There is an increasing number of studies of acceptance, mindfulness, and values-based action in relation to chronic pain. Evidence from these studies suggests that these processes may be important for reducing the suffering and disability arising in these conditions. Taken together these processes entail an overarching process referred to as “psychological flexibility.” While these processes have been studied in people with chronic pain contacted in specialty treatment centers, they have not yet been investigated in primary care. Thus, participants in this study were 239 adults with chronic pain surveyed in primary care, through contact with their General Practitioners (GPs), in the UK. They completed measures of acceptance of chronic pain, mindfulness, psychological acceptance, values-based action, health status, and GP visits related to pain. Correlation coefficients demonstrated significant relations between the components of psychological flexibility and the measures of health and GP visits. In regression analyses, including both pain intensity and psychological flexibility as potential predictors, psychological flexibility accounted for significant variance, ΔR2 = .039–.40 (3.9–40.0%). In these regression equations pain intensity accounted for an average of 9.2% of variance while psychological flexibility accounted for 24.1%. These data suggest that psychological flexibility may reduce the impact of chronic pain in patients with low to moderately complex problems outside of specialty care. Due to a particularly conservative recruitment strategy the overall response rate in this study was low and the generality of these results remains to be established.
It is widely understood that the experience and impact of chronic pain are determined to some extent by psychological processes. One relatively well integrated and theory-based set of processes for application to chronic pain are those that constitute what is called psychological flexibility [8], [9] and [15]. The processes underlying psychological flexibility have been previously investigated in more than 30 published studies in patients with chronic pain in specialist treatment settings (e.g. [3], [11], [13], [14], [15], [16], [17], [18], [19], [23], [24] and [29]), but never outside of these settings.
Psychological flexibility is a process based in the interaction of cognition and direct environmental contingencies that allows a person’s behavior to persist or change in line with their long term goals and values [8]. Relevant theory recognizes essentially two sets of influences on behavior: those arising from direct contact between the environment, behavior, and experienced consequences; and those from verbal or cognitively-based sources, such as instructions or rules. Rigid and unworkable behavior that does not adhere to naturally occurring contingencies can arise particularly from the ways that verbal or cognitive influences can limit contact with direct experience, thus entailing distressed and restricted functioning [9]. Processes of psychological flexibility can counteract this. These include acceptance, contact with the present moment, values-based action, committed action, self-as-context, and cognitive defusion [8].
Previous studies of people with chronic pain provide support for role of the various components of psychological flexibility in their well-being and daily functioning, including the processes of acceptance of pain [3], [13], [14], [16], [19], [23] and [24], mindfulness (a process that includes acceptance, contact with the present moment, self-as-context, and cognitive defusion [16] and [17]), value-based action [19] and [21], and general psychological flexibility itself [18]. Another recent study, focusing on the development of a new assessment instrument, provided evidence for negative impact of psychological inflexibility, including components of avoidance and cognitive fusion, also provides implicit support for the role of psychological flexibility [29].
Virtually every time a study is published on some component of psychological flexibility in chronic pain a particular limitation is noted. Study authors have repeatedly stressed that results from specialty care samples may not generalize to patients with less complex difficulties, such as those seen in primary care. The purpose of the present study is to address this gap in the literature by investigating processes of acceptance, mindfulness, and values-based action in a sample of patients with chronic pain contacted in primary care. We predicted that we would observe the same results in primary care as have been observed in specialty care: positive relations between these processes and a measure of health, including emotional, physical, and social functioning. Secondarily, we predicted negative relations between these processes and measures of pain and healthcare consumption.
