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Cited by 126Mindfulness and Compassion InterventionsPsychological Well-being and Life SatisfactionAnxiety, Depression, Psychometrics, Treatment, Cognitive Processes

Both positive mental health and psychopathology should be monitored in psychotherapy: Confirmation for the dual-factor model in acceptance and commitment therapy

Open access
Trompetter, H.R., Lamers, S.M.A., Westerhof, G.J., Fledderus, M., Bohlmeijer, E.T.·2017·Behaviour Research and Therapy
DOI 10.1016/j.brat.2017.01.008
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Abstract

The dual-factor model of mental health suggests that enhancing positive mental health and alleviating psychopathology do not automatically go hand-in-hand. This study investigates the relationship between the effectiveness on depression/anxiety symptoms and positive mental health of Acceptance and Commitment Therapy (ACT). It draws on RCT data (n = 250) of a self-help ACT. Patients’ depression/anxiety symptoms and positive mental health were completed at baseline, at post-intervention after nine weeks, and at follow-up after five months. Percentage of unique variance of depression/anxiety symptoms explained by positive mental health (and vice versa), and the degree of classificatory agreement between improvements in positive mental health and depression/anxiety, were examined using regression analysis and Reliable Change Index (RCI). Positive mental health, i.e. baseline and change, explained 15% and 12% of the variance in follow-up depression and anxiety symptoms, beyond the 7% and 9% that was explained by baseline levels of depression and anxiety. Depression and anxiety symptoms, i.e., baseline and change, explained 10% and 9% of the variance in follow-up positive mental health, on top of the 35% that was explained by baseline levels of positive mental health. Cross-classification of the Reliable Changes showed that 64% of the participants that improved during the ACT-intervention, improved on either depression symptoms or positive mental health, and 72% of the participants improved on either anxiety symptoms or positive mental health. The findings support the dual-factor model and suggest that it is important to systematically implement measures of both psychopathology and positive mental health in mental health care and therapy evaluations. © 2017 Elsevier Ltd

Integrity signals

Registry

Crossref · 10.1016/j.brat.2017.01.008

Cites

54 of 54 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

9 of 26 cited sources checked · 7 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    Cross-sectional studies have provided strong support for the dual-factor model.

    “Although the dual-factor model has been wellestablished in cross-sectional studies (e.g., Westerhof & Keyes, 2009), this is the first study to our knowledge that has investigated the applicability of the dual-factor model of mental health in an intervention study based on an effective psychotherapeutic intervention, namely, ACT (Fledderus et al., 2012).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Westerhof & Keyes, 2009 source
  • Premisecitation

    Multiple meta-analyses indicate that diverse psychological interventions can both enhance positive mental health and reduce psychopathological symptoms.

    “Several meta-analyses have shown that a broad range of psychological interventions such as positive psychological interventions (Bolier et al., 2013;Lyubomirsky, King, & Diener, 2005), existential therapies (Vos, Craig, & Cooper, 2015, pp. 115e128), and CBT (Spek et al., 2007) are effective in increasing positive mental as well as in alleviating psychopathological symptoms.”
    Quote in the paperSubstantial claim2 of 2 sources checked
    • cites Bolier et al., 2013 source
    • cites Spek et al., 2007 source

      The available passages labeled Abstract contain bibliographic information identifying Spek et al. as a meta-analysis of internet-based CBT for depression and anxiety symptoms, but no findings. Searches for treatment effects and positive mental health found no passage establishing that CBT increased positive mental health or alleviated symptoms. (LLM, conf=0.70)

      Experimental — accuracy not yet measured
  • Premisereasoning

    ACT explicitly incorporates many elements from both dimensions of mental health.

    “More so than for its effectiveness, we included ACT in this study as ACT is explicitly aligned with many elements of both mental health dimensions.”
    Quote in the paperSubstantial claim2 of 3 sources checked
    • cites Biglan, Hayes, & Pistorello, 2008 source
    • cites Bohlmeijer et al., 2015 source
    • cites Ciarrochi & Kashdan, 2013

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Findingown data

    In the study sample, baseline and change in positive mental health were associated with follow-up depression and anxiety symptoms after controlling for baseline depression and anxiety symptoms.

    “The effects of baseline and change in positive mental health on follow-up depression/anxiety symptoms, beyond the effects of baseline depression/anxiety symptoms (N ¼ 250).”
    Quote in the paperSubstantial claim
  • Findingnone given

    For two-thirds to three-quarters of the participants, improvement in psychopathology and improvement in positive mental health did not occur together.

    “two-third to three-quarters of the participants improvements do not go hand-in-hand.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 12
  • May combine two claims. 13
  • The quote only partly states this claim. 1

  • Classified as probably not a substantial claim.

    Premisecitation

    The dual-factor model holds that positive mental health and psychopathology are two related but distinct dimensions of mental health, not opposite ends of one continuum.

    “The dual-factor model of mental health suggests that enhancing positive mental health and alleviating psychopathology do not automatically go hand-in-hand (Keyes, 2005a).”
    • Also stated in: § Abstract · boosted
      “A wide range of studies have shown that positive mental health and psychopathology are not simply opposite poles, but form two negatively related dimensions of mental health”
    • Also stated in: § 3. Discussion · plain
      “The dual-factor model of mental health states that positive mental health and psychopathology should be considered as two related yet distinct dimensions of mental health.”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites Keyes, 2005a

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites Westerhof & Keyes, 2009 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The MHC-SF has demonstrated sound psychometric properties in the Dutch population.

    “The MHC-SF has shown good psychometric properties in the Dutch population (Lamers, Glas, Westerhof, & Bohlmeijer, 2012;Lamers et al., 2011).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites Lamers, Glas, Westerhof, & Bohlmeijer, 2012 source
    • cites Lamers et al., 2011 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Positive emotions can reduce recurrent relapses in depression.

    “positive aspects such as positive emotions can reduce recurrent relapses in depression (Santos et al., 2013).”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites Santos et al., 2013 source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Both face-to-face and self-help ACT can produce significant improvements in outcomes such as acceptance skills and depressive and anxiety symptoms across a broad and varied range of somatic and psychiatric disorders.

    “Face-to-face and self-help ACT can significantly improve outcomes including acceptance skills, depressive and anxiety symptoms in a large and heterogeneous range of somatic and psychiatric disorders (A-Tjak et al., 2015;Cavanagh, Strauss, Forder, & Jones, 2014).”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites A-Tjak et al., 2015 source

      The Results section reports that ACT significantly outperformed controls on pooled secondary outcomes and process measures, and the Discussion supports its use across anxiety, depression, addiction, and somatic health problems. Our copy does not establish separate benefits for face-to-face and self-help ACT, or identify significant improvements specifically in acceptance skills and depressive and anxiety symptoms. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites Cavanagh, Strauss, Forder, & Jones, 2014 source

  • May combine two claims.

    Findingown data

    In total, 43.6% of participants showed improvement from baseline to follow-up in positive mental health and/or depression symptoms, while 69.6% showed improvement in positive mental health and/or anxiety symptoms.

    “Overall, 43.6% of participants improved on positive mental health and/or depression symptoms from baseline to follow-up, and 69.6% improved on positive mental health and/or anxiety symptoms from baseline to follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among those who improved on positive mental health and/or depression symptoms, 35.9% improved on both outcomes, whereas 64.1% improved on one outcome but not the other.

    “Of the participants that improved on positive mental health and/or depression symptoms, 35.9% improved on both positive mental health and depression symptoms and 64.1% improved on either one of the outcomes but not the other.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Among those who improved on positive mental health and/or anxiety symptoms, 27.6% improved on both outcomes, whereas 72.4% improved on one outcome but not the other.

    “Of the participants that improved on positive mental health and/or anxiety symptoms, 27.6% improved on both positive mental health and anxiety symptoms and 72.4% improved on either one of the outcomes but not the other.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Change in positive mental health had a moderate negative correlation with change in depression symptoms (r = -0.51, p < 0.001) and with change in anxiety symptoms (r = -0.36, p < 0.001).

    “The change in positive mental health had a moderate relation to both the change in depression symptoms (r ¼ -0.51; p < 0.001) and anxiety symptoms (r ¼ -0.36; p < 0.001).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    A lower baseline level of depression and a greater decrease in depression during the intervention each predicted significantly higher positive mental health at follow-up.

    “A lower baseline level of depression symptoms (b ¼ -0.22) and a decrease in depression during the intervention (b ¼ -0.38) were significantly related to a higher positive mental health at follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Additional analyses using absolute cut-offs for clinically meaningful change yielded percentages very similar to those from the reliable change criterion, thereby replicating and strengthening the findings.

    “The fact that the percentage of people shifting from either non-flourishing to flourishing, and/or from at risk for depressive or anxiety disorder to not-at-risk for depressive or anxiety disorder, is highly identical to outcomes using the reliable change criterion replicates and strengthens our findings.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    A higher baseline level of positive mental health and a greater increase in positive mental health during the intervention each predicted significantly fewer depression symptoms at follow-up, after adjusting for baseline depression.

    “Both a higher baseline level of positive mental health (b ¼ -0.32) and an increase in positive mental health during the intervention (b ¼ -0.38) were significantly related to less depression symptoms at follow-up, controlled for baseline levels of depression (b ¼ 0.20).”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data

    In the study sample, baseline and change in depression and anxiety symptoms were associated with follow-up positive mental health after controlling for baseline positive mental health.

    “The effects of baseline and change in depression/anxiety symptoms on follow-up positive mental health, beyond the effects of baseline positive mental health (N ¼ 250).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The ACT intervention in this study produced significant improvements in positive mental health and significant reductions in depression and anxiety symptoms.

    “These considerations are in line with the significant effects of the ACT intervention in this study in increasing positive mental health and decreasing depression and anxiety symptoms, making it a good case study to investigate the relationship between the two mental health dimensions”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    A total of 376 participants were randomly allocated to either the ACT condition or a waiting list condition.

    “After signing informed consent forms, a total of 376 participants were randomly assigned to the Acceptance and Commitment Therapy (ACT; N ¼ 250) and waiting list (N ¼ 126) condition.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The CES-D has demonstrated good validation in Dutch samples.

    “The CES-D has been well-validated in Dutch samples (Bouma, Ranchor, Sanderman, & Sonderen, 1995).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bouma, Ranchor, Sanderman, & Sonderen, 1995

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The study received approval from an independent medical ethics committee and was registered in the Dutch primary trial register for clinical trials.

    “The study was approved by an independent medical ethics committee (METIGG; no.9212) and recorded in the Dutch primary trial register for clinical trials (NTR1985).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    The dual-factor model's confirmation indicates that a therapy that reduces psychopathology does not necessarily improve positive mental health, and the reverse also holds.

    “The confirmation of the dual-factor model shows that an intervention that is effective in alleviating psychopathology is not necessarily effective in enhancing positive mental health, and vice versa.”
    • Also stated in: § 3. Discussion · plain
      “Although a moderate correlation between the effects on positive mental health and psychopathology exists, interventions that are effective in enhancing positive mental health are not necessarily effective in alleviating psychopathology, and vice versa.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The results supported both the dual-factor model and the hypotheses derived from it.

    “Our findings confirmed the dual-factor model and our hypotheses based on this model.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Reliable Change Index is regarded as a stringent standard for clinically meaningful change.

    “As the Reliable Change Index can be considered a stringent criterion for clinically meaningful change (Eisen, Ranganathan, Seal, & Spiro III, 2007), we performed additional analyses using absolute cut-offs for clinically meaningful change available for all three measures.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Eisen, Ranganathan, Seal, & Spiro III, 2007 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    The HADS-A has shown good validation in Dutch samples.

    “The HADS-A has been well validated in Dutch samples (Spinhoven et al., 1997).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Spinhoven et al., 1997 source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Patients' resistance to therapy is associated with their non-adherence.

    “the patients' resistance towards therapy is related to their non-adherence (Zickgraf et al., 2015).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Zickgraf et al., 2015

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • May combine two claims.

    Interpretationown data

    For two-thirds to three-quarters of participants who improved during the ACT intervention, improvement occurred in only one domain-either positive mental health or depressive/anxiety symptoms-a pattern consistent with the dual-factor model.

    “This means that two-thirds to three-quarters of participants that improved during the ACTintervention, only showed improvement on either positive mental health or depressive or anxiety symptoms, which is in line with our hypothesis based on the dual-factor model of mental health.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The dual-factor finding may be even more pronounced in therapies that target only one mental health dimension, such as CBT.

    “this finding may be even more profound in psychotherapies that primarily aim at improving one of the mental health dimensions instead of both, such as CBT.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: ACT is designed to target both psychopathology vulnerabilities and positive mental health resources.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    Mental health is best defined as a complete state combining the presence of positive mental health and the absence of psychopathology.

    “our findings confirm that mental health is best defined as a complete state of both the presence of positive mental health and absence of psychopathology.”
    Quote in the paperNot a substantial claim
24 of 24

  • The authors state this as an assumption.

    A traditional unidimensional model assumes that the latent constructs of positive mental health and psychopathology, and their measures, would correlate at r = 0.75 or higher.

    “If such a traditional, unidimensional model of mental health had fitted the data better, the percentage would certainly not be the majority of participants, based on the assumption that expected intercorrelations between the latent constructs of positive mental health and psychopathology and their operationalisations would be r ¼ 0.75 or, expectedly, even higher.”

  • The paper relies on this without support.

    ACT is designed to target both psychopathology vulnerabilities and positive mental health resources.

    “ACT aims to improve vulnerabilities for psychopathology (experiential avoidance) as well as resources for flourishing (acceptance, present-moment-awareness, recognizing and undertaking valued activities)”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Married participants are called a majority despite being 42.8%

    Minor

    The reported married group is less than half of the ACT participants, so it cannot be a majority.

1 of 1

Cites

Flagged first, then by citations

1 of the 55 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. Jacobson, 1991, Vol. 59
  2. Keyes, 2010, Vol. 42
  3. Vos, 2015, Vol. 83

Cited by

Sorted by citations

Related

Authors
Trompetter, H. R., Lamers, S. M. A., Westerhof, G. J., Fledderus, M., & Bohlmeijer, E. T.
Affiliations
  • University of Twente (NL)
  • Tactus Verslavingszorg (NL)
Corresponding author
Trompetter, H.R.
ORCID
Venue
Behaviour Research and Therapy
Publisher
Elsevier BV
Published
2017-04
Volume
91
Pages
58-63
ISSN
0005-7967 (ISSN-L)
DOI
10.1016/j.brat.2017.01.008
OpenAlex
W2579332627
Cited by
126
References
55
Citations by year
2026: 7 · 2025: 12 · 2024: 15 · 2023: 17 · 2022: 22 · 2021: 13 · 2020: 7 · 2019: 15 · 2018: 16 · 2017: 2
FWCI
13.54
Type
journal article
Language
en
Open access
Licence
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations
  • Behaviour Research and Therapy (publishedVersion)
  • Research portal (Tilburg University) (publishedVersion)
  • PubMed (publishedVersion)
  • University of Twente Research Information (publishedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • University of Twente Research Information (submittedVersion, other-oa)
Funders
Netherlands Foundation for Mental Health (Fonds Psychische Gezondheid)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
  • Social Sciences › Psychology › Social Psychology › Psychological Well-being and Life Satisfaction
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Keywords
dual-factor model of mental health, positive mental health, psychopathology, depressive symptoms, anxiety symptoms, acceptance and commitment therapy, treatment outcome monitoring, reliable change index
MeSH terms
Adult, Anxiety, Depression, Female, Humans, Male, Mental Health, Models, Psychological, Young Adult, Acceptance and Commitment Therapy

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