Randomized controlled trial of an Acceptance and Commitment Therapy and compassion-based group intervention for persons with inflammatory bowel disease: the LIFEwithIBD intervention.

Objectives: This study tested the acceptability and efficacy of an Acceptance and Commitment Therapy and compassion-based intervention (LIFEwithIBD) in people with IBD through a two-arm RCT. Methods: Participants were recruited at the Gastroenterology Department of the Coimbra University Hospital between June and September 2019. Of the 355 patients screened, those who accepted to participate were randomly assigned to one of two conditions: experimental group (LIFEwithIBD; n = 25) or control group (waitlist; n = 29). Participants completed self-report measures at baseline (T0), post-intervention (T1), and 3-month (T2) and 12-month (T3) follow-ups. Intervention acceptability was assessed. Efficacy was examined using intent-to-treat ANCOVA at post-intervention after adjusting for baseline values of depressive, anxiety, and stress symptoms (primary outcomes). Linear mixed models for all longitudinal outcomes were also analysed. Inflammatory and disease biomarkers were determined at T0 and T3. Results: Acceptability results revealed a high level of satisfaction and perceived usefulness regarding the intervention. Both groups experienced a significant decrease in stress symptoms and IBD symptom perception at T1. No significant differences were observed at follow-up for the primary outcomes. The experimental group reported significantly lower Crohn's disease Symptom severity at T2 than the control group. Post-hoc analyses designed to mitigate floor effects revealed substantial treatment effects for the experimental group regarding anxiety symptoms. No significant differences were observed in clinical biomarkers from T0 to T3. Conclusion: The LIFEwithIBD intervention shows promising, although preliminary, benefits for managing disease activity and reducing anxiety symptoms in IBD patients with high severity of psychological distress.Clinical trial registration: https://www.clinicaltrials.gov/ct2/show/NCT03840707, identifier NCT03840707.

Corrigendum: Efficacy of an ACT and compassion-based ehealth program for self-management of chronic pain (iACTwithPain): study protocol for a randomized controlled trial.

[This corrects the article DOI: 10.3389/fpsyg.2021.630766.].

Usability Study of the iACTwithPain Platform: An Online Acceptance and Commitment Therapy and Compassion-Based Intervention for Chronic Pain.

Background: This pilot study aims to test the usability of the iACTwithPain platform, an online ACT-based intervention for people with chronic pain, to obtain information on which intervention and usability aspects need improvement and on expected retention rates. Methods: Seventy-three Portuguese women with chronic pain were invited to complete the first three sessions of the iACTwithPain intervention assess their quality, usefulness and the platform's usability. Twenty-one accepted the invitation. Additionally, eight healthcare professionals working with chronic medical conditions assessed the platform and the intervention from a practitioner's point of view. Results: This study presented a considerable attrition rate (71.43%) among chronic pain participants, with six completers. There were no significant differences in demographic or clinical variables between dropouts and completers except for completed education (participants who dropped out presented less education than completers). Reasons for dropout were related to difficult personal events occurring during the time of the intervention, lack of time, or having forgotten. There seemed to be an overall satisfaction with both the intervention, its contents and form of presentation of information, and the platform, concerning its design, appearance, and usability. Real image videos were preferred over animations or audio by chronic pain participants. Healthcare professionals emphasized the appealing and dynamic aspects of the animation format. Conclusion: This study informs the ongoing improvement of the iACTwithPain platform and provides valuable information on aspects researchers should consider while developing online psychological interventions for chronic pain. Further implications are discussed.

Beyond the Centrality of Shame: How Self-Concealment and Fear of Receiving Compassion From Others Impact Psychological Suffering in Transgender Adults.

Shame-based social interactions are a minority social stressor commonly experienced by transgender individuals. However, few studies have explored the centrality of shame experiences in transgender identity and mental health. Also, the ability to receive care and soothing support may be influenced by intrapersonal shame- and fear-related factors, which may hinder openness, and support and care seeking, thus contributing to psychological distress. This study aims to examine the relationship between central shame experiences, fear of receiving compassion from others, self-concealment, and psychological distress (depression, anxiety, and stress symptoms) in a sample of Portuguese transgender adults. Following a cross-sectional design, data from a convenience sample of 70 self-identified transgender individuals undergoing gender-affirming medical interventions (GAMIs) were analyzed, using SPSS PROCESS, to determine whether the relationship between central shame experiences and psychological suffering occurred indirectly through fear of receiving compassion from others, and self-concealment. Results suggest that fear of receiving compassion from others, but not self-concealment, was the underlying factor between central shame experiences, and depression and anxiety. Results suggest that the centrality of shame experiences and stress symptomatology associate sequentially through fear of compassion and, in turn, through self-concealment. Clinical implications for mental health interventions with transgender individuals undergoing GAMI are discussed.

Corrigendum: The LIFEwithIBD Intervention: Study Protocol for a Randomized Controlled Trial of a Face-to-Face Acceptance and Commitment Therapy and Compassion-Based Intervention Tailored to People With Inflammatory Bowel Disease.

[This corrects the article DOI: 10.3389/fpsyt.2021.699367.].

Water stress signaling and hydraulic traits in three congeneric citrus species under water deficit.

Morpho-physiological strategies to deal with water deficit vary among citrus species and the chemical signaling through ABA and anatomical, hydraulic, and physiological traits were evaluated in saplings of Rangpur lime, Swingle citrumelo and Valencia sweet orange. Trunk and roots of Swingle citrumelo presented lower vessel diameter and higher vessel frequency as compared to the other species. However, relative water content at the turgor loss point (RWCTLP), the osmotic potential at full turgor (Ψ0), the osmotic potential at the turgor loss point (ΨTLP), bulk modulus of elasticity (ε) and the xylem water potential when hydraulic conductivity is reduced by 50% (Ψ50) and 88% (Ψ88) indicated similar hydraulic traits among citrus species, with Rangpur lime showing the highest hydraulic safety margin. Roots of Rangpur lime and Swingle citrumelo were more water conductive than ones of Valencia sweet orange, which was linked to higher stomatal conductance. Chemical signaling through ABA prevented shoot dehydration in Rangpur lime under water deficit, with this species showing a more conservative stomatal behavior, sensing, and responding rapidly to low soil moisture. Taken together, our results suggest that Rangpur lime - the drought tolerant species - has an improved control of leaf water status due to chemical signaling and effective stomatal regulation for reducing water loss as well as decreased root hydraulic conductivity for saving water resources under limiting conditions.

Corrigendum: The LIFEwithIBD Intervention: Study Protocol for a Randomized Controlled Trial of a Face-to-Face Acceptance and Commitment Therapy and Compassion-Based Intervention Tailored to People With Inflammatory Bowel Disease.

[This corrects the article DOI: 10.3389/fpsyt.2021.699367.].

Self-Compassion and Mental Health in Sexual and Gender Minority People: A Systematic Review and Meta-Analysis.

Purpose: Literature shows that sexual and gender minority (SGM) individuals are at higher risk of developing minority stress-related mental health problems. Recently, it has been suggested that promoting self-compassion through affirmative mental health care for SGM people can be beneficial. However, no systematic analysis has been published exploring the relationship between self-compassion and mental health indicators in SGM individuals. We aim to fill this gap by synthesizing and meta-analyzing studies that focus on the relationship between self-compassion and mental health in SGM people. Methods: After registering in PROSPERO (CRD42021254774), PubMed, PsycINFO, CENTRAL, and Web of Knowledge were systematically searched to identify studies assessing the association between self-compassion and mental health and/or minority stress indicators in SGM individuals. All screening steps and data extraction were performed independently by the two researchers. The quality of each study was assessed with the National Heart, Lung and Blood Institute tool, and meta-analysis was performed on R software. Results: Twenty-one studies were included in the meta-analysis, corresponding to a total of 6573 nonheterosexual and/or noncisgender participants. All meta-analytic models were significant: higher levels of self-compassion were associated with less depression, anxiety, psychological distress, suicidal ideation, internalized homophobia/transphobia, and stigma, and with more well-being, outness, and social support. Conclusion: This meta-analysis suggests that self-compassion is significantly associated with mental health indicators in SGM people, and this relationship is especially strong with internalized homophobia/transphobia in older SGM adults, and with suicidal ideation in younger SGM individuals. Results suggest that affirmative mental health care may benefit from promoting self-compassion.

A pilot randomized controlled trial of online acceptance and commitment therapy versus compassion-focused therapy for chronic illness.

Literature suggests that acceptance and commitment therapy (ACT) is effective in improving well-being and in reducing psychopathological symptoms commonly experienced by people with chronic illness (CI). Compassion-focused therapy (CFT) reduces psychological distress, especially in individuals with high levels of shame and self-criticism, but few studies have explored CFT in CI. Additionally, studies almost exclusively compared ACT and CFT with inactive controls (wait-list; treatment as usual). Also, there is an interest in developing cost-effective mental health solutions, such as low-intensity online psychological interventions. This randomized controlled trial (RCT) aimed to assess the acceptability and compare the efficacy of four-session online ACT (n = 25) and CFT (n = 24) interventions in a sample of people with CI. Results showed both interventions were acceptable, with attrition rates at post-intervention comparable to those found in similar studies (around 50%). Intention-to-treat analyses showed that participants presented significantly less illness-related shame, less uncompassionate self-responding and more valued living after the intervention, although no difference was found between conditions. Results were sustained at 3- and 6-month follow-up. Results did not find statistical differences between conditions through reliable change index (RCI). Correlation between demographics and RCI showed that, at post-intervention, younger participants presented more behavioural awareness, men presented more valued action, and participants with CI for shorter periods presented less uncompassionate self-responding and less anxiety. Results suggest that low-intensity (four sessions) online ACT and CFT are cost-effective approaches to promote mental health of individuals with CI. Results and limitations are thoroughly discussed.

Self-compassion in Acceptance and Commitment Therapy for chronic pain: a pilot study.

OBJECTIVES: Evidence shows that Acceptance and Commitment Therapy (ACT) is an empirically supported psychological approach for chronic pain (CP) management. Although self-compassion is not explicitly a target of ACT, it seems to be one mechanism of change in ACT for CP. However, research is lacking on the benefits of including explicit self-compassionate exercises in ACT for CP. The current study pilot tested a Compassionate ACT 8-session group program (COMP.ACT; n=9), as well as an ACT-only 8-session group program (ACT; n=7), in a sample of women with CP. METHODS: The current study follows a quasi-experimental design, and conducts Reliable and Significant Change analyses comparing pre- to post-intervention scores of self-report measures. RESULTS: No differences were found between conditions at baseline, nor between completers and drop-outs. Although preliminary, results showed COMP.ACT led to greater clinical improvements in depression and anxiety, while ACT led to greater improvements in stress and uncompassionate self-responding. Reliable and Significant Change analysis showed that some participants improved significantly (in psychopathological symptoms, valued living and uncompassionate self-responding) in both conditions, while the majority did not change significantly. CONCLUSIONS: More research is needed to conclude whether explicit self-compassion exercises are useful in ACT for CP. Limitations and implications are further discussed.

The COVID-19 Pandemic Strain: Teleworking and Health Behavior Changes in the Portuguese Context.

The COVID-19 pandemic has forced a societal essay, based on thorough measures of individual and communitarian protection, ranging from compulsory social distancing to quarantine. Following WHO recommendations, more or less strict policies were adopted by governments worldwide in order to mitigate public health risks. In Portugal, the first state of emergency was declared on 18 March 2020 and renewed until 2 May 2020. During this time, most citizens stayed in quarantine with practical implications regarding their work and daily activities. This exploratory study, conducted within the pandemic crisis context in Portugal, intends to grasp specificities of the adaptation to the lock down and social isolation/distancing measures, concerning, specifically, teleworking conditions and physical activity practice. Data was collected from March to May 2020 through an online survey from 1148 participants of different age groups and literacy. Considering that COVID-19 features a mutual feedback loop of disease and social dynamics-governmental measures, civic adjustments, and individual coping-to know more about what was featured, the first wave may provide some cues to ensure a more efficient co-operation among social actors and, ultimately, tailor better public policies towards teleworking, online distance learning, and the promotion of healthy behaviours.

The LIFEwithIBD Intervention: Study Protocol for a Randomized Controlled Trial of a Face-to-Face Acceptance and Commitment Therapy and Compassion-Based Intervention Tailored to People With Inflammatory Bowel Disease.

Background: There is ample evidence of the high mental health burden caused by Inflammatory Bowel Disease (IBD). Several constructs such as experiential avoidance, cognitive fusion, shame, and self-criticism have recently emerged as potential intervention targets to improve mental health in IBD. Psychotherapeutic models such as Acceptance and Commitment Therapy and compassion-based interventions are known to target these constructs. In this protocol, we aim to describe a two-arm Randomized Controlled Trial (RCT) testing the efficacy of an ACT and compassion-focused intervention named Living with Intention, Fullness, and Engagement with Inflammatory Bowel Disease (LIFEwithIBD) intervention + Treatment As Usual (TAU) vs. TAU in improving psychological distress, quality of life, work and social functioning, IBD symptom perception, illness-related shame, psychological flexibility, self-compassion, disease activity, inflammation biomarkers, and gut microbiota diversity. Methods: This trial is registered at ClinicalTrials.gov (Identifier: NCT03840707, date assigned 13/02/2019). The LIFEwithIBD intervention is an adaptation to the IBD population of the Mind programme for people with cancer, an acceptance, mindfulness, and compassion-based intervention designed to be delivered in a group format. The LIFEwithIBD intervention's structure and topics are presented in this protocol. Participants were recruited at the Gastroenterology Service of the Coimbra University Hospital between June and September 2019. Of the 355 patients screened, 61 participants were selected, randomly assigned to one of two conditions [experimental group (LIFEwithIBD + TAU) or control group (TAU)] and completed the baseline assessment. Outcome measurement took place at baseline, post-intervention, 3- and 12-month follow-ups. Discussion: Results from this RCT will support future studies testing the LIFEwithIBD intervention or other acceptance and/or compassion-based interventions for IBD.

A Systematic Review of Self-Compassion in Chronic Pain: From Correlation to Efficacy.

Chronic pain (CP) is a common condition affecting millions of people worldwide. Compassion-related interventions are proving to be advantageous in CP, and self-compassion (SC) is hypothesized to be related with pain regulation physiological processes, as well as with psychological benefits in CP. We aimed to review scientific literature on: 1) Compassion-based psychological interventions and their changes in pain outcomes; and 2) associations between SC and pain-related outcomes. We performed a systematic research in four electronic databases: MEDLINE, EMBASE, PsycINFO and the Cochrane Library from inception until April 2020. In Question 1, we included studies involving adult patients with CP who participated in compassion-based psychological interventions. In Question 2, we included studies that examined the associations between SC and pain outcomes in adults with CP. We identified 16 studies. For Question 1, we included seven studies focused on different compassion-based interventions that assessed at least one pain outcome, in a total of 253 participants with CP associated with multiple conditions. For Question 2, we included nine studies, in a total of 1,430 participants, with eight different pain outcomes: Intensity, acceptance, catastrophizing, self-efficacy, disability, distress, pain related coping and anxiety. Considering the high heterogeneity between studies and the poor-quality assessment, we could not draw definitive conclusions on the efficacy of compassion-based interventions nor on the association between SC and pain outcomes. Studies are further discussed in detail. This review can be a starting point for large-scale and high-quality trials in this area as it provides an organized overview of the current literature on this topic.

Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis.

Acceptance and Commitment Therapy (ACT) has been widely tested for chronic pain, with demonstrated efficacy. Nevertheless, although there is meta-analytical evidence on the efficacy of face-to-face ACT, no reviews have been performed on online ACT in this population. The aim of this meta-analysis is to determine the efficacy of online ACT for adults with chronic pain, when compared with controls. PubMed, PsycINFO, CENTRAL, and Web of Knowledge were searched for randomized controlled trials (RCTs) of online-delivered ACT for chronic pain. Effects were analyzed at post-treatment and follow-up, by calculating standardized mean differences. Online-delivered ACT was generally favored over controls (5 RCTs, N = 746). At post-treatment, medium effects for pain interference and pain acceptance, and small effects for depression, mindfulness, and psychological flexibility were found. A medium effect for pain interference and acceptance, and small effects for pain intensity, depression, anxiety, mindfulness, and psychological flexibility were found at follow-up. ACT-related effects for pain interference, pain intensity, mindfulness, and anxiety increased from post-treatment to follow-up. Nevertheless, the current findings also highlight the need for more methodologically robust RCTs. Future trials should compare online ACT with active treatments, and use measurement methods with low bias. PERSPECTIVE: This is the first meta-analytical review on the efficacy of online ACT for people with chronic pain. It comprises 5 RCTs that compared online ACT with active and/or inactive controls. Online ACT was more efficacious than controls regarding pain interference, pain intensity, depression, anxiety, mindfulness, and psychological flexibility.

Efficacy of an ACT and Compassion-Based eHealth Program for Self-Management of Chronic Pain (iACTwithPain): Study Protocol for a Randomized Controlled Trial.

BACKGROUND: Chronic pain (CP) has serious medical and social consequences and leads to economic burden that threatens the sustainability of healthcare services. Thus, optimized management of pain tools to support CP patients in adjusting to their condition and improving their quality of life is timely. Although acceptance and commitment therapy (ACT) is considered an evidence-based psychological approach for CP, evidence for the efficacy of online-delivered ACT for CP is still scarce. At the same time, studies suggest that self-compassion mediates the change in disability and psychopathological symptoms in ACT interventions for CP, although self-compassion is not a specific target in ACT. Thus, an explicit focus on self-compassion might increase the efficacy of ACT interventions for CP, although this hypothesis has not been tested. This study aims to develop an eHealth ACT and compassion-based self-management intervention for CP, the iACTwithPain, and to compare its efficacy in improving health outcomes to a similar ACT-only intervention and a medical TAU group. METHODS: The eHealth platform that will host the interventions will be developed using a flat design identity and will be interactive. The iACTwithPain intervention will comprise eight weekly self-management sessions and will be developed taking into consideration the psychological flexibility model applied to CP, with the addition of explicit compassion-based components. To analyze whether the iACTwithPain intervention will present superiority in improving CP's impact and related health markers over the two other conditions, this study will follow an RCT design with three arms. CP patients will be recruited through direct contact with patient associations and healthcare services and a national press release in Portugal. Outcome measurement will be conducted at baseline, post-intervention and at 3- and 6-month follow-ups. The interventions' acceptability will also be assessed. DISCUSSION: The iACTwithPain intervention is expected to improve CP patients' psychosocial functioning, quality of life, and empowerment, by promoting adaptive disease management and regulation of pain-related internal experiences. Results will contribute to a better understanding on the pertinence of adding compassion elements to ACT for CP and to reach an optimized intervention for CP. CLINICAL TRIAL REGISTRATION: This trial has been registered at ClinicalTrials.Gov (NCT04200183; 16 December 2019; https://clinicaltrials.gov/ct2/show/NCT04200183). The current manuscript comprises the first version of this clinical trial's protocol.

Above and beyond emotional suffering: the unique contribution of compassionate and uncompassionate self-responding in chronic pain.

Objectives Studies have shown that self-compassion plays a protective role against depression in women with chronic pain (CP). However, the majority of studies in CP have used the total score of the self-compassion scale (SCS), which have raised concerns due to potential overlap, not only between the uncompassionate self-responding factors and psychopathology, but also between self-compassion as a whole and other well-known psychological processes (e.g., mindfulness, acceptance, psychological flexibility). This calls for a more nuanced understanding of which components of (un)compassionate self-responding adds to better mental health in CP. Methods This study explores the unique contribution of compassionate and uncompassionate self-responding to depressive symptoms in women with CP undergoing pain consultation (n = 49). Results Correlation analyses suggest that compassionate self-responding only significantly correlates with progress in valued living, while the uncompassionate self-responding significantly correlates with pain fusion, pain avoidance, obstructions to valued living and depression. Multiple regression analysis showed that self-compassion contributes to depressive symptoms (R2 = 8%) above and beyond pain intensity and disability (R2 = 12%) and psychological (in) flexibility processes (R2 = 31%), and uncompassionate (but not compassionate) self-responding uniquely contributes to depressive symptoms (sr 2  = 18%). Conclusions Findings suggest that uncompassionate self-responding is a stronger contributor to depression in CP than compassionate self-responding. Clinical implications are further discussed.

Cognitive fusion and depressive symptoms in women with chronic pain: A longitudinal growth curve modelling study over 12 months.

This study aims to (a) explore individual differences in women with chronic pain (CP) in regard to pain intensity, functional impairment, cognitive fusion, and depressive symptoms and (b) longitudinally test whether cognitive fusion is a significant predictor of depression symptoms, while controlling for pain intensity and functional impairment, over a 12-month period. This study follows a longitudinal design and was conducted in a sample of 86 women with CP who responded to an online battery of questionnaires in three equally spaced assessment moments. In order to explore the growth trajectory of variables of interest, latent growth curve models were examined. Also, correlation analyses were conducted between demographic and illness-related variables and depressive symptoms, as well as between all variables in all assessment moments. Cognitive fusion and functional impairment (but not pain intensity) were significantly associated with baseline levels of depressive symptoms. Cognitive fusion significantly predicted the growth trajectory of depressive symptoms, whereas pain intensity and functional impairment did not. No demographic (age, marital status, education, socio-economic) nor illness-related variables (number of CP diagnoses, duration of CP, taking medication) were associated with depressive symptoms at any point. These results suggest that the trajectory of depressive symptoms in women with CP is not predicted by the intensity of pain nor pain-related functional impairment, but rather by the tendency to get entangled with internal experiences (e.g., thoughts, emotions, and physical sensations), which may or may not be related to pain-specific contents. Clinical implications are discussed.

Incorporating psychoeducation, mindfulness and self-compassion in a new programme for binge eating (BEfree): Exploring processes of change.

This study explores the efficacy of BEfree, a 12-session group intervention that integrates psychoeducation, mindfulness, compassion and value-based action, in a sample of overweight and obese women with binge eating disorder ( N = 31). We used repeated measures analyses of variance and explored processes of change in binge eating and eating psychopathology. At post-intervention, participants decreased in binge eating severity, eating psychopathology, external shame, self-criticism, psychological inflexibility, body image cognitive fusion and increased self-compassion and engagement with valued actions. These results were maintained at 3- and 6-month follow-up. The changes in binge eating were mediated by the changes in the psychological processes promoted by BEfree.

Pain and Depressive Symptoms: Exploring Cognitive Fusion and Self-Compassion in a Moderated Mediation Model.

The association between chronic pain (CP) and depression is complex and influenced by several psychological processes. Cognitive fusion (i.e. being entangled with one´s internal experiences) and self-compassion (i.e. being touched by one´s suffering, with a motivation to alleviate it) have been hypothesized as relevant psychological processes in physical and mental health, but few studies have addressed them in CP, and none in a comprehensive model relating pain intensity and depressive symptoms. This study tests, in a moderated mediation model, the mediator role of cognitive fusion between pain intensity and depressive symptoms, and the moderator effect of self-compassion in this mediation. In a cross-sectional study, 231 female CP patients (Age: M = 48.51, SD = 10.89) responded online self-report measures. PROCESS, an SPSS macro for conducting path analysis modeling, was used to test the hypothesized model. The model explained 63% of depressive symptoms, and cognitive fusion mediates the association between pain intensity and depressive symptoms. Also, self-compassion moderates this mediation (regardless of self-compassion being low, moderate or high). Although pain intensity is a predictor of depressive symptoms, fusion with thinking in general mediates this association, this relationship is buffered when patients are able to respond to setbacks and perceived shortcomings with self-kindness and warmth. Clinical and theoretical implications are discussed.

Mindfulness, selfcompassion, and depressive symptoms in chronic pain: The role of pain acceptance.

OBJECTIVE(S): The aim of this study was to test a theory driven model in which pain acceptance (both pain willingness [PW] and activity engagement [AE]) mediates the relationships of mindfulness and selfcompassion with depressive symptoms, while controlling for pain intensity. METHODS: A path analysis was conducted using AMOS software to test a meditational model in a sample of women with chronic musculoskeletal pain (N = 231). RESULTS: Participants with higher levels of mindful awareness and selfcompassion presented lower levels of pain intensity and depressive symptoms, and higher levels of AE. PW did not significantly correlate with any variable in study. The mediation analysis showed that AE mediated the relationship between selfcompassion and depressive symptoms, independently from pain intensity. CONCLUSIONS: These findings seem to corroborate the hypothesis that selfcompassion is rooted in a motivational system, as it seems to correlate with less depressive symptoms through increasing the engagement with valued actions despite experiencing pain.