Open Access Open Access  Restricted Access Subscription or Fee Access

Examining Fidelity of Web-based Acceptance and Commitment Interventions for Women with Chronic Widespread Pain

Andrea Aparecida Goncalves Nes, Espen Andreas Brembo, Sandra van Dulmen, Ólöf Birna Kristjánsdóttir, Rikard Wicksell, Hilde Eide


Objectives. To examine the protocol adherence to the theoretical background of Acceptance and Commitment Therapy (ACT) in a RCT of a web-based intervention including e-diaries and written personalized feedback delivered via smartphone for persons with chronic widespread pain.

Methods. The data consisted of 790 written feedback. A qualitative descriptive design on how ACT and other therapeutic processes were used in the feedback which was applied. The analysis was done with a feedback coding scheme developed employing a combination of an inductive and deductive approach.

Results. The coded feedback messages reflected five of the six main ACT processes in addition to communication and motivation strategies. The degree of inter-rater reliability between the researchers coding the feedback, measured by Cohen’s kappa, was 0.790.

Conclusions. Based on the level of adherence to ACT-principles the treatment integrity can be judged as high. The developed coding scheme can serve as a basis for coding written therapeutic feedback and thereby serve as a tool for a reliable assessment of the treatment fidelity in ACT based interventions delivered by internet.

Practice Implications. Internet-delivered psychological interventions to support people with chronic conditions are increasingly common. Such interventions can be seen as person-centered therapeutic approaches. This study indicates that ACT can reliably be delivered in a written web-based format.





Chronic Widespread Pain; Acceptance and Commitment Therapy; M- health; Internet; Treatment Fidelity

Full Text:



. Breitenstein SM, Gross D, Garvey CA, Hill C, Fogg L, Resnick B. Implementation fidelity in community-based interventions. Research in Nursing & Health. 2010;33(2):164-73.

. Mowbray CT, Holter MC, Teague GB, Bybee D. Fidelity Criteria: Development, Measurement, and Validation. American Journal of Evaluation. 2003 September 1, 2003;24(3):315-40.

. Hayes SC, Levin ME, Plumb-Vilardaga J, Villatte JL, Pistorello J. Acceptance and Commitment Therapy and Contextual Behavioral Science: Examining the Progress of a Distinctive Model of Behavioral and Cognitive Therapy. Behavior Therapy. 2013;44(2):180-98.

. Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and Commitment Therapy: Model, processes and outcomes. Behaviour Research and Therapy. [doi: DOI: 10.1016/j.brat.2005.06.006]. 2006;44(1):1-25.

. McCracken LM, Keogh E. Acceptance, Mindfulness, and Values-Based Action May Counteract Fear and Avoidance of Emotions in Chronic Pain: An Analysis of Anxiety Sensitivity. Journal of Pain. 2009;10(4):408-15.

. Dahl JA, Lundgren T. Living beyond your pain: Using acceptance and commitment therapy to ease chronic pain: New Harbinger Pubns Inc; 2006.

. Hayes S, Strosahl K, Wilson K. Acceptance and commitment therapy: An experiential approach to behavior change. New York: The Guilford Press, 2003.

. Vowles K, McCracken L, Eccleston C. Processes of change in treatment for chronic pain: the contributions of pain, acceptance, and catastrophizing. European Journal of Pain 2007;11(7):779.

. Powers MB, Zum Vörde Sive Vörding MB, Emmelkamp PMG. Acceptance and Commitment Therapy: A Meta-Analytic Review. Psychotherapy and Psychosomatics. 2009;78(2):73-80.

. Wicksell RK, Melin L, Lekander M, Olsson GL. Evaluating the effectiveness of exposure and acceptance strategies to improve functioning and quality of life in longstanding pediatric pain – A randomized controlled trial. Pain. 2009;141(3):248-57.

. Wicksell RK, Kemani M, Jensen K, Kosek E, Kadetoff D, Sorjonen K, et al. Acceptance and commitment therapy for fibromyalgia: A randomized controlled trial. Eur J Pain. 2012;23(10):1532-2149.

. Oerlemans S, van Cranenburgh O, Herremans P-J, Spreeuwenberg P, van Dulmen S. Intervening on cognitions and behavior in irritable bowel syndrome: A feasibility trial using PDAs. Journal of Psychosomatic Research. 2011;70(3):267-77.

. Hesser H, Gustafsson T, Lundén C, Henrikson O, Fattahi K, Johnsson E, et al. A randomized controlled trial of Internet-delivered cognitive behavior therapy and acceptance and commitment therapy in the treatment of tinnitus. Journal of Consulting and Clinical Psychology. 2012;80(4):649-61.

. Carlbring P, Hägglund M, Luthström A, Dahlin M, Kadowaki Å, Vernmark K, et al. Internet-based behavioral activation and acceptance-based treatment for depression: a randomized controlled trial. Journal of Affective Disorders. 2013;148(2-3):331-7.

. Buhrman M, Skoglund A, Husell J, Bergström K, Gordh T, Hursti T, et al. Guided internet-delivered acceptance and commitment therapy for chronic pain patients: a randomized controlled trial. Behaviour Research and Therapy. 2013;51(6):307-15.

. Kristjánsdóttir OB, Fors EA, Eide E, Finset A, Stensrud TL, van Dulmen S, et al. A smartphone-based intervention with diaries and therapist-feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain: randomized controlled trial. Journal of Medical Internet Research. 2013;15(1):e5-e.

. Nes AA, Eide H, Kristjansdottir OB, van Dulmen S. Web-based, self-management enhancing interventions with e-diaries and personalized feedback for persons with chronic illness: A tale of three studies. Patient Educ Couns. 2013;21(13):00050-5.

. Nes AA, van Dulmen S, Eide E, Finset A, Kristjansdottir OB, Steen IS, et al. The development and feasibility of a web-based intervention with diaries and situational feedback via smartphone to support self-management in patients with diabetes type 2. Diabetes Res Clin Pract. 2012;97(3):385-93.

. Kristjansdottir OB, Fors EA, Eide E, Finset A, Stensrud TL, van Dulmen S, et al. A smartphone-based intervention with diaries and therapist feedback to reduce catastrophizing and increase functioning in women with chronic widespread pain. part 2: 11-month follow-up results of a randomized trial. J Med Internet Res. 2013;15(3).

. Kristjansdottir OB, Fors EA, Eide E, Finset A, van Dulmen S, Wigers SH, et al. Written online situational feedback via mobile phone to support self-management of chronic widespread pain: a usability study of a Web-based intervention. BMC Musculoskeletal Disorders. 2011;12(1):51.

. Thagaard T. Systematikk og innlevelse : en innføring i kvalitativ metode. Bergen: Fakboglaget; 2003.

. Schimmel-Bristow A, Bricker JB, Comstock B. Can Acceptance & Commitment Therapy be delivered with fidelity as a brief telephone-intervention? Addictive Behaviors. 2012;37(4):517-20.

. Crabtree BF, Miller WL. Using Codes and Code Manuals. A Template Organizing Style of Interpreation. In: Crabtree BF, Miller WL, editors. Doing qualitative research. Thousand Oaks, Calif.: Sage Publications; 1999. p. 163-77.

. McHugh ML. Interrater reliability: the kappa statistic. Biochemia Medica. 2012;22(3):276-82.

. Cicchetti DV. Guidelines, criteria and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess. 1994;4:284-90.

. Webb TL, Joseph J, Yardley L, Michie S. Using the internet to promote health behavior change: a systematic review and meta-analysis of the impact of theoretical basis, use of behavior change techniques, and mode of delivery on efficacy. Journal of Medical Internet Research. 2010;12(1).

. Riley WT, Rivera DE, Atienza AA, Nilsen W, Allison SM, Mermelstein R. Health behavior models in the age of mobile interventions: are our theories up to the task? Transl Behav Med. 2011;1(1):53-71.

. Hruschka DJ, Schwartz D, St.John DC, Picone-Decaro E, Jenkins RA, Carey JW. Reliability in Coding Open-Ended Data: Lessons Learned from HIV Behavioral Research. Field Methods. 2004;16(3):307-31.

. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M, et al. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ (Clinical Research Ed). 2008;337.

. MacQueen KM, McLelland E, Kay K, Milstein B. Codebook development for team-based qualitative analysis. Cultural Anthropology Methods. 1998;10:31-6.

. Fereday J, Muir-Cochrane E. Demonstrating Rigor Using Thematic Analysis: A Hybrid Approach of Inductive and Deductive Coding and Theme Development. International Journal of Qualitative Methods. 2006;5(1).

. Cuijpers P, van Straten A, Andersson G. Internet-administered cognitive behavior therapy for health problems: a systematic review. Journal of Behavioral Medicine. 2008;31(2):169-77.



  • There are currently no refbacks.