When we can’t make it stop – ACT in chronic pain

23 Jun 2015  |  Print

When we can’t make it stop – ACT in chronic pain

When a patient comes in with chronic pain, the chances are that the first thing they will ask their doctor to do is ‘make it stop’. This is entirely understandable, and pain control is very valuable when it can be achieved, particularly if it also helps to improve long-term functioning.

But is pain management enough? And what if it does not work?

Efforts to control pain can often be problematic, particularly when they:[1]

  • Dominate the patient’s life and do not succeed;
  • Cause unwanted side effects or complications; and/or
  • Lead the patient away from the things that are important to them, such as work, friends and family.

When patients focus on pain control, it may lead to extended periods of rest, activity avoidance, frequent visits to healthcare providers, and reduced work productivity. This can make it difficult to strike a balance between managing pain and maintaining focus on valued activities of normal daily living. If the former dominates, quality of life may be sacrificed. Furthermore, excessive avoidance of chronic pain may actually be associated with greater suffering and disability.[1]

This is where acceptance and commitment therapy (ACT) for chronic pain comes in.

What is ACT?

According to the American Psychological Association, ACT is “a type of cognitive behavioral therapy that stems from research and theory on experiential avoidance – the idea that private experiences (emotions, thoughts, and symptoms including pain) that are routinely avoided lead to various disorders.”[2]

ACT is a model of therapy, not a particular protocol, and there are various ways in which it can be conducted.[2] Whatever methods are employed, the aim is to change the relationship that the patient has with their own feared or avoided thoughts and sensations. In practice, it uses acceptance and ‘mindfulness’ strategies that focus the patient’s awareness on the present moment, while acknowledging and accepting their pain.

Hence, the ultimate goal of ACT is not to reduce symptoms or pain (although other simultaneous therapies may well be aimed at achieving this). Instead, its goal is to improve functioning by increasing psychological flexibility and the ability to act according to personal values, even in the presence of negative experiences, like pain.[2]

ACT – the evidence base

ACT has met the American Psychological Association’s criteria for having “strong research support”.[2] This means that, in their view, well-designed studies conducted by independent investigators have converged to support the efficacy of ACT.

A recent systematic review and meta-analysis also reached a positive, albeit slightly more reserved, conclusion regarding the effectiveness of ACT.[3] It concluded that while the evidence base is not yet well established for any disorder, it is strongest in chronic pain. In this setting, ACT is “probably efficacious”.[3] 

A review of ACT in chronic pain, published in 2014 by two leading exponents – Lance McCracken from King’s College London, UK, and Kevin Vowles from the University of New Mexico, USA – noted that there are now at least six randomized controlled trials and multiple partially controlled trials that support for the use of ACT in this setting.[4] Positive effects have consistently been observed with regard to increases in physical and social functioning and decreases in pain-related medical visits, even at 3 years following treatment.[4]

Comparison with traditional cognitive behavioral therapy

A meta-analysis of 22 trials of ACT for chronic pain concluded that its effectiveness is similar to that of traditional cognitive behavioral therapy (CBT).[5]

Comparative trials would, of course, be desirable. However, few such trials have been performed. One of the key problems with such comparisons is that ACT and CBT employ many similar methods, and hence very large samples sizes would be needed to demonstrate the superiority of one approach over the other.[4]

However, while there are similarities, it must be stressed that ACT and CBT are not the same. There are important distinctions in how they are practiced. An online survey of 88 licensed practitioners who identified themselves as either traditional CBT therapists or acceptance-based therapists identified a number of differences in the treatment techniques used.[6] Those who described themselves as acceptance-based practitioners reported greater use of exposure, mindfulness, family systems techniques and a wider range of techniques in total. Meanwhile, those who said they were more oriented towards traditional CBT reported greater use of cognitive restructuring and relaxation.

ACT in daily practice

In many ways, traditional CBT has been a successful treatment for chronic pain. It has demonstrated small-to-medium effect sizes across a variety of domains, including reductions in pain and improvements in functioning,[7] and is familiar to patients, healthcare providers and funding bodies.[4]

However, this should not preclude the development of new methods like ACT that could further improve the psychological treatment of chronic pain. When we cannot ‘make it stop’, techniques like ACT can offer an important avenue for many chronic pain patients.


  1. 1. McCracken LM, Carson JW, Eccleston C, Keefe FJ. Acceptance and change in the context of chronic pain. Pain 2004;109:4-7.
  2. 2. Society of Clinical Psychology, American Psychological Association, Division 12. Acceptance and Commitment Therapy for Chronic Pain. Available at: www.div12.org/PsychologicalTreatments/treatments/chronicpain_act.html. Accessed March 2015.
  3. 3. Ost LG. The efficacy of Acceptance and Commitment Therapy: an updated systematic review and meta-analysis. Behav Res Ther 2014;61:105-121.
  4. 4. McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol 2014;69:178-187.
  5. 5. Veehof MM, Oskam MJ, Schreurs KM, Bohlmeijer ET. Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain 2011;152:533-542.
  6. 6. Brown LA, Gaudiano BA, Miller IW. Investigating the similarities and differences between practitioners of second- and third-wave cognitive-behavioral therapies. Behav Modif 2011;35:187-200.
  7. 7. Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag 2014;7:115-124.