The Impact of Psychological Flexibility on Mental Health of Chinese University Students: A Narrative Review
Abstract
Psychological flexibility (PF) is a core concept of Acceptance and Commitment Therapy (ACT), the "third wave" of Cognitive Behavioural Therapy, which is closely related to mental health. This review elaborates on the origins, concepts, connotations, and bio-psycho-social significance of Psychological flexibility. By summarising the progress of research in China and abroad, we explore the relevant factors, interventions, and prospects of psychological flexibility affecting the mental health of Chinese university students to provide a basis for enhancing the psychological flexibility and promoting the mental health of Chinese university students. We systematically searched all literature published from March 2004 to March 2024 through PsycINFO, Web of Science, Scopus, and China National Knowledge Infrastructure (CNKI) databases. A total of 12 articles were included based on the inclusion and exclusion criteria. The reviewed articles showed that psychological flexibility is closely related to personality health and coping mechanisms of Chinese university students, and affects existing psychological symptoms and negative behaviours such as stress, pain, anxiety, and depression. Many factors, including sociodemographic factors, will affect psychological flexibility. Therefore, some intervention measures can be implemented to improve psychological flexibility and promote mental health. This review shows that it is necessary to pay attention to the psychological flexibility of Chinese university students and analyse its impact on mental health to develop effective targeted intervention measures.
Downloads
References
Azadeh, S. M., Kazemi-Zahrani, H., & Besharat, M. A. (2016). Effectiveness of acceptance and commitment therapy on interpersonal problems and psychological flexibility in female high school students with social anxiety disorder. Global journal of health science, 8(3), 131-138.
Bai, Z., Luo, S., & Zhang, L. (2020). Acceptance and commitment therapy (ACT) to reduce depression: a systematic review and meta-analysis. Journal of Affective Disorders, 260, 728-737.
Bardeen, J. R., & Fergus, T. A. (2016). The interactive effect of cognitive fusion and experiential avoidance on anxiety, depression, stress and posttraumatic stress symptoms. Journal of contextual behavioral science, 5(1), 1-6.
Beeckman, M., Hughes, S., Van Ryckeghem, D., Van Hoecke, E., Dehoorne, J., Joos, R., & Goubert, L. (2019). Resilience factors in children with juvenile idiopathic arthritis and their parents: the role of child and parent psychological flexibility. Pain Medicine, 20(6), 1120-1131.
Bluett, E. J., Lee, E. B., Simone, M., Lockhart, G., Twohig, M. P., Lensegrav-Benson, T., & Quakenbush-Roberts, B. (2016). The role of body image and psychological flexibility in the treatment of eating disorders in a residential facility. Eating Behaviors, 23, 150-155.
Brenner, L. A., Forster, J. E., Hoffberg, A. S., Matarazzo, B. B., Hostetter, T. A., Signoracci, G., & Simpson, G. K. (2018). Window to hope: a randomized controlled trial of a psychological intervention for the treatment of hopelessness among veterans with moderate to severe traumatic brain injury. The Journal of Head Trauma Rehabilitation, 33(2), E64-E73
Brown, F. L., Whittingham, K., & Sofronoff, K. (2015). Parental experiential avoidance as a potential mechanism of change in a parenting intervention for parents of children with pediatric acquired brain injury. Journal of Pediatric Psychology, 40(4), 464-474.
Callahan, K. E., Stori, S. A., & Donahue, J. J. (2021). Psychological inflexibility processes and nonsuicidal self-injury: Concurrent and prospective associations. Journal of Clinical Psychology, 77(6), 1394–1411.
Cattivelli, R., Castelnuovo, G., Musetti, A., Varallo, G., Spatola, C. A., Riboni, F. V., ... & Molinari, E. (2018). ACT on health study protocol: promoting psychological flexibility with activity tracker and health tools to foster healthful lifestyle for obesity and other chronic health conditions. Trials, 19, 1-11.
Chen, L., Zhao, R. L., & Chen, H. (2017). Some university freshmen in Wuhan responded to the Research on the relationship between style and non-suicidal self-injurious behavior. Middle Chinese Journal of Epidemiology,38(12), 1607-1610.
Chen, W. Q., Duan, T. B., & Xiao, Y. N. (2019). Analysis of mental health of medical students. Industry and Technology Forum, 18(12), 126-127.
Chen, W., Chen, X., & Wang, G. P. (2010). Investigation and Analysis of Mental Health Status and the Influencing Factors in University of South China Students. Journal of University of South China (Medical Edition), 11(05), 606-610+637. https://doi.org/
CNKI:SUN:HYYY.0.2010-05-005.
Chen, Y. & Zhu, Z.H. (2019). Application of acceptance and commitment therapy in the treatment of depression (review). Chinese Journal of Mental Health, 33(9), 679-684.
Chirico, F. (2016). Spiritual well-being in the 21st century: it is time to review the current who is health definition. Journal of Health and Social Sciences, 1(1), 11-16.
Densham, S., Williams, D., Johnson, A., & Turner-Cobb, J. M. (2016). Enhanced psychological flexibility and improved quality of life in chronic fatigue syndrome/myalgic encephalomyelitis. Journal of psychosomatic research, 88, 42-47.
Dyson, R., & Renk, K. (2006). Freshmen adaptation to university life: Depressive symptoms, stress, and coping. Journal of Clinical Psychology, 62(10), 1231–1244. https://doi.org/10.1002/jclp.20295
Egger, M., Smith, G. D., & Altman, D. G. (2001). Systematic Reviews in Health Care: Meta-Analysis in Context. London, UK: BMJ Publishing Group.
Foster, K. T., Ehrnstrom, C., Chermack, S., & Hosanagar, A. (2016). Pain moderates changes in psychological flexibility but not substance use symptoms during substance use disorder treatment. Psychiatry research, 245, 51-57.
Ge, L., Guo, J., & Wang, J. J. (2011). Application and prospects of acceptance and commitment therapy in mental illness. Contemporary Nurses, 28(11), 5-7.
Ge, X. H. (2016). Research on the relationship between adolescents’ mobile phone dependence, psychological flexibility and social support. Journal of Jiangxi Youth Vocational College, 26(5), 23-26.
Glende, P. (2008). Preparing literature reviews: Qualitative and quantitative approaches. Journalism History, 34(1), 58-59.
Grant, M. J., & Booth, A. (2009). A typology of reviews: an analysis of 14 review types and associated methodologies. Health information & libraries journal, 26(2), 91-108.
Green, B. N., Johnson, C. D., & Adams, A. (2006). Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. Journal of chiropractic medicine, 5(3), 101-117.
Grégoire, S., Lachance, L., Bouffard, T., & Dionne, F. (2018). The use of acceptance and commitment therapy to promote mental health and school engagement in university students: A multisite randomized controlled trial. Behavior therapy, 49(3), 360-372.
Guo, H. N., Xiong, P. D., Cao, J. Ge, X. H., & Zhu, Z. H. (2015). Study on the relationship between psychological flexibility and Type D personality of enterprise employees. Chinese Journal of Health Statistics, 32(02), 267–269. https://doi.org/ CNKI:SUN:
ZGWT.0.2015-02-023
Han, R. H., Schmidt, M. N., Waits, W. M., Bell, A. K. C., & Miller, T. L. (2020). Planning for Mental Health Needs During COVID-19. Current Psychiatry Reports, 22, 1–10. https://doi.org/10.1007/s11920-020-01189-6
Hayes, S. C. (2016). Acceptance and Commitment Therapy, Relational Frame Theory, and the Third Wave of Behavioral and Cognitive Therapies – Republished Article. Behavior Therapy, 47(6), 869–885. https://doi.org/10.1016/j.beth.2016.11.006
Hayes, S. C. (2019). Acceptance and commitment therapy: Towards a unified model of behaviour change. World Psychiatry, 18(2), 226. https://doi.org/10.1002/wps.
Hayes, S. C., & Wilson, K. G. (1994). Acceptance and commitment therapy: Altering the verbal support for experiential avoidance. The Behavior Analyst, 17(2), 289-303.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: model, processes and outcomes. Behaviour Research & Therapy, 44(1), 1-25.
Hayes, S. C., Masuda, A., Bissett, R., Luoma, J., & Guerrero, L. F. (2004a). DBT, FAP, and ACT: How empirically oriented are the new behavior therapy technologies?. Behavior therapy, 35(1), 35-54. https://doi.org/10.1016/S0005-7894(04)80003-0
Hayes, S. C., Strosahl, K. D., & Strosahl, K. (Eds.). (2004b). A practical guide to acceptance and commitment therapy.New York: Springer Science & Business Media. https://doi.org/10.1007/978-0-387-23369-7
Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and commitment therapy as a unified model of behavior change. The Counselling Psychologist, 40(7), 976-1002. https://doi.org/10.1177/0011000012460836
Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2023). The idionomic future of cognitive behavioral therapy: What stands out from criticisms of ACT development. Behavior Therapy, 54(6), 1036-1063. https://doi.org/10.1016/j.beth.2023.07.011
Hayward, R. D., Taylor, W. D., Smoski, M. J., Steffens, D. C., & Payne, M. E. (2013). Association of five-factor model personality domains and facets with presence, onset, and treatment outcomes of major depression in older adults. American Journal of Geriatric Psychiatry, 21(1), 88–96. https://doi.org/10.1016/j.jagp.2012.
012
Hsu, T., Adamowicz, J. L., & Thomas, E. B. (2023). The effect of acceptance and commitment therapy on the psychological flexibility and inflexibility of undergraduate students: A systematic review and three-level meta-analysis. Journal of contextual behavioral science, 30, 169-180. https://doi.org/10.1016/j.jcbs.2023.10.006
Hu, L., Cao, J., &Zhu, Z. H. (2015). Analysis on the relationship between psychological flexibility and the state of anxiety and depression of cancer patients.Chinese Journal of Behavioral Medicine and Brain Science, 24(6), 517-520.https://doi.org/10.3760/
cma.j.issn.1674-6554.2015.06.010.
Hu, Z. Z., Hu, M. R., & Chen J. Y. (2021). Acceptance and commitment therapy in borderline people: Application in personality disorders. Chinese Journal of Behavioral Medicine and BrainSciences, 30(1), 84-89.
Huang, B. Z., Lin, T. T., & Chen, Z. Y. (2019). Correlation analysis of medical students’ personality traits and mental health status. Medical Education Research and Practice, 27(02), 304-308.
Huang, F., Guo, L. X., & Zhu, X. M. (2017). The mediating role of psychological flexibility between type D personality and pathological Internet use in college students. Chinese Journal of Behavioral Medicine and Brain Science, 26(12), 1123–1126.
Jiang, J. B., Ren, L., & Wu, Lin. (2019). Research on mindfulness therapy. Chinese health medicine Journal of Science and Technology, 21(6), 604-606. https://doi.org/10.3969/j.issn.1674-3245.2019.06.037.
Juncos, D. G., Heinrichs, G. A., Towle, P., Duffy, K., Grand, S. M., Morgan, M. C., ... & Kalkus, E. (2017). Acceptance and commitment therapy for the treatment of music performance anxiety: A pilot study with student vocalists. Frontiers in Psychology, 8, 1-16.
Kamody, R. C., Berlin, K. S., Rybak, T. M., Klages, K. L., Banks, G. G., Ali, J. S., ... & Diaz Thomas, A. M. (2018). Psychological flexibility among youth with type 1 diabetes: relating patterns of acceptance, adherence, and stress to adaptation. Behavioral Medicine, 44(4), 271-279.
Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical psychology review, 30(7), 865-878.
Larsson, A., Hartley, S., & McHugh, L. (2022). A randomised controlled trial of brief web-based acceptance and commitment Therapy on the general mental health, depression, anxiety and stress of college Students. Journal of Contextual Behavioral Science, 24, 10-17. https://doi.org/10.1016/j.jcbs.2022.02.005
Lei, T. Y., Tang, Z. H., Wei, Q. L., & Li, C. Z. (2019). Intervention study of acceptance and commitment therapy on college students with psychological abnormalities. Journal of Science and Education, 8(Mid-term issue), 164-166.
Li, J. L. (2020). An analysis of university students' mental health problems and their influencing factors. Reform & opening, (08), 124–125. https://doi.org/10.16653/
j.cnki.321034/f.2020.08.061.
Li, M., Su, W., & Zhou, T. (2017). Investigation on the impact of clinical internship stress on the mental health of medical students. Chinese Journal of Health Psychology, 25(04),595-598.
Li, X., Ji,Y., & Zhu. Z. H. (2015). A study on the relationship between psychological flexibility and mental health of university students. Chinese Journal of Health Statistics, 32(02), 313-316. https://doi.org/:CNKI:SUN:ZGWT.0.2015-02-040.
Liu, B., & Zhang, Y. B.(2019). Research on the correlation between mental health and psychological flexibility of university students. China Health Statistics, 36(2),252-254.
McCracken, L. M. (2013). Committed action: An application of the psychological flexibility model to activity patterns in chronic pain. The Journal of Pain, 14(8), 828-835.
McHugh, L. (2011). A new approach in psychotherapy: ACT (acceptance and commitment therapy). The World Journal of Biological Psychiatry, 12(sup1), 76-79.https://doi.org/10.3109/15622975.2011.603225.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Prisma Group. (2010). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. International journal of surgery, 8(5), 336-341.
Moola, S., Munn, Z., Tufanaru, C., Aromataris, E., Sears, K., Sfetcu, R., … Mu, P. (2017). Systematic reviews of aetiology and risk. In E. Aromataris & Z. Munn (Eds.), Joanna briggs institute reviewer's manual. Adelaide, Australia: The Joanna Briggs Institute.
Paliliunas, D., Belisle, J., & Dixon, M. R. (2018). A randomized control trial to evaluate the use of acceptance and commitment therapy (ACT) to increase academic performance and psychological flexibility in graduate students. Behavior analysis in practice, 11, 241-253.
Peltz, J.S., Rogge, R.D., Bodenlos, J.S., Kingery, J.N., & Pigeon, W.R. (2020). Changes in psychological inflexibility as a potential mediator of longitudinal links between college students’ sleep problems and depressive symptoms. Journal of contextual behavioralscience, 15, 110–122.
Prevedini, A. B., Presti, G., Rabitti, E., Miselli, G., & Moderato, P. (2011). Acceptance and commitment therapy (ACT): the foundation of the therapeutic model and an overview of its contribution to the treatment of patients with chronic physical diseases. G Ital Med Lav Ergon, 33(1 Suppl A), A53-63.
Ran, Y.Q. (2020). Research on the relationship between social support, self-esteem and mental health of poor college students - based on questionnaire survey data of college students in Chongqing. Higher Education Research and Practice, 39(02),74-79.
Rose, M. R., Norton, S., Vari, C., Edwards, V., McCracken, L., Graham, C. D., ... & Chalder, T. (2018). Acceptance and Commitment Therapy for Muscle Disease (ACTMus): protocol for a two-arm randomised controlled trial of a brief guided self-help ACT programme for improving quality of life in people with muscle diseases. BMJ open, 8(10), e022083.
Saleem, J., Iftikhar, A., Saleem, S., Majeed, S., Siddiqui, A., & Ain, Qurat. Ul. (2022). Personality Styles and Mental Health Challenges in University Students. Pakistan Journal of Medical and Health Sciences, 16(8), 156–159. https://doi.org/10.53350/
pjmhs22168156
Scent, C. L., & Boes, S. R. (2014). Acceptance and commitment training: A brief intervention to reduce procrastination among college students. Journal of College Student Psychotherapy, 28(2), 144-156. https://doi.org/10.1080/87568225.
883887
Simon, E., & Verboon, P. (2016). Psychological inflexibility and child anxiety. Journal of Child and Family Studies, 25, 3565-3573.
Tee, K. R., Ismail, A. S., Ang, Y. H., Hishamuddin, H. H., Paul, V. J., Aizuddin, A. N., & Zaini, I. Z. (2022). Prevalence of Anxiety and Burnout, and Coping Mechanisms among Clinical Year Medical Undergraduate Students in Universiti Kebangsaan Malaysia Amidst the COVID-19 Pandemic. International Journal of Environmental Research and Public Health, 19(20), 13010. https://doi.org/10.3390/ijerph192013010
Tufanaru, C., Munn, Z., Aromataris, E., Campbell, J., & Hopp, L. (2017). Systematic reviews of effectiveness. In E. Aromataris & Z. Munn (Eds.), Joanna briggs institute reviewer's manual. Adelaide, Australia: The Joanna Briggs Institute.
Twohig, M. P., Abramowitz, J. S., Smith, B. M., Fabricant, L. E., Jacoby, R. J., Morrison, K. L., ... & Ledermann, T. (2018). Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial. Behaviour research and therapy, 108, 1-9.
Villatte, J. L., Vilardaga, R., Villatte, M., Vilardaga, J. C. P., Atkins, D. C., & Hayes, S. C. (2016). Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes. Behaviour research and therapy, 77, 52-61.
Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., & Taylor, C. B. (2015). Effectiveness of Acceptance and Commitment Therapy in treating depression and suicidal ideation in Veterans. Behaviour research and therapy, 74, 25-31.
Wang, H. L., Liu, W. F., Tao, R. (2014). Effect of acceptance and commitment therapy group psychological counselling on social anxiety among college students. Sichuan Mental Health, 27 (1),13-15.
Wang, K., & Qi, B. (2015). Research on review on psychological flexibility and health. Journal of Baoding University, 29(2), 86- 92.https://doi.org/10.13747/j.cnki.
bdxyxb.2015.02.015.
Wang, P. (2015). Psychological Flexibility as a Protective Factor for Mental Health. Journal of Soochow University(Educational Science Edition), (02), 57-64. https://doi.org/ j.cnki.sdjk.2015.02.007.
Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. International journal of clinical and health psychology, 18(1), 60-68. https://doi.org/10.1016/j.ijchp.2017.09.002
Woidneck, M. R., Morrison, K. L., & Twohig, M. P. (2014). Acceptance and commitment therapy for the treatment of posttraumatic stress among adolescents[J]. Behavior Modification, 38(4), 451-476.
Xu, L. (2022). Research on the intervention of music group therapy on psychological flexibility and psychological stress of college students. Art Education, 22, 119-120.
Xu, S.S., Li, J. X., Fan, W., & Zhang, J. (2018). The impact of acceptance and commitment therapy teaching on the mental health of college students in sports colleges. Sports Research, 39(3), 92-98.
Yang, C. Y., Liu, J., & Liu, L. (2019). The relationship between cognitive fusion, experiential avoidance and depression level in patients with depression. Clinical Psychiatry, 33(3), 182-186.
Yang, X., Wang, S. J., & Zhu Z. H. (2019). Big-data-based research on the correlation between psychological flexibility and healthy personality of undergraduates. Anatomy Research, 41(6), 522-526,530. https://doi.org/CNKI:SUN:GDJP.0.2019-06-01
Yıldız, E. (2020). The effects of acceptance and commitment therapy on lifestyle and behavioral changes: A systematic review of randomized controlled trials. Perspectives in psychiatric care, 56(3), 657-690.
Zarling, A., Lawrence, E., & Marchman, J. (2015). A randomized controlled trial of acceptance and commitment therapy for aggressive behavior. Journal of consulting and clinical psychology, 83(1), 199-212.
Zhang, L. L., Wang, F., Chu, Y. Y. (2021). Research progress on adolescent psychological flexibility. Occupation and Health, 37(11), 1567-1571. https://doi.org/10.13329/
j.cnki.zyyjk.2021.0380
Zhang, Q., Wang, S., & Zhu, Z. (2012). The psychopathological model and therapeutic approach of acceptance and commitment therapy. Chinese Mental Health Journal, 26(5), 377–381.
Zhang, Y., & Liu, B. (2019). A study on the correlation between mental health and psychological flexibility of college students. Chinese Journal of Health Statistics, 36(2), 252–254.
Zhao, X. (2023). Models, measurements, influencing factors, and interventions of psychological flexibility. Advances in Psychology, 13(9), 4062–4067. https://doi.org/
12677/AP.2023.139511