Acceptance and Commitment Therapy for chronic pain: advancing science and practice – Whitney Scott, PhD.
I am delighted to introduce Dr. Whitney Scott, a Clinical Health research psychologist at Kings College London, UK. Whitney is a renowned expert on chronic pain along with her colleagues such as Lance McCracken and Joseph Chilcott. She conducts some of the most innovative and insightful intervention work and treatment program evaluations published in the clinical literature. Many of us will suffer from chronic pain at some point in our lives and it is then you realise how important and impactful this line of research really is. In this very informative and insightful blog Whitney discusses the application of the Psychological Flexibility model of Acceptance and Commitment Therapy to help people cope with chronic pain. Enjoy! – Dr. Ian Tyndall, University of Chichester, UK.
Imagine sitting in your house and the fire alarm rings. What would this be like? You’d probably be a bit concerned. At first, you might treat the alarm as a legitimate signal of fire and evacuate the house. What if it was a trick? After evacuating, you realise there is no fire and the alarm persists. What would you do then? You might investigate whether there was something setting the alarm off by accident, or faulty wiring. No luck. The alarm continues all day, every day; you have no idea when it will stop. You try getting a new alarm, but same thing. The small chance of a real fire means you choose not to get rid of having an alarm altogether. You feel trapped. You know the alarm is meant to keep you safe, but it feels like it’s destroying your life.
Variants of the faulty fire alarm metaphor are commonly used to demonstrate the nature of chronic pain. Acute pain is evolutionarily adaptive and serves to motivate humans (and non-human animals) to protect themselves from injury. Chronic pain is like an alarm that rings when there is no fire. It does not serve the adaptive function of acute pain, but it tends to coordinate similar responses; namely, motivation to avoid the threat of harm.
Chronic pain can uproot a person’s life. It can fundamentally alter a person’s sense of self and their place in the world. Life for a person with chronic pain can be filled with a constant barrage of threat and uncertainty which, understandably, captures attention, takes priority, and can take focus away from the things they once cared about most. Efforts to control pain often don’t work and come at the expense of valued activities and relationships.
In many ways, the psychological flexibility (PF) model and Acceptance and Commitment Therapy (ACT) are conceptually relevant to managing chronic pain; McCracken & Morley (2014) provide an important summary in this regard. It’s beyond the scope of this blog to give an in-depth overview of research on PF and ACT as applied to chronic pain. Instead, I’ll use this blog to highlight a few challenges in the application of ACT and PF to chronic pain and corresponding opportunities for progress. These challenges centre on increasing the effectiveness and accessibility of ACT for chronic pain. This blog is informed by my experiences as a researcher and clinician with a deep passion for helping people with chronic pain to live full and satisfying lives.
A 2016 meta-analysis of 25 RCTs of acceptance and mindfulness-based treatments showed that these approaches are associated with small to moderate improvements in key outcomes, including pain interference and emotional functioning compared to inactive controls. Studies comparing ACT directly with traditional CBT for pain yield no difference. So, we can demonstrate the efficacy of ACT and we can certainly do better.
One key strategy to improve treatment outcomes is to better understand the mechanisms underlying ACT for pain. Studies support the association between improvements in psychological flexibility processes, such as acceptance, defusion, and committed action, and improvements in pain outcomes. However, progress has been hampered by a lack of well-validated measures of all six PF processes. A measure of self-as-context has recently been developed and validated. Observational cohort data show interdisciplinary ACT is associated with improvements in self-as-context, and these improvements are associated with improvements in functioning in people with pain. Further progress will require more frequent, diary-type assessment of PF processes to better understand the nature and time-course of changes. We also need to better identify who is likely to benefit from ACT. To date, research has yielded largely inconsistent findings regarding treatment moderators, and a theoretically-guided strategy for testing moderators is needed.
People with chronic pain often have other persistent symptoms, such as fatigue, sleep problems, gastrointestinal problems, tinnitus, dizziness, and the like. This is a challenge for the branding of services which are often organised around a single predominant symptom. The transdiagnostic nature of ACT makes it a good candidate to reduce the impact of a range of persistent symptoms. However, my clinical impression is that people presenting at a pain service can sometimes, understandably, get “stuck” in applying ACT skills only to pain symptoms. This can feel like a game of whack-a-mole: the success of whacking the pain ‘mole’ (i.e., helping someone to live more fully with pain) is tempered by another long-term symptom ‘mole’ popping up and interfering with valued living. Research is needed to optimise our ability to help people generalise ACT skills across the range of persistent symptoms they may experience. A different strategy might be a re-branding of services providing support for people with a range of commonly co-occurring long-term symptoms so as to not imply that separate symptoms necessarily separate behavioural management approaches.
One thing I’ve struggled with as a clinician delivering ACT is the presence of unhelpful social systems that contribute to distress and disability among people with chronic pain. These include societal stigma about pain, racial disparities in pain treatment, and unfair employment and disability benefit policies. ACT can help people respond more effectively to these challenges. However, focusing at the individual-level alone is not enough. We also need to advocate to create fairer and less stigmatising policies and practices towards people with pain. In this regard, I’m inspired by the CHAMP study which examined a combined ACT and social justice capacity building intervention that brought together people living with HIV and stakeholders from relevant community groups. Results showed improvements in well-being and increased tendencies for social justice advocacy. Such an approach could yield meaningful benefits in the chronic pain context.
Despite the usefulness of ACT, not everyone who might benefit can access it. A growing body of research shows that Internet-delivered ACT may be efficacious for chronic pain and may help increase treatment access. Further research is needed to enhance participant engagement in online delivery. This may be facilitated, for example, through greater individual tailoring of online delivery systems and investigating how to optimise the therapeutic relationship in the online context. There may also be opportunities to up-skill a large existing workforce of allied health professionals, such as primary care mental health workers (e.g., through IAPT in England) or physiotherapists to deliver ACT-based treatment for pain. Lastly, even in well-resourced settings, we might draw on innovations from global mental health approaches in training lay peers and family members to support people with pain to develop psychologically-informed pain management strategies.
Much of the research on PF and ACT applied to chronic pain to date has been carried out in specialty chronic pain clinics. This gives a biased view of the experience of chronic pain and factors associated with functioning in this population. We could do better at identifying and researching people in the community who are living well and thriving with chronic pain. If that’s the direction of travel we’re hoping to help treatment participants move towards, it makes sense to learn from people who are already making the journey effectively.