Guided internet-delivered acceptance and commitment therapy for chronic pain patients: A randomized controlled trial
Introduction
For many individuals chronic pain has adverse consequences on daily activity, employment, relationships, and emotional functioning (Breivik, Collett, Ventafridda, Cohen & Gallcher, 2006). Several studies have investigated the prevalence of chronic pain among adults. Results show that 15–20 percent of adults experience chronic pain. Considering all sources of expenditures, chronic pain has a large financial impact on society (Breivik et al., 2006).
Chronic pain is a demoralizing situation that compromises all aspects of the person's life, including disability and emotional distress. Psychological research has identified the central role of cognitive, behavioural and emotional factors contributing to the perpetuation of chronic pain (Kerns, Sellinger, & Goodin, 2011). Cognitive-behavioural therapy (CBT) delivered in a multidisciplinary setting has been shown in several controlled studies to be effective in the treatment of chronic pain (e.g. Hoffman, Papas, Chatkoff, & Kerns, 2007; Morley, Eccleston, & Williams, 1999). A common factor for the psychologically oriented interventions for chronic pain is that the focus is on the consequences that pain has on one's life, rather than on pain intensity, as a way of directly addressing adaptive behavioural change (Kerns et al., 2011).
In the so called third generation of cognitive behavioural treatments, e.g. acceptance and commitment therapy (ACT), function is emphasized in contrast to form. Behaviour is analysed from a functional perspective, i.e. the aim is to understand why a particular behaviour is maintained rather than describing what kind of behaviour a person performs. In order to understand how influence can affect the function of behaviour it is important to alter the social/verbal context through identification of basic processes that are common across settings (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes, Strosahl, & Wilson, 1999). From this perspective, chronic pain can be viewed as an experiential avoidance disorder. Experiential avoidance has been defined as attempts to avoid thoughts, feelings, memories, physical sensations, and other internal experiences, which often creates suffering in the long-run (McCracken, Vowles, & Eccleston, 2004; Vowles & McCracken, 2010). Studies have shown that experiential avoidance is associated with higher pain intensity, pain-related anxiety, depression and physical and psychosocial disability (Feldner et al., 2006; McCracken, 1998; McCracken & Vowles, 2006). These results suggest that acceptance of pain and a willingness to abandon the struggle to avoid or reduce pain, will enable the individual to be more present in the moment. Mindfulness exercises, have its roots in Asian religious traditions, help the individual to fully experience the phenomenon in the present moment without the influence of verbal content (Fletcher & Hayes, 2005). Being present in the moment will help the individual distancing from pain-related thoughts and acting in accordance with chosen values (McCracken, 1998; McCracken & Eccleston, 2003; McCracken & Vowles, 2006; McCracken et al., 2004; Wetherell et al., 2011).
A systematic review showed that acceptance based therapies could be an alternative to CBT although the researchers stated that more controlled studies are needed (Veehof, Oskam, Schreurs & Bohlmeijer, 2011). The review included seven ACT-studies and fifteen mindfulness-based stress reduction (MBSR) programs. In addition, ACT has been listed as an empirically supported treatment for chronic pain and depression (APA, 2006/2011).
There are many obstacles for persons with chronic pain to seek or receive adequate help such as, financial barriers, reluctance to seek treatment, and paucity of clinicians trained in CBT (including evidence-based multidisciplinary treatment options) (Jamison, Gintener, Rogers, & Fairchild, 2002). The use of internet as a delivery format for CBT interventions could be a way to overcome many of these barriers. Internet-delivered cognitive behaviour therapy (ICBT) has proved effective for various conditions both in the physical and mental health domains (Andersson et al., 2008; Barak, Hen, Boniel-Nissim, & Shapira, 2008; Cuijpers, van Straten, & Andersson, 2008). Some of the advantages with internet-based treatments are: reducing therapist time and waiting lists, allowing patients to work in their own pace, no need for scheduling with a therapist, availability to a greater number of patients and cost-effectiveness (Cuijpers et al., 2008).
In the field of pain, several internet-based treatments have been developed (Bender, Radhakrishnan, Diorio, Englesakes & Jadad, 2011; Macea, Gajos, Daglia-Calil, & Fregni, 2010). These have mainly concerned CBT and participants have been recruited through newspaper advertisements (Brattberg, 2006; Buhrman, Fältenhag, Ström, & Andersson, 2004; Buhrman, Nilsson-Ihrfelt, Jannert, Ström, & Andersson, 2011; Carpenter, Stoner, Mundt, & Stoelb, 2012; Ruehlman, Karoly, & Enders, 2012). One study showed that a self-help intervention based on ACT for chronic pain was superior to applied relaxation. The participants in that study received one face-to-face session and a self-help manual with reading instructions including a CD with exercises (Thorsell et al., 2011). Even though there have been ACT elements in some of these studies there is no study on internet-based ACT for chronic pain to date in use.
The purpose of the present study was to investigate if a guided internet-based ACT intervention could help chronic pain patients. Participants were recruited from a clinical setting. The active treatment group was compared to a moderated online discussion forum which has been used as an active intervention in previous studies (e.g. Lorig et al., 2002).
Section snippets
Recruitment procedure and inclusion
All participants were recruited from the Pain Center at the Uppsala University hospital in Sweden. The patients had undergone a medical examination but had not received any multidisciplinary rehabilitation. Information about the present study was sent to 273 patients from the patient register. The letter also informed the patients that they would be contacted via telephone and that they could decline participation without being further contacted. The patients were contacted by telephone in
Materials
Measures were obtained pre- and post-intervention and administered via the internet. Self-report questionnaires generally show the same psychometric properties as paper-and-pencil administration (Buchanan, 2003). In order to be able to compare the results with our previous studies several outcome variables were similar to the ones used in our earlier trials (Buhrman et al., 2004, 2011), with the exception of the acceptance measure. Given that the present study focused on ACT, acceptance was
Chronic Pain Acceptance Questionnaire (CPAQ)
After controlling for pretest scores, there were significant effects between groups on the CPAQ- activity engagement scale [F(1,73) = 4.36, p = .04], CPAQ- pain willingness scale [F(1,73) = 6.69, p = .012], and on the total scale on CPAQ [F(1,73) = 6.0, p = .017], all in favour for the treatment group. The corresponding effects sizes were medium to small with Cohen's being d = 0.60 (CI95% = 0.11–1.03), d = 0.49 (CI95% = 0.04–0.94), and d = 0.41 (CI95% = 0.0–0.86) respectively. The six months
Discussion
The present study examined if an internet-based ACT intervention could help chronic pain patients and the findings support this intervention therapy. Results are encouraging considering that participants in the study were recruited from a clinical setting and had average pain duration of 15 years. Moreover, the majority was on sick leave and half of the participants had concurrent psychiatric problems (see Table 1). Improvements were maintained over a 6-month follow-up period.
The choice of
Conflict of interest
No conflicts of interest.
Acknowledgements
We thank the Multidisciplinary Pain Center at Uppsala University hospital for support during the trial. We also thank Alexander Alasjö for web support. Dr Andersson is supported in part by a grant from Linköping University, a grant from Rehsam/Vårdalsstiftelsen, and the Swedish council for working and life research.
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