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. Author manuscript; available in PMC: 2025 Aug 20.
Published in final edited form as: Biopsychosoc Sci Med. 2025 Mar 24;87(4):271–279. doi: 10.1097/PSY.0000000000001387

Psychological Flexibility, Coping Styles, and Mood Among Individuals With Cystic Fibrosis

Patrick J Smith 1, Christopher F Drescher 2, Heather Bruschwein 3, Krista Ingle 4, Chelsi Nurse 5, Catherine Virginia O’Hayer 6
PMCID: PMC12364521  NIHMSID: NIHMS2097697  PMID: 40167140

Abstract

Objective:

An emerging body of evidence suggests that psychological flexibility may be an important and underexamined determinant of overall psychological functioning. The chronic nature of cystic fibrosis (CF) may require a greater level of flexibility to navigate complex and dynamic health concerns in an increasingly aging population.

Methods:

We examined associations between psychological flexibility, coping styles, psychological grit, and negative affectivity (anxiety and depressive symptoms) from baseline assessments of randomized trials among adults with CF. Regression models controlling for age, sex, income, psychotropic medication use, and pulmonary function were used to characterize associations between psychological flexibility, coping styles, and negative affect.

Results:

A total of 124 individuals were included in analyses, 74 (60%) of whom were taking psychotropic medication. Depressive [Beck Depression Inventory-II = 18.6 (SD = 9.9)] and anxious [Beck Anxiety Inventory = 13.8 (SD = 9.3)] symptoms were both elevated. Greater levels of psychological flexibility were associated with lower negative affect, such that individuals reporting less cognitive fusion (B = −0.59, p < .001) and greater psychological acceptance (B = −0.51. p < .001) exhibited lesser levels of anxiety and depressive symptoms. Psychological flexibility was the most robust correlate of negative affect after accounting for other coping variables (B = −0.50, p < .001), and this association was not moderated by forced expiratory volume in 1 second/forced vital capacity levels.

Conclusions:

Psychological flexibility is robustly associated with decreased negative affect among individuals with CF, independent of background and clinical characteristics.

Keywords: psychological flexibility, cystic fibrosis, grit, depression, anxiety, coping

INTRODUCTION

Cystic fibrosis (CF) is a genetically mediated, chronic condition affecting ~1 in 4000 births.1 Persons with CF (PwCF) experience lifelong medical challenges that require constant management through behavioral modification.2 These include treatments to help reduce gastrointestinal symptoms, pulmonary disease, and increased vulnerability to infections.3–5 Understandably, many individuals with CF experience elevated symptoms of anxiety and depression, as well as worse quality of life.6 In addition, individuals who exhibit more avoidant coping strategies experience worse psychological functioning and quality of life, suggesting that better understanding of the relationship between coping and psychological functioning in the CF population may be important for refining available psychological treatments [eg, cognitive behavioral therapy (CBT)].7–12

The relationship between coping and mental health outcomes is particularly important in CF due to the chronic nature of self-management requirements and the potential for adverse clinical outcomes in the setting of non-adherence.13,14 The chronicity of CF treatments requires individuals to be more behaviorally vigilant, resilient in the face of potentially recurrent hospitalizations, and to navigate psychosocial complexities germane to adolescence and young adulthood while experiencing additional stressors from their CF experience.9,15,16 For some PwCF, this may create a tension between behavioral control tendencies, with greater behavioral rigidity potentially helping to reduce non-adherence to routine treatments and greater behavioral flexibility potentially being advantageous as their clinical course changes over time to require new treatment approaches.17–21 Moreover, recent developments in treatments for CF (eg, immunomodulators) have dramatically altered the clinical course and availability of life-altering therapies for some CF individuals.1 This unique combination of chronic self-management and flexibility to embrace rapidly evolving therapies underscores the importance of coping in the CF population.21

The relationship between coping and psychological function has been an area of interest for many years, with different dimensional constructs becoming codified and few studies delineating their overlap.22–25 For example, approach-oriented versus avoidant coping styles have canonically been considered the cornerstone of psychological interventions.26 Psychological resilience and psychological grit have also been examined as playing important roles in linking behaviors to various outcomes of interest.22,25,27 Recent work has focused on the affective mechanisms linking psychological factors and behavioral resilience,28 suggesting that there are important differences that have yet to be delineated between emotion-focused versus behaviorally-focused coping styles.29–33 Additional complexities that appear to require clarification include how to conceptualize the importance of stress reactivity and coping,26,34,35 the relative contributions of dispositional coping tendencies and their relationship to changes in coping patterns following intervention, and the importance of malleability of the psychological challenges one is facing.23,26 Put more simply, different coping styles may be more useful in different situations, depending on the challenge.36 This nuance has spawned an additional interest in coping flexibility, in which the previously unidimensional understanding of coping styles has been expanded to include profiles of coping across several facets.34 Emerging data suggest that psychological flexibility may have important benefits in determining coping skills efficacy among individuals with chronic diseases.31,37,38 Psychological flexibility is a construct that was developed within the acceptance and commitment therapy (ACT) literature and is conventionally defined by relative levels of six core domains:39,40 acceptance (eg, tolerance of uncomfortable experiences), cognitive defusion (eg, detachment from literal content of thoughts), present moment awareness, self-as-context (eg, seeing oneself from a broader perspective), personal values, and committed action (eg, taking intentional steps to engage in behaviors consistent with one’s values). In contrast to constructs such as grit,41,42 which focuses on perseverance in pursuit of specific goals (eg, running a marathon), psychological flexibility is more focused on choosing behaviors that align with personal values and taking a more flexible behavioral approach to act in accordance with these values over time (eg, exercising to maintain health).43 Another distinction between psychological flexibility and the desired treatment outcome of conventional coping skills therapies (eg, CBT) is that the latter often emphasizes control over one’s inner experience. For example, in CBT, maladaptive thought content is directly targeted in efforts to challenge distressing thoughts. In contrast, within the ACT framework, psychological flexibility is viewed as prioritizing valued (external) behaviors while de-emphasizing control over internal experiences, such as thoughts and emotions. In fact, within the ACT framework exerting ever-greater levels of control is conceptualized as the problem, not as a desired goal.44 Rather than challenging painful thought content, ACT focuses on how to cultivate psychological flexibility to allow one to hold painful thoughts and emotions lightly, as one might a butterfly, rather than trying to hold onto or get rid of such internal experiences. Recent data from the coronavirus disease 2019 pandemic suggested that greater psychological flexibility was robustly associated with lower mental health symptoms, including depressive, anxious, and stress symptoms.45 Despite broader interest in these constructs and their potential overlap, very few studies have attempted to delineate how different coping styles, psychological flexibility dimensions, and other related psychological constructs are associated with mental health outcomes. The objective of the present study was to characterize the associations between psychological flexibility, coping styles, and tendencies towards over-vs-under controlled behaviors with negative affect, as well as the relative magnitude of association between these various coping-related constructs. The present study attempted to characterize these associations in a large sample of adult PwCF, for whom coping with their chronic condition is an important and under-studied determinant of quality of life and clinical outcomes.

METHODS

Participants

The present cohort was comprised of 124 PwCF (87 females, 37 males) from baseline assessments of a randomized, telehealth ACT trial (https://clinicaltrials.gov/study/NCT04114227; NCT04114227). The parent trial included 124 adult PwCF, all of whom were utilized in the present analyses. The parent trial recruited individuals from four primary sites (Thomas Jefferson University, University of Virginia, Duke University Medical Center, Augusta University) who were then randomized to receive six sessions of either ACT or supportive (non-directed) psychotherapy over the course of six weeks. As shown in Table 1, participants tended to be White, had previously participated in psychotherapy, were taking psychotropic medications at the time of participation, and exhibited elevated anxiety and/or depressive symptoms. Inclusion criteria were age of 18 or older, diagnosis of CF, and a score of 4 or higher on the Generalized Anxiety Disorder-7 and/or the Patient Health Questionnaire-9. Consent was obtained electronically or in person. Sessions were conducted through telehealth using a Health Insurance Portability Accountability Act-compliant Zoom webcam platform. The Thomas Jefferson University IRB was the IRB of record, and participating sites also obtained IRB approval from their institutions.

TABLE 1.

Background and Demographic Characteristics of the Sample

Variable ACT Group (n = 61) Supportive Psychotherapy Group (n = 63) Full Cohort (n = 124)
Demographics
 Age 35.3 (SD = 11.9) 35.5 (SD = 11.1) 35.4 (SD = 11.5)
 Sex (F), n (%) 46 (75) 41 (65) 87 (70)
 Race/ethnicity, n (%)
  White 55 (90) 54 (86) 109 (88)
  African-American 0 2 (3) 2 (2)
  Hispanic 3 (5) 0 3 (2)
  Asian/Pacific Islander 2 (3) 0 2 (2)
  Other/did not respond 1 (2) 7 (11) 8 (6)
 Married or cohabitating, n (%) 29 (48) 29 (46) 58 (47)
 Self-reported income (per year), n (%)
  < $15,000 7 (11) 11 (17) 18 (15)
  $15–30,000 12 (20) 8 (13) 20 (16)
  $30–75,000 14 (23) 14 (22) 28 (23)
  > $75,000 27 (44) 25 (40) 52 (42)
  Did not respond 1 (2) 5 (8) 6 (5)
 Education, n (%)
  High school/vocational school 7 (11) 4 (6) 11 (9)
  Some college 15 (25) 12 (19) 27 (22)
  College degree 16 (26) 29 (46) 45 (36)
  Professional or graduate degree 22 (36) 13 (21) 35 (28)
  Did not respond 1 (2) 5 (8) 6 (5)
 Current psychotropic use (y), n (%) 40 (66) 34 (55) 74 (60)
 Prior therapy participation (y), n (%) 46 (75) 42 (68) 88 (72)
Clinical variables
 Forced expiratory volume (liters) 3.06 (SD = 1.38) 2.83 (SD = 1.13) 2.93 (SD = 1.24)
  < 2, n (%) 17 (28) 15 (24) 32 (26)
  2–3, n (%) 19 (31) 27 (43) 36 (29)
  3–4, n (%) 12 (20) 17 (27) 29 (23)
  ≥ 4, n (%) 10 (16) 4 (6) 14 (11)
 Forced expiratory volume (%) 79.8 (SD = 29.3) 74.2 (SD = 21.5) 76.7 (SD = 25.2)
 FVC (liters) 3.75 (SD = 1.1) 3.74 (SD = 0.94) 3.74 (SD = 1.01)
 FVC (%) 85.0 (SD = 20.7) 82.2 (SD = 21.5) 83.5 (SD = 20.9)
 Body mass index (kg/m2) 24.0 (SD = 4.8) 24.0 (SD = 4.8) 24.0 (SD = 4.8)
 Current CFTR modulator use, n (%) 43 (68) 40 (66) 83 (67)
Psychosocial functioning
 BDI-II 20.5 (SD = 8.8) 16.7 (SD = 10.6) 18.6 (SD = 9.9)
 BAI 14.8 (SD = 8.5) 12.7 (SD = 9.9) 13.8 (SD = 9.3)
 AAQ-II 26.8 (SD = 8.9) 23.4 (SD = 10.7) 25.1 (SD = 9.9)
 CFQ 51.9 (SD = 11.4) 46.6 (SD = 13.5) 49.2 (SD = 12.7)
 Cognitive Flexibility Scale 23.0 (SD = 5.4) 25.2 (SD = 5.4) 24.1 (SD = 5.5)
 Grit 3.1 (SD = 0.7) 3.5 (SD = 0.6) 3.3 (SD = 0.7)
 Over-vs-under control 2.5 (SD = 0.2) 2.6 (SD = 0.9) 2.5 (SD = 0.9)
 Avoidant coping 2.6 (SD = 0.9) 2.6 (SD = 0.9) 2.6 (SD = 0.9)
 Support seeking 3.1 (SD = 1.0) 3.2 (SD = 0.9) 3.1 (SD = 0.9)
 Acceptance 3.1 (SD = 0.8) 3.2 (SD = 0.8) 3.2 (SD = 0.8)
 Resignation 1.6 (SD = 0.7) 1.5 (SD = 0.7) 1.5 (SD = 0.7)
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AAQ = Acceptance and Action Questionnaire; ACT = acceptance and commitment therapy; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CFQ = Cognitive Fusion Questionnaire; CFTR = cystic fibrosis transmembrane regulator; FVC, forced vital capacity.

Income was assessed by asking participants, “What is your combined gross family income?” Continuous data are described using SD. Categorical data are described using n (%).

Measures

The present cross-sectional analyses are based on baseline data from a previously reported randomized ACT trial among PwCF.46 Participants completed a demographic questionnaire and psychometric measures of depression [Beck Depression Inventory-II (BDI-II)], anxiety [Beck Anxiety Inventory (BAI)], cognitive fusion [Cognitive Fusion Questionnaire (CFQ)-13, Acceptance and Action Questionnaire (AAQ)-II], quality of life [Cystic Fibrosis Mental Health and Wellness Questionnaire; Cystic Fibrosis Questionnaire-Revised (CFQ-R)], treatment adherence (Treatment Adherence Questionnaire-CF), and coping (Medical Coping Modes Questionnaire, Coping Flexibility Scale, Short Grit Scale, Styles of Coping Word-Pairs) at baseline, posttreatment, and 3-month follow-up.

Negative Affect

To examine associations between coping, psychological flexibility, and control styles with mood-related variables, we utilized two canonical measures of depressive and anxious symptoms, which were combined for analysis (see “Data Analysis” section). We elected not to use the screening measures above (Generalized Anxiety Disorder-7 and Patient Health Questionnaire-9) in either the primary trial or the present analyses, as we wanted to minimize bias associated with annual, repeated administrations of these routinely obtained screening measures.

The Beck Depression Inventory-II

The BDI-II47 is a 21-item self-report measuring symptoms of depression over the past two weeks. Item responses range from 0 to 3, and total scores from 0 to 63, with higher scores indicating higher levels of symptoms. Total BDI-II scores are conventionally interpreted as 0 to 13 suggesting minimal depressive symptoms, 14 to 19 suggesting mild symptoms, 20 to 28 suggesting moderate symptoms, and 29 to 63 suggesting severe depressive symptoms.

The Beck Anxiety Inventory

The BAI48 is a 21-item self-report measure assessing symptoms of anxiety over the past week. Answer options range from 0 (not at all) to 3 (severely), and total scores range from 0 to 63, with higher scores indicating higher levels of anxiety symptoms. Total BAI scores are conventionally interpreted as 0 to 7 suggesting minimal anxiety symptoms, 8 to 15 suggesting mild symptoms, 16 to 25 suggesting moderate symptoms, and 26 to 63 suggesting severely elevated anxiety symptoms.

Psychological Flexibility

To assess psychological flexibility, we collected data using two of the most commonly deployed measures assessing subcomponents of psychological flexibility and the degree to which individuals reported engagement with values-consistent behaviors in their daily lives. We selected the 2 measures below because they are the most widely used within the ACT literature and associated with the 2 subdomains most strongly associated with symptomatic improvements from psychological interventions.49 These 2 canonical variables were combined to provide a mean rank score of psychological flexibility (see “Data Analysis” section).

The Cognitive Fusion Questionnaire-13

The CFQ-1350 is a 13-item self-report measure of cognitive fusion, which is best understood as the degree of rigid attachment one has to their thought content and the tendency for thoughts to dictate behaviors. For example, individuals who tend to overthink their responses, become “stuck in their head,” and who may actively try to keep themselves from having unwanted thoughts (which they cannot fully control) would be considered to have more cognitive fusion. Responses range from 1 (not true at all) to 7 (always true), and total scores from 13 to 91, with higher scores indicating a greater degree of cognitive fusion.

The Acceptance and Action Questionnaire-II

The AAQ-II51 is a 7-item measure of psychological flexibility. Responses range from 1 (never true) to 7 (always true), and higher scores indicate higher levels of inflexibility/experiential avoidance.

Medical Coping Modes Questionnaire

The Medical Coping Modes Questionnaire52 is a 20-item self-report measure for use with patients with a life-threatening disease. Domains of confrontation, avoidance, and resignation are measured. Items are rated from 0 (never) to 4 (always), and the domain with the highest score reflects the coping style most likely to be used.

Coping Flexibility Scale

The Coping Flexibility Scale53 is a 10-item measure of coping flexibility, with subscales of evaluation of coping (ineffective) and adaptive coping. Respondents rate how stress-coping situations relate to them on a scale from 1 (not true) to 4 (very true). Total scores range from 10 to 40, with higher scores indicating more flexible coping styles.

The Short Grit Scale

The Short Grit Scale54 is a self-report measure of “grit,” or trait-level perseverance and passion for long-term goals. Respondents rate how well statements described them on a 5-point scale, from “not like me at all” to “very much like me.” Total scores are averaged across all items and, therefore, range from 1 to 5, with higher scores indicating greater levels of self-reported grit.

The Styles of Coping Word-Pairs Questionnaire

The Styles of Coping Word-Pairs55,56 is a 47-item forced-choice measure of overall personality style. Scores indicate if the respondent’s coping style tends to be more over-controlled or undercontrolled. Higher scores indicate greater tendencies towards response patterns characterized by exerting greater levels of control.

Participant Health Information

Data regarding lung function were extracted from participants’ electronic health records and included forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC; the total amount of air that can be exhaled), and FEV1/FVC ratio.

Data Analyses

Analyses were conducted in SAS 9.4 and R 4.4.3. Sample size was determined at the time of the initial grant application for the parent trial. General linear models were used to examine the associations between coping styles and psychological outcomes, controlling for age, sex, and pulmonary function. To reduce the total number of analyses and mitigate against type-I error, psychological outcomes were combined into a mean rank, global score.57,58 We have used this approach extensively to enhance power in small sample sizes and reduce multiplicity among highly interrelated outcome measures, both of which are common within behavioral trials utilizing psychometric outcomes.59–65 We elected to combine our two measures of psychological flexibility (CFQ-13 and the AAQ-II) based both on their shared conceptual overlap and their high degree of intercorrelation in the present sample (r = 0.75, p < .001). We also conducted secondary analyses to characterize levels of depressive and anxious symptoms among individuals with high (ie, the top quartile) versus low (ie, the lowest quartile) psychological flexibility. Similarly, the negative effect was comprised of the BDI-II and BAI. Sample size estimates for the parent trial were based on conservative assumptions from prior behavioral intervention trials, which assumed an r-squared between covariates and the outcome of interest of 0.50, a 30% attrition rate, and an approximate effect size of Cohen d = 0.45. Multiple imputation using PROC MI in SAS 9.4 with 200 imputations was used to account for missing data (<5%). Data and/or code for all analyses are available upon request from the corresponding author.

RESULTS

Background Characteristics

From April 2020 to March 2023, a total of 146 individuals were screened for potential inclusion in the trial. Among the 124 individuals who were available at baseline and provided psychometric data, 74 (60%) were taking psychotropic medication. FEV1/FVC ratios varied widely [median = 76% (interquartile range = 66, 85)], and participants demonstrated a strong tendency towards over-vs-under control [median log-transformed control style = 5.4 (5.0, 5.8)]. Depressive [BDI-II = 18.6 (SD = 9.9)] and anxious [BAI = 13.8 (SD = 9.3)] symptoms were both elevated. Fifty participants (39%) were married, and most participants were using modulator therapy at the time of randomization. Acceptance and Action scores and Cognitive Fusion scores were highly correlated and, therefore, combined into a mean rank and global score to assess their association with mood (mean rank combination of the BDI-II and BAI).

Psychological Flexibility, Coping, and Mood

Table 2 displays unadjusted correlations between different coping measures, psychological flexibility, and behavioral control styles. Greater levels of psychological flexibility were associated with lower negative affect (B = −0.60, p < .001, Fig. 1, Table 3). Follow-up analyses revealed robust associations between negative affect and both acceptance (B = −0.51. p < .001, Fig. 2A) and cognitive fusion (B = −0.59, p < .001, Fig. 2B). Similarly, greater levels of avoidance (B = 0.32, p < .001), resignation (B = 0.37, p < .001), lower levels of grit (B = −0.35, p < .001), and lower tendencies towards over-vs-under control (B = −0.29, p = .003) all associated with greater negative affect. Additional analyses of baseline data revealed that greater negative affect was associated with worse FEV1 levels (B = −0.19, p = .046), with the strongest association for the BDI-II (B = −0.22, p = .029). Although our composite measure of psychological flexibility was not associated with FEV1 levels (B = 0.13, p = .152), exploratory analyses revealed that higher scores on the AAQ-II tended to be associated with FEV1 (B = 0.17, p = .062). Hierarchical regression analyses demonstrated that greater psychological flexibility was the most robust correlate of lower negative affect after accounting for other coping variables (B = −0.50, p < .001), and this association was not moderated by FEV1/FVC levels. Explanatory analyses revealed that lower levels of cognitive fusion on the CFQ (B = −0.54, p < .001) and lower psychological acceptance and action on the AAQ-II (B = 0.61, p < .001) were strongly associated with higher levels of negative affect.

TABLE 2.

Unadjusted Correlations Between Different Coping Measures, Psychological Flexibility, and Behavioral Control Styles

Variable Psychological Flexibility Cognitive Flexibility Grit Over-vs-Under Control Avoidant Coping Support Seeking Resignation Acceptance
Psychological flexibility — −0.48a −0.39a −0.40a 0.30a −0.14 0.47a −0.13
Cognitive flexibility — — 0.33a 0.20b −0.15 0.34a −0.35a 0.42a
Grit — — — 0.36a −0.05 0.14 −0.30a 0.13
Over-vs-under control — — — — −0.07 −0.02 −0.17 0.17
Avoidant coping — — — — — −0.02 0.37a 0.05
Support seeking — — — — — — −0.27a 0.47a
Resignation — — — — — — — −0.28a
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a

P < .01.

b

P < .05.

FIGURE 1.

FIGURE 1.

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Psychological flexibility and negative affect, adjusted for age, sex, FEV1, income, and current use of psychotropic medication usage. BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; FEV1 = forced expiratory volume in 1 second. Color image is available online only.

TABLE 3.

Full Results for Our Primary Regression Model Associating Negative Affect With Psychological Flexibility

Variable Parameter Estimate (SE) Standardized Parameter Estimate p
Intercept 6.5 (15.1) 0 .666
Age −0.1 (0.2) −0.01 .820
Sex (M) 11.3 (5.2) 0.2 .032
Baseline FEV1 2.7 (2.1) 0.1 .210
Income −0.6 (2.2) −0.02 .776
Psychotropic medication use (Y/N) 10.2 (4.7) 0.17 .034
Psychological flexibility, mean rank 0.6 (0.1) 0.60 < .001
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FEV1 = forced expiratory volume in 1 second.

FIGURE 2.

FIGURE 2.

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A and B, Psychological flexibility and associations with the AAQ-II (A) and CFQ (B) adjusted for age, sex, FEV1, income, and current use of psychotropic medication usage. AAQ = Acceptance and Action Questionnaire; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CFQ = Cognitive Fusion Questionnaire; FEV1 = forced expiratory volume in 1 second. Color image is available online only.

To characterize clinically meaningful levels of depressive and anxious symptoms, we conducted secondary analyses in which we examined BDI-II and BAI levels among individuals in the lowest quartile of psychological flexibility (ie, ≤25th percentile) compared with individuals in the top quartile (ie, ≥75th percentile). Results suggested that individuals with low compared with high psychological flexibility had clinically meaningful differences in depressive and anxious symptoms. For the BDI-II, individuals with high versus low psychological flexibility had depressive symptom scores corresponding to minimal-mild depressive symptoms versus moderate-severe symptoms [lowest quartile: mean BDI-II = 11.3 (SD = 6.3) vs highest quartile: mean BDI-II = 27.3 (SD = 10.4)]. For anxiety symptoms, high versus low psychological flexibility corresponded to low versus moderate levels of anxiety [lowest quartile: mean BAI = 9.9 (SD = 7.9) vs highest quartile: mean BAI = 22.3 (SD = 9.7)]. To visually display levels of psychological flexibility across levels of depressive symptoms, Figure 3 shows both unadjusted (Fig. 3A) and adjusted (Fig. 3B) psychological flexibility scores across levels of depressive symptoms. As shown, greater depressive symptoms are associated with higher (worse) psychological flexibility scores (p < .001).

FIGURE 3.

FIGURE 3.

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A and B, Psychological flexibility (mean rank of AAQ-II and CFQ) across depressive symptom levels. Black = minimal symptoms (BDI-II scores: 0–13), blue = mild symptoms (BDI-II scores: 14–19), yellow = moderate symptoms (BDI-II scores: 20–28), red = severe symptoms (BDI-II scores: ≥29). A, Raw Psychological Flexibility scores across levels of depression. B, Residualized levels of psychological flexibility after adjustment for age, sex, FEV1, income, and psychotropic medication use. AAQ = Acceptance and Action Questionnaire; CFQ = Cognitive Fusion Questionnaire; FEV1 = forced expiratory volume in 1 second. Color image is available online only.

DISCUSSION

Our results provide additional evidence adding to an emerging literature that suggests greater levels of psychological flexibility are an important marker of psychological resilience and may be better associated with clinically relevant psychological measures of mood compared with other canonical psychometric constructs. Within the present sample of PwCF, we demonstrated that multiple measures associated with coping, coping flexibility, grit, and control tendencies are all associated with levels of depression and anxiety. However, markers of psychological flexibility were not only associated more robustly with measures of mood but also remained significantly associated even after controlling for all other measures of coping-related constructs. This finding underscores the potential unique addition that psychological flexibility may provide to enhance understanding of effective coping strategies.23 These findings are particularly important for PwCF, for whom the past decade has introduced novel therapies (eg, cystic fibrosis transmembrane regulator modulators) that have dramatically altered expectations regarding survival and quality of life.66,67

The importance of coping on mood within chronic disease samples has been an area of extensive study over the past several decades.68–71 Prior work has suggested that different coping styles, such as approach-oriented or avoidant coping, may provide critical data to inform targeted treatments to enhance coping abilities.72–74 Notwithstanding the clear importance of proactive coping styles,75,76 data over the past decade have begun to enhance this perspective by underscoring the importance of contextual demands in understanding the relationship between coping and mood.36 For example, for individuals with a chronic health problem that is unrelenting or less pliable by approach oriented coping styles, efforts to change behavior may not only be ill advised but may also worsen mood and clinically relevant outcomes.43,77 Acceptance-based psychological approaches embrace this important distinction by focusing on the importance of psychological flexibility as an important target to cultivate adaptive coping styles, which may involve some combination of approach, acceptance, or even avoidance of stressors depending on individual contextual challenges.43

Psychological flexibility has several important components that all contribute to more adaptive coping. These include greater experiential acceptance, lower cognitive fusion, clarity of personal values, self-as-context (ie, having a more stable sense of self that does not change across settings), present moment awareness, and committed action.21,78 Two of the key components that appear most modifiable by treatment within the ACT framework are training individuals to have greater levels of psychological acceptance of uncomfortable experiences in the service of valued actions and greater detachment from their thought content as literally true.79 Within the present study, both of these constructs are associated robustly with levels of depression and anxiety and thus could be targets of psychological intervention. While there are some elements of psychological flexibility that may be associated with grit, coping styles, and control tendencies, it is possible that acceptance and cognitive fusion may reflect more thought-based aspects of the coping process that are then reflected by a variety of different, more effective behaviors.80,81

The present analyses must be viewed with several important limitations in mind. First, our assessments of coping and other relevant behaviors were obtained almost exclusively from self-report and should, therefore, be interpreted with some caution. Future studies might benefit from additional assessment of behavioral adherents, physical activity, and other clinically relevant health behaviors that are germane to the population of the study. Second, it is unclear to what extent the present findings are unique to individuals with CF or may extend beyond this population. PwCF has unique and chronic health challenges that may require different coping styles for affected behavioral management. It is notable, for example, that individuals in the present sample reported a very high level of over versus undercontrol tendencies, suggesting a high level of engagement and an impulse towards more regimented behavioral responses, which may not generalize to people living with CF as a whole or to other medical populations. Third, our analysis was cross-sectional, and it is unclear to what extent the observed pattern of findings holds across time. Notably, within the present sample, parallel analyses of psychological flexibility and negative affect following 6-weeks of ACT treatment not only replicated findings at baseline but demonstrated stronger associations with flexibility and mood (B = −0.69, p < .001), suggesting that this association may be robust. Future studies should nevertheless replicate the present pattern of associations to ensure their validity. Finally, it should be noted that our sample was likely highly selective in several ways, including socioeconomic status, degree of prior psychotherapy, and degree of psychotropic medication usage. It is, therefore, likely that those individuals who enrolled had higher socioeconomic status and were more inclined to utilize psychological services relative to participants who did not enroll. This may limit the generalizability of these findings to other more representative samples.

CONCLUSION

Our data underscore the burgeoning body of evidence suggesting that psychological flexibility is an important correlate of mood within PwCF. Moreover, it is possible that psychological flexibility provides a unique and previously underexamined component of coping processes that may enhance our understanding of psychological resilience among individuals with chronic health conditions. Future studies targeting psychological flexibility to improve physical and psychological quality of life should examine whether improvements in psychological flexibility mediate improvements in patient-centered outcomes.

Source of Funding and Conflicts of Interest:

This work was supported by the Boomer Esiason Foundation and 1R61AG080615-01 from the National Institute of Aging. C.V.O. and P.J.S. have received funding from Alexion Pharmaceuticals for the development of Acceptance and Commitment therapy protocols among other medical populations.

Contributor Information

Patrick J. Smith, Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Christopher F. Drescher, Department of Psychiatry and Health Behavior, Augusta University, Augusta, Georgia.

Heather Bruschwein, Department of Psychiatry and Neurobehavioral Sciences, University of Virginia, Charlottesville, Virginia.

Krista Ingle, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.

Chelsi Nurse, Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Catherine Virginia O’Hayer, Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

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