Contribution of Online Stress and Pain Mindfulness Treatment to ACT Process Change and Outcomes in Chronic Pain

Detailed Description

Mindfulness can be defined operationally as Paying attention; on purpose in the present moment and non-judgmentally.

Evidence-based (often referred to as 'secular') mindfulness has seen an exponentially increasing interest in the scientific literature and the estimated number of published scientific journals has recently been reported to have grown from one single journal in 1982, to 667 scientific publications in 2016 and in excess of 30,000 Media Pieces in Newspapers.

However, there are unknowns around the mechanisms (the 'vehicles' of change) by which mindfulness works. These must be better understood in order to avoid continued professional and public misinformation, poor research and ultimately, potential harm to the end user. (Van Dam, van Vugt et al. 2018).

ISSUES WITH AND IMPLICATIONS OF WHAT THE INVESTIGATORS CURRENTLY DEFINE AS MINDFULNESS AND ITS APPLICATION TO CHRONIC PAIN

Within the context of the exponential growth of interest in and research of mindfulness including in the treatment of chronic pain, several factors have contributed to the consideration for the current project:

1. The integration of mindfulness based interventions in gold-standard multidisciplinary treatments for chronic pain, such as ACT.
2. Researchers' calls to improve intention to treat, to better understand facets of what is understood to be mindfulness, better targetting of and a more unified approach to mindfulness-change process variables - thus aiming to reduce treatment burden.
3. There are relevant mindful mechanisms and processes specifically in chronic pain that have made a case from both the ACT and the more purist mindfulness research derived from group based interventions or meditation alone in chronic pain - and that are not currently typically or routinely included in mindfulness groups research for chronic pain.
4. Methodological issues including
5. lack of clarity about providers' competencies and requirements in chronic pain,
6. arbitrary removal of essential components of a given intervention,
7. often no active or waiting list control condition and
8. no consideration at all of utilising a theoretically valid and coherent process-measurement frameworks nor consideration for the teachers' competencies requirements when delivering mindfulness courses to chronic pain patients From reviewing the evidence quoted, the research on mindfulness for chronic pain has exclusively utilised standardised mindfulness groups typically aimed at stress populations, excluded less researched pain explicit (contextually relevant to pain) mindfulness group interventions, ignored theoretically valid mindful-process measurement provided by frameworks such as the ACT framework, or not controlled appropriately for significant confounding factors. This debate is increasingly important considering that recently published audit data suggests that mindfulness in one format or the other, or as part of ACT-based multidisciplinary treatment is being provided regularly in pain management centres in the UK . This has been leading, possibly prematurely, to discussion about providing training in mindfulness competencies for pain practitioners such as mindfulness enquiry or leading meditations, which may lead, in turn, to implementing professional skills without sound, targeted and theoretically evidenced rationale. METHODOLOGICAL ISSUES WITH CURRENT MINDFULNESS RESEARCH AND THE IMPROVEMENTS WITH THIS STUDY The current research will therefore aim to address and control, some of the currently reported methodological issues in research on group mindfulness based interventions (MBIs), including:

• Utilising a waiting list for the whole group as a control prior to randomisation. This will act as a pseudo treatment-as-usual condition and will track key outcome and process measures across this time.
• Utilising two active interventions, Mindfulness for Stress (MfS) and Mindfulness for Health-Mindfulness Based Pain Management (MfH-MBPM), with a standardised, transparent, comparable in content, time and delivery process that can therefore be easily evaluated for adherence and treatment fidelity.
• Using established and matched teacher's competence in line with UK Network standards for the intervention delivered.
• Utilising the same 'dosage' and type of interventions (groups with similar structure, delivery times and requirements for practice) utilising MfH-MBPM and MfS protocols, teacher notes and processes that are standardised
• Inter-rater reliability assessment of fidelity to the treatment provided
• Using appropriate psychometric and qualitative analysis and targeting of explicit process-change.
• Reporting adverse side effects
• Measures in line with IMMPACT recommendations for research on chronic pain
• the investigators may also submit Ethics amendments to include Heart Variability Measurement in a proportion of the study cohort, to have a biological correlate. Identified Risks Likelihood Potential Impact/Outcome Risk Management/Mitigating Factors: Practicing mindfulness meditation has been known to trigger distressing memories in patients with existing Trauma/PTSD Low Participant:
• Psychological Stress Researcher
• Anxiety about dealing with a complex situation • Exclusion criteria for enrolling in the study will include those with pre-existing psychiatric comorbidities, particularly Trauma/PTSD conditions
• As the investigators are recruiting from primary care GPs will be informed of this criteria as will patients themselves in their information packs
• The researcher will be able to signpost participant to the relevant support services Discussion of sensitive topics in interview has potential to cause distress to participant Low Participant:
• Psychological Stress Researcher
• Anxiety about dealing with a complex situation • Offer to cease interview
• Exclusion criteria (as above)
• The researcher will be able to signpost participant to the relevant support services Conflict between participants in group setting Low Participant:
• Psychological Stress Researcher
• Anxiety about dealing with a complex situation
• The researcher will have the necessary training and experience in group facilitation to handle conflicts Data collection \& interviews may possibly take place in an unfamiliar location with people not already known to the researcher High Researcher
• Physical Injury or Psychological Harm • Visit location prior to data collection to assess possible risks associated with built and social environment
• Use this information to plan session
• Identify back up at location or online preferably
• Allow extra time to familiarise participants with research and environment
• Researcher to have contact details and means of making timely contact with back up Disclosure of information about poor practice Low Immediate, urgent or prompt response may be required from service providers • Ensure all verbal and written information about research indicates possible researcher response to disclosure
• The researcher will be able to signpost participant to the relevant support services Disclosure of unmet health or social care needs Medium Immediate, urgent or prompt response may be required from service providers • Ensure all verbal and written information about research indicates possible researcher response to disclosure
• The researcher will be able to signpost participant to the relevant support services Research participant in danger of harm to self or others Low Immediate, urgent or prompt response may be required from service providers • Ensure all verbal and written information about research indicates possible researcher response to disclosure
• The researcher will be able to signpost participant to the relevant support services STATISTICAL POWER This study will be a modification of a previous pilot test trial of a brief, widely inclusive UK primary care setting (McCracken, Sato and Taylor, 2013), to include the whole sample of participants acting as a waiting list control, randomly allocated to two active treatment conditions. In line with this study which was delivered in a population area of 119,000 people, power calculations were not completed, nor were formal predictions of significant treatment effects. This was on the basis that the same treatment format and in a community based sample had not been tried before and demonstrated of successful recruitment of > 60 participants within a two-month period and reporting moderate effect sizes for the active condition. Given the whole island population of Jersey (N.B. this is United Kingdom Jersey - not US) is estimated currently at 106,000, power calculations will not be provided in this study as the sample size was deemed appropriate in the previous that also cited a number of studies with similar sample sizes and obtained from populations greater than Jersey. Plan for missing data to address situations where variables are reported as missing, unavailable, non-reported, uninterpretable, or considered missing because of data inconsistency or out-of-range results: The investigators will utilise mean substitution for missing items or alternative substitution technique. The quantitative analysis will be also bolstered by a qualitative study: DESIGN AND SETTING A qualitative study involving semi-structured interviews will be held, with a topic guide informed by the ACT psychological flexibility model and Day's framework for mindfulness-relevant processes in chronic pain, and based on mindfulness research improvement based on adaptations of Mindfulness Based Cognitive Therapy (MBCT) for chronic pain Exclusion criteria (in addition to quantitative study criteria): Non-completers (participants who completed less than 6/8 course sessions) Declined to take part in interviews SAMPLING An opportunity sample from all patients invited to take part to the quantitative research aspect, invited as part of the initial quantitative study informed consent process. We will invite all participants from the sample, aiming from 10-15 participants from each the stress and pain version of the courses, hence a total sample of 30 participants maximum and a target of 10 completed interviews for each intervention. N.B. This study's initial Ethics Submission was for a face to face project in February 2019. However, due to Covid-19 and lack of funding, the investigators requested and agreed Ethics amendments to go online. These amendments were approved by the Jersey Healthcare Ethics Committee after submission on 24/05/2022, their meeting on 26/05/2022 and formal email of approval on 30/05/2022.