H.R. Trompetter

Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

Abstract The number of acceptance- and mindfulness-based interventions for chronic pain, such as acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT), increased in recent years. Therefore an update is warranted of our former systematic review and meta-analysis of studies that reported effects on the mental and physical health of chronic pain patients. Pubmed, EMBASE, PsycInfo and Cochrane were searched for eligible studies. Current meta-analysis only included randomized controlled trials (RCTs). Studies were rated for quality. Mean quality did not improve in recent years. Pooled standardized mean differences using the random-effect model were calculated to represent the average intervention effect and, to perform subgroup analyses. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. Included were twenty-five RCTs totaling 1285 patients with chronic pain, in which we compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Effect sizes ranged from small (on all outcome measures except anxiety and pain interference) to moderate (on anxiety and pain interference) at post-treatment and from small (on pain intensity and disability) to large (on pain interference) at follow-up. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT. Studies’ quality, attrition rate, type of pain and control group, did not moderate the effects of acceptance- and mindfulness-based interventions. Current acceptance- and mindfulness-based interventions, while not superior to traditional cognitive behavioral treatments, can be good alternatives.

Measuring Values and Committed Action With the Engaged Living Scale (ELS): Psychometric Evaluation in a Nonclinical Sample and a Chronic Pain Sample

This article describes the development and evaluation of the Engaged Living Scale (ELS) as a new self-report, process-specific measure to assess an engaged response style as conceptualized in acceptance and commitment therapy (ACT). The psychometric properties of the ELS test scores were evaluated in both a nonclinical sample (N = 439) and a clinical sample consisting of chronic pain patients who participated in a study on the effects of an online ACT intervention (N = 238). Item analysis and exploratory factor analysis in the nonclinical sample suggested a 16-item version of the ELS with 2 subscales, Valued Living (10 items) and Life Fulfillment (6 items). A bifactor model with 2 specific factors and 1 general underlying factor showed the best fit in confirmatory factor analyses in the chronic pain sample. In both samples, the scores on the ELS and its subscales showed good internal consistency and construct validity by consistent patterns of relationships with theoretically related process and outcome variables, such as psychological well-being, anxiety/depression, acceptance, mindfulness, and pain interference in daily life. Furthermore, in the chronic pain sample, the ELS showed incremental validity in explaining anxiety and depression, positive mental health, and pain interference beyond both acceptance and mindfulness. This study suggests the ELS shows promise as a useful tool for the measurement of an engaged response style, enabling more comprehensive evaluation of working mechanisms of ACT.

Psychological flexibility and catastrophizing as associated change mechanisms during online Acceptance & Commitment Therapy for chronic pain

The underlying mechanisms of the effectiveness of cognitive behavioural interventions for chronic pain need further clarification. The role of, and associations between, pain-related psychological flexibility (PF) and pain catastrophizing (PC) were examined during a randomized controlled trial on internet-based Acceptance & Commitment Therapy (ACT) for chronic pain. We assessed (1) the unique and combined indirect effects of PF and PC on outcomes, and (2) the causality of relations between PF, PC and the primary outcome pain interference in daily life (MPI) during ACT. A total of 238 pain sufferers were allocated to either ACT, a control condition on Expressive Writing, or a waiting list condition. Non-parametric cross-product of coefficients mediational analyses and cross-lagged panel designs were applied. Compared to control conditions, both baseline to post-intervention changes in PF and PC seemed to uniquely mediate baseline to three-month follow-up changes in pain interference and psychological distress. Only PF mediated changes in pain intensity. Indirect effects were twice as large for PF (κ2 = .09-.19) than for PC (κ² PCS = .05-.10). Further assessment of changes during ACT showed, however, that only PF, and not PC, predicted subsequent changes in MPI, while early and late changes in both PF and PC predicted later changes in each other. In conclusion, only PF functioned as a direct, causal working mechanism during ACT, with larger indirect effects that occurred earlier than changes in PC. Additionally, PC may function as an indirect mechanism of change during ACT for chronic pain via its direct influence on PF.

Positive Psychological Wellbeing Is Required for Online Self-Help Acceptance and Commitment Therapy for Chronic Pain to be Effective

The web-based delivery of psychosocial interventions is a promising treatment modality for people suffering from chronic pain, and other forms of physical and mental illness. Despite the promising findings of first studies, patients may vary in the benefits they draw from self-managing a full-blown web-based psychosocial treatment. We lack knowledge on moderators and predictors of change during web-based interventions that explain for whom web-based interventions are especially (in)effective. In this study, we primarily explored for which chronic pain patients web-based Acceptance and Commitment Therapy (ACT) was (in)effective during a large three-armed randomized controlled trial. Besides standard demographic, physical and psychosocial factors we focused on positive mental health. Data from 238 heterogeneously diagnosed chronic pain sufferers from the general Dutch population following either web-based ACT (n = 82), or one of two control conditions [web-based Expressive Writing (EW; n = 79) and Waiting List (WL; n = 77)] were analysed. ACT and EW both consisted of nine modules and lasted nine to 12 weeks. Exploratory linear regression analyses were performed using the PROCESS macro in SPSS. Pain interference at 3-month follow-up was predicted from baseline moderator (characteristics that influence the outcome of specific treatments in comparison to other treatments) and predictor (characteristics that influence outcome regardless of treatment) variables. The results showed that none of the demographic or physical characteristics moderated ACT treatment changes compared to both control conditions. The only significant moderator of change compared to both EW and WL was baseline psychological wellbeing, and pain intensity was a moderator of change compared to EW. Furthermore, higher pain interference, depression and anxiety, and also lower levels of emotional well-being predicted higher pain interference in daily life 6 months later. These results suggest that web-based self-help ACT may not be allocated to chronic pain sufferers experiencing low levels of mental resilience resources such as self-acceptance, goals in life, and environmental mastery. Other subgroups are identified that potentially need specific tailoring of (web-based) ACT. Emotional and psychological wellbeing should receive much more attention in subsequent studies on chronic pain and illness.

Towards a science and practice of resilience in the face of pain

The primary objective of this paper is to discuss how a resilience approach to (chronic) pain may advance our current understanding of (mal)adaptation to pain. Different resilience perspectives are described, and future challenges for research, prevention and treatment of (chronic) pain are discussed. Literature searches were performed in Web of Science and PubMed to identify relevant literature on risk and resilience in the context of pain. Resilience can be best defined as the ability to restore and sustain living a fulfilling life in the presence of pain. The Psychological Flexibility Model, the Broaden‐and‐Build Theory, and Self‐Determination Theory are described as theories that may provide insight into resilience within the context of (chronic) pain. We describe how a resilience paradigm shifts the outcomes to pursue in pain research and intervention and argue the need for including positive outcomes in addition to negative outcomes. Psychological flexibility, positive affect and basic psychological needs satisfaction are described as potentially important resilience mechanisms with the potential to target both sustainability and recovery from pain. A resilience approach to chronic pain may have important implications for the prevention and treatment of chronic pain problems, as it may give specific indications on how to empower patients to continue living a fulfilling life (in the presence of pain).

How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms

BackgroundAcceptance and Commitment Therapy (ACT) has been demonstrated to be effective in reducing depressive symptoms. However, little is known how and for whom therapeutic change occurs, specifically in web-based interventions. This study focuses on the mediators, moderators and predictors of change during a web-based ACT intervention.MethodsData from 236 adults from the general population with mild to moderate depressive symptoms, randomized to either web-based ACT (n = 82) or one of two control conditions (web-based Expressive Writing (EW; n = 67) and a waiting list (n = 87)), were analysed. Single and multiple mediation analyses, and exploratory linear regression analyses were performed using PROCESS and linear regression analyses, to examine mediators, moderators and predictors on pre- to post- and follow-up treatment change of depressive symptoms.ResultsThe treatment effect of ACT versus the waiting list was mediated by psychological flexibility and two mindfulness facets. The treatment effect of ACT versus EW was not significantly mediated. The moderator analyses demonstrated that the effects of web-based ACT did not vary according to baseline patient characteristics when compared to both control groups. However, higher baseline depressive symptoms and positive mental health and lower baseline anxiety were identified as predictors of outcome across all conditions. Similar results are found for follow-up.ConclusionsThe findings of this study corroborate the evidence that psychological flexibility and mindfulness are distinct process mechanisms that mediate the effects of web-based ACT intervention. The results indicate that there are no restrictions to the allocation of web-based ACT intervention and that web-based ACT can work for different subpopulations.Trial registrationNetherlands Trial Register NTR2736. Registered 6 February 2011.

Exploring the relation between positive emotions and the functional status of older adults living independently: a systematic review

ABSTRACT Objectives: Literature suggests that positive emotions positively influence physiological parameters but their relation to functioning in the daily life of older adults living independently remains unclear. The present work aims to investigate the relation between positive emotions and functional status in daily life of older people living independently. Method: A systematic literature review was conducted using the PubMed, PsycINFO and Scopus electronic databases. Included works were peer-reviewed empirical studies that analysed the relation between positive emotions and ability to perform activities of daily living with older adults living independently. Results: After removal of duplicates, 10 out of 963 papers met the inclusion criteria. Cross-sectional studies (n = 6) provided limited evidence about a relation between positive emotions and functioning in daily life. However, longitudinal studies (n = 4) provide significant evidence for an interaction between the two factors, suggesting that time influences this interaction. Conclusion: The variety on the design and samples of the studies included in this review does not allow a cohesive conclusion of the results. Nevertheless, limited evidence suggests that higher frequency in the experience of positive emotions might be associated with lower functional limitations. The issue of causality in emotions-functioning remains unclear from the review. Further observational studies are highly recommended, supported by innovative technologies.

Measuring avoidance of pain: validation of the Acceptance and Action Questionnaire II-pain version

Psychometric research on widely used questionnaires aimed at measuring experiential avoidance of chronic pain has led to inconclusive results. To test the structural validity, internal consistency, and construct validity of a recently developed short questionnaire: the Acceptance and Action Questionnaire II-pain version (AAQ-II-P). Cross-sectional validation study among 388 adult patients with chronic nonspecific musculoskeletal pain admitted for multidisciplinary pain rehabilitation in four tertiary rehabilitation centers in the Netherlands. Cronbach’s &agr; was calculated to analyze internal consistency. Principal component analysis was performed to analyze factor structure. Construct validity was analyzed by examining the association between acceptance of pain and measures of psychological flexibility (two scales and sum), pain catastrophizing (three scales and sum), and mental and physical functioning. Interpretation was based on a-priori defined hypotheses. The compound of the seven items of the AAQ-II-P shows a Cronbach’s &agr; of 0.87. The single component explained 56.2% of the total variance. Correlations ranged from r=−0.21 to 0.73. Two of the predefined hypotheses were rejected and seven were not rejected. The AAQ-II-P measures a single component and has good internal consistency, and construct validity is not rejected. Thus, the construct validity of the AAQ-II-P sum scores as indicator of experiential avoidance of pain was supported.

Development and Validation of the Forms of Self-Criticizing/Attacking and Self-Reassuring Scale—Short Form

Studies investigating the effectiveness of compassion-focused therapy (CFT) are growing rapidly. As CFT is oriented toward helping people deal with internal processes of self-to-self-relating, having instruments to measure these processes is important. The 22-item Forms of Self-Criticizing/Attacking and Self-Reassuring Scale (FSCRS) has been found a useful measure. In the present study, a 14-item short form of the FSCRS (FSCRS-SF) suited to studies requiring brief measures was developed and tested in a Dutch community sample (N = 363), and cross-validated in a sample consisting of participants in a study on the effectiveness of a guided self-help compassion training (N = 243). Confirmatory factor analysis (CFA) indicated acceptable to good fit of the FSCRS-SF items to a three-factor model. Findings regarding internal consistency were inconsistent, with Study 1 showing adequate internal consistency for all subscale scores and Study 2 demonstrating satisfactory internal consistency only for the reassured self (RS) subscale score. Furthermore, the results showed that the FSCRS-SF subscale scores had adequate test–retest reliability and satisfactory convergent validity estimates with theoretically related constructs. In addition, the FSCRS-SF subscale scores were found to be sensitive to changes in self-to-self relating over time. Despite mixed findings regarding its reliability requiring further investigation, the FSCRS-SF offers a valid and sensitive measure which shows promise as a complimentary shorter version to the original FSCRS suited to nonclinical populations. Given that the FSCRS is increasingly used as a process and outcome measure, further research on this short form in nonclinical and clinical populations is warranted.

The economic utility of clinical psychology in the multidisciplinary management of pain

Chronic musculoskeletal pain is the leading sources of disability worldwide, imposing an enormous burden to both societies and healthcare systems (Vos et al., 2012). Direct medical expenses and indirect costs due to losses in work productivity exceed