The Journal of Pain, Vol 15, No 3 (March), 2014: pp 235-236 Available online at www.jpain.org and www.sciencedirect.com
Commentaries Psychological Flexibility: What Theory and Which Predictions?
I
n their review, McCracken and Morley4 elegantly present a new theoretical model that aims to integrate current knowledge of the psychology of pain and to expand where existing theoretical models reach their boundaries. The authors introduce a fresh new concept, ‘‘psychological flexibility,’’ which they define not so much in terms of content but more in terms of processes and behaviors that can be qualified as ‘‘open, aware and active,’’ in which language and thought are key mechanisms. Psychological inflexibility is said to occur when an individual generates and strictly adheres to dysfunctional rules about himself or herself or the environment, thereby creating personal struggles that in turn prevent engagement in behavior that serves long-term valued goals. The psychological flexibility model includes 6 core processes that symmetrically increase or reduce problems: defusion from current thoughts, willingness to accept, considering self as observer, taking committed action, identifying values, and making contact with the present moment. The authors also review the current empirical status of acceptance and commitment therapy that is specifically developed to increase psychological flexibility. The result is an impressive and rapid accumulation of empirical studies, including pilot, (un)controlled outcome, and instrument development studies. To highlight the unique features of the psychological flexibility model, the authors compare the main existing theoretical models of pain within the cognitive-behavioral treatment (CBT) tradition along their organizing concepts: key outcomes, primary treatment process, and characteristic treatment methods. After (re)reading this well-wrought piece of work, I was left with a mix of feelings of enthusiasm, reminiscence, and curiosity.
Enthusiasm Progress in science occurs when existing models cannot account for certain events and new paradigms emerge. A unique feature of the psychological flexibility model is its meta-analytic orientation and its prominent focus on language and context. It provides a novel behavior-analytic way to better understand the functional conditions associated with human suffering. With the 6 core processes J.W.S.V. is supported by the Research Foundation–Flanders, Belgium (FWO Vlaanderen), and is member of the Philips Pain Management Global Advisory Board. The author declares no conflict of interest.
that seem to be malleable, the psychological flexibility model opens a fresh window on novel and exciting ways to therapeutically interact with our patients.
Reminiscence Although apparent differences exist among the existing models within CBT, there may be more commonalities than the authors seem to suggest. All are typically rooted in basic learning theories. The operant model pioneered by Wilbert E. Fordyce is solidly grounded in Skinnerian instrumental learning theory. The fear-avoidance model’s key theory is Pavlovian (fear) conditioning, which is much richer than commonly assumed.5,6 Traditional CBT includes both of these but selects thoughts and beliefs as the main focus. Interestingly, the psychological flexibility model builds on relational frame theory,2 according to which the core of language and cognition is the learned and contextually controlled ability to relate events and to derive relationships among events, and thus nicely advances from Skinner’s analysis of verbal behavior as operants.1
Curiosity Good theoretical models integrate and organize knowledge. Yet there is more: A good theory is one that predicts, and generates hypotheses that are falsifiable. The existing models seem to do this quite well, within the boundaries of their specific focus (see Table 1 for a different organization of the existing models), but the predictions of the psychological flexibility model still need crystallization. A number of methodological challenges may lie ahead: How do we operationalize and measure the core qualities of psychological flexibility: ‘‘open, aware and active’’? How do we monitor the influences that are based in verbal, language-based processes such as rules, instructions, and several other products of mental analysis, and how do we limit the risk of being overinclusive? Are the 6 core psychological flexibility processes each a sufficient or necessary condition for the occurrence of psychological flexibility, and how do they interrelate? Furthermore, what exactly are the fundamental relational frame theory principles underpinning these 6 processes, and can knowledge of these be used to 235
236
The Journal of Pain
Psychological Flexibility: What Theory and Which Predictions?
Existing Models Within the CBT Framework, With Their Theory, Their Core Thesis, and a Typical Prediction
Table 1.
MODEL
THEORY
CORE THESIS
Operant
Operant learning theory
A change in behavior is a function of the meaningful consequences that followed that behavior.
Fear avoidance
Pavlovian (fear) learning theory
Neutral stimuli can acquire motivational properties by virtue of their contingency with biologically relevant unconditioned stimuli.
Cognitive-behavioral
Cognitive (information processing) theory
A change in behavior is a function of the thoughts and beliefs related to current events and behavior.
enhance therapeutic effects and to reveal why novel treatments such as acceptance and commitment therapy work? In fact, current developments in relational frame theory research are exciting and worth following closely.3 In conclusion, although the psychological flexibility model is relatively new, it is rooted in a behavioral tradition that stems from Skinner’s early work. A particular strength is that it brings the role of language and context more prominently to the forefront. Awaiting its specific predictions, we expect the model to have great potential to strengthen our current CBT treatments. The review is not easy reading, as it introduces a host of new concepts and paradigms, but
References 1. Barnes-Holmes D, Barnes-Holmes Y, Cullinan V: Relational frame theory and Skinner’s verbal behavior: A possible synthesis. Behav Anal 23:69-84, 2000 2. Hayes SC, Barnes-Holmes D, Roche B (eds): Relational Frame Theory; A Post-Skinnerian Account of Human Language and Cognition, New York, NY, Kluwer Academic/ Plenum, 2001 3. Hussey I, Barnes-Holmes D: The IRAP as a measure of implicit depression and the role of psychological flexibility. Cogn Behav Pract 19:573-582, 2012
TYPICAL PREDICTION When voluntary (pain) behavior is followed by a reinforcing stimulus, the probability of the occurrence of that behavior increases. When a previously neutral stimulus is causally associated with pain, these (conditioned) stimuli will elicit fearful and protective behavior (avoidance, escape). When a painful event is interpreted as uncontrollable and/or unpredictable, the event (or its representation) elicits negative emotions.
the authors have done a splendid job in making this complexity readily accessible.
Acknowledgments Thanks to Marc Patrick Bennett for insightful reflections on a previous version of this commentary.
Johan W. S. Vlaeyen, PhD Research Group Health Psychology, University of Leuven Leuven, Belgium Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands 4. McCracken LM, Morley S: The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management. J Pain 15:221-234, 2014 5. Rescorla RA: Pavlovian conditioning. It’s not what you think it is. Am Psychol 43:151-160, 1988 6. Vlaeyen JW, Linton SJ: Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 153:1144-1147, 2012
Commentaries Psychological Flexibility: What Theory and Which Predictions?
I
n their review, McCracken and Morley4 elegantly present a new theoretical model that aims to integrate current knowledge of the psychology of pain and to expand where existing theoretical models reach their boundaries. The authors introduce a fresh new concept, ‘‘psychological flexibility,’’ which they define not so much in terms of content but more in terms of processes and behaviors that can be qualified as ‘‘open, aware and active,’’ in which language and thought are key mechanisms. Psychological inflexibility is said to occur when an individual generates and strictly adheres to dysfunctional rules about himself or herself or the environment, thereby creating personal struggles that in turn prevent engagement in behavior that serves long-term valued goals. The psychological flexibility model includes 6 core processes that symmetrically increase or reduce problems: defusion from current thoughts, willingness to accept, considering self as observer, taking committed action, identifying values, and making contact with the present moment. The authors also review the current empirical status of acceptance and commitment therapy that is specifically developed to increase psychological flexibility. The result is an impressive and rapid accumulation of empirical studies, including pilot, (un)controlled outcome, and instrument development studies. To highlight the unique features of the psychological flexibility model, the authors compare the main existing theoretical models of pain within the cognitive-behavioral treatment (CBT) tradition along their organizing concepts: key outcomes, primary treatment process, and characteristic treatment methods. After (re)reading this well-wrought piece of work, I was left with a mix of feelings of enthusiasm, reminiscence, and curiosity.
Enthusiasm Progress in science occurs when existing models cannot account for certain events and new paradigms emerge. A unique feature of the psychological flexibility model is its meta-analytic orientation and its prominent focus on language and context. It provides a novel behavior-analytic way to better understand the functional conditions associated with human suffering. With the 6 core processes J.W.S.V. is supported by the Research Foundation–Flanders, Belgium (FWO Vlaanderen), and is member of the Philips Pain Management Global Advisory Board. The author declares no conflict of interest.
that seem to be malleable, the psychological flexibility model opens a fresh window on novel and exciting ways to therapeutically interact with our patients.
Reminiscence Although apparent differences exist among the existing models within CBT, there may be more commonalities than the authors seem to suggest. All are typically rooted in basic learning theories. The operant model pioneered by Wilbert E. Fordyce is solidly grounded in Skinnerian instrumental learning theory. The fear-avoidance model’s key theory is Pavlovian (fear) conditioning, which is much richer than commonly assumed.5,6 Traditional CBT includes both of these but selects thoughts and beliefs as the main focus. Interestingly, the psychological flexibility model builds on relational frame theory,2 according to which the core of language and cognition is the learned and contextually controlled ability to relate events and to derive relationships among events, and thus nicely advances from Skinner’s analysis of verbal behavior as operants.1
Curiosity Good theoretical models integrate and organize knowledge. Yet there is more: A good theory is one that predicts, and generates hypotheses that are falsifiable. The existing models seem to do this quite well, within the boundaries of their specific focus (see Table 1 for a different organization of the existing models), but the predictions of the psychological flexibility model still need crystallization. A number of methodological challenges may lie ahead: How do we operationalize and measure the core qualities of psychological flexibility: ‘‘open, aware and active’’? How do we monitor the influences that are based in verbal, language-based processes such as rules, instructions, and several other products of mental analysis, and how do we limit the risk of being overinclusive? Are the 6 core psychological flexibility processes each a sufficient or necessary condition for the occurrence of psychological flexibility, and how do they interrelate? Furthermore, what exactly are the fundamental relational frame theory principles underpinning these 6 processes, and can knowledge of these be used to 235
236
The Journal of Pain
Psychological Flexibility: What Theory and Which Predictions?
Existing Models Within the CBT Framework, With Their Theory, Their Core Thesis, and a Typical Prediction
Table 1.
MODEL
THEORY
CORE THESIS
Operant
Operant learning theory
A change in behavior is a function of the meaningful consequences that followed that behavior.
Fear avoidance
Pavlovian (fear) learning theory
Neutral stimuli can acquire motivational properties by virtue of their contingency with biologically relevant unconditioned stimuli.
Cognitive-behavioral
Cognitive (information processing) theory
A change in behavior is a function of the thoughts and beliefs related to current events and behavior.
enhance therapeutic effects and to reveal why novel treatments such as acceptance and commitment therapy work? In fact, current developments in relational frame theory research are exciting and worth following closely.3 In conclusion, although the psychological flexibility model is relatively new, it is rooted in a behavioral tradition that stems from Skinner’s early work. A particular strength is that it brings the role of language and context more prominently to the forefront. Awaiting its specific predictions, we expect the model to have great potential to strengthen our current CBT treatments. The review is not easy reading, as it introduces a host of new concepts and paradigms, but
References 1. Barnes-Holmes D, Barnes-Holmes Y, Cullinan V: Relational frame theory and Skinner’s verbal behavior: A possible synthesis. Behav Anal 23:69-84, 2000 2. Hayes SC, Barnes-Holmes D, Roche B (eds): Relational Frame Theory; A Post-Skinnerian Account of Human Language and Cognition, New York, NY, Kluwer Academic/ Plenum, 2001 3. Hussey I, Barnes-Holmes D: The IRAP as a measure of implicit depression and the role of psychological flexibility. Cogn Behav Pract 19:573-582, 2012
TYPICAL PREDICTION When voluntary (pain) behavior is followed by a reinforcing stimulus, the probability of the occurrence of that behavior increases. When a previously neutral stimulus is causally associated with pain, these (conditioned) stimuli will elicit fearful and protective behavior (avoidance, escape). When a painful event is interpreted as uncontrollable and/or unpredictable, the event (or its representation) elicits negative emotions.
the authors have done a splendid job in making this complexity readily accessible.
Acknowledgments Thanks to Marc Patrick Bennett for insightful reflections on a previous version of this commentary.
Johan W. S. Vlaeyen, PhD Research Group Health Psychology, University of Leuven Leuven, Belgium Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands 4. McCracken LM, Morley S: The psychological flexibility model: A basis for integration and progress in psychological approaches to chronic pain management. J Pain 15:221-234, 2014 5. Rescorla RA: Pavlovian conditioning. It’s not what you think it is. Am Psychol 43:151-160, 1988 6. Vlaeyen JW, Linton SJ: Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain 153:1144-1147, 2012
