International Journal of Sport and Exercise Psychology

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Effectiveness of the
mindfulness–acceptance–commitment approach:
a meta-analysis

Martin Ptáček, Ricardo G. Lugo, Karl Steptoe & Stefan Sütterlin

To cite this article: Martin Ptáček, Ricardo G. Lugo, Karl Steptoe & Stefan Sütterlin (2023):
Effectiveness of the mindfulness–acceptance–commitment approach: a meta-analysis,
International Journal of Sport and Exercise Psychology, DOI: 10.1080/1612197X.2023.2180070

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INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY
https://doi.org/10.1080/1612197X.2023.2180070

Effectiveness of the mindfulness–acceptance–commitment

approach: a meta-analysis
Martin Ptáčeka, Ricardo G. Lugob,c, Karl Steptoed and Stefan Sütterlinc,e
a
Department of Psychology, Faculty of Arts, Masaryk University, Brno, Czech Republic; bDepartment of
Information Security and Communication Technology, Norwegian University of Science and Technology,
Trondheim, Norway; cDepartment of Welfare, Management and Organization, Østfold University College,
Halden, Norway; dSchool of Sport, Exercise, and Health Sciences, Loughborough University, Loughborough,
UK; eFaculty of Computer Science, Albstadt-Sigmaringen University, Sigmaringen, Germany

ABSTRACT ARTICLE HISTORY

The presented study evaluates the evidence base underpinning the Received 29 June 2022
use of the Mindfulness–Acceptance–Commitment approach (MAC) Accepted 15 January 2023
in applied sport psychology. To assess the effectiveness of the MAC
KEYWORDS
protocol on improving mindfulness and psychological flexibility, Mindfulness–Acceptance–
and on enhancing sport performance and well-being among Commitment approach;
athletes, we used Robust Bayesian Meta-Analysis with Publication meta-analysis; mindfulness;
Selection Model-Averaging (RoBMAPSMA). In total, there were psychological flexibility;
eleven controlled trials included in the meta-analysis. Results of sport performance
the RoBMAPSMA show: a moderate model-averaged effect size
estimate for developing mindfulness with strong evidence (g =
0.64, 95% CI 0.00–0.91, BFes = 25.35); a small model-averaged
effect size estimate for experiential acceptance with anecdotal
evidence (g = 0.36, 95% CI 0.00–0.92, BFes = 2.32); and a small
model-averaged effect size estimate for improving sport
performance with moderate evidence (g = 0.37, 95% CI 0.00–0.79,
BFes = 3.27). Only one study assessed the effectiveness of the
MAC protocol on well-being and averaged effect sizes ranged
from 0.01 to 0.82. Based on the results of the meta-analysis, the
Mindfulness–Acceptance–Commitment protocol can be effective
in improving mindfulness. In addition, results suggest that the
MAC protocol might be effective in improving sport performance.
Currently available trials, however, do not provide sufficient
evidence supporting the MAC protocol’s effectiveness in
developing psychological flexibility, experiential acceptance, and
promoting well-being among athletes.

The popularity of sport psychology has continued to grow over the last twenty years as
has engagement in structured psychological training from key stakeholders. Sport psy-
chology practitioners work with athletes, teams, coaches, sport scientists, parents, and
organisations to cope with the known psychological demands of a sport, such as
failure, low levels of motivation, career transition, injury rehabilitation, and social press-
ures (e.g., fans, media, sponsors), and to positively influence sport performance and

CONTACT Martin Ptáček m.ptacek@mail.muni.cz Masaryk University, Arne Nováka 1, 602 00 Brno, Czech
Republic
Supplemental data for this article can be accessed online at https://doi.org/10.1080/1612197X.2023.2180070
© 2023 International Society of Sport Psychology
2 M. PTÁČEK ET AL.

well-being. To achieve these goals, various approaches have been designed with the
intention of either altering the content of internal experience (i.e., emotions, thoughts,
feelings) or improving self-regulation processes to increase task-focused attention
(Mesagno et al., 2020).
To alter the content of internal experience, sport psychologists often use cognitive–
behavioural techniques, such as goal setting, arousal control, imagery, or self-talk.
Approaches adopting these techniques are often referred to as psychological skills train-
ing (PST: Vealey, 1988). In applied practice, these psychological skills are usually inte-
grated and delivered through an evidence-based systematic intervention program
designed for the specific needs of an athlete. The goal is to help athletes systematically
integrate these techniques into a pre-competition routine to mentally prepare for the per-
formance and minimise the effects of choking under pressure (Wergin et al., 2020).
Efforts to suppress unwanted internal experiences, however, have been found to para-
doxically increase their occurrence. This effect is known in the field of psychology as the
ironic rebound effect or ironic mental processes and supports a shift to approaches
designed to increase task-focused attention (Mesagno et al., 2020; Wang et al., 2020).
These approaches draw upon the theoretical developments emerging from the “third-
wave” acceptance-based behavioural movement in clinical psychology (Hayes et al.,
1999), and in contrast to PST, they suggest that performance is positively influenced by
an athlete’s ability to remain non-judgmentally present with their internal experiences
while remaining focused, on the environmental cues and demands of a given perform-
ance, despite possible internal discomfort (Gross et al., 2016; Moore, 2009).
Based on acceptance and commitment therapy (ACT) principles, the Mindfulness–
Acceptance–Commitment (MAC) protocol uses mindfulness exercises and other tech-
niques (i.e., cognitive defusion techniques, promotion of experiential acceptance and
commitment, and values clarification) to promote task-focused attention and psychologi-
cal flexibility (Gardner & Moore, 2007). Mindfulness is defined as “paying attention in a
particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-
Zinn, 1994, p. 4). The construct of psychological flexibility is defined as the ability to be
fully in contact with the present moment and the internal processes without unnecessary
defence, and, depending upon what the current situation affords, to function in accord-
ance with one’s values and goals (Bond et al., 2011; Hayes et al., 2006). It is suggested that,
over time, a new kind of metacognition evolves within athletes through the development
of psychological flexibility and mindfulness during the MAC program. This change in
metacognition then allows ineffective overlearned automatic behaviours driven by
emotions to be replaced by more functional behaviours driven by values both in sport
and life, and thus improve sport performance and overall well-being of athletes
(Gardner & Moore, 2007). In this regard, mindfulness and psychological flexibility are con-
sidered primary and closely related outcomes of the MAC protocol, and both influence the
psychological processes of athletes which in turn facilitate performance and well-being
(Gardner & Moore, 2007).
As a manualised intervention program, the MAC protocol provides a good starting
point for sport psychology practitioners without any prior experience with acceptance
and mindfulness-based approaches. However, there is a need for further empirical evalu-
ation of the current research exploring the effects of the protocol. Even though a meta-
analysis of Bühlmayer and colleagues (2017) provides preliminary evidence of moderate
 INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 3

to large effect sizes supporting the effectiveness of mindfulness on physiological and

psychological surrogates related to performance, and accuracy-based performance (k =
9), a systematic review of Noetel and colleagues (2019) points out several problems of
the research assessing the effectiveness of acceptance and mindfulness-based interven-
tions in sport psychology (k = 66). More specifically, they point out issues of low internal
validity and low overall quality of the research, as neither of the 17 randomised trials
included in the review achieved a low risk of bias based on results obtained from the
Cochrane Risk of Bias Assessment tool. Furthermore, they argue that it is important to
not consider all interventions that fall under the umbrella of acceptance and mindful-
ness-based approaches as equivalent, as each intervention might differ in implemented
exercises and target different overall outcomes. For example, similarly to the MAC proto-
col, the Mindful Sport Performance Enhancement program (MSPE: Kaufman et al., 2018)
emphasises the development of mindfulness and through mindfulness a degree of accep-
tance, but unlike the MAC protocol, the MSPE program does not focus on commitment,
value clarification, or value-driven behaviour (Kaufman et al., 2009), and therefore, it may
have a different impact on athletes. The length of the program is also an important aspect
of the intervention as programs longer than four weeks might have a larger impact than
shorter interventions (Bühlmayer et al., 2017; Kaufman et al., 2009; Thompson et al., 2011).
For these reasons, the presented meta-analysis focuses merely on controlled trials adopt-
ing the MAC protocol (Gardner & Moore, 2007) or its cultural variations (e.g., the Chinese
culture variation MAIC; Su et al., 2019) in sport, and addresses the research question of
whether the MAC protocol is effective in improving mindfulness and psychological flexi-
bility and enhancing sport performance and well-being of athletes.

Methods
Search strategy and study selection
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) guidelines (Hutton et al., 2015), and the PICO search strategies with Boolean
operators, the first author (MP) conducted the literature search on 29th September
2022 using the EBSCOhost platform with six databases included (Academic Search Ulti-
mate, Academic Search Complete, MEDLINE Complete, APA PsycArticles, APA PsycInfo,
and SPORTDiscuss). Searched terms for each element of the PICO acronym are shown
in Table 1.
Additional searches utilised previously conducted meta-analyses and systematic
reviews (Bühlmayer et al., 2017; Carraça et al., 2018; Noetel et al., 2019; Sappington &

Table 1. Search strategy (PICO).

PICO elements Search terms
Participants (P) Athletes OR players
Intervention (I) Mindfulness–Acceptance–Commitment OR Mindfulness–Acceptance-Insight-Commitment OR
mindfulness-based OR acceptance-based
Comparison Not applicable
(C)
Outcomes (O) Mindfulness OR performance OR (well-being OR wellbeing OR well being) OR psychological flexibility
OR experiential acceptance OR experiential avoidance OR values OR cognitive defusion OR
commitment OR committed action
4 M. PTÁČEK ET AL.

Longshore, 2015). Reference sections of cited articles were also searched for additional
relevant articles. After duplicates had been removed, the first two authors of the study
(MP, RL) screened the remaining articles using the screening procedure searching by
title, abstract, and full text. The inclusion or exclusion of a study was decided in a discus-
sion between the first and the second author, and was based on the following eligibility
criteria: (i) participants were athletes competing in a sport; (ii) a study used the MAC pro-
tocol (Gardner & Moore, 2007) or its cultural variation as the intervention; (iii) a study
assessed effects of the intervention on mindfulness, psychological flexibility or at least
one of its facets, performance, or well-being; (iv) a study adopted randomised controlled
trial or non-randomised controlled trial as a study design; (v) a study was published as an
article in a peer-reviewed journal or a study was successfully defended as a doctoral dis-
sertation thesis. Any disputes over the inclusion or exclusion were resolved with the third
and the fourth author of the study (KS, SS). In Table 2, we present all relevant information
about studies that met the inclusion criteria and are included in the meta-analysis.

Data extraction
The first two authors independently extracted the data for mindfulness and facets of
psychological flexibility as sum scores with means, and standard deviations for various
questionnaires. If all the necessary descriptive statistics were not included in the article,
we contacted the authors via email requesting the missing information.
For the category of performance, using the same processes of extraction, we extracted
the data as sum scores with means, and standard deviations for self-rated or coach-rated
questionnaires assessing sport performance. In addition, Zhang and colleagues (2016),
and Shea (2019) measured performance directly. The study by Zhang and colleagues
(2016) implemented a dart-throwing task in which participants were asked to aim for
the bullseye of a dartboard with ten concentric circles (bullseye = 10 points; outside of
board = 0 points). The total score of each participant was obtained from five consecutive
rounds with three dart throws in each round. Shea (2019) used in her study three tests of
strength (i.e., max weight on bench press, power clean, and squat), and one agility task
(i.e., 5–10–5 pro agility test) to assess athletic performance. The average of two attempts
of the agility task was used as a final record for each participant. Mean scores with stan-
dard deviations from the dart-throwing task, strength tasks, and agility task were
extracted for effect size calculation.
And finally, if the study reported several measurements of the same metric [e.g., Naderi
and colleagues (2020) report scores for trait and state mindfulness, Shea (2019) reports
four effect sizes for athletic performance (three for strength and one for agility), etc.],
we averaged the effect sizes. All effect sizes used for averaging are reported in notes of
included forest plots.

Statistical analysis and software

Following the data extraction, we computed Cohen’s d for each dependent variable from
mean gains, pre-test and post-test standard deviations, and post-test sample sizes of
experimental and control groups (i.e., change from baseline effect size) using a web-
based calculator (Wilson, n.d.). Additionally, Hedge’s g, as a standardised mean difference
Table 2. Overview of included studies in the meta-analysis.
Post-int. sample
Type of Research size
Author(s) (year) document design exp/con Experimental group Control group Analysed dependent variables
Dehghani et al. Article RCT 14/15 MAC No Psychological flexibility (AAQ), Performance (SPQ)

INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY

(2018) intervention
Goodman et al. Article nRCT 13/13 MAC and hatha yoga No Mindfulness (MAAS), Psychological flexibility (AAQ-II, DDS, VLQ)
(2014) intervention
Gross et al. (2016) Article RCT 10/10 MAC PST Mindfulness (MAAS), Psychological flexibility (AAQ-II), Performance
(SPQ)
Josefsson et al. Article RCT 30/25 (26/23) MAC PST Mindfulness (AMQ), Performance [Single item (10-point Likert
(2019) scale)]
Macdougall et al. Article RCT 9/9 MAC and motivational No Mindfulness (CAMS-R), Psychological flexibility (AAQ-II),
(2019) interview intervention Performance (Unspecified questionnaire)
Mohebi et al. (2021) Article RCT 20/20 MAC Active control Mindfulness (MIS)
Naderi et al. (2020) Article RCT 81/79 MAC Active control Mindfulness (CHIME, TMS)
Ning et al. (2022) Article RCT 24/23 MAIC No Mindfulness (FFMQ)
intervention
Shea (2019) Dissertation RCT 17/18 MAC Active control Mindfulness (FFMQ), Performance (Strength/Agility tasks)
thesis
Zadeh et al. (2019) Article RCT 22/22 MAC No Mindfulness (MSPQ), Performance [Single item (7-point Likert
intervention scale)]
Zhang et al. (2016) Article RCT 22/21 MAIC Active control Mindfulness (FFMQ), Psychological flexibility (AAQ-II), Performance
(Dart-throwing task)

5
6 M. PTÁČEK ET AL.

with correction for small sample sizes, was then computed for each dependent variable in
Microsoft Excel (Equation (1); Hedges & Olkin, 1985). And finally, we computed standard
errors for effect sizes using Microsoft Excel using Equation (2) (Cohen, 1988).
The equation for Hedge’s g
3
ESg = d × (1 − ) (1)
4m − 1
The equation for standard error






























N1 + N2 g2
SEg = + (2)
N1 N2 2(N1 + N2 − 2)

The obtained data were then analysed in JASP (version 0.16.4; JASP Team, 2022) using
the Robust Bayesian Meta-Analysis with Publication Selection Model-Averaging
(RoBMAPSMA) (Bartoš et al., 2022). Simulation studies adopting the RoBMA show that
this methodology performs well under high heterogeneity conditions, can quantify evi-
dence in favour of the absence of publication bias, and reduces the risk of confirmation
bias as it provides model-averaged effect size estimates (Bartoš et al., 2022; Maier et al.,
2022). Prior probabilities of each model were set to default; 18 of 36 models assumed
the presence of the effect [P(M) = 0.50], 18 of 36 models assumed the presence of hetero-
geneity [P(M) = 0.50], and 32 of 36 models assumed the presence of publication bias [P(M)
= 0.50]. Prior and posterior probabilities for each model are in depth presented in sup-
plementary materials. To interpret the Bayes factor (BF) and assess evidence in favour
(against) a hypothesis, we used the rule of thumb proposed by Bartoš and colleagues
(2022: 1–3 (0.3–1), anecdotal evidence; 3–10 (0.1–0.3), moderate evidence; 10 or higher
(0.1 or lower), strong evidence. To assess effect size estimates, we classified Hedge’s g
on the following scale: 0.00–0.19, negligible effect; 0.20–0.49, small effect; 0.50–0.79, mod-
erate effect; 0.80 or higher, large effect (Cohen, 1988).

Results
Study search results
In total, we identified 161 articles through the literature search after duplicates were
removed. Firstly, we removed articles with irrelevant titles. If the title was unclear or
the researchers uncertain, the abstract of the article was screened for clarification.
Altogether, we removed 141 articles after the title and the abstract screening. The
full text of 21 articles was retrieved. These articles were assessed for eligibility based
on the inclusion criteria. Fourteen articles met the inclusion criteria, but we were
able to extract all necessary data only from eleven articles. These eleven articles
were included in the meta-analysis. We present the process of study selection in
Figure 1.

Study population
In total, there were 262 participants in experimental groups and 255 participants in
control groups across eleven trials. The number of participants per study was ranging
 INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 7

Figure 1. PRISMA diagram – study screening and selection.

from 9 to 81 participants in the experimental groups, and from 9 to 79 in the control

groups.

Risk-of-bias assessment of included studies

To assess the risk of bias in individual randomised controlled trials, we used the Cochrane
Risk of Bias 2 tool (Sterne et al., 2019). The excel-based tool evaluates the randomisation
process, deviations from the intervention, missing outcome data, measurement of the
outcome, selection of reported results, and overall bias of studies included in systematic
reviews and meta-analyses. Two researchers (MP, RL) independently assessed included
randomised trials on these factors. If the researchers did not agree with the assessment
of all factors, discussions followed with the third and the fourth researcher (KS, SS) to
resolve disputes. Results of the risk-of-bias assessment are presented in table 3.
Additionally, the meta-analysis includes one non-randomised trial (Goodman et al.,
2014). We consider the trial to be high risk because (i) participants in the experimental
group differ from participants in the control group in the level of competition, and (ii)
8 M. PTÁČEK ET AL.

Table 3. Results of risk-of-bias assessment obtained from RoB 2 Tool.

Missing Selection of
Randomisation Deviation from outcome Measurement of the reported
Study process the intervention data the outcome result Overall
Dehghani et al. + + + !c + !
(2018)
Gross et al. + + + !c !d !
(2016)
b c d
Josefsson et al. + + ! ! ! !
(2019)
Macdougall + –a + !c + –
et al. (2019)
d
Mohebi et al. + + + + ! !
(2021)
Naderi et al. + + + + !d !
(2020)
d
Ning et al. + + + + ! !
(2022)
Shea (2019) + + + + !d !
Zadeh et al. + + + !c !d !
(2019)
Zhang et al. + + + + !d !
(2016)
Note: +, Low risk; !, Some concerns, –, High risk.
a
Deviation from the MAC protocol (extension of the intervention).
b
More than 5% missing post-test data compared to pre-test.
c
Indirect measurement of performance (otherwise low risk).
d
No pre-registered protocol.

the MAC protocol was extended with hatha yoga which could affect the dependent vari-
ables included in the study.

Analysis of mindfulness
There were 10 studies included in the meta-analysis of the Mindfulness–Acceptance–Com-
mitment approach’s effectiveness in enhancing mindfulness. Effect sizes ranged from −0.15
to 1.72 and sample sizes of included studies ranged from 9 to 81. In total, there were 248
participants in experimental groups and 240 participants in control groups.
The results show a moderate model-averaged effect size estimate (g = 0.64, 95% CI
0.00 to 0.91), and the evidence for the presence of the effect is strong [P(M|data) = 0.96,
BFes = 25.35]. Furthermore, there is anecdotal evidence for the presence of heterogeneity
[P(M|data) = 0.62, BFht = 1.60] and anecdotal evidence for the absence of publication bias
[P(M|data) = 0.34, BFpb = 0.51]. All effect sizes included in the analysis, the model-averaged
effect size estimate, and 95% confidence intervals are presented in the forest plot (Figure 2).
Furthermore, five of ten studies included follow-up measurements in their study
designs. Effect sizes from post-intervention to follow-up measurements ranged from
−0.68 to 0.22 (Figure 3). The results of the RoBMAPSMA show negligible negative effect
(g = −0.04, 95% CI −0.44 to 0.03), and the Bayesian factor indicates moderate evidence
for the absence of the effect [P(M|data) = 0.21, BFes = 0.27].

Analyses of psychological flexibility

In total, five studies were included in the meta-analysis of the Mindfulness–Acceptance–Com-
mitment approach’s effect on the development of psychological flexibility. All studies in the
 INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 9

Figure 2. Forest plot for mindfulness from pre-test to post-test. Note: 1Average of State mindfulness
(g = 0.50); 2Average of the FFMQ subscales [Observing (g = −0.22), Describing (g = 0.70), Acting with
awareness (g = 0.52), Nonjudging inner experience (g = 0.55), Nonreactivity inner experience (g =
0.37)].

analysis examined the effect of the MAC protocol on experiential acceptance. These effect
sizes ranged from −0.28 to 1.42. Sample sizes of included studies ranged from 9 to 22, and
there were only 68 participants in experimental groups and 68 participants in control groups.

Figure 3. Forest plot for mindfulness from post-test to follow-up.

10 M. PTÁČEK ET AL.

Figure 4. Forest plot for experiential acceptance.

The results of this analysis show a small model-averaged effect size estimate (g = 0.36,
95% CI 0.00 to 0.92; Figure 4) for increasing experiential acceptance in the MAC approach,
however, there is anecdotal evidence supporting the presence of the effect [P(M|data) =
0.70, BFes = 2.32]. In addition, there is anecdotal evidence for the presence of heterogen-
eity [P(M|data) = 0.67, BFht = 2.04] and anecdotal evidence for the absence of publication
bias [P(M|data) = 0.41, BFpb = 0.70].
In addition to experiential acceptance, Goodman and colleagues (2014) report two
other dependent variables falling under the umbrella of psychological flexibility: commit-
ment to values (g = −0.09, 95% CI −0.93 to 0.74), and cognitive defusion (g = −0.05, 95%
CI −0.89 to 0.78). Both effect sizes relating to these variables are negative and classified as
negligible.

Analysis of sport performance

Seven studies assessed the effect of the Mindfulness–Acceptance–Commitment approach
on sport performance. Effect sizes ranged from −0.08 to 1.41. In total, there were 120 par-
ticipants in the experimental groups and 118 participants in the control groups. Sample
sizes of included studies ranged from 9 to 26.
Results of the meta-analysis suggest a small model-averaged effect size estimate
(g = 0.37, 95% CI 0.00 to 0.79; Figure 5), and the evidence supporting the presence
of the effect is moderate [P(M|data) = 0.77, BFes = 3.27]. Furthermore, there is anec-
dotal evidence for the absence of heterogeneity [P(M|data) = 0.48, BFht = 0.91] and
anecdotal evidence for the presence of publication bias [P(M|data) = 0.51, BFpb =
1.02].
 INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 11

Figure 5. Forest plot for sport performance. Note: 1Average of bench press (g = −0.01), power clean
(g = −0.17), squat (g = −0.15), 5–10–5 test (g = 0.02).

Analysis of well-Being
Only one study included in the meta-analysis aimed to assess the effectiveness of the
Mindfulness–Acceptance–Commitment approach on well-being (Macdougall et al.,
2019). In summary, the study presents negligible to large, averaged effect sizes for
increasing subjective well-being (g = 0.82, CI 95% −0.15 to 1.79), psychological well-
being (g = 0.60, CI 95% −0.35 to 1.55), social well-being (g = 0.01, CI 95% −0.91 to 0.93),
and physical well-being (g = 0.38, CI 95% −0.55 to 1.31).

Discussion
The presented meta-analysis aimed to explore the effectiveness of the MAC protocol in
improving mindfulness, and psychological flexibility, and enhancing sport performance
and well-being among athletes. The results of the meta-analysis are based on eleven con-
trolled trials and present model-averaged effect size estimates with quantified evidence
supporting the presence (or absence) of the effect.

MAC approach’s effects on process outcomes

The manualised Mindfulness–Acceptance–Commitment approach aims to develop task-
focused attention and psychological flexibility (Gardner & Moore, 2007). Mindfulness exer-
cises in the MAC protocol aim to develop the ability to non-judgmentally notice internal
processes while maintaining task-focused attention to external cues and demands of a
given situation. This meta-analysis found a moderate model-averaged effect size estimate
with strong evidence; thus, we can conclude that the MAC protocol is effective in
12 M. PTÁČEK ET AL.

enhancing mindfulness among athletes. These results are in accordance with studies
adopting the idiographic methodology. For example, Wong and colleagues (2022)
assessed the effectiveness of the MAC approach among six sub-elite squash players
using a single-case A-B design, and the results suggest a moderate to large overall
effect of the MAC approach on enhancing mindfulness among athletes. The long-term
effects of the MAC protocol on mindfulness, however, are still not clear as the current lit-
erature is limited in this regard. Two of five studies that included the follow-up measure-
ment showed noticeable changes from post-test to follow-up, but these results are mixed.
While participants in the study by Gross and colleagues (2016) improved in mindfulness
scores from post-intervention to follow-up with a small effect, mindfulness scores of par-
ticipants in the study of Zhang and colleagues (2016) decreased with a moderate effect.
Furthermore, three of the five studies differed in the intervals between post-intervention
measurement and follow-up measurement (intervals ranged from 2 weeks to 3 months).
To draw a generalisable conclusion with stronger evidence, following research including
follow-up measurements is needed in this domain.
Because mindfulness is recognised as a multi-faceted construct, another weakness of
the current literature stems from an absence of a commonly accepted model of mindful-
ness’ facets and components (for example, see Birrer et al., 2012). Furthermore, with
exception of Shea (2019), neither of the included studies in the meta-analysis presents
scores for facets of mindfulness. As argued by Birrer and colleagues (2012), careful inves-
tigation of the facets and components of mindfulness is important to determine their
impact mechanisms and their effects on psychological processes because empirical
research suggests different components of mindfulness make different contributions to
psychological processes and thus lead to different benefits (Cash & Whittingham,
2010). A unified model of mindfulness should be developed within the context of sport
and performance. A conceptualisation suggested by Zhang and colleagues (2017)
seems to be a good starting point in the domain of sport psychology. Drawing on the
model presented by Birrer and colleagues (2012), future research could then focus on
determining what impact mechanisms underline individual facets and components,
how psychological interventions affect these facets, and how it affects sport performance
and the overall well-being of athletes.
In addition to mindfulness, the MAC protocol aims to develop psychological flexibility
within athletes (Gardner & Moore, 2007). Although psychological flexibility, as previously
defined, is a multi-facet construct, all five studies included in the analysis examined the
effects of the MAC protocol on experiential acceptance, but only one study included
other facets of the construct, namely commitment to values and cognitive defusion
where only negligible and negative effects were observed (Goodman et al., 2014).
Through the analysis of experiential acceptance, we found a small effect size estimate
suggesting improvement in experiential acceptance using the MAC protocol among ath-
letes. Nevertheless, the evidence underlying the estimate is limited and does not provide
sufficient support for concluding that the MAC protocol is effective in improving this
outcome. These results, however, are in accordance with the results of the recent study
by Wong and colleagues (2022) where effect sizes among six sub-elite squash players
ranged from small negative effects to large positive effects, and no overall effect was
found. According to the authors, these results might stem from (i) already low initial base-
line levels of experiential avoidance, or (ii) trait characteristics of experiential acceptance
 INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 13

[assuming the experiential acceptance is a function of the personality trait of openness

(Giluk, 2009; Hayes et al., 2004)] where changes would be expected, at least for some indi-
viduals, to occur in more gradual rate compared to skill acquisition of mindfulness. To
conclude these assumptions, following research including follow-up measurements of
experiential acceptance in research designs is needed as the current literature concerning
the long-term effects of the MAC approach is limited.
As suggested by Birrer and colleagues (2012), several non-pathological psychological
inhibitors and other factors can negatively influence the athletic performance and well-
being of athletes. These inhibitors and factors include competitive anxiety (Hardy et al.,
2018), perceived pressure (Beilock & Gray, 2007), fear of re-injury (Covassin et al., 2015),
negative emotions, and avoidant emotion-driven behaviour (Gardner & Moore, 2007;
Jordet & Hartman, 2008), overtraining (Carter et al., 2014), interpersonal problems or
life-balance (Hardy et al., 2018), and others. Fostering psychological flexibility within ath-
letes seems to be a promising applied approach to overcome these psychological inhibi-
tors. But further research exploring the effects of the MAC protocol on psychological
flexibility and its facets is still needed to extend currently limited findings. Especially
including comprehensive methods assessing psychological flexibility in its complexity is
necessary as evidence regarding MAC protocol’s effectiveness in developing other
facets of the construct is practically non-existent. For example, the CompACT question-
naire (Francis et al., 2016) seems to be a promising tool for these purposes.

MAC approach’s effects on secondary outcomes

The main goal of the MAC protocol is to enhance performance and overall well-being,
through the development of task-focused attention and psychological flexibility. This
meta-analysis found a small model-averaged effect size estimate for enhancing sport per-
formance. Even though the evidence supporting the presence of the effect is moderate,
these results need to be taken with caution. Firstly, most of the included studies used
indirect measurements of performance. We suggest that athletic performance should
be measured directly in sports when possible as such measurements could provide
more objective and possibly more accurate results than self-rated or coach-rated ques-
tionnaires assessing sports performance. For example, the study of Wong and colleagues
(2022) presents mixed results concerning performance enhancement. Authors of the
study observed overall positive effects in coach-rated performance (Cohen’s d ranged
from −0.03 to 2.72), but mixed results for self-rated performance (Cohen’s d ranged
from −1.32 to 2.96). Furthermore, studies assessing the accuracy of self-rated height
and weight measures show mixed results compared to measured anthropometric data
(see, Bowring et al., 2012; Hill & Roberts, 1998). A similar trend might be seen when
using self-rated or coach-rated sport performance questionnaires. For example, perfectio-
nistic athletes or coaches may set overly high standards for performance and strive for
flawlessness which may lead to an overly critical evaluation of sport performance
(Stoeber, 2012) and thus may lead to underestimation of self-rated or coach-rated athletic
performance. When using objective performance measures, however, we suggest carry-
ing out several pre-intervention and post-intervention measurements of performance
to set a baseline to control possible variance in the outcome (i.e., underperforming or
overperforming). The type of performance needs to be also taken into an account. For
14 M. PTÁČEK ET AL.

example, the results show a negative negligible effect of the MAC protocol on strength
and agility-based performance (Shea, 2019), but a positive large effect on accuracy-
based performance where attentional processes may play a more significant role as mech-
anisms of action (Bühlmayer et al., 2017; Zhang et al., 2016).
Theorised mechanisms of action in ACT-based approaches are attentional processes
and psychological flexibility (Gardner & Moore, 2007; Hegarty & Huelsmann, 2020;
White et al., 2021). However, while mindfulness may influence attentional processes
that may have a direct and immediate effect on performance, psychological flexibility
may contribute to performance enhancement more indirectly. More specifically, as pre-
viously mentioned, developing mindfulness and psychological flexibility during the
program aims to help athletes avoid emotion-driven behaviours and replace them with
value-driven behaviours (i.e., sticking to a meal plan even when craving unhealthy
food, overcoming boredom during an important training drill instead of skipping the
last few repetitions, etc.). If these assumptions concerning changes in metacognition
are true, we would expect athletes to benefit from these changes more gradually; thus,
the changes will not have a significant influence on performance in the relatively short-
term context of a controlled trial without follow-up measurement. However, to confirm
or disprove these assumptions, further research examining the long-term effects of the
MAC program on the process outcomes, and how these theorised mechanisms of
action relate to the secondary outcomes, is needed.
Alongside performance enhancement, the MAC protocol aims to promote well-being
among athletes (Gardner & Moore, 2007). However, the current state of the evidence base
examining the effectiveness of the MAC protocol did not allow us to conduct a meta-
analysis because only one study included in the meta-analysis examined the effects of
the MAC protocol on this outcome (Macdougall et al., 2019). In summary, the study pre-
sents a large positive effect on subjective well-being, a moderate positive effect on
psychological well-being, a small positive effect on physical well-being, and a negligible
positive effect on social well-being. However, there are only 9 participants in the study,
thus generalised conclusions about the MAC protocol’s effects on well-being cannot be
made.
Future research should include measures of well-being as it is, alongside sport per-
formance, one of the main secondary outcomes, that the MAC protocol aims to
improve (Gardner & Moore, 2007). For example, Satisfaction With Life Scale (SWLS:
Diener et al., 1985) assesses subjective well-being and it is only a five-item questionnaire,
thus its inclusion in a test battery would not be time and effort costly for participants but
would provide valuable information about the effectiveness of the MAC protocol.

Strengths and limitations, and future directions

To the extent of our knowledge, this is the first meta-analysis focusing merely on the MAC
protocol and its cultural variations, and providing the evidence base for its use in practice
since the introduction of the MAC protocol into applied sport psychology in 2007. The
main limitation of the presented meta-analysis remains the low number of included
studies. In total, there were eleven studies included in the meta-analysis but the analysis
of psychological flexibility, for example, included only five studies. Furthermore, five of
eleven trials utilised control groups without any intervention (i.e., wait-list control
 INTERNATIONAL JOURNAL OF SPORT AND EXERCISE PSYCHOLOGY 15

groups). The absence of an active control group in the design increases the risk of the
presence of the placebo effect which might lead to an overestimation of true effect sizes.
Despite the low number of included studies, adopting the RoBMAPSMA allowed us to
quantify evidence supporting the presence (or absence) of the effect, heterogeneity,
and publication bias. Although we cannot rule out publication bias as evidence for the
absence of the bias is limited (or evidence for the presence of the bias in the case of
sport performance), adopting the RoBMAPSMA allowed us to provide fairly accurate
effect size estimates accounting for the possibility of publication bias as well as hetero-
geneity; thus, allowed us to avoid confirmation bias and all-or-nothing decisions regard-
ing these factors (Bartoš et al., 2022). Unfortunately, RoBMAPSMA does not account for the
dependency of effect sizes. We have decided to handle this limitation by averaging
dependent effects. This approach, however, artificially reduces the variance between
effect sizes and, in the case of the presented meta-analysis, may lead to an underestima-
tion of the effect size estimates and Bayesian factors underlying the evidence behind the
estimated effects. An alternative approach to handle dependent effect sizes might utilise
Correlated and Hierarchical Effects’ models with Robust Variance Estimation (CHE-RVE)
(Harrer et al., 2021). This approach, however, requires further information concerning
the correlation between dependent effects within studies. Neither of included studies
with dependent effect sizes reports this metric; thus, utilising this approach would rely
on our bare estimation of the value. Furthermore, our estimation of the correlation
might be considered a manipulation of the data that could, consequently, lead to over-
estimation. In this regard, we chose to report more conservative results despite the possi-
bility of underestimations of the effect size estimates and Bayesian factors corresponding
to the effects. Nevertheless, in the supplementary materials, we report the results of
alternative analyses utilising the CHE-RVE to handle dependency of effect sizes using
Spearman’s rho values we consider realistic. The alternative results, however, do not
change our interpretations and conclusions of the study.
As previously mentioned, we encourage researchers to include comprehensive ques-
tionnaires of psychological flexibility assessing all facets of the construct, and measures
of well-being in their test batteries to extend limited findings concerning the effects of
the MAC protocol in this regard. Including follow-up measurements in the study
designs is also important for future research as the current results are limited, thus the
long-term effects of the MAC protocol are unclear. Furthermore, we encourage research-
ers to implement direct measurements of dependent variables in their study designs
when possible. Sport performance is a good example of such measurement. We argue
performance tasks or in-game statistics have better ecological validity compared to
self-rated or coach-rated questionnaires assessing athletic performance. We also rec-
ommend implementing multiple measurements in the pre-intervention phase and the
post-intervention phase when using performance tasks to set a baseline of average per-
formance to control possible variance in performance due to overperforming or under-
performing in the given task at a given time point of a study.
As argued by Barker and colleagues (2020), nomothetic designs (i.e., randomised, and
non-randomised controlled trials) do not allow for the detailed and objective exploration
of individual real-world settings during the intervention phase. In this regard, studies
using single-case experimental designs, such as the study by Wong and colleagues
(2022), may find larger effect sizes compared to group designs, therefore single-case
16 M. PTÁČEK ET AL.

experimental designs should be considered for future research in addition to nomothetic

methodology.

Conclusion
In conclusion, based on the results of the presented meta-analysis, the MAC protocol
assessed by randomised and non-randomised controlled trials can improve mindfulness.
In addition, results suggest that the MAC protocol might be effective in improving sport
performance, but these results need to be taken with caution due to several limitations of
the current research. And finally, available controlled trials do not provide sufficient evi-
dence supporting the MAC protocol’s effectiveness in developing psychological flexibility,
experiential acceptance, and promoting well-being among athletes.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The study was funded by Masaryk University through a specific research project [grant number
MUNI/A/1360/2021].

Data availability statement

The data are available on the Open Science Framework at https://osf.io/p9dz6/.

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