ORIGINAL RESEARCH

published: 11 March 2016

doi: 10.3389/fpsyg.2016.00353

Positive Psychological
Wellbeing Is Required for Online
Self-Help Acceptance and
Commitment Therapy for Chronic
Pain to be Effective
Hester R. Trompetter 1*, Ernst T. Bohlmeijer 1 , Sanne M. A. Lamers 1 and
Karlein M. G. Schreurs 1,2
1
Centre for eHealth and Wellbeing, Department of Psychology, Health and Technology, University of Twente, Enschede,
Netherlands, 2 Roessingh Research and Development, Enschede, Netherlands

The web-based delivery of psychosocial interventions is a promising treatment modality

for people suffering from chronic pain, and other forms of physical and mental illness.
Despite the promising findings of first studies, patients may vary in the benefits they draw
from self-managing a full-blown web-based psychosocial treatment. We lack knowledge
on moderators and predictors of change during web-based interventions that explain for
whom web-based interventions are especially (in)effective. In this study, we primarily
Edited by:
Angelo Compare,
explored for which chronic pain patients web-based Acceptance and Commitment
University of Bergamo, Italy Therapy (ACT) was (in)effective during a large three-armed randomized controlled trial.
Reviewed by: Besides standard demographic, physical and psychosocial factors we focused on
Daniela Villani,
positive mental health. Data from 238 heterogeneously diagnosed chronic pain sufferers
Catholic University of the Sacred
Heart, Italy from the general Dutch population following either web-based ACT (n = 82), or one of
Raffaella Calati, two control conditions [web-based Expressive Writing (EW; n = 79) and Waiting List
Istituto di Ricovero e Cura a Carattere
Scientifico Centro San Giovanni di
(WL; n = 77)] were analysed. ACT and EW both consisted of nine modules and lasted
Dio, Fatebenefratelli, Brescia, Italy nine to 12 weeks. Exploratory linear regression analyses were performed using the
*Correspondence: PROCESS macro in SPSS. Pain interference at 3-month follow-up was predicted from
Hester R. Trompetter
baseline moderator (characteristics that influence the outcome of specific treatments in
[email protected]
comparison to other treatments) and predictor (characteristics that influence outcome
Specialty section: regardless of treatment) variables. The results showed that none of the demographic or
This article was submitted to
physical characteristics moderated ACT treatment changes compared to both control
Psychology for Clinical Settings,
a section of the journal conditions. The only significant moderator of change compared to both EW and WL
Frontiers in Psychology was baseline psychological wellbeing, and pain intensity was a moderator of change
Received: 4 September 2015 compared to EW. Furthermore, higher pain interference, depression and anxiety, and
Accepted: 26 February 2016
Published: 11 March 2016 also lower levels of emotional well-being predicted higher pain interference in daily
Citation: life 6 months later. These results suggest that web-based self-help ACT may not be
Trompetter HR, Bohlmeijer ET, allocated to chronic pain sufferers experiencing low levels of mental resilience resources
Lamers SMA and Schreurs KMG
such as self-acceptance, goals in life, and environmental mastery. Other subgroups
(2016) Positive Psychological
Wellbeing Is Required for Online are identified that potentially need specific tailoring of (web-based) ACT. Emotional and
Self-Help Acceptance psychological wellbeing should receive much more attention in subsequent studies on
and Commitment Therapy for Chronic
Pain to be Effective. chronic pain and illness.
Front. Psychol. 7:353. Keywords: chronic pain, moderator, predictor, psychological wellbeing, Acceptance and Commitment Therapy,
doi: 10.3389/fpsyg.2016.00353 web-based, online, resilience

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Trompetter et al. Moderators Online ACT for Pain

INTRODUCTION guided, self-help web-based program based on Acceptance and

Commitment Therapy (ACT) (Hayes et al., 2012; Trompetter
Chronic pain is a prevalent, disabling and difficult-to-treat et al., 2014). ACT is a distinct form of CBT that teaches pain
condition that affects both individual pain sufferers and society patients to recognize and abandon unfruitful and narrowing
(Breivik et al., 2006). Where biomedical oriented treatment attempts to avoid the pain experience itself and related thoughts
modalities focus on pain removal, psychosocial treatments based and feelings (Hayes et al., 2006). Overall, therapeutic processes
on a cognitive behavioral framework try to effectively restore that are targeted in ACT – including pain acceptance, cognitive
functioning and enhance pain management (Williams et al., defusion and mindfulness – promote psychological flexibility, the
2012). The last decade has seen an expansion in studies exploring ability to behave in accordance with personal, meaningful values
web-based delivery of psychosocial interventions for chronic pain from an open, accepting and present-moment stance toward
and an additional, broad range of physical and mental health the pain experience. ACT is an effective treatment for both
problem. First review studies indicate that web-based Cognitive chronic pain and a broader range of mental and physical health
Behavioural Therapies (CBT) are effective for chronic pain and problems (Powers et al., 2009; Veehof et al., 2011; A-Tjak et al.,
other disorders (Cuijpers et al., 2010; Bender et al., 2011). 2015). Outcomes of the RCT generally showed small to moderate
Advantages that are associated with web-based psychosocial effects for the ACT-program Living with Pain compared to two
interventions are its cost- and time-effectiveness and its ability to (minimal intervention and waiting-list) control conditions in
reach physically disabled, stigmatized, or isolated patient groups. improving several disability-related processes and outcomes
Furthermore, online interventions enable individuals to follow an (Trompetter et al., 2014).
intervention at their own pace (Andersson and Cuijpers, 2008). Of specific interest is positive mental health in addition to
Even minimal improvements during self-help interventions standard demographic, physical and psychosocial domain factors
that can be easily disseminated through the Internet to many in chronic pain and psychosomatic research (Keyes, 2002).
individuals may contribute to alleviate the general disease burden Positive mental health is a state of optimal mental functioning
of chronic pain and illness. Despite the promising findings of that consists of the aspects emotional, psychological and social
first studies, patients may vary in the benefits they draw from wellbeing (Keyes, 2002). While emotional wellbeing relates to
self-managing a full-blown web-based psychosocial treatment. hedonic aspects of happiness, psychological wellbeing relates
At present, however, studies are lacking that specify for whom to eudemonic aspects of functioning that, for example, include
web-based cognitive behavioral interventions can be more or less feelings of personal growth and environmental mastery (Ryff,
profitable (Macea et al., 2010; Bender et al., 2011). 1989, 2014). Social wellbeing pertains to feelings of social
In general, to explore what, how, why and for whom coherence, integration and social contribution (Keyes, 2002).
psychosocial treatment does or does not work is a promising Positive mental health and especially psychological wellbeing is
pathway to increase the effectiveness of psychosocial related to resilience, the ability to maintain wellbeing despite
interventions for chronic pain and other physical and mental life adversities such as enduring pain or to bounce back after
health problems (Kraemer et al., 2002; Morley and Keefe, 2007). adversities (Fava and Tomba, 2009; Ryff et al., 2012). We
Knowledge on moderators of change (‘for whom’) can inform included a measure of positive mental health in our trial
future allocation of patients to treatment and guide tailoring since the focus of ACT on commitment to personal goals
of interventions to patient characteristics, thereby potentially that are intrinsically motivated, acceptance and mindfulness, is
enhancing both treatment effectiveness and efficiency (Morley intrinsically and empirically supportive of increasing an rich, full
et al., 2013). Such knowledge would be especially helpful in and engaged life (Fledderus et al., 2012; Kashdan and Ciarrochi,
the area of chronic pain, as effects of both biomedical and 2013; Bohlmeijer et al., 2015). Also, psychological wellbeing is
psychosocial interventions are small to moderate and not all an underrepresented, but important and independent factor in
patients can be helped effectively at present (Turk et al., 2011; relation to outcomes such as distress, chronic pain and physical
Eccleston et al., 2013). Unfortunately, there is a paucity of frailty (Ruini et al., 2003; Schleicher et al., 2005; Gale et al., 2014).
knowledge in this area. Factors that have been identified in Based on previous studies on face-to-face CBT for chronic
face-to-face CBT for chronic pain to be negatively associated with pain, we predicted that psychosocial domain factors (depression,
treatment response include baseline levels of high psychological anxiety and positive mental health), and not physical domain
distress, low perceptions of pain control, high levels of negative factors (pain intensity, pain disability and pain interference) or
thinking (e.g., catastrophizing) toward the pain, and stress demographic characteristics would function as moderators and
(McCracken and Turk, 2002; Turner et al., 2007). No consistent predictors of change in pain interference in daily life during the
relationships were found in previous CBT-studies between RCT.
patient outcomes and demographic variables (McCracken and
Turk, 2002).
The present study explores moderators (baseline MATERIALS AND METHODS
characteristics that interact with treatment to affect outcome)
and non-specific predictors (baseline characteristic that do Participants and Procedure
not interact with treatment, but predict outcome regardless The sample for the current study stems from the original sample
of treatment) of treatment change during a large, three- in the RCT on the effectiveness of web-based ACT (Trompetter
armed randomised controlled trial (RCT) on the efficacy of a et al., 2014). The original RCT protocol was approved by

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Trompetter et al. Moderators Online ACT for Pain

the Dutch Medical-Ethical Review Board (METC, trial number again focused on committed action, and it was explored how
NL38622.044.11), which operates under the Dutch Central one would cope with setbacks and failure in the long term.
Committee for Research involving human participants (CCMO). Participants were encouraged to download new mindfulness
All subjects gave written informed consent in accordance with exercises weekly (e.g., ‘body scan,’ ‘breathing toward pain’ or
the Declaration of Helsinki. Participants were a heterogeneously ‘observe your thinking’), and practice mindfulness daily for
diagnosed group of pain sufferers recruited from the general 10–15 min. Participants were advised to spend approximately
Dutch population through advertisements in Dutch newspapers 30 min each day, or 3 h per week in total, on the course.
and online patient platforms. Study inclusion criteria were In EW, the general assignment was to emotionally disclose
(a) 18 years or older, (b) momentary pain intensity Numeric (write) on a regular basis about experiences and emotions either
Rating Scale (11-point NRS) score > 4, (c) having pain for related to chronic pain or to other situations. These emotions
at least three days per week, (d) for at least 6 months. could be either negative or positive, depending on specific
Exclusion criteria were partly based on the Hospital Anxiety weekly assignments. Additionally, each module started with some
and Depression Scale (HADS) (Zigmond and Snaith, 1983) and short psycho-education about emotions and emotion regulation.
Psychological Inflexibility in Pain scale (PIPS) (Wicksell et al., Participants were asked to invest 2 h or more per week, or
2010), and were (a) severe psychological distress (HADS > 24), 15 min per day on the course. In both ACT and EW, participants
(b) extremely low levels of psychological inflexibility (PIPS < 24), could keep an online diary. The average time-investment was
(c) current participation in another CBT-based treatment, (d) self-assessed at multiple times throughout the course. 48% and
having no internet or e-mail address, (e) reading problems due 47% of participants in ACT and EW respectively adhered to the
to insufficient Dutch language skills or illiteracy, and (f) an intervention, which meant they both completed the intervention
unwillingness or inability to invest approximately 30 min per day. and invested the advised amount of time interacting with the
The primary reason for exclusion prior to randomization was course [adherence is the extent to which individuals experience
severe psychological distress. the content of an intervention. This is different from drop-out,
Participants in this study followed either the ACT-condition which refers to the number of people who did not follow the
(n = 82) or were allocated to one of both control conditions, research protocol (i.e., did not fill in questionnaires; Kelders et al.,
being either Expressive Writing (EW) (n = 79) or Waiting List 2012)].
(WL) (n = 77). EW was included as a control condition to control
for general, non-specific effects (i.e., receiving attention from a Measures
counselor, working actively to reduce pain-related complaints). The primary outcome was measured at 3-month follow-up,
Small improvements in EW were expected as a large meta- 6 months after baseline assessment (T1). All other measures
analysis showed that EW has small effects on physical and functioned as possible moderators/predictors of change and were
mental health outcomes in chronic pain (Frattaroli, 2006). Those assessed at baseline, prior to randomization (T0).
allocated to ACT or EW followed a 9-week web-based self-help
program. WL-participants were not offered any intervention, Outcome
but were free to access any other form of treatment. These Pain interference in daily life
participants could follow the ACT-intervention 6 months from The Multidimensional Pain Inventory (MPI), subscale pain
baseline. interference consists of nine items and measures the degree to
which pain interferes with different life domains, such as work,
Intervention household work and social activities (Kerns et al., 1985). Higher
Each participant in ACT and EW received weekly minimal scores indicate more pain interference (range 0–54). Internal
guidance and support on a fixed day of the week by trained consistency in the present study was at baseline α = 0.87, at T1
clinical psychology students. In the ACT-condition, modules α = 0.89.
mainly consisted of text, metaphors and exercises based on
the six ACT-therapeutic processes (pain acceptance/experiential Moderator/Predictors
avoidance, cognitive defusion, self-as-context, present-moment Demographic variables
awareness, values and committed action) (Hayes et al., 2012). Demographic variables that were assessed as possible
Two extra modules were included that did not explore ACT- moderators/predictors were age, gender, educational level,
processes, but focused on psycho-education regarding chronic employment status, and duration of pain complaints.
pain (first module) and communicating about pain complaints Pain intensity
with one’s social context (eight’ module). Following the first
Pain intensity was measured with a 11-point Numeric Rating
module on psychoeducation, the next four modules primarily
Scale (NRS), ranging from ‘no pain’ (0) to ‘pain as bad as you
explored favorite ways to experiential avoid pain, and explored
can imagine’ (10). Item formulation and response categories were
acceptance of pain as an alternative strategy. Simultaneously,
consistent with IMMPACT recommendations on core outcome
participants explored their values and subsequent goals in
measures in chronic pain research (Dworkin et al., 2005).
different life domains. The following two modules mainly
explained and explored the two ACT-processes cognitive Pain disability
defusion and self-as-context, to learn to relate differently to The Pain Disability Index (PDI) (Pollard, 1984) consists of seven
oneself, one’s thinking states and one’s context. The final module items and assesses the degree to which chronic pain disables a

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Trompetter et al. Moderators Online ACT for Pain

person from performing daily activities, such as work, household moderators/predictors, dummy variables were created for
responsibilities and recreational activities. Total scores range gender (male = 1, female = 0), employment status (working
from 7 to 70, with higher scores indicating more pain disability. full/parttime = 1, other = 0), and duration of pain complaints
Internal consistency in the current study at baseline was α = 0.82. (>5 years = 1, <5 years = 0). Educational level was divided
into three groups (low, medium and high). During the analyses,
Psychological distress
each potential moderator/predictor was grand mean centered to
The HADS (Zigmond and Snaith, 1983) consists of 14 items. The
reduce possible scaling problems and multicollinearity (Aiken
scale measures the presence and severity of symptoms regarding
and West, 1991). In the regression models, the MPI-interference
anxiety (seven items) and depression (seven items). In this study
score at T1 was entered as the dependent variable. The dummy
the both subscales were used, with sum scores for each scale
variable representing Treatment (web-based ACT = 1, WL = 0
ranging from 0–21. Higher scores indicate more anxiety or
or EW = 0), the centered potential moderator/predictor, and the
depression. Internal consistency in the present study at baseline
Treatment by centered moderator/predictor interaction variable
was at α = 0.73 (anxiety) and α = 0.79 (depression).
were entered as independent variables. To control for baseline
Positive mental health variation in outcome scores, the MPI interference score at T0 was
The Mental Health Continuum-Short Form (MHC-SF) (Keyes, added as independent variable to the model in the same step as all
2002) consists of 14 items that measure three dimensions other independent variables. Analyses were performed separately
of positive mental health. Participants rate their frequency for ACT compared to EW, and ACT compared to WL.
of feelings over the past month. Dimensions are emotional In the presence of a significant interaction effect the variable in
wellbeing, pertaining to positive feelings, happiness and concern was interpreted as being a moderator of change. In case
satisfaction with life (three items) (score range 3–18); the interaction effect was not significant but the main effect for
psychological wellbeing, pertaining to aspects of positive the variable was, a variable was interpreted as being a predictor of
psychological functioning, such as autonomy, environmental change. Moderators are baseline characteristics that interact with
mastery and personal growth (six items) (score range 6–36); and treatment to affect outcome, meaning that patient improvement
social wellbeing, pertaining to feelings of positive functioning depends on the value on the moderator variable. When a variable
in community life (five items) (score range 5–30). The MHC is not a moderator, it is possibly a non-specific predictor of
items did not show differential item functioning in a sample change. Non-specific predictors do not interact with treatment
of individuals suffering from physical diseases compared to a but predict later scores on outcomes for all participants. Both
healthy subsample (Lamers et al., 2012b). The total scale and moderators and predictors of change should be measured prior
all subscales are analyzed separately in this study. In general, to treatment randomization (Turner et al., 2007; Pincus et al.,
higher scores indicate more wellbeing. Internal consistency in 2011). Overall, significance of the moderators and predictors was
the current study at baseline was α = 0.91 (total MHC), α = 0.85 interpreted at p < 0.05. Although the number of tests performed
(emotional wellbeing), α = 0.82 (psychological wellbeing) and could call for a restriction on the borderline p-value, the p-value
α = 0.73 (social wellbeing). was not adjusted as such given the exploratory nature of this
study. In case of significant interactions, simple slopes for mean,
Statistical Analyses −1 and +1 standard deviation moderator values as calculated in
There were no missing data at T0. Missing data at T1 PROCESS were interpreted, as were outcomes of the Johnson-
(29.8%) were imputed using the Expectation Maximization (EM) Neyman technique (Johnson and Fay, 1950; Hayes, 2013). This
Algorithm (Dempster et al., 1977). Prior to main analyses, latter method derives a zone of significance, thereby identifying
independent sample t-tests and χ2 -tests were applied to exact cut-off values of the moderator for which web-based ACT
determine if there were significant differences in all potential was (not) more effective compared to control conditions.
moderator/predictor variables at T0 between ACT and both
control conditions.
In performing exploratory analyses, we followed steps RESULTS
taken by Turner et al. (2007) in a well-regarded study on
moderators and predictors of change during CBT for chronic Outcomes of independent sample t-tests and χ2 -tests revealed
pain (Morley and Keefe, 2007). Pain interference in daily life there were no significant differences at T0 between ACT and both
at 3-month follow-up, as measured with the MPI interference control conditions on all included potential moderator/predictor
subscale, was used as indicator of treatment effect. To variables, although the difference between ACT and WL in the
determine if selected moderator/predictor variables functioned percentage of people working full/part-time reached marginal
as moderators or predictors of change in MPI interference, significance, with ACT participants working full/part-time more
linear regression models were applied using the PROCESS macro often than WL participants [χ2 (1) = 3.439, p = 0.064].
for SPSS (Hayes, 2013). All tests were two-tailed. Thirteen A large proportion of participants were highly educated
moderator/predictor variables were assessed, including age, (44.1%), female (76.0%) pain sufferers with an average age of
gender, educational level, employment status, pain duration, pain 52.80 years (SD = 12.37). More than half of the participants
intensity (NRS), pain disability (PDI), pain interference (MPI suffered from pain complaints for more than 5 years (63.0%), and
subscale), depression (HADS), anxiety (HADS), and emotional, almost all participants (93%) reported pain on a daily basis. Most
psychological and social well-being (MHC). For demographic prevalent diagnoses were fibromyalgia (20.2%), back complaints

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Trompetter et al. Moderators Online ACT for Pain

TABLE 1 | Baseline characteristics of participants in ACT and both control wellbeing cut-off score for reaching significant effects of ACT
conditions.
compared to WL was 23.57. ACT was more effective in changing
ACT (n = 82) EW (n = 79) WL (n = 77) the primary outcome MPI interference than WL for those in
the highest 51% of MHC scores. Compared to control condition
Demographic characteristics
EW, the MHC Psychological Wellbeing cut-off score for reaching
Mean age, years (SD) 52.9 (13.3) 52.3 (11.8) 53.2 (12.0)
significant effects of ACT was 16.97. ACT was more effective
Female gender (%) 76.8 75.9 75.3
in changing MPI interference than EW for those in the highest
Education (%)
88.2% of MHC scores.
Low 19.5 19.0 22.1
None of the measures representing the physical domain, being
Intermediate 35.4 36.7 35.0
pain intensity, PDI and MPI interference, showed significant
High 45.1 44.3 42.9
interaction effects compared to WL. However, a significant
Working full-/part-time (%) 42.7 48.1 28.6
moderation effect existed for ACT compared to EW alone on
Pain duration >5 years (%) 58.5 69.6 61.0
pain intensity (NRS) (b = −2.018, p = 0.003). An inspection
Diagnosis
of the output of the Johnson-Neyman technique indicated that
None 14.6 17.7 19.5
ACT was more effective than EW for those individuals having
Back complaints 9.8 13.9 14.3
the highest 85.1% scores on pain intensity (NRS) at baseline. The
Fibromyalgia 15.9 29.1 15.6
corresponding cut-off score was 4.61.
Joint complaints 8.5 7.6 9.1
Rheumatic disease 9.8 7.6 11.7
Neuropathic complaints 11.0 6.3 9.1
Predictors of Change in MPI Interference
Other 30.5 20.8 20.7
Outcomes regarding non-specific predictor analyses can be found
Physical domain measures
in Table 3. As was the case for moderator analyses, none of
Mean MPI Interference (SD) 32.3 (9.8) 32.2 (9.8) 33.3 (9.8)
the demographic characteristics were significantly associated
Mean Pain intensity (SD) 6.3 (1.8) 6.1 (1.6) 6.2 (1.6)
with MPI interference at 3-month follow-up, and neither
Mean Pain Disability (SD) 36.0 (12.7) 36.4 (12.0) 36.1 (12.7)
were baseline PDI and pain intensity. T0 measures that were
Psychosocial domain measures
significantly associated with MPI interference 6 months later
Mean HADS depression (SD) 6.1 (3.5) 6.5 (3.5) 6.1 (3.2)
were similar for both sets of analyses (ACT compared to EW
Mean HADS anxiety (SD) 7.2 (3.1) 7.5 (3.2) 6.9 (3.4)
and ACT compared to WL). Significant predictors were MPI
Mean MHC emotional (SD) 12.4 (3.1) 12.1 (2.9) 11.1 (3.2) interference (vs. EW: b = 0.732, p < 0.001, vs. WL: b = 0.760,
Mean MHC psychological (SD) 23.9 (5.7) 23.9 (5.8) 22.8 (6.4) p < 0.001), HADS depression (vs. EW: b = 0.632, p < 0.001, vs.
Mean MHC social (SD) 16.2 (4.9) 16.2 (5.1) 16.0 (4.6) WL: b = 0.628, p < 0.001), HADS anxiety (vs. EW: b = 0.806,
p < 0.001, vs. WL: b = 0.529, p = 0.013) and MHC Emotional
ACT, Acceptance and Commitment Therapy; EW, Expressive Writing; WL, Waiting
List; MPI, Multidimensional Pain Inventory; HADS, Hospital Anxiety and Depression
wellbeing (vs. EW: b = −0.554, p = 0.007, vs. WL: b = −0.627,
Scale; PDI, Pain Disability Index; MHC, Mental Health Continuum. p = 0.001).

(12.7%), rheumatic diseases (9.7%), neuropathic complaints

(8.8%), and other joint complaints (8.4%). An overview of
DISCUSSION
demographic characteristics and baseline scores on all measures The present study explored moderators and predictors of
can be found in Table 1. treatment change during a previously evaluated RCT on the
efficacy of a guided, self-help web-based program based on ACT
Moderators of Changes in MPI in chronic pain patients (Trompetter et al., 2014). Compared
Interference to both control conditions neither demographic nor physical
Outcomes of interaction tests for all 13 potential moderators domain factors prospectively predicted or moderated pain
can be found in Table 2. No significant interaction effects on interference in daily life after 6 months. Despite variable findings
MPI interference at 3-month follow-up were present for any in individual studies, this is in line with knowledge on predictors
of the demographic variables. Of the remaining measures, the of face-to-face CBT treatment effects (McCracken and Turk,
only interaction effect that reached significance compared to 2002). Importantly, the only existing moderator compared to
both control conditions was MHC Psychological wellbeing (vs. both control conditions was psychological wellbeing as a central
EW: b = −0.424, p = 0.035; vs. WL: b = −0.419, p = 0.022). aspect of positive mental health and optimal human functioning
A visual representation of the outcomes of simple slope analyses (Keyes, 2002).
for mean scores, and scores one standard deviation below Emotional and psychological wellbeing are highly relevant
and above the mean value, are displayed in Figure 1. Web- factors that function independent from vulnerabilities and
based ACT was no more effective than WL in changing MPI distress in predicting mental and physical illness (Ruini et al.,
interference for those scoring one standard deviation below mean 2003; Steptoe et al., 2009; Boehm and Kubzansky, 2012; Lamers
(effect MPI interference T1 ACT vs. WL = 0.323, p = 0.837). et al., 2012a). This study suggests that psychological wellbeing
More specifically, an interpretation of the output of the is also relevant for allocation of treatment. Self-managing
Johnson-Neyman technique showed that the MHC Psychological a challenging intervention that requires the transformation

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Trompetter et al. Moderators Online ACT for Pain

TABLE 2 | Interaction effect outcomes of linear regression models to assess possible moderators of change in MPI interference.

ACT vs. EW ACT vs. WL

b 95% CI p-value b 95% CI p-value

Demographic characteristics
Age −0.152 −0.37; 0.07 0.172 0.804 −4.56; 6.18 0.768
Gender −2.422 −9.10; 4.25 0.475 −0.003 −0.18; 0.18 0.978
Educational level 2.19 −1.39; 5.77 0.228 −0.110 −3.07; 2.85 0.941
Employment status 3.018 −2.00; 8.04 0.237 −2.788 −7.59; 2.02 0.253
Pain duration 0.878 −3.85; 6.61 0.763 2.289 −2.35; 6.93 0.332
Physical domain measures
Pain intensity −2.018 −3.36; −0.68 0.003 −0.371 −1.74; 1.00 0.594
Pain disability (PDI) −0.179 −0.37; 0.02 0.073 −0.161 −0.34; 0.01 0.071
Pain interference (MPI) −0.077 −0.37; 0.22 0.606 −0.135 −0.37; 0.10 0.251
Psychosocial domain measures
Depression (HADS) 0.263 −0.40; 0.92 0.431 0.169 −0.46; 0.80 0.599
Anxiety (HADS) 0.254 −0.51; 1.01 0.510 0.732 −0.04; 1.50 0.063
Emotional wellbeing (MHC) −0.712 −1.50; 0.07 0.074 −0.525 −1.22; 0.17 0.138
Psychological wellbeing (MHC) −0.424 −0.82;-0.03 0.035 −0.419 −0.78; −0.06 0.022
Social wellbeing (MHC) −0.460 −0.99; 0.07 0.128 −0.451 −0.95; 0.05 0.078

95% CI, 95% confidence interval.

FIGURE 1 | Pain interference outcome scores at different baseline values of moderator MHC Psychological Wellbeing for ACT compared to both
control conditions.

of cognitive-behavioral patterns that narrowed effective living functioning at baseline. A primary task for future web-based
for a prolonged period of time, could simply be too much trials is to examine if aspects of resilience and psychological
for individuals lacking psychological resources. This process wellbeing recurrently function as moderators of treatment
could evolve, for example, through a lack of feelings of change for pain and other physical and mental health
environmental mastery, personal growth and positive social problems.
relations. Among other things, these processes relate to The design of psychosocial interventions that aim at
the feeling that oneself is able to develop new attitudes enhancing resilience and psychological wellbeing provides
and behaviors, a sense of control over the external world, interesting and perhaps necessary treatment opportunities for
and the feeling that one is supported by significant others chronic pain and illness. Wellbeing Therapy (WBT) is a
(Ryff, 1989, 2014; Fava and Tomba, 2009). Practically, these primary example of an effective, positive intervention designed
results indicate that web-based ACT should perhaps not be explicitly to complement CBT that improves psychological
allocated to those experiencing low positive psychological wellbeing and prevents relapse for depression and anxiety

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Trompetter et al. Moderators Online ACT for Pain

TABLE 3 | Main effect outcomes of linear regression models to assess possible predictors of change in MPI interference.

ACT vs. EW ACT vs. WL

b 95% CI p-value b 95% CI p-value

Demographic characteristics
Age 0.012 −0.10; 0.12 0.830 −0.061 −0.15; 0.03 0.183
Gender 2.997 −0.34; 6.33 0.078 1.412 −1.27; 4.11 0.299
Educational level −1.054 −2.85; 0.74 0.247 0.084 −1.40; 1.56 0.911
Employment status −0.928 −3.53; 1.67 0.482 2.006 −0.383; 4.39 0.099
Pain duration 0.369 −2.45; 3.19 0.796 −0.332 −2.65; 1.99 0.778
Physical domain measures
Pain intensity 0.344 −0.44; 1.13 0.388 −0.570 −1.30; 0.15 0.118
Pain disability (PDI) 0.009 −0.20; 0.22 0.931 −0.054 −0.18; 0.08 0.420
Pain interference (MPI) 0.732 0.59; 0.88 < 0.001 0.760 0.64; 0.88 < 0.001
Psychosocial domain measures
Depression (HADS) 0.632 0.22; 1.04 0.003 0.628 0.27; 0.99 0.001
Anxiety (HADS) 0.806 0.37; 1.25 < 0.001 0.529 0.11; 0.95 0.013
Emotional wellbeing (MHC) −0.554 −0.96; 0.15 0.007 −0.627 −0.99; −0.26 0.001
Psychological wellbeing (MHC) −0.384 −0.59; −0.18 < 0.001 −0.377 −0.57; −0.19 < 0.001
Social wellbeing (MHC) −0.205 −0.47; 0.06 0.128 −0.197 −0.44; 0.05 0.117

95% CI, 95% confidence interval.

disorders (Fava et al., 1998, 2004, 2005). Such an increase application of persuasive technology in developing web-based
of psychological wellbeing to be able to bounce back from interventions offers interesting future venues for the future
highly frequent and intense moments of distress can be (Kelders et al., 2012).
highly relevant for those suffering from chronic pain and An important limitation to this study is that the RCT
illness. We suggest future study explores the efficacy of the protocol of this study was not powered a priori for the
parallel application of resilience-based treatments such as WBT application of moderator analyses. Therefore, analyses were
in addition to standard psychosocial treatments aimed at post-hoc and exploratory, and should be interpreted accordingly.
reducing pain-related complaints. The increase of effective It might be that the number of participants available to
adaptation and normal functioning in the face of chronic perform moderator analyses was not sufficient to indicate
pain might help to overcome the modest effects of current other potential relevant moderators of change in addition the
chronic pain treatment (Turk et al., 2011; Eccleston et al., moderators we identified. Nevertheless, our study pertains to
2013). methodological requirements of exploratory moderators studies
Two other findings deserve exploration. First, a further (Turner et al., 2007; Pincus et al., 2011), and highlighted
interpretation of moderator findings indicates that EW might several interesting outcomes. Another limitation is that we
not work so well when high in pain intensity. This explains produced specific cut-off scores to exemplify for whom self-
outcomes from a range of studies indicating that EW has help ACT seems specifically (in)effective. This is the first
mixed and at best, modest, benefits for people suffering from efficacy trial to produce cut-off scores, which are therefore not
chronic pain (e.g., Lumley et al., 2013), while it seems more readily transferable to clinical practice. However, we believe
effective for mild and major depression (e.g., Gortner et al., that the production of our cut-off scores is one step forward
2006). Emotional disclosure can be an unsettling experience to translating scientific output into useful applications for
that can instigate more pain and negative mood in those practice.
suffering from chronic pain. Although not the primary target Overall, this study was the first to assess moderators
of our study, these findings can possible fuel further study and predictors of change during web-based psychosocial
on EW in chronic pain. Additionally, several non-specific treatment for chronic pain. This resulted in relevant
predictor of change were identified. Higher baseline levels insights on the future allocation to pain sufferers of
of depression, anxiety and pain interference in daily life, the ‘Living with Pain’ program in specific, and other
and lower levels of emotional wellbeing, were prospectively web-based psychosocial interventions for pain and the
and generically related to higher levels of pain interference. broader range of physical and mental health disorders in
Practically, this knowledge can be used to further explore general. Illuminating theoretical insights were gathered
if specific tailoring of web-based ACT and other web-based regarding ACT theory (Hayes et al., 2012) and findings
interventions toward these characteristics is helpful. Applying revealed that, broadly, moderators of change for web-
more intensive therapist guidance and monitoring for specific based ACT treatment seem to follow similar patterns as
individuals are examples of tailoring opportunities. Also, the in face-to-face CBT. We hope that future studies use these

Frontiers in Psychology | www.frontiersin.org 7 March 2016 | Volume 7 | Article 353

Trompetter et al. Moderators Online ACT for Pain

outcomes as a springboard for further study. Of all topics writing. SL contributed to data interpretation and writing of
discussed, a focus on psychological wellbeing and resilience the manuscript. KS was responsible for conception of the study,
seem most promising to further increase effective and supervised acquisition and analysis of data, and contributed to
efficient intervention for chronic pain and illness in the data interpretation and writing of the manuscript. All authors
future. contributed to critical revisions of the manuscript and approved
the final version of the manuscript.

AUTHOR CONTRIBUTIONS
FUNDING
HT designed the study, performed acquisition, analysis and
interpretation of the data, and drafted the manuscript. EB was Funding for the original study was provided by the Innovation
involved in the conception of the study, data interpretation and Fund Health Insurers (Innovatiefonds Zorgverzekeraars).

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