Associations Between Six Core Processes of Psychological Flexibility and Functioning for Chronic Pain Patients: A Three-Level Meta-Analysis

Abstract

The previous research showed contradictions in the relationships between psychological flexibility processes and functioning. This meta-analysis is the first to provide a comprehensive meta-analysis of the associations between six core processes of psychological flexibility and functioning among chronic pain patients. Four databases were searched (PsycINFO; PubMed; CINAHL; Web of Science) along with reference lists. Thirty-six cross-sectional studies were included (7,812 chronic pain patients). A three-level meta-analytic model was used to examine the associations. The publication bias was assessed with the Egger test, funnel plot, and p-curve analysis. Significant associations were found between functioning and six processes of psychological flexibility (i.e., acceptance, defusion, present moment, committed action, self as context, and values). Except for the relationship between defusion and functioning, the relationships between the other five psychological flexibility processes and functioning were all moderated by domains of functioning. No moderators were found regarding age, percentage of females, country, or type of instrument used to measure functioning. These findings may carry significant implications for chronic pain patients and clinical workers. It might be more effective to focus on functioning-related psychological flexibility processes rather than all therapy packages if the relationships between functioning and specific processes of psychological flexibility were better informed. Limitations were also discussed.

Keywords: acceptance; acceptance and commitment therapy; chronic pain; meta-analysis; physical functioning; processes of psychological flexibility; psychological functioning.

FIGURE 1

Study flow diagram.

FIGURE 2

Forest plot of effect size (r) for the relationship between acceptance and functioning.

FIGURE 3

The p-Curve for statistically significant results on the relationship between acceptance and functioning. The observed p-curve includes 35 statistically significant (p < 0.05 results, of which 35 are p < 0.025. There were four additional results entered but excluded from p-curve because they were p > 0.05.

FIGURE 4

Forest plot of effect size (r) for the relationship between committed action and functioning.

FIGURE 5

The p-Curve for statistically significant results on the relationship between committed action and functioning. The observed p-curve includes 13 statistically significant (p < 0.05) results, of which 12 are p < 0.025. There was one additional result entered but excluded from p-curve because it was p > 0.05.

FIGURE 6

Forest plot of effect size (r) for the relationship between defusion and functioning.

FIGURE 7

The p-Curve for statistically significant results on the relationship between defusion and functioning. The observed p-curve includes 10 statistically significant (p < 0.05) results, of which 10 are p < 0.025. There were 6 additional results entered but excluded from p-curve because they were p > 0.05.

FIGURE 8

Forest plot of effect size (r) for the relationship between present moment and functioning.

FIGURE 9

The p-Curve for statistically significant results on the relationship between present moment and functioning. The observed p-curve includes 8 statistically significant (p < 0.05) results, of which 8 are p < 0.025. There were five additional results entered but excluded from p-curve because they were p > 0.05.

FIGURE 10

Forest plot of effect size (r) for the relationship between self as context and functioning.

FIGURE 11

The p-Curve for statistically significant results on the relationship between self and context and functioning. The observed p-curve includes three statistically significant (p < 0.05) results, of which three are p < 0.025. There were four additional results entered but excluded from p-curve because they were p > 0.05.

FIGURE 12

Forest plot of effect size (r) for the relationship between values and functioning.

FIGURE 13

The p-Curve for statistically significant results on the relationship between values and functioning. The observed p-curve includes 11 statistically significant (p < 0.05) results, of which 11 are p < 0.025. There were four additional results entered but excluded from p-curve because they were p > 0.05.