Psychological flexibility correlates with patient-reported outcomes independent of clinical or sociodemographic characteristics



The evidence for the effectiveness of psychological interventions for cancer patients is currently unclear. Acceptance and Commitment Therapy (ACT), which increases individual’s levels of psychological flexibility, may be more effective than other frameworks of psychological intervention, but good quality research is needed to inform adoption and implementation. This study explored the correlation between psychological flexibility and patient-reported outcomes to assess the viability of this intervention for cancer survivors.


Recruitment was coordinated through a regional cancer centre. One hundred twenty-nine respondents completed a cross-sectional postal questionnaire. They were of mixed gender, diagnosis and cancer stage; a mean 61 years old; and a mean 207 days post-diagnosis. Self-report questionnaires assessed psychological flexibility, mood, anxiety, depression, stress, quality of life and benefit finding.


Psychological flexibility was a strong and consistent correlate of outcome; effects were maintained even when potentially confounding clinical and sociodemographic characteristics were controlled.


Psychological flexibility can be modified through ACT-based interventions. Given the strong correlational evidence found in this study, it seems that such interventions might be useful for cancer survivors. High-quality and well-designed controlled trials are now needed to establish effectiveness.

This is a preview of subscription content, access via your institution.


  1. 1.

    Gao W, Bennett MI, Stark D, Murray S, Higginson IJ (2010) Psychological distress in cancer from survivorship to end of life care: prevalence, associated factors and clinical implications. Eur J Cancer 46:2036–2044. doi:10.1016/j.ejca.2010.03.033

    Article  PubMed  Google Scholar 

  2. 2.

    Macmillan (2006) Worried sick: the emotional impact of cancer. Macmillan Cancer Support, London UK

    Google Scholar 

  3. 3.

    Maguire P (2000) Psychological aspects. In: Dixon M (ed) ABC of breast diseases. BMJ Books, London, pp 150–153

    Google Scholar 

  4. 4.

    Osborn RL, Demoncada AC, Feuerstein M (2006) Psychosocial interventions for depression, anxiety and quality of life in cancer survivors: meta-analysis. Int J Psychiatry Med 36:13–34. doi:10.2190/EUFN-RV1K-Y3TR-FK0L

    Article  PubMed  Google Scholar 

  5. 5.

    Edwards AGK, Hulbert-Williams NJ, Neal RD (2008). Psychological interventions for women with metastatic breast cancer. Cochrane Database of Systematic Reviews Issue 2. Art. No.: CD004253, doi: 10.1002/14651858.CD004253.pub3.

  6. 6.

    Williams C, Garland A (2002) A cognitive-behavioural therapy assessment model for use in everyday clinical practice. Adv Psychiatr Treat 8:172–179. doi:10.1192/apt.8.3.172

    Article  Google Scholar 

  7. 7.

    Hayes SC, Strosahl KD, Wilson KG (2011) Acceptance and Commitment Therapy: the process and practice of mindful change. Guildford Press, New York

    Google Scholar 

  8. 8.

    Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J (2006) Acceptance and Commitment Therapy: model, processes and outcomes. Behav Res Ther 44:1–15. doi:10.1016/j.brat.2005.06.006

    Article  PubMed  Google Scholar 

  9. 9.

    Hulbert-Williams NJ, Storey L, Wilson KG (2015) Psychological interventions for patients with cancer: psychological flexibility and the potential utility of Acceptance and Commitment Therapy. Eur J Cancer Care (Engl) 24:15–27. doi:10.1111/ecc.12223

    CAS  Article  Google Scholar 

  10. 10.

    Longmore RJ, Worrell M (2007) Do we need to challenge thoughts in cognitive behavior therapy? Clin Psychol Rev 27:173–187. doi:10.1016/j.cpr.2006.08.001

    Article  PubMed  Google Scholar 

  11. 11.

    Powers MB, Zum Vörde Sive Vörding MB, Emmelkamp PMG (2009) Acceptance and Commitment Therapy: a meta-analytic review. Psychother Psychosomatics 78:73–80. doi:10.1159/000190790

    Article  Google Scholar 

  12. 12.

    Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL (2007) Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. J Consult Clin Psychol 75:336–343. doi:10.1037/0022-006X.75.2.336

    Article  PubMed  Google Scholar 

  13. 13.

    Lundgren T, Dahl J, Yardi N, Melin L (2008) Acceptance and Commitment Therapy and yoga for drug-refractory epilepsy: a randomized controlled trial. Epilepsy Behav 13:102–108. doi:10.1016/j.yebeh.2008.02.009

    Article  PubMed  Google Scholar 

  14. 14.

    Skinta MD, Lezama M, Wells G, Dilley JW (2014). Acceptance and compassion-based group therapy to reduce HIV stigma. Cognitive and Behavioural Practice e-publication ahead of print. doi:10.1016/j.cbpra.2014.05.006.

  15. 15.

    Wicksell RK, Kemani M, Jensen K, Kosek E, Kadetoff D, Sorjonen K, Ingvar M, Olsson GL (2012) Acceptance and commitment therapy for fibromyalgia: a randomized controlled trial. Eur J Pain 17:599–611. doi:10.1002/j.1532-2149.2012.00224.x

    Article  PubMed  Google Scholar 

  16. 16.

    Wetherell JL, Afari N, Rutledge T, Sorrell JT, Stoddard JA, Petkus AJ, Solomon BC, Lehman DH, Liu L, Lang AJ, Atkinson JH (2011) A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioural therapy for chronic pain. Pain 152:2098–2107. doi:10.1016/j.pain.2011.05.016

    Article  PubMed  Google Scholar 

  17. 17.

    Feros DL, Lane L, Ciarrochi J, Blackledge JT (2013) Acceptance and Commitment Therapy (ACT) for improving the lives of cancer patients: a preliminary study. Psycho-Oncology 22:459–464. doi:10.1002/pon.2083

    PubMed  Google Scholar 

  18. 18.

    Rost AD, Wilson KG, Buchanan E, Hildebrandt MJ, Mutch D (2012) Improving psychological adjustment among late-stage ovarian cancer patients: examining the role of avoidance in treatment. Cogn Behav Pract 19:508–517. doi:10.1016/j.cbpra.2012.01.003

    Article  Google Scholar 

  19. 19.

    Gillanders DT, Sinclair AK, MacLean M & Jardine K (2015). Illness cognitions, cognitive fusion, avoidance and self-compassion as predictors of distress and quality of life in a heterogenous sample of adults, after cancer. J Contextual Behav Scie, 1–2. DOI: 10.1016/j.jcbs.2015.07.003

  20. 20.

    Luoma JB, Kohlenberg BS, Hayes SC, Fletcher L (2012) Slow and steady wins the race: a randomized clinical trial of acceptance and commitment therapy targeting shame in substance use disorders. J Consult Clin Psychol 80:43–53. doi:10.1037/a0026070

    Article  PubMed  Google Scholar 

  21. 21.

    Trompetter HR, Bholmeijer ET, Veehof MM, Schreurs KMG (2014). Internet-based guided self-help intervention for chronic pain based on Acceptance and Commitment Therapy: a randomized controlled trial. Journal of Behavioral Medicine, e-publication ahead of print doi: 10.1007/s10865-014-9579-0.

  22. 22.

    McCracken LM, Sato A, Taylor GJ (2013) A trial of a brief group-based form of acceptance and commitment therapy (ACT) for chronic pain in general practice: pilot outcome and process results. J Pain 14:1398–1406. doi:10.1016/j.jpain.2013.06.011

    Article  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Hawkes AL, Patrao TA, Green A, Aitken JF (2012) CanPrevent: a telephone-delivered intervention to reduce multiple behavioural risk factors for colorectal cancer. BMC Cancer 12:560–569. doi:10.1186/1471-2407-12-560

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Bond FW, Hayes SC, Baer RA, Carpenter KM, Guenole N, Orcutt HK, Waltz T, Zettle RD (2011) Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther 42:676–688. doi:10.1016/j.beth.2011.03.007

    Article  PubMed  Google Scholar 

  25. 25.

    Baer RA, Smith GT, Allen KB (2004) Assessment of mindfulness by self-report. Assessment 11:191–206. doi:10.1177/1073191104268029

    Article  PubMed  Google Scholar 

  26. 26.

    Carver CS (1997) You want to measure coping but your protocol’s too long: consider the brief COPE. Int J Behav Med 4:92–100. doi:10.1207/s15327558ijbm0401_6

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Meyer B (2001) Coping with severe mental illness: relations of the brief COPE with symptoms, functioning, and well-being. J Psychopathol Behav Assess 23:265–277

    Article  Google Scholar 

  28. 28.

    Watson M, Law MG, dos Santos M, Greer S, Baruch J, Bliss J (1994) The Mini-MAC: Further development of the Mental Adjustment to Cancer Scale. J Psychosoc Oncol 12:33–46. doi:10.1300/J077V12N03_03

    Article  Google Scholar 

  29. 29.

    Watson D, Clark LA, Tellegen A (1988) Development and validation of brief measures of positive and negative affect: the PANAS scales. J Pers Soc Psychol 54:1063–1070. doi:10.1037/0022-3514.54.6.1063

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Zigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavia 67:361–370. doi:10.1111/j.1600-0447.1983.tb09716.x

    CAS  Article  Google Scholar 

  31. 31.

    Cohen S, Kamarack T, Mermelstein R (1983) A global measure of perceived stress. J Health Soc Behav 3:385–396

    Article  Google Scholar 

  32. 32.

    Cella DF, Tulsky DS, Gray G, Sarafian B, Linn E, Bonomi A, Silberman M, Yellen SB, Winicour P, Brannon J (1993) The Functional Assessment of Cancer Therapy (FACT) scale: development and validation of the general measure. J Clin Oncol 11:570–579

    CAS  PubMed  Google Scholar 

  33. 33.

    Carver CS, Antoni MH (2004) Finding benefit in breast cancer during the year after diagnosis predicts better adjustment 5 to 8 years after diagnosis. Health Psychol 26:595–598. doi:10.1037/0278-6133.23.6.595

    Article  Google Scholar 

  34. 34.

    Tabachnick BG, Fidell LS (2006) Using multivariate statistics, 5th edn. Pearson Education Ltd., London UK

    Google Scholar 

  35. 35.

    Stanton AL, Leucken LJ, MacKinnon DP, Thompson EH (2013) Mechanisms in psychosocial interventions for adults living with cancer: opportunity for integration of theory, research, and practice. J Consult Clin Psychol 81:318–335. doi:10.1037/a0028833

    Article  PubMed  Google Scholar 

  36. 36.

    Watson EK, Rose PW, Neal RD, Hulbert-Williams N, Donnelly P, Hubbard G, Elliot J, Campbell C, Weller D, Wilkinson C (2012) Personalised cancer follow-up: risk stratification, needs assessment or both? Br J Cancer 106:1–5. doi:10.1038/bjc.2011.535

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  37. 37.

    Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M (2008) Developing and evaluating complex interventions: the new Medical Research Council Guidance. Br Med J 337:1655. doi:10.1136/bmj.a1655

    Article  Google Scholar 

  38. 38.

    Ciarrochi J, Fisher D, Lane L (2011) The link between value motives, value success, and well-being among people diagnosed with cancer. Psycho-Oncology 20:1184–1192

    Article  PubMed  Google Scholar 

  39. 39.

    Patel V, Chowdhary N, Rahman A, Verdeli H (2011) Improving access to psychological treatment: lessons from developing countries. Behav Res Ther 49:523–528. doi:10.1016/j.brat.2011.06.012

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Edwards P, Roberts I, Clarke M, DiGuiseppi C, Pratap S, Wentz R, Kwan I (2002) Increasing response rates to postal questionnaires: systematic review. Br Med J 324:1183. doi:10.1136/bmj.324.7347.1183

    Article  Google Scholar 

  41. 41.

    Ream E, Quennell A, Fincham L, Faithfull S, Khoo V, Wilson-Barnett J, Richardson A (2008) Supportive care needs of men living with prostate cancer in England: a survey. Br J Cancer 98:1903–1909. doi:10.1038/sj.bjc.6604406

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Morrison V, Henderson BJ, Zinovieff F, Davies G, Cartmell R, Hall A, Gollins S (2012) Common, important, and unmet needs of cancer outpatients. Eur J Oncol Nurs 16:115–123. doi:10.1016/j.ejon.2011.04.004

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Swash B, Hulbert-Williams N, Bramwell R (2014) Unmet psychosocial needs in haematological cancer: a systematic review. Support Care Cancer 22:1131–1141. doi:10.1007/s00520-014-2123-5

    CAS  Article  PubMed  Google Scholar 

Download references


We are grateful to Lynda Appleton and Helen Wong at The Clatterbridge Cancer Centre (UK) for their help in identifying suitable patients for this study. We would also like to thank Lee Hulbert-Williams for statistical and data analysis advice. This study was funded through a Capacity Building Grant from the University of Chester UK.

Author information



Corresponding author

Correspondence to Nicholas J. Hulbert-Williams.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest in respect to this work, and the publication thereof. The authors have full control of all primary data which can be provided to the journal on request.

Ethics approval

Ethical approval was granted via University and NHS Ethics Committees (NRES Committee North West—Liverpool East; REC Reference 11/NW/0381) and research governance approval was granted from the primary Cancer Treatment Centre.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Hulbert-Williams, N.J., Storey, L. Psychological flexibility correlates with patient-reported outcomes independent of clinical or sociodemographic characteristics. Support Care Cancer 24, 2513–2521 (2016).

Download citation


  • Cancer
  • Oncology
  • Intervention
  • Quality of life
  • Distress
  • Acceptance