ACT – some evidence for acceptance & commitment therapy in chronic pain

ResearchBlogging.orgFor a relatively young therapy, ACT has a lot of research to support its use in chronic pain. A very quick search through PsychInfo located 51 studies since 2002 with the keyword ‘acceptance’, and the majority of these (I didn’t count them up!) were related to ACT studies.
I’m not intending to run through a review of the evidence for ACT, that’ll come later! but I do think it’s useful to have a look at one study from the Bath University colleagues of McCracken and Vowles.

This study was carried out with a group of over 100 participants attending a pain management programme.  Two measurement times were used – at the time of screening for acceptance onto the programme and at the time participants started treatment, with a period of 18 weeks or so between them.  None of the participants in the study had active treatment, so this is simply a study of the relationship between one variable at one point in time, and another variable at another point in time without intervention.  Although you could argue that assessment is an interventions, and it’s certainly something we’ve observed at Pain Management Centre.

While its a correlational analysis (remember, no conclusions about causation!), it’s notable that ‘acceptance of pain and values-based action measured at Time 1 were significantly correlated with pain, pain-related distress, pain-related  anxiety and avoidance, depression, depression-related interference with functioning, and physical and psychosocial disability measured at Time 2.’

The measures used were the Chronic Pain Acceptance Questionnaire developed by McCracken et al (2004), Chronic Pain Values Inventory (McCracken & Yang, 2006), the Pain Anxiety Symptoms Scale and British Columbia Major Depression Inventory.  To measure disability, the Sickness Impact Profile was used.

Some interesting points to note:

  • Although no treatments were carried out, and pain-related anxiety, depression, depression-related interference with functioning, physical and psychosocial disability, and uptime did not change from T1 to T2, pain intensity did reduce, distress reduced and medication use reduced.  Several people started work.  So it looks similar to the findings we’ve obtained at Pain Management Centre from simply assessing also occur in this process.

Can we conclude that assessment is an intervention? Does the impact of assessment differ depending on how the assessment is carried out and what is included in it?  Certainly something that seems intuitively important is that people have the opportunity to tell their story and feel heard as part of assessment.  It might be the first time for some of them to have the psychosocial aspects of their pain assessed, and this alone may help them make sense of their situation.  It may also be that the way in which recommendations are made from an assessment (often through a case formulation) provides both understanding and an opportunity for the person to start taking their own steps toward recovery.

  • Measures of acceptance and values also changed between T1 and T2. Each increased significantly, including activity engagement, pain willingness, total acceptance of pain, and values-based action, although the increase was quite small.

Pondering this, I wonder whether acceptance may increase as part of the process of being advised that pain is going to persist, and that there is no medical ‘fix’. It would have been helpful had some of the details of the assessment process had been included in this study – but failing that, and assuming that assessment for inclusion in the programme involves advising patient that their pain is chronic and there is a way forward, I’m thinking that some of this information alone could be helpful for people to begin the process of acceptance.

The discussion of this paper notes that ‘measures of acceptance of pain and values-based action predict functioning later in time for patients seeking treatment for chronic pain.’  It also states ‘On average, the acceptance and values scores accounted for 18.3% of the variance in the six regression equations where they accounted for significant variance in the measures of functioning.’  So, what is important to a person (values), and teh degree to which a person is prepared to accept having pain, has an influence on what that person does functionally.  As McCracken & Vowles state ‘Flexible and effective behavior will tend to have both qualities [acceptance and values] and these qualities are expected to mutually enhance each other, with acceptance loosening up restrictive influences exerted by pain on behavior in the near term, and values giving direction and purpose to behavior over the longer term.’ They also make the point that physical function and especially work-related function are less influenced by acceptance and values than emotional functioning.  Maybe there are other factors that influence physical function, unrelated to acceptance – pain-related anxiety and avoidance springs to mind.

What can we conclude from this study?

Acceptance and values, two important aspects of ACT, seem to influence patient status and functioning over time in a group of people seeking treatment from a tertiary-level pain management facility.  These patients present as quite disabled (although not a lot different from the people presenting for treatment at Pain Management Centre where I work), and they hadn’t received treatment – so this is a ‘natural’ study of processes that occur without professional input.  On its own this study can’t draw major conclusions, but it adds another level of evidence for the importance of examining the process of acceptance in helping people learn to live with persistent pain.

McCracken, L., & Vowles, K. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain. Health Psychology, 27 (2), 215-220 DOI: 10.1037/0278-6133.27.2.215
McCracken, L. M., Vowles, K. E., & Eccleston, C. (2004). Acceptance of
chronic pain: Component analysis and a revised assessment method.
Pain, 107, 159–166.
McCracken, L. M., & Yang S.-Y. (2006). The role of values in a contextual
cognitive-behavioral approach to chronic pain. Pain, 123, 137–145.

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