Relationship between Orientation and Pain Severity in Fibromyalgia Patients:

Self-Compassion as a Coping Mechanism Downloaded from https://academic.oup.com/sw/article-abstract/64/3/253/5499221 by University of Michigan user on 24 September 2019 Edward C. Chang, Abigael G. Lucas, Olivia D. Chang, Harrison D. Angoff, Mingqi Li, Ashley H. Duong, Judy Huang, Marisa J. Perera, Fuschia M. Sirois, and Jameson K. Hirsch

The study examined the relationship between future orientation and fibromyalgia- related pain severity in a sample of 287 with fibromyalgia. Specifically, authors examined dimensions of self-compassion (for example, self-kindness, isolation, mindfulness) as possible mechanisms through which future orientation might be associated with pain severity. Results of conducting a multiple mediator test with 10,000 bootstraps indicated that the significant negative association between future orientation and pain severity was mediated through one specific self-compassion dimension, namely, isolation. The article concludes with a discussion of the implications of the present findings for working with fibromyalgia patients, specifically the potential of social workers working with fibromyalgia patients to build future orientation as a resilience factor to combat pain severity. Also discussed is the value of working with patients to develop a sustainable social support system that can disrupt experiences of social isolation and disconnectedness from others, and which appear to contribute to greater pain severity.

KEY WORDS: adults; fibromyalgia; future orientation; pain; self-compassion

ibromyalgia is a rheumatic condition that of future orientation, the belief that things will is difficult to diagnose because of a lack get better in the future even when faced with F of reliable biomarkers on which to base difficult situations (Hirsch et al., 2007), for a diagnosis (Wolfe et al., 2010). The prevalence understanding adjustment in this population. First, rate of this condition is estimated at 1.75 percent findings from past studies have shown that other among the general population (Walitt, Nahin, positive future (for example, ) Katz, Bergman, & Wolfe, 2015). Fibromyalgia are associated with pain severity in fibromyalgia symptoms are varied, but often include chronic patients (see, for example, Hellström, Jansson, & and widespread pain at specific bodily locations, Carlsson, 2000; Morea, Friend, & Bennett, 2008). tenderness to touch, physical exhaustion, and Second, and relatedly, unlike broad positive fu- cognitive difficulties pertaining to attention and ture cognitions like optimism or , future ori- memory, among other physical and psychological entation is predicated on embodying resilience symptoms (Arnold et al., 2016; Bennett et al., during times of distress (Hirsch et al., 2007). Thus, 2009; Hirsch & Sirois, 2016; Wolfe et al., 2010). for fibromyalgia patients, believing in a better fu- Until the 1980s, fibromyalgia was considered ture might help establish a positive outlook that largely a psychosomatic illness (Inanici & Yunus, is associated with experiencing less pain severity. 2004), and some medical professionals continue However, such an association is likely explained by to question its existence (Sturge-Jacobs, 2002). the fibromyalgia patients engage in or As a result, fibromyalgia patients have to deal not use when coping with their distressing condition only with chronic pain experiences associated with (Purdie & Morley, 2016). In that regard, grow- their condition, but also with the added strain of ing research focusing on the importance of self- not being understood by others, including health compassion as an important coping mechanism experts (Wierwille, 2012). might be useful for understanding pain severity In the context of fibromyalgia patients, there in fibromyalgia patients. According to Neff (2003), are at least two reasons to consider the usefulness self-compassion is a multidimensional construct in-

doi: 10.1093/sw/swz013 © 2019 National Association of Social Workers 253 volving an inward process of relating to oneself association with pain severity by potentially bol- during stressful times and is made up of six distinct stering engagement in positive self-compassion dimensions, the presence of three positive pro- activities, rather than by diminishing engagement cesses (that is, self-kindness, common humanity, in negative self-compassion activities. and mindfulness) and the absence of three nega- tive processes (that is, isolation, self-judgment, and METHOD Downloaded from https://academic.oup.com/sw/article-abstract/64/3/253/5499221 by University of Michigan user on 24 September 2019 overidentification). Because higher levels of self- Participants compassion have been linked to lower levels of A sample of 287 adults with fibromyalgia (275 pain severity in other patient populations (for ex- female and 12 male) was recruited using an online ample, obese adults) (Wren et al., 2012), it would = be useful to determine whether any association platform. Ages ranged from 18 to 76 years (M = found between future orientation and pain severity 48.07, SD 12.31). Of all participants, 92.7 = in fibromyalgia patients might be accounted for percent (n 266) identified as white. by their engagement in different forms of self- compassion. Accordingly, the present study was Measures conducted to examine whether dimensions of self- Future Orientation. Future orientation was assessed compassion represent possible mechanisms through using the Future Orientation Scale (FOS) (Hirsch which future orientation might be associated with et al., 2006). The FOS is a six-item measure pain severity in fibromyalgia patients. designed to assess the belief that the future is changeable even during difficult times (for exam- PURPOSE ple, “No matter how badly I feel, I know it will Given these considerations, the present study was not last”). Participants are asked to indicate the conducted in an population of fibromyalgia extent to which each item is important to how patients to (a) examine the associations between they deal with stressors on a five-point Likert-type future orientation, self-compassion, and fibro- scale, ranging from 1 = extremely unimportant to myalgia pain symptomatology; and (b) determine 5 = extremely important.Higher FOS scores indi- whether the expected association to be found be- cate a greater belief in a positive,changeable future. tween future orientation and pain severity might Self-Compassion. Self-compassion was assessed be mediated by components of self-compassion. using the Self-Compassion Scale (SCS) (Neff, Consistent with past research pointing to the 2003). The SCS is a 26-item measure designed role of future orientation in adjustment, including to assess for dimensions of self-compassion (for pain severity (see, for example, Hellström et al., example, “I try to be loving towards myself when 2000), we expected future orientation to be nega- I’m feeling emotional pain”).Participants are asked tively associated with pain severity in fibromyalgia to indicate how often they behave in the manner patients. Furthermore, consistent with the notion stated in each item on a five-point Likert-type that self-compassion might operate as an important scale, ranging from 1 = almost never to 5 = almost means by which fibromyalgia patients cope with always. Higher SCS scores indicate greater self- experiences of pain, we expected to find the compassion. association between future orientation and pain Pain Severity of Fibromyalgia Symptoms. Pain severity to be mediated by self-compassion. Given severity was assessed using the third component that there has not been much research examining the different dimensions of self-compassion asa (that is, Domain 3) of the Revised Fibromyalgia potential mediator of the link between individual Impact Questionnaire (FIQ-R) (Bennett et al., differences variables and pain severity in adults, we 2009), a 10-item subscale of the total FIQ-R that did not have any basis to make a strong hypothesis is designed to assess for severity of fibromyalgia regarding which dimensions of self-compassion symptoms in the previous seven days (for example, would uniquely mediate the association. That said, “Please rate your level of pain”). For each symp- however, given some research on how positive tom, participants rate their experience with the constructs can often lead to “upward spirals” respective symptom using a scale ranging from no (Garland et al., 2010), we tentatively surmised that symptomatology (that is, no pain) to high experi- future orientation might have the strongest indirect ence of symptomatology (that is, unbearable pain).

254 Social Work Volume 64, Number 3 July 2019 Higher scores on this FIQ-R subscale indicate Hayes’s (2008) bootstrapping methods (with 10,000 greater fibromyalgia-related pain severity. bootstraps) for detecting total effects and specific indirect effects for instances in which multiple Procedure mediators are involved in the prediction model. Approval for the study was obtained prior to data Results of this analysis indicated that the total collection from the institutional review board at indirect effect was found to be significant (p < .05), Downloaded from https://academic.oup.com/sw/article-abstract/64/3/253/5499221 by University of Michigan user on 24 September 2019 a large public university in the Southeast. Partic- as the interval did not contain a zero. ipants were recruited online, on a secure server, That said, an examination of the indirect effects from local, regional, and national organizations of all six self-compassion dimensions indicated and support groups focused on chronic pain con- that only one was significant. Specifically, the ditions. After providing written informed consent, indirect effect of isolation was the only dimension participants completed the survey electronically. found to be significant (p < .05), without a con- fidence interval containing a zero. As shown RESULTS in Figure 1, isolation emerged as the only dimen- All correlations were significant and in the ex- sion of self-compassion to mediate the association pected directions (for a copy of the correlation between future orientation and pain severity. Be- table, please contact the first author). For example, cause the total effect of future orientation on pain future orientation was negatively associated with severity became nonsignificant (c = –.10, n.s.) pain severity (r = –.15, p < .001). Similarly,future after the inclusion of self-compassion, our findings orientation was positively associated with the three indicate that isolation fully mediated the previ- positive self-compassion dimensions (rs = .17 to ously significant association found between future .29, p < .01) and negatively associated with the orientation and pain severity (c = –.32, p < .01). three negative self-compassion dimensions (rs = –.20 to –.28, p < .001). DISCUSSION To examine self-compassion dimensions as me- The present study examined the associations be- diators of the association between future orien- tween future orientation,self-compassion,and pain tation and pain severity, we used Preacher and severity in fibromyalgia patients. Consistent with

Figure 1: Estimated Mediation Model of Future Orientation and Pain Severity through Self-Compassion in an Adult Community Sample of Fibromyalgia Patients (N = 288)

Chang et al. / Relationship between Future Orientation and Pain Severity in Fibromyalgia Patients 255 expectations, we found that future orientation was work with patients to help identify supportive associated with less pain severity in fibromyalgia individuals in their life (for example, spouse, part- patients. Thus, fibromyalgia patients who held the ner,and parents) and have those significant individ- resilient conviction that the future would be uals play a collaborative role in fostering a positive better despite their situation were more likely and supportive environment for the patient to experience less pain severity associated with (Montoya, Larbig, Braun, Preissl, & Birbaumer, Downloaded from https://academic.oup.com/sw/article-abstract/64/3/253/5499221 by University of Michigan user on 24 September 2019 their condition. It is important to note, however, 2004). Indeed, findings from studies show that the that results from our mediation testing indicated greatest impact of social support on reports of pain that the manner in which this association exists severity among pain patients is by encouraging the might be through self-compassion, specifically, by use of effective coping strategies (see, for example, thwarting experiences of isolation. That is, we Holtzman, Newth, & Delongis, 2004). Thus, social found that greater belief in a changeable future was workers using, for example, cognitive–behavioral associated with less ruminative thinking associated strategies that focus on the training of effective with one’s lack of connectedness with others (for and meaningful coping skills (for example, cogni- example, “When I think about my inadequacies, tive restructuring, problem solving) to directly (for it tends to make me feel more separate and cut example, increase tolerance of pain) or indirectly off from the rest of the world”). In turn, the (for example, reduce emotional distress associated tendency to engage in less rumination about one’s with pain experiences) manage pain experiences disconnectedness with others was associated with among fibromyalgia patients,might achieve greater less experience of pain severity in fibromyalgia positive outcomes when significant others are patients.This is consistent with findings from other included as facilitators or partners in the patient’s studies pointing to a reliable association between pain management program. In more extreme cases loneliness and pain experiences in fibromyalgia in which such efforts appear to have little to no patients (see, for example, Wolf & Davis, 2014). beneficial effect for the patient, the practitioner Thus, future orientation may do more to abate may suggest expanding the management team to “downward spirals” than activate “upward spirals” include medical professionals to determine whether involved in experiences of pain severity among pharmacological treatments (for example, opioids) fibromyalgia patients (Garland et al., 2010). might be warranted (Rosenblum, Marsch, Joseph, Although our findings are preliminary, they & Portenoy,2008). may be taken to suggest two possible ways that Second, and relatedly,given our mediation find- may prove to be useful for profes- ings, there may be specific value in working to sionals working with fibromyalgia patients expe- build future orientation only insofar as such efforts riencing high levels of pain. First, our findings reduce the tendency of fibromyalgia patients to suggest that in addition to existing multidisciplin- engage in ruminative processes that isolate them ary strategies for treatment (for example,narratives, from others. Alternatively, as previously noted, medication, physical therapy) (Kelley & Clifford, working to increase and sustain the support system 1997; Wells, Pasero, & McCaffery, 2008; Wijma, available to fibromyalgia patients (for example, van Wilgen, Meeus, & Nijs, 2016), it might be patient groups, online support groups) might also useful to help fibromyalgia patients build a strong help disrupt the tendency to resign themselves sense of future orientation. For example, social to the belief that they are isolated and alone. In workers might work with fibromyalgia patients that regard, social workers might help establish with low future orientation to build greater pos- a weekly support group for both fibromyalgia itive expectancies for their future. This might be patients and members of their support network done not only by having patients work on iden- not only to help offer a space to discuss any tifying and acknowledging personal strengths and challenges and concerns patients may sometimes sources of resilience (for example, social support) have about increased perceptions of social isolation that are available to them (Boehm, Eisenberg, & or lack of social support, but also to help sustain Lampel, 2011), but also by helping them learn their collective commitment to overcoming this to reframe stressful situations as opportunities for condition (Turner, 2011). For example, the social positive personal change and growth (Robitschek worker can help articulate or codify a plan of et al., 2012). For example, social workers might commitment between the patient and support

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