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Psychological flexibility and catastrophizing as associated change mechanisms during online Acceptance & Commitment Therapy for chronic pain
Open accessAbstract
The underlying mechanisms of the effectiveness of cognitive behavioural interventions for chronic pain need further clarification. The role of, and associations between, pain-related psychological flexibility (PF) and pain catastrophizing (PC) were examined during a randomized controlled trial on internet-based Acceptance & Commitment Therapy (ACT) for chronic pain. We assessed (1) the unique and combined indirect effects of PF and PC on outcomes, and (2) the causality of relations between PF, PC and the primary outcome pain interference in daily life (MPI) during ACT. A total of 238 pain sufferers were allocated to either ACT, a control condition on Expressive Writing, or a waiting list condition. Non-parametric cross-product of coefficients mediational analyses and cross-lagged panel designs were applied. Compared to control conditions, both baseline to post-intervention changes in PF and PC seemed to uniquely mediate baseline to three-month follow-up changes in pain interference and psychological distress. Only PF mediated changes in pain intensity. Indirect effects were twice as large for PF (κ2 = .09-.19) than for PC (κ² PCS = .05-.10). Further assessment of changes during ACT showed, however, that only PF, and not PC, predicted subsequent changes in MPI, while early and late changes in both PF and PC predicted later changes in each other. In conclusion, only PF functioned as a direct, causal working mechanism during ACT, with larger indirect effects that occurred earlier than changes in PC. Additionally, PC may function as an indirect mechanism of change during ACT for chronic pain via its direct influence on PF.
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“For mediators of change, the number of studies doing formal mediational analyses of psychological flexibility and mindfulness in web-based ACT interventions is small [7, 30].”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [30]
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“Previous studies have found a mediating relationship between psychological flexibility and improved psychological outcomes in ACT interventions (Lin et al., 2018; Trompetter et al., 2015).”
From ACT2COPE: A pilot randomised trial of a brief online acceptance and commitment therapy intervention for people living with chronic health conditions during the COVID-19 pandemic (2023) · cites this paper as Trompetter et al., 2015
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“Psychological flexibility has been proposed as a mediator of change, specifically in ACT, for reducing pain-associated disability [25,29].”
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“In the study of Trompetter et al. [30] improvements in psychological flexibility mediated the effect of web-based ACT on psychological distress, further substantiating that psychological flexibility is a core component of the ACT model.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [30]
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“In the study of Trompetter et al. [30] improvements in psychological flexibility mediated the effect of web-based ACT on psychological distress, further substantiating that psychological flexibility is a core component of the ACT model.”
From How and for whom does web-based acceptance and commitment therapy work? Mediation and moderation analyses of web-based ACT for depressive symptoms (2016) · cites this paper as [30]
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“Pain-specific expectations have also been identified as one of the core mechanisms underlying placebo analgesia 365, 366.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [366]
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van de Graaf, D. L., Lodder, P., Smeets, T., van der Lee, M. L., Trompetter, H. R., Schreurs, K. M. G., Børøsund, E., Nes, L. S., & Mols, F. (2026) · Psycho-Oncology · doi:10.1002/pon.70608
Self-citation
Metadata
- Authors
- Trompetter, H. R., Bohlmeijer, E. T., Fox, J.-P., & Schreurs, K. M. G.
- Affiliations
- University of Twente (NL)
- Roessingh Research and Development (NL)
- Corresponding author
- Trompetter, Hester R.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2015-11
- Volume
- 74
- Pages
- 50-59
- ISSN
- 0005-7967 (ISSN-L)
- OpenAlex
- W1789908247
- Cited by
- 112
- References
- 58
- Citations by year
- 2026: 7 · 2025: 13 · 2024: 6 · 2023: 10 · 2022: 11 · 2021: 13 · 2020: 11 · 2019: 12 · 2018: 8 · 2017: 12 · 2016: 8
- FWCI
- 11.57
- Type
- journal article
- Language
- en
- Open access
- green
- research.utwente.nl
- Licence
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- University of Twente Research Information (acceptedVersion, other-oa)
- University of Twente Research Information (submittedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Keywords
- psychological flexibility, pain catastrophizing, acceptance and commitment therapy, online therapy, chronic pain, mechanisms of change, pain interference, psychological distress, pain intensity, expressive writing, mediation analysis
- MeSH terms
- Adult, Depression, Female, Humans, Male, Middle Aged, Netherlands, Pain Measurement, Surveys and Questionnaires, Cognitive Behavioral Therapy, Treatment Outcome, Telemedicine, Internet, Catastrophization, Chronic Pain, Acceptance and Commitment Therapy
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