The role of positive goal engagement in increased mental well-being among individuals with chronic non-cancer pain

Abstract

Individuals with chronic pain commonly report significant functional impairment and reduced quality of life. Despite this, little is known about psychological processes and mechanisms underpinning enhancements in well-being within this population. The study aimed to investigate whether (1) increased levels of pain intensity and interference were associated with lower levels of mental well-being, (2) increased positive goal engagement was associated with higher levels of mental well-being and (3) whether the relationships between pain characteristics and mental well-being were mediated by increased positive goal engagement. A total of 586 individuals with chronic pain participated in the cross-sectional, online study. Participants completed self-report measures to assess pain intensity and interference, mental well-being and goal motivation variables. Results showed that pain interference and positive goal engagement were associated with mental well-being. Moreover, the relationship between pain interference and mental well-being was partially mediated by positive goal engagement. The results provide tentative evidence for the protective role of positive goal engagement in enabling individuals with chronic pain to maintain a sense of mental well-being. The study develops the biopsychosocial model of chronic pain by examining the roles and relationships of relevant yet previously unexplored psychological constructs. The promotion of mental well-being through the enhancement of positive goal engagement is discussed, offering a platform for further research and clinical interventions.

Introduction

The impact of chronic pain is multifaceted and best understood from a biopsychosocial perspective which takes into account the complex interplay of factors that contribute towards an individual’s experience.¹ Relationships between pain intensity, associated impaired function and poor psychological health are well documented within the literature.² Maladaptive cognitive processes such as pain catastrophising^3,4 and rumination⁵ have been found to underpin and perpetuate pain-related psychological distress.⁶ Psychological health is described as ‘not just the absence of stress or mental illness (i.e. languishing), but also the presence of flourishing⁷ (i.e. well-being)’. By solely measuring reductions in levels of psychological distress or symptomatology, researchers and clinicians may inadvertently omit clinical outcomes relevant to improvements in well-being and quality of life.

Past research has found the protective role of positive psychological traits such as self-efficacy,⁸ acceptance, hope and optimism⁹ to be associated with increased psychological adjustment to pain and lower pain perception. Understanding the psychological mechanisms associated with improved well-being among individuals with chronic pain is of particular significance given the somewhat limited effectiveness of medical and pharmaceutical interventions within this area.¹⁰

Those with persistent pain often exhibit avoidance behaviours as a means to reduce pain in the short term.¹¹ This increased motivation to avoid or reduce pain can lead to further pain-related disability through inactivity and deter the pursuit of previously valued goals.¹² Goal motivation is fundamental to human experience and giving people a sense of meaning, purpose and fulfilment in life.^13–16 How individuals adjust and regulate their goal pursuit when experiencing chronic pain may be a key determinant in accounting for individual differences in pain tolerance and management, and understanding psychological well-being.^17,18 Recent goal-related research indicates two emerging areas in the physical health field: the solution-focused approach and goal-focused hope. Both have been applied therapeutically in clinical interventions in an effort to improve the well-being of people living with chronic pain.

Positive psychological interventions underpinned by solution-focused approaches that draw upon inherent personal strengths and resilience to facilitate goal-orientated action have led to increased mental well-being in chronic pain populations.¹⁹ Promoting individuals’ ability to engage in ‘solution-focused thinking’²⁰ and increasing positive attentional bias enables individuals to better notice their internal resources and exceptions to the pain-related problems, leading to an increased sense of well-being.²¹

Hope-based interventions have been shown to significantly increase levels of well-being.^22,23 Personal goals are also thought to promote hope. Specifically, goal-focused hope is defined as future oriented goal motivation (i.e. the ‘will’) and the belief in one’s ability to plan how a goal may be achieved (i.e. the ‘way’).²⁴ Goal-focused hope has been found to be an independent predictor of well-being²⁵ and has been linked to higher pain threshold and greater pain tolerance.²⁶ Individuals in chronic pain with high levels of trait hope may be more likely to adopt alternative goals, and seek pathways to achieve their goals, thus sustaining motivational goal pursuit in the face of obstacles.²⁷

This is the first study to examine adaptive psychological goal-motivational processes in relation to mental well-being among individuals with chronic pain. We aimed to investigate whether characteristics of the pain experienced were associated with mental well-being, and whether ‘positive goal engagement’ (measured by solution-focused thinking and goal-focused hope) mediated the relationships between pain characteristics and mental well-being. We hypothesised that (1) increased levels of pain intensity and interference would be associated with diminished mental well-being, (2) increased positive goal engagement would be associated with greater mental well-being and (3) positive goal engagement would mediate the relationships between pain characteristics and enhanced mental well-being.

Materials and methods

Procedure and participants

This was a cross-sectional, internet-based study. A total of 12 member charities of Pain UK advertised the study via a link on their social media pages and discussion forums. Institutional and ethical approval was obtained from the University of Liverpool (Ref: IPHS-1415-068) and individuals with chronic pain who attended a service-user led support group were consulted regarding the study to increase its relevance, accessibility and participation. Inclusion criteria were (1) having experienced non-malignant physical pain for three consecutive months or longer, (2) being aged 18 years or over, (3) being a resident of the United Kingdom and (4) being fluent in English.

The total sample comprised 586 participants. The vast majority were female (95.1%, n = 557) and the mean age was 41.6 years (standard deviation [SD], 12.5; range, 18–86 years). In total, 94.7% (n = 555) had reported receiving a formal diagnosis of a chronic pain condition from a health professional, though specific diagnoses varied. The range in duration since the initial onset of the pain also varied, with participants most commonly reporting having experienced pain for more than 15 years (25.4% of all respondents). A total of 88.6% (n = 519) reported taking analgesic medication on a daily basis to manage pain-related symptoms. Only complete datasets were included in the final analysis though examination of the available demographic information revealed no significant differences in relation to gender, regular use of analgesia and the frequency of formal diagnoses between the 586 participants who completed the online questionnaire in its entirety and the 171 individuals who did not (all ps > .001). A significant difference was apparent between completers and non-completers in relation to age, t (755) = 4.09, p < .001, where there was a tendency for non-completers to be younger than those who completed all of the survey. Even though the participants reported persistent pain, the overall completion rate of 71% is comparable to those reported in other research studies utilising online surveys.²⁸

Measures

Solution-Focused Inventory

The 12-item Solution-Focused Inventory (SFI) was used to assess solution-focused cognitive processing.²⁰ The measure com-prised three subscales, each consisting of four items: problem disengagement, goal orientation and resource activation. Items were rated on 6-point Likert-type scales. The problem disengagement subscale assessed the extent to which individuals could disengage from problem-focused cognitive processing (e.g. rumination or negative attentional bias which impairs one’s ability to disengage from persistent focusing on difficulties, impairments or causal aetiology). The goal orientation subscale measured the extent to which an individual could construct personally valued goals and engage in active self-regulation to approach and achieve them. Finally, the resource activation subscale assessed a person’s capacity to identify and utilise their own personal strengths and resources in developing solutions to problems, reflecting the presence of resilience and optimism. Higher scores represented greater levels of problem disengagement, goal orientation and resource activation. Validation research using a non-clinical sample demonstrate adequate to good Cronbach’s α estimates (problem disengagement α = .78, goal orientation α = .78 and resource activation α = .68) and confirmatory factor analysis of the individual items within each subscale demonstrates support for a three-factor model. The internal consistency for each of the subscales within this study was good (problem disengagement α = .82, goal orientation α = .84 and resource activation α = .76).

The Adult Hope Scale

The 12-item Adult Hope Scale (AHS) was used to measure trait goal-focused hope.²⁹ The scale is based on Snyder and colleagues’ cognitive model of hope²⁹ and comprised two subscales: pathway and agency. Participants indicated their responses on an 8-point Likert-type scale for each item. The pathway subscale assessed one’s ability to plan how a goal may be accomplished, and the agency subscale measured an individual’s goal-directed motivation, or determination to achieve the goal. Factor analysis has supported the use of the two-factor model and higher levels of trait goal-focused hope were represented by higher pathway and agency scores. Past research has demonstrated good internal consistency for both the pathway (α = .80) and agency (α = .76) subscales, as also shown in the current sample (pathway α = .84, agency α = .82).

Warwick-Edinburgh Mental Well-being Scale

Mental well-being was measured using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS).³⁰ This measure comprised 14 positively worded items addressing hedonic and eudaimonic perspectives of positive mental health. Items were rated on 5-point Likert-type scales, with higher scores reflecting higher levels of mental well-being. The scale has shown good internal reliability and good test–retest reliability (α = .91 and α = .83) and confirmatory factor analysis supports the single-factor hypothesis. The internal consistency of the measure in this study was α = .93.

Brief Pain Inventory Short-Form

The Brief Pain Inventory Short-Form (BPI-SF) was used to assess the intensity of participants’ pain and the impact of this pain upon daily functioning.³¹ Widely used in both clinical and research settings, the BPI-SF is a 17-item self-report measure comprising a series of 0–10 numeric rating scales. Mean scores were calculated to inform two subscales relating to pain intensity and pain interference (i.e. impact upon everyday functioning). Higher scores for each subscale indicated greater pain intensity and pain interference. The two-factor model has been found to demonstrate good construct validity for individuals with chronic non-cancer pain³² and both the intensity and interference scales demonstrate good internal consistency (α = .87 and α = .92, respectively). In the current sample, the internal consistency of each scale was α = .84 for intensity and α = .91 for interference.

Analysis

SPSS 22³³ was used to conduct the statistical analyses. Data met the statistical assumptions required for structural equation modelling (SEM). AMOS³⁴ was used to analyse the proposed SEM a priori model, which was developed taking into account existing theory and literature within the fields of positive psychology, goal motivation, mental well-being and chronic pain. Model fit was assessed via a range of fit statistics, including the chi-square statistic (χ²), the root mean square error of approximation³⁵ (RMSEA), the comparative fit index³⁶ (CFI) and the standardised root mean square residual (SRMR). For a model to be regarded as an acceptable fit, the χ² should be non-significant (p > .05) although it is notable that this statistic can often be overly sensitive to large sample sizes, leading to an inflated χ² which may erroneously imply a poor data-to-model fit.^37,38 With respect to other fit indices, Hu and Bentler³⁹ recommend that values ⩽.06 for the RMSEA and SRMR suggest good fit and values ⩽.08 indicate adequate fit. A CFI value of >.95 suggests a good model fit to the observed data. In this study, 95% bias-corrected bootstrap confidence intervals were calculated to examine the indirect effects of the hypothesised mediator variable (positive goal engagement) in the SEM model.⁴⁰ The total number of bootstrap samples was 5000, as recommended when undertaking scientific research.⁴¹

The minimum recommended sample size required for SEM analysis is at least 10 participants per estimated parameter.^42,43 The model presented in this study had 20 parameters (9 regression weights, 9 error variances and 2 covariances), suggesting that at least 200 participants were required. The sample size in this study was 586, indicating that the SEM analysis was adequately powered.

Results

Data screening

The skewness and kurtosis values of all variables fell comfortably within the recommended parameters of +1 and −1 and examination of the histograms did not suggest significant departures from normality. The distribution of residuals was examined by conducting a series of multiple regression analyses. Each of the proposed endogenous variables (problem disengagement, goal orientation, resource activation, agency, pathway and mental well-being) was entered singly as the dependent variable, and all the remaining variables were entered as predictor variables. This process was repeated for each of the above variables. Examination of the histograms and scatterplots suggested normality and homoscedasticity.

Descriptive statistics

Mean descriptive statistics for the study variables are displayed in Table 1. There were no significant gender differences across the key study variables (all ps > .05). Furthermore, no statistically significant differences were found between participants with a formal diagnosis of a pain condition versus those without a formal diagnosis on the psychological variables (all ps > .05). Individuals taking medication to manage pain symptoms, relative to those not on regular medication, reported significantly higher levels of pain interference, t (584) = 3.00, p < .01, but not intensity (p = .07). No other significant differences across both the demographic and psychological variables with respect to medication were found (all ps > .05). Statistically significant differences in problem disengagement, F (13, 572) = 2.88, p < .001, agency, F (13, 572) = 2.33, p < .05, intensity, F (13, 572) = 3.87, p < .001 and interference, F (13, 572) = 3.10, p < .001 across differing pain conditions were evident and the implications of these differences are discussed later in this article.

Table 1.

Descriptive statistics.

Variable	Mean	Standard deviation	Minimum–maximum score range
MWB	40.43	9.35	18–63
BPI-SF Intensity	5.49	1.75	0–10
BPI-SF Interference	6.50	2.29	0–10
SFI PD	15.59	4.46	4–24
SFI RA	15.86	3.68	5–24
SFI GO	15.14	3.77	4–24
AHS Agency	20.60	6.15	4–32
AHS Pathway	21.05	5.38	4–32

MWB: mental well-being; BPI-SF: Brief Pain Inventory Short-Form; SFI PD: Solution-Focused Inventory Problem Disengagement subscale; SFI RA: Solution-Focused Inventory Resource Activation subscale; SFI GO: Solution-Focused Inventory Goal Orientation subscale; AHS: Adult Hope Scale.

Correlations

Pearson’s correlations are reported in Table 2. As expected, mental well-being correlated negatively with pain intensity and interference and positively with the solution-focused thinking and goal-focused hope subscales. There was also a small but significant positive relationship between income and mental well-being, though contrary to previous findings,⁴⁴ no significant relationships between mental well-being, pain duration and age were shown. As predicted, pain intensity and interference correlated negatively with hope agency and pathway, indicative of a relationship between high pain levels (that impact significantly upon everyday functioning) and poor motivation to plan and accomplish valued goals.

Table 2.

Correlation matrix of all study variables.

Variable	1	2	3	4	5	6	7	8	9	10	11
1. MWB
2. BPI-SF Intensity	−.28**
3. BPI-SF Interference	−.48**	.63**
4. SFI PD	.54**	.06	−.16**
5. SFI RA	.43**	−.12**	−.29**	.32**
6. SFI GO	.56**	−.09*	−.23**	.46**	.46**
7. AHS Agency	.65**	−.22**	−.34**	.47**	.49**	.77**
8. AHS Pathway	.61**	−.14**	−.31**	.46**	.56**	.70**	.76**
9. Income	.22**	−.19**	−.22**	.02	.04	.12**	.25**	.17**
10. Duration	.02	.01	.02	.04	−.07	−.02	−.03	.01	.03
11. Age	.05	.15**	.10*	.25**	−.11**	−.12**	−.10*	.04	.03	.16**

^*Significant at .05 level, two-tailed; **significant at .01 level.

MWB: mental well-being; BPI-SF: Brief Pain Inventory Short-Form; SFI PD: Solution-Focused Inventory Problem Disengagement subscale; SFI RA: Solution-Focused Inventory Resource Activation subscale; SFI GO: Solution-Focused Inventory Goal Orientation subscale; AHS: Adult Hope Scale.

Resource activation and goal orientation correlated negatively with both pain intensity and interference. A significant negative correlation was evident between problem disengagement and pain interference only, and not for pain intensity. As can be seen in Table 2, all three solution-focused subscales were highly correlated with hope agency and pathway. This is not surprising as conceptually these constructs are all closely related, involving a positive orientation towards and engagement with goals.^45,46 Multicollinearity between predictor variables can be problematic in SEM and lead to inaccuracies in the estimation of parameters.⁴⁷ While such issues may be alleviated by means of good measure reliability and adequate statistical power through an appropriate sample size,⁴⁸ such as in this study, multicollinearity can lead to inference errors when two variables do not have sufficient independent variation.⁴⁹ Given these statistical considerations, and the possibility of a common theoretical process underlying the scales, we modelled the five subscales as indicators of one higher-order latent variable in the SEM model, ‘positive goal engagement’.

SEM analysis

SEM was used to test a proposed theoretical model whereby positive goal engagement (comprising the two AHS subscales and three SFI subscales) mediated the relationships between pain intensity and mental well-being, and pain interference and mental well-being, respectively. The maximum likelihood method was used to estimate the parameters of the hypothesised model, χ²(16) = 120.24, p < .01. The χ² was significant and suggested that the hypothesised model did not acceptably fit the data, though this figure may have been biased by the large sample size. Further examination of the fit indices revealed that the model was an adequate fit of the data (CFI = .96, RMSEA = .11, SRMR = .05). The modification indices highlighted that the hypothesised model could be improved, though no such amendments were made in order to avoid over-fitting the data and thereby limiting the generalisability of the model. Figure 1 displays the model completely with the standardised and unstandardised regression weights, significance values and R² values.

Figure 1.

Graphical representation of the SEM model.

Standardised regression slopes for direct effects are represented by single-headed arrows. Covariance between variables is depicted by curved double-headed arrows. The unstandardised regression weights are reported in the brackets. The total standardised proportion of variance accounted for (R²) is reported to the top right-hand corner for each endogenous variable.

MWB: mental well-being; BPI-SF: Brief Pain Inventory Short-Form; PD: Solution-Focused Inventory Problem Disengagement subscale; RA: Solution-Focused Inventory Resource Activation subscale; GO: Solution-Focused Inventory Goal Orientation subscale; Agency: Adult Hope Scale Agency subscale; Pathway: Adult Hope Scale Pathway subscale. **Significant at .001 level.

Indirect effects

Positive goal engagement partially mediated the relationship between pain interference and mental well-being. The relationship between pain intensity and mental well-being was no longer significant in the model, and there was no indirect effect of positive goal engagement between these variables. The standardised and unstandardised indirect effects are reported in Table 3.

Table 3.

Indirect effects for the SEM model.

Predictor	Outcome	Standardised indirect effect	Unstandardised
			Indirect effect	Lower CI	Upper CI
BPI-SF Intensity	MWB	.04	.24	−.16	.63
BPI-SF Interference	MWB	−.25**	−1.01	−1.31	−.73

BPI-SF: Brief Pain Inventory Short-Form; MWB: mental well-being; CI: confidence interval; SEM: structural equation modelling.

^**Significant at .001 level, two-tailed.

Discussion

This study investigated the role of chronic pain characteristics and positive goal engagement in relation to mental well-being. As expected, results showed that a greater level of pain interference in everyday functioning was associated with reduced mental well-being, though no direct effect of pain intensity in relation to decreased mental well-being was found. As hypothesised, increased positive goal engagement (comprising factors derived from the solution-focused approach and goal-focused hope) was associated with increased mental well-being. Furthermore, positive goal engagement was found to partially mediate the relationship between pain interference and increased mental well-being. This is the first study to evidence the protective role of positive goal engagement in enabling individuals with chronic pain to enhance a sense of mental well-being, while accounting for the effects of the functional impact of pain itself.

The finding that a higher level of pain interference was a significant independent predictor of reduced mental well-being is consistent with past research.⁵⁰ In this study, pain interference was strongly associated with reduced mental well-being, though no such relationship with respect to pain intensity was evident, indicating that it is the extent to which the pain prevents individuals from engaging in everyday activities, as opposed to the level of pain that has the greatest impact upon mental well-being. The results suggest that greater pain interference may impair one’s capacity to engage in everyday goal pursuits. Furthermore, pain intensity and interference were found to differ across the broad range of chronic pain conditions. As would be expected, those with localised pain specific to certain sites on the body (e.g. shoulder pain) reported less pain intensity and interference than those with more generalised pain conditions such as chronic regional pain syndrome (CRPS). While there is a paucity of research that investigates the differing effects of pain characteristics upon mental well-being specifically, the variability between the strength of these relationships upon depression has been replicated in previous research.⁵¹ The disabling and enduring nature of pain and its subsequent impact upon function is apt to contribute towards a reduced sense of mental well-being over time.

Notably, positive goal engagement was significantly associated with higher levels of mental well-being and mediated the effects of pain interference upon mental well-being. Past literature has implicated adaptive goal regulation in subjective well-being⁵² and also maladaptive goal regulation in affective disorders.⁵³ For the first time, the present findings show that adaptive positive goal engagement in the face of chronic pain is a significant factor in the maintenance and enhancement of mental well-being. Arguably, positive goal engagement augments one’s opportunity to engage in rewarding and enjoyable activities, thus reinforcing sustained positive goal pursuit (even when experiencing pain), and the promotion of mental well-being. Goals-based interventions aimed at assisting individuals to recognise and utilise their strengths, internal resources, goal plans or strategies in the pursuit of personally meaningful goals may be particularly beneficial in promoting effective coping and well-being within pain populations. The present positive goal engagement findings support the view that it is beneficial to study asset-based constructs, as opposed to deficit based, as personal assets are likely to promote mental health and serve as a protective buffer against psychological distress.⁵⁴

Some methodological considerations deserve comment. Our research used trait measures to assess positive goal engagement. State measures may show a different pattern of results, although there is evidence to suggest that both state and trait hope measures are highly correlated.⁵⁵ The SEM model was based upon hypotheses generated from relevant theory and existing literature; however, the cross-sectional nature of the data means that it is not possible to infer the direction of effects.⁵⁶ For instance, it is plausible that increased mental well-being predicts greater levels of positive goal engagement. Longitudinal and experimental studies are required to establish whether the promotion of positive goal engagement in interventions improves the mental well-being of individuals with chronic pain over time. Finally, the fact that the study participants were predominantly female limits the generalisability of the findings to males with chronic pain.

Our findings highlight positive goal engagement to be a relevant and important construct within processes of mental well-being and individuals’ experiences of living with chronic pain. The promising results suggest that identifying specific mechanisms involved in positive goal engagement may be advantageous in the development of effective treatments to maintain well-being among individuals with chronic pain. This research complements and extends existing literature within the positive psychology, goal motivation and chronic pain fields and highlights potentially useful components of goals-based clinical interventions for individuals living with chronic pain.