key: cord-1014998-1a3qule6
authors: Kroska, Emily B.; Roche, Anne I.; Adamowicz, Jenna L.; Stegall, Manny S.
title: Psychological Flexibility in the Context of COVID-19 Adversity: Associations with Distress
date: 2020-08-06
journal: J Contextual Behav Sci
DOI: 10.1016/j.jcbs.2020.07.011
sha: bd12b16e6ffe852c166c4d82e4b7d81fa3584e44
doc_id: 1014998
cord_uid: 1a3qule6

The COVID-19 pandemic has led to hardship for individuals across the globe, and research to-date has indicated a significant impact of the pandemic on mental health functioning. In order to promote psychological resilience during this time, it is important to understand modifiable targets for clinical intervention. The current study examined demographic characteristics, pandemic-related adversity, and psychological flexibility in relation to general and peritraumatic distress in a sample of United States survey respondents during May of 2020. Participants were recruited from Amazon Mechanical Turk (MTurk), N = 485. Participants completed measures of pandemic-related adversity, psychological flexibility components (openness to experience, behavioral awareness, and valued action), peritraumatic distress, and general distress. Hierarchical regression analyses examined whether demographic characteristics, pandemic-related adversity, and components of psychological flexibility were associated with general and peritraumatic distress. Results indicated that higher pandemic-related adversity, lower openness to experience, and lower behavioral awareness were significantly associated with higher general distress. Greater pandemic-related adversity, lower openness to experience, lower behavioral awareness, and higher valued action were significantly associated with higher peritraumatic distress. Adding the components of psychological flexibility to the model increased the amount of variance accounted for in both measures of distress. The results indicated that psychological flexibility components may be particularly important targets for prevention and intervention efforts in the midst of the COVID-19 pandemic. Transdiagnostic interventions, such as Acceptance and Commitment Therapy, that target psychological flexibility may be useful as the impact of the pandemic continues to unfold.

. Conversely, access to health information and engagement in certain preventive measures (e.g., hand washing) have been shown to be associated with fewer psychological difficulties .

Individuals in the United Kingdom (UK) are also reporting pandemic-related concerns, including concerns about isolation, social distancing, mental illness, employment/finances, and negative feelings (Holmes et al., 2020) . Cumulative adverse experiences during the pandemic and cumulative worries were associated with anxiety and depressive symptoms in UK adults (Wright et al., 2020) . Similarly, fear of COVID-19 was related to depression and anxiety in an Iranian sample (Ahorsu et al., 2020) . Newly termed "coronaphobia" contributed to depression, anxiety, and death anxiety over and above demographic characteristics and risk factors, indicating the importance of the fear of contracting the virus as a specific construct (Lee et al., 2020) . In contrast, results from a study in Italy suggested that social engagement may help to prevent mental health symptoms during isolation (Pancani et al., 2020) . Additionally, physical activity, diet quality, and better sleep were identified as factors that may promote greater mental well-being during the pandemic in a Middle Eastern sample (Kilani et al., 2020) .

Overall, early research across the globe has indicated that the COVID-19 pandemic is associated with psychological distress. In addition to prevalence and risk factor identification, it is equally important to identify targets for psychotherapeutic intervention. Given the array of challenges that may be experienced (e.g., anxiety, depression, trauma-related symptoms), one approach is to target transdiagnostic processes that are associated with a variety of mental health outcomes. Psychological flexibility, a key process targeted in multiple transdiagnostic psychotherapeutic interventions, has been previously identified as a modifiable target to promote general public health (Gloster et al., 2017) .

A significant body of research has indicated that experiential avoidance (EA), or unworkable attempts to control or change unpleasant internal experiences (e.g., thoughts, emotions), is related to a variety of psychological outcomes (Chawla & Ostafin, 2007) .

Importantly, EA is associated with poorer psychological functioning following adverse life events (Plumb et al., 2004) . Multiple studies have indicated that EA mediates the association between trauma exposure and adverse outcomes such as obsessive-compulsive and internalizing symptoms , psychological distress (Marx & Sloan, 2002) , posttraumatic stress symptoms (Orcutt et al., 2005) , somatization , and problematic or risky health behaviors .

In contrast, psychological flexibility, or the ability to remain in the present moment and engage in values-based behavior, even in the presence of unpleasant internal experiences, is associated with numerous aspects of psychological health (Kashdan & Rottenberg, 2010) .

Psychological flexibility has been shown to be related to lower levels of depression and posttraumatic stress in military personnel after returning from deployment (Bryan et al., 2015) and to buffer the association between stress and a variety of health outcomes (Gloster et al., 2017) , indicating that the process may protect against psychological distress following stressful experiences. Psychological flexibility has been characterized as being composed of three core interactive components: 1) openness, a willingness to have unpleasant internal experiences (e.g., feelings, memories) in service of what matters; 2) awareness, purposefully paying attention when engaging in behavior rather than being on "automatic pilot"; and 3) engagement, or identifying and engaging in valued actions that one finds meaningful and important (Francis et al., 2016; Strosahl et al., 2012) . Psychological flexibility is not unique to one specific condition J o u r n a l P r e -p r o o f or set of symptoms but is instead a transdiagnostic process that promotes mental health and wellbeing across a variety of psychological struggles. Thus, psychological flexibility has the potential to promote resilience in times of adversity.

A first step toward prevention programs is to first characterize the relation between hardships and mental health, and second, identify modifiable psychotherapeutic mechanisms that explain psychological symptoms (Holmes et al., 2020) . The current study cross-sectionally investigates associates of distress during the COVID-19 pandemic, including demographic characteristics, pandemic-related adversity, and components of psychological flexibility using hierarchical regression analyses. Components of psychological flexibility measured in this study include openness to experiences, behavioral awareness, and valued action. We hypothesized that components of psychological flexibility would significantly relate with distress over and above pandemic-related adversity.

Participants (N = 523) were recruited from MTurk in May 2020. Of the participants, 485 completed validity checks and were included in analyses. The sample was on average 37.42 years of age (SD = 11.46), heterosexual (85.8%), and employed full-time (76.3%). Gender identity was relatively balanced (59.6% male). Racial identity was most commonly White (78.1%). Ethnicity was largely non-Hispanic (82.9%). On average, participants reported about 15.09 years of education (SD = 2.93). See Table 1 for further information.

J o u r n a l P r e -p r o o f Participants were recruited through MTurk's CloudResearch platform and were paid $3.50 via Amazon Payments within three days of survey completion. CloudResearch blocks suspicious geolocations and screens for automated responding. Recruitment was limited to United States participants who had previously completed ≥ 100 tasks and had ≥ 95% approval rating. As this project aims to follow-up with these individuals longitudinally, our goal was to recruit users who were consistently participating in MTurk studies and had received high ratings on past participation.

Within the Qualtrics survey, validity checks were included to ensure that responders were high quality, engaged, and not automated. Google reCAPTCHA was the first question following consent, and if incomplete, the survey did not proceed. A simple arithmetic question that required user input was used to filter out internet bots. Attention checks verified reading of the questions. Participants who did not pass validity checks were excluded from analyses.

Pandemic Adversity. The Pandemic Adversity Measure (PAM) quantifies psychosocial adversity related to COVID-19. PAM was developed by the first author, and validation of this measure is underway. PAM quantifies hardship by creating a Total Adversity score across financial, home, work/business, health, and social domains. Several items are weighted to quantify the extent of the adversity (e.g., the percentage of lost income). Total scores range from 0-50. Internal consistency scores were not calculated, as items are scored categorically and not expected to correlate meaningfully.

Therapy processes (CompACT) measured three components of psychological flexibility: openness to experience, behavioral awareness, and valued action (Francis et al., 2016) . The J o u r n a l P r e -p r o o f measure demonstrated convergent, discriminant, and concurrent validity (Francis et al., 2016) .

Participants rate 23 items on a 7-point Likert scale. Higher scores indicate greater openness to experience, behavioral awareness, and valued action. In this sample, openness to experience (α = .84), behavioral awareness (α = .93), and valued action (α = .90) demonstrated adequate internal consistency.

Peritraumatic Distress. The Peritraumatic Distress Inventory (PDI) measured emotional and physiological distress during and immediately following a traumatic event. The PDI demonstrated test-retest reliability, convergent validity, and discriminant validity (Brunet et al., 2001) . Participants rate 13 items on a 5-point Likert scale, and the mean is the composite score.

Higher scores denote more distress. In this sample, the measure demonstrated high internal consistency (α = .95).

Psychological Distress. The Kessler Psychological Distress Scale-10 (K10) was used to measure anxiety and depressive symptoms in the past 30 days (Kessler et al., 2002) . Participants rate 10 items on a 5-point Likert scale. Higher total scores denote more distress. In this sample, the K10 demonstrated high internal consistency (α = .96).

All analyses were conducted in SPSS, version 25. Hierarchical linear regression analyses included two dependent variables: general distress (K10) and peritraumatic distress (PDI).

Though general distress (K10) and peritraumatic distress (PDI) were highly correlated in the current sample (r = 0.82, p < .001), the measures are theoretically distinct. The K10 measures general distress, depression, and anxiety symptoms, while the PDI measures emotional and physiological symptoms associated with a specific acutely stressful (and potentially traumatic) event (in this case, the COVID-19 pandemic). Given the importance of understanding both J o u r n a l P r e -p r o o f factors that may influence general distress and factors that may influence acute stress during the pandemic, each measure was of unique interest, and scales were examined separately. Models included three steps to examine relations between demographic characteristics, pandemic-related adversity, and psychological flexibility components. Change in R 2 statistics allowed for examination of the amount of variance contributed between steps, and of particular interest was the added variance from psychological flexibility.

Item-level missing data were imputed when ≤ 20% of items were missing in the following quantities: K10 (13), PDI (24), and CompACT (44). For the Adversity scale, total scores were calculated without the missing items (assuming 0, or absence of adverse experience) when ≤ 20% of items were missing.

Data were examined for normality, skewness, and kurtosis. The skewness and kurtosis values were within the acceptable respective ranges, and thus, no transformations were conducted. Data were examined for outliers, and outlier's data were verified to ensure valid responding throughout the survey (including measures not utilized in the current analyses).

Demographic characteristics were examined for inclusion as covariates in analyses. For between-groups comparisons, Levene's equality of variances test was used, and if significant, the results were interpreted with equal variances not assumed and adjusted degrees of freedom.

Gender identity (female, male) was not associated with differences in K10 (t(479) = -0.02, p = 0.99) or PDI (t(479) = 0.33, p = 0.75). Age related to K10 (r = -0.16, p < .001) but not PDI (r = -0.07, p = .10). Racial groups were combined for between-groups comparisons due to small sample in some groups. There were no significant differences between White and non-White Bivariate correlations among independent variables were examined. Openness to experience correlated with behavioral awareness (r = .68, p < .001), valued action (r = .36, p < .001), and pandemic-related adversity (r = -.39, p < .001). Behavioral awareness correlated with valued action (r = .31, p < .001) and pandemic-related adversity (r = -.57, p < .001). Valued action correlated with pandemic-related adversity (r = -.12, p = .009).

Hierarchical regression analyses examined the amount of variance accounted for by independent variables (demographic characteristics, pandemic-related adversity, and psychological flexibility components) in relation to general distress (K10) and peritraumatic distress (PDI). Variance inflation factor statistics were examined to evaluate multicollinearity.

With the outcome of general distress, the final model is conveyed in Table 2 . The demographic characteristics of age, ethnicity, and education were not significant (ps > .05). Pandemic-related adversity significantly related to general distress (β = .34, t(417) = 9.03, p < .001). Openness to experiences significantly related to lower general distress (β = -.25, t(417) = -5.90, p < .001), as did behavioral awareness (β = -.33, t(417) = -7.31, p < .001). Valued action was not significantly related to general distress (β = -.06, t(417) = -1.87, p = .06). Variance inflation factors were less than 3 and deemed acceptable.

Step 1 (demographic characteristics) accounted for 11% of the variance (R 2 = .11). When adding in Step 2 (pandemic-related adversity), there was a significant J o u r n a l P r e -p r o o f change in R 2 (R 2 = .42, F-change (1, 420) = 218, p < .001). Finally, when adding in Step 3 (psychological flexibility components), there was once again a significant change in R 2 (R 2 = .64, F-change (3, 417) = 82.96, p < .001). The total variance accounted for by the final model was 63.5%.

With the dependent variable of peritraumatic distress, ethnicity and education were not significantly related to peritraumatic distress (ps > .05). Pandemic-related adversity associated with greater peritraumatic distress (β = .40, t(428) = 9.90, p < .001). Openness to experience was associated with lower peritraumatic distress (β = -.12, t(428) = -2.74, p = .006), as was behavioral awareness (β = -.38, t(428) = -7.67, p < .001). Valued action significantly associated with greater peritraumatic distress (β = .08, t(428) = 2.29, p = .023). Variance inflation factors were deemed acceptable. The demographic characteristics (Step 1) accounted for about 10% of the variance in peritraumatic distress (R 2 = .10). Pandemic-related adversity significantly added to the model (R 2 = .42, F-change (1, 431) = 233.37, p < .001). The psychological flexibility components also significantly added to the model (R 2 = .56, F-change (3,428) = 45.82, p < .001).

In total, the model accounted for 55.8% of the variance in peritraumatic distress.

Though research regarding the impact of the COVID-19 global pandemic on mental health continues to emerge, available evidence suggests serious psychological consequences (Qiu et al., 2020; . Because early indications point to an enduring impact of the pandemic on mental health (Wang, Pan, Wan, Tan, Xu, McIntyre, et al., 2020) , the identification of modifiable therapeutic processes is critical to the development of targeted interventions. Transdiagnostic processes are most efficient and broadly applicable, providing intervention across diagnoses and promoting functional improvement and well-being.

Psychological flexibility, the target of several contextual behavioral interventions, including Acceptance and Commitment Therapy (ACT), is one modality that can promote vitality.

The current study examined components of psychological flexibility in association with general and peritraumatic distress. Hierarchical regression analyses allowed for examination of which components of psychological flexibility related with two distress outcomes, while controlling for both demographic characteristics and pandemic-related adversity. By including the psychological flexibility components in one step, the R 2 statistic provides the total variance that can be attributed to psychological flexibility. Further, this procedure identifies the key components of psychological flexibility, while controlling for shared variance. Results indicated that COVID-19-related adversity was associated with greater general and peritraumatic distress, and adversity remained significant even when adding psychological flexibility components to the model. Higher openness to experience and behavioral awareness were associated with lower general and peritraumatic distress. These components of psychological flexibility were associated with general and peritraumatic distress over and above demographic characteristics and pandemic-related adversity. Valued action was not significantly associated with general distress but was positively associated with peritraumatic distress.

The current findings support the development and evaluation of psychotherapeutic interventions that promote psychological flexibility during the COVID-19 pandemic. Openness and awareness processes appear to be of particular importance. Specifically, remaining in the present moment and choosing actions intentionally (behavioral awareness) and being open to (rather than avoidant of) difficult thoughts and emotions (openness to experience) may be particularly relevant processes to promote emotional well-being. Notably, valued action was not significantly related to general distress, but was positively related to peritraumatic distress J o u r n a l P r e -p r o o f specific to COVID-19. This relation suggests that those with a greater ability to identify and engage in behaviors that are personally meaningful and important, even when challenging or stressful, are reporting greater emotional and physiological distress surrounding the pandemic.

This finding may reflect that values-based behavior often comes with a variety of difficult internal experiences, particularly in stressful contexts. For example, an individual who visits grandparents weekly during the pandemic may experience distress for fear of infecting loved ones or oneself, and choosing to converse more frequently by phone may bring about painful guilt, isolation, and frustration, even if consistent with values. The healthcare worker spending twelve hours in personal protective equipment may experience a variety of difficult emotions, and yet, treating patients during COVID-19 may be important. While being exposed, healthcare professionals may have to limit physical contact with family and friends, bringing about further stress. Finally, given that the psychological flexibility processes are intricately interrelated, it is important to note that the analyses convey that openness and awareness seem to be most important during the current circumstances, but this considers the components as part of a whole.

Openness involves willingness to engage in difficult experiences, but only in service of one's values. Similarly, awareness is contextualized within one's values and intentional, mindful decision-making. Ultimately, further research should continue to examine the interrelated psychological flexibility components and the relations with pandemic-related distress.

Acceptance and Commitment Therapy (ACT) is a transdiagnostic, acceptance-and mindfulness-based behavioral intervention that may be well-suited to ameliorate the psychological impact of pandemic-related adversity. ACT targets both behavioral awareness and openness to experience. More specifically, ACT may help individuals take the perspective of an observer on thoughts (e.g., "this pandemic will never end"), emotions (e.g., frustration, fear), and J o u r n a l P r e -p r o o f physical sensations (e.g., racing heart). Cultivating awareness is in service of the pursuit of one's values under the premise that when present in the moment, one can make intentional choices with awareness of the function of behavior. ACT aims to promote acceptance of internal experiences through helping individuals to notice the connection between difficult emotions and personal values (e.g., sadness surrounding loss of a loved one). By fostering these skills, The findings should be considered along with several limitations. First, respondents were recruited through MTurk. There are several concerns regarding this recruitment platform that necessitate validity questions and data screening (Chmielewski & Kucker, 2019) . Validity checks were implemented to ensure integrity of the data. Recruitment through MTurk can also be limited by selection bias, as we likely included participants who are interested in responding to surveys, and we specifically recruited MTurk workers who had completed 100 surveys. This study also relied on self-report measures. While the included constructs (psychological flexibility, peritraumatic distress, adversity) are commonly measured via self-report in behavioral research, this remains a limitation. The study also measured participants at a single timepoint, so J o u r n a l P r e -p r o o f longitudinal conclusions cannot be drawn. The present findings cannot yield causal conclusions, but instead, suggest that psychological flexibility is related to distress during the COVID-19

pandemic. Finally, this study measured COVID-19 related hardship with the PAM, an unvalidated measure that was created in the context of COVID-19. Prior research examining the adversity of other collective traumas (e.g., natural disasters, infectious disease) on psychological functioning have used similar protocols. For example, investigators created measures of adversity to explore the impact of wildfires (McFarlane, 1987) , ice storms (King & Laplante, 2005) , and floods (Brock et al., 2014; Kroska et al., 2017) on participants. Though measuring COVID-19 related hardship with a valid measure would be optimal, the creation and use of an event-specific scale aligns with the previous literature. Nevertheless, this measure is not yet validated, and results should be interpreted with that in mind.

In conclusion, as the COVID-19 global pandemic endures, the identification of modifiable mechanisms to target with therapeutic interventions is critical. These findings suggest that psychological flexibility is one such process that may help to promote well-being and reduce psychological distress amidst COVID-19 adversity. Therefore, ACT, which aims to increase psychological flexibility, may be well-suited for those who are coping with hardship and experiencing distress. Future research should continue to examine these relations and, further, the efficacy of targeted transdiagnostic interventions for COVID-19 related hardship and associated distress.

J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f Note. Openness to Experiences, Behavioral Awareness, and Valued Action are subscales of the Comprehensive Assessment of ACT processes.

J o u r n a l P r e -p r o o f Note. Openness to Experiences, Behavioral Awareness, and Valued Action are subscales of the Comprehensive Assessment of ACT processes.

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J o u r n a l P r e -p r o o f Conflicts of Interest: This work was supported in part by the National Institute of Health T32 pre-doctoral training grant: T32GM108540 (A.I.R, J.L.A) and by the University of Iowa's Ballard Seashore Fellowship (A.I.R). Neither the NIH nor the University of Iowa had any role in the study design, collection, analysis, or interpretation of the data, writing of the manuscript, or the decision to submit the paper for publication. The authors have no conflicts of interest to disclose.