The Effectiveness of an Acceptance and Commitment Therapy Self-Help Intervention for Chronic Pain

Originally considered a medical problem, newer biopsychosocial models of pain address physical, psychological, and environmental factors that influence how people experience pain. Interestingly, the first mindfulness meditation program Kabat-Zinn’s Mindfulness-Based Stress Reduction was developed for people with chronic pain for whom other medical treatments had failed. There is growing research on the use of mindful acceptance in allowing people to live more effectively with their pain. Recently, a group of researchers in New Zealand led by Marnie Johnston evaluated an Acceptance and Commitment Therapy (ACT) self-help book for chronic pain called Living Beyond Your Pain. ACT emphasizes active acceptance of one’s experiences and movement towards meaningful life directions.

Researchers randomly assigned participants to either receive a copy of the book that they reviewed over a 6-week period, or to remain on a waitlist for 6 weeks before receiving the book. For participants who received the book, the researchers also conducted weekly phone check-ins, asking whether they had done any of the reading and exercises, how easy the reading was, and how useful they found the book. The researchers then answered any questions participants had about the book. Participants in the waitlist condition simply received weekly phone calls evaluating their pain. Everyone completed a battery of tests at the beginning and end of the study.

Results indicate that people who used the book reported reduced pain. Additionally, they reported improvements in acceptance, quality of life, satisfaction with their lives, and living according to their values. The results suggest people with chronic pain may successfully use Living Beyond Your Pain as a self-help book—with minimal support. This latter point is worth emphasizing. As participants received weekly phone calls—which they commented were helpful in increasing motivation and allowing them to ask questions—it remains unclear whether people using the book alone would be as successful. (By contrast, John Forsyth has conducted a more naturalistic study of his self-help book, the Mindfulness and Acceptance Workbook for Anxiety).

Overall, these results are very promising. At the very least this study suggests Living Beyond Your Pain may be a useful adjunct to psychotherapy, something clients can work on between sessions with a little therapist guidance. It also adds to the growing body of literature on the use of mindfulness and acceptance-based treatments for pain.

For members of Association for Contextual Behavioral Science, you can download a copy of the article here. You can find a copy of the book here.

For the full article:

Johnston, M., Foster, M., Shennan, J., Starkey, N. J., &; Johnson, A. (2010). The effectiveness of an Acceptance and Commitment Therapy self-help intervention for chronic pain. Clinical Journal of Pain, 26(5), 393-402.

The full title for the self-help book is:

Dahl, J., & Lundgren, T. (2008). Living Beyond Your Pain: Using Acceptance and Commitment Therapy to Ease Chronic Pain. Oakland, CA: New Harbinger.

Functional Neural Correlates of Mindfulness Meditations in Comparison with Psychotherapy, Pharmacotherapy, and Placebo Effect

In a recent issue of Acta Neuropsychiatrica, Chiesa and colleagues, a group of researchers in Italy, published a review article of neuro-imaging studies. They were interested in comparing neural correlates of mindfulness meditation with those of psychotherapy, pharmacotherapy (e.g., antidepressants), and placebo. The main areas of the brain the researchers focused on were the prefrontal cortex, the anterior cingulate cortex, and the amygdala.

I found the placebo piece of the review particularly interesting as there’s a huge research literature showing placebo effects are powerful enough to be a treatment in themselves. Like psychotherapy, it’s hard to create an adequate placebo substitute for something like meditation, especially as people know more about it today than they did decades ago when this research began.

The authors’ findings suggest that mindfulness meditation may help facilitate a greater flexibility in emotion regulation, and an improved ability to step back from negative mood states by engaging the frontal cortex (higher order functions) in order to dampen amygdala activation (emotion response, especially fear). The authors also found there’s a great deal of overlap in the brain structures activated by mindfulness meditation, psychotherapy, pharmacotherapy, and placebo effects.

They make a preliminary suggestion that mindfulness meditation, psychotherapy, and placebo act through “top down” regulation (i.e., through other processes), whereas antidepressants have a “bottom-up” effect (i.e., more directly). For example, they suggest mindfulness meditation may regulate the amygdala through frontal brain areas whereas antidepressants target the amygdala directly. I found this curious, as Irving Kirsch and others have recently suggested that much of the benefit from antidepressants is through placebo or expectancy effects (here's a short review of this debate). I am not trained as a neuroscientist nor am I an expert in this area of research, so I won’t directly challenge the authors’ conclusions. Nonetheless, I was left uncertain how much of the notion of grouping meditation, psychotherapy, and placebos into one category, and antidepressants in another, is based more on theory than on data.

Nonetheless, I think the authors did a nice job of trying to organize and summarize a growing but somewhat disparate body of research. Additionally, they’ve raised some important questions for other researchers to begin to explore in a more systematic manner. As I blogged about last week, Fletcher and colleagues (2010) recently suggested ways in which a neuroscientific understanding of mindfulness may be refined. This is a really exciting avenue of study, but I agree with the latter authors in that what researchers should really focus on is building our understanding of the neurological underpinnings of mindfulness and meditation in a very deliberate and step-by-step approach.

Full Citation:

Chiesa, A., Brambilla, P., & Serretti, A. (2010). Functional neural correlates of mindfulness meditations in comparison with psychotherapy, pharmacotherapy and placebo effect. Is there a link? Acta Neuropsychiatrica, 22(3), 104-117.

Searching for Mindfulness in the Brain

In the new journal Mindfulness, Fletcher, Schoendorff, and Hayes, researchers well known within the Acceptance and Commitment Therapy (ACT) community, published an article about refining the approach towards using neuro-imaging techniques (i.e., brain scans) to study mindfulness.

The authors point out some of the flaws in the current literature, such as the lack of precision about definitions of mindfulness and accompanying processes, and difficulty measuring subjective reports of different psychological states. The authors advocate greater precision in understanding and delineating the different processes that may underlie mindfulness before subjecting mindfulness to neurobiological study.

As they authors admit, the lens through which they seek to understand mindfulness is the behaviorist approach ACT. They readily acknowledge that this is but one way to understand mindfulness. Their main point is that some clearly defined model of mindfulness, whatever that may be, is necessary before a true neurological study of mindfulness can be undertaken. Otherwise, inquiry may lead to sloppy science.

I applaud the authors for this undertaking. Although I think there is a great deal of value in neuroscience, there is such a mystique surrounding it (e.g., “It’s the brain, so it must be true!”), that I think some of the methodological limitations get overlooked. For example, as with any research technique, there is random error in measurement. The authors note an amusing study by Bennett and colleagues (2009) that found the brain area of dead salmon reliably lit up when the fish were shown emotional scenes. It’s highly unlikely the dead fish were having an emotional reaction! Yet this is precisely the problem we face when we stick people in a scanner and ask them to meditate without first clearly defining the task (e.g., What does it mean to meditate?), and what we’re looking for.

Although it’s not my main area of training, I find the neuroscience research on mindfulness and meditation pretty interesting. I think there is a great deal of potential in this particular avenue of exploration. However, I agree wholeheartedly with Fletcher and colleagues that there should be a movement towards greater scientific rigor with studies executed in a more systematic fashion.

For Full Citation:

Fletcher, L. B., Schoendorff, B., & Hayes, S. C. (2010). Searching for Mindfulness in the Brain: A Process-Oriented Approach to Examining the Neural Correlates of Mindfulness. Mindfulness, 1(1), 41-63.

The Effects of Brief Mindfulness Meditation Training on Experimentally Induced Pain

Zeidan and colleagues at the University of North Carolina-Charlotte published a study investigating the effects of a mindfulness meditation intervention on the experience of pain.

Before and after the intervention, participants were tested on pain threshold using painful electrical stimulation. The experimenters obtained ratings of a “low” threshold (rated a 2 and 3 on a 0-6 scale) and a “high” threshold (rated 4 and 5).

In Experiment 1, participants received a mindfulness meditation intervention after pain threshold was assessed. The mindfulness meditation intervention was specifically designed to be very brief. After the first testing session, participants engaged in 20 minute mindfulness meditation trainings for 3 consecutive days, with different skills taught each day with increasing detail. They were then retested on pain threshold.

In Experiment 2, participants completed three conditions: 1.) baseline; 2.) “math distraction task” (participants were asked to subtract from 1000 by 7); 3.) or a relaxation task. The order of administration was counter-balanced to account for order effects. Similar to the Experiment 1, a second pain testing session was conducted three days after the first.

In Experiment 3, participants completed relaxation, math distraction, and mindfulness meditation conditions. The order of administration was counter-balanced to account for order effects.

Across three experiments, participants in the mindfulness meditation intervention exhibited decreases in subjective pain ratings and state anxiety, and increases in mindfulness. Additionally, participants in the mindfulness meditation intervention reported less pain at both the high and low intensities compared to their baseline scores before the intervention. There was also pain reduction for participants using the math distraction task but not the relaxation task.

The authors conclude that mindfulness meditation can dampen pain response—an analgesic effect—even after only a brief intervention.

There are some weaknesses to this study. Samples sizes across each experiment ranged from 20-22, which are a little small, especially as conditions were counterbalanced within each experiment. Additionally, these were healthy college students: people with chronic pain conditions were screened out.

Nonetheless, the study offers some indication that mindfulness meditation has a greater analgesic effect than relaxation and distraction, and that this effect can be accessed with a very brief intervention.

For the full study, click here.

Full citation:

Zeidan, F., Gordon, N. S., Merchant, J., & Goolkasian, P. (2010). The Effects of Brief Mindfulness Meditation Training on Experimentally Induced Pain. The Journal of Pain, 11(3),199-209.