Make friends with your pain monster : internet-delivered acceptance- and value-based exposure in chronic pain : model and treatment

Background: Chronic pain is a complex and common condition, often affecting functioning across a wide range of outcomes as pain interferes with daily activities. The understanding of mechanisms for development and maintenance is however limited, with chronic pain syndromes being the result of a complex matrix of biopsychosocial factors reciprocally impacting each other. Medical treatments are often insufficient in reducing suffering and increasing functioning. Acceptance and Commitment Therapy (ACT) targets psychological flexibility – the ability to continue towards a valued direction in life, despite inner distress and obstacles – and is a promising treatment approach. Access to ACT treatment is limited, and internet-delivery could improve access and reach.

Aim: The purpose of this thesis was to develop a feasible and effective internet-delivered ACT intervention for adults with chronic pain, and increase our understanding of potential mechanisms in pain-related disability and treatment.

Methods: Four studies were conducted. In study I we used a cross-sectional design to evaluate validity aspects of the Valuing Questionnaire (VQ). In study II, also using a cross- sectional design, psychological flexibility was examined as a potential resilience factor for persons with chronic pain. Study III investigated the feasibility and potential efficacy of iACT – a novel internet-delivered treatment in a microlearning format – for clinical and self- referred adults with chronic pain. An open pilot design was used. In study IV a randomized controlled trial design was used to compare the efficacy of iACT to a waitlist control group. Primary outcome was pain interference, secondary outcomes were psychological inflexibility, value orientation, quality of life (QoL), pain intensity, anxiety, insomnia and depressive symptoms.

Results: VQ had adequate model fit and internal consistency, and also contributed to the variance in pain interference, depressive symptoms and QoL. In study II, PF was found to be a candidate for a modifiable resilience factor in chronic pain. In study III results indicated that the iACT treatment was feasible and preliminary efficacious for both clinical and self- referred patients. In study IV, participants in the iACT arm showed improvements compared to the WLC across all nine outcomes investigated.

Conclusions: Values can be effectively assessed with the brief self-rating questionnaire VQ. Psychological flexibility may be a modifiable resilience factor for the development and maintenance of chronic pain. A micro-learning format of ACT via the internet can be both feasible and efficacious as to increase functioning across a wide range of outcomes for chronic pain patients. The studies in this thesis provides a groundwork for future scientific investigations of some of the psychological mechanisms relevant for chronic pain.

List of scientific papers

I. Rickardsson J., Zetterqvist V., Kemani M.K., Holmström L., Andersson E., Wicksell R.K. (2019). Assessing values – Psychometric properties of the Swedish version of the Valuing Questionnaire in adults with chronic pain. Journal of Contextual Behavioral Science. 14:40-49.
https://doi.org/10.1016/j.jcbs.2019.08.009

II. Gentili C., Rickardsson J., Zetterqvist V., Simons L.E., Lekander M., Wicksell R.K. (2019). Psychological Flexibility as a Resilience Factor in Individuals With Chronic Pain. Frontiers in Psychology. 10:2016.
https://doi.org/10.3389/fpsyg.2019.02016

III. Rickardsson, J., Zetterqvist, V., Gentili, C., Andersson, E., Holmström, L., Lekander, M., Persson, M., Persson, J., Ljótsson, B., Wicksell, R. K. (2020). Internet-delivered Acceptance and Commitment Therapy (iACT) for chronic pain – feasibility and preliminary effects in clinical and self-referred patients. mHealth. 6:27.
https://doi.org/10.21037/mhealth.2020.02.02

IV. Rickardsson, J., Gentili, C., Holmström, L., Zetterqvist, V., Andersson, E., Persson, J., Lekander, M., Ljótsson, B., Wicksell, R. K. iACT – internet- delivered Acceptance and Commitment Therapy as microlearning for chronic pain - A randomized controlled study with one-year follow-up. [Manuscript]