A Confirmatory Factor Analysis of Facets of Psychological Flexibility in a Sample of People Seeking Treatment for Chronic Pain

Background: Evidence supports the validity of individual components of the psychological flexibility model in the context of chronic pain. However, there is a need to test the inter-relationships amongst measures of individual components of psychological flexibility in a more integrative manner. In particular, research is needed to examine whether a model with discrete facets as proposed is indeed reflected in data from currently used assessment measures in people with chronic pain. Purpose: This cross-sectional study investigated the underlying structure of measures of processes of psychological flexibility amongst individuals with chronic pain and the associations between this measurement model and patient functioning. Methods: Five-hundred and seventy-three adults with chronic pain completed measures of pain, physical and social functioning, mental health, depression and processes of psychological flexibility, including acceptance, cognitive defusion, decentering and committed action. Confirmatory factor analyses tested lower-order, higher-order and bifactor models to examine the structure of psychological flexibility process measures. Results: A single general factor reflecting openness explained variability in items across all of the psychological flexibility process measures. In addition to this general factor, distinct decentering and committed action group factors emerged in the data. As expected, the general factor was strongly correlated with measures of social functioning, mental health and depression. Conclusions: Future research is needed to determine the most useful means by which the presence of the general factor can be reflected in the measurement and theory of psychological flexibility.</p

Psychological factors and treatment opportunities in low back pain

A large body of evidence suggests that psychological factors, including emotions, beliefs and avoidant behaviours, are linked to poor outcomes in low back pain. At the same time, the evidence from trials of psychological interventions suggests that they improve outcomes mostly in the short term and against passive controls only. These suboptimal results may be due to low competency or fidelity in delivery, or inadequate matching of treatment methods with specific patient problems. Most importantly, there is insufficient theoretical guidance and integration in the design, selection and delivery of methods that precisely target known process of pathology. We identify several new directions for research and opportunities to improve the impact of psychological interventions and to change clinical practice. These include better ways to conceptualise and deliver reassurance at early stages of back pain, utilising models such as the psychological flexibility model to guide treatment development, and essentially extend the fear-avoidance model.</p

Change in “Self-as-Context” (“Perspective-taking”) Occurs in Acceptance and Commitment Therapy for People with Chronic Pain and is Associated with Improved Functioning

Acceptance and commitment therapy (ACT) is based on the Psychological Flexibility (PF) model, which includes a therapeutic process, referred to as “self-as-context” (SAC). This study investigates whether ACT is associated with an effect on SAC and whether this effect is linked to treatment outcomes in people with chronic pain. 412 adults referred to a pain management center participated in the study. Participants completed measures of treatment processes (SAC, pain acceptance) and outcomes (pain-related interference, work and social adjustment, depression) before treatment, upon completion of treatment, and at nine-month follow-up. Paired sample t-tests and analyses of meaningful change were conducted to examine changes in processes and outcomes. Regression analyses with residualized change scores from process and outcome variables, and bivariate growth curve modeling were used to examine the association between change in SAC and change in outcomes. Participants significantly improved on all process and outcome variables at post-treatment (d=.38 to .98) and nine-month follow-up (d=.24 to .75). 42.0% to 67.5% participants showed meaningful improvements on each outcome at post-treatment and follow-up. Change in SAC was associated with change in outcomes (β=-.21 to -.31; r=-.16 to -.46). Results support a role for change in SAC in treatment as the PF model suggested. Perspective This study shows the delivery of a treatment for chronic pain based on Acceptance and Commitment Therapy was associated with improved self-as-context (SAC) and improved functioning for people with chronic pain, and increases in SAC were associated with improved functioning. These results can inform future treatment development

An investigation of the associations between stigma, self-compassion, and pain outcomes during treatment based on Acceptance and Commitment Therapy for chronic pain

Introduction: Stigma adversely affects people with chronic pain. The qualities within self-compassion may be particularly useful for buffering the impact of stigma on people with pain. In the context of an Acceptance and Commitment Therapy-based (ACT) treatment for chronic pain, this study investigated the association between changes in stigma and self-compassion and pain outcomes, and the potential moderating role of self-compassion on the association between stigma and pain outcomes. Materials and methods: Five-hundred and nineteen patients completed standardized self-report questionnaires of stigma, self-compassion, psychological flexibility, pain intensity and interference, work and social adjustment, and depression symptoms at the start of an interdisciplinary ACT-based treatment for chronic pain. The same measures were completed at post-treatment (n = 431). Results: The results indicated that key pain outcomes and self-compassion significantly improved during treatment, but stigma did not. Changes in stigma and self-compassion were significantly negatively correlated and changes in these variables were associated with improvements in treatment outcomes. There were significant main effects of stigma and self-compassion for many of the pre- and post-treatment regression models when psychological flexibility was not controlled for, but self-compassion did not moderate the association between stigma and pain outcomes. Stigma remained significant when psychological flexibility variables were controlled for, while self-compassion did not. Discussion: The findings add to our conceptual understanding of the inter-relationships between stigma, self-compassion, and psychological flexibility and can contribute to treatment advancements to optimally target these variables

Treatment of Chronic Pain for Adults 65 and Over:Analyses of Outcomes and Changes in Psychological Flexibility Following Interdisciplinary Acceptance and Commitment Therapy (ACT)

Objective. The purpose of this study was to examine the effectiveness of acceptance and commitment therapy (ACT) for older adults with chronic pain. Secondarily, we examined the associations between changes on processes of psychological flexibility and treatment outcome variables.Subjects. Participants were 60 adults with chronic pain age 65 and older selected from a larger consecutive sample of 928 adults of any age. All participants had longstanding pain that was associated with significant distress and disability.Methods. Participants completed measures of pain, functioning, and depression, and processes of psychological flexibility at baseline, immediately post-treatment, and at a 9-month follow-up. Treatment consisted of a 2- or 4-week residential program based on principles of ACT delivered by an interdisciplinary team. Treatment was designed to increase daily functioning by enhancing key processes of psychological flexibility, including openness, awareness, and committed action.Results. Participants showed significant improvements in functioning and mental health at posttreatment. Participants also showed significant increases in pain acceptance and committed action from pre- to post-treatment. Small effect sizes were observed for most treatment outcome and process variables in the pre-treatment to follow-up intervals; however, these improvements were not statistically significant. In secondary analyses, changes in facets of psychological flexibility were significantly associated with improvements in social functioning and mental health.Conclusion. This study supports the potential effectiveness of ACT for chronic pain among older adults. Future research is needed to determine how to maximize the impact of this treatment, particularly through greater impact on psychological flexibility.</p

A pilot study examining the effects of priming headache illness schema on attentional engagement towards pain relief medication, in those with high and low medication treatment beliefs

Few studies have assessed the underlying theoretical components of the Common Sense Model. Past studies have found, through implicit priming, that coping strategies are embedded within illness schema. Our aim was to evaluate the effect priming ‘headache’ illness schema upon attentional engagement to pain relief medication and to examine the interaction with illness treatment beliefs. Attentional engagement to the pain relief medication (‘Paracetamol’) was assessed using a 2 (primed vs. control) × 2 (strong belief in medication efficacy vs. weak belief in medication efficacy) design. During a grammatical decision task (identifying verbs/non-verbs), participants were randomised to receive a headache prime or a control. Response latency to the target word, ‘Paracetamol’ was the dependent variable. ‘Paracetamol’ treatment beliefs were determined using the brief illness perception questionnaire. Sixty-three participants completed the experiment. There was a significant interaction between illness-primed vs. control and high vs. low treatment efficacy of Paracetamol (p &lt; .001), suggesting an attentional disengagement effect to the coping strategy in illness-primed participants whom held stronger treatment beliefs regarding the efficacy of Paracetamol. In summary, implicit illness schema activation may simultaneously activate embedded coping strategies, which appears to be moderated by specific illness beliefs

A Short Version of the Pain Anxiety Symptoms Scale (PASS-20): Preliminary Development and Validity

BACKGROUND:Research has shown significant relations between fear and avoidance of pain and the suffering and disability of chronic pain. Effective measurement tools have formed the foundation for studying these relations.METHODS:The present article describes the initial development and validation of the PASS-20, a short form version of the Pain Anxiety Symptoms Scale (PASS). Like the original inventory, the PASS-20 measures fear and anxiety responses specific to pain. Items were selected for the short version based on item variance, item intercorrelation and reliability analyses.RESULTS:The PASS-20 shows strong internal consistency, reliability, and good predictive and construct validity. Item reduction appears to result in minimal shrinkage of validity correlations.CONCLUSIONS:Overall, the results suggest that the short form retains adequate psychometric properties. Possible research and clinical implications for the PASS-20 include more efficient screening during evaluations of patients with chronic pain, and use when the time or effort needed for the full version is prohibitive.</jats:p

Delivering an Optimised Behavioural Intervention (OBI) to people with low back pain with high psychological risk; results and lessons learnt from a feasibility randomised controlled trial of Contextual Cognitive Behavioural Therapy (CCBT) vs. Physiotherapy

BACKGROUND: Low Back Pain (LBP) remains a common and costly problem. Psychological obstacles to recovery have been identified, but psychological and behavioural interventions have produced only moderate improvements. Reviews of trials have suggested that the interventions lack clear theoretical basis, are often compromised by low dose, lack of fidelity, and delivery by non-experts. In addition, interventions do not directly target known risk mechanisms. We identified a theory driven intervention (Contexual Cognitive Behavioural Therapy, CCBT) that directly targets an evidence-based risk mechanism (avoidance and ensured dose and delivery were optimised. This feasibility study was designed to test the credibility and acceptability of optimised CCBT against physiotherapy for avoidant LBP patients, and to test recruitment, delivery of the intervention and response rates prior to moving to a full definitive trial. METHODS: A randomised controlled feasibility trial with patients randomised to receive CCBT or physiotherapy. CCBT was delivered by trained supervised psychologists on a one to one basis and comprised up to 8 one-hour sessions. Physiotherapy comprised back to fitness group exercises with at least 60 % of content exercise-based. Patients were eligible to take part if they had back pain for more than 3 months, and scored above a threshold indicating fear avoidance, catastrophic beliefs and distress. RESULTS: 89 patients were recruited. Uptake rates were above those predicted. Scores for credibility and acceptability of the interventions met the set criteria. Response rates at three and six months fell short of the 75 % target. Problems associated with poor response rates were identified and successfully resolved, rates increased to 77 % at 3 months, and 68 % at 6 months. Independent ratings of treatment sessions indicated that CCBT was delivered to fidelity. Numbers were too small for formal analysis. Although average scores for acceptance were higher in the CCBT group than in the group attending physiotherapy (increase of 7.9 versus 5.1) and change in disability and pain from baseline to 6 months were greater in the CCBT group than in the physiotherapy group, these findings should be interpreted with caution. CONCLUSIONS: CCBT is a credible and acceptable intervention for LBP patients who exhibit psychological obstacles to recovery. TRIAL REGISTRATION: ISRCTN43733490 , registered 15/12/2010

Using mixed methods case-series evaluation in the development of a guided self-management hybrid CBT and ACT intervention for multiple sclerosis pain

PURPOSE: Two-thirds of the people with multiple sclerosis (pwMS) experience pain. Medications provide minimal relief, and current non-pharmacological interventions lack a clear conceptualization of MS pain. This study explored the potential efficacy of a telephone-supported hybrid cognitive behavior therapy and acceptance and commitment therapy self-management intervention for pwMS based on an empirically supported model of MS pain using a replicated single-case series design.METHODS: Seven pwMS with varied demographic and disease characteristics completed the 8-week home-based program alongside 3 hours of telephone support. Online questionnaires were completed every four days for 16 weeks (4-weeks baseline, 8-weeks treatment, 4-weeks follow-up). The primary outcomes were pain severity and pain interference. Psychological process variables drawn from the MS pain model were also completed, and post-treatment qualitative interviews conducted.RESULTS: Simulation modeling analysis (SMA) showed three patients had large improvements in pain outcomes, two showed no change and two worsened. Five participants showed significant change on various psychological process variables. Change in pain catastrophizing was the most consistent finding.CONCLUSIONS: The findings suggest a self-management program for MS pain with minimal therapy support may be effective for some pwMS, but not those with more complex comorbidities. The participants suggested web-based delivery may simplify the approach, and therapist telephone contact was highly valued. Implications for Rehabilitation This case series suggests a hybrid CBT/ACT self-management workbook program for MS pain improves severity and impact of pain in some pwMS. Pain-related catastrophizing reduced in most pwMS, whilst change in other ACT and CBT process variables varied across the individuals. PwMS feedback suggests a tailored web-based delivery of the program with therapist telephone support may be optimal. PwMS with serious co-morbid depression and very advanced disease may not respond well to this self-management approach.</p

Competing patient and professional agendas in service development

Purpose – The purpose of this paper is to engage stakeholders in the development of a community based chronic pain-management service and identify their different agendas for service design and delivery.Design/methodology/approach – Data were collected using the Nominal Group Technique (NGT), a ten-step process that generates qualitative and quantitative data. Seven NGT groups were conducted in the south-west region of the UK, three with General Practitioners and nurses, three with chronic pain patients, and one with Healthcare Commissioners.Findings – The patient agenda for service development focused on process of care issues particularly the need for deep- empathy and emotional support from providers, while professionals prioritised cost-effectiveness. While there was some overlap between agendas they were largely discrete and often contradictory.Research limitations/implications – The findings imply service planners will need to make trade- offs between cost-containment and patient satisfaction. The methodology did not allow trade-offs to be put to participants in a structured form. However, such techniques are available, for example, Conjoint Analysis. There may also be value in bringing together patients and professionals in joint focus groups, to see if the gap between their different agendas can be bridged through discussion.Originality/value – The findings provide a novel insight into the competing agendas of patients and professionals regarding service development and design which will be of value to service planners and managers as they strive to reconcile these differences.</p