Using the Internet to deliver Acceptance and Commitment Therapy for chronic pain

Cognitive-behavioural therapy (CBT) can improve quality of life and functioning in people with chronic pain. However, many people cannot access CBT in a timely manner, or at all. Simply put, there are too few psychologists with adequate training in pain management. There are also practical barriers to engaging in CBT, such as distance, work, and childcare commitments.

The widespread availability of the Internet may radically transform access to CBT. Web-based programmes are not constrained by practical barriers that limit face-to-face delivery. They require less therapist time, are delivered remotely and “on demand,” and may be more scalable than face-to-face formats. There has been a proliferation of studies of online CBT for a range of health problems and the evidence for its application in chronic pain is growing [1].

We conducted a feasibility randomized-controlled trial (RCT) of online Acceptance and Commitment Therapy (ACT) for chronic pain [5]. ACT is a more recent development under the CBT umbrella. This approach seeks to help people to let go of the struggle to control pain and related thoughts and feelings when this struggling isn’t helpful. ACT encourages people to make room for difficult experiences (e.g., pain) to be present, while they do what matters to them. ACT has a growing evidence base of RCTs supporting its efficacy for chronic pain, although outcomes are similar to those produced by traditional CBT [8]. Our trial evaluated a version of online ACT comprising an initial phone or face-to face meeting with a therapist, 8 online video-based sessions with support via messages, and a final therapist meeting.

When we started our trial, there were only two RCTs of online ACT for chronic pain [2; 7]. Previous research into online treatments highlights potential challenges, such as the potential for low treatment adherence. Also, while online and community-based recruitment may be convenient and effective, participants recruited this way may differ in important ways to those presenting at treatment centres. As such, we wanted to determine the generalisability of previous trials of online ACT to the UK context and for participants recruited from a specialty pain management centre. 

Participants in our study had chronic pain, clinically meaningful interference in daily activities, and a positive screen for depression symptoms. They were randomly assigned to receive online ACT plus treatment as usual within the specialty consultant-lead pain service or treatment as usual only. As this was a feasibility trial, we were interested in recruitment potential, and treatment completion and study retention rates. Secondarily, we wanted to estimate between-groups effects for outcomes such as pain interference, mood, and participants’ overall impression of change at follow-up.

We recruited 63 participants and 48 provided follow-up data. Sixty-one percent of participants who received ACT online completed a treatment “dose”, which was lower than what we had hoped for (70%). Interestingly, participants who didn’t complete treatment were more likely to be working than those who did. At three-months post-randomisation over half the people who received online ACT rated themselves as ‘much improved’ or ‘very much improved’ compared to less than one quarter in the control group. We saw small to medium effects favouring online ACT for disability and mood at three-months. This was maintained for disability, but not mood, at nine-months. We concluded that there is support for the feasibility of a larger trial of online ACT in our context, although this may require some refinements to trial and treatment procedures. We’re not the only ones doing this, which is encouraging. A recent RCT in Canada [6] and a large one in Germany [4] provide further support for online ACT for pain.

Our finding that working participants were less likely to complete online ACT was surprising as the flexibility of treatment delivery meant it could be completed around participants’ schedules. The numbers here are small, so conclusions are tentative. However, we may need to better target the needs of working participants. More broadly, we do not have sufficient data to judge who is most likely to engage well with CBT-based approaches, delivered online or face-to-face [3]. As ever, there is more work to do to answer questions about what works for whom, under which circumstances, and how.

Beyond adapting face-to-face treatments for online delivery, there are opportunities to potentially enhance CBT-based approaches with digital innovations. These include frequent tracking and shaping of behaviour and real-time feedback that occurs in the context of daily life rather than a therapist’s office. A flexible online delivery system with real-time assessment of therapeutic processes could tailor treatment to each participant’s needs in the moment. It is also intriguing to consider how virtual reality could enhance exposure to valued activities within ACT. Creative and flexible use of digital technology holds exciting promise to enhance our skills, impact, and reach as clinicians – helping more people with pain to do more of what matters to them.

About the authors

Whitney Scott is a clinical psychologist and an NIHR postdoctoral fellow at King’s College London. She works clinically one day per week at the INPUT Pain Unit at St Thomas’ Hospital in London, UK. The study discussed in this blog was funded in part through the IASP John J. Bonica Trainee Fellowship awarded to Whitney in 2014. For more information about her research check out: https://kclpure.kcl.ac.uk/portal/whitney.scott.html

Lance McCracken is a clinical psychologist and Professor of Clinical Psychology at Uppsala University in Sweden. He has delivered pain services for more than 25 years and remains involved in delivery of online treatment at Guy’s and St Thomas’ Hospital. For more information click here: https://www.researchgate.net/profile/Lance_Mccracken

References

[1] Andersson G. Internet-delivered psychological treatments. Annual Review of Clinical Psychology 2016;12:157-179.

[2] Buhrman M, Skoglund A, Husell J, Bergström K, Gordh T, Hursti T, Bendelin N, Furmark T, Andersson G. Guided Internet-delivered Acceptance and Commitment Therapy for chronic pain patients: A randomized controlled trial. Behaviour Research and Therapy 2013;51:307-315.

[3] Gilpin HR, Keyes A, Stahl DR, Greig R, McCracken LM. Predictors of treatment outcome in contextual cognitive and behavioral therapies for chronic pain: a systematic review. The Journal of Pain 2017;18:1153-1164.

[4] Lin J, Paganini S, Sander L, Lüking M, Ebert D, Buhrman M, Andersson G, Baumeister H. An Internet-based intervention for chronic pain. Deutsches Arzteblatt International 2017;114:681-688.

[5] Scott W, Chilcot J, Guildford B, Daly‐Eichenhardt A, McCracken LM. Feasibility randomized‐controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom. European Journal of Pain 2018;22:1473-1484.

[6] Simister HD, Tkachuk GA, Shay BL, Vincent N, Pear JJ, Skrabek RQ. Randomized controlled trial of online Acceptance and Commitment Therapy for fibromyalgia. The Journal of Pain 2018; 19:741-753.

[7] Trompetter HR, Bohlmeijer ET, Veehof MM, Schreurs KM. Internet-based guided self-help intervention for chronic pain based on Acceptance and Commitment Therapy: A randomized controlled trial. Journal of Behavioral Medicine 2015; 38: 66-80.

[8] Veehof M, Trompetter H, Bohlmeijer E, Schreurs K. Acceptance-and mindfulness-based interventions for the treatment of chronic pain: A meta-analytic review. Cognitive Behaviour Therapy 2016;45:5-31.