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1 Stress pissn X, eissn Stress 2017;25(2): REVIEW ARTICLE 마음챙김명상의메타분석 : ACT 와 MBSR 중심으로 조희현ㆍ이주희 동신대학교상담심리학과 A Meta-Analysis on the Effectiveness of Mindful Meditation: Focused on ACT and MBSR Hee-hyun Cho, Ju-hee Lee Department of Counseling Psychology, Dongshin University, Naju, Korea Key messages 본연구는마음챙김에기반을둔개입들의전반적인효과크기를알아보고, 효과크기에영향을주는중재변인을규명하기위해수행하였다. 이를위해국내학술지에게재된연구들중에서 ACT (Accetance & Commitment Therapy) 와 MBSR (Mindfullness-Based Stress Reduction) 를개입프로그램으로사용하고우울과불안을종속변인으로하는연구들을대상으로메타분석을수행하였다. 불안의경우 ACT (Hedges g= 0.596) 에서는유의미한차이를보이고있으나 MBSR (Hedges g= 0.419) 에서는유의미한차이를보이지않았다. 우울의경우 ACT (Hedges g= 0.622) 와 MBSR (Hedges g= 0.784) 에서모두유의미한차이를보이고있다. 중심단어 : 마음챙김, ACT, MBSR, 메타분석 Received February 20, 2017 Revised April 14, 2017 Accepted May 11, 2017 Corresponding author Hee-hyun Cho Department of Counseling Psychology, Dongshin University 13 Hoeseo-ro 21beon-gil, Nam-gu, Gwangju 61717, Korea Tel: Fax: jundosalove@daum.net Copyright 2017 by Stress. All rights reserved. Abstract The study is performed to recognize overall effect size of interventions based on mindfulness and further find the moderator s which affect the effect size. In order to achieve this goal, we have selected ACT and MBSR as intervention programs among many studies published in the national academic journals and performed meta-analysis of studies treating depressive and anxiety symptom as dependent s. In case of anxiety symptom, it showed a significant difference in ACT (Hedges g= 0.596), however, it did not show any significant difference in MBSR (Hedges g= 0.419). In case of depressive symptom, both ACT (Hedges g= 0.622) and MBSR (Hedges g= 0.784) showed significant differences. Key Words: Mindfulness, ACT, MBSR, Meta-analysis 서론 1. 연구의필요성최근에사적경험의수용을강조하는마음챙김기법이인지행동치료의제3의흐름을형성하고있다 (Moon HM, 2005). 사적경험으로는정서, 사고, 기억, 행동적경향성, 신체적감각등이포함된다. 기존인지행동치료에비해마음챙김을기반으로하는인지행동치료의제3의흐름에서는신체적감각을중요한관찰대상으로여기고있다. 수용전념치료 (Acceptance & Commitment Therapy, ACT) 는인간의심리적고통은정상적이며보편적인것이라고본다 (An HY et al., 2007). 즉수용전념치료는인지-행동적접근내에서새롭게보완된마음챙김기반심리치료기법이다. 내재화문제의핵심인우울과불안에는경험회피 (experimental avoidance) 가 내포되어있는데, 우울이나불안을접촉하지않고상황을바꾸고자할때경험회피가생기게된다. 수용전념치료는심리적수용의증진을통해서경험회피에서벗어나우울과불안을경험하게한다. 마음챙김기반스트레스감소프로그램 (Mindfullness-Based Stress Reduction: MBSR) 은스트레스관련질환과만성적인통증을지닌환자들을위해개발되었다 (An HY et al., 2007). 다양한연령대에서폭넓게참여하며스트레스로인한불편한증상을완화하는효과가임상적으로보고되고있다. 또한기억, 지능, 대인관계개선, 행복, 긍정적정동, 공감, 자기실현, 신뢰감등의긍정적효과를미치는것으로보고되고있다 (Hayes, 1994). MBSR은 ACT와같이비판단적인방법으로사적경험에대하여주의를주는것이포함된다. 또한사고와감정을분리하고지금-여기의알아차림을유지

2 70 Hee-hyun Cho, Ju-hee Lee 하는것이 MBSR의목적이다 (Ludwig et al., 2008). MBSR 관련해외논문에서는 MBSR프로그램이우울과불안경감에효과가있다고보고되고있다 (Rachel EG et al., 2014). 심리적인문제를내재화와외재화로구분할경우, 내재화의대표적인문제는우울과불안이다. 우울과불안은인간의삶속에서경험하게되는매우보편적인정서이다. 그러나무력감, 무망감같은또다른정서적불편감과연결되면서동기적, 신체적, 정서적측면에서의부적응을초래하게한다. 우울과불안에대한사회적문제가심각해지면서다양한치료법이개발되어왔으며, 우울과불안치료에 CBT( 인지행동치료 ) 가효과적이라는연구가다수보고되고있다 (Park GY et al., 2001). 지난수십년동안인지행동치료는심리치료에서수많은공헌을하였다. 인지행동치료는우울과불안유발에있어서부정적사고와부정적자기도식이핵심이므로, 이에대한검증과반박을통해환자의핵심도식과비합리적인신념을재구조화하는데중점을두었다. 그러나인지행동치료를통해서비합리적생각의문제를인지하는데까지는목표를달성할수있으나이러한통찰이심리적인문제를극복하거나행동을변화시키는데까지이르는데는어려움이있다. 마음챙김기반치료에서는우울과불안을자연스러운감정상태로보며통제되어야할상태로여기지않는다. 우울과불안과관련된사고를억압하는과정에서이러한사고에더몰두하게되어결과적으로부정적인효과를가져온다고본다. 다시말해인간이면누구나느끼는심리적고통을통제하거나제거하려고할때고통은더가중된다는개념에기초한다. 통제는고통스러운감정에더휘말리게하며, 더외상적인것으로변화되게한다는개념에기초한다 (Hayes, 2014). 미국 Psychotherapy Networker 2007년도 3월호보고에의하면, 심리치료사가활용하는치료기법으로인지행동치료 (68.8%), 마음챙김 (41.4%), 정신분석 (35.5%) 순이었다 (Kim JD et al., 2010). 2015년기준으로한국심리학회에서발행된논문수를비교해보면, 인지행동치료관련논문은 72 편, 마음챙김기반관련논문은 298편, 정신분석관련논문은 27편이었다. 본연구에서는다수의논문들이출간되고있고심리치료프로그램으로주목을받고있는마음챙김기반프로그램의효과에대하여알아보고자한다. 마음챙김기법을통 해서내재화에핵심문제인우울과불안에어느정도효과가있는지메타분석을통해서검증해보고자한다. 2. 연구목적본연구는국내에서수행된 ACT 및 MBSR 프로그램에대한연구의효과를메타분석하여첫째, 연구특성을분석하고, 둘째우울과불안관련종속변수의효과크기를분석하여, 셋째, 종속변수에따른 ACT와 MBSR프로그램의효과크기를비교하고자한다. 연구방법 1. 자료검색및선정과정분석대상연구의선정기준은 Fig. 1과같다. 문헌선정과정은 4단계를거쳐진행하였다. 데이터베이스를통한자료검색은 2015년 5월이전으로이루어졌다. 국내에서명상중재프로그램 (ACT, MBSR) 적용한석박사학위논문및학술지논문을검색하였다. 본연구에서사용된주제검색어로는 ACT, MBSR, 명상, 마음챙김, 수용전념치료 를활용하였다. 해당문헌을검색하기위하여국내데이터베이스를이용하여학술연구정보서비스 (Research Information Sharing Service [RISS]), 한국학술정보서비스 (Koreanstudies Information Service System [KISS]) 및학술데이터베이스서비스 (DataBase Periodical Information Academic [DBpia]) 의학술연구정보를활용하여검색하였다. 최초로검색된연구의수는 ACT 127개, MBSSR 162개로총 289개였으며 (1단계 ), 저자별제목확인과정에서및포스터나논문초록만제시한논문및중복논문 (n=90) 제외한후에는총 199개의논문이선정하였다 (2단계). 이후 199개논문의초록을검토하여통제집단이없는논문, 상관논문, 질적연구, 예비연구등을추가적으로제외하여선정된논문은 33개였다 (3단계). 다음으로측정도구에서우울이나불안관련측정도구가없는논문을제외하여메타분석에사용된논문은 ACT 5, MBSR 12개로최종 17개였다. 분석대상연구논문은참고문헌에메타분석관례에따라 * 표시로제시되었다. Fig. 1. Flow chart of study selection.

3 A Meta-Analysis on the Effectiveness of Mindful Meditation: Focused on ACT and MBSR 코딩및자료분석먼저선정된우울및불안통계수치를각각입력한후, 연구절차순서에따라서입력하여분석하였다. 각연구에서제시하고있는기본통계적수치, 즉표준편차, 표본크기에대한정도, 사후평균등을취합하였다. 모든연구결과에대한효과크기를선택함에있어서, 표본크기가그다지크지않다는점을인식하여교정표준화된효과크기 (corrected standardized mean difference), 즉 Hages g를산출하였다. 95% 신뢰기준 (Confidence interval [Cl]) 를계산하였고, 각효과크기의가중치 (weight) 는분산의역수 (inverse of variance) 를이용하였다. 즉 Hages g를산출한것은 Cohens d를보완하는방법으로표본이작을경우과대추정되는약점을보완한효과크기이기때문이다 (Hedges & Olkin, 1985). 그리고효과크기의분석을위해서메타분석전용프로그램인 R을활용하였다. R프로그램은뉴질랜드오클랜드대학교에서시작되었으며, 그이후 R development team의과학자들에의해개발되었다. 본연구는 R 프로그램을활용하여분석하였다. 평균효과크기 (summary effect) 는각연구의연구방법, 표본, 개입방법이서로다양한점을인정하며무선효과모형 (random-effects model) 을적용하여산출하였다. 또한효과크기의통계적이질성 (heterogeneity) 을평가하였다. 결과 1. 선정된연구의특성본연구의분석대상논문의출판연도, 사례수, 성별, 마음챙김기법, 프로그램 1회기시간, 종속변수특정도구의특징을살펴보면다음과같다. 분석대상연구논문 17편으로연구논문은 2006년 1편, 2007년 1편, 2008년 2편, 2011년 1편, 2012년 4편, 2013년 3편, 2014년 4편, 2015년 1편이출간되었다. 대상자의특징으로는, 전체대상자의수는최소 6명에서최대 37명으로, 6 10명은 3편, 11 15명은 3편, 15 20명은 7편, 21 25명은 0편, 26 30명은 2편, 30 35명은 0편, 35 40명은 1편으로 15 20명사이가가장많았다. 성별로는남녀혼성집단이 10편, 여성동성집단은 6 편, 남성동성집단은 1편으로혼성집단이가장많았다. 치료기법으로는 K-MBSR이 12편, MBSR은 0편, ACT는 5편이었다. 프로그램적용시간은 90분 120분사이가 12편으로가장많았다. 중재횟수는 8회인경우 8편으로가장많았으며그다음으로 6회인경우 4편이었다. 종속변수우울과불안을측정하기위한도구로총 7가지척도가사용되었다. 구체적으로, 우울관련측정도구는 BDI (Beck Depression Inventory), 한국우울증검사 (KDS-30), 직무스트레스척도 ( 우울 ), SCL-47-DEP (Symptom Check List-47-Depression), 스트레스반응-우울 (Stress response-depression), 노인우울척도, SCL-90-R (Symptom Check List-90-Revised-Depression) 였으며 BDI도구사용이 8편으로가장많은비중을차지했으며다음으로간이정신진단검사로 3편이었다. 불안관련측정도 구로는 BAI (Beck Anxiety Inventory), STAI (State- Trait Anxiety Inventory), 직무스트레스척도 ( 불안 ), SCL- 47-ANX (Symptom Check List-47-Anxiety), SCL-90-R (Symptom Check List-90-Revised-Depression) 였으며 STAI 도구사용이 6편으로가장많은비중을차지했으며다음으로 BAI도구로 5편이었다. 대부분논문에서대상자의연령관련하여대학생, 성인, 노인등으로언급하고있어대상자의연령에따른특징을알아볼수없었다. 2. 우울의중재효과크기 Table 1에서보듯이, 우울증상에대해 15개의효과크기가계산되었으며, 이를가중평균한효과크기는 0.72 (p<.001) 로통계적으로유의하다. 연구들간의이질성을검증하는 Q 값은 (p<.001) 으로통계적으로유의하였다. 하위집단간메타회귀분석을실시하여연구들간이질성의원인이무엇인지확인을시도하였다. Table 2을보면, 우울증상에대한연구의중재변인에따른효과크기및연구간의이질성을확인할수있다. 먼저, 마음챙김프로그램유형에따른효과크기차이를확인하였다. 총 15개의효과크기에서 MBSR보다 ACT에서우울증상을줄이는데효과크기가큰것으로나타났지만, 이러한차이는통계적으로유의하지않았다 (p=0.643). 참가자성별의경우남성만을대상으로한연구는 1편밖에되지않아하위집단을대표하기는어려운것으로보아이를제외하고, 혼성과여성만을대상으로한연구의효과크기를비교하였다. 분석결과, 참가자성별이혼성인경우보다여성인경우효과크기가큰것으로나타났지만통계적으로유의한차이는아니었다 (p=0.138). 한회기시간이 80시간이상인경우가 80시간이하인경우보다효과크기가큰것으로나타났지만통계 Table 1. The size of effect of studies on depression symptoms Author of paper Year Size of effect Lower limit Upper limit Weight Bae JH et al Chu KS Lee BG Kang MJ et al Kim MH et al Lee SY et al Lee YG et al Lee HS Park SR et al Park K et al Kim SY et al Jung YM Kang EH Cho IH Kim KN et al Overall 0.718*** The size of effect is Hedes's g- (corrected size of effect). (The meta-analysis program used: R) A total of 15 effect sizes were calculated over depressive symptoms and the averaged effect size was statistically significant with 0.72 (p<.001).

4 72 Hee-hyun Cho, Ju-hee Lee Table 2. Sub-group analysis of studies on depression symptom Moderator Sub-category (No. of studies) Size of effect Verification of heterogeneity of the size of effect Q Degree of freedom p Mindfulness technique ACT (6) MBSR (11) Gender Mixed gender (9) Female (7) Duration of one session 80 min or less (6) min or more (11) No. of session 8 sessions or under (11) sessions or more (6) (The meta-analysis program used: R) ACT was shown to have larger effect sizes than MBSR in reducing depressive symptoms in a total of 15 effect sizes, but this difference was not statistically significant (p=0.643). The effect sizes were compared between the studies with the mixed-gender participants and those with the female subjects only. As a result of the analysis, the studies with female participants only were shown to have larger effect sizes than those with mixed-gender participants, but the difference was not statistically significant (p=0.138). The studies with more than 80 hours per session showed larger effect sizes than those with less than 80 hours per session, but this difference was not statistically significant (p=0.861). The studies with less than 9 sessions showed large effect sizes, which was not statistically significant (p=0.400). Table 3. Meta-regression analysis of studies on depression symptom Predicator Estimated (slope) Size of effect (SE) Lower limit Upper limit Z p Year of publication Intervention session (The meta-analysis program used: R) When publishing years were put to use as predicting s, the estimated of the slope was not significant with (p=0.738). The estimated of the slope also in the number of the sessions was not statistically significant with (p=0.741). 적으로유의한차이는아니었다 (p=0.861). 회기수와관련된분석에서는 9회이상인경우가효과크기가큰것으로나타났지만통계적으로유의한차이는아니었다 (p=0.400). Table 4. The size of effect of studies on anxiety symptoms Author of paper Year Size of Effect Lower limit Upper limit Weight 1) 우울메타회귀분석 Table 3에서우울증상에대한연구의효과크기에대해출판연도와마음챙김프로그램의회기수를예측변인으로하여각각메타회귀분석을수행하였다. 먼저, 출판연도를예측변인으로하였을때기울기추정값이 0.026로통계적으로유의하지는않았다 (p=0.738). 또한회기수에서도기울기추정값이 0.052로통계적으로유의하지않았다 (p=0.741). 3. 불안의중재효과크기 Table 4에서보듯이, 불안증상에대해 13개의효과크기가계산되었으며, 이를가중평균한효과크기는 0.49 (p<.001) 로통계적으로유의한것으로해석할수있다. 연구들간의이질성을검증하는 Q값은 (p<.001) 로통계적으로유의하였다. 하위집단과메타회귀분석을실시하여연구들간이질성의원인이무엇인지확인을시도하였다. Table 5를보면, 불안증상에대한연구의중재변인에따른효과크기및연구간의이질성을확인할수있다. 먼저, 마음챙김프로그램유형에따른효과크기차이를확인하였다. 총 13개의효과크기에서 ACT보다 MBSR에서불안증상을줄이는데효과크기가큰것으로나타났지만, 통계적으로유의한차이는아니었다 (p=0.632). 참가자성별의경우남성만을대상으로한연구는 1편밖에되지않아하위집단을대표하기는어려운것으로보아이 Bae JH et al Chu KS Kim MJ Lee JY Lee YG Lee SY et al Lee HS Park SR et al Park K et al Kim SY et al Jung YM Kang EH Kang MJ et al Overall 0.494*** (The meta-analysis program used: R) A total of 13 effect sizes were calculated over anxiety symptoms, and their weighted average was statistically significant with 0.49 (p<.001) and could be interpreted to be large with more than 0.8. The Q, which tests the heterogeneity between the studies, was statistically significant with (p<.001). A meta-regression analysis was performed to attempt to identify the causes of the heterogeneity between the studies. 를제외하고, 혼성과여성만을대상으로한연구의효과크기를비교하였다. 분석결과, 참가자성별이혼성인경우보다여성인경우효과크기가큰것으로나타났지만통계적으로유의한차이는아니었다 (p=0.982). 1회기시간이 80시간이하인경우가 80시간이상인경우보다효과크기가큰것으로나타났지만통계적으로유의한차이는아니었다 (p=0.499). 회기수와관련된분석에서는 9회이상인경우가효과크기

5 A Meta-Analysis on the Effectiveness of Mindful Meditation: Focused on ACT and MBSR 73 Table 5. Analysis of sub-group of studies on anxiety symptom Moderator Sub-category (No. of studies) Size of effect Verification of heterogeneity of the size of effect Q Degree of freedom p Mindfulness technique ACT (5) MBSR (10) Gender Mixed gender (8) Female (6) Duration of one session 80 min. or less (5) min. or more (10) No. of sessions 8 sessions or under (9) sessions or more (6) (The meta-analysis program used: R) The difference in the effect sizes according to the mindfulness programs was identified. ACT was shown to have larger effect sizes than MBSR in reducing anxiety symptoms in a total of 15 effect sizes, but this difference was not statistically significant (p=0.632). The effect sizes were compared between the studies with the mixed-gender participants and those with the female subjects only. As a result of the analysis, the studies with mixed-gender participants were shown to have larger effect sizes than those with female participants only, but the difference was not statistically significant (p=0.982). The studies with less than 80 hours per session showed larger effect sizes than those with more than 80 hours per session, but this difference was not statistically significant (p=0.499). The studies with more than 9 sessions showed large effect sizes, which was not statistically significant (p=0.714). Table 6. Meta regression analysis of studies on anxiety symptoms Predicator Estimated (slope) Size of effect (SE) Lower Limit Value Upper Limit Value Z p Year of publication No. of intervened sessions (The meta-analysis program used: R) When publishing years were put to use as predicting s, the estimated of the slope was not significant with (p=0.463). The estimated of the slope also in the number of the sessions was not statistically significant with (p=0.387). 가큰것으로나타났지만통계적으로유의한차이는아니었다 (p=0.714). 1) 불안증상메타회귀분석 Table 6에서불안증상에대한연구의효과크기에대해출판연도와마음챙김프로그램의회기수를예측변인으로하여각각메타회귀분석을수행하였다. 먼저출판연도를예측변인으로하였을때기울기추정값이 0.05로통계적으로유의하지는않았다 (p=0.463). 또한회기수에서도기울기추정값이 0.123로통계적으로유의하지않았다 (p=0.387). 고찰 본연구는마음챙김에기반을둔개입들의전반적인효과크기를알아보고, 효과크기에영향을주는중재변인을규명하기위해수행되었다. 이를위해국내학술지에게재된연구들중에서 ACT와 MBSR을개입프로그램으로사용하고우울과불안증상을종속변인으로하는연구들을대상으로메타분석을수행하였다. 그결과, 우울의경우 ACT (Hedges g= 0.622) 와 MBSR (Hedges g= 0.784) 에서모두유의미한차이를보이고있다. 불안의경우 ACT (Hedges g= 0.596) 에서는유의미한차이를보이고있으나 MBSR (Hedges g= 0.419) 에서유의미한차이를보이지않았다. 결과적으로우울에서는 ACT와 MBSR 모두효과가있었으나불안의경우 ACT만효과가있었다. 우울과불안외에다른연구특성들에따른효과크기의차이를검토한결과, 마음챙김기법의 여부, 참가자의성별, 참가자의대상, 1회기시간의길이, 회기수에따른효과는통계적으로유의하지않았다. 출판연도와회기수가개입의효과에미치는영향에관해메타회귀분석을통해살펴본결과, 우울및불안증상에대한개입의효과는출판연도에영향을받지않았다. 불안증상에대한개입의효과를높이기위해서는 MBSR보다 ACT가효과가있음시사한다. 본연구의한계점과향후연구방법에관해살펴보면다음과같다. 첫째, 본연구에서는참가자들이다른종류의증상들을함께가졌는지여부와무관하게그들의우울과불안에개별적으로초점을맞추었다. 따라서마음챙김에기반을둔개입의효과를일반화할때에이러한점을고려해야할필요가있다. 둘째, 본연구에서중재변인의하위유형에서대부분유의하지않은결과가, 논문수가적어통계적검증력이낮은결과일가능성이있으므로추후논문수가누적되면다시검증할필요가있다. 셋째, 본연구에서아동, 청소년, 노인, 남성집단은포함되지않았다. 문헌검색결과, 이들을대상으로한연구가성인에비해상당히적었다는점을고려하였는데, 관련연구들이더많이축적되면제외된대상으로한메타분석을수행해볼필요가있다. 넷째, 본연구는개입전과개입후의측정치들을비교한효과크기에만초점을맞추었다. 추수결과가빠져마음챙김에기반을둔개입의효과가지속되는지여부에관해확신을할수없는한계점이있다. 따라서프로그램이끝난후시간이경과한후에도그효과가지속되는지, 유지된다면어느정도기간동안지속되는지에관해지속적인연구를수행할필요가있다. 다섯째,

6 74 Hee-hyun Cho, Ju-hee Lee 본연구에서는효과크기의추정치에출판편파가관여될가능성이시사되었다. 다시말해, 효과크기가적은연구들이상대적으로덜출판되었을가능성이있다는것이다. 현재마음챙김기반에관한관심이증대되고있고많은논문들이축적되고있으므로추후연구가많아질것으로보인다. 여섯째본연구에서는 ACT와 MBSR에국한되어연구되어졌다. 마음챙김기법은크게 ACT와 MBSR외에 MBCT, DBT 등도있으므로, 차후에는 4가지를종합적으로메타분석을할필요가있을것이다. 일곱째, 본연구는한국에서출간된논문을바탕으로효과분석하였다. 차후에는해외에서발간된마음챙김프로그램을추가하여메타분석을시행할필요가있다. 여덟째, 본연구에서는 ACT와 MBSR 등마음챙김에기반한프로그램들간의비교분석하였다. 차후에는마음챙김기반프로그램과인지행동치료프로그램을효과분석하여비교할필요가있을것이다. 아홉째, 해외관련연구를살펴보면, ACT관련메타분석에서는불안과우울모두에서효과가있다고보고하였다 (Peter et al., 2017). 해외연구결과는본연구결과와일치하고있다. 이에비해 MBSR 메타분석에서도불안과우울모두에서효과있다고보고되었다 (Paul et al., 2004). 본연구에서는 MBSR이우울에서만효과가있다고보고되고있는데, 이러한차이점에대한추가연구가필요해보인다. 이러한한계점들에도불구하고, 본연구는몇가지에서의의를갖고있다. 첫째, 최근많은심신건강분야실무자들로부터관심을끌고있고다수의논문이발행되는마음챙김기반의개입에관한연구들을종합하여그효과크기를계량화하였다는점에서의의가있다. 둘째, 우울문제를다룰때마음챙김프로그램의개입에대한신뢰감을갖게했다는점에의의가있다. 셋째, 마음챙김에기반을둔개입에서효과크기가연구의특성에따라어떻게다른지구체적으로파악함으로써, 프로그램을구성하고대상을선별하는데도움을제공할수있다는점에서의의가있다. 넷째, 차후마음챙김관련메타연구를계획시, 본연구가연구방향을설정하는데도움을제공할수있다는점에서의의가있다고본다. References *References to studies included in this review. 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Korea J of Stress Reserch 21:256. *Park SR, Lee HJ (2012). The Effect of the ACT-Based Value Exploration Program on Valued Living and Psychological Adjustment. Korea J Cog and Behav 12:13. Paul G, Ludger N, Stefan S, Herald W (2004). Mindfulness-Based Stress Reduction and health benefits A meta-analysis. Journal of Psychosomatic Reasearch. 57: Peter AS, Tom M, Jorge EE (2017). A systematic review of randomized controlled trials using Acceptance and commitment therapy as an intervention in the management of non-malignant, chronic pain in adult. International Journal of Osteopathic Medicine. 30:1-14. Rachel EG, James IG, Samantha AC, John WB, Brighid K, Megan MH (2014) Mindfulness- Based Stress Reduction for Posttraumtic Stress Symptom s : Building Acceptance And decresing Shame. J. Evidence-Based Complementary & Alternative Medicine, 19:227. Shapiro SL, Schwartz GER, Bonner G (1998) Effect of Mindfullness-based stress reduction on medical and premedical student. J. Behavior Medicine, Song HJ, Son JR (2011). The Effects of Acceptance and Commitment Therapy on Ager, Stress, and Binge Eating Behaviour of the Binge Eating Disorder-prone College Students. Korea J health Psychol 16:22. Son JR, H YS (2013). Effects of Acceptance and Commitment Therapy on Emotional Clarity, Avoidant Emotional Regulation and Study-related Stress of Adolescent with Emotion Dysregulation. Korea J health Psychol 18: Yoon BS (2014). The Effect of Korean Version of Mindfulness Based Stress Reduction Program on Stress and Distraction of University Students. Korea J of Stress Research 22:235. Yoo DS, Son JR (2014). The Effects of Acceptance and Commitment Therapy(ACT) on Diabetes Stress, Self-Care, Quality of Life and Acceptance and Action of Adolescents with Type 1 Diabetes. Korea J health Psychol 19:1646.

한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -