Of Pain and Suffering: exploring the role of psychological processes in chronic pain, and development of a compassionate acceptance program for pain management (COMP.ACT)

Abstract

Introduction: Chronic pain is a debilitating medical condition with a detrimental impact on patients quality of life, functioning and mental health. In addition to pain itself, psychopathological symptoms usually co-occur and contribute to the nefariousness and pervasiveness of chronic pain. The study of psychological factors contributing to chronic pain has been fueled by scientific advances in clinical psychology, particularly in cognitive and behavioral approaches. Mindfulness, acceptance and compassion-based approaches have recently helped shift the focus of therapy from the elimination of symptoms and maladaptive cognitions, to the overall cultivation of an open, aware and self-compassionate stance to personal suffering, while fostering commitment to valued action. However, although these approaches seem to be valuable tools to chronic pain management, their core processes present conceptual overlap (e.g., by sharing core elements, such as mindful awareness and acceptance), thus raising concerns regarding their unique contribution to chronic pain. The current thesis aimed to study the uniqueness and interconnection between mindfulness-, acceptance- and compassion-related processes in chronic pain, through four main routes: 1) to develop and/or validate adequate assessment tools; 2) to explore patterns of associations between psychological processes, pain outputs and depressive symptoms; 3) to examine risk and protective psychological factors associated with the development of depressive symptoms; 4) to develop and pilot test the efficacy of a Compassionate Acceptance and Committment Therapy (COMP.ACT), and examine the added value of (self)compassion in ACT for chronic pain. Methods: The present thesis comprises 10 empirical studies, including 2 psychometric studies, 5 cross-sectional studies, 2 time-lagged studies, and 1 clinical study. These were performed in convenience samples of adult women with musculoskeletal chronic pain, as well as of adult men and women from the general population. Recruitment was conducted online and in a chronic pain healthcare unit. Data was collected through self-report measures. Results: The psychometric studies showed that i) the Valuing Questionnaire (VQ) presents good psychometric properties and its original factor structure was confirmed; ii) the Perceived Validation and Criticism in Pain Questionnaire (PVCPQ) is a psychometrically valid two-factor measure of perceived validation and criticism by signficant others when experiencing pain, and PVCPQ contributes to functional impairment beyond pain, background variables and other related psychological processes. Cross-sectional studies showed that iii) self-compassion is more strongly (negatively) associated with depressive symptoms than mindful awareness, and activity engagement mediates this relationship; iv) self-compassion buffers the mediator effect of cognitive fusion between pain intensity and depression; v) rumination and obstructions to valued living mediate the negative association between mindful awareness and depression; vi) self-compassion relates to social safeness through less fears of receiving compassion from others; vii) uncompassionate self-responding is a strong contributor to depression. Time-lagged studies showed that viii) cognitive fusion is a predictor of the trajectory of depression beyond pain intensity and impairment, and ix) self-compassion prospectively predicts depression. The clinical study showed that x) COMP.ACT did not significantly differ from ACT-only, both were acceptable, and COMP.ACT seemed to result in more valued living. Conclusions: Overall, these studies suggest that, more than pain intensity and functional impairment, psychological processes contribute significantly to depression in chronic pain, which suggests the importance of targeting psychological processes, and not only focus on reducing pain in pain management programs. Self-compassion seems to be an especially protective factor against depression in chronic pain, which suggests the usefulness of integrating compassion-inducing practices in chronic pain management programs.