The Structural Impact of Acceptance and Commitment Processes on Demoralization in Cancer Patients: Mediating Roles of Post-Traumatic Growth and Depreciation

Document Type : Original Article

Authors

1 MSc student in Clinical Psychology, Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran.

2 Associate Professor of Health Psychology, Department of Clinical Psychology, Faculty of Psychology and Educational Sciences, Semnan University, Semnan, Iran.

10.48308/apsy.2026.242663.1944

Abstract

Aim: The present study aimed to examine the structural impact of acceptance and commitment processes on demoralization in cancer patients, with a focus on the mediating roles of post-traumatic growth and post-traumatic depreciation.
 
Method: This correlational study was conducted with 260 cancer patients who attended Omid Hospital in Isfahan during the spring and summer of 2024. Participants were selected using convenience sampling. Data collection instruments included the Acceptance and Commitment Therapy Process Scale (Francis et al., 2016), the Demoralization Scale (Robson et al., 2016), and the Expanded Post-traumatic Growth and Depreciation Questionnaire (Tako et al., 2021). Data were analyzed using Pearson correlation and structural equation modeling (SEM) with Amos-26 software.
 
Results: The analysis revealed a significant negative correlation between acceptance and commitment processes and demoralization (P<0.001). Post-traumatic growth and post-traumatic depreciation significantly mediate the relationship between acceptance and commitment processes and demoralization (P<0.001). The final model demonstrated an adequate fit to the data (P<0.05).
 
Conclusion: The acceptance and commitment processes play a role in demoralization, both directly and through post-traumatic growth and depreciation. It is recommended that interventions targeting acceptance and commitment processes, as well as fostering post-traumatic growth and reducing post-traumatic depreciation, be developed to alleviate demoralization in cancer patients.

Keywords

Main Subjects

References

Abdi, F. and Sadeghi, F. (2024). The Relationship Between Cognitive Emotion Regulation and Marital Intimacy with Quality of Life in Women with Breast Cancer. Applied Psychology, 18(2), 152-172. https://doi.org/10.48308/apsy.2024.234640.1610 [link]
Baron, R. M., & Kenny, D. A. (1986). The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. https://doi.org/10.1037/0022-3514.51.6.1173 [link]
Barrington, A., & Shakespeare-Finch, J. (2013). Posttraumatic Growth and Posttraumatic Depreciation as Predictors of Psychological Adjustment. Journal of Loss and Trauma, 18(5), 429–443. https://doi.org/10.1080/15325024.2012.714210 [link]
Bourgognon, F., Bechet, D., Huin-Schohn, C., Strelow, A., Demarche, L., Guillou, M., Adam, V., Fall, E., & Omorou, A. Y. (2024). A mixed method feasibility and acceptability study of a flexible intervention based on acceptance and commitment therapy for patients with cancer. Frontiers in psychology, 15, 1409308. https://doi.org/10.3389/fpsyg.2024.1409308 [link]
Bovero, A., Cito, A. L., Botto, R., Pidinchedda, A., Olivetti, V., Tucci, M., & Geminiani, G. C. (2025). Demoralization Syndrome in End-Of-Life Cancer Patients: A Qualitative Study. The American journal of hospice & palliative care, 42(6), 542–549. https://doi.org/10.1177/10499091241274315 [link]
Călinici, M. S., & Călinici, T. (2021). Comprehensive Assessment of ACT Processes CompACT. Romanian adaptation and short form validation. Journal of Evidence-Based Psychotherapies, 21(2), 209–226. https://doi.org/10.24193/jebp.2021.2.19 [link]
Chang, T. G., Hung, C. C., Huang, P. C., Hsu, C. Y., & Yen, T. T. (2022). Demoralization and Its Association with Quality of Life, Sleep Quality, Spiritual Interests, and Suicide Risk in Breast Cancer Inpatients: A Cross-Sectional Study. International journal of environmental research and public health, 19(19), 12815. https://doi.org/10.3390/ijerph191912815 [link]
Clarke, D. M., & Kissane, D. W. (2002). Demoralization: its phenomenology and importance. The Australian and New Zealand journal of psychiatry, 36(6), 733–742. https://doi.org/10.1046/j.1440-1614.2002.01086.x  [link]
Fava, M., Sorg, E., Jacobs, J. M., Leadbetter, R., & Guidi, J. (2023). Distinguishing and treating demoralization syndrome in cancer: A review. General hospital psychiatry, 85, 185–190. https://doi.org/10.1016/j.genhosppsych.2023.10.004 [link]
Ferlay, J., Colombet, M., Soerjomataram, I., Parkin, D. M., Piñeros, M., Znaor, A., & Bray, F. (2021). Cancer statistics for the year 2020: An overview. International Journal of Cancer, 10.1002/ijc.33588. Advance online publication. https://doi.org/10.1002/ijc.33588 [link]
Foroughi, A., Khanjani, S., Moghadam, M. S., & Parvizifard, A. (2024). The psychometric properties of the Persian version of the Demoralization Scale (DS-II) in women with breast cancer. Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences, 29, 14. https://doi.org/10.4103/jrms.jrms_94_23 [link]
Francis, A. W., Dawson, D. L., & Golijani-Moghaddam, N. (2016). The development and validation of the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT). Journal of Contextual Behavioral Science, 5(3), 134–145. https://doi.org/10.1016/j.jcbs.2016.05.003 [link]
Green, S. M. C., Hall, L. H., Ellison, R., Clark, J., Wilkes, H., Hartley, S., Naik, J., Buckley, S., Hirst, C., Hartup, S., Neal, R. D., Velikova, G., Farrin, A., Collinson, M., Graham, C. D., & Smith, S. G. (2025). Acceptability of acceptance and commitment therapy for medication-decision-making and quality of life in women with breast cancer: A qualitative process evaluation. British journal of health psychology, 30(2), e12802. https://doi.org/10.1111/bjhp.12802 [link]
Gunzler, D., Chen, T., Wu, P., & Zhang, H. (2013). Introduction to mediation analysis with structural equation modeling. Shanghai archives of psychiatry, 25(6), 390–394. https://doi.org/10.3969/j.issn.1002-0829.2013.06.009 [link]
Hajloo, N., Pourabdol, S., Sobhi Gharamaleki, N., & Beyki, M. (2022). Psychometric Properties of the Comprehensive assessment of Acceptance and Commitment Therapy processes (CompACT). Qom University of Medical Sciences Journal, 15 (11), 766-777. https://doi.org/10.32598/qums.15.11.2542 [link]
Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. The Guilford Press. [link]
Hayes S. C. (2019). Acceptance and commitment therapy: towards a unified model of behavior change. World Psychiatry : Official Journal of the World Psychiatric Association (WPA), 18(2), 226–227. https://doi.org/10.1002/wps.20626 [link]
Ho, S. M. Y., & Cheng, C.-T. (2024). Illusory versus constructive posttraumatic growth in cancer. In R. Berger (Ed.), The Routledge international handbook of posttraumatic growth (pp. 21–28). Routledge. [link]
Ho, S. M. Y., Cheng, C. T., Shih, S. M., Taku, K., & Tedeschi, R. G. (2022). The Chinese version of Posttraumatic Growth and Depreciation Inventory-Expanded version (PTGDI-X) for cancer survivors. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 30(1), 237–249. https://doi.org/10.1007/s00520-021-06223-8 [link]
Hong, Y. T., Lin, Y. A., Pan, Y. X., Lin, J. L., Lin, X. J., Zhang, J., & Huang, F. F. (2022). Understanding factors influencing demoralization among cancer patients based on the bio-psycho-social model: A systematic review. Psycho-oncology, 31(12), 2036–2049. https://doi.org/10.1002/pon.6023 [link]
Jayawickreme, E., Infurna, F. J., Alajak, K., Blackie, L. E. R., Chopik, W. J., Chung, J. M., Dorfman, A., Fleeson, W., Forgeard, M. J. C., Frazier, P., Furr, R. M., Grossmann, I., Heller, A. S., Laceulle, O. M., Lucas, R. E., Luhmann, M., Luong, G., Meijer, L., McLean, K. C., Park, C. L., … Zonneveld, R. (2021). Post-traumatic growth as positive personality change: Challenges, opportunities, and recommendations. Journal of personality, 89(1), 145–165. https://doi.org/10.1111/jopy.12591 [link]
Jelodari, S., Sodagar, ُ. and Bahrami Hidaji, M. (2020). The effectiveness of Acceptance and Commitment Therapy (ACT) on psychological flexibility and cognitive emotion regulation in women with breast cancer. Applied Psychology, 13(4), 527-548. https://doi.org/10.29252/apsy.13.4.527 [link]
Kim, J. S., & Kim, J. S. (2025). Differences in symptom experiences and coping strategies based on post-traumatic growth and depreciation in cancer patients undergoing chemotherapy: a cross-sectional study. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 33(12), 1107. https://doi.org/10.1007/s00520-025-10175-8 [link]
Kissane, D. W., Wein, S., Love, A., Lee, X. Q., Kee, P. L., & Clarke, D. M. (2004). The Demoralization Scale: a report of its development and preliminary validation. Journal of palliative care, 20(4), 269–276. [link]
Kline, R. B. (2023). Principles and Practice of Structural Equation Modeling. Guilford Publications. [link]
Koranyi, S., Hinz, A., Hufeld, J. M., Hartung, T. J., Quintero Garzón, L., Fendel, U., Letsch, A., Rose, M., Esser, P., & Mehnert-Theuerkauf, A. (2021). Psychometric Evaluation of the German Version of the Demoralization Scale-II and the Association Between Demoralization, Sociodemographic, Disease- and Treatment-Related Factors in Patients With Cancer. Frontiers in psychology, 12, 789793. https://doi.org/10.3389/fpsyg.2021.789793 [link]
Marsh, H. W., Hau, K. & Wen, Z. (2004). In Search of Golden Rules: Comment on Hypothesis-Testing Approaches to Setting Cutoff Values for Fit Indexes and Dangers in Overgeneralizing Hu and Bentler’s Findings. Structural Equation Modeling, 11, 320-341.
http://dx.doi.org/10.1207/s15328007sem1103_2 [link]
Mathew, A., Doorenbos, A. Z., Jang, M. K., & Hershberger, P. E. (2021). Acceptance and commitment therapy in adult cancer survivors: a systematic review and conceptual model. Journal of cancer survivorship : research and practice, 15(3), 427–451. https://doi.org/10.1007/s11764-020-00938-z [link]
Musa, N., Pang, N. T. P., Kamu, A., Ho, C. M., Waters, C., Berrett, J., Moghaddam, N., & Wider, W. (2022). The Development and Validation of the Comprehensive Assessment of Acceptance and Commitment Therapy Processes (CompACT)-Malay Version. International journal of environmental research and public health, 19(15), 9624. https://doi.org/10.3390/ijerph19159624 [link]
Nisiraiou, A., Bozas, A., Kyrou, D., Stavrogianni, K., Vasilopoulou, M., Kalomoiris, G. M., Tsintsifa, N., Nikitara, K., Koulierakis, G., & Karamanidou, C. (2025). Post-Traumatic Growth in Adult Cancer Survivors: A Scoping Review of Psychological Factors, Predictors, and Interventions. International journal of psychology: Journal international de psychologie, 60(5), e70097. https://doi.org/10.1002/ijop.70097 [link]
Park, C. L. (2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301. https://doi.org/10.1037/a0018301 [link]
Robinson, S., Kissane, D. W., Brooker, J., Hempton, C., Michael, N., Fischer, J., Franco, M., Sulistio, M., Clarke, D. M., Ozmen, M., & Burney, S. (2016). Refinement and revalidation of the demoralization scale: The DS-II-external validity. Cancer, 122(14), 2260–2267. https://doi.org/10.1002/cncr.30012 [link]
Romeo, A., Castelli, L., Zara, G., & Di Tella, M. (2022). Posttraumatic Growth and Posttraumatic Depreciation: Associations with Core Beliefs and Rumination. International journal of environmental research and public health, 19(23), 15938. https://doi.org/10.3390/ijerph192315938 [link]
Sarizadeh, M. S., Boogar, I. R., Talepasand, S., & Gharemanfard, F. (2021). Acceptance and commitment therapy for demoralization syndrome and cancer-related trauma: a randomized clinical trial study. International Journal of Cancer Management, 14 (11). ‏ https://doi.org/10.5812/ijcm.11637 [link]
Sender, A., Hinz, A., Broemer, L., Mehnert-Theuerkauf, A., Strauß, B., Briest, S., & Rosendahl, J. (2025). Demoralization in breast cancer survivors. Frontiers in psychology, 16, 1523164. https://doi.org/10.3389/fpsyg.2025.1523164 [link]
Soleimani, Z., Shairi, M., Gholami Fesharaki, M., & Ghomian, S. (2022). Examination of Psychometric Properties of The Comprehensive Assessment of Acceptance and Commitment Therapy Processes (compact) Scale in Iranian Non-Clinical Samples. Clinical Psychology and Personality, 19(2), 121-137. https://doi.org/10.22070/cpap.2021.3077 [link]
Taghilou, E., Heidarzadeh, M., Molaei, B., & Khameslou, M. A. (2024). Determining psychometric properties of the Persian version of demoralization scale-II in patients with cancer. BMC psychology, 12(1), 1. https://doi.org/10.1186/s40359-023-01507-6 [link]
Taku, K., Tedeschi, R. G., Shakespeare-Finch, J., Krosch, D., David, G., Kehl, D., Grunwald, S., Romeo, A., Di Tella, M., Kamibeppu, K., Soejima, T., Hiraki, K., Volgin, R., Dhakal, S., Zięba, M., Ramos, C., Nunes, R., Leal, I., Gouveia, P., . . . Calhoun, L. G. (2021). Posttraumatic growth (PTG) and posttraumatic depreciation (PTD) across ten countries: Global validation of the PTG-PTD theoretical model. Personality and Individual Differences, 169, Article 110222. https://doi.org/10.1016/j.paid.2020.110222 [link]
Tedeschi, R. G., & Calhoun, L. G. (2004). Target Article: "Posttraumatic Growth: Conceptual Foundations and Empirical Evidence". Psychological Inquiry, 15(1), 1–18. https://doi.org/10.1207/s15327965pli1501_01 [link]
Tomita, M., Takahashi, M., Tagaya, N., Kakuta, M., Kai, I., & Muto, T. (2017). Structural equation modeling of the relationship between posttraumatic growth and psychosocial factors in women with breast cancer. Psycho-oncology, 26(8), 1198–1204. https://doi.org/10.1002/pon.4298 [link]
Tsatsou, I., Nikoloudi, M., Galanis, P., & Mystakidou, K. (2025). Understanding psychological outcomes in cancer: The interplay between hope, dignity, demoralization, and posttraumatic growth. European journal of oncology nursing : the official journal of European Oncology Nursing Society, 79, 102984. Advance online publication. https://doi.org/10.1016/j.ejon.2025.102984 [link]
Xiong, Y., Li, H., Cai, K., Yu, M., Zhou, J., Li, J., Knobf, M. T., & Ye, Z. (2025). Demoralization and dignity loss in breast cancer: A network analysis and computer simulation study. Asia-Pacific journal of oncology nursing, 12, 100803. https://doi.org/10.1016/j.apjon.2025.100803 [link]
Zhou, D., Shi, F., Yang, J., Jiang, L., Yang, L., & Wen, J. (2025). The status and determinants of demoralization in patients with colorectal cancer: a cross-sectional study in China. Journal of cancer research and clinical oncology, 151(5), 156. https://doi.org/10.1007/s00432-025-06206-w [link]

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