Psychological Flexibility Model Research Articles

Investigating the potentially important role of psychological flexibility in adherence to antiretroviral therapy in people living with HIV

ABSTRACT Antiretroviral therapy (ART) has significantly improved immune health and survival rates in HIV, but these outcomes rely on near perfect adherence. While many psychosocial factors are related to sub-optimal adherence, effectiveness of associated interventions are modest or inconsistent. The Psychological Flexibility (PF) model underlying Acceptance and Commitment Therapy (ACT) identifies a core set of broadly applicable transdiagnostic processes that may be useful to explain and improve non-adherence. However, PF has not previously been examined in relation to ART adherence. Therefore, this cross-sectional study (n = 275) explored relationships between PF and intentional/unintentional ART non-adherence in people with HIV. Adults with HIV prescribed ART were recruited online. Participants completed online questionnaires assessing self-reported PF, adherence and emotional and general functioning. Logistic regressions examined whether PF processes were associated with intentional/unintentional non-adherence. Fifty-eight percent of participants were classified as nonadherent according to the Medication Adherence Rating Scale, of which 41.0% reported intentional and 94.0% unintentional non-adherence. Correlations between PF and adherence were small. PF did not significantly explain intentional/unintentional non-adherence after controlling for demographic and disease factors. Further clarification of the utility of PF in understanding ART non-adherence is warranted using prospective or experimental designs in conjunction with more objective adherence measures.

How are Experiential Avoidance and Cognitive Fusion Associated with Alexithymia?

A transdiagnostic approach to psychiatric disorders presents an opportunity to evaluate the relationship between alexithymia and the concepts of psychopathology according to the psychological flexibility model. This study aimed to investigate the relationship between alexithymia, cognitive fusion and experiential avoidance. A total of 133 outpatient participants were included in this cross-sectional study. Sociodemographic Data Form, Toronto Alexithymia Scale-20, Acceptance and Action Questionnaire-II, Cognitive Fusion Questionnaire, Hospital Anxiety and Depression Scale, and Ten-Item Personality Inventory were used. The non-alexithymic group consisted of 37 participants while the alexithymic group of 26. The alexithymic group had higher scores in terms of depression, anxiety, experiential avoidance, and cognitive fusion. Difficulty in identifying and differentiating feelings and total alexithymia scores had positive correlations with anxiety, experiential avoidance, and cognitive fusion. In hierarchical regression analysis, the only difficulty in identifying feelings was predicted by both experiential avoidance and cognitive fusion. These results revealed that alexithymia might also be conceptualized adopting the psychological flexibility point of view.

The Intervening Roles of Psychological Inflexibility and Functional Impairment in the Relation between Cancer-related Pain and Psychological Distress.

Psychological distress is a significant problem among patients with a diagnosis of cancer and is associated with elevated risk for mortality; however, not all patients with a diagnosis of cancer experience significant psychological distress. Cancer-related pain has been associated with greater psychological distress among patients with a cancer diagnosis (current or previous). The current study aimed to examine potential theoretical mechanisms (i.e., cognitive fusion, experiential avoidance, and functional impairment) as proposed by the psychological flexibility model, for the association between cancer-related pain and psychological distress. We hypothesized that cancer-related pain would be indirectly positively associated with psychological distress among patients with a cancer diagnosis (current or previous) through psychological inflexibility (i.e., cognitive fusion and experiential avoidance) related to pain and functional impairment, in serial. Sixty-one adult outpatients diagnosed with cancer completed self-report assessments of cancer-related pain, psychological inflexibility related to pain, pain-related functional impairment, and psychological distress. Cancer-related pain was positively associated with psychological distress indirectly through greater pain-related psychological inflexibility (i.e., cognitive fusion and experiential avoidance) and functional impairment, in serial. Alternative models were explored but unsupported. Consistent with the psychological flexibility model, psychological inflexibility and functional impairment may be potential mechanisms underlying the association between cancer-related pain and psychological distress among patients with a cancer diagnosis (current or previous).

Testing the model of psychological flexibility in the Serbian cultural context: The psychometric properties of the acceptance and action questionnaire

The aim of this study was to examine the theoretical model of psychological flexibility proposed by creators of Acceptance and Commitment Therapy. To do this, we investigated the structural and convergent validity of the Acceptance and Action Questionnaire ? II, translated into the Serbian language. The study was performed on 1781 Serbian speaking adults. By methods of robust confirmatory factor analysis, two models have been tested. The best fit was achieved with the data-driven model constructed by adding three pairs of correlated residuals to the original hypothesized model of latent structure. This model demonstrated it`s structural invariance across samples divided by gender and by previous experience with services provided by mental health professionals. Excellent convergent validity of the scale was demonstrated through adequate correlations with indicators of subjective well-being, styles of emotional regulation, and coping strategies. Our findings suggest that the Serbian adaptation of the Acceptance and Action Questionnaire ? II is a valid and reliable measure of behavioral avoidance, implicating that the construct of psychological flexibility has been demonstrated as conceptually similar to those previously found across various languages and cultural contexts.

Beyond Adaptive Mental Functioning With Pain as the Absence of Psychopathology: Prevalence and Correlates of Flourishing in Two Chronic Pain Samples.

Chronic pain outcomes are traditionally defined in terms of disability and illness. A definition of adaptive functioning in the context of chronic pain beyond the mere absence of negative outcomes, is the ability to flourish (i.e., experience emotional, psychological and social well-being; Keyes, 2002). We explored in two chronic pain samples the prevalence and sociodemographic, physical and psychological correlates of flourishing, and complemented this exploration with a similar examination of (being at risk for) psychopathology to help contextualize findings. Sample 1 (n = 1498) was a nationally representative sample. Subgroups included people with regular joint pain (1), regular joint pain and rheumatoid arthritis (2) and without chronic pain (3). Using chi-square tests we calculated the prevalence of both mental health outcomes and examined if people with or without chronic pain were more/less likely to flourish/at risk for psychopathology. Sample 2 (n = 238) concerned baseline data of a Randomized Controlled Trial on the effectiveness of Acceptance and Commitment Therapy for chronic pain (Trompetter et al., 2015b). We performed logistic regression analysis to identify flourishers/those at risk for depression. The Mental Health Continuum-Short Form was used to measure flourishing. The prevalence of flourishing was 34% (recurrent joint pain) and 38% (recurrent joint pain and arthritis) in sample 1, and 23% in sample 2. Compared to those without chronic pain, people with chronic pain were as likely to flourish, but more likely to be at risk for psychopathology. In sample 2, both flourishing and being at risk for depression were related foremost to psychological correlates. While engaged living was the most important correlate of flourishing, pain catastrophizing and psychological inflexibility were most important correlates of being at risk for depression. In conclusion, people with chronic pain are able to flourish. Findings suggest that positive and negative chronic pain outcomes function on two different continua, with potentially unique protective and risk factors. The Psychological Flexibility model provides pathways to explain both poor and optimal functioning in the presence of chronic pain. A better understanding of people with chronic pain who are able to flourish can be a fruitful endeavor to improve chronic pain models and interventions.

Communication skills in the context of psychological flexibility: training is associated with changes in responses to chronic pain in physiotherapy students in Spain.

The aim of this study is to explore the effectiveness of a training programme aimed at managing patients' chronic pain in physiotherapy students in Spain. The programme addressed providing them with efficient skills to manage patients' chronic pain from psychological flexibility (PF) perspective. The programme integrates communication skills training into PF-based training. It sought to contribute to better recognise the role of psychosocial factors in chronic pain and to better promote adherence to treatment. This is an observational study with a pre- and post-training programme design and a 2-month follow-up. A total of 35 physiotherapy students, divided into three groups, participated in a 10-hour training course. Training focused on three areas: (1) communication skills, (2) therapeutic adherence and (3) managing distress and pain. The three areas were addressed from the PF point of view. Impact of training was measured through standardised questionnaires that assessed attitudes towards chronic pain, an ad hoc questionnaire that assessed responses to difficult communicative situations and a training satisfaction scale. Final analyses showed that attitudes changed significantly after training, biomedical attitude scores decreased and biopsychosocial attitude increased, while pain was considered less disabling, and informed empathic responses in communication situations increased. These changes were maintained at 2-month follow-up. Satisfaction with the training was high. We conclude that a brief training programme based on the PF model may help students develop a more comprehensive approach and improve their skills for managing chronic pain.

Change in fatigue in acceptance and commitment therapy-based treatment for chronic pain and its association with enhanced psychological flexibility.

Fatigue is commonly reported by people with chronic pain. The purpose of the current study was to examine Acceptance and Commitment Therapy (ACT), based on the Psychological Flexibility (PF) model, for fatigue in chronic pain. This study included 354 adults attending an interdisciplinary ACT-oriented treatment for chronic pain. T-tests and analyses of clinically meaningful change were used to investigate participant improvements in fatigue interference after the treatment. Pearson's correlations and hierarchical regressions were conducted to investigate associations between improvement in fatigue interference and improvements in PF processes. Finally, mixed effects models were used to explore associations between baseline fatigue interference and changes in treatment outcome measures. Participants improved in fatigue interference (d = 0.37), pain, some PF processes and daily functioning (d = 0.18-1.08). 39.7% of participants demonstrated clinically meaningfully improvements in fatigue interference. Changes in fatigue interference was associated with changes in pain, PF processes and daily functioning, |r| = 0.20-0.46. Change in fatigue interference was associated with change in pain acceptance independent of change in pain, β = -0.36, p < .001. However, baseline fatigue interference did not predict any treatment outcome. Overall, people with fatigue appeared to benefit from the ACT-oriented interdisciplinary treatment for chronic pain, and relatively higher levels of fatigue did not appear to impede this benefit. ACT-based treatments may benefit people with chronic pain and fatigue. Future studies including experimental designs, and studies investigating other PF processes, are needed to better understand the utility of ACT for comorbid fatigue and pain. This study investigates the association between fatigue interference and psychological flexibility processes in chronic pain, and the first one investigating fatigue interference as a predictor of functioning in chronic pain following Acceptance and Commitment Therapy (ACT)-based treatment. Findings of the study provide preliminary evidence for the association between ACT and fatigue in people with chronic pain and support the potential benefit of ACT for people with comorbid chronic pain and fatigue.

The development of the Acceptance and Commitment Therapy Fidelity Measure (ACT-FM): A delphi study and field test.

Being able to assess whether psychological therapies are delivered according to their own principles is helpful for assuring treatment quality in research and training. We aimed to develop and preliminarily test a measure of therapist fidelity to Acceptance and Commitment Therapy (ACT) that is concise in measuring key therapist behaviours, reliable, practicable and potentially applicable across therapy contexts. This measure was developed via expert consensus in a Delphi study (Study 1). Here, thirteen expert ACT practitioners (average of 11 years’ experience with ACT, including 6 ACBS Peer Reviewed ACT Trainers) participated in three iterative rounds of online questionnaires. A preliminary draft of the measure was used to initiate discussion. In the first two rounds, participants rated and commented on existing items, the manual, and structure of the measure, and generated new items for consideration. In a third round, participants commented on the emergent draft of The ACT Fidelity Measure (ACT-FM). The Delphi study resulted in a 24-item measure with items structured around the three-part model of psychological flexibility (“Tri-flex”) alongside Therapist Stance. Eighty-three percent of the chosen items met the specified criteria for consensus. In Study 2, to investigate usability and preliminary psychometric properties of the ACT-FM, a separate group of nine clinicians used the ACT-FM to rate a video of an ACT therapy session. Inter-rater reliability was moderate to excellent. Based on clinician feedback, the measure was expanded to 25 items. To reach the stated aims, further work is required – particularly evaluating the utility of the ACT-FM across therapy contexts.

Watch Me Try: ACT for Improving Athletic Performance of Young Adults with ASD

Few studies have examined the effects of contextual behavior science interventions for adult athletes with Autism Spectrum Disorder. Those few, reviewed herein, show preliminary empirical support for treating behavioral deficits exhibited by young adults with Autism Spectrum Disorder engaged in competitive sports. In the current study, we evaluated a novel iteration of Acceptance and Commitment Training called Watch Me Try and compared it with direct contingency management to facilitate athletic performance of young adults with Autism Spectrum Disorder. A concurrent multiple baseline across participants design was used to measure changes in tardy arrivals to practice, heart rate, and fall lengths during practice climbs. Direct contingency management strategies included task analysis, modeling, prompting, stimulus control shaping, differential reinforcement, self-monitoring, goal setting, and performance feedback. The Watch Me Try intervention included three modules designed to incorporate all six repertoires that comprise the psychological flexibility model upon which ACT is based. All three athletes increased their attendance, heart rate, and length of falls during training to simulate desired performance during competitions and subsequently, their competition performances improved. One improved with direct contingency management alone; the other two required the Watch Me Try approach to bolster their performance. Results bolster the literature that supports Acceptance and Commitment Training as a treatment modality that supplements behavioral programs with the aim of improving socially significant behavior that can be observed and measured in applied contexts.

Acceptance and Commitment Therapy for Elderly Issues

Aging continued to be a crucial developmental stage; it is noticeable that many individuals of older people have various issues in their life. The article provides an overview of applying Acceptance and Commitment Therapy (ACT) for elderly issues, as a result of increased size of these people around the globe. The ACT is considered to be an evidence-based treatment and one of the third wave therapies; the article discussed the effect of ACT in treating issues of older people. Also, it presented the theoretical literature and psychological flexibility model of ACT. Further, the article introduces some of the more recent researches that supported the effectiveness of applying ACT for elderly issues to help them to achieve well-being. In conclusion, the article introduced some recommendations for future directions that may participate in treating elderly issues.

Functioning with fibromyalgia: The role of psychological flexibility and general psychological acceptance

ObjectivesFibromyalgia is a chronic condition characterised by widespread musculoskeletal pain, fatigue, mood disturbances, and cognitive difficulties. Psychological flexibility (PF), particularly acceptance of pain, has been associated with the physical and psychological functioning (functional status) of chronic pain patients. Further investigation is required to assess the unique contribution of PF model components to functional status in people with fibromyalgia. This study investigated the role of both pain‐related PF and general acceptance of psychological experiences in a fibromyalgia sample after accounting for self‐efficacy beliefs, the use of traditional pain management strategies, and demographic variables.MethodsParticipants with fibromyalgia (n = 339; 95% female) were recruited primarily from fibromyalgia social media‐based support groups and support services. Participants completed an online questionnaire measuring PF components, self‐efficacy, traditional pain management strategies, and functional status.ResultsPain‐related PF, general psychological acceptance, and self‐efficacy were significantly related to functional status, with higher levels of these variables associated with higher functioning. Use of traditional pain management strategies was not significantly related to functional status. Hierarchical multiple regression analysis demonstrated pain‐related PF explained a statistically significant but small (2%) amount of variance in functional status over and above self‐efficacy, traditional pain management strategies, and demographic variables. General psychological acceptance explained a further significant 2% of unique variance in functional status.ConclusionsPain‐related PF and general psychological acceptance added benefit to functioning of individuals with fibromyalgia. Nevertheless, this additional benefit was small, suggesting other psychological variables such as self‐efficacy may be more clinically relevant to functioning with fibromyalgia.

Acceptance and commitment therapy: towards a unified model of behavior change.

The present article summarizes the assumptions, model, techniques, evidence, and diversity/social justice commitments of Acceptance and Commitment Therapy (ACT). ACT focused on six processes (acceptance, defusion, self, now, values, and action) that bear on a single overall target (psychological flexibility). The ACT model of behavior change has been shown to have positive outcomes across a broad range of applied problems and areas of growth. Process and outcome evidence suggest that the psychological flexibility model underlying ACT provides a unified model of behavior change and personal development that fits well with the core assumptions of counseling psychology.

Investigation of Psychological Flexibility in Patients with Schizophrenia

The application of psychotherapies in schizophrenia is becoming increasingly common. Although studies showing the effectiveness of Acceptance and Commitment Therapy (ACT) in patients with schizophrenia based on the psychological flexibility model are increased, there is insufficient information on the mechanisms of action. Our study aims to evaluate the validity of psychological flexibility and the relationship between clinical features in patients with schizophrenia. The study included participants between 18-65 years old, consisted of 110 patients who had been diagnosed with schizophrenia and 110 healthy individuals. Participants in both groups filled Sociodemographic Data Form, Cognitive Fusion Questionnaire(CFQ), Valued Living Questionnaire(VLQ), Self-as-Context Scale(SACS), Freibirg Mindfulness Inventory(FMI) and Acceptance and Action Questionnaire(AAQ-II), in addition, Positive and Negative Syndrome Scale(PANNS) was applied to schizophrenia group by clinicians. The patient and control groups were matched in terms of age, gender, and educational level;. The points in the schizophrenia group AAQ-II and CFQ were higher; and the points of SACS, FMI and VLQ were found lower. Furthermore, the PANNS positive subscale points, SACS, AAQ-II points on the schizophrenia group; PANNS negative subscale points with SACS, VLQ, FMI, AAQ-II points were found associated with each other. PANSS general psychopathology was associated with subscale scores of CCQ, VLQ, FMI and AAQ-II points, PANSS total scores were also associated with SACS, VLQ, FMI, AAQ-II. In this study, it was found that schizophrenia patients were more inflexible than healthy individuals. Our results also imply that psychological flexibility components are related to clinical features of patients. The contribution of the psychological flexibility model to the treatment of schizophrenia patients should be investigated with advanced clinical studies.

Profiles of Psychological Flexibility: A Latent Class Analysis of the Acceptance and Commitment Therapy Model.

There exists uncertainty for clinicians over how the separate subcomponent processes of psychological flexibility, a core construct of the Acceptance and Commitment Therapy model, interact and influence distress experienced. The present study (N = 567) employed latent class analysis to (a) identify potential classes (i.e., subgroups) of psychological flexibility based on responses on measures of key subcomponent process and (b) examine whether such classes could reliably differentiate levels of self-reported psychological distress and positive and negative emotionality. We found three distinct classes: (a) High Psychological Flexibility, (b) Moderate Psychological Flexibility, and (c) Low Psychological Flexibility. Those in the Low Psychology Flexibility class reported highest levels of psychological distress, whereas those in the High Psychological Flexibility class reported lowest levels of psychological distress. This study provides a clearer view to clinicians of the profile of the broader spectrum of the psychological flexibility model to facilitate change in clients.

Identifying the Underlying Mechanisms of Change During Acceptance and Commitment Therapy (ACT): A Systematic Review of Contemporary Mediation Studies.

Mediation studies test the mechanisms by which interventions produce clinical outcomes. Consistent positive mediation results have previously been evidenced (Hayes et al., 2006) for the putative processes that compromise the psychological flexibility model of acceptance and commitment therapy (ACT). The present review aimed to update and extend the ACT mediation evidence base by reviewing mediation studies published since the review of Hayes et al. (2006). ACT mediation studies published between 2006 and 2015 were systematically collated, synthesized and quality assessed. Twelve studies met inclusion criteria and findings were synthesized by (a) the putative processes under investigation, and (b) the outcomes on which processes were tested for mediation. Mediation results were found to be generally consistent with the psychological flexibility model of ACT. However, studies were limited in methodological quality and were overly focused on a small number of putative processes. Further research is required that addresses the identified methodological limitations and also examines currently under-researched putative processes.

Current status of acceptance and commitment therapy for chronic pain: a narrative review.

It is well known that chronic pain is prevalent, complex to manage, and associated with high costs, in health care and society in general. Thanks to advances in new forms of cognitive behavioral therapy (known as third-wave CBT), currently clinicians and researchers have an empirically validated psychological treatment with increasing research support for the treatment of chronic pain. This treatment is called acceptance and commitment therapy (ACT). The main aim of this paper is to provide a narrative review that summarizes and integrates the current state of knowledge of ACT in the management of chronic pain as well as discuss current challenges and opportunities for progress. Based on the psychological flexibility model, ACT extends previous forms of CBT and integrates many CBT-related variables into six core therapeutic processes. ACT is a process-based therapy that fosters openness, awareness, and engagement through a wide range of methods, including exposure-based and experiential methods, metaphors, and values clarification. To our knowledge, there are three published systematic reviews and meta-analyses that support the effectiveness of ACT for chronic pain and many studies focused on specific processes derived from the psychological flexibility model. There is also promising support for the cost-effectiveness of ACT; however, the current evidence is still insufficient to establish firm conclusions about cost-effectiveness and the most efficient means of delivery. Additional well-designed economic evaluations are needed. Other research aims include delineating the neurobiological underpinnings of ACT, refining available outcome and process measures or develop new ones for ACT trials, and meeting the challenge of wide dissemination and implementation in real-world clinical practice.

Value-guided action: Within-day and lagged relations of experiential avoidance, mindful awareness, and cognitive fusion in a non-clinical sample

Experiential avoidance (EA), cognitive fusion (CF), and lack of present-moment awareness contribute to the development and maintenance of various forms of psychopathology, principally through their negative impact on value-guided action. However, little research has examined these behavioral processes at the daily level and, as such, the temporal association of each process on the others and daily value-guided action is unclear. This study evaluated the relations of daily EA, CF, mindful awareness, and self-reported value-guided action in a nonclinical sample (n = 104) who participated in a 16-day mindfulness meditation study. Results indicated high EA was associated with low engagement, whereas high mindful awareness was related to high engagement, in same-day value-guided behavior. Time-lagged analysis showed that high EA predicted high next-day CF, and high CF predicted reduced next-day mindful awareness. Results illuminate temporal relations within the psychological flexibility model and identify processes that may be amenable to influence and change in the clinical setting.

The role of psychological flexibility in relation to suicidal thinking in chronic pain.

Suicidal thinking (ST) is common in people with chronic pain. It is relevant as it can be associated with suicidal attempts, and typically reflects significant suffering. While little is known about the psychological processes that contribute to ST, current psychological models, such as the Psychological Flexibility (PF) model, could help guide further investigation. This study investigates relations between ST and components of PF in chronic pain. Participants were 424 adults attending treatment for chronic pain in the UK. Included in measures administered before treatment were standardized measures of depression, pain, pain-related interference, and measures of PF, including acceptance, cognitive defusion, committed action, and self-as-context. An item from the measure of depression was used to reflect ST. A large proportion of the sample reported ST, 45.7%. ST was uncorrelated with participant background characteristic, medications taken, or pain intensity. However, it was correlated with the presence of widespread pain, pain-related interference, and depression. Each component of PF was found to be significantly negatively associated with ST, as predicted. General acceptance correlated with ST at a level equal to that achieved by the depression score. In adjusted multivariate logistic regression general acceptance and committed action remained significantly uniquely associated with it. This preliminary study suggests for the first time that components of PF are associated with part of a pattern of suicidal behaviour in people with chronic pain. They may be relevant for reducing avoidance in general and providing more positive behavioural options. This study provides evidence that components of psychological flexibility are associated with a reduced frequency of suicidal thinking in people with chronic pain. Treatments targeting psychological flexibility may help mitigate the impact of chronic pain on suicidal thinking.

Concept and validation of the German version of the Cognitive Fusion Questionnaire (CFQ-D)

Within the ACT model of psychological flexibility, cognitive fusion (CF) refers to individuals’ attitudes towards their own thoughts and beliefs, more specifically, the extent to which they identify with and are behaviorally regulated by the form and content of their own thoughts and beliefs. This concept is of growing interest for those treating chronic conditions. Evidence supports the relevance of CF in the context of pathological conditions such as chronic pain. Recently developed measures of CF are available in English but so far, have been lacking in German. This study aims to explore the reliability and validity of the German translation of the Cognitive Fusion Questionnaire (CFQ) within a clinical sample (n = 216) of patients suffering from chronic pain at a rehabilitation clinic and a non-clinical sample (n = 166). Participants also completed a set of standard clinical measures as well as the German translation of the Psychological Inflexibility in Pain Scale (PIPS) to assess concurrent and convergent validity. Confirmatory factor analysis (CFA) confirmed a one-factor solution, referred to as CF, which had been identified previously. The scale had good psychometric properties. Furthermore, the CFQ-D total sum score was correlated with measures of psychological inflexibility in pain, pain intensity, self-reported state of health and limitation of physical functioning, functional ability, quality of life, pain related self-instructions and depression. Further analyses indicate that CFQ-D is a reliable and valid instrument for assessing CF in a German-speaking population.

The Relationship Between Posttraumatic Stress Disorder and Chronic Pain in People Seeking Treatment for Chronic Pain

The symptoms of posttraumatic stress disorder (PTSD) and chronic pain are thought to interact to increase the severity and impact of both conditions, but the mechanisms by which they interact remain unclear. This study examines the relationship between PTSD and chronic pain and whether indices of Psychological Flexibility mediate the relationship between these 2 conditions. Standardized self-report measures of PTSD, pain severity, pain interference, depression, and psychological flexibility (pain-related acceptance, committed action, cognitive fusion, and values-based action) were obtained from 315 people seeking treatment for chronic pain who also reported at least 1 traumatic experience. People seeking treatment for chronic pain and reporting symptoms consistent with a current diagnosis of PTSD had significantly higher levels of pain severity, pain interference, depression, and cognitive fusion and lower levels of pain-related acceptance and committed action than those reporting symptoms below the diagnostic threshold for PTSD. Pain-related acceptance, committed action, cognitive fusion, and depression mediated the relationship between PTSD and pain severity/interference, with pain-related acceptance being the strongest mediator from the Psychological Flexibility model. Processes from the Psychological Flexibility model were identified as mediators of the relationship between PTSD and chronic pain in people seeking treatment for chronic pain. The Psychological Flexibility model may be useful as an overarching model to help understand the relationship between PTSD and chronic pain. It is possible that targeting pain-related acceptance, committed action, and cognitive fusion (among other processes) in the treatment of chronic pain may produce corresponding improvements in comorbid symptoms of PTSD when these are present and may reduce impacts of PTSD on outcomes of chronic pain. Conversely, targeting of these processes in the treatment of PTSD may produce similar improvements for symptoms of chronic pain. Further research to evaluate these possibilities is needed.