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Psychological Flexibility May Lead to Better Response to Pain Treatments

January 22, 2018
A study employing acceptance and commitment therapy to foster a more positive mental outlook demonstrates improved outcomes for pain patients who receive guided therapy.

With Elmer G. Pinzon, MD, MPH

Psychological flexibility (PF) appears to be one mechanism responsible for the effectiveness of acceptance and commitment therapy (ACT) to enhance treatment outcomes in people with chronic pain, according to study findings published online in the journal PAIN.1

A positive outlook and contentment related to basic psychological needs such as belonging, competence and self-sufficiency are key aspects for a person to support psychological health.To have psychological flexibility promises good health, and conversely, an absence of PF places a person, in particular, a patient with chronic pain, at greater risk for suffering,2 according to Todd B. Kashdan, PhD, a professor of psychology at George Mason University in Fairfax, Virginia.

Guided therapy offers better outcomes following treatment for chronic pain.

Acceptance and commitment therapy is a form of cognitive behavioral therapy that relies on recognition and mindfulness strategies as well as commitment and behavior change approaches that foster a greater psychological flexibility. A number of studies have shown ACT to be effective in the treatment of chronic pain.3,4

In the study,2 the researchers used mediation analysis to assess the indirect effects of the treatment on the outcomes through changes in PF. In this way, they sought to better understand the process underlying treatment effects and further improve outcomes for patients with chronic and intractable pain.

Examining Role of Psychological Flexibility in Pain Outcomes

Individuals over age 18 years with a diagnosis of chronic pain for at least six months were recruited through a comprehensive online and print advertising in collaboration with a German health insurance company.A total of 302 people were accepted into the trial and randomly assigned to either the online ACT program (ACTonPain) group with or without a therapist (n = 100 and 101, respectively) or waitlisted control group (n = 100).

Primary outcomes were pain interference based on the Multidimensional Pain Inventory (German version), to assess interference of pain with seven activities of daily living. Four secondary outcomes were measured: physical functioning (analyzed using the Brief Pain Inventory), emotional functioning, health-related quality of life, and pain intensity.2

ACTonPain encompassed one introductory module and seven treatment modules consisting of “psychoeducative elements, videos and audio files, metaphors, mindfulness exercises, and interactive features such as quizzes.”2 Stories of people with chronic pain are used throughout the study to model behavior patterns reflecting core aspects of PF. Participants are also given homework related to the modules. Those on the waitlist were allowed to receive their personal treatment as usual.

Assessing the Role of Psychological Flexibility

Group membership was positively associated with increases in PF, with larger increases in PF seen in both treatment groups than those seen in individuals in the waitlist group. The researchers noted that this finding is in line with previous studies showing that ACT is associated with increases in aspects of PF in individuals suffering from chronic pain. 

Another important aspect of the study was to assess the effectiveness of online ACT-based programs. “Like in other trials of online ACT approaches for chronic pain, this study shows that PF can increase when the treatment is delivered online,” wrote lead author Jiaxi Lin, PhD, a research associate at the University of Freiburg, Germany, and colleagues.

Elmer Pinzon, MD, MPH, a physiatrist in private practice in Knoxville, Tennessee, agreed that online treatment can be a useful tool for chronic pain management in reviewing the study on behalf of Practical Pain Management.

“Given that most clinical practices involved in chronic pain management are also internet-based for marketing and for electronic health records (EHR) – this may serve a role in pain management clinics’ treatment options,” Dr. Pinzon said.

“In many clinics, this may be incorporated as a part of the usual screening process with use of an iPad or laptop, and administered in the waiting area or in the examination room as a questionnaire conducted by clerical staff or medical assistants. The information collected may be beneficial to use for each of the patient’s progress in his/her chronic pain treatment,” he told Practical Pain Management.  

Program Efficacy Enhanced with Guided Therapy

The researchers also found that guided programs were more effective than unguided ones, with greater changes in PF seen in the guided group. This is also consistent with previous research.3,4

In addition, the mediation model uncovered a temporal relationship for changes in PF.2 These changes were seen between pre-treatment and at 9 weeks post-randomization, with improvements in outcomes seen between the 9-week follow-up and 6 months post-randomization.2

“This temporal ordering contributes to the implicit causal assumption that the effects of ACTonPain on PF occur prior to the treatment effects on the outcomes,” according to the researchers.

The findings strengthen existing evidence for the theoretical framework incorporated in ACT “by showing that PF may function as a mechanism of change in an [online program] for chronic pain,”2 the author concluded.

Dr. Pinzon agreed. “This study also contributes strong evidence in favor of the theoretical framework incorporated in ACT by showing that PF may function as a mechanism of change for chronic pain. For the future, the assessment of both process and outcome variables at multiple time points, such as daily or weekly ratings, are needed to allow for more sophisticated methodological approaches and designs.”

According to Dr. Lin et al, “the assessment of both process and outcome variables at multiple time points, such as daily or weekly ratings, are needed to allow for more sophisticated methodological approaches and designs, such as latent growth curve models, and autoregressive models.”

Regarding financial disclosures, only Dr. Baumeister reported consulting for the German chamber for psychotherapists and receiving payment for lectures and workshops on Internet- and mobile-based interventions, none of the other authors had any conflicts.

Last updated on: January 26, 2018
Continue Reading:
Behavioral Medicine: How to Incorporate CBT Into Pain Management

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