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How Does Acceptance And Commitment Therapy (ACT) Differ From Traditional Cognitive Behavioral Therapy (CBT) Or Pain Education Interventions?
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In this episode, we’re discussing how does ACT or Acceptance and Commitment Therapy differ from traditional cognitive behavioral therapy or pain education interventions, which are commonly used for the treatment of chronic pain. Many of you sent me emails or instant messaging me on Facebook, and you ask me questions about pain and other aspects of biopsychosocial care with regard to chronic pain. This is one of the most common questions. How does act differ from pain education or pain neuroscience? How does ACT differ from traditional cognitive behavioral therapy? I figured I would do an episode specifically dedicated to this topic, discuss the differences, and share a little bit about the evidence-based research.
I’m also doing something brand new and exciting that I’m thrilled to share with you. This episode is going to be available for continuing education units. You’re more than welcome to access this for free. You can also access this episode now and earn continuing education units. With that, I want to be able to share some objectives with you because we’ll discuss what we’re going to be learning about now. In this episode, you’ll be able to identify three cognitive processes of change related to pain and explain three ways that ACT differs from cognitive behavioral therapy or pain education. By the end, you’ll learn how to use three simple cognitive defusion techniques for the treatment of chronic pain. Cognitive defusion is a technique that we use in Acceptance and Commitment Therapy.
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Let’s begin with how ACT differs from traditional cognitive behavior therapy or pain education interventions. A good place to start is to go over a little definition of what pain education is. We have a little bit of a context as far as where we’re going with this episode and this learning. Pain education is a method of educating patients about the neurophysiology of pain that aims to reconceptualize pain from indicator damage to an interpretation of signals by the brain and nervous system. We’re helping someone reconceptualize pain from one of bodily damage from that biomedical or biomechanical approach of bodily damage to one of the biopsychosocial causes or biopsychosocial approach toward healing pain. The 10,000-foot view pain education methods help patients understand the biology and physiology of chronic pain, as well as the psychosocial factors that influence pain. With that, there’s a changing or a reconciling of faulty cognitions or maladaptive cognitions, whatever word you want to use with regards to thoughts and beliefs associated with pain and their impact on disability.
What’s called psychoeducation or what we now all know as pain education started in the early 1980s, one of the first studies around 1986 was conducted. That was not what we would identify as pain education now. It was more of a back school in essence, where we provide some information with regard to how to maintain a healthy back. Some of that was primarily from a biomedical model. Over the course of many decades, with the work of Lorimer Moseley and David Butler, Adrian Lowe, and many other people have contributed to pain education. We now have that more biopsychosocial approach to pain education, but pain education or psychoeducation is very similar. Psychoeducation is a component of traditional cognitive behavioral therapy and from that we’ve taken that component psychoeducation. We built it out to that larger pain education approach. They’re all similar where we help people with that biopsychosocial recognition of what’s happening. We help them change distorted beliefs or distorted thoughts with regard to their pain and their injury.
Cognitive Behavioral Therapy
Let’s briefly touch on mechanisms of change or processes of change. Let’s talk about cognitive behavioral therapy first. Cognitive behavior therapy is a large intervention. It can be anywhere between one session to upwards of 21 sessions. I covered many different types of topics. In general, we look at cognitive behavioral therapy for the treatment of chronic pain. The psychological processes associated with that change are one, psychoeducation, which we’ve already mentioned. Cognitive reappraisal, helping people reappraise their thoughts, modifying core beliefs, behavioral activations, helping people with pleasant activities and exposure or graded exposure, arousal reduction.
That’s things like stress modification or relaxation therapy and then finally, motivational enhancement. There are lots of different types of processes of change. I gave you the top seven right here, psychoeducation, cognitive reappraisal, modifying core beliefs, behavioral activation, arousal reduction, exposure strategies, and then finally motivational enhancement. Those are the seven to be most aware of when you’re working with cognitive-behavioral techniques or cognitive-behavioral intervention. The proposed mechanisms of change for pain education is that reconceptualization or that conceptualization around concepts associated with fear, fear-avoidance, knowledge and beliefs about pain and in essence pain itself. With pain education techniques or interventions, we hope that we are imparting new learning on someone who has pain. With that, it changes their self-efficacy. There are improved therapeutic relationships that happen with patients once they realize that we’re giving them new information that helps them cope with or help them helps them overcome their pain.
There’s the enhancement of motivation. Finally, probably the most important part is the promotion of behavior changes, all about behavior change. That’s what we’re all aiming for, which leads to improved functional outcomes. On some level, both traditional cognitive behavioral therapy and pain education, pain neuroscience education, all have to do with changing or modifying thoughts and beliefs. I want you to reflect for a moment there. I want you to think about the average patient, who you’ve seen in your clinic that has had chronic lower back pain. That’s been to anywhere between 2 to 10 different practitioners.
We know that patients see many different types of practitioners before they come to a viable solution for their pain. Think about all the various types of thoughts and beliefs that exist in their mind that some they have developed on their own. Some have been placed there by practitioners that are not up to date on the latest modern pain science or pain education. Things like a weak core or herniated disc in your back or your pelvis are out of alignment or your spine is unstable, or there’s a pinched nerve or your spine is narrowing and it’s pressing on nerves or potentially that you’re getting old. Your body doesn’t function well when you get older anymore.
As you get degeneration, it means you’ll move less or you’ll move in a less healthy way. All these are thoughts and beliefs that patients sometimes adopt through their process and sometimes through interaction with other practitioners. There’s a lot that we’re trying to help people cope with here as they’re overcoming pain. The question I want to pose to you now as we shift from the more traditional CBT approaches toward more third wave approaches, is can we change thoughts? If we can change thoughts and in essence, we’re saying on some level we can control thoughts. Can we change pain-related beliefs? Can we reframe pain? Can we reconceptualize pain?
Think about that. Can we change thoughts? Can we change beliefs? Can we reframe and reconceptualize pain? Let’s look at some of the research on that. This is a systematic review and meta-analysis on pain neuroscience education for chronic low back pain. This is 2018 in the European Journal of Pain. There are three important outcomes that they found with regard to pain and disability after pain neuroscience education for the treatment of chronic pain. The first point is that pain neuroscience education probably improves disability in the short-term, irrespective of whether it’s delivered in conjunction with physical therapy or not. Some good information there, you may decide to deliver PNE or other types of pain education by itself.
If you decide to deliver it with physical therapy, you’re more likely to have a more clinically significant improvement in disability. You can deliver it on its own. If you deliver it with another intervention, specifically physical therapy, more likely to have significant improvement in disability. Good news there, PNE as a standalone intervention or in combination with physical therapy in general, according to this systematic review has little effect on pain scores in both the short-term and the long-term. The idea that this is going to alleviate someone’s pain significantly, we probably don’t have a lot of good research on that. Another mixed methods, systematic review and meta-analysis, this is from the American Pain Society and The Journal of Pain. This is 2019. There’s little more information that they gave us. I’ll give you the does and does not.
Pain neuroscience education does not produce clinically significant decreases in pain. It does not produce clinically significant decreases in disability. Not good news there, but it does produce significant decreases in kinesiophobia. It does produce significant decreases in pain catastrophizing. These bottom two, kinesiophobia and pain catastrophizing, are important. When you look back toward those processes of change, when you look at negative thinking or you look at the reappraisal of thoughts, those two are important. That fear of movement, that kinesiophobia, and that pain catastrophizing is very important moderators with regard to the persistence of pain.
You can safely say that pain neuroscience education or other pain education interventions explaining pain are good for kinesiophobia and pain catastrophizing. The one article that I want to share with you, which is in Pain Research & Management 2018, was a qualitative study that looked at the reconceptualization of pain after pain neurophysiology education in adults with chronic low back pain. The researchers of this article tried to decipher, did people reconceptualize pain after an intervention of pain neuroscience education? There are only about twelve subjects in this study, but when they look at those 12, 3 fully reconceptualize pain and 3 subjects showed no evidence of the reconceptualization of pain, what is most important is that six subjects had partial or patchy reconceptualization.
That partial or patchy means that they use language that was consistent with the reconceptualization of pain, but also a language that was consistent with a biomedical understanding of pain. There was that partial or patchy reconceptualization. It starts to point to the fact that there may be a small group that we can completely change thoughts and change beliefs, meaning they fully reconceptualize. The vast majority of clients or patients that we see probably have partial or patchy reconceptualization. There’s a number of different reasons why that may happen. Some of that is clinician expertise. How good a clinician is at delivering pain education? Some of it is the education of the patient themselves with regard to learning and adopting this new information.
Some of it is the amount of time that we spent, whether that was the total amount of time or whether it was spread out over multiple sessions. A lot goes into delivering a cognitive intervention like this. If we can’t change pain-related thoughts and beliefs, then we have to turn to other types of approaches or methods with regard to people’s thoughts and beliefs around pain. There are more advanced cognitive-behavioral approaches that are newer. Acceptance and commitment therapy is one of them where there’s less of an emphasis on changing thoughts, on changing beliefs and the essence of changing pain itself. There’s not a big emphasis on changing the pain itself.
Acceptance And Commitment Therapy
ACT is a cognitive-behavioral intervention that uses mindfulness and acceptance processes along with commitment and behavior change processes to increase a core psychological process known as psychological flexibility. Psychological flexibility is a big topic. We don’t have time to go into all of it, but a definition of psychological flexibility is the ability to maintain open contact with either unpleasant or unwanted thoughts, feelings, memories, and physical sensations, while you choose behaviors that are in line with your personal values or goals. What does that mean? For example, I don’t particularly enjoy public speaking. I do it because I have to. It’s what I do for a living. When I public speak, oftentimes I have unpleasant or unwanted thoughts like, “Maybe people think that I’m stupid or they don’t understand what I’m thinking or they think I look funny or they think I’m a short guy and I appear taller on video.” There are many different thoughts going through my head about different things.
In essence, there is an unpleasant experience that comes up. For me to engage in a process of psychological flexibility, I can maintain contact or observe those thoughts as well as the feelings in my body. For example, when I have anxiety about people thinking those thoughts about me as I’m lecturing at a conference, I get a little bit nervous. I get a little bit of a stomach pain. My palms get sweaty. I get memories back when I was in college and I had to give my first presentation. It’s all sorts of different experiences that tend to come up. However, I choose to do this type of work because it’s in line with my personally chosen values and goals. My personal value is I like helping people overcome their pain. I have to teach to some extent. I like helping practitioners learn new ways that they can implement different types of strategies into their clinical practice.
Public speaking fits with my values and my goals. With regards to pain, it would be helping someone maintain contact with both physical pain in their body, as well as thoughts about pain or feelings of being inadequate or feelings of pain-related anxiety or memories of maybe injuring themselves. Being able to contact all of that psychological content, but still choose behaviors that are in line with their personal values and goals. That’s an example of psychological flexibility. What’s the mechanism behind Acceptance and Commitment Therapy? There are six different core processes. They’re present moment awareness, values, committed action, selfless context, cognitive defusion, which we would go into on this episode, and acceptance.
Those six processes in essence, fold into one larger process called psychological flexibility. Let’s zoom in on one of those processes now so you can have some good take-homes with you and that’s cognitive defusion. In traditional cognitive behavioral therapy, there’s cognitive reappraisal where we help people change their thoughts and beliefs. In the ACT, there’s something called cognitive defusion, which is basically helping someone watch or observe their thoughts or watch and observe their thinking. A couple of examples of this is allowing thoughts to come and go. You can think of thoughts like the weather. At times the weather rolls in and it’s nice, calm and sunny. At times the weather rolls in and it’s dark and stormy. Our thoughts can be that way as well. Allowing thoughts to come and go as they wish a second one would be noticing thoughts or not getting caught up in thoughts. The third would be noticing thoughts and not having them influence behavior.
In essence, we can have negative thoughts or we can have negative beliefs, but they don’t necessarily have to influence our behavior. It’s super important with regard to chronic pain. For example, you may have a thought that this exercise is not good for my back, but it doesn’t necessarily have to influence your behavior of you engaging with that exercise or engaging with other activities that are similar to that exercise thinking that they’re going to be damaging for your spine. It’s an example of cognitive defusion. Allowing thoughts to come and go, noticing thoughts and not getting caught up in them and noticing that thoughts do not have to influence behavior.
Comparing cognitive restructuring or cognitive reappraisal with cognitive defusion techniques has been studied. This is a 2016 article from the Journal of Behavior Modification, where they looked at cognitive restructuring versus cognitive defusion to cope with negative thoughts. Three important things came out of this that I put up here. The first is that negative thoughts are experienced by 80% to 99% of the population. Sharing that with people who have pain is super important because it normalizes our normal patterns of human thinking.
If you can normalize that all of us have negative thoughts, those of us who don’t have pain, and those of us that have pain. It’s a good way to help decrease someone’s anxiety about their entire pain experience. The second bullet here that we have is that cognitive defusion lowered the believability of thoughts, which is interesting. Even though we’re not trying to target beliefs with ACT that in some way cognitive defusion did lower believability. It increased someone’s comfort and willingness to have negative thoughts and an increased positive affect more than cognitive restructuring.
Finally, the most important data that came out of this study was that the negative thought frequency was reduced in the defusion group. It was maintained in the restructuring group and that had increased in the control group or the group that had no instruction. Cognitive defusion, with this particular group with regard to negative thoughts, helps decrease the frequency of thoughts, cognitive restructuring maintained. There was no change with regard to cognitive restructuring. Some good information that shows that there may be a strong place to use cognitive defusion to allow thoughts or to notice thoughts versus changing thoughts and beliefs simply. Earlier, I promised you three simple cognitive defusion techniques that you can take to your clinic right now. We help people with their awareness of thoughts or help them observe thoughts or to notice thoughts. Here’s what you can do with your patient to ask them to notice thoughts.
The first is what is your mind telling you right now? It’s a simple question. Maybe as you’re starting them on a new exercise or maybe you’re doing a manual therapy technique that maybe is a little bit painful, or they’re talking about an experience they have with their pain, stop them nice and gently and say, “What is your mind telling you right now about pain?” See what they say. Stopping the flow of their thoughts and having them recognize or observe what their mind is telling them right now. The second phrase, what is your mind broadcasting? In essence, looking at the mind as almost like the news, what is your mind broadcasting? What story is your mind telling you? I’m not saying the story is true or false. What is your mind broadcasting? If you were to stop right now for one minute and notice your thoughts, you would notice the mind broadcast all different types of thoughts within 60 seconds.
Finally, what type of thoughts is your mind generating? Is your mind generating negative thoughts right now or is your mind generating positive thoughts? Helping people notice that the mind generates both positive, negative as well as neutral thoughts, whether or not we do anything to facilitate that, on its own, the mind broadcast different thoughts, the mind broadcast thoughts that are positive, thoughts that are negative and some that are neutral. Recognizing or noticing or observing what your mind is telling you right now is a way to work on that process of cognitive defusion. In addition to noticing thoughts, we help people identify what’s called workability and acceptance in cognitive therapy. Workability is the concept of, is the behavior you’re engaging workable for your personally held values and goals? What’s interesting about behavioral therapies, in general, is that thoughts are looked upon as a behavior. We help people become more aware of the workability of their thoughts.
Three questions you can ask your patient is if you hold onto this thought tightly, does it help you return to the activity and the life you want? Second, if you let this thought tell you what to do, will it you toward the life you want or keep you stuck suffering? In essence, the mind can almost be a bully and bully you into doing things. Third, if you stop because your mind says this will hurt or because your mind broadcast the thought that doesn’t do this, will that move you toward or away who and what’s important in your life? The concept of workability and working that into your session with regard to cognitive defusion is very important.
Finally, we ask patients to notice when they’re fused with their own thoughts. Being fused with your own thought is imagine like a swirl of thoughts, circling all around your head and you can’t see the road in front of you. We help people gain some space or create some distance between them and their thoughts. For example, here and now, how caught up are you in that thought? You might want to ask someone that if they say, “No, I can’t do this exercise. This exercise is not good for my back.” Here and now how caught up, how caught up are you in the thought that if you bend forward, it’s going to cause you to have more pain in your back. Second, you might ask, did you notice how your mind hooked you or try to take control or protect you or bully you as you’re doing this exercise or as we’re engaged in our therapy session together. Simple ways to help patients notice when they’re fused with their own thinking.
The question is if traditional cognitive behavioral therapy and pain education focuses on symptom reduction, specifically the symptoms are pain, but also the symptoms of fear and anxiety are big with those approaches. Changing thoughts is pain reduction and changing thoughts necessary for a return to function. This is from the Journal of Consulting Clinical Psychologist, 2017, which asks the question, are reductions in pain intensity and pain delayed distress necessary? What they did was they took patients who went through a multidisciplinary acceptance and commitment therapy program for the treatment of pain. They did some follow up studies at three months with about 174 patients.
What they found was that decreases in pain and pain-related distress, things like anxiety, depression and pain catastrophizing did not necessarily have to decrease in order for functioning to increase. Reductions in pain intensity, thoughts and beliefs related to pain do not necessarily have to change to see our patients return to that rich, full and active life that they desire. In addition to those multidisciplinary type interventions that are in hospitals, we have a definite lack of those in the United States of America. If you’re a physical therapist or another practitioner who is weaving principles of ACT into your care or into your treatment sessions, in 2019, the Journal of Pain that showed that ACT combined with physical therapy was successful for reducing disability. It was acceptable to both patients and clinicians to deliver this type of care in the clinic. That physical therapist could incorporate principles of ACT with high fidelity, meaning they can stay true to the ACT model of pain.
Seven Distinctions Between ACT And Pain Education
Probably the most common question I get from a physical therapist, “Joe, what’s the difference between ACT and pain education?” There are seven differences or seven distinctions between ACT and pain education. Pain education changes thoughts or beliefs. ACT is about allowing thoughts and beliefs. Pain education focuses on alleviating pain or symptoms. ACT helps people respond differently to pain or other types of symptoms. There are no values work in pain education. There is a values clarification process, which is a key process of cognitive change, which is part of Acceptance and Commitment Therapy. In pain education, there is what’s called graded exposure. That’s either time contingent that happens over time. With ACT, there’s more behavioral exposure. If someone wants to engage in an activity or an exercise, even that is in line with their values, and we encourage them to do that, even if there may be some discomfort or even some pain.
Pain education has one process of change, which is a new knowledge or new education. ACT has those six core processes that fold into that seven processes of psychological flexibility. With regard to ACT, there have been over 300 randomized control trials in about 6 or 7 meta-analyses for the treatment of chronic pain and associated conditions. Less with regard to pain education, that’s a much newer technique. We’re still learning more about pain education. It’s important work that we should continue to learn about.
Finally, I’ll do an episode on this topic with regard to the therapeutic relationship. In general, the therapeutic relationship with pain education runs the risk of one where it’s a relationship of inequality because the provider or the practitioner has more knowledge than the patient has. With regard to ACT, because we’re working on being open, aware and engaged or open, aware and active, not only with the patient, but with us as well, with commissions as well. We want to cultivate the same psychological processes. With that, we aimed for a therapeutic relationship of equality.
Meaning as a practitioner, I don’t necessarily have any great or important information. I believe that the information to help someone heal and move on or move forward from their pain resides in them. What I’m doing as a practitioner is facilitating their values and their goal is to help them move beyond the pain. The therapeutic relationship is very different between pain education and Acceptance and Commitment Therapy. At this point, you’re probably thinking there’s traditional cognitive behavioral therapy. There is Acceptance and Commitment Therapy. There’s pain education, pain neuroscience education, which method should I choose? There was a study that explores this in the European Journal of Pain. They asked the question, what are the necessary components of psychological treatment in chronic pain management programs?
The outcome was that there were three aspects or three components that are the gold standard for the psychological treatment of pain and that’s pain education or psychoeducation. You can use those interchangeably. Any type of cognitive-behavioral approach and strategy to increase physical activity. If you can combine those three, those three are the necessary components for the psychological treatment of pain. In this particular study, they said any cognitive-behavioral therapy. I’d like to share with you why I tend to lean a little bit more toward ACT with regard to the treatment of chronic pain. The first from this systematic review and meta-analysis from 2011, is that we know that ACT has comparable effect sizes with regards to both physical and mental health when compared to other types of traditional cognitive behavioral therapy. We know it’s probably as good as traditional cognitive-behavioral therapies.
Later on, in 2016, the Journal of Cognitive Behavioral Therapy, ACT showed significantly higher effects on depression and anxiety than mindfulness-based stress reduction or mindfulness-based cognitive therapy. Mindfulness-based stress reduction is not technically a cognitive behavioral therapy, but it has lots of principles of cognitive and behavioral components wrapped into it. Mindfulness-based cognitive therapy is a traditional cognitive-behavioral model where they weave in a little bit of mindfulness. ACT showed higher effects on depression and anxiety than those two different interventions. That’s important. I know that many of our clients struggle with depression and anxiety. ACT may be better for certain people.
Finally, in 2017, a new systematic review and meta-analysis were that there was significant medium, large effect sizes with regard to pain, acceptance, and psychological flexibility. That’s important, especially as a physical therapist, pain acceptance, if I can help move the needle a little bit on pain acceptance and psychological flexibility, people are more likely to engage with exercise and physical activity. I want to thank you for reading this episode of the show and attending this session. This is available for two hours of CE/CEUs. You can access that on the website at the IntegrativePainScienceInstitute.com. Go over to the Courses tab and then down to Listen and Learn, and then click on Episode Number 195. Once you get inside the course, you’ll be able to access that episode again if you want to read it again, the entire slide presentation will be there and there’ll be a short, brief, easily negotiable quiz for you to take so you can get your CEUs.
To summarize this episode, there are many cognitive-behavioral methods to choose from with regard to the treatment of chronic pain. Some focus on changing thoughts and beliefs, others like ACT focused on observing and relating differently to thoughts and beliefs. These methods can coexist together. For example, you can spend the first session and work on a little bit of pain education. From there, if you notice that thoughts and beliefs are not changing, then it might be wise to shift toward a more acceptance and mindfulness-based approach to pain. These methods can co-exist together.
I recommend that you try to integrate them together because the truth is there’s no one method that works for every patient. There’s no one method that works for every type of diagnosis that out there. I recommend that you mix and match this to patient needs and to the patient’s clinical presentation. It’s been great spending this time with you to discuss how ACT differs from traditional cognitive behavioral therapy or pain education interventions. This is a listen, learn and earn CEU episodes. Make sure you go to the website at the Integrated Pain Science Institute and sign up for that low cost easily and affordable CEU. I’ll see you next time.
- National Board for Certification and Occupational Therapy
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