Psychological Flexibility Model Research Articles

Cognitive Defusion in Acceptance and Commitment Therapy: What Are the Basic Processes of Change?

Acceptance and commitment therapy (ACT) is a contextual–behavioral approach to psychotherapy and other behavioral health concerns that has progressively attracted attention from both researchers and clinicians. ACT’s psychological flexibility model relies on middle-level terms that, despite being less precise than behavioral principles, are seen as being valuable for teaching and practicing ACT. One such term is cognitive defusion, which refers to the reduction of stimulus function transformation that occurs through verbal relations. In other words, defusion aims to minimize the influence of verbal relations, such as thoughts, on behavior, when doing so leads to adaptive behavior and valued living. Recently, some authors have stressed the importance of functionally defining middle-level terms, establishing clear links between the concept and basic behavioral processes. This article begins this endeavor by analyzing these links with respect to cognitive defusion. First, we briefly contextualize ACT’s theoretical roots. Second, we present cognitive defusion as a therapeutic intervention, reviewing its objectives, procedures, outcomes, and hypothesized processes as stated in the relevant literature. Third, the outlined process of change is critically examined, leading to a new conceptualization of cognitive defusion. Finally, the conceptual, clinical, and research implications of this new conceptualization are considered.

Committed Action, Disability and Perceived Health in Individuals with Fibromyalgia

ABSTRACTCommitted action, one of the components of psychological flexibility, has been shown to be related with measures of pain-relevant function domains in patients with chronic pain. However, the associations between measures of committed action and of physical health and function in individuals with fibromyalgia (FM) have not yet been examined. The aim of the present cross-sectional study was to better understand the role that committed action plays in (1) pain-related disability and (2) mental and physical health in individuals with FM. One hundred twenty-nine adult females with a diagnosis of FM from a rheumatologist were administered measures of committed action, disability, physical health, and mental health. After controlling for age and pain intensity, committed action explained an additional 24% of the variance of pain disability, 39% of the variance of physical health, and 41% of the variance of mental health. This study provides important new information on the associations between a measure of committed action and perceived health and function in a sample of women with FM. The findings are also consistent with the psychological flexibility model for understanding pain and its impact in patients with FM.

Acceptance and Commitment Therapy for Health Behavior Change: A Contextually-Driven Approach.

Promoting health behavior change presents an important challenge to theory and research in the field of health psychology. In this paper, we introduce a context-driven approach, the Acceptance and Commitment Therapy (ACT) model which is built on Relational Frame Theory. The ACT-based intervention aims to promote individuals’ new health behavior patterns through the improvement of the key construct of psychological flexibility, which is defined as the ability to contact the present moment more fully with acceptance and mindfulness as a conscious human being. Building on the psychological flexibility model, implemented through the six core ACT processes, individuals improve maintenance of long term health behavior change through committed acts in service of chosen values while acknowledging and accepting the existence of contrary thoughts, rules, and emotions as part of themselves but not determinant of their behaviors. Taking advantage of this context-driven approach of health behavior change, we recommend researchers and practitioners to design their health behavior change intervention programs based on ACT.

Experiential avoidance, cognitive fusion, and suicide ideation among psychiatric inpatients: The role of thwarted interpersonal needs

ABSTRACTObjective: The interpersonal theory of suicide posits the simultaneous presence of thwarted belongingness and perceived burdensomeness (i.e., thwarted interpersonal needs) leads to active suicide ideation. According to the psychological flexibility model, psychological inflexibility is in part a product of cognitive fusion (i.e., becoming entangled or wrapped up in one’s thoughts) and experiential avoidance (i.e., avoidance of internal private experiences, which include thoughts and feelings). We hypothesized that thwarted belongingness and perceived burdensomeness, in parallel, would mediate the positive relation between experiential avoidance and suicide ideation and between cognitive fusion and suicide ideation. Method: Participants were 118 adult psychiatric inpatients who completed self-report assessments of thwarted interpersonal needs, cognitive fusion, experiential avoidance, and suicide ideation. Results: Using bootstrapped parallel mediation regression procedures, results indicated thwarted belongingness and perceived burdensomeness mediated, in parallel, the positive relation between experiential avoidance and suicide ideation and between cognitive fusion and suicide ideation. Additionally, thwarted belongingness, but not perceived burdensomeness, independently mediated the relation between cognitive fusion and suicide ideation. Conclusion: The current findings indicate that psychological inflexibility variables are associated with increased thwarted interpersonal needs and suicide ideation. The findings of this study provide support for the integration of the interpersonal theory of suicide and psychological flexibility model to improve our conceptualization of suicide risk among psychiatric inpatients.Clinical or methodological significance summary: The findings of this study provide support for the integration of the interpersonal theory of suicide and psychological flexibility model to improve our conceptualization of suicide risk among psychiatric inpatients.

Valued living, life fulfillment, and suicide ideation among psychiatric inpatients: The mediating role of thwarted interpersonal needs

Suicide is one of the leading causes of death in psychiatric hospitals with an estimated rate of 100–400 per 100,000 admissions. The current study aimed to examine suicide ideation among psychiatric inpatients utilizing perspectives from the psychological flexibility model (Hayes, Strosahl, & Wilson, 2012) and the interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010) to better understand suicide risk among psychiatric inpatients. We hypothesized that valued living (i.e., connection with one's values and committed action) and life fulfillment would each be negatively associated with suicide ideation and that these relations would be mediated by thwarted interpersonal needs (i.e., additive effect of thwarted belongingness and perceived burdensomeness) in parallel. We also hypothesized that the direct and indirect association between valued living and suicide ideation would be moderated by life fulfillment, such that those lower in life fulfillment would report a stronger direct and indirect association between valued living and suicide ideation. Results obtained from bootstrapped parallel mediation regression procedures indicated greater valued living and life fulfillment were each associated with lower thwarted interpersonal needs and suicide ideation. Further, a significant interaction between valued living and life fulfillment suggests those lower in both valued living and life fulfillment reported the greatest suicide ideation. Research examining the psychological flexibility model in the context of the interpersonal theory of suicide may improve suicide risk conceptualization, assessment and treatment among psychiatric inpatients.

Developments on committed action: Validity of the CAQ-8 and analysis of committed action's role in depressive symptomatology in breast cancer patients and healthy individuals.

Committed action, a process of acceptance and commitment therapy's psychological flexibility model, is considered an understudied construct that currently can only be measured by one instrument, the Committed Action Questionnaire (CAQ-8). This study aims at analysing the psychometric properties of the CAQ-8 in healthy individuals and breast cancer patients. This study also aims to explore the specific meditational role of committed action in the well-established relationship between experiential avoidance and depression symptoms. The healthy sample comprised 294 adults from the general population, and the breast cancer samples comprised 82 participants. Both groups completed the validated self-report measures. CAQ-8's robustness was examined through validity analyses, confirmatory factor analyses, and multigroup analysis. The meditational model was conducted using structural equation modelling. The CAQ-8 presented good internal consistency and construct, convergent, concurrent, and divergent validity in both samples. Further, the CAQ-8 showed incremental validity over a measure of engaged living. Findings also demonstrated measurement invariance between healthy individuals and breast cancer patients. Regarding the conducted meditational model that was also invariant between the two analysed groups, it was demonstrated that part of the effect that experiential avoidance holds on depressive symptomatology is explained by committed action. This study suggests that the CAQ-8 is adequate for use in healthy and cancer populations. Moreover, it provides novel, empirical support regarding the links between committed action, experiential avoidance, and depressed mood, being also the first investigation to particularly study committed action in a cancer population. Implications for theory and practice are discussed.

Dimensionality and validity of the Committed Action Questionnaire (CAQ-8) in a chronic pain and university student population

The Committed Action Questionnaire (CAQ-8) assesses the construct of committed action drawn from the Psychological Flexibility (PF) model of Acceptance and Commitment Therapy (ACT). Despite the centrality of committed action in the PF model, there is no instrument available to assess committed action for French-speaking researchers and clinicians working with ACT. In addition, past studies on the CAQ-8 have mostly been conducted mostly among chronic pain populations limiting the use of the CAQ-8 to a specific context and population. The aim of this study was to validate a French version of the CAQ-8 in a chronic pain population and to extend the use of the CAQ-8 in a non-clinical population. This study includes analyses of the reliability, as well as the construct, convergent, concurrent, and incremental validities of the French CAQ-8 in two independent populations. The first sample was comprised of 716 participants from the community living with chronic pain symptoms. The second sample consisted of 405 university students. Results from competing confirmatory factor analyses models suggest that the CAQ-8 assess two distinct and meaningful constructs. Moreover, results showed support on the convergent, concurrent, and incremental validities of the French CAQ-8. Finally, reliability analyses revealed a good internal consistency of the scale. Overall, the French CAQ-8 constitutes a short valid and reliable instrument to assess committed action drawn from the conceptual framework of ACT in clinical and non-clinical populations.

Further validation of the Chronic Pain Values Inventory in a Swedish chronic pain sample

PurposeValue based action is an important process in the psychological flexibility model and is associated with daily functioning in people with chronic pain, but measures of it are not well-developed. The purpose of the present study was to examine the reliability and validity of a Swedish-language version of the Chronic Pain Values Inventory (CPVI) in a large sample of adults seeking treatment for chronic pain. Material and methodsA Swedish version of the CPVI was created and administered alongside other measures of psychological flexibility and pain-related functioning in a convenience sample of 232 patients admitted for treatment at the Pain Rehabilitation Unit at Skåne University Hospital between February 2014 and December 2015. Internal consistency of the CPVI was assessed as was its relationship to theoretically related facets from the psychological flexibility model. The utility of values-related processes in explaining variance in pain-related functioning was also examined by correlations and hierarchical regression analyses. ResultsOverall, this Swedish-language version of the CPVI was found to have satisfactory reliability and validity. The CPVI subscales yielded high levels of internal consistency. Evidence of construct validity in relation to other measures from the psychological flexibility model was observed as well as evidence of clinical utility in relation to measures of pain-related functioning. DiscussionThis brief self-report measure of values-based action seems to yield valid data in Swedish adults suffering from chronic pain. Values based processes appear important within evidence-based treatments for chronic pain, especially Acceptance and Commitment Therapy (ACT), and the CPVI may help assess these, particularly in predictor studies of pain-related functioning and analyses of therapeutic change processes or mechanisms.

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

The resilience approach put forward in this review spotlights sustainability of positive outcomes (e.g. engagement in meaningful activities) in the presence of pain as an outcome to pursue beyond recovery of negative outcomes. We illuminate the evidence-base and practical application of promising resilience mechanisms (positive emotions, psychological flexibility, needs satisfaction). For this article, a commentary is available at the Wiley Online Library.

The Psychological Flexibility Model from a cultural perspective: an interpretative analysis of two Native American healing rituals

ABSTRACTWhile the growth of Acceptance and Commitment Therapy and its underlying construct, psychological flexibility, has been supported by numerous studies, it has received little attention from sociocultural disciplines. With the aim of considering the transdiagnostic Psychological Flexibility Model from a cultural perspective and from an interdisciplinary approach combining both Psychology and Anthropology, this article proposes an interpretative theoretical analysis of two Native American healing rituals: sweat lodge ceremonies and peyote ceremonies. Drawing from the fieldwork of Calabrese among the Navajo and Wilson among the Lakota Sioux, both healing rituals are interpreted and compared in light of the six processes of psychological flexibility. While recognising the adaptability of the model outside the cultural sphere of Western mental health sciences, the article concludes with two remarks: the relevance of the sociocultural construction of values and a potential connection between psychologica...

Preliminary investigation of self-as-context in people with fibromyalgia.

Acceptance and commitment therapy (ACT), based on the Psychological Flexibility (PF) model, has been recently applied to fibromyalgia (FM), and appeared effective in improving functioning. However, evidence for some of the processes within the PF model, self-as-context (SAC) in particular, is lacking within this population. The current study validates a measure of SAC, the Self Experiences Questionnaire (SEQ), and preliminarily investigates the role of SAC in relation to functioning in FM. Participants (N = 298, 93.3% women) self-reporting a diagnosis of FM were recruited via the Internet and completed an online survey. Measures included pain, pain acceptance and SAC, as processes, and pain interference, work and social adjustment, depression and depression-related interference, as outcomes. Confirmatory factor analysis of the SEQ suggested a bi-factor structure, with a general factor underlying all items and two sub-factors, self-as-distinction and self-as-observer (χ2 = 46.55, p = .06, comparative fit index (CFI) = .99, Tucker-Lewis Index (TLI) = .99, root mean square error of approximation (RMSEA) = .04). Component factors showed good reliability, Cronbach's α = .90, and construct validity, supported by significant Pearson's correlations between SEQ scores, acceptance and outcomes (r = -.14 to -.33). In multiple regression analyses, SEQ scores significantly predicted pain-related interference (β = -.17, p < .05), work and social adjustment (β = -.14, p < .05) and depression (β = -.21, p < .01), but not depression-related interference, after controlling for pain, but only significantly predicted depression after controlling pain acceptance. These preliminary results show potentially important associations between SAC and functioning in people with FM.

A psychological flexibility-based intervention for modulating the impact of stigma and prejudice: a descriptive review of empirical evidence

Abstract: In recent years, there have been growing efforts to understand and modulate stigma and prejudice from the standpoint of the psychological flexibility model, a pragmatic model of complex human behavior. The present paper provides an overview of the empirical evidence on the applicability of the psychological flexibility model, and its applied strategy, acceptance and commitment therapy (ACT), to stigma and prejudice. Preliminary findings suggest that the psychological flexibility model and ACT are promising avenues for reducing stigma and prejudice; however, further investigation and refinement of the model and ACT are crucial for significantly ameliorating human suffering related to stigma and prejudice.Una intervención psicológica basada en la flexibilidad para modular el impacto del estigma y prejuicio: una revisión descriptiva de la evidencia empírica. Resumen: En los últimos años, se han producido crecientes esfuerzos por comprender y modular el estigma y los prejuicios desde la perspectiva del modelo de flexibilidad psicológica, un modelo pragmático de la conducta humana compleja. El presente artículo ofrece una visión general de la evidencia empírica sobre la aplicabilidad del modelo de flexibilidad psicológica, y su estrategia de aplicación, la terapia de aceptación y compromiso (ACT) en el estigma y los prejuicios. Los resultados preliminares sugieren que el modelo de flexibilidad psicológica y ACT son estrategias prometedoras para la reducción del estigma y el prejuicio; sin embargo, la investigación y el perfeccionamiento del modelo y de ACT son cruciales para mejorar significativamente el sufrimiento humano relacionado con el estigma y los prejuicios.

What explains high life satisfaction in men living with Duchenne muscular dystrophy? A preliminary study to inform psychological intervention.

There are increasing numbers of men with Duchenne muscular dystrophy (mDMD). For those who struggle to live with the condition, psychological interventions may be helpful. However, it is unclear how these should be tailored for mDMD. To inform intervention, this study assessed whether 2 well-validated psychological models (Leventhal's Self-Regulatory Model; Psychological Flexibility Model) could explain variation in life satisfaction (LS). Sixteen mDMD, aged 18-43 years, completed an online survey comprised of questionnaire measures of LS, mood, and both psychological models: Illness Perceptions (Leventhal's Self-Regulatory Model); engagement in meaningful activity, and acceptance/awareness of difficult thoughts and feelings (Psychological Flexibility Model). A median split enabled comparison of high and low LS groups. Those with higher LS were characterized by the ability to undertake personally meaningful activity in acceptance of difficult thoughts and feelings. Results supported the Psychological Flexibility Model. However, methodological limitations mean that these findings should be considered preliminary. Muscle Nerve 56: 163-166, 2017.

Help-Seeking Stigma in Asian American College Women: the Role of Disordered Eating Cognitions and Psychological Inflexibility

Help-seeking stigma is considered a major obstacle to seeking professional psychological services in Asian American college women. Informed in part by objectification theory and the psychological flexibility model of behavior change, the present cross-sectional study examines the role of disordered eating cognition and psychological inflexibility in help-seeking stigma among a sample of Asian American college women (N = 257). More specifically, this study examined whether disordered eating cognitions and psychological inflexibility would mediate the association between psychological distress and stigma tolerance for seeking psychological services in this group. Results revealed that both greater disordered eating cognition and greater psychological inflexibility were associated with lower stigma tolerance, and each of them uniquely mediated the association between greater psychological distress and lower stigma tolerance. These findings suggest that disordered eating cognitions and avoidance-based coping and beliefs may contribute to help-seeking stigma and its association with psychological distress. Limitations of the study and the directions of future research are discussed.

Change in "Self-as-Context" ("Perspective-Taking") Occurs in Acceptance and Commitment Therapy for People With Chronic Pain and Is Associated With Improved Functioning.

This study shows the delivery of a treatment for chronic pain based on ACT was associated with improved SAC and improved functioning for people with chronic pain, and increases in SAC were associated with improved functioning. These results can inform future treatment development.

A preliminary examination of willingness and importance as moderators of the relationship between statistics anxiety and performance

Statistics coursework presents a significant challenge for college students, often associated with anxiety, which further inhibits performance. Applied to statistics anxiety and performance, the psychological flexibility model suggests that statistics anxiety may not inhibit performance when it is approached willingly in service of important values. The current study offered a preliminary consideration of statistics-related willingness and importance as moderators of the relationship between statistics anxiety and performance. Undergraduate students completed a measure of statistics anxiety, willingness to engage statistics, and the importance attributed to statistics engagement, then took a short statistics quiz. Results provided preliminary evidence that both willingness and importance moderate the relationship between statistics anxiety and performance on a statistics quiz.

Psychological Distress among Latina/o College Students: the Roles of Self-Concealment and Psychological Inflexibility

There is a dire need to understand behavioral health outcomes in U.S. Latina/o individuals. Following the psychological flexibility model of behavior change, the present cross-sectional study investigated the role of self-concealment in a range of distress variables in a U.S. Latina/o college sample. Participants (N = 83, 76 % female, range = 17–50 years old) completed self-report measures online. Results revealed a direct effect of self-concealment on depression and large indirect effects of self-concealment on general distress, somatization, and anxiety through psychological inflexibility. These findings suggest that maladaptive cognitive and emotion regulation processes in general, and psychological inflexibility in particular, contribute to distress in the present Latina/o sample. Future research should examine whether psychological inflexibility and self-concealment predict onset, recurrence, and/or maintenance of psychological distress among Latina/o individuals over time.

Changes in Sleep Problems and Psychological Flexibility following Interdisciplinary Acceptance and Commitment Therapy for Chronic Pain: An Observational Cohort Study.

Aims: Cognitive and behavioral treatments (CBT) for sleep problems and chronic pain have shown good results, although these results could improve. More recent developments based on the psychological flexibility model, the model underlying Acceptance and Commitment Therapy (ACT) may offer a useful addition to traditional CBT. The aim of this study was to examine whether an ACT-based treatment for chronic pain is associated with improved sleep. Secondly, we examined the associations between changes on measures of psychological flexibility and sleep-related outcomes.Methods: The study used an observational cohort methodology. Participants were 252 patients (73.8% female) attending a 4-week, interdisciplinary, pain management program in London, United Kingdom. Participants completed standard self-report measures of pain and functioning, sleep outcomes, and processes of psychological flexibility. Pre- to post-treatment, and pre-treatment to follow-up measures were examined for statistically significant differences using paired samples t-tests. Secondarily, hierarchical multiple regression analyses were conducted to examine change in process measures in relation to change in treatment outcome.Results: Participants showed statistically significant improvements (all p < 0.001) at post-treatment on measures of insomnia severity (d = 0.45), sleep interference (d = 0.61), and sleep efficiency (d = 0.32). Significant improvements in insomnia severity and sleep interference were also observed at 9-month follow up. Small to medium effect sizes were observed across the sleep outcomes. Statistically significant changes were also observed on measures of psychological flexibility, and these improvements were significantly associated with improvements on sleep-related outcomes, independently contributing up to 19% of unique variance.Conclusion: This study supports the potential usefulness of ACT-based treatments for chronic pain for addressing co-occurring sleep difficulties. Further research is needed to determine how to improve the impact of this treatment for co-morbid pain and sleep difficulties, possibly using a randomized-controlled trial design.

Psychological Treatment Needs for Chronic Pain in Singapore and the Relevance of the Psychological Flexibility Model.

The goals of the present study were (a) to assess the psychological treatment needs and treatment delivery preferences in people attending services or contacting a hospital website for chronic pain in Singapore, and (b) to explore potential relevance of the psychological flexibility (PF) model for this group by investigating associations between PF and pain-related outcomes. This was a cross-sectional questionnaire study of people with chronic pain in Singapore. Current users of treatment services at a tertiary pain management clinic (PMC), users of pain treatment services elsewhere, and non-treatment users. Participants were either recruited face-to-face at a pain clinic or via an online portal. All participants completed a questionnaire, including a survey of treatment barriers and needs, treatment delivery preferences for chronic pain, and standardized measures of PF, pain interference, emotional functioning, and health care use. A total of 200 participants completed the study. Cost of treatment was identified as a main deterrent, while proof of treatment success was identified as a main facilitator for treatment uptake. A majority of participants (88.5%) indicated a preference for face-to-face treatment. In multiple regression analyses, after controlling for relevant demographic variables and pain intensity, PF explained 14% of the variance for pain interference and impact of depressive symptoms and 22% of the variance for depressive symptoms. A focus on meeting patients' needs at low cost, and providing proof of treatment success may increase psychological treatment uptake. Increasing PF for pain in people from Singapore may also contribute to better patient functioning.

The Self Experiences Questionnaire (SEQ): Preliminary analyses for a measure of self in people with chronic pain

Investigations of “self” in chronic pain have applied widely varied conceptualizations of the term. The purpose of the current study was to develop a measure based on the three-facet conceptualization of self rooted in the Psychological Flexibility model. Participants in this study included 528 adults referred to a pain management center who completed twenty-nine items intended as the basis for a measure called the Self Experiences Questionnaire (SEQ). Factor analyses were conducted to reduce the item pool and explore underlying dimensions. Following item and scale analyses fifteen items were selected forming a preliminary two-dimensional scale (Self as distinction, Self as observer), overall α=.90. Adequate construct validity for the total score was supported through correlations with pain acceptance, r=.34, decentering, r=.66, and committed action, r=.36, all p<.001. Adequate predictive validity was supported through correlations with measures of patient functioning, after controlling for pain and process from the PF model, including: depression, β=−.15, p<.01, work and social adjustment, β=−.10, p<.05, and pain interference, β=−.11, p<.05. A preliminary measure of contextual elements of self with adequate reliability and validity emerged here. However, assessing self presents challenges and is complex. Refinements in this measure may be needed in the future.