Author’s Accepted Manuscript The relationship between psychological flexibility, early maladaptive schemas, perceived parenting and psychopathology Timothy D Fischer, Matthew F Smout, Paul H Delfabbro www.elsevier.com/locate/jcbs
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S2212-1447(16)30034-5 http://dx.doi.org/10.1016/j.jcbs.2016.06.002 JCBS131
To appear in: Journal of Contextual Behavioral Science Received date: 12 June 2015 Revised date: 11 April 2016 Accepted date: 6 June 2016 Cite this article as: Timothy D Fischer, Matthew F Smout and Paul H Delfabbro, The relationship between psychological flexibility, early maladaptive schemas, perceived parenting and psychopathology, Journal of Contextual Behavioral Science, http://dx.doi.org/10.1016/j.jcbs.2016.06.002 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
PSYCHOLOGICAL FLEXIBILITY SCHEMAS The relationship between psychological flexibility, early maladaptive schemas, perceived parenting and psychopathology Timothy D Fischera, Matthew F Smoutb*, Paul H Delfabbroa a
University of Adelaide
Centre for Treatment of Anxiety and Depression
Corresponding author. Matthew Smout, Centre for Treatment of Anxiety and Depression, 30 Anderson St, Thebarton SA 5031, AUSTRALIA. Email: [email protected]
Abstract Background Clinicians have begun to integrate Acceptance and Commitment Therapy (ACT) and Schema Therapy (ST) but there has been no empirical investigation into the relationship between their theoretical processes. Aims This study sought to explore the relationships between psychological flexibility, perceived parent behavior, early maladaptive schemas and psychopathology in a non-clinical undergraduate sample (N=117). Design
Using a series of structural equation models, psychological flexibility, measured as a latent variable (indicators: Acceptance and Action Questionnaire (AAQ-II), Cognitive Fusion Questionnaire (CFQ), Mindfulness Attention Awareness Scale (MAAS), Valuing Questionnaire (VQ)) was tested as both a mediator, and a moderator of the effect of Early Maladaptive Schemas (EMS, indicator: Young Schema Questionnaire (YSQ-3S)) on psychopathology (indicator: Depression Anxiety Stress Scales (DASS)), and of the effects of perceived parent behavior (indicator: Young Parenting Inventory (YPI)) on EMS. Results Psychological flexibility fully mediated the effect of EMS on psychopathology; EMS did not mediate the effect of psychological flexibility on psychopathology. Psychological flexibility also fully mediated the effect of parenting behavior on EMS, however a model where EMS mediated the effect of parenting behavior on psychological flexibility was equally viable. Simple slopes analysis suggested EMS moderated the effect of psychological flexibility on psychopathology. Parent behavior was not a significant predictor of EMS when measured with psychological flexibility. These results warrant exploration in clinical samples and using longitudinal designs. 1.1
PSYCHOLOGICAL FLEXIBILITY SCHEMAS A characteristic feature of acceptance and commitment therapy (ACT) is that it focuses on enhancing psychological flexibility and eschews attempts to alter cognitive structures (Hayes, Strosahl & Wilson, 2011). Psychological flexibility is “the ability to contact the present moment more fully as a conscious human being, and to change or persist with behavior when doing so serves valued ends” (Hayes, Luoma, Bond, Masuda & Lillis, 2006, p.7). There is considerable evidence that: psychological inflexibility is associated with depression (Leahy, Tirch & Melwani, 2012), anxiety (Panayiotou, Karekla, & Mete, 2014) and other psychopathology (e.g., Oliver, O’Connor, Jose, McLachlan, & Peters, 2012); that psychological flexibility is associated with health and resilience (Kashdan & Rottenberg, 2010); and, that ACT interventions influence its components (Levin, Hildebrandt, Lillis, & Hayes, 2012). Although the ACT therapist is instructed to understand the function of client private experiences in context - including their historical context - childhood developmental experiences are not particularly privileged and ACT protocols do not usually explore the origins of presenting problems in any systematic way. By contrast, Schema therapy (ST) “is explicitly concerned with the development (etiology) of current symptoms, and not only with the factors that maintain them” (Rafaeli, Bernstein, & Young, 2011, p.1). ST emerged out of 1980s efforts to integrate the structure and pragmatic focus of cognitive behavior therapy with case formulations inspired by psychodynamic and Gestalt therapies (Edwards & Arntz, 2012). ST focuses on helping clients identify and alter early maladaptive schemas (EMS): pervasive patterns of memories, emotions, cognitions and bodily sensations about the self and others, established in childhood or adolescence and repeated throughout life (Young, Klosko, & Weishaar, 2003). EMS are equivalent to dysfunctional “working models” in attachment theory. EMS have been found to be associated with depressive symptoms (Shah & Waller, 2000); eating disorders (Damiano, Reece, Reid, Atkins & Patton, 2015) and substance use (Shorey, Stuart, & Anderson, 2013). Intervention studies have demonstrated a reduction in strength of these EMS associated with a reduction in the degree of symptom severity (Nordahl, Holthe & Haugum, 2005; Wegener, Alfter, Geiser, Liedtke & Conrad, 2013). ST was developed to address the needs of the significant proportion of individuals who did not respond to traditional cognitive therapy and has demonstrated impressive success in promoting recovery from personality disorders (Bamelis, Evers, Spinhoven & Arntz, 2014; Giesen-Bloo et al., 2006). Recently, several authors have begun to recommend an integration of ACT and ST based upon complementarities and compatibilities in these approaches (McKay, Lev & Skeen, 2012; Parfy, 2012; Cousineau, 2012). ST provides inventories and a theoretical framework for detecting prototypical patterns of rules, evaluations and action tendencies likely to be prime objects of cognitive fusion. ST adopts a similar experiential style to ACT and may contribute new intervention strategies likely to promote defusion, such as ascribing thought content to different parts of the self in schema mode work. Similarly, acceptance and self-ascontext exercises drawn from ACT may serve to facilitate the ability to attend to schema triggers in order to recognise and label them (Cousineau, 2012). However, at present, there are no data available to indicate whether an integration of ACT and ST would improve outcomes compared to ACT or ST alone. 2
PSYCHOLOGICAL FLEXIBILITY SCHEMAS
Theoretical integration: psychological flexibility and early maladaptive schemas
At the theoretical level, little is known about the relationship between psychological flexibility and EMS. It seems likely that they share common influences. Certain parental styles are associated with the development of particular schemas. For example, emotional abuse (derogation, rejection, extortion, teasing) is associated with developing most types of EMS but especially those representing expectations of malevolent treatment by others (mistrust), abandonment, being vulnerable to harm and insufficient self-control (McCarthy & Lumley, 2012). Similarly, parental styles influence the development of psychological flexibility, with authoritarian (cold, distant, intrusive) parenting inhibiting it, and warm, democratic parenting promoting flexibility (Williams, Ciarrochi & Heaven, 2012). In research on mentalizing (the capacity to understand human behavior in relation to internal states such as thoughts, needs, feelings and wishes), certain facets of psychological flexibility have been theorized to develop from the reciprocal interactions between infants and their caregivers which also give rise to dysfunctional schemas. The infant’s capacity for both mindfulness and acceptance is thought to depend on the ability of the caregiver to attune to the infant’s emotions and simultaneously mirror back the affect and communicate that the affect is tolerable (Fonagy & Target, 1997). There is increasing evidence in adults that dispositional mindfulness is associated with secure attachment (Pepping & Duvenage, 2016). It also seems likely that EMS and psychological flexibility will interact during development. It is possible that some or all psychological flexibility components might constitute more advanced skills that may only be possible to develop after EMS are already acquired, but which may mitigate (i.e., moderate) the negative impact of EMS on psychological functioning. At the same, it is possible that EMS might constrain the extent to which psychological flexibility develops (i.e., EMS moderates effect of parenting experiences on psychological flexibility). A further possibility is that underdevelopment of psychological flexibility skills creates EMS (psychological flexibility mediates the effect of parenting experiences on EMS). By the time individuals reach adulthood, the nature of the relationship between EMS and psychological flexibility remains of interest, particularly with respect to their influence on psychopathology. A strong version of the psychological flexibility model suggests that the presence of EMS need not adversely affect an individual. ACT manuals frequently emphasize that suffering is normal, and no distinction is made between suffering that occurs during early childhood and that experienced later in life (e.g., Hayes et al., 2011). The degree of fusion with cognitive content, experiential avoidance of schema-driven affect and associated memories, would determine how much suffering is experienced. This is essentially a full mediation model: if EMSs exert an effect on psychopathology it is via reducing the degree of psychological flexibility. Alternatively, one could adopt a more interactionist perspective, where psychopathology was determined jointly by current levels of psychological flexibility and strength of EMS. It might be the case for example, that psychological flexibility has a greater influence on psychopathology for individuals with few 3
PSYCHOLOGICAL FLEXIBILITY SCHEMAS or weak EMS but for individuals with many and/or strong EMS, psychological flexibility has less influence on psychopathology (i.e., EMS moderates the relationship between psychological flexibility and psychopathology). Or equally plausibly, EMS may exert a strong effect on psychopathology at low levels of psychological flexibility but have less or no effect at high levels of psychological flexibility (i.e., psychological flexibility moderates the relation between EMS and psychopathology). The nature of the relationship between EMS, psychological flexibility and psychopathology should have implications for psychotherapy. If psychological flexibility mediates the effect of EMS on psychopathology, interventions that aim to alter schema content that do not also increase psychological flexibility would be unnecessary. Of course, if EMS have an independent effect on psychopathology, ACT protocols may need to be supplemented with interventions aimed at altering schemas to optimise outcomes. Establishing moderation relationships could inform decisions about whom to provide which intervention to. Wetherall and colleagues’ (2015) study illustrates a moderation effect of age on treatment response: older individuals with chronic pain responded better to ACT whereas younger adults responded better to cognitive behavior therapy. If EMS moderated the effect of psychological flexibility on psychopathology such that psychological flexibility was weakly related to psychopathology among those with many and/or strong EMS, it might suggest ST rather than ACT would be a preferred treatment for these individuals. However, it must be stressed that establishing which interventions best modify EMS or psychological flexibility is a separate endeavour to uncovering which variable best serves as moderator or mediator. For example, psychological flexibility might mediate the effect of EMS on psychopathology, but ST may better promote psychological flexibility than ACT interventions! Nevertheless, establishing relationships between the key theoretical variables should inform future efforts to modify protocols for both approaches.
Aims of the present study
It would be useful to know if and how early maladaptive schemas and psychological flexibility are related in adults. To our knowledge, there are no published investigations at this time. The present study sought to explore the relationships between retrospectivelyreported parenting experiences, early maladaptive schemas, psychological flexibility and psychopathology. In particular, it examined:
Whether psychological flexibility acted as a mediator or a moderator of the effect of schemas on psychopathology; Whether psychological flexibility acted as a mediator or moderator of the relationship between early parenting experiences and maladaptive schemas
1.3.1 Psychological Flexibility as a latent variable We chose to measure psychological flexibility as a latent construct using multiple indicators. Although the Acceptance and Action Questionnaire (AAQ-II, Bond et al., 2011) has been 4
PSYCHOLOGICAL FLEXIBILITY SCHEMAS most widely used measure of psychological flexibility, recently there have been concerns that it is conflated with psychological distress (Wolgast, 2014). Additionally, measures have recently been developed to measure specific core psychological flexibility processes that contribute additional variance in associated psychological processes beyond the AAQ (Gillanders et al., 2014; Smout et al., 2014). Furthermore, while multiple regression procedures assume that predictor variables are measured without error, this is rarely the case in practice. Modelling constructs of interest as latent variables allows the researcher to partition variance into that associated with measurement error and that reflecting the theoretical “true” score on the variable, which in turn can improve the precision of estimates of the strength of theoretical relationships involving the construct (Ullman, 2007). Scott, McCracken and Norton (2015) found a single latent psychological flexibility factor provided adequate fit accounting for the variability across three indicators. To our knowledge this is the first study to conduct mediation analyses using psychological flexibility as a latent variable.
In the absence of previous empirical findings and stronger theory we adopted the following working hypotheses: 1) We expected psychological flexibility to moderate the association between early maladaptive schemas and psychopathology, such that there would be a stronger association between schemas and psychopathology with lower psychological flexibility than at higher levels. 2) We expected that psychological flexibility would moderate the effect of perceived early parenting behavior on reported maladaptive schemas. Specifically, there would be less association between perceived parental behavior and maladaptive schemas with high psychological flexibility, but a strong association with low psychological flexibility. We also investigated whether psychological flexibility might fully mediate the relationship between perceived parenting behavior and maladaptive schemas, and the relationship between maladaptive schemas and psychopathology to provide a starting point for testing causal pathways in future studies.
Participants (N = 130) were University of Adelaide students, the majority (72%) from the introductory psychology course who received course credit. All others were unpaid volunteers. Twelve participants completed the survey faster than the minimum time permitted (15 minutes, based on pre-testing) and their data was excluded. A further 5
PSYCHOLOGICAL FLEXIBILITY SCHEMAS participant was excluded for apparent non-random insufficient effort responding. The final sample (n=117) was predominantly young (M = 20.0, SD = 4.11, range 18-42) and female (72%), participating for course credit (72%).
2.2.1 Psychopathology Psychopathology was assessed using the Depression Anxiety Stress Scales (DASS-21, Lovibond & Lovibond, 1995) which consists of three (Depression, Anxiety, Stress) 7-item scales rated on a scale of 0 (“did not apply to me at all”) to 3 (“applied to me very much or most of the time”) to yield a total score ranging from 0-63. The DASS has high internal consistency and strong convergent validity with other measures of anxiety and depression (Crawford & Henry, 2003). We attempted to model psychopathology from the 3 DASS subscales but preliminary confirmatory factor analyses of the measurement model (including specification of psychological flexibility in order to identify the model) found this did not fit the observed data adequately (χ2 =34.55, p < .001). Instead, we treated psychopathology as a single-indicator latent variable estimated from the DASS total score, which improved measurement model fit (χ2 = 1.52, p = .911). 2.2.2 Early Maladaptive Schemas Early Maladaptive Schemas (EMS) was treated as a single-indicator latent variable estimated from the Young Schema Questionnaire Version 3 – Short Form (YSQ-S3). The YSQ-S3 is a 90-item questionnaire containing beliefs associated with 18 early maladaptive schemas (Young, 2004). Items such as “I feel that people will take advantage of me” (from Mistrust/Abuse subscale) are rated on a 6-point scale from 1(“completely untrue of me”) to 6(“describes me perfectly”). Although the YSQ-S3 was designed to measure distinct subscales, a single generic factor accounts for approximately half of the explained variance across items in a nonclinical population (Kriston et al., 2012). Given we had no hypotheses about differential relations between psychological flexibility and specific schema subscales, the average rating across items was used as a measure of total early maladaptive schema severity. 2.2.3 Early parenting experiences Early parenting experiences was treated as a single-indicator latent variable estimated from the Young Parenting Inventory - Short Version (YPI-R, Young, 1999). The YPI-R consists of 72 items intended to measure parenting behavior thought to be associated with 17 of the 18 early maladaptive schemas. Ratings are made of both mother and father for items such as “withdrew or left me alone for extended periods” (from Abandonment subscale) on a 6-point scale from 1(“completely untrue”) to 6(“describes him/her perfectly”). Sheffield, Waller, Emanuelli, Murray & Meyer (2005) identified a shorter version (YPI-R) consisting of 9 of the subscales with adequate internal consistency for both maternal and paternal ratings. Again, in this study we did not have hypotheses about specific schema subscales, so used the 6
PSYCHOLOGICAL FLEXIBILITY SCHEMAS average rating across items (and across mother and father ratings) comprising the YPI-R as a measure of total perceived maladaptive parental behavior. 2.2.4 Psychological Flexibility Psychological Flexibility was treated as a latent variable estimated from the following four indicators: 18.104.22.168
The Acceptance and Action Questionnaire (AAQ-II) is a 7-item questionnaire intended to assess psychological inflexibility. Items such as “I’m afraid of my feelings” are rated on 7point scale from 1(“never true”) to 7 (“always true”) and summed to yield a total from 7-49. The AAQ-II has good internal consistency and test-retest reliability (Bond et al., 2011). Here, totals were inverted so high scores indicated low experiential avoidance. 22.214.171.124
The Mindfulness Attention Awareness Scale (MAAS) is a 15-item trait questionnaire intended to measure the extent to which people fail to pay attention during tasks. Items such as “I find myself doing things without paying attention” are rated on a 6-point scale from 1(“almost always”) to 6(“almost never”). The MAAS has good internal consistency and criterion validity (Brown & Ryan, 2003). The average rating across items was used as a measure of inattentiveness with lower scores indicating less attentiveness. 126.96.36.199
Valuing Questionnaire – Progress Subscale (VQ).
The VQ Progress subscale is intended to measure the extent to which people perceived they had enacted their values in the past week, and so is a self-report measure of committed action. Items such as “I was proud about how I lived my life” are rated on a 7-point scale from 0 (“not at all true”) to 6 (“completely true”). The VQ progress subscale has good internal consistency and convergent validity with measures of wellbeing (Smout, Davies, Burns & Christie, 2014). 188.8.131.52
Cognitive Fusion Questionnaire (CFQ).
The CFQ (Gillanders et al., 2014) measures the extent to which thoughts overly regulate and influence behavior. The CFQ has a stable one-factor structure, excellent internal consistency and good test-retest reliability (r = .81) (Gillanders et al., 2014). Items such as “I struggle with my thoughts” are measured on a 7-point scale from one (“Never true”) to seven (“Always true”). Here, total scores were inverted so that high scores indicated high cognitive defusion (i.e., low fusion).
The study was approved by the Human Research Subcommittee in the School of Psychology, University of Adelaide (Approval code: 14/3). All questionnaires were administered via an online survey.
PSYCHOLOGICAL FLEXIBILITY SCHEMAS 2.4
Data were screened in R (version 3.2.4 Revised). There were no extreme univariate outliers, no multivariate outliers and no missing data. Residuals were normally distributed. There was no significant multicolinearity. The data were not multivariate normal according to the Mardia test (Package MVN, Korkmaz, Goksuluk, & Zararsiz, 2015). Therefore, mediation and moderation analyses were employed using robust maximum likelihood estimation with Satorra-Bentler scale correction via the program sem in the lavaan (version 0.5-17) package (Rosseel, 2012). Single-indicator latent variables included error terms fixed according to Kline’s (2016) formula: (1-rxx)*variance. Because moderation analyses involved the interaction of latent variables with different numbers of indicators, the latent variable for the moderator variable was created by first summing scores across the four psychological flexibility indicators. Moderator indicators were then created with indProd in the semtools package and mean-centered without nonlinear constraints (Lin, Wen, Marsh & Lin, 2010). In separate models, we tested the effect of psychological flexibility as a mediator of: 1) the influence of early maladaptive schemas on psychopathology; and 2) perceived parenting behavior on early maladaptive schemas. For each of these hypothesized models, we tested an alternative “control” model, where the position of psychological flexibility and early maladaptive schemas was exchanged. We then tested the moderating effect of psychological flexibility on: 1) the relationship between early maladaptive schemas and psychopathology; and 2) the relationship between perceived parent behavior and early maladaptive schemas.
RESULTS Descriptive statistics and bivariate correlations
Table 1 reports means, standard deviations, internal consistency reliabilities and bivariate correlations. The large correlations between the DASS-21 and YSQ-S3, and the moderate to large correlations between psychological flexibility indicators and the DASS-21 demonstrate a large amount of shared variance and suggest that the planned mediation and moderation analyses concern clinically significant associations. Correlations involving the YPI with both the DASS-21 and YSQ-S3 were considerably smaller, so there is less shared variance for the mediating and moderating variables to explain in analyses concerning the effect of perceived parental behavior.
3.2.1 Psychological flexibility as a mediator of early maladaptive schemas on psychopathology Figure 1 displays the hypothesized structural equation model with standardised parameter estimates (unstandardized coefficients and their standard errors are reported in the tests of 8
PSYCHOLOGICAL FLEXIBILITY SCHEMAS mediation below). The model converged normally. Structural equation modelling deemphasises null-hypothesis testing (see Kline, 2016 for a discussion). Rather, the tested model proposes a pattern of covariance among variables. The first step in model evaluation is to test whether the model-implied pattern of covariance approximately matches the pattern obtained in the data. The model adequately accounted for the observed covariances: χ2(8) = 2.76, p = .949 and approximate fit indices were good (CFI = 1.000; TLI = 1.020; RMSEA = 0.000 [0.000, 0.008]; SRMR = 0.014). The model accounted for 68.0% of the variance in psychopathology. This step alone does not support our hypothesis that psychological flexibility acted as a mediator. In structural equation modelling, multiple configurations of the same set of variables and numbers of parameters would produce an identical set of overall fit indices. However, had these indices indicated a poor fit between the model and the data, it would be invalid to interpret the path coefficients below. Unlike multiple regression, structural equation models of mediation test the a, b, ab, and c paths simultaneously. Mediation is demonstrated when the a, b, and ab paths are significant. When the c path is not significant, the mediating variable fully mediates the effect of the predictor on the dependent variable. In our hypothesized model, the a path (the effect of early maladaptive schemas on psychological flexibility) was significant (b = -11.86 [0.82], p < .001), the b path (the effect of psychological flexibility on psychopathology) was significant (b = -1.17[.26], p < .001) and the ab path (the effect of EMS on psychopathology through its effect on psychological flexibility) was also significant (b = 13.07 [2.78], p < .001). The c path (the effect of early maladaptive schemas on psychopathology when controlling for the effect of psychological flexibility) was not significant (b = -0.00[3.15], p = 1.0). Psychological flexibility fully mediated the effect of early maladaptive schemas on psychopathology. We next tested whether an alternative model (EMS mediates the effect of psychological flexibility on psychopathology) would be equally viable to our hypothesized model. The a path (the effect of EMS on psychological flexibility) was significant (b = -0.07[.01], p < .001), but the b path (the effect of EMS on psychopathology) was not significant (b = 0.00 [2.68], p = 1.00) indicating that EMS did not mediate the effect of psychological flexibility on psychopathology. To summarise, psychological flexibility fully mediated the effect of EMS on psychopathology, but EMS did not mediate the effect of psychological flexibility on psychopathology. Following Kenny (2015) we also compared model fit via sample-corrected Bayesian Information Criteria (BIC) for the full hypothesized mediation model (BIC = 4165.973) with models that: 1) removed the direct path (from EMS to psychopathology) (BIC = 4703.177); 2) removed the cause-to-mediator path (did not converge); 3) removed the mediator to outcome path (BIC = 4704.788). The full mediation model had better fit than simpler models as indicated by smallest BIC.
PSYCHOLOGICAL FLEXIBILITY SCHEMAS 3.2.2 Psychological flexibility as a mediator of perceived parental behavior on early maladaptive schemas The model of psychological flexibility mediating the effect of perceived parental behavior on early maladaptive schemas converged normally, and provided an adequate fit for the obtained data (χ2(8) = 5.85, p = .665; CFI = 1.000; TLI = 1.01; RMSEA = 0.000 [0.000, 0.084]; SRMR = 0.019). The model accounted for 79.3% variance in EMS. The a path (the effect of perceived parenting on psychological flexibility) was significant (b = -0.66[0.16], p < .001), the b path (the effect of psychological flexibility on EMS) was significant (b = -0.07[0.01], p < .001) and the ab path was significant (b = 0.04 [0.01], p < .001), while the c path (direct effect of perceived parenting on EMS) was not significant (b = 0.01 [0.01], p = .138). Psychological flexibility fully mediated the effect of perceived parental behavior on early maladaptive schemas. The control model was that EMS would mediate the effect of perceived parental behavior on psychological flexibility. This model was equally viable and accounted for 78.6% variance in psychological flexibility. The a path (effect of perceived parenting on EMS) was significant (b = 0.06 [0.01], p < .001), the b path (effect of EMS on psychological flexibility) was significant (b = -11.1, p < .001), the ab path was significant (b = -0.62 [0.16], p < .001), but the c path (direct effect of perceived parenting on psychological flexibility) was not (b = 0.04 [0.10], p = .671). This in the control model, EMS fully mediated the effect of perceived parenting behavior on psychological flexibility. The full hypothesised mediation model (BIC = 4072.191) fit better than simpler models without a c path (BIC = 4611.741), a path (BIC = 4610.996) or b path (BIC = 4610.996).
3.3.1 Psychological flexibility as a moderator of early maladaptive schemas on psychopathology A model including paths for the conditional effects of early maladaptive schemas, psychological flexibility and their interaction to psychopathology converged normally and provided an adequate fit to the obtained data (χ2(11) = 8.14, p = .701; CFI = 1.000; TLI = 1.012; RMSEA = 0.000 [0.000, 0.077]; SRMR = 0.024). This model accounted for 72.5% of the variance in psychopathology. The interaction was significant indicating that the effect of EMS on psychopathology depends on psychological flexibility (b = -0.40 [0.06], p < .001). The conditional effect of psychological flexibility on psychopathology was also significant (b = -1.24 [0.20], p < .001) but the conditional effect of EMS was not (b = - 0.11 [0.21], p = .598). We explored both interpretations of the interaction effect using simple slopes with conventional values of 0, and + 1 standard deviation. Figure 2 shows the simple slopes plot treating psychological flexibility as moderating the effect of EMS on psychopathology. At higher levels of psychological flexibility, there was a negative relationship between EMS and 10
PSYCHOLOGICAL FLEXIBILITY SCHEMAS psychopathology (for psychological flexibility 1 standard deviation above the mean, b = 0.52 [0.21], Wald = -2.50, p = .012). At the mean level of psychological flexibility, there was no significant relationship between EMS and psychopathology (b = -0.11 [0.20], Wald = 0.56, p = .573). At one standard deviation below the mean of psychological flexibility, there was no significant relationship between EMS and psychopathology (b = 0.29 [0.21], Wald = 1.36, p = .173), however at two standard deviations below the mean, there was a significant positive relationship between EMS and psychopathology (b = 0.69 [0.24], Wald = 2.90, p = .004). Figure 3 depicts treating EMS as a moderator of the effect of psychological flexibility on psychopathology. Psychological flexibility was consistently negatively associated with psychopathology, however this association was strongest at higher levels of early maladaptive schemas (b = -1.63 [0.21], Wald = 7.72, p < .001) and weakest at lower levels of early maladaptive schemas (b = -0.83 [0.23], Wald = -3.59, p < .001).
3.3.2 Psychological flexibility as a moderator of the effect of perceived parental behavior on early maladaptive schemas A model including paths for the conditional effects of perceived parental behavior, psychological flexibility and their interactive effect on EMS converged normally and adequately fit the obtained data (χ2(11) = 11.04, p = .440; CFI = 1.000; TLI = 1.000; RMSEA = 0.005 [0.000, 0.096]; SRMR = 0.028). This model accounted for 74.4% of the variance in EMS. The interaction was not significant (b = -0.13 [0.07], p = .068), nor was the conditional effect of perceived parental behavior (b = 0.10 [0.08], p = .198), although the conditional effect of psychological flexibility on EMS was significant (b = -0.67 [0.05], p < .001). These results indicate that the influence of perceived parental behavior on EMS was not significant when considering psychological flexibility and its interaction with EMS, so there was no effect to moderate. Increased psychological flexibility was associated with lower EMS regardless of perceived parental behavior.
Comparison of psychological flexibility as mediator or moderator
While comparisons of nonhierchical models via fit indices should be treated tentatively (Klein, 2016), the model where psychological flexibility was treated as a mediator of the effect of EMS on psychopathology (BIC = 4226.03) provided better fit than the model that treated it as a moderator (BIC = 5561.33).
This study is the first preliminary investigation into the relationship between psychological flexibility as defined in ACT, early maladaptive schemas as defined in schema therapy, and 11
PSYCHOLOGICAL FLEXIBILITY SCHEMAS perceived parental behavior and psychopathology. To our knowledge, it is also the first study to measure psychological flexibility as a latent variable within mediation or moderation analyses. In understanding the intercorrelations between psychopathology, EMS and psychological flexibility, the data clearly supported the model where psychological flexibility fully mediated the effect of EMS on psychopathology. An alternative model testing whether EMS might mediate the effect of psychological flexibility on psychopathology was not supported. This suggests EMS exert their effect on psychopathology through increasing experiential avoidance, fusion (presumably with schema content), and reducing or inhibiting mindfulness and value-consistent behavior. It suggests both ACT and ST share a common set of target processes that account for the majority of variance in psychopathology. These data further encourage continued experimentation from both schools of therapy in search of interventions and sequences of intervention that best increase psychological flexibility. These data also suggest psychological flexibility measures might be useful in tracking client progress through schema therapy. The present data also supported a model where psychological flexibility mediated the effect of perceived parent behavior on EMS. However, there were no statistical grounds to favour this over an alternative control model where EMS mediated the effect of perceived parent behavior on psychological flexibility. The distinction between models may not be meaningful during infancy and early childhood, where parental behavior likely to produce EMS is likely to also train psychological inflexibility. However, by adulthood, a much broader array of social interactions could contribute to the independent establishment of both EMS and psychological flexibility. Here, both models are plausible depending on philosophical assumptions about what is considered a sufficient explanation. In favour of EMS mediating the effect of parent behavior on psychological flexibility is that EMS are thought to be established early in life and it seems likely that psychological flexibility skills would need to be practised across the lifespan (Ietsugu et al., 2015). In relational frame theory terms, the relational networks described as EMS in schema therapy may be so coherent and resistant to transformation of function, that resulting psychological inflexibility is explained by these intransigent networks. The alternative model is that EMS are sustained and maintained by psychological inflexibility: experiential avoidance (especially of schemaincompatible information), continued rule-following, inadequate participation in schemaincompatible committed action. We hope our findings might stimulate further investigation into exploring the longitudinal causal relations between parenting, EMS and psychological flexibility. Although there was some support for a model of psychological flexibility as a moderator of EMS on psychopathology, we would be cautious about accepting this without further research. Firstly, in this study, the moderator model did not provide as good fit for the data as the mediator model. Secondly, although we would expect psychological flexibility to change the direction of the relationship between early maladaptive schemas and psychopathology, the negative relationship between EMS and psychopathology at high levels of psychological flexibility was not predicted or consistent with ACT theory and would 12
PSYCHOLOGICAL FLEXIBILITY SCHEMAS require replication to inspire confidence. One could speculate that it reflects a greater openness to report symptoms. The fact that the expected relationship between EMS and psychopathology held at the very lowest levels of psychological flexibility suggests the hypothesized moderating relationship might be obtained in a clinical sample. More plausible was the alternative interpretation of the interaction effect, that EMS moderated the effect of psychological flexibility on psychopathology. Simple slopes analysis indicated the expected direction of association between psychological flexibility and psychopathology at each level of EMS. Somewhat surprisingly, the negative relationship between psychological flexibility and psychopathology was stronger at higher levels of EMS. We speculated that EMS might constrain the beneficial effects of psychological flexibility, but this was not the case. It appears that psychological flexibility more strongly protects against psychopathology, the more EMS one has. Finally, interestingly, there was no significant association between parenting behavior and EMS once including psychological flexibility, and hence no association to moderate. Psychological flexibility nevertheless was strongly associated with EMS, controlling for parental behavior. These findings support ACT’s de-emphasis on historical factors and emphasis on improving current psychological flexibility in clients who do not have severe psychopathology or personality disorders.
We present these findings as a stimulus for further research and are cautious to avoid drawing any causal conclusions from this cross-sectional design and non-clinical sample. It is possible that within the group of clients with personality disorders that schema therapy was developed to help, the present pattern of findings may not hold. There was no attempt here to measure presence of personality disorder per se, the average level of psychopathology and EMS was relatively low and the sample was homogenous, predominantly young, Caucasian female university students. The sample size was not prohibitively small for structural equation modelling but was too small to take advantage of using subscales as multiple indicators of psychopathology, perceived parenting and early maladaptive schemas. On the other hand, given the high number of items on these scales, we expect the single indicator measures would have been very reliable. There are many alternative measures of psychopathology, psychological flexibility indicators and early parenting experiences and these should be explored in future replications to ensure the role of psychological flexibility as a mediator is robust to variations in measurement. Future investigations could build upon the present data by testing these relations in larger nonclinical samples and in clinical samples to see whether the pattern of relationships was stable. Ideally, future investigations should measure the causal variables on separate occasions to the dependent variables, as the participant’s mood while reporting could artificially inflate the congruence between ratings of past and present events. 13
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Potential clinical implications
If psychological inflexibility is the process through which EMS influences psychopathology, ACT and schema therapy, despite their ostensibly different foci, are targeting a common process. Similarities in practice already exist in their recognition of avoidant coping and priority given to illustrating the workability of avoidance as a necessary first step in therapy. They similarly promote defusion from maladaptive inner monologues. In their latter phases they both focus more on committed action. Both therapies are conceptual frameworks for understanding psychopathology and have traditionally integrated a range of technical procedures from a wide variety of other psychotherapies, harnessed coherently toward the goals implied by their models. If the present findings are robust, it supports those already experimenting with the integration of ACT and schema therapy, and encourages further cross-fertilisation. We reiterate that even if psychological flexibility is a common pathway to overcoming psychopathology, that interventions within previous ACT protocols may not be the most powerful modifiers of psychological flexibility. Common schema therapy interventions such as imagery rescripting and chair dialogues might be harnessed to promote psychological flexibility in ACT interventions. Although ACT creates distance from mental content by attributing it to “the mind”, this may be too impersonal and abstract for some personality disordered individuals who may better relate to different “parts” of the mind, each with its own theme and agenda. Schema therapy models may help ACT clinicians be mindful of the deficits in the experiential repertoires of individuals with impoverished or abusive childhoods which may prevent them from benefiting from standard ACT protocols. Conversely, schema therapy might be enhanced by integrating ACT strategies, such as creative hopelessness interventions when attempting to bypass maladaptive coping modes and psychoeducation about the limitations of mental content when fighting punitive or self-critical modes. While schema therapy explores idiosyncratic childhood messages, arguably the messages and rules the parent imparts about experiencing and expressing emotions are almost universally important, and schema therapy manuals could benefit from supplementation from ACT psychoeducation about emotions. Acceptance practice in ACT, especially situated in selfcompassion, may enrich limited reparenting within schema therapy. Values clarification methods are well suited to developing a Healthy adult mode in schema therapy, after maladaptive coping modes no longer disrupt therapy and the client achieves some competence in defusing from self-critical modes. These speculations await empirical investigation, but seem promising.
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Table 1 Means (Sd), internal consistency, bivariate correlations M
YPIR .43 .45
VQ Progress -.47 -.46 -.27 .53 .34
DASS-21 17.00 13.09 .94 -.72 -.55 - .77 YSQ-S3 2.78 .76 .97 -.75 -.61 -.79 YPI-R 2.61 .59 .85 -.42 -.30 -.35 AAQ* 25.52 10.46 .93 .60 .81 MAAS 3.72 .69 .86 .64 VQ 15.71 6.45 .84 .53 Progress CFQ* 26.70 10.83 .95 * Mean reported according to standard scoring, but inverted to match direction of other measures of psychological flexibility in correlations. NB: All correlations significant at p < .01 (2-tailed)
Psychological flexibility mediated effect of EMS on psychopathology EMS moderated the effect of psychological flexibility on psychopathology Psychological flexibility mediated the effect of perceived parenting on EMS
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Figure 1: Hypothesized model: psychological flexibility as a mediator of early maladaptive schemas on psychopathology. NB: Standardised coefficients. All significant at p < .01 except where indicated “ns”.
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Figure 2: Simple slopes plot of psychological flexibility moderating the effect of early maladaptive schemas on psychopathology.
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Figure 3: Simple slopes plot of early maladaptive schemas moderating the effect of psychological flexibility on psychopathology.