| | General psychological acceptance and chronic pain: There is more to accept than the pain itselfReceived 25 November 2008; received in revised form 21 January 2009; accepted 8 March 2009. published online 06 April 2009. Abstract An increasing body of research demonstrates that acceptance of pain is significantly associated with the quality of daily functioning in people with chronic pain. The aim of the present study was to examine acceptance more broadly in relation to a wider range of undesirable experiences these people may encounter, such as other physical symptoms, experiences of emotional distress, or distressing thoughts. One hundred forty-four, consecutive, adult patients attending interdisciplinary treatment for chronic pain participated in this study. They completed the Acceptance and Action Questionnaire-II (AAQ-II [Bond F, Hayes SC, Baer RA, Carpenter KM, Orcutt HK, Waltz T, Zettle RD. Preliminary psychometric properties of the Acceptance Action Questionnaire-II: a revised measure of psychological flexibility and acceptance, submitted for publication]), measuring their general psychological acceptance. They also completed measures of emotional, physical, and psychosocial functioning, pain acceptance, and mindfulness. The AAQ-II achieved satisfactory internal consistency, α =.89, and factor analysis revealed a unitary factor structure. Primary results showed that general psychological acceptance significantly correlated with depression, r=−.69, pain-related anxiety, r=−.59, physical disability, r=−.42, and psychosocial disability, r=−.65, all p<.001. Hierarchical regression analyses showed that general psychological acceptance added a significant increment of explained variance to the prediction of patient functioning, independent of patient background characteristics, pain, acceptance of pain, and mindfulness. These results suggest that, when people with chronic pain are willing to have undesirable psychological experiences without attempting to control them, they may function better and suffer less. General acceptance may have a unique role to play in the disability and suffering of chronic pain beyond similar processes such as acceptance of pain or mindfulness. 1. Introduction  Chronic pain is a prevalent health problem that has marked adverse effects on the quality of life of those who suffer with it (Breivik et al., 2006). It also involves considerable healthcare and disability costs (Maniadakis and Gray, 2000, Gatchel and Okifuji, 2006). Ultimate uncontrollability of chronic pain by medical treatment and significant collateral emotional suffering are hallmark features, particularly in those who seek specialty care. It is partly for these reasons that researchers and clinicians seek to understand psychological processes associated with chronic pain. Chronic pain is remarkably intractable. Even so patients with chronic pain can persist with great tenacity in seeking to control their pain. This persistence, rather ironically, seems to both deny and at the same time prove their pain’s ultimately intractable nature. The contradiction inherent in this situation has led to interest in a more balanced approach, including attempts at control over aspects of the pain experience that are usefully controllable, and acceptance of those aspects that are not (Viane et al., 2003, McCracken et al., 2004a, McCracken et al., 2004b, McCracken and Vowles, 2006). Here acceptance includes a willingness to engage in activity with pain present and to allow pain to register in experience without attempts to control or avoid it. Numerous studies support the role of acceptance of pain in the daily functioning of people with chronic pain. In clinical samples acceptance of pain is associated with less pain, distress, disability (McCracken, 1998, McCracken et al., 2004a, McCracken et al., 2004b), and greater psychological wellbeing (Viane et al., 2003). In treatment outcome studies acceptance-based methods are associated with improved emotional, psychosocial and physical functioning, and reduced healthcare use (Dahl et al., 2004, McCracken et al., 2005, Wicksell et al., 2007, Vowles and McCracken, 2008). Just as patients with chronic pain unsuccessfully resist, or defend against, their pain they may unsuccessfully resist other experiences, such as other physical symptoms, unwanted emotional experiences, or thoughts that arise with their experience of pain. It is possible that acceptance of some of these experiences could prove beneficial. In fact, general psychological acceptance, as measured by an instrument called the Acceptance and Action Questionnaire (AAQ-II), is a significant predictor of psychological functioning in a wide range of clinical and non-clinical samples (Hayes et al., 2006). As far as we are aware, acceptance of psychological experiences outside of the pain itself has not been studied in chronic pain settings. The purpose of this study was to assess general psychological acceptance in people seeking treatment for chronic pain. The specific aims of the study were to (a) examine the reliability and construct validity of the AAQ-II, (b) test the prediction that higher levels of general psychological acceptance would be associated with better physical and psychosocial functioning, (c) examine the relative ability of general acceptance and pain-related acceptance in predicting patient functioning, and (d) examine the additive utility of general acceptance in the prediction of the functioning of chronic pain patients, in a wider model including related variables, such as acceptance of pain and mindfulness (McCracken et al., 2007). 2. Methods 2.1. Participants This study included 144 consecutive patients (63.9% women) commencing treatment at an interdisciplinary, tertiary care, pain management centre in the UK between September 2006 and January 2008. Most identified themselves as White British (96.5%). The mean age of the sample was 42.4 years (SD=11.5). Just over half of the patients were either married or co-habitating (58.4%), the others were single (29.9%), divorced (11.1%), or widowed (0.7%). They had completed an average of 13.2 years of education (SD=3.46). Common diagnoses of these patients were chronic pain syndrome (47.9%), fibromyalgia (13.9%), failed back surgery (10.4%), or other (27.8%). The most commonly reported primary location of pain was lower back (56.3%), followed by lower limbs (16.0%), upper limbs (9.0%), full body (5.6%), and other locations (13.1%). The average chronicity of pain was 139.0 months (SD=100.1). Only 9.8% of patients were working full or part-time away from home. Most patients were not working due to pain (72.9%), and others were working part-time due to pain (5.1%). Some identified themselves as homemakers (2.8%), and the remainders were not working for reasons other than pain (4.9%). Average time out of work was 64.3 months (SD=57.1). Before the start of treatment, patients were asked to complete the set of standardized questionnaires used in the present study. These were primarily designed to assess their emotional, physical and psychosocial functioning and other clinically relevant responses to their pain. They also completed a brief inventory providing their background information, work status, pain characteristics, and ratings of pain from 0 (no pain) to 10 (worst pain possible) and pain-related distress from 0 (not distressing) to 10 (extremely distressing), in the past week. Approval for this study was granted by local ethics and research and development committees. The patients provided written consent for their data to be used in research. 2.2. Measures 2.2.1. Acceptance action questionnaire (AAQ-II) The 10-item AAQ-II (Bond et al., submitted for publication) was the primary measure of this study. This scale was designed to assess peoples’ ability to accept undesirable thoughts and feelings and pursue their goals in the presence of these potentially difficult private experiences (e.g. “It’s OK if I remember something unpleasant”, “My thoughts and feelings do not get in the way of how I want to live my life”). It is sometimes referred to as a measure of “psychological flexibility.” Patients are asked to rate each statement on a scale from 1 (never true) to 7 (always true). The seven negatively phrased items (e.g. ‘I’m afraid of my feelings’, ‘Worries get in the way of my success’) are reversed before the items are summed to form the total score. Higher scores represent higher levels of general acceptance. The initial development studies found that AAQ-II achieved a satisfactory internal consistency reliability, α=.83, based on a mixed sample of university students, people seeking treatment for substance abuse, and adults contacted at their work setting (N=3280). These analyses also revealed a predicted unitary factor structure. Scores from the AAQ-II significantly correlated with measures to which they are theoretically connected, such as depression, anxiety and overall psychological distress, and did not significantly correlate with a measure of social desirability, thus supporting their validity (Bond et al., submitted for publication). 2.2.2. British Columbia-major depression inventory (BC-MDI) The BC-MDI (Iverson and Remick, 2004) is a 19-item questionnaire designed to measure symptoms of depression and their interference with functioning. Items 1–16 represent symptoms of depression and patients are asked whether they have experienced these symptoms over the past two weeks. For each symptom they have experienced they are then asked to rate the severity from 1 (very mild problem) to 5 (very severe problem). Items 1–16 were summed to form the total score for symptoms of depression. Items 17–19 ask patients to rate the interference of their endorsed symptoms on their work, social, and family life, on a scale from 0 (no impact) to 4 (very severe impact). Scores from the BC-MDI demonstrate convergent and discriminate validity (Iverson, 2001), and high sensitivity and specificity for detecting cases of depression as identified by a structured clinical interview (Iverson and Remick, 2004). 2.2.3. Chronic pain acceptance questionnaire (CPAQ) The CPAQ (McCracken et al., 2004b) is a 20-item scale assessing levels of acceptance to pain, derived from a measure originally presented by Geiser (1992). It consists of two sub-scales: activity engagement and pain willingness. These measure a patient’s tendency to perform activities in the presence of pain and the relative absence of attempts to control or avoid pain. Patients are asked to rate each item on a scale of 0 (never true) to 6 (always true), and the nine negatively phrased items are reversed before the items were summed to form the total score. CPAQ has demonstrated satisfactory alpha reliability, at .78–.82, and showed moderate to high correlations with measures of avoidance, distress, and daily functioning, supporting its validity as a measure of acceptance of pain (McCracken et al., 2004b). The CPAQ was used in this study to examine the construct validity of AAQ-II, the AAQ-II representing the broader and more inclusive version of the two theoretically related constructs. It was also used to investigate the degree to which general psychological acceptance can account for variance in patient functioning, over and above that accounted for by pain-related acceptance. 2.2.4. Mindful attention awareness scale (MAAS) The MAAS (Brown and Ryan, 2003) is a 15-item measure of mindfulness. Mindfulness is defined as the skill of focused attention and non-reactivity to private experiences (e.g. Kabat-Zinn, 1982). The items were designed to reflect the opposite of mindfulness, or ‘mindlessness’, such as ‘I rush through activities without being really attentive to them’. Patients rate each item from 1 (almost always) to 6 (almost never). The items are averaged to form the total score and higher scores indicate higher levels of mindfulness. The initial development studies of MAAS were very comprehensive, demonstrating very good temporal consistency reliability, an expected unidimensional factor structure; and very good concurrent, discriminant, and incremental validity (Brown and Ryan, 2003). Similar to the CPAQ the MAAS was used in this study to examine the validity of the AAQ-II and also to test the additive ability of general acceptance to predict patient functioning over and above the patient’s degree of mindfulness. 2.2.5. Pain anxiety symptoms scale (PASS-20) The PASS-20 (McCracken and Dhingra, 2002) is a 20-item measure of fear, avoidance, and other anxiety responses to pain. Patients rate each item on a scale from 0 (never) to 5 (always) depending on how often they experience each of the responses. Items are summed to form the total score. Scores from the PASS-20 show good internal consistency reliability, a factor structure concordant with the subscale structure, and significant correlations with conceptually related measures of emotional, physical, and social functioning, supporting this scale’s validity as a measure of pain-related anxiety responses (McCracken and Dhingra, 2002, Roelofs et al., 2004). 2.2.6. Sickness impact profile (SIP) The SIP (Bergner et al., 1981) is a 136-item scale assessing the impact of an illness on daily functioning. It includes two primary domains: physical disability and psychosocial disability. Patients are asked to endorse statements that describe problems they were having with functioning as a result of their health. In scoring, each item is given a weight reflecting differing degrees of disability and a weighted sum is calculated that ranges from 0 to 1 for each scale. The SIP has achieved a good internal consistency reliability, α=.92, along with good convergent and discriminant validity (Bergner et al., 1981). 2.3. Plan of statistical analysis Reliability and validity analyses and factor analysis were first conducted to verify the suitability of the AAQ-II for use in a chronic pain setting. Correlation analyses were conducted between the AAQ-II and patient background variables along with measures of acceptance of pain and mindfulness to explore construct validity and factors potentially influencing an individual’s AAQ-II score. Next, correlation analyses were conducted between both the AAQ-II and the CPAQ with measures of emotional distress and disability as a preliminary examination of the potential role of general acceptance in relation to patient functioning. Z-tests were conducted to examine whether general psychological acceptance differs from pain acceptance in the strength of its association with patient functioning, essentially exploring which appears more important. These analyses were done in a purely exploratory fashion, not guided by hypotheses. Finally, hierarchical regression analyses were used to investigate the contribution of general psychological acceptance in the prediction of emotional, physical, and psychosocial functioning, within a wider model, independent of other variables demonstrated to be significant predictors or functioning. 3. Results 3.2. Construct validity and correlations with patient background characteristics Correlations with measures of pain acceptance, mindfulness, and pain-related avoidance were used to examine the construct validity of the AAQ-II. As expected, general psychological acceptance scores significantly positively correlated with total pain acceptance from the CPAQ, r=.55, mindfulness as measured by the MAAS, r=.53, and with the pain willingness, r=.49, and activity engagement, r=.46, subcomponents of pain-related acceptance, again as measured by the CPAQ, p<.01 in all cases. The acceptance scores were negatively correlated with pain-related avoidance as measured by the PASS, r=−.38, p<.01, also as expected. General psychological acceptance was significantly associated with gender, r=−.19, p<.05, also demonstrated by t-test, t(133)=2.24, p<.03, indicating that men reported significantly higher levels of general psychological acceptance than women (M=41.85 versus 36.69). General psychological acceptance was not significantly related to other background factors, such as age, r=.05, years of education, r=−.05, chronicity of pain, r=.09, or pain intensity, r=−.15. 3.3. Factor analysis In order to investigate the factor structure of the AAQ-II scores, preliminary analyses were carried out to examine the adequacy of the sample data for factor analysis. Bartlett’s test of sphericity was significant and Kaiser–Meyer–Olkin (KMO) sampling adequacy was above .88, meeting the minimum requirements. The case/variable ratio was 13.5 indicating adequate sample size, and there was no inter-correlation between items above .90, suggesting no multicollinearity. A principle component analysis was then carried out to examine the factor structure of the AAQ-II. Initial extraction results showed that there was only one factor with an eigenvalue greater than one (eigenvalue=5.27). A scree plot showed clearly just one factor significantly above a line fit to the eigenvalues of nine small factors. The one factor accounted for 52.7% of the variance in the item set. A one-factor solution was clearly substantiated by these results. 3.5. Comparison of relative strength or relations between general acceptance and pain acceptance with patient functioning A series of Z-score tests, for comparing correlated correlation coefficients (Meng et al., 1992), were conducted to examine whether general acceptance and pain acceptance significantly differed in the magnitude of their correlations with measures of patient functioning (see Z-scores in Table 1). The two processes did not significantly differ in their correlations with pain-related distress or physical disability. However, when compared to pain acceptance, general acceptance demonstrated significantly stronger correlations with depression and psychosocial disability. In turn, pain acceptance demonstrated a significantly stronger correlation with pain-related anxiety. Further tests of the relative relations with measures of avoidance and mindfulness were deemed potentially interesting and were conducted as well (see Table 1). In these analyses pain acceptance was the stronger predictor of pain-related avoidance, and general acceptance was the stronger predictor of mindfulness. 3.6. Regression analyses A series of tests were carried out to examine the suitability of the current data for regression analysis. Normality tests and probability plots of residuals showed a normal distribution of residuals for each model. Durbin–Watson values for each model were within the range of 1.6–2.4, indicating homoscedasticity of residuals. Tolerance values in each model were above .1, suggesting there was no multicollinearity. All models had a case/variable ratio of 14–15, meeting the minimum requirement. Overall, the results indicate that these data are adequate for regression analysis. Five hierarchical multiple regression analyses were conducted to investigate the contribution of general psychological acceptance to patient functioning, after the variance contributed by patient background characteristics, pain intensity, pain acceptance, and mindfulness was taken into account. The total variance accounted for by these combined processes was also examined. The five dependent variables were pain-related distress, depression, pain-related anxiety, physical and psychosocial disability (see Table 2). | | |  | Steps and predictors | Beta (final) | ΔR2 | R2 adjusted | |
|---|
| Pain-related distress | | | 1. Pain intensity | .53⁎⁎⁎ | .37⁎⁎⁎ | | | | 2. Pain-related acceptance | −.21⁎ | .09⁎⁎⁎ | | | | 3. Mindfulness | −.01 | .01 | | | | 4. General acceptance | −.19⁎ | .02⁎ | .47⁎⁎⁎ | | | | | | Depression (BC-MDI) | | | 1. Gender | .13⁎ | .07⁎⁎ | | | | 2. Pain intensity | .05 | .01 | | | | 3. Pain-related acceptance | −.20⁎⁎ | .25⁎⁎⁎ | | | | 4. Mindfulness | −.29⁎⁎⁎ | .18⁎⁎⁎ | | | | 5. General acceptance | −.40⁎⁎⁎ | .09⁎⁎⁎ | .57⁎⁎⁎ | | | | | | Pain-related anxiety (PASS) | | | 1. Pain intensity | .13⁎ | .09⁎⁎⁎ | | | | 2. Pain-related acceptance | −.57⁎⁎⁎ | .47⁎⁎⁎ | | | | 3. Mindfulness | −.20⁎⁎ | .07⁎⁎⁎ | | | | 4. General acceptance | −.16⁎ | .02⁎ | .62⁎⁎⁎ | | | | | | Physical disability (SIP) | | | 1. Chronicity of pain | .22⁎⁎ | .05⁎ | | | | 2. Pain intensity | .17⁎ | .07⁎⁎ | | | | 3. Pain-related acceptance | −.28⁎⁎ | .19⁎⁎⁎ | | | | 4. Mindfulness | −.18⁎ | .07⁎⁎⁎ | | | | 5. General acceptance | −.21⁎ | .02⁎ | .37⁎⁎⁎ | | | | | | Psychosocial disability (SIP) | | | 1. Pain intensity | .03 | .01 | | | | 2. Pain-related acceptance | −.16⁎ | .22⁎⁎⁎ | | | | 3. Mindfulness | −.37⁎⁎⁎ | .27⁎⁎⁎ | | | | 4. General acceptance | −.40⁎⁎⁎ | .09⁎⁎⁎ | .57⁎⁎⁎ | | | | |
Age, gender, education, and chronicity of pain were tested for entry as a block at the first step of each regression, using the stepwise method to retain only the significant patient background factors. The pain intensity scores were entered at the second step, as they showed significant correlations with most of the measures of functioning. Scores for pain acceptance (CPAQ) and the mindfulness score (MAAS) were entered separately at the next two steps, followed by general psychological acceptance scores as measured by the AAQ-II. Overall, results showed that there was a positive relationship between general psychological acceptance and functioning, suggesting that higher levels of acceptance predicted better emotional, physical, and psychosocial functioning. In all of the equations, general psychological acceptance added a significant increment, independent of relevant patient background characteristics, pain intensity, pain acceptance, and mindfulness. The average variance attributable to general psychological acceptance was 4.8%. Its variance ranged from 2% for pain-related distress, pain-related anxiety and physical disability, to 9% for depression and psychosocial disability. Table 2 shows that most patient background factors accounted for little variance across most measures of patient functioning, and were therefore statistically excluded from these models. However, there were two exceptions. Gender showed a significant contribution in predicting depression, with women reporting more severe depression than men. Chronicity of pain also accounted for a significant variance in physical disability: the longer the pain duration the more severe the physical disability. Pain acceptance contributed significantly to all equations, accounting for an average 24% in explained variance. The variance captured by pain acceptance included 47% in pain-related anxiety, 25% in depression, 22% in psychosocial disability, 19% in physical disability, and 9% in pain-related distress. Pain intensity scores also added a significant contribution in the prediction of most of the functioning variables, account for an average of 11%. Its greatest contribution was in pain-related distress at 37%. Across most measures of functioning, mindfulness added a significant increment of variance in the prediction, accounting for an average of 12%, with the greatest contributions being 27% in psychosocial disability, and 18% in depression. The total variance accounted for by the regression models was relatively large, ranging from 37% to 62%. 4. Discussion As far as we have ascertained this is the first study of general psychological acceptance in patients with chronic pain. The results of our analyses showed that patients who reported a greater willingness to experience negatively evaluated psychological experiences also reported better emotional, physical, and social functioning. The magnitude of these relations generally was in a moderate range. General psychological acceptance remained a significant predictor of patient functioning even when tested within a wider model that included other relatively strong predictors of patient functioning, including pain, pain acceptance, and mindfulness. These findings suggest that general psychological acceptance has a significant and unique role to play in the suffering and disability of chronic pain patients. These findings are consistent with several previous studies done outside of a chronic pain population. Each of these has found that when people lack psychological acceptance they are more vulnerable to emotional difficulties, such as depression and anxiety (Bond et al., submitted for publication, Raes et al., 2008, Feldner et al., 2003). The present and previous findings then converge to suggest the importance of general psychological acceptance particularly in relation to psychological functioning. A comparison between the current sample and a diverse clinical and non-clinical sample consisting of students, persons seeking treatment for substance abuse, and adults contacted at work (Bond et al., submitted for publication) showed intriguing differences. Patients in the present study reported significantly lower levels of general acceptance than did the comparison sample. This suggests several possible interpretations. It is possible that the experience of chronic pain induces low acceptance or that low acceptance is somehow a risk factor for chronic pain-related disability. In trying to disentangle these processes, we know that chronicity of pain appears unrelated to levels of general acceptance in our data. This suggests there may be no simple linear relationship between pain history and acceptance. It may be that the difference in the acceptance level between these two samples is present because persons with pain who habitually attempt to avoid or control difficult psychological experiences suffer from greater and longer term disability and distress. This, in turn, could lead them to seek treatment and to appear in our sample. Thus, low acceptance in our patient group could be either a result of chronic pain, a vulnerability factor of chronic pain and disability, or a result of a selection effect arising in a treatment seeking population. Further prospective research may clarify these processes. The causal direction between general acceptance and patient functioning cannot be inferred definitively due to the cross-sectional design of the current study. Nevertheless, the results allow us to speculate that a willingness to experience undesirable psychological experiences, such as other symptoms, emotional experiences, thoughts, or memories, is likely to enhance the overall functioning and wellbeing of chronic pain patients. This would presumably occur because the suffering and disability experienced by chronic pain patients are not all direct results of pain. Beyond the restrictions in functioning imposed by the pain itself, chronic pain sufferers experience obstacles in their functioning from a wide range of life circumstances. These may include important losses (job, health, fitness, friends, sense of self, etc.), relationship discord, economic stress, or other symptoms. When patients are confronted with these adverse life experiences in addition to their pain, a range of unpleasant emotions and thoughts may arise. Attempts to control or avoid these undesirable psychological experiences may both hamper their movement forward in life and exacerbate the initial distress. According to the model of suffering that includes acceptance as an ameliorating influence, an unwillingness to have a source of primary discomfort often produces secondary discomfort, while the primary discomfort remains (Hayes et al., 1999). This study not only demonstrates the role of general acceptance in chronic pain, but also provides additional support the role of pain acceptance, over and above the pain itself. Across the various measures of disability and suffering, the two acceptance processes, general acceptance and pain acceptance, combine to account for much greater variance (averaging 29%) than that explained by pain intensity (averaging 11%). This occurred despite the fact that pain intensity scores were entered at an earlier and statistically more advantageous stage in the regression analyses. Both general psychological acceptance and acceptance of pain concern qualities of active willingness and non-avoidance in behavior in relation psychological experiences. Conceptually, however, general psychological acceptance is broader than acceptance of pain. General psychological acceptance includes behavior in relation to many varied psychological experiences (again, unwanted emotional experiences, memories, thoughts, urges, other physical symptoms, etc.). Acceptance of pain includes a narrower focus on behavior specifically in relation to pain. For example, mindfulness also is a general process, a process of moment-to-moment awareness while in contact with whatever emerges in experience. The finding that mindfulness was more highly correlated with the AAQ-II than with CPAQ supports the more general and inclusive quality of general psychological acceptance. Again, while mindfulness conceptually includes mindfulness of pain, this is a specific behavior pattern within the larger class of mindful behavior. Conceptual distinctions aside, qualities of acceptance in the behavior of pain sufferers are presumed to be situation dependent and idiosyncratic as determined by an individual’s history, and only generalized or specific to the extent determined by this same history. Due to differences in history, in a particular situation where both pain and guilt are present, one person struggles with both, another person struggles with pain but not guilt, and a third struggles with neither. In recent years, well integrated, theory-based, and process-oriented treatments for chronic pain have been derived from the model of behavior and suffering that includes acceptance (Hayes et al., 1999, McCracken, 2005). The methods are called Acceptance and Commitment Therapy (ACT) or Contextual Cognitive-Behavioral Therapy (CCBT). Mindfulness meditation also has been suggested as an effective treatment method for chronic pain (Kabat-Zinn, 1982, Morone et al., 2008). Results from the current study provide further support for these treatment approaches. The results of the present study support the adequacy of the AAQ-II scale as a measure for general psychological acceptance among persons with chronic pain. First of all, the AAQ-II showed good internal consistency and a unitary factor structure, confirming that AAQ-II is a reliable and unidimensional measure. Second, the results also supported the construct validity of this scale. A positive correlation was found between levels of general acceptance and variables thought to be theoretically linked to general acceptance, such as pain acceptance, mindfulness, and avoidance. As the psychometric characteristics of the AAQ-II appear well supported, further investigation using this scale may be warranted. The current study has limitations. A primary limitation is the reliance on measures of general acceptance and functioning taken at a single point in time. This cross-sectional method with no manipulation of acceptance means that causal relations between general acceptance and functioning cannot be determined definitively. Experimental evidence or treatment outcome analyses are required to answer this question. Secondly, data collection in the present study relied solely on self-reports. This is due to the fact that many of the responses of interest are only directly observable by the pain sufferers themselves. Nonetheless, there is always the possibility that reported behavior may differ significantly from actual behavior, which may affect the accuracy of the results. Lastly, the sample studied is highly selective in that it includes patients who have longstanding pain and have failed many other treatments before being referred to a specialty pain management program. Therefore, care should be taken when generalizing results from this study to other groups of chronic pain sufferers, such as non-treatment seekers or those seen in primary care. 5. Summary This study showed that a measure of general psychological acceptance significantly correlates with measures of emotional, physical, and psychosocial functioning in people seeking treatment for chronic pain. This suggests, perhaps somewhat ironically, that when people with chronic pain allow themselves to experience at least some of the unwanted psychological experiences that occur in their life and do not attempt to control these, they are more likely to function better and suffer less. Additional results indicate that general acceptance appears to be a beneficial process even when included in a model with other beneficial processes, such as pain acceptance and mindfulness. To clarify, acceptance as described here is not a rigid rejection of all means of control over unwanted experiences, but rather a flexible willingness to have some these experiences on some occasions, a process intended to allow a wider range of behavior in response to these unwanted experiences, beyond attempts at control but not excluding these out of hand. References Bergner et al., 1981. 1.Bergner M, Bobbit RA, Carter WB. The sickness impact profile: development and final revision of a health status measure. Med Care. 1981;29:787–805. Bond et al., submitted for publication. 2.Bond F, Hayes SC, Baer RA, Carpenter KM, Orcutt HK, Waltz T, Zettle RD. Preliminary psychometric properties of the Acceptance Action Questionnaire-II: a revised measure of psychological flexibility and acceptance, submitted for publication. Breivik et al., 2006. 3.Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10:287–333. Abstract | Full Text |
Full-Text PDF (1495 KB)
|
CrossRef
Brown and Ryan, 2003. 4.Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. J Person Soc Psychol. 2003;84:822–848. Dahl et al., 2004. 5.Dahl J, Wilson KG, Nilsson A. Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: a preliminary randomized trial. Behav Ther. 2004;35:785–802.
CrossRef
Feldner et al., 2003. 6.Feldner MT, Zvolensky MJ, Eifert GH, Spira AP. Emotional avoidance: an experimental test of individual differences and response suppression using biological challenge. Behav Res Ther. 2003;41:403–411. MEDLINE |
CrossRef
Gatchel and Okifuji, 2006. 7.Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7:779–793. Abstract | Full Text |
Full-Text PDF (261 KB)
|
CrossRef
Geiser, 1992. 8.Geiser DS. A comparison of acceptance-focused and control-focused psychological treatments in a chronic pain treatment centre. Unpublished Doctoral Dissertation, University of Nevada, Reno; 1992. Hayes et al., 1999. 9.Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy – an experiential approach to behavioural change. New York: The Guildford Press; 1999;. Hayes et al., 2006. 10.Hayes SC, Luoma JB, bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25. MEDLINE |
CrossRef
Iverson, 2001. 11.Iverson GL. Psychometric properties of the British Columbia major depression inventory. Can Psychol. 2001;42:49. Iverson and Remick, 2004. 12.Iverson GL, Remick R. Diagnostic accuracy of the British Columbia major depression inventory. Psychol Rep. 2004;95:1241–1247. MEDLINE |
CrossRef
Kabat-Zinn, 1982. 13.Kabat-Zinn J. An outpatient program in behavioral for chronic pain patients based on the practice of mindfulness mediation: theoretical considerations and preliminary results. Gen Hosp Psychiat. 1982;4:33–47. Maniadakis and Gray, 2000. 14.Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain. 2000;84:95–103. Abstract | Full Text |
Full-Text PDF (278 KB)
|
CrossRef
McCracken, 1998. 15.McCracken LM. Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain. 1998;74:21–27. Abstract | Full Text |
Full-Text PDF (55 KB)
|
CrossRef
McCracken, 2005. 16.McCracken LM. Contextual cognitive-behavioral therapy for chronic pain. Seattle: IASP Press; 2005;. McCracken and Dhingra, 2002. 17.McCracken LM, Dhingra L. A short version of the pain anxiety symptoms scale (PASS-20): preliminary development and validity. Pain Res Manage. 2002;7:45–50. McCracken and Vowles, 2006. 18.McCracken LM, Vowles K. Acceptance of chronic pain. Cur Pain Headache Rep. 2006;10:90–94. McCracken et al., 2004a. 19.McCracken LM, Carson JW, Eccleston C, Keefe FJ. Acceptance and change in the context of chronic pain. Pain. 2004;109:4–7. Full Text |
Full-Text PDF (75 KB)
|
CrossRef
McCracken et al., 2004b. 20.McCracken LM, Vowles KE, Eccleston C. Acceptance of chronic pain: component analysis and a revised assessment method. Pain. 2004;107:159–166. Abstract | Full Text |
Full-Text PDF (100 KB)
|
CrossRef
McCracken et al., 2005. 21.McCracken LM, Vowles KE, Eccleston C. Acceptance-based treatment for persons with complex, longstanding chronic pain: a preliminary analysis of treatment outcome in comparison to a waiting phase. Behav Res Ther. 2005;43:1335–1346. MEDLINE |
CrossRef
McCracken et al., 2007. 22.McCracken LM, Gauntlett-Gilbert J, Vowles K. The role of mindfulness in a contextual cognitive-behavioral analysis of chronic pain-related suffering and disability. Pain. 2007;131:63–69. Abstract | Full Text |
Full-Text PDF (130 KB)
|
CrossRef
Meng et al., 1992. 23.Meng XL, Rosenthal R, Rubin DB. Comparing correlated correlation coefficients. Psychol Bull. 1992;111:172–175.
CrossRef
Morone et al., 2008. 24.Morone NE, Greco CM, Weiner DK. Mindfulness meditation for treatment of chronic low back pain in older adults: a randomized controlled pilot study. Pain. 2008;134:310–319. Abstract | Full Text |
Full-Text PDF (145 KB)
|
CrossRef
Raes et al., 2008. 25.Raes F, Williams JMG, Hermans D. Reducing cognitive vulnerability to depression: a preliminary investigation of memory specificity training (MEST) in inpatients with depressive symptomatology. J Behav Ther Exp Psychiat. 2008;. Roelofs et al., 2004. 26.Roelofs J, McCracken L, Peters ML, Crombez G, van Breukelen G, Vlaeyen JWS. Psychometric evaluation of the pain anxiety symptoms scale (PASS) in chronic pain patients. J Behav Med. 2004;27:167–183. MEDLINE |
CrossRef
Viane et al., 2003. 27.Viane I, Crombez G, Eccleston C, Poppe C, Devulder J, Van Houdenhove B, et al. Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain. 2003;106:65–72. Abstract | Full Text |
Full-Text PDF (107 KB)
|
CrossRef
Vowles and McCracken, 2008. 28.Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: a study of treatment effectiveness and process. J Consult Clin Psychol. 2008;76:397–407.
CrossRef
Wicksell et al., 2007. 29.Wicksell RK, Melin L, Olsson GL. Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain – a pilot study. Eur J Pain. 2007;11:267–274. Abstract | Full Text |
Full-Text PDF (159 KB)
|
CrossRef
Centre for Pain Services, Royal National Hospital for Rheumatic Diseases and Centre for Pain Research, University of Bath, Bath BA1 1RL, UK  Corresponding author.
PII: S1090-3801(09)00055-X doi:10.1016/j.ejpain.2009.03.004 © 2009 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Inc. All rights reserved. | |
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