where the participant had at least minimal contact with a practitioner linked to the intervention) that have assessed SWB in adults. Face-to-face and guided interventions were chosen as the focus of this review, as they have been shown to be superior to unguided interventions within the literature (Andersson & Titov, 2014; French et al., 2017; Richards & Richardson, 2012). The current study aimed to evaluate the methodological rigor of RCTs of ACT interventions; the range of standardised SWB measures being used; and the reported efficacy of ACT (versus control groups) for bringing about changes in SWB. Specifically, the current review, and meta-analysis aimed to address the following questions:
- 1.
What is the range of SWB measures used as outcome measures in ACT RCT intervention studies?
- 2.
What is the efficacy of ACT interventions (compared to control groups) for bringing about changes in subjective wellbeing?
- 3.
What risks of bias are inherent in the relevant studies?
Section snippets
Pre-registration of the systematic review protocol
The protocol for this review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) number CRD42018097352.
Search strategy
Following initial scoping searches, four electronic databases (Medline, PsycINFO, Scopus and Web of Science) were searched for relevant literature from inception to July 2018. Search terms were adapted from a previous, published review exploring SWB in a clinical sample (Schrank et al., 2013). An information specialist with expertise in bibliographic
Results
Fig. 1 illustrates the PRISMA flow from searches to included articles as recommended by PRISMA guidelines. The searches identified 921 records, of which 11 studies met full criteria and are included in the current review.
Results of the meta-analyses
As mentioned previously, meta-analyses were conducted separately for each SWB measure post-treatment (MHC-SF score, PWB score, SWLS score, WBMMS score and WEMWBS score). As previously stated, SMD is a standardised measure used in meta-analysis when included studies assess the same outcome (SWB) but measure it in a variety of ways. As illustrated in Fig. 4, results in those studies that measured SWB using the MHC-SF, and SWLS show consistent, significant small-moderate effect sizes in favour of
Discussion
The aim of the current review was to synthesise and critically appraise the research findings of randomised controlled trials (RCTs) investigating ACT interventions that assessed subjective wellbeing (SWB) as an outcome. The review sought to evaluate the methodological rigor of these RCTs, the ranges of assessment measures used, and the reported levels of efficacy of ACT in bringing about changes in SWB. Eleven studies were identified as meeting criteria for inclusion.
Methodological quality and rigor
The Cochrane Risk of Bias Tool was utilised to assess risk of bias (Higgins & Green, 2011). The methodological quality of the included studies was variable. In one domain ‘blinding of participants/personnel’, a high risk of performance bias was found across all the included studies. This represents an important limitation of therapy research in general, and is not specific to ACT (Munder & Barth, 2018). Three studies (Pots et al., 2016; Räsänen et al., 2016; Trompetter et al., 2014)
Conclusion
The current systematic review sought to synthesise and critically appraise the research findings of RCTs of ACT interventions that have assessed SWB. Whilst caution must be exercised when generalising the findings of this review, the included studies indicate that ACT interventions show evidence of being beneficial in enhancing SWB in clinical and non-clinical populations. Future RCTs that include standardised measures of SWB are necessary to facilitate further meta-analysis. The methodological
Declaration of competing interest
None.
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