Welcome back to the Healing Pain Podcast with Dr. Amanda C de C Williams
In this episode, we’re discussing the different types of psychological therapies available for the treatment of chronic pain. Do they help? Are they safe? How much confidence can we place in them and what we should further investigate regarding this topic as we move forward? My expert guest this episode is Dr. Amanda Williams. Amanda was a full-time clinician in a pain management program for many years, then she transitioned to teaching and research. She’s a professor of clinical health psychology at The University College London and a consultant clinical psychologist at the Pain Management Centre University College London Hospital in the United Kingdom. We discussed the findings from her paper called Psychological Therapies for the Management of Chronic Pain in Adults, which can be found in the August 2020 Cochrane Library of Systematic Reviews. The paper updates the literature regarding the effectiveness of different kinds of psychological therapy, including traditional Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and Behavioral Therapy.
It also asks the question as to whether these interventions are safe and if we’ve investigated safety and harm enough in the literature. This paper was well-received by many, however, as with any study, there were some questions regarding the findings and how much emphasis we should place on psychological therapies versus other types of therapies to help people living with chronic pain. The paper also had some significant criticisms as to developing research base around Acceptance and Commitment Therapy for chronic pain, a topic we’ve discussed many times on the show. It’s important that as professionals and as general members of the public, we’re informed as to the argument and all sides of the literature, research and perspectives with regard to the various treatments of psychological therapies for the treatment of chronic pain. We discuss all of this and more on this episode. Let’s meet Dr. Amanda Williams.
Watch the episode here:
Psychology for Chronic Pain: Does It Help? With Dr. Amanda C de C Williams
Evidence And Controversies In CBT, ACT And Behavior Therapy
Amanda, welcome to the show. It’s great to have you here.
Joe, it’s great to be here.
I got an alert one day from PubMed because I have lots of different alerts set up for different types of studies and topics that interest me and your study came up. It’s a study that everyone can access. It’s an important study. It’s called Psychological Therapies for the Management of Chronic Pain in Adults. It’s a review that was published in August of 2020. You can find it in the Cochrane Library of Systematic Reviews. I want it to have you on to discuss the important findings of that paper as well as some other questions that people might have around psychological therapy. Thank you for doing this study, it’s an important work that I know people in the UK will use as well as other people around the world. Tell us why it’s important that you publish this study now.
It’s an ongoing question for lots of people with chronic pain and those to provide their services. What should we be providing? Is there one method that’s better than others because it can be quite disappointing. We’ve done previous reviews in the series, but they need updating as people bring out new studies. Otherwise, people don’t know whether to go back to the old reviews or try and add on new studies. The point about doing systematic reviews, you’ve got everything that’s out there. We don’t restrict it to the English language. We do put a few restrictions on, but we’ve got all the relevant studies. We put them all together into an analysis, which is much more powerful than any single analysis. Nearly 9,500 people in this paper by putting all themselves together. That means you can be much more confident about your results than if you have one population with its own quirks, which they all have.
You did publish this study in 2012. This is an update to that one. Can you tell us how this review is different from the one in 2012 other than more information, more people pulled, and more data?
It almost doubles the size, but also, we were able to separate different types of therapy. What we did in 2012 one was we still put everything psychological into one analysis as it were. We do separate the different outcomes and immediately from a long time after treatment. This time, we’re able to separate Cognitive Behavioral Therapy or CBT, Acceptance and Commitment Therapy or ACT, and behavioral therapy, which is a funny mix of things.
As you’re touching on that, maybe you can tell us about the different types of psychological therapies that are out there for the treatment of pain or that professionals are using and implementing into their practice.
People are picking a whole lot of things out of the toolbox and every trial varies. There are some changes over time that you see early on. People have a lot more faith in things like relaxation, attention, diversion methods and so on. Those were disappointing and some of the earliest methods put much more emphasis on exercise. Whereas now, there’s a bit more on people getting to do what goals they want to do without seeing exercise as an essential stepping stone. Methods have changed from the early ones in stress management to more cognitive ones, which are very like those used in the mental health field. Challenging and trying to change thoughts, which lead to over pessimistic predictions and overcautious ways of going about life with pain. Trials take a while to pick up on introductions of Acceptance and Commitment Therapy where people are asked more to disengage from their thoughts. Not to engage and grapple with them and change, but to disengage from them and take a more dispassionate approach to what they do and how they do it.
This study focused on those three areas, traditional Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, and behavioral therapy.
The behavioral therapies are a mix of things like relaxation and feedback, more social reinforcement of what people do and don’t do, which can be activity-based. Some specific work towards goals by specific quotas, which overlaps with some of the other work towards goals. They’re not walls between these methods and in practice, they do merge a lot.
People who read this are relatively familiar with CBT and ACT. You mentioned behavioral therapy, can that be used synonymously with operant conditioning type approaches?
Yes. Operant conditioning described a social reinforcement because that’s the powerful better bit, but people can also observe what huge effect their behavior on their own lives. A lot of it is about trying to make sure that when people try new things and manage them despite the pain, that it’s recognized, enjoyed, and celebrated almost by those around them, rather than people say, “Are you sure you’re okay? Was that a good idea? If you hurt tomorrow, I’m not going to be sorry for you.” That’s discouraging for people who’ve taken their courage in both hands and had to go at doing something they’re quite concerned about doing.
What were the outcomes that you were attracting in this particular review that people can look back to and say, “There’s some good data that these outcomes are either there or not there regarding this systematic review?”
We only used three. That was another change from 2012 when we had four. Whether the pain is planned or not, it does seem to change with these therapists, but it’s not usually the main target. In earlier studies, perhaps, it was more from the main target. In the pain study, it’s essential to measure pain and to recognize that it’s there so we analyzed it. The two important ones are disability and distress. What people couldn’t do because of the pain? The anxiety, de-motivation, low mood and so on that it caused them.
Pain, disability, and distress. People understand disability because we’re talking about functional disability. What people can do regarding physical activity in their ADLs potentially, work, and things like that?
It can even mean social things as well. Whether people get to see their friends and family, enjoy time with them and whether they can do creative things. Work is important as well as self-care, but it’s quite important that we see people’s lives as broadly as possible.
When you mentioned distress, can you build that out a little bit for people what distress means in the context of this study?
It’s most often measured in terms of depression, but people aren’t necessarily in a clinical range of depression. It’s somewhere a mild to moderate low mood that might fluctuate. A lot of that is because people are not living the lives that they would be doing without pain. They’re immensely frustrated about what they can’t do or feel it’s not safe to do. It also merges a bit of anxiety, which is why I think the term distress is quite useful. Anxiety is usually referred to more around acute pain, but there’s anxiety all the time about, “Should I do this? Should I carry on? Should I stop now and take a break? Should I try another doctor? Should I go back to the doctor I went to?”
All these questions all the time for people with no clear guidance. No doubt people around them are all saying different things. You’re giving genuinely heart meant, but different advice. If you feel that there’s something wrong with you, which isn’t quite understood and you don’t quite understand yourself, you might make yourself significantly worse by pushing hard to do something or doing it in the wrong way. It can be frightening to try to do things that people tell you are safe, but then they’re not the ones who are going to suffer if it doesn’t work out. There is a lot of anxiety around that and we don’t engage with them.
As far as the psychosocial distress, you were saying that depression and anxiety are a factor, but in this study, you zero in on depression as one variable.
It’s more of you pull the measures that more people used. If they use one or other of anxiety and depression, more people use depression, but quite a few of the scales that people use were for both. We used the combination where we could. In any case, depression questionnaires have anxiety items and depression on them. They’re not opposites. They’re close.
Give us the update and tell us what your study, how your study updates our knowledge on psychological therapies, and their impact.
We set a threshold for studies. They had to have at least twenty people in each arm of the trial. Let’s say you had CBT versus Behavior Therapy versus waiting lists. Each of those had to have at least twenty people in them by the end of treatment. That cuts out a lot of small trials but small notorious for producing anomalous results. Ideally, we would use an even higher bar, to be honest. We would use something more like 50 cut out for a lot of trials. We had that as a bar. It had to be face to face treatment because ones we’ve reviewed elsewhere and mixed them up doesn’t count. We are also required that it was taught by psychologists or people adequately trained. They couldn’t be reading a script or have done a weekend course because delivering psychological treatment properly is not reading a script or using common sense.
As you talk to each person, you’re tailing it around their needs, their strengths and other things. Given that, most of our trials were CBT. They tend to be the larger trials. They more than made it to our gate. They showed in general small but definite improvements in disability and distress, both straight after treatment and that 6 to 12 months follow up. Some of the results were not quite clear at follow-up and it matters that the effects last. This was against treatment as usual. If you compare with another treatment, you get much less effective because you’ve got two strong things going against each other, but most people’s choice is not, “Would you like this psychological treatment or that one?” It’s, “Would you like this or nothing?” That’s perhaps more likely aligned.
CBT looked good, but the changes are small. These are average changes. They’re made up of people who changed a lot. Some people who changed not at all and a few who get worse. A few trials of Behavior Therapy made it through. They are mostly earlier trials. An awful lot of small trials disappeared. They didn’t look good at all. Nothing much changed. Our confidence in the findings, which has to do with things about the quality of evidence was much lower than it was for CBT. The surprise to a lot of people, including us was only five trials of ACT made it through the gate. There are an awful lot of small trials back, which is a bit surprising given that the more trials tend to be bigger. We weren’t seeing any improvement on where we were. The quality of evidence was low that we couldn’t show that’s published when it’s added. It won’t change the results in a negative direction. That was a bit surprising given the strength of taking up of ACT by practitioners all over the place.
There’s been sufficient or a moderate amount of evidence-based on your review that shows that traditional Cognitive Behavioral Therapy has small but significant changes for people and looked at these larger-scale trials. Let’s talk to people with pain first because on this show we have both, people who have pain or interested in learning more about alternatives and what they can do to self-manage their pain. We also have professionals. What does this mean first for people living with chronic pain?
It should give them confidence that if they’re offered CBT, they stand a good chance of making some improvements in disability and less distress coming out of it and were able to do the things they want to do, which is good news. It’s not going to turn their lives around completely. We’re still unsure of the longer-term effects of this. Ideally, once talking about changes in behavior, which then not only last but as it will start being used for all sorts of things that people weren’t initially doing. If they work, they should work on new things. If someone starts to think of going back to work, that should give them confidence. We wouldn’t want them to take the message that ACT is not helpful. We’re not saying ACT is not effective, but the evidence is not there to say it is or it isn’t.
I hope it would be of interest to patients, but it’s not the thing that patients can do. We would like ACT to be a bit more critical about evaluating itself with the same outcomes as other people that are using. There are a lot of ACT trials that measure acceptance at the end. People are better at acceptance, but it doesn’t necessarily mean that they’re able to do what they want to do more. It could do, but we can’t assume it. People didn’t necessarily come to the course saying, “I want to be more accepting.” They were saying, “I want to be able to garden more, play with my grandkids, and go back to work.”
As a researcher talking to another researcher, you were saying that ACT looks positive, but you would like to see larger-scale studies that have more power to them and have the same ruler or litmus that all cognitive-behavioral interventions are using. What you’re saying is oftentimes, there are six core processes of ACT, and one of them is using pain acceptance as the measure, but in traditional Cognitive Behavioral Therapy, they’re not necessarily looking at pain acceptance.
There are a few trails that do. That’s interesting because it enables us to understand it. We want to look out into the bonus and see how all this works. It could well be that there are common processes for which we use different language and apparently, different lessons, but it’s all doing the same thing. That’s perfectly possible. Acceptance and Commitment Therapy grew out of Cognitive Therapy and still do share quite a lot of thinking. We have to think about what matters most to patients. I’m not saying, patients or people with pain who come into these programs. I’m not saying that distress and disability are the only things. If you ask patients as they did in a very large state, what matters most was the enjoyment of life. We never measured that. What a lovely thing to have a response target and things like social relationships, concentration, memory, sleep, things we don’t routinely measure. They all came out high. We need to be careful not to focus on things we think are important like flexibility and so on. Those may be why therapists work, but we can’t be 100% sure and they are not a proxy for real life.
We have lots of questions still. That’s why we do research like this. As I was reading through in this study or review, you had those 3 or 4 pain, intensely, disability, and distress. In your previous ones, it looked a little bit more at catastrophizing and other mechanisms and moderators of pain, which I found interesting as well. In this study, you made strong mention of long-term outcomes. The question that maybe we should ask ourselves as clinicians is that we see people for 6, 8, and 12 weeks. Maybe if you’re in an inpatient chronic pain multidisciplinary program that lasts for three months, and then we don’t see people again. They’re gone, out of sight out of mind.
I almost wonder, when COVID hit, after a while, all of us are saying, “I haven’t seen my dentist again. My teeth were cleaned in months. I need to go back and get my teeth cleaned.” We have some of the most challenging people who are suffering physically as well as emotionally. They go through our care, but we don’t follow them in the long-term. We don’t give them a booster session. How does your study start to look at those questions and start to make us think about, “What should we be doing for the long-term care to support people effectively?”
We don’t look at that. We’re giving people the treatments and then following them up. Longer time intervals don’t necessarily answer any of the questions about what people need. Interestingly enough, if you look at the trials of giving people booster sessions or refresher sessions, the evidence is they don’t make any difference. People like them, they get high satisfaction scores. When people say, “They’re glad they came,” but nothing changes in terms of distress, disability or other outcomes that people use. For me, in a way that’s not terribly surprising. What I would love to be able to do, but nobody would ever fund is to have a little team of the people who did pain management to go to people in their own homes and problem solve with them about the difficulties they’d had putting stuff into practice.
If they didn’t learn it the first time, then the one-day refresher is not going to do the trick. Assuming that people did pick up a whole lot of different ways of doing things, when they’re doing pain management, then the question is, “What is it that makes it difficult at home?” There are lots of things that can make it difficult at home from the physical layout to who they live with, and who isn’t around supporting resource. We know that with getting people back to work, it’s never enough to intervene with the person themselves. You need to intervene with the workplace as well, because however adaptable and thoughtful about pain management someone is, if their line manager says, “No, you’re not doing things any different to anyone else. You come back 100% or not at all,” and you’ve got to do that within the next few weeks, it’s not going to work. We’ve put the burden of making the whole thing work forever on the person themselves. There’s a lot in the context that we don’t know about and we need to get better at knowing about, but we’re not going to do it by inviting people back to our clinics. That’s my dream.
That shifts things a little bit from the psychological to the social part of things. As you’re talking, I’m sure if there are occupational therapists reading this, they’re probably cheering you. A lot of the work and the theories that they have in occupational therapy focus on therapy in the home, at work itself or in the school environment versus coming to an institutionalized setting where it’s clean and perfect, but life isn’t always clean and perfect.
The pain team I work in is part-time, but there were large and that’s University College London Hospital has turned to do lots of groups online for COVID. They’re working astonishingly well. They are popular with patients who no longer have that awful business of trying to find their way into Central London and sometimes parking on public transport, pay for taxes or all the rest of it. They feel different in their own homes. It is harder for them to make the connections between them, but an important part of all those group programs got support. I sometimes wonder if we could do more to facilitate that. When I started, we didn’t have the technology we now have, and people quickly set up Facebook things, WhatsApp groups and so on as a patient group and a lot of important stuff goes on in there.
What does your review say the same or what does it say that’s different versus past reviews or other reviews that are out there that may not be Cochrane-based reviews?
On the ACT side, it’s not as positive as the other reviews. That’s largely because the other reviews took on both of these smaller trials. Also, it included some of the online ones and that’s impressive if the online ones also have had good effects. It’s not that the CBT is not that different from other reviews, but the other reviews tend to be for a specific type of pain, almost always back pain. We felt that a lot of the problems with chronic pain are common, whether people have back pain, knee pain, pelvic pain or facial pain. Although it can be important in some ways to have groups that are specific for people and understand the problems better because there are some problems that are more specific than an awful lot of problems that are in general. It’s important for us to think about psychological aspects and not always think of pain in terms of anatomical sites.
You write about adverse effects, which we rarely see written out in hardly any research study. I would love to see more of that. What does this tell us about adverse effects and why should we pay more attention to it?
It mainly tells us that people aren’t measuring them. The tempting thing to do under lots of trials is to do this though not so much in the ones we reviewed this time around. You recruit a whole lot of people, then some dropouts. Some could be 5%, but it can be nearly 50%. You never know what happens to them. If you ring them up, they often help you not feel too bad by saying, “My cat died or something, and thank you,” but they don’t come back. In the end, you only look at the results of those who stuck it out. You might find them even to be a minority. At follow-up, it’s even a small minority who come back. Those are presumably the people who’ve done better or happier with it. For them, it got them some the way they wanted to go, but that’s not telling about the whole population.
We need to know who’s made worse because when I worked clinically, I did see some people who became more depressed as they realized, as they started to think more about how much they’ve lost and how hard it was going to be. People often different in a phase of life from when the pain started. They can’t hope to go back to where they were and pick it up. They’ve lost the children’s childhoods or their grandchildren’s childhoods, all the chances and career. Unless we tried to get to grips firstly with people who don’t get on within drop out. Secondly, looking at the results of those who do stick it and then, if they don’t improve or even get worse. That’s an important part of what works for whom question, because ideally, by the end of all these reviews, we will have a much better idea of matching.
If we pretend that people can only get better or stay the same, it’s not good enough. Also, my concern is that often not only the clinicians blame the patient for not improving with treatment, but the patient themselves may feel that it’s a personal failure and it may discourage them from seeking other similar treatments. It maybe wasn’t the right timing or they weren’t engaged effectively in the whole process at the beginning. Having another go in a little while or with a different tune might well be helpful, but if they feel that it’s them that failed. They’re not going to be responsive to those opportunities. We need much more thinking and it would be helpful to hear more from patients who do feel they’ve got worse and who have dropped out so that we have a better understanding of what we should be looking for baseline. It certainly isn’t anything simple. It’s not older or younger patients. It’s not necessarily those who are most depressed at the beginning or those who are most disabled. It’s not going to be simple things that mean that people don’t do well.
When I was looking at pain, that was the adverse effects and upon a simple first glance, you’re like, “That makes perfect sense.” We don’t want to cause more pain for people and pain shouldn’t increase. We are treating pain in some aspects. The other part of me thinks with things like rated exposure and in vivo exposure and some of the treatments that are wrapped up in traditional CBT, as well as the more “third wave” or more mindfulness-based approaches that have some of that exposure whether it’s imaginal or interoceptive exposure. I almost wonder if we should be focusing on that as an adverse effect itself.
It’s an interesting thought because we need to be honest with people with the outset. What the likelihood is of increase or decreases in pain by the end and increase and decrease in other outcomes and you can’t tell them. The problem for me with pain is that we know that the rating of pain or even if you use a more complex measure of pain, it’s affected by the pain at the moment you feel it in and by our mood. It isn’t a simple thing of saying, “It was 7 out of 10 when I started and it’s now 5 out of 10.” I vividly remember a patient who told by the doctor that he now had 50% of the pain.
He rated himself having at the beginning of treatment and he was 50% relieved. He should be happy, but he said, “The pain is 100% now,” and he was worried. He wanted the rest to go. I don’t know how solid ground we’re on when using pain ratings as outcomes in that way. They certainly matter. I’m concerned if people’s pain ratings go up, but I don’t know how to understand it if they go down. Maybe it means the intensity is the same, but it doesn’t bother them as much because they’re looking forward to things more and they’re sleeping better.
A couple of things I would like to pick out of this study and discuss with you. These are some questions that the community will be interested in thinking about. As they read your paper, in your study, there’s a clear mention that psychological treatments have a relatively agnostic approach. You make note that we haven’t explored how some potentially psychodynamic approaches or the emotional aspect of this with regards to prior adverse experiences have an impact on the treatment of chronic pain. It goes to mention that the studies in your review didn’t include any of that or potentially did not include any type of treatment along those lines.
We did find several studies that we included in the narrative part of the review, which used more psychodynamic methods. They are interesting and potentially quite promising. There’s a lot of interesting trauma in relation to chronic pain and compassion focused therapy. People learning to generally be candid to themselves, which comes up in other therapists, but also being able to self soothe and think about the way they treat themselves in a different way. There are some interesting ideas coming up and it’s great to see them happening in trials. Maybe next time we update this, there’ll be a handful and we can look at them together.
The early psychodynamic ones were done as very long individual treatment, which one couldn’t understand what was done because there was so much based around that particular person and often, that particular therapist. They didn’t give themselves to RCTs, but people are now bringing these things together and doing some interesting and promising studies. I said a bit like evolution. If you have a variety, then if you can exercise some effects that work like selection, you should get the best, the most effective out of the other end. That’s a rather crude analogy, but you see what I mean? We need variety in order to learn about what’s most useful and what doesn’t work for a large number of people.
You included ACT and there is a lot of mindfulness in that. It’s both looked upon as a process, as well as a technique in ACT in many ways, but you didn’t look at pure mindfulness interventions, mindfulness-based stress reduction or mindfulness-based cognitive therapy as a whole family of those. Can you tell us about why maybe the MBSR and MBCT were left out of the analysis?
There are two related reasons. One was that it’s difficult to draw the line into what’s the treatment for pain because often, the trials are for people with a whole mixed set of disorders. They might have chronic fatigue, irritable bowel syndrome or psychological disorders. People will be in a whole mixed group. It wasn’t about that chronic pain, but it’s outcomes. Also, some were almost 60% yoga, 40% mindfulness. That’s not something we have psychological theorist for, nor that we should assume that a psychologist should be the one teaching as we could be with other psychological therapists. In fact, psychologists might be the 4th or 5th choice as the best person to be doing a mindfulness group. There are people far more trained in the methods, the understanding, using themselves and their meditation practices for a long time. It felt that we couldn’t put it into clear categories or apply the boundaries in the same way. The mindfulness reviews that around out there in the literature have the same problem. They all involve the line as a different place. Some will include yoga and Tai Chi, whether the mindfulness practices are perhaps more implicit.
I pulled a quote from your paper that I would like to read for everyone. You said, “A typical example of treatment with insufficient psychological content is a mindfulness meditation treatment that refers only to education and meditation practice and has no theory to support behavior change.” That statement there is interesting for me to think about. Are we saying that mindfulness doesn’t have a proven cognitive component to it or are we saying that we haven’t been able to support that mindfulness has an impact on behavior change the way that other traditional cognitive-behavioral therapies have?
It’s more of the latter. We were looking for things that we’re trying to help people change their behavior in relation to pain. That can be the outcome of all sorts of things, whether or not they intended, but it wasn’t the explicit intense, particularly when groups were mixed and not everybody had pain. It’s not that there isn’t cognitive content and I’m sure there’s cognitive content, but the aim we felt we’d be trying to overlay our own ideas of what mindfulness all could do on people’s descriptions of what they were trying to do. We didn’t want to do that. We wanted to take onboard the trials, which we’re trying to get people to be more active in the things they want to do and less distress.
Many of the trials were multidisciplinary, so they included psychology, but other professional interventions like physiotherapy, occupational therapy, other types of counseling, and art therapy. Where does exercise therapy fit into this? When I think of exercise, socially and culturally, we break it down into this thing is meant to make us robust and healthy. Although we know that there are cognitive and aspect dimensions that are at work no matter who is providing the exercise intervention based on how that’s provided.
Exercise is an important part of working towards goals. Everyone’s goals are different than working towards them. It is often done away from the program itself and that’s not necessary. When the focus is more on people working towards goals, then the exercise tends to take a more generic strengthening, slightly improving, more capacity and stretching. It is getting people to have more confidence in their bodies in a way that relate better to their body. They feel that their bodies can give them good feelings as well as bad ones. That’s been a move over time from the programs where every day you do as a routinized exercise, which doesn’t necessarily carry over into being able to sit long enough to have supper with your family or walk far enough that you can shop easily when you get that kind of thing. It’s moved from the traditional exercise to natural function, but still, physical therapists are doing it. They can be analytic about what units need to change to enable the activities.
There’s an aspect of operant and/or behavioral therapy within any exercise instructor.
Physiotherapists have become more psychological in that practice over time. The more that happens, the better. If we’re all using the same methods and some of the same language to help people change then that’s an asset.
Let’s talk for a moment about ACT because it is a big part of your study and probably the most controversial that came out of this study. Most questions are with regard to that. I was going through the review and it’s hard for me to calculate the exact number, but there are probably somewhere between 20 to 30 different studies on ACT that were excluded. There’s a lot of studies and in some of those were meta-analysis and systematic reviews, but did not meet Cochrane standards.
Some of them were teams, but they don’t make proper standards.
You said there’s much enthusiasm for ACT shown in many non-Cochrane reviews, which may include many small trials that report beneficial outcomes, but there’s no high-quality evidence to support the findings, high quality, adequately powered trials are needed, preferably multicenter and run by investigators with equally post.
One of the problems is that when any therapy is new, the trials tend to be done by people who are fantastically enthusiastic about that therapy. They’re the ones who will stay up late at night and write all the stuff that gets the grant to get to do the trial. It’s admirable that the enthusiasm barge into that. When you’re trying to think of it from the point of view of a randomized control trial, when you want everything, but the actual treatment people get to be equal to train them. If people are getting either someone who is enthusiastic and committed or somebody who’s standing in front of them and reading from an educational script, which is common in a trial, you can see how there are going to be differences there that aren’t about the treatment they get.
There’ve been several treatments that are CBT versus ACT. They’re not actually in our review, but they’ve all been done by ACTs enthusiasts. It’s quite interesting because although the results show both have brought benefits, they were not exactly the same ones, but equal in some ways. When you read the abstract, you’d believe the ACT is far superior to CBT. There’s a bit of spin in all this. We would like to see the spin come out of talking about ACT and some more thinking about common pathways, common processes. As we were talking about in terms of measuring acceptance, flexibility, and things in CBT, understanding is not going to be fostered by saying, “We’ve got the best thing.” That’s what we mean by the post. We want something replicable beyond the enthusiastic citizens in the trial. We want it to be doable across lots of centers and for someone else to be able to read the manual and do it if they have the background training, not for it to rely on charisma and passion.
There was a study in the 2011 Journal of Pain. It’s a meta-analysis and systematic view. I’m sure you’ve read the Acceptance-Based Interventions for the Treatment of Pain. Veehof was the publisher there if people want to access it. The outcome was the effect size of ACT was somewhere between 0.3 to 0.4, which is in that small range effect size. It looks like it’s comparable to CBT and there are nine RCTs in there. They’re smaller. My question is if we’re finding based on your study that CBT has small effect sizes and this study, even though it’s based on smaller RCTs, yet they find equal effect sizes. Is ACT potentially a good alternative for people who’ve maybe gone through CBT or maybe CBT doesn’t necessarily fit for them or interest them? Is it a healthy alternative for them to look toward with regard to overcoming pain?
In principle, it could be. In fact, that 2011 review, he mixed randomized control trials and online device trials. Some of it is pre-post, which is not the same thing at all as having control. That tends to inflate the effect sizes. I thought it’s a bit bigger than that. In his 2016 review, he used RCTs. People often ask that. In a way, it’s an alternative and we need to understand the size or changes it makes, but it could be that people who are helped by CBT are also helped by ACT and people who aren’t helped by CBTs also aren’t helped by ACT. While it would be convenient that we have 2, 3 or 4 types of treatment, and if one doesn’t work, one of the others pretty well was likely to. I don’t think we know enough about them to know what’s going to happen. We could find that some people need all the different treatments and different forms of delivery. Another thing I wished we were able to do and I’ve never seen done except occasionally single cases is when people are disabled. I think treatment needs to be spread over a year or two, not weeks or months.
It brings me to my next point, which was an important part of your review was your recommendations to funders was that we take CBT now and we explore it in psychiatric comorbidities, mild cognitive dysfunction, learning disabilities, opioid overuse, and those with otherwise unrepresented in the literature. That’s important.
Those people are excluded from trials commonly because, in trials, you want as fast as possible for the population not to have too many other things going on that could affect the results and you won’t be able to describe them well. In clinical populations, people are treating such patients, but they’re often being a bit cautious and the rest of the evidence there. It was probably common to have other problems as well than to have chronic pain and the rest of your life to be going seemingly. Those are important and urgently needed, and it’s a bit frustrating. It feels like people go on doing similar CBT versus nothing and CBT versus minimal control again with tiny differences.
It matters that we get a grip with people who are stuck on opioids and told they should come off to them, but understandably terrified, not feeling they’re being offered anything in exchange. I have CBT used with people with mild learning difficulties who have huge unacknowledged problems with pain. People listen to them much less than they do to the average person that complains of chronic pain quite successfully, particularly some of the behavioral methods and creating routines and so on, but cognitive methods too. I would like to see much more of that going on.
There are many different types of populations to study other than fibromyalgia and low back pain, and these are patients that we see every day.
I’m pleased you raised that because there are virtually no trials in any of those areas and we badly need them.
Amanda, it’s been a pleasure speaking with you. I appreciate the work that you’re doing both in research, as well as clinically. Can you tell people how they can learn more about you and follow your work?
I’ve got a web page at University College London. That gives you publication links and so on.
Make sure to check out her study called Psychological Therapies for the Management of Chronic Pain in Adults. It was a review in the August 2020 Cochrane Library of Systematic Reviews. It’s been a pleasure being with you. Make sure you share this episode with your friends and family on Facebook, LinkedIn, Twitter, wherever anyone’s hanging out, talking about the effective and safe treatment of chronic pain. I’ll see you on the next episode.
- Dr. Amanda Williams
- Psychological Therapies for the Management of Chronic Pain in Adults
- Acceptance-Based Interventions for the Treatment of Pain
About Dr. Amanda C de C Williams
Amanda C de C Williams is a Reader – Professor from October 2020 – in clinical health psychology at University College London, and a consultant clinical psychologist at the Pain Management Centre, University College London Hospital, UK. She also works for the International Centre for Health and Human Rights, and is Section Editor for Psychology on PAIN.
Amanda was a full-time clinician in a pain management programme for many years, and research on this formed part of her PhD. After obtaining her PhD in 1996, she moved increasingly into academic posts, joining University College London in 2004. Her research interests include evidence-based medicine applied to psychologically-based treatments for pain; evolutionary perspectives on pain; behavioural expression of pain and its interpretation by clinicians; better recognition and treatment of pain from torture; and responsive wearable technology to extend healthcare into patients’ own environments. She has written over 300 papers and chapters on pain and psychology.
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