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12 Articles in Volume 21, Issue #2
Advanced Practice Matters with Theresa & Jeremy: MAT and the DATA Waiver Debate
Analgesics of the Future: The Potential of Vocacapsaicin Injections for Knee Pain
Authorities Update Opioid and Naloxone Prescribing Policies as Overdoses Soar
Autologous Adipose-Derived Biocellular (Stem Cell-Rich) Prolotherapy into Hoffa’s Fat Pad Improves Knee Osteoarthritis
Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care
Case Report: How We Grew Our Pain Practice Amidst Pandemic, Opioid Crisis
Chronic Overlapping Pelvic Pain Disorders: Differential Diagnoses and Treatment
Fentanyl Transdermal Patch: Variability is Key When Prescribing
Optimizing Opioid Therapy with Pharmacogenetics
Research Insights: Advances in Shoulder Arthroplasty and Revision Surgery
Research Insights: How to Address Osteoarthritis Treatment Gaps in Women
Topical Anti-Inflammatories: Analgesic Options for Arthritis Beyond NSAIDs

Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care

Brief biopsychosocial interventions may make significant improvements in maladaptive thinking and coping for people with chronic pain in as few as 4 sessions.

Chronic pain is a complex phenomenon characterized by biological, psychological, and social mechanisms and has been found to be best treated using interdisciplinary approaches. Despite this, approximately 100 million Americans with chronic pain are treated predominately by primary care physicians (PCPs) informed predominately by traditional medical models.1-3 PCPs often report increased stress from treating patients who suffer from chronic pain, largely due to limited training and experience.4-5

Further, today’s PCPs are responsible for the important task of assessing patients’ risks for opioid use disorders (OUDs), including opioid diversion and aberrant behaviors. Diagnoses of addiction require complex, biopsychosocial assessments and treatment planning that challenge often already overwhelmed, frontline practitioners.4,6,7

Essentially, PCPs are being called upon to provide psychosocial counseling in conjunction with traditional medical care, often without adequate training, experience, and resources.8   Here, we describe one possible route – focused acceptance and commitment therapy – that primary care providers may consider when presented with these cases. Understanding its effectiveness and potential as a brief intervention may also help pain specialists and other frontline providers treating patients with chronic pain.

How is Acceptance and Commitment Therapy Used in a Clinical Setting?

Acceptance and commitment therapy (ACT) is a psychotherapeutic approach found to be effective at treating the biopsychosocial symptoms of chronic pain. The therapy is typically delivered over 12 visits in specialty clinics but as described below, can be modified to a briefer format. PCPs can use this information to explain the treatment to their patients and refer to behavioral specialists.

The research investigating the impact of ACT on chronic pain across different populations is robust.9-18 ACT uses acceptance and mindfulness strategies paired with commitment and behavior-change strategies to increase somatic awareness and psychological flexibility. Further, ACT aims to target repetitive negative thinking patterns, and experiential avoidance – both of which have been implicated in the treatment process and outcome for chronic pain.19-20

Access to Care

The demand for healthcare at times outweighs the supply – and this has never been more apparent than in the COVID-19 pandemic we are facing. The firm Merritt Hawkins found that the average patient in a large metropolitan area waited approximately 29 days to see a family medicine practitioner.22 In 2014, under the direction of President Obama, the Department of Veterans Affairs (VA) launched the Accelerating Access to Care Initiative, a nationwide program to ensure timely access to care and reduce waiting times.23 Healthcare systems are addressing this call to action by casting a wider net and aiming to optimize care.

Brief interventions (ie, those that require only a few sessions) allow for greater accessibility to services and minimize use of patient and providers’ time. (iStock)

The Benefits of Brief Interventions, Group Interventions

Ensuring optimal access to care is especially important when treating chronic pain, as patients have been found to use healthcare resources at a higher rate compared to patients without chronic pain conditions.24

In response, brief, group psychosocial approaches targeting pain-related disability are ideally suited to address the concerns outlined in primary care, general medicine clinic, and other settings.

Brief interventions (ie, those that require only a few sessions) allow for greater accessibility to services and minimize use of patient and providers’ time. Past research has shown that improvement occurs very early in treatment with diminishing benefit over time.25 Also, lengthier therapies do not always demonstrate incremental efficacy compared to brief therapies.26 Importantly, brief interventions have been shown to lead to clinically significant patient improvement.27,28 In fact, they can lead to reduced symptoms, improved functioning, and social integration in as few as two sessions when delivered in an integrated primary care setting.29

Changes seen with ACT have traditionally been shown to be robust and stable over a 2-year follow-up period.30 Furthermore, group-based formats of brief interventions have been found to significantly reduce wait times for pain management services31 and provide an additional source of support, which patients with chronic pain report as a valuable part of their treatment.32-34          

Focused Acceptance and Commitment Therapy (fACT)

While ACT is traditionally most often delivered across 12 sessions, as noted, it can be modified to a briefer format, known as focused acceptance and commitment therapy (fACT)35 (see Figure 1). The fACT intervention simplifies the original six core treatment processes of ACT (acceptance, contact with the present moment, self-as-context/perspective taking, defusion, values, and committed action) into three pillars:

  1. openness
  2. awareness
  3. engagement

Openness involves strategies to help increase acceptance of difficult experiences and defusion of difficult cognitions so that new ways of living can be considered. Awareness helps patients to be more present in the moment using mindfulness practices to take new perspectives (self-as-context versus content), which can enhance behavior change. Engagement helps patients to identify their values and find ways of connecting with those values in ways that are workable over time.

Unfortunately, there are few studies investigating the efficacy of the fACT intervention. One such study by Glover and colleagues (2016) provided some insight into patient outcomes using fACT in a group format with veterans. Participants in this study were 51 patients who attended this group as part of routine clinical care. They found that a 4-session intervention delivered in the VA integrated primary care setting and mental health setting demonstrated:

  • significant effects for patients’ perceived quality of life (QoL)
  • moderate effects for decreased depressive symptoms
  • improved perceptions of mental health functioning
  • minor effects for patients’ perceptions of stress and physical health functioning.36

To date, there are even fewer published investigations that have examined fACT for use with the chronic pain population. One study, however, found significant overall improvements in patients after a 4-session fACT intervention, including reduced depression and disability, and increased pain acceptance compared to treatment as usual.37  

Applying Focused ACT to Patients with Mixed Chronic Pain

Kanzler and colleagues (2018) also published a manuscript that describes the rationale and methods for a protocol to pilot test the feasibility and effectiveness of fACT delivered by behavioral health consultants in a primary care setting.38 Based on this, Cosio developed and initiated fACT pain treatment groups to determine the feasibility of a fACT intervention with veterans who suffer from chronic pain with mixed, idiopathic conditions (ie, back, neck, extremity, head, and fibromyalgia).

Intervention

The intervention consisted of four, 90-minute sessions, held once a week. The pain fACT group intervention was informed using a tailored manual, which was an amalgamation of established protocols39,40 and a self-help workbook.41 One established protocol proposed a 4-session intervention that combined individual and group,39 while the second established protocol was an 8-session intervention that presented a similar coverage of topics typical of a traditional cognitive-behavioral therapy protocol.40 A self-help book provided more details, and served as an introduction to the therapy.41 Thus, the current manualized group intervention was generated by incorporating, organizing, and expanding upon the aforementioned protocols to develop an experiential, fACT consistent protocol aimed to meet the needs of the chronic pain population in a brief, group format (see Table I).

Methods and Assessment Tools

A sample of 36 veterans ranging from 18 to 89 years who suffer from chronic pain were recruited from the pain education program at a midwestern VA Medical Center for the Pain fACT Group. Veterans voluntarily participated in the groups and were free to withdraw at any time. As part of the introduction to the Pain fACT groups, all participants completed quality assurance outcome measures, which included pain, enjoyment of life, and general activity (PEG), perceived global distress (PGD), the coping strategies questionnaire-catastrophizing scales (CSQ-CAT), and the chronic pain coping inventory-short form (CPCI-SF).42-45

(See also, how clinicians can reduce stigma around pain)

Measures that assess the outcomes of psychotherapy have the potential to inform quality improvement efforts and bring greater accountability to the delivery of mental health care. Those patients who received the group psychotherapy completed the same set of outcome measures at the end of the intervention to determine if they experienced any improvements in their symptoms and functioning.

The PEG scale score is the average of 3 separate numerical scales. Each scale has ratings ranging from 0 to 10. Individuals rate their pain level concerning 3 different areas: pain (on average), pain interference with enjoyment of life, and interference with general activities over the past week. The PGD scale is a 10 cm line, giving a scale score from 0 to 10 whereby 0 represents no problems and 10 represents the worst possible situation. The CSQ-CAT score is the sum of the ratings on 6 statements that measure negative self-statements, catastrophizing thoughts, and ideations about pain using a 0-5 Likert scale.

The CPCI-SF scale produces two scores: one is for illness-focused coping (guarding, resting, and asking for assistance) and the other is for wellness-focused coping (exercise/ stretching, relaxation, task persistence, seeking social support, and coping self-statements). Participants were asked to describe how many days in the past week they used each strategy to manage pain. The scores are the sum of days they used those coping skills. The quality assurance data was analyzed with paired samples t-test (one-tailed) using the Data Analysis ToolPak Excel add-on.

Findings on fACT for Chronic Pain and Next Steps

Preliminary findings indicate a significant decrease in pain catastrophizing (maladaptive thinking) scores as measured by CSQ-CAT and a significant decrease in illness-focused coping scores at post-intervention compared to pre-intervention as measured by CPCI-SF. These findings are consistent with previous research studies investigating the effectiveness of ACT with veterans suffering from chronic pain.11,46

However, the quality improvement effort did not find significant differences in pain interference and global distress, which is inconsistent with previous research.11,46 This may be due to using different abbreviated measures, such as the PEG and PGD. More research is needed to better understand the change mechanisms in group-administered, fACT interventions. Importantly, research investigating the impact of telehealth delivery of fACT for chronic pain would further its reach, especially to underserved populations.

Frontline and primary care providers are experiencing an increased need to make services more accessible and to cut down on appointment wait times. At the same time, PCPs are tasked with effectively treating and managing complex biopsychosocial symptoms in a growing number of patients with persistent pain. To optimize providers’ time without sacrificing outcomes, brief biopsychosocial interventions in primary care, general medicine clinics, and other settings are needed.

Furthermore, decisions about the development and implementation of brief group interventions requires the collaboration of many stakeholders, including consumers, providers, health plans, payers, and state agencies. Group-based formats such as focused Acceptance and Commitment Therapy (fACT) have demonstrated the potential to maximize limited resources while providing an additional, interpersonal, support factor, which has been found to be valuable for patients with chronic pain. The fACT intervention for chronic pain presented herein is one brief intervention that shows promise for treating the biopsychosocial symptoms of chronic pain in an overburdened healthcare system.

Practical Takeaways

  • PCPs are often faced with having to provide psychosocial counseling in conjunction with traditional medical care without adequate training, experience, and resources.
  • There is an increased need to decrease appointment wait times and improve access to care; brief group interventions offer an opportunity for providers to offer greater accessibility to services while optimizing the use of their time.
  • Preliminary data suggests that focused ACT group interventions may make significant improvements in maladaptive thinking and coping in the chronic pain population in as few as 4 sessions.

Disclaimer: The views expressed in this article are those of the author and do not represent the views of the Department of Veterans Affairs or any other governmental agency.

Last updated on: March 2, 2021
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