Behavioral Medicine: How to Incorporate Into Pain Management
There is a great deal of evidence to support the effectiveness of various cognitive-behavioral interventions for reducing pain intensity and improving a patient’s coping skills. Behavioral medicine approaches aim to modify the overall pain experience, help restore functioning, and improve the quality of life of patients who suffer from chronic pain. The most common interventions include acceptance and commitment therapy (ACT) and traditional cognitive-behavioral therapy (CBT).
The literature has shown that ACT compares favorably with traditional CBT in the treatment of chronic pain among different populations, including cancer patients,1 individuals in a university-based pain management outpatient clinic,2 Australian patients at a pain management unit,3 and community samples including a small representation of veterans.4 Research has also found that for chronic pain, both ACT and CBT interventions decrease pain intensity,2,5-8 disability,2,9-11 and pain interference.4,5,8,12
In addition, both ACT and CBT interventions have been found to increase readiness to adopt a self-management approach13,14 and create changes in the way a person copes with chronic pain.15,16 However, considerable variability in outcomes exists between these interventions: ACT and CBT do not have uniform effects and are not effective for all patients.3,4,17 For example, ACT and traditional CBT tend to overlap in terms of behavioral techniques and strategies, but there are specific theoretical differences that exist with regard to the role of cognitions and emotional regulation strategies.
Acceptance & Commitment Therapy
Chronic pain is a complex biopsychosocial condition, requiring a multimodal approach to management. The first wave of behavioral medicine interventions, based on behavior theory, commenced in the 1920s, while the second wave, based on cognitive-behavioral theory, emerged in the 1970s. ACT is one of the more actively researched approaches amongst the third wave of developing psychotherapies.18
ACT is distinct from other mindfulness-based interventions, such as mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and dialectical behavior therapy (DBT). For example, MBSR uses a combination of mindfulness meditation, body awareness, and yoga to help people become more mindful. MBCT uses traditional CBT methods and adds in mindfulness meditation. Mindfulness is a core exercise used in DBT, which combines standard cognitive behavioral techniques for emotion regulation with concepts of distress tolerance derived from Buddhist meditative practice. What sets ACT apart is that it is a form of clinical behavior analysis that uses acceptance and mindfulness strategies, mixed with commitment and behavior-change strategies, to increase psychological flexibility.
ACT is a style of therapy with a lot of flexibility, and the therapeutic process is more experiential than didactic. Therefore, efficacy will depend largely on the patient’s level of commitment and participation in treatment. The experiential elements challenge patients to learn and practice new and more flexible ways of responding to pain. The basic idea of ACT is for patients to shift their primary focus from reducing or eliminating pain to fully engaging in their lives. ACT is about changing how patients relate with their internal experiences; it is about living better.
A primary goal of treatment is for the patient to suffer less through becoming actively involved in what they really care about and what matters most in their life, despite having and experiencing pain. ACT treatment is difficult, as there are no simple solutions to chronic pain. Patients might feel a range of emotions (sad, angry, anxious, hopeless, and/or uncomfortable) during the intervention, but this response is natural and perfectly normal. The role of the therapist is to help patients accept whatever discomfort exists, both physical and emotional, while continuing to live their lives according to their values. Doing so can help patients make meaningful changes in their lives and reduce suffering.
There are a number of established protocols that have been published for ACT for chronic pain.19-20 One protocol proposed a 4-session intervention, which combined individual and group treatments, and thus established the feasibility of using ACT to treat people with chronic pain.19 This protocol was one of the first to address case formulation and clinical techniques in a practical way with a chronic pain population. The second protocol is an 8-session intervention that presents topics typical of a traditional CBT protocol (activity pacing, goal setting, homework, etc).20 There are also separate self-help books that provide step-by-step instructions. The self-help books serve as an introduction to the therapy rather than a protocol.21
ACT applies 6 core treatment processes (willingness to accept, contact with the present moment, observing the self, cognitive defusion, values, and committed action) through different experiential exercises to create psychological flexibility.22 The model is best illustrated using a hexaflex (Figure 1). A simplified model may suggest the intervention helps patients to become more open, present, and take action.