The Journal of Pain, Vol 8, No 9 (September), 2007: pp 700-707

Available online at www.sciencedirect.com

Psychological Flexibility and Traditional Pain Management

Strategies in Relation to Patient Functioning With Chronic Pain:
An Examination of a Revised Instrument
Lance M. McCracken and Kevin E. Vowles
Pain Management Unit, Royal National Hospital for Rheumatic Disease and University of Bath, Bath, United
Kingdom.

Abstract: Recent developments in cognitive behavioral theory emphasize the role of “psychological
flexibility” in adaptive functioning. Psychological flexibility includes processes of acceptance, mind-
fulness, values, and cognitive defusion. The present study was intended to investigate aspects of
psychological flexibility in relation to the functioning of patients with chronic pain. Two hundred
sixty patients seeking treatment for chronic pain completed a battery of measures, including an
expanded version of an instrument assessing responses to pain that reflect both psychological
flexibility and traditionally conceived “pain management strategies” (ie, pacing, relaxation, positive
self-statements). Initial psychometric evaluation of the expanded instrument yielded 2 reliable sub-
scales, as hypothesized. Both subscales were correlated with measures of emotional functioning and
psychosocial disability, although psychological flexibility achieved larger correlations and was corre-
lated with additional measures of physical functioning, health care use, and work status. Regression
analyses indicated that, after pain and patient background variables were statistically controlled,
psychological flexibility accounted for significant variance in eight separate measures of functioning
while pain management strategies accounted for significant variance in none. These results may call
for a shift in our approaches to chronic pain in line with developments taking place in broader areas
of behavioral and cognitive therapy.
Perspective: This study includes development of an instrument for assessing coping, consisting of
traditionally conceived coping strategies and a process that may be unfamiliar to most readers, termed
“psychological flexibility.” Results demonstrated that this process, a blend of acceptance, values-based
action, mindfulness, and cognitive defusion, is significantly related to patient functioning with chronic
pain.
© 2007 by the American Pain Society
Key words: Chronic pain, coping, cognitive-behavioral therapy, acceptance, mindfulness, assessment.

C
hronic pain can seriously affect the lives of those
who have it, leading to significant suffering for
these people and their families and to significant
costs to our communities and healthcare systems.5,17 If
we are to lighten the burden of chronic pain, we may
require a deeper understanding of the basic psychologi-
cal processes underlying the reduced daily functioning
Received February 23, 2007; Revised April 12, 2007; Accepted April 24,
2007
Address reprint requests to Dr. Lance M. McCracken, Pain Management Unit,
RNHRD, Bath, BA1 1RL, UK. E-mail: lance.mccracken@rnhrd-tr.swest.nhs.uk
1526-5900/$32.00
© 2007 by the American Pain Society
doi:10.1016/j.jpain.2007.04.008
and the suffering experienced, particularly in those who
seek treatment.
The behavioral and cognitive therapies have effec-
tively addressed the suffering and disability of many
with chronic pain to a certain degree.28 At the same
time, recent theoretical developments from the broader
behavioral and cognitive therapy tradition advocate an
expansion of current approaches, including unique basic
principles of psychopathology, and a new model of hu-
man suffering.13 This model posits that a primary source
of suffering is what is termed psychological inflexibility.
This inflexibility occurs when cognitive processes such as
learning from instruction or rules, thinking, verbal prob-
lem solving, or reasoning, alter or overwhelm the effects
of other behavioral processes.11 For example, under the

700
ORIGINAL REPORT/McCracken and Vowles
influence of these cognitive processes, avoidant behav-
ior can be rigid, and fail to change even with evidence of
its clearly disabling effects; or otherwise healthy behav-
ior can be nonpersistent, stopping whenever pain or a
worry occurs. In either case, the behavior patterns seem
likely to result in significantly reduced functioning in the
long term.
Psychological inflexibility, in turn, includes a number
of psychological processes, which are described in
depth elsewhere.12-14 Briefly, these entail unworkable
attempts to control private psychological experiences
(experiential avoidance), failures in what is loosely
considered attention and awareness (loss of contact
with the present), failures of what is held as important
to guide action (absence of values-based action), and
excessive or inappropriate regulation of behavior by
verbal/cognitive processes (cognitive fusion). Some of
the variables described here may look new in the field
of pain management; however, they are commonplace
in other literature (see the Discussion section of this
paper or Hayes et al11-13 for further detail).
As psychological inflexibility is a primary source of suf-
fering, “psychological flexibility” is proposed as the aim
of treatment. In turn, psychological flexibility is estab-
lished through core processes of acceptance, mindful-
ness, values-based action, and cognitive defusion,
among others.12 As applied to chronic pain, this treat-
ment approach, derived from the model of Acceptance
and Commitment Therapy (ACT),13 is referred to as Con-
textual Cognitive-Behavioral Therapy (CCBT).18 Indeed,
research with chronic pain sufferers has demonstrated
that interrelated processes of acceptance,20,21,25,29,34
mindfulness (McCracken LM, Gauntlett-Gilbert, Vowles K:
The role of mindfulness in a contextual cognitive-behav-
ioral analysis of chronic pain-related suffering and disabil-
ity. Pain 2007 [E-pub ahead of print, available at http://
www.sciencedirect.com/science/journal/03043959]) and
values-based processes,27 are significantly related to im-
portant aspects of patient functioning, as the present
model would predict. Further support for this approach
to chronic pain is provided by a small randomized treat-
ment trial,7 a nonrandomized wait-list controlled trial,26
and analyses of clinically significant change in complex
chronic pain sufferers.23
The purpose of the present study was to further inves-
tigate the role of psychological flexibility in patients with
chronic pain. For this study, the content of a previously
designed measure of pain coping, the Brief Pain Coping
Inventory (BPCI),22 was expanded to include additional
items related to acceptance, mindfulness, values-based
action, and cognitive defusion. A preliminary aim was to
demonstrate adequate reliability and validity for this ex-
panded measure. The primary aim then was to test the
prediction that psychological flexibility would positively
correlate with measures of patients’ emotional, social,
and physical functioning and negatively correlate with
health care use. The original content within the BPCI
included a range of traditionally conceived pain coping
strategies, such as pacing, relaxation, and positive self-
statements, and this allowed us the opportunity to ex-
701
amine the combined role of these coping strategies
along side the behavior patterns entailing psychological
flexibility.
Methods
Participants for this study were 260 consecutive adult
patients seen for assessment on a specialty pain manage-
ment unit, in southwest England, between November
2004 and July 2006, and completing all of the measures
used in the study. A majority of participants were
women, 64.6%, and white European, 98.1%. Their mean
age was 47.5 years (SD ⫽ 11.5) and they had completed
an average of 12.6 years of formal education (SD ⫽ 2.4).
Reported diagnoses included fibromyalgia, 32.8%, other
nonspecific musculoskeletal pain conditions, 21.3%, un-
known, 15.6%, post lumbar surgery pain, 11.5%, or
other, 18.8%. The median duration of pain was 84.0
months (range, 8.0 –552.0). Only 8.1% of participants
were continuing to work full time away from home, and
77.3% were receiving some type of wage replacement
benefit at the time of the assessment.
All patients received a standard set of self-report in-
ventories at home in preparation for their assessment
appointment. They were asked to complete them and
bring them in to the clinic on the day of their visit. All
patients provided written informed consent allowing
their data to be used in research, and the study was
approved by the appropriate local research committee.
There were a number of cases excluded beforehand and
therefore not considered a part of the current sample of
260, including 67 who either did not complete all mea-
sures, did not give consent, or whose data were lost due
to errors in reproducing the forms or other administra-
tive errors.
Measures
A brief patient background inventory asked partici-
pants to report their general personal characteristics,
work status, current pain medications, ratings of their
pain and pain-related distress on a 0 (none) to 10 (worse
imaginable) scale, number of GP, specialist, and emer-
gency department visits in the past 6 months related to
pain, and an estimate of time spent standing or walking
on an average day in the past week (uptime). The medi-
cation information was used to calculate a summary
score for the number of different classes of medication
being taken related to pain (ie, weak opioids, strong
opioids, nonsteroidal anti-inflammatory drugs [NSAIDS],
tricyclic antidepressants, muscle relaxants, sedatives, an-
ticonvulsants, selective serotonin reuptake inhibitors,
over-the-counter analgesics), as classified by a research
assistant using the British National Formulary (BNF). Sim-
ilarly, the GP, specialist, and emergency department vis-
its for pain were summed to form an overall pain-related
medical visit score.
Brief Pain Coping Inventory-2 (BPCI-2)
The BPCI-2 was administered as a pool of 29 items,
including the 18 original items of the BPCI,22 with the
702
intent to further develop the measure based on the cur-
rent analyses. The BPCI was designed as a brief clinical
instrument to assess a range of responses to pain includ-
ing acceptance-based (eg, “realized that pain does not
prevent activity,” or “struggled to get control of the
pain,” which is negatively keyed) and typical cognitive-
behaviorally based (“used a relaxation strategy to re-
duce feelings of pain,” or “changed my activity to keep
myself focused on something other than pain”), each
assessed by individual item responses. For each item, pa-
tients are asked to indicate how many days in the past
week they responded to their pain in the way described
on a scale from 0 –7. Previous data demonstrate ade-
quate item intercorrelations and correlations with mea-
sures of acceptance of pain and patient functioning to
support validity of the BPCI items as a measure of accep-
tance-oriented and traditional cognitive-behavioral cop-
ing responses.22 The purpose of the additional 11 items
added to form the BPCI-2 was an attempt to derive multi-
item summary scores from the inventory, as the original
single item format was open to criticism regarding inad-
equate reliability and stability. The items were written by
1 of the authors (LM), in consultation with 3 other clinical
psychologists working in pain management, and de-
signed to encompass psychological flexibility, including
acceptance, mindfulness, values-based action, and cog-
nitive defusion; or a traditional CBT approach, including
activity pacing, exercise, relaxation, positive self-state-
ments, distraction, and pain coping. Deriving and vali-
dating these summary scales (psychological flexibility
and traditional pain management) was 1 of the purposes
of the present study. (Note: Further information, the
original item pool, or a copy of the final measure can be
obtained from the first author.)
Validation Measures and Measures of
Patient Functioning
Three measures were used to validate the psychologi-
cal flexibility summary score. These included a measure
of acceptance of pain, the 20-item Chronic Pain Accep-
tance Questionnaire (CPAQ),25 a measure of avoidance,
the 5-item Avoidance subscale of the 20-item Pain Anxi-
ety Symptoms Scale (PASS-20),19 and a measure of mind-
fulness, the 15-item Mindful Attention Awareness Scale
(MAAS).6 Each of these has demonstrated reliability, is
well-validated, and has been used in previous studies of
chronic pain (McCracken LM, Gauntlett-Gilbert, Vowles
K: The role of mindfulness in a contextual cognitive-be-
havioral analysis of chronic pain-related suffering and dis-
ability. Pain 2007 [E-pub ahead of print, available at http://
www.sciencedirect.com/science/journal/03043959]). The
CPAQ items are rated 0 (never true) to 6 (always true).
The PASS items are rated on a scale from 0 (never) to 5
(always). The MAAS items are rated on a scale from 1
(almost always) to 6 (almost never).
Three measures were used to assess patient function-
ing and adjustment to chronic pain. These included the
total scores from the PASS-20,19,30 the British Columbia
Major Depression Inventory (BC-MDI),14 and summary
Psychological Flexibility in Chronic Pain
scores from the Sickness Impact Profile (SIP).3 As with the
validation measures, each of these measures has demon-
strated adequate reliability and validity and has been
used in multiple studies of patients with chronic pain.
The total score of the PASS-20 is the sum of items rated
0 –5. The BC-MDI provided a total score from 16 depres-
sive symptoms, rated 1 (very mild problem) to 5 (very
severe problem). Finally, the SIP also provided 2 scores:
Composite scores for Physical Disability and Psychosocial
Disability. The SIP is a 136-item inventory in which pa-
tients endorse problems with functioning related to
their health in 12 different domains. The physical do-
main is made up of separate Ambulation, Mobility, and
Body Care and Movement scales. The psychosocial do-
main is made up of Social Interaction, Alertness, Emo-
tional Behavior, and Communication.
Analyses
The analyses for the present study proceeded in 4
stages. First, the adequacy of the item pool for the BPCI-2
was examined with frequency, descriptive, and correla-
tion analyses. The purpose of these analyses was to elim-
inate items that provide little information or adversely
affect scale internal consistency. Second, factor and reli-
ability analyses were conducted to derive summary
scores from the final BPCI-item pool. Third, correlations
between the BPCI-2 summary scores and measures of
acceptance of pain, avoidance, mindfulness, and pain
were calculated to test the validity of the factor-derived
scales. Finally, predictive analyses, including correlation
and multiple regression, were completed to compare the
relative values of differing coping scales in relation to
measures of patient functioning and test the primary
prediction of the study. A useful description of the type
of scale development methods used here is available
from Jensen.10
Results
Preliminary Item Frequency and
Correlation Analyses
Preliminary analyses led to elimination of 10 items
from the BPCI-2. Two items, “saw my reactions to pain as
just reactions and not true facts,” and “practiced mind-
fulness,” each showed approximately 15.0% missing
data. Four additional items showed highly skewed fre-
quency distributions. These included the items, “used a
relaxation strategy to help me focus and act produc-
tively,” “sought attention, advice, or treatment from a
health care provider,” and “accepted the pain and real-
ized I did not need to change it,” which each received
extremely low endorsement rates, with less than 35.0%
endorsing these at any frequency, and the item, “used
pain medication,” for which 74.2% of the sample en-
dorsed the highest possible rating (ie, 7 of 7 days. Finally,
a series of inter-item and item-total correlation, and pre-
liminary reliability analyses were conducted as a test of
correlation between items and potential summary scales.
Four items did not correlate with other items or with the
ORIGINAL REPORT/McCracken and Vowles 703

proposed item clusters adequately enough to support
further analyses. These included “contacted a friend of
family member for support,” “asked for or accepted help
with a task,” “tried not to think of the pain,” and “used
a sedative medication, had a drink of alcohol, or a smoke,
to try to feel better.” Based on these analyses, 19 of 29
BPCI-2 items were retained for further study, 11 items
from the original BPCI and 8 of the newly added items.
Factor Analyses
A Principal Components Analyses (PCA) with orthogo-
nal rotation was conducted for data reduction purposes
and to explore potential subscales within the BPCI-2 item
pool. The PCA yielded 5 factors with eigen values greater
than one. This included 2 small factors, and the solution
was considered uninterpretable. Examination of the
scree plot suggested a 3-factor solution. A 3-factor solu-
tion also appeared highly interpretable and accounted
for a modest 41.0% of the variance in the variable set.
The first factor included a range of commonly practiced
pain management techniques and was thus labeled sim-
ply “Pain Management Strategies.” The second factor
included several reversed avoidance and pain control
Table 1.Results From Principal Components
Analyses With Orthogonal Rotation of the
Items of the Brief Pain Coping Inventory-2
FACTOR LOADINGS
items as well as items related to doing activities without
pain being a barrier, and was labeled “Pain Acceptance.”
The third factor included items related to awareness of
painful thoughts and feelings and taking goal- or values-
directed action and was labeled “Awareness and Values-
based Action.” The factor loadings from the rotated fac-
tor solution are shown in Table 1.
Reliability analyses demonstrated that a scale made up
of items from Factor 1 achieved a Cronbach’s ␣ of .73.
Cronbach’s ␣ for the items from Factors 2 and 3 were
lower at .68 and .63, respectively. Both of these techni-
cally fall below the .70-level typically regarded as a rule
of thumb lower boundary for acceptable reliability.
Upon further analysis we also found that summary scores
for these 2 factors were significantly correlated, r ⫽ .42,
P ⬍ .001. We therefore elected to combine Factors 2 and
3, and we labeled the combined scale “Psychological
Flexibility,” as the content of the factors together in-
cludes acceptance, mindfulness, values-based action,
and defusion elements of this overall process, as origi-
nally hypothesized (Table 1). This combined scale
achieved a Cronbach’s ␣ within an adequate range, at
.73. Hence, 2 summary scales were derived for further
analyses: “Pain Management Strategies” (8 items) and
“Psychological Flexibility” (11 items). The scales were
correlated at r ⫽ .27, P ⬍ .001. The mean scores for the
Pain Management Strategies and Psychological Flexibil-
ity scales were 3.32 (SD ⫽ 1.60) and 3.40 (SD ⫽ 1.35),
respectively.

ITEM CONTENT SUMMARIES 1 2 3 Validity Analyses: Correlations

with Acceptance, Avoidance,
10. Paced myself .69 ⫺.02 .09
3. Used physical exercise .61 .22 ⫺.08
Mindfulness, and Pain
14. Changed activity to focus away from pain .58 ⫺.10 .15 Correlation analyses of the pain management and psy-
1. Encouraged self or changed thinking .56 .06 .29 chological flexibility scores from the BPCI-2 with patient
24. Rested briefly then resumed activity .54 ⫺.01 .15 background characteristics showed that the pain man-
29. Tried to think positive before taking action .53 .16 .42 agement score was positively correlated with duration of
15. Used ice, heat, massage, or TENS .52 .06 ⫺.28 pain, r ⫽ .15, P ⬍ .05, and negatively correlated with
8. Used relaxation .50 ⫺.08 ⫺.01
strong opioid use, r ⫽ ⫺.15, P ⬍ .05, but uncorrelated
7. Rested most of the day* .10 .74 ⫺.03
with age or gender. The flexibility score was positively
2. Avoided a painful activity* ⫺.22 .64 .07
4. Kept doing activity without pain stopping .09 .57 .39 correlated with age, r ⫽ .22, P ⬍ .001, female gender (1 ⫽
it men, 2 ⫽ women), r ⫽ .18, P ⬍ .01, and duration of pain,
11. Realized pain does not prevent activity .41 .55 .26 r ⫽ .16, P ⬍ .01, and negatively correlated with strong
23. Used pain as a reason not to do activity* ⫺.04 .53 .19 opioid use, r ⫽ ⫺.18, P ⬍ .01. Neither score was corre-
17. Struggled to get control of pain* .00 .52 ⫺.13 lated with years of education.
22. Chose not to struggle with .05 .07 .68 Table 2 includes correlation results from the pain man-
thoughts/feelings agement and psychological flexibility scales of the BPCI-2
25. Chose to act on what I value, not pain .12 .18 .64
with the measures used to examine validity. The pain
20. Remained aware of pain in a wider .24 ⫺.03 .56
situation
management strategies score significantly correlated
27. Did what works despite thoughts/feelings .27 .39 .51 with acceptance of pain and avoidance but not with
19. Noticed pain without doing anything ⫺.12 ⫺.02 .49 mindfulness or pain intensity. The psychological flexibil-
about it ity score significantly correlated with acceptance of pain,
Percent variance 15.69 12.78 12.41 avoidance, mindfulness, and pain intensity, supporting
the validity of the scale as a measure of psychological
Abbreviation: TENS, transcutaneous electrical nerve stimulation.
flexibility. Although these correlations with acceptance
NOTE. The 3 factors here were labeled “Pain Management Strategies,” “Pain
Acceptance,” and “Awareness and Values-based Action.” Factors 2 and 3 and avoidance were relatively large, suggesting nearly
were subsequently combined and labeled “Psychological Flexibility.” 40% and 24% overlapping variance, respectively, the
*These items reversed before entry into the factor analysis. correlation with mindfulness was much smaller.
704 Psychological Flexibility in Chronic Pain

Table 2.Correlations Between Summary larger. These correlations were each in the predicted di-
Scores From the Brief Pain Coping Inventory- rection.
2 With Measures of Acceptance of Pain,
Mindfulness, and Patient Functioning Multiple Regression Analyses
(N ⴝ 260) A series of 9 hierarchical multiple regression analyses
were conducted to examine the potential combined in-
SUBSCALES FROM THE BPCI-2
fluences of pain management strategies and psycholog-
ical flexibility on patient functioning after controlling for
PAIN PSYCHOLOGICAL pain and patient background variables, where relevant.
MANAGEMENT FLEXIBILITY The criterion variables included the rating of pain-re-
Validity analyses lated distress, pain-related anxiety, depression, physical
Acceptance of pain (CPAQ) .25‡ .63‡ and psychosocial disability, analgesic medication use,
Avoidance (PASS) ⫺.13* ⫺.49‡ pain-related medical visits, uptime, and work status. The
Mindfulness (MAAS)1 .17 .25* pain rating and patient background variables were
Pain intensity (0–10 rating) .04 ⫺.19† tested for entry in consecutive initial steps based on sta-
Predictive analyses tistical entry criteria (probability of F to enter ⬍.05; prob-
Pain-related distress (0–10 ⫺.08 ⫺.36‡ ability of F to remove ⬎.10). The 2 summary scores from
rating) the BPCI-2 were entered together on a single step after
Pain-related anxiety (PASS) ⫺.20† ⫺.50‡
that. The results of the regression analyses are included
Depression (BCMDI) ⫺.21‡ ⫺.46‡
in Table 3.
Physical disability (SIP) ⫺.03 ⫺.29‡
Psychosocial disability (SIP) ⫺.17† ⫺.36‡
We were able to generate 9 of 9 significant prediction
Medication (number different ⫺.05 ⫺.20† equations with regression. Pain intensity was a signifi-
analgesics) cant predictor in 8 of these equations, with the exception
Medical visits (visits related to ⫺.07 ⫺.20† of the equation for daily uptime. The variance accounted
pain last 6 mo) for by pain intensity ranged from 2.5% in the equation
Uptime (hours per day standing .10 .27‡ for psychosocial disability to 40.0% in the equation for
or walking) pain-related distress. Pain was also a relatively large pre-
Work status (0 ⫽ not working, 1 .02 .15* dictor of physical disability, accounting for 12.0% or vari-
⫽ working) ance. The patient background variables were generally
n ⫽ 111 for analyses including the MAAS.
1 small and inconsistent predictors of patient functioning
*P ⬍ .05. and were selected as significant just 3 times out of 36
†P ⬍ .01. tests. Together the BPCI-2 summary scores added a sig-
‡P ⬍ .001. nificant increment in explained variance in 8 of 9 equa-
tions, failing to significantly predict work status. Signifi-
cant variance accounted for by the BPCI-2 summary
scores ranged from 2.7% in the equation for pain-re-
Correlation Results From BPCI-2
lated medical visits to 21.0% in the equation for pain-
Summary Scores With Measures of related anxiety. The summary scores also accounted for a
Patient Functioning notable 16.0% of variance in depression. Interestingly,
Examination of the correlations between the pain the regression coefficients for psychological flexibility
management strategies scale and 9 measures of patient were significant in 8 of 9 equations, whereas the regres-
functioning in Table 2 showed a surprisingly small num- sion coefficients for pain management strategies were
ber of significant correlations, just 3, of relatively small significant in none. Psychological flexibility most fre-
magnitude, none above r ⫽ –.21. Nonetheless, the pain quently achieved the largest regression coefficient over-
management strategies score was significantly corre- all across the 9 analyses. It appeared as the strongest
lated with pain-related anxiety, depression, and psycho- predictor of pain-related anxiety, depression, psychoso-
social disability. In each case, the relationship was nega- cial disability, medication use, uptime, and medical visits,
tive suggesting that when patients report more frequent although on 4 of these occasions it was only minimally
performance of the strategies in this scale, they also re- larger than pain intensity. In each case, psychological
port less emotional distress and problems with psychos- flexibility was related to patient functioning in the pre-
ocial functioning. dicted direction: Patients who reported behavior pat-
The correlations from the psychological flexibility scale terns entailing greater psychological flexibility also re-
were generally stronger than those achieved by the pain ported better functioning.
management strategies scale. Each of the 9 correlations
between the psychological flexibility scale and the mea-
sure of pain and patient functioning were significant.
Discussion
The correlations with work status, medication use, and The present study examined a range of patient re-
medical visits for pain were small, while correlations with sponses to chronic pain, some designed to reflect tradi-
general pain-related distress, pain-related anxiety, de- tional pain management strategies and the others de-
pression, and psychosocial disability were relatively signed to reflect what is termed psychological flexibility.
ORIGINAL REPORT/McCracken and Vowles 705

Table 3.Hierarchical Multiple Regression background variables were controlled, psychological

Analyses of Pain Management Strategies and flexibility significantly predicted eight key aspects of pa-
Psychological Flexibility in Relation to tient functioning while pain management strategies,
Patient Functioning in Chronic Pain surprisingly, predicted none.
The findings presented here are similar to the results
STEP PREDICTOR ␤ (FINAL) ⌬R2 TOTAL R2 from numerous studies over the years demonstrating that
Pain-related distress (0–10) reliable and potent adaptive strategies are relatively diffi-
1. Pain intensity (0–10) .58‡ .40‡ cult to identify from within the class of traditionally con-
2. Pain management strategies ⫺.044 ceived pain coping strategies while “maladaptive” strat-
Psychological flexibility ⫺.23‡ .058‡ .46‡ egies appear readily identifiable, reliable, and more
Pain-related anxiety (PASS) strongly related to patient functioning (McCracken LM,
1. Pain intensity (0–10) .17** .062‡ Samuel VM: The role of avoidance, pacing, and other ac-
2. Gender ⫺.064 .024* tivity patterns in chronic pain. Pain 2007 [E-pub ahead of
3. Pain management strategies ⫺.081 print, available at http://www.sciencedirect.com/science/
Psychological flexibility ⫺.45‡ .21‡ .30‡
journal/03043959]).8,9,31,32 They are also consistent with
Depression (BC-MDI)
studies demonstrating that one element of psychological
1. Pain intensity (0–10) .21‡ .079‡
2. Gender ⫺.046 .016*
flexibility, acceptance of pain, is substantially better than
3. Pain management strategies ⫺.099 traditionally conceived coping variables at predicting the
Psychological flexibility ⫺.37‡ .16‡ .25‡ emotional, physical, and social functioning of patients
Physical disability (SIP) with chronic pain.20 The present study expands these
1. Pain intensity (0–10) .30‡ .12‡ results by including additional elements of psychological
2. Pain management strategies .072 flexibility beyond acceptance alone.
Psychological flexibility ⫺.24‡ .050‡ .17‡ It is perhaps surprising that the pain management
Psychosocial Disability (SIP) items did not perform better in the prediction analyses,
1. Pain intensity (0–10) .11 .025* given that the strategies captured by these items are
2. Gender ⫺.064 .016*
often trained in treatment programs. For example,
3. Pain management strategies ⫺.092
thinking positively, activity pacing, relaxation, and dis-
Psychological flexibility ⫺.29‡ .099‡ .14‡
Medication use (number of different analgesics being used) traction are common components of many cognitive-be-
1. Pain intensity (0–10) .16* .039† havioral treatment programs,28,33 yet the present results
2. Pain management strategies .00 suggest they are associated with little benefit, at least
Psychological flexibility ⫺.18† .031* .070‡ when assessed in treatment naïve patients. It may be that
Medical visits (pain-related GP, specialist, or emergency visits last 6 these strategies improve with treatment, such as
months) through changes in the situations where, or the skillful-
1. Pain intensity (0–10) .14* .029† ness with which, they are done. On the other hand, it
2. Pain management strategies ⫺.018 may be that, although these behaviors look like they
Psychological flexibility ⫺.16* .027* .056†
should help, they may actually result in less benefit, or
Uptime (hours per day)
more restriction of functioning, than previously thought.
1. Pain management strategies .014
Psychological flexibility .26‡ .071‡ .071‡
Clearly, further investigation is required before firm con-
Work status (0 ⫽ not working, 1 ⫽ working) clusions can be drawn.
1. Pain intensity (0–10) ⫺.17* .035† The theoretical approach employed here is based on
2. Pain management strategies .00 the model underlying ACT.13 As indicated earlier, we call
Psychological flexibility .095 .010 .045* our application of this model to chronic pain CCBT.18 ACT
includes 6 core therapeutic processes: Acceptance, being
NOTE: In each of these regression analyses age, gender (1⫽ men, 2 ⫽
present (eg, an aspect of mindfulness), values, cognitive
women), years of education, duration of pain, and pain intensity were tested
for entry based on statistical criteria (probability of F to enter ⬍.05; probability defusion, committed action, and self as context.12 Our
of F to remove ⬎.10), then the 2 summary scores from the BPCI-2 were particular research and clinical developments have fo-
entered simultaneously after that. cused on 4 of these: Acceptance (see McCracken and
*P ⬍ .05. Vowles for a review),24 mindfulness (McCracken LM,
†P ⬍ .01. Gauntlett-Gilbert, Vowles K: The role of mindfulness in a
‡P ⬍ .001.
contextual cognitive-behavioral analysis of chronic pain-
related suffering and disability. Pain 2007 [E-pub ahead of
print, available at http://www.sciencedirect.com/science/
In correlation analyses, both pain management strate- journal/03043959]) values,27 and cognitive defusion (in
gies and psychological flexibility scores were associated clinical developments only). These processes focus on re-
with patients’ emotional functioning and psychosocial ducing the ways that language and cognitive influences
disability. Psychological flexibility was associated with interact with direct nonverbal contingencies and create
additional aspects of physical functioning, healthcare behavior patterns that do not continue or do not change
use, and work status, and overall achieved the larger as purposes of important long term goals would re-
correlations of the 2 predictors. Based on regression quire.12 When an individual’s actions are caught up with
analyses in which pain intensity and relevant patient processes of language and cognition and fail to achieve
706
important goals, they demonstrate psychological inflex-
ibility.
According to the model presented here psychological
flexibility occurs when behavior patterns demonstrate pro-
cesses of (a) contact with painful psychological experiences
without being restricted by, or attempting to control, them
(acceptance), (b) contact with the present moment in a way
that is not solely based in language and thought (mindful-
ness), (c) influence from important long-term goals and
values (values), and (d) freedom from unhelpful response-
narrowing influences of thoughts or beliefs (cognitive de-
fusion). Treatment approaches employing the processes of
this model have demonstrated good results in randomized
trials for depression,38 worksite stress,4 psychosis,1 and
other conditions.12
Most of the work in chronic pain from a contextual
model has focused on acceptance. Acceptance includes
willingness to have the experience of pain without at-
tempts to control or avoid it. The other processes from
the model are perhaps worth clarifying, at least briefly.
Mindfulness is a way of directing attention to remain in
contact with each present moment, in a way that is ac-
cepting, and free from the influences of interpretations
and judgments.2,16 Values clarification and values-based
action are designed to produce behavior that is guided
by desired long terms purposes, explicitly chosen by the
patient, rather than purposes of not feeling pain or from
social pressures, for example.13,37 And finally, cognitive
defusion concerns ways in which thoughts have their
impact on behavior, ways that are modifiable on the
level of context (the psychological situation that gives
them their impact), separate from the level of their con-
tent (their form or frequency).13 Defusion includes the
“delinking” or “unblending” of cognitive content from the
events it describes and a reduction in restrictive or re-
sponse-narrowing influences on the person’s responses.
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