Cognitive behavioral therapy improves functioning for people with chronic pain

Cognitive Behavioral Therapy (CBT) is the most frequently used psychological intervention for people with chronic pain, and new approaches for improving CBT outcomes may be found in the psychological flexibility model and Acceptance and Commitment therapy (ACT), according to research reported in The Journal of Pain.

Acceptance and Commitment Therapy (ACT) is based on the psychological flexibility model, which includes a therapeutic process known as "self-as-context" (SAC). Contextual self refers to a sense of self that is not based on self-evaluations. It is similar to being an observer of one's own psychological experiences. Researchers in the United Kingdom writing in The Journal of Pain examined whether ACT influences SAC and if changes in measures of SAC are associated with treatment outcomes.

"Psychological flexibility is the ability to be more aware, more focused on goals and more engaged. Another aspect of psychological flexibility pertinent to chronic pain, and supported by SAC, is called committed action, which involves goal-directed, flexible persistence," said co-author Lance M. McCracken, Professor of Behavioral Medicine, Institute of Psychiatry, Psychology and Neuroscience, Kings College London. "For pain management, ACT is an approach based on the psychological flexibility model and focuses on building effective patterns of behavior change rather than symptom reduction."

Four hundred twelve adults referred to a pain management center at Guy's and St. Thomas' Hospital in London were subjects for the study. They completed measures of treatment processes, such as SAC and committed action, and outcomes (pain-related interference, work and social adjustment, depression) before treatment, upon treatment completion and after nine months.

Wider outcomes research suggests that ACT is effective for enhancing daily functioning and for decreasing psychological distress. A study published in 2011 assessed the long-term efficacy of acceptance and commitment therapy in more than 100 people with chronic pain. The evidence showed at three-year follow-up that 65 percent of study subjects had reliably improved in at least one key clinical domain, and improvements in psychological flexibility were associated with improvements in outcomes measures.

Results of the current Kings College study showed that scores from both the process and outcomes measures significantly improved after treatment and were maintained at nine-month follow-up. The ACT-oriented treatment was associated with improved SAC as well as improved functioning. Changes in SAC were associated with changes in pain-related interference, work and social adjustment and depression.

"Greater psychological flexibility is associated with less pain-related anxiety and avoidance, less depression, less physical and psycho-social disability and other measures of patient function," said McCracken. "Based on studies of forms of CBT that did not include ACT, acceptance of pain, one component of psychological flexibility, may be a general mechanism by which CBT treatments achieve improvements in functioning, and more specific targeting of pain-related acceptance may lead to further improvement is CBT outcomes."

The authors concluded that that the study results are consistent with an increasing number of longitudinal and mediation studies showing that ACT for chronic pain improves patient functioning, specifically through enhanced psychological flexibility.