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Assessing Psychological Flexibility in Chronic Illness

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Abstract

Objectives: The present study aimed at assessing psychological flexibility, the core construct of the acceptance and commitment therapy model, in the context of chronic illness. In particular, the present study aimed at validating the 18-item Portuguese CompACT measure of psychological flexibility in a chronic illness sample (total n = 419; 83.8% women; 16.2% men) collected via online survey. Method: In particular, we studied the internal structure of the scale employing exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), gender-based invariance, and associations with conceptually relevant constructs (shame, anxiety, depressive symptoms, insomnia severity, and self-compassion). Results: All items from the Openness to Experience subscale were removed due to low loading values on the EFA. The CFA confirmed the adequacy of an 8-item Portuguese CompACT with two subscales, Behavioral Awareness (α = .87) and Valued Action (α = .86). Both subscales correlated negatively with shame, anxiety, depressive symptoms, and insomnia severity. The Valued Action subscale additionally correlated positively with self-compassion. Conclusion: An 8-item version of the Portuguese CompACT, with two subscales, seems to be well-suited for application for clinicians with clients with chronic illness.

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Data available upon request from last author.

References

  • Åkerblom, S., Perrin, S., Rivano Fischer, M., & McCracken, L. M. (2021). Predictors and mediators of outcome in cognitive behavioral therapy for chronic pain: The contributions of psychological flexibility. Journal of Behavioral Medicine, 44(1), 111–122.

    Article  PubMed  Google Scholar 

  • Alho, I., Lapppalainen, P., Muotka, J., & Lappalainen, R. (2022). Acceptance and commitment therapy group intervention for adolescents with type 1 diabetes: A randomized controlled trial. Journal of Contextual Behavioral Science, 25, 153–161.

    Article  Google Scholar 

  • Assaz, D., Tyndall, I., Oshiro, C., & Roche, B. (2023). A process-based analysis of cognitive defusion in acceptance and commitment therapy. Behavior Therapy, 54(6), 1020–1035.

    Article  PubMed  Google Scholar 

  • Bastien, C. H., Vallieres, A., & Morin, C. H. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297–307.

    Article  PubMed  Google Scholar 

  • Blakey, S. M., Halverson, T. F., Evans, M. K., Patel, T. A., Hair, L. P., Meyer, E. C., DeBeer, B. B., Beckham, J. C., Pugh, M. J., Calhoun, P. S., & Kimbrel, N. A. (2021). Experiential avoidance is associated with medical and mental health diagnoses in a national sample of deployed Gulf War veterans. Journal of Psychiatric Research, 142, 17–24. https://doi.org/10.1016/j.jpsychires.2021.07.033

    Article  PubMed  PubMed Central  Google Scholar 

  • Bodenlos, J. S., Hawes, E. S., Burstein, S. M., & Arroyo, K. M. (2020). Association of cognitive fusion with domains of health. Journal of Contextual Behavioral Science, 18, 9–15.

    Article  Google Scholar 

  • Burns, M. F., Secinti, E., Johns, S. A., Wu, W., Helft, P. R., Turk, A. A., Loehrer, P. J., Sr., Sehdev, A., Al-Hader, A. A., & Mosher, C. E. (2023). Impact of acceptance and commitment therapy on physical and psychological symptoms in advanced gastrointestinal cancer patients and caregivers: Secondary results of a pilot randomized trial. Journal of Contextual Behavioral Science, 27, 107–115.

    Article  PubMed  Google Scholar 

  • Carvalho, S. A., Skvarc, D., Barbosa, R., Tavares, T., Santos, D., & Trindade, I. A. (2022). A pilot randomized controlled trial of online acceptance and commitment therapy versus compassion-focused therapy for chronic illness. Clinical Psychology & Psychotherapy, 29(2), 524–541. https://doi.org/10.1002/cpp.2643

    Article  Google Scholar 

  • Castilho, P., Pinto-Gouveia, J., & Duarte, J. (2015). Evaluating the multifactor structure of the long and short versions of the Self-Compassion Scale in a clinical sample. Journal of Clinical Psychology, 71(9), 856–870. https://doi.org/10.1002/jclp.22187

    Article  PubMed  Google Scholar 

  • Chen, F. F. (2007). Sensitivity of goodness of fit indexes to lack of measurement invariance. Structural Equation Modeling, 14, 464–504.

    Article  Google Scholar 

  • Ciarrochi, J., Sahdra, B., Marshall, S., Parker, P., & Howarth, C. (2014). Psychological flexibility is not a single dimension: The distinctive flexibility profiles of underweight, overweight, and obese people. Journal of Contextual Behavioral Science, 3, 236–247.

    Article  Google Scholar 

  • Coutinho, M., Trindade, I. A., & Ferreira, C. (2021). Experiential avoidance, committed action, quality of life: Differences between college students with and without chronic illness. Journal of Health Psychology, 26(7), 1035–1045.

    Article  PubMed  Google Scholar 

  • Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785–801.

    Article  Google Scholar 

  • Dochat, C., Woodbridge, J. S., Herbert, M. S., Lee, M. W., & Afari, N. (2021). Single-session acceptance and commitment therapy (ACT) interventions for patients with chronic health conditions: A systematic review and meta-analysis. Journal of Contextual Behavioral Science, 20, 52–69.

    Article  PubMed  PubMed Central  Google Scholar 

  • DeZutter, J., Luyctx, K., & Wacholtz, A. (2015). Meaning in life in chronic pain patients over time: Associations with pain experience and psychological well-being. Journal of Behavioral Medicine, 38(2), 384–396.

    Article  PubMed  Google Scholar 

  • Fawson, S., Moon, Z., Novogrudsky, K., Moxham, F., Forster, K., Tribe, I., Moss-Morris, R., Johnson, C., & Hughes, L. D. (2023, September 25). Acceptance and commitment therapy and their association with distress in cancer: A systematic review and meta-analysis. Health Psychology Review, 1–22.

  • Francis, A. W., Dawson, D. L., & Golijani-Moghaddam, N. (2016). The development and validation of the Comprehensive Assessment Of Acceptance and Commitment Therapy Processes (CompACT). Journal of Contextual Behavioral Science, 5(3), 134–145. https://doi.org/10.1016/j.jcbs.2016.05.003

    Article  Google Scholar 

  • Gloster, A. T., Meyer, A. H., & Lieb, R. (2017). Psychological flexibility as a malleable public health target: Evidence from a representative sample. Journal of Contextual Behavioral Science, 6, 166–171. https://doi.org/10.1016/j.jcbs.2017.02.003

    Article  Google Scholar 

  • Gloster, A. T., Walder, N., Levin, M., Twohig, M., & Karekla, M. (2020). The empirical status of acceptance and commitment therapy: A review of meta-analyses. Journal of Contextual Behavioral Science, 18, 181–192.

    Article  Google Scholar 

  • González-Fernandéz, S., & Fernández-Rodríguez, C. (2019). acceptance and commitment therapy in cancer: Review of applications and findings. Behavioral Medicine, 45, 255–269.

    Article  PubMed  Google Scholar 

  • Graham, C. D., Gouick, J., Krahe, C., & Gillanders, D. (2016). A systematic review of the use of acceptance and commitment therapy (ACT) in chronic disease and long-term conditions. Clinical Psychology Review, 46, 46–58.

    Article  PubMed  Google Scholar 

  • Hair, J., Blak, W., Babin, D, & Anderson, R. (2014). Multivariate data analysis (7th ed.). Pearson.

  • Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behavior Research & Therapy, 44, 1–25. https://doi.org/10.1016/j.brat.2005.06.006

    Article  Google Scholar 

  • Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and commitment therapy as a unified model of behavior change. The Counselling Psychologist, 40, 976–1002.

    Article  Google Scholar 

  • Herbert, M. S., Dochat, C., Wooldridge, J. S., Materna, K., Blanco, B. H., Tynan, M., Lee, M. W., Gasperi, M., Camodeca, A., Harris, D., & Afari, N. (2022). Technology-supported acceptance and commitment thrapy for chronic health conditions: A systematic review and meta-analysis. Behavior Research and Therapy, 148, e103995. https://doi.org/10.1016/j.brat.2021.103995

    Article  Google Scholar 

  • Karademas, E. C., Karekla, M., Flourini, M., Vasilou, V. S., Kasinopoulos, & Papacosta, S. S. (2017). The impact of experiential avoidance on the relationship between illness representations, pain catastrophising, and pain interference in chronic pain. Psychology & Health, 32, 1461–1484. https://doi.org/10.1080/08870446.2017.1346193

    Article  Google Scholar 

  • Karekla, M., Karademas, E. C., & Gloster, A. T. (2019). The common sense model of self-regulation and acceptance and commitment therapy: Integrating strategies to guide intervetions for chronic illness. Health Psychology Review, 13(4), 490–503.

    Article  PubMed  Google Scholar 

  • Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review, 30, 865–878. https://doi.org/10.1016/j.cpr.2010.03.001

    Article  PubMed  PubMed Central  Google Scholar 

  • Lillis, J., Hayes, S. C., & Levin, M. E. (2011). Binge eating and weight control: The role of experiential avoidance. Behavior Modification, 35, 252–264.

    Article  PubMed  Google Scholar 

  • Maguire, R., Hanly, P., & Maguire, P. (2021). Living well with chronic illness: How social support, loneliness and psychological appraisals relate to well-being in a population-based European sample. Journal of Health Psychology, 26(1), 1494–1507. https://doi.org/10.1177/1359105319883923

    Article  PubMed  Google Scholar 

  • Mathew, A., Doorenbros, A. Z., Jancy, M. K., & Hershberger, P. E. (2021). Acceptance and commitment therapy in adult cancer survivors: A systematic review and conceptual model. Journal of Cancer Survivorship, 15(3), 427–451.

    Article  PubMed  Google Scholar 

  • McLoughlin, S., & Roche, B. T. (2023). ACT: A process-based therapy in search of a process. Behavior Therapy, 54(6), 939–955.

    Article  PubMed  Google Scholar 

  • Ong, C. W., Pierce, B. G., Pertersen, J. M., Barney, J. L., Fruge, J. E., Levin, M. E., & Twohig, M. P. (2020). A psychometric comparison of psychological inflexibility measures: Discriminant validity and item performance. Journal of Contextual Behavioral Science, 18, 34–47.

    Article  Google Scholar 

  • Pais-Ribeiro, J., Silva, I., Ferreira, T., Martins, A., Meneses, R., & Baltar, M. (2007). Validation study of a Portuguese version of the Hospital Anxiety and Depression Scale. Psychology, Health & Medicine, 12(2), 225–235. https://doi.org/10.1080/13548500500524088

    Article  Google Scholar 

  • Podsakoff, P. M., MacKenzie, S. B., & Podsakoff, N. P. (2012). Sources of method bias in social science research and recommendations on how to control it. Annual Review of Psychology, 63, 539–569.

    Article  PubMed  Google Scholar 

  • Proctor, C. J., Reiman, A. J., & Best, L. A. (2023). Cancer, what next? A cross-sectional study examining physical symptoms, subjective well-being, and psychological flexibility. Health Psychology & Behavioral Medicine, 11(1), 2266220.

    Article  Google Scholar 

  • Raes, F., Pommier, E., Neff, K., & Van Gucht, D. (2011). Construction and factorial validation of a short form of the Self-Compassion Scale. Clinical Psychology & Psychotherapy, 18(3), 250–255. https://doi.org/10.1002/cpp.702

    Article  Google Scholar 

  • Rehfeldt, R. A., & Tyndall, I. (2022). Why we are not ACTing to save ourselves: ACT, health, and culture. Behavior Analysis in Practice, 15, 55–70.

    Article  PubMed  Google Scholar 

  • Rochefort, C., Baldwin, A., & Chmielewski, M. (2018). Experiential avoidance: An examination of the construct validity of the AAQ-II and MEAQ. Behavior Therapy, 49, 435–449.

    Article  PubMed  Google Scholar 

  • Scott, W., Chilcott, J., Guildford, B., Daly-Eichenart, A., & McCracken, L. M. (2018). Feasibility randomized-controlled trial of online acceptance and commitment therapy for patients with complex pain in the United Kingdom. European Journal of Pain, 22(8), 1473–1484.

    Article  Google Scholar 

  • Scott, W., Hann, K. E. J., & McCracken, L. M. (2016). A comprehensive examination of changes in psychological flexibility following acceptance and commitment therapy for chronic pain. Journal of Contemporary Psychotherapy, 46, 139–148.

    Article  PubMed  PubMed Central  Google Scholar 

  • Simister, H. D., Tkachuk, G. A., Shay, B. L., Vincent, N., Pear, J. J., & Skrabek, R. Q. (2018). Randomized controlled trial of online acceptance and commitment therapy for fibromyalgia. Journal of Pain, 19(7), 741–753.

    Article  PubMed  Google Scholar 

  • Trindade, I. A., Barbosa, R., Ferreira, C., & Pinto-Gouveia, J. (2020). Further validation of the Cognitive Fusion Questionnaire-Chronic Illness (CFQ-CI) in different health condition samples. Journal of Contextual Behavioral Science, 16, 45–48.

    Article  Google Scholar 

  • Trindade, I. A., Ferreira, N. B., Mendes, A. L., Ferreira, C., Dawson, D., & Golijani-Moghaddam, N. (2021). Comprehensive Assessment of Acceptance and Commitment Therapy Processes (CompACT): Measure refinement and study of measurement invariance across Portuguese and UK samples. Journal of Contextual Behavioral Science, 21, 30–36. https://doi.org/10.1016/j.jcbs.2021.05.002

    Article  Google Scholar 

  • Trindade, I. A., Ferreira, C., & Pinto-Gouveia, J. (2017). Chronic illness-related shame: Development of a new scale and novel approach for IBD patients' depressive symptomatology. Clinical Psychology & Psychotherapy, 24(1), 255–263. https://doi.org/10.1002/cpp.2035

    Article  Google Scholar 

  • Trindade, I. A., Ferreira, C., & Pinto-Gouveia, J. (2018a). The longitudinal effects of emotion regulation on physical and psychological health: A latent growth analysis exploring the role of cognitive fusion in inflammatory bowel disease. British Journal of Health Psychology, 23, 171–185. https://doi.org/10.1111/bjhp.12280

    Article  PubMed  Google Scholar 

  • Trindade, I. A., Ferreira, C., & Pinto-Gouveia, J. (2018b). Assessment of chronic illness-related cognitive fusion: Preliminary development and validation of a new scale with an IBD sample. Journal of Clinical Psychology in Medical Settings, 25(4), 356–366.

    Article  PubMed  Google Scholar 

  • Trindade, I. A., Pinto, H., Gomes, A. A., Knowles, S. R., & Ferreira, N. B. (2023). Behavioral response to illness: Development and validation of a self-report measure of illness behavior avoidance. Current Psychology, 42, 9261–9269.

    Article  Google Scholar 

  • Trindade, I. A., Vagos, P., Moreira, H., Fernandes, D. F., & Tyndall, I. (2022). Further validation of the 18-item CompACT scale using a multi-sample design: Confirmatory Factor Analysis and correlates of psychological flexibility. Journal of Contextual Behavioral Science, 25, 1–9.

    Article  Google Scholar 

  • Tynan, M., Afari, N., Dochat, C., Gasperi, M., Roesch, S., & Herbert, M. S. (2022). Confirmatory factor analysis of the Comprehensive Assessment of Acceptance and Commitment Therapy (CompACT) in active-duty personnel. Journal of Contextual Behavioral Science, 25, 115–121.

    Article  PubMed  PubMed Central  Google Scholar 

  • Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Dawson, D. L. (2019). The Acceptance and Acton Questionnaire-II (AAQ-II) as a measure of experiential avoidance: Concerns over discriminant validity. Journal of Contextual Behavioral Science, 12, 278–284.

    Article  Google Scholar 

  • Tyndall, I., Waldeck, D., Pancani, L., Whelan, R., Roche, B., & Pereira, A. (2020). Profiles of psychological flexibility: A latent class analysis of the acceptance and commitment therapy model. Behavior Modification, 44(3), 365–393.

    Article  PubMed  Google Scholar 

  • Vowles, K. E., Sowden, G., & Ashworth, J. (2014). A comprehensive examination of the model underlying acceptance and commitment therapy for chronic pain. Behavior Therapy, 45, 390–401.

    Article  PubMed  Google Scholar 

  • Zhang, C.-Q., Leeming, E., Smith, P., Chung, P.-K., Hagger, M. S., & Hayes, S. C. (2018). Acceptance and commitment therapy for health behavior change: A contextually-driven approach. Frontiers in Psychology, 8, e2350. https://doi.org/10.3389/fpsyg.2017.02350

    Article  Google Scholar 

  • Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Psychology, University of Chichester, College Lane, West Sussex, PO196PE, Chichester, UK

    Ian Tyndall

  2. Faculty of Psychology and Education Sciences, University of Coimbra, CINEICC, Coimbra, Portugal

    Paula Vagos, Helena Pinto & Inês A. Trindade

  3. Instituto de Desenvolvimento Humano Portucalense, Universidade Portucalense, Porto, Portugal

    Paula Vagos

  4. Instituto Superior Miguel Torga, Coimbra, Portugal

    Soraia Cano

  5. Centre of Health and Medical Psychology, School of Behavioral, Social, and Legal Sciences, University of Orebro, Orebro, Sweden

    Inês A. Trindade

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  1. Ian Tyndall
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  2. Paula Vagos
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  3. Soraia Cano
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  4. Helena Pinto
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  5. Inês A. Trindade
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Contributions

Ian Tyndall—lead writing, reviewing and editing, interpretation & analysis; Paula Vagos—conceptualization, data analysis, data presentation; reviewing and editing; Soraia Cano—participant recruitment and data management; Helena Pinto—participant recruitment and data management; Ines A Trindade—study lead, conceptualization, project management; data analysis; writing, reviewing and editing.

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Correspondence to Ian Tyndall.

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Tyndall, I., Vagos, P., Cano, S. et al. Assessing Psychological Flexibility in Chronic Illness. Psychol Rec 73, 565–574 (2023). https://doi.org/10.1007/s40732-023-00572-y

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