Abstract

There is a high prevalence of distress amongst cancer patients, with up to 40% reporting clinically-significant levels of distress, such as depression, anxiety, and death anxiety. Acceptance and Commitment Therapy (ACT) has a growing evidence base in health populations, such as in diabetes and chronic pain, counteracting the avoidant behaviours which are negatively implicated in outcomes. ACT claims that experiential acceptance is key to shifting the avoidant responses people exhibit towards their inner experiences and psychological pain. Thus far, there is limited research exploring ACT processes within a cancer population. Traditional existentially-informed theory has claimed that accepting death anxiety would be psychologically paralysing and that mortality must be defended against, yet evidence for acceptance suggests the opposite. This study therefore aimed to explore the relationship between acceptance and outcomes of quality of life and distress in a cancer population, in order to explore the implications for an accepting response style, and also whether avoidant or approach response styles were implicated in better or worse psychological outcomes.
Using a longitudinal design, six standardised questionnaires, well-utilised in cancer populations, were issued to 72 adults with experience of cancer, measuring clinical variables, cancer appraisals, response styles, and both quality of life and distress outcomes. The addition of a follow-up questionnaire, completed by 31 participants after three months, allowed for predictive and cross-lag analyses to be carried out. Results showed acceptance to be an independent explanatory and predictive response style variable for both quality of life and distress outcomes, in the direction of psychological health. ‘Avoidant’ response styles were negatively implicated in outcomes, and many ‘approach’ response styles other than acceptance did not reach correlational significance with outcome variables. Acceptance and avoidant response styles remained stable over time, whilst outcomes continued to change, and acceptance was thought to be driving future outcomes in a one-way direction.
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The findings support the notion that experiential acceptance is implicated in beneficial psychological outcomes for cancer populations, rather than being detrimental to functioning, as suggested by existential theorists. Acceptance demonstrated significantly more influence over outcomes than either disease characteristics or threatening illness appraisals, and may influence future functioning. Furthermore, avoidant responses to cancer-related experiences were negatively implicated in psychological distress and also quality of life, which continued to deteriorate over time despite avoidant response styles remaining stable. Acceptance may be a helpful and influential response style, given that it predicts and potentially influences future functioning, and may provide a reasonable treatment target for psychological intervention with cancer patients, over and above the direct targeting of cancer appraisals.

Objective. 40% of cancer patients may experience clinically-significant levels of distress, yet evidence for appropriate psycho-oncological interventions remains lacking. This study aimed to explore acceptance, as defined by acceptance and commitment therapy (ACT), in cancer patients. Primary aims investigated whether acceptance was related to and predictive of better quality of life and distress outcomes, and whether acceptance interacted with cancer appraisals to influence outcomes.
Design. Longitudinal, quantitative design with a follow-up after three months. Participants completed a battery of questionnaires at times one and two.
Measures. 72 participants completed standardised questionnaire batteries comprising: Brief Illness Perception Questionnaire; Brief COPE; Acceptance and Action Questionnaire II; Hospital Anxiety and Depression Scale; Functional Assessment of Cancer Therapy – General (FACT-G); and Death Anxiety Scale (DAS). 31 participants repeated the battery after three months.
Results. Acceptance was an independent explanatory and predictive variable for quality of life and distress scores, in the direction of psychological health, and predicted functioning over time. Acceptance had greater explanatory power for outcomes than either cancer appraisals or avoidant response styles, including denial and self-distraction. Avoidant response styles showed significant associations with outcomes, but in the directions of greater distress and poorer quality of life.
Conclusions. The findings support the role of an accepting response style in improved psychological outcomes. Avoidant responses were consistently related to poorer outcomes in a population with distress and death anxiety. Acceptance predicts functioning, and is supported as a helpful response style for cancer patients.