According to the latest data from the National Institutes of Health (NIH), over 25 million Americans are currently living with chronic pain.
More and more studies have shown that cognitive behavioral therapy (CBT) helps people cope with the condition. But, as some have pointed out, it is not entirely clear which aspects of the therapy are helpful for people with chronic pain, or how the treatment could be improved in order to achieve better results.
This is why a team of researchers from King's College London (KCL) in the United Kingdom set out to examine the benefits of a particular form of CBT - called "acceptance and commitment therapy" (ACT) - on the functioning and well-being of patients with chronic pain.
The first author of the new study is Lin Yu, of the Institute of Psychiatry, Psychology, and Neuroscience at KCL, and the findings were published in the Journal of Pain.
As Lance M. McCracken, professor of Behavioral Medicine at KCL and corresponding author on the new study explains, "[f]or pain management, ACT [...] focuses on building effective patterns of behavior change rather than symptom reduction."
ACT and the contextual self
As Yu and colleagues point out, ACT relies on the psychological flexibility model.
In a previous paper - co-authored by McCracken - psychological flexibility is defined as "the capacity to persist or to change behavior in a way that 1) includes conscious and open contact with thoughts and feelings, 2) appreciates what the situation affords, and 3) serves one's goals and values."
As McCracken puts it, in reference to the new study, "[p]sychological flexibility is the ability to be more aware, more focused on goals, and more engaged. Another aspect of psychological flexibility pertinent to chronic pain [...] is called committed action, which involves goal-directed, flexible persistence."
Yu and colleagues note that a key aspect of the flexibility model is a therapeutic process called "self-as-context" (SAC) or "contextual self."
As the authors explain, "self-as-context" (SAC) - sometimes also called "self-as-observer" - refers to a theory of self that is not grounded in self-evaluations. In this understanding of the self, we are able to "experience a perspective where we are neither defined by nor harmed by our own thoughts and feelings."
For the new research, Yu and colleagues wanted to see if ACT has an effect on the SAC and if SAC measurements correlate with chronic pain outcomes for patients who underwent the treatment.
ACT significantly improved functioning
Yu and colleagues examined 412 adult participants from a pain management center in London.
The researchers measured SAC and pain acceptance, as well as treatment outcomes, such as "pain-related interference, work and social adjustment, depression."
These measurements were taken at three points in time: before the treatment started, after it was completed, and 9 months after the treatment ended.
Then, the researchers carried out paired sample t-tests and other analyses in order to assess changes in SAC and changes in patient outcomes.
Overall, the results showed significant improvements after treatment. Participants had considerably improved outcomes, and these improvements were confirmed after 9 months.
Specifically, up to 67.5 percent of the participants showed "meaningful improvements" both after the treatment and at the 9-month follow-up.
Furthermore, changes in SAC were found to correlate with changes in each of the treatment outcomes: pain-related interference, work and social adjustment, as well as depression. In other words, increases in SAC seemed to improve functioning in people with chronic pain.
The corresponding author summarizes the findings.
"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," McCracken says.
He also comments on the wider significance of the results.
"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 [in] CBT outcomes."
Lance M. McCracken