How to Conduct ACT Telehealth Interventions for Chronic Pain

More than one third of people with chronic pain have been found to drop out of treatment,1 most often due to adverse experiences such as medication side effects.¹˒² However, untreated chronic pain can lead to increased disability and lower quality of life. Efforts have been made to address barriers to chronic pain management through enhancements in interventions and delivery models.

Self-management approaches have been identified as a gold standard, among other approaches, for chronic pain treatment³ and traditional Acceptance and Commitment therapy (ACT) has been found to be effective at increasing self-management.⁴ However, time, transportation, and the ongoing COVID-19 pandemic serve as barriers to accessing and continuing therapies such as ACT.⁵ Fortunately, ACT has been developed and tailored for remote delivery. Here, we review the effectiveness of ACT telemedicine for chronic pain and provide tips for how to enhance the behavioral intervention.

Online treatment delivery has specifically been lauded for its ability to address several barriers to care. Telemedicine has the benefit of no transportation and travel time issues, and improved treatment access for people living in rural or under-resourced areas.⁵˒⁶ Additional benefits include the flexibility that comes with telehealth delivery resulting in patient empowerment through participation⁷ and a reduction in burdened healthcare provider workloads.⁸

Telehealth is, however, not considered appropriate for new patients who require a physical exam, those with new and changing symptoms, diagnostically challenging and medically complex patients, and for patients put at high-risk for medication misuse or abuse.⁵ Other reported limitations of telehealth include challenges when developing a relationship between the provider and patient,⁵˒⁷ unrelatable intervention content, issues around technology literacy, problems with up-to-date technology devices, and unstable internet access.⁷ Further, there may be privacy issues when discussing sensitive information where others might be present, as well as possible distractions in the home environment.⁵

ACT is a mindfulness-based, behavioral, psychological treatment that has been found to be effective in the treatment of chronic pain,⁹ specifically pain acceptance.¹⁰ There are numerous protocols available in the literature about how to conduct ACT interventions in-person for patients with chronic pain. One of the first protocols released to the public was a four-session intervention, which combined individual and group treatments and established the feasibility of utilizing ACT to treat chronic pain.¹¹

Soon thereafter, an eight-session ACT intervention was presented, but was found to have a similar coverage of topics (eg, activity pacing, goal setting, and homework) typical of a traditional, cognitive-behavioral therapy protocol.¹² At that time, a self-help book was released, which provided more details, but served better as an introduction to ACT therapy rather than a protocol.¹³ A previous column discussed the use of ACT in primary care.

Future ACT protocols were generated by incorporating, organizing, and expanding upon the aforementioned works to develop ACT-consistent group protocols to meet the needs of the chronic pain population.¹⁴ In fact, the content of one of the 10-session ACT group interventions is described along with some examples of its application in the literature.¹⁵

Telehealth-ACT and traditional, in-person ACT interventions have been compared for effectiveness. Outcomes from studies comparing these two types of interventions indicate no differences between their effectiveness.¹⁶ Participants in guided interventions have been found to complete more treatment modules compared to those in unguided treatments.¹⁷

Several telehealth-ACT interventions have been developed and investigated for the treatment of chronic pain, including ACTsmart, Pain Tracker Self-Manager (PTSM), and iACT.

• ACTsmart is a telehealth treatment delivered to the patient's smartphone through micro-learning modules. It has been found to have a 90% treatment retention rate with participants completing 84% of the content.8 In the same study, patients sent, on average, approximately six chat messages to their therapist over the course of treatment, and providers spent approximately 15 minutes a week on each patient.

• Pain Tracker Self-Manager (PTSM) is another telehealth-ACT treatment.¹⁸ In a pilot study, PTSM has been found to positively impact self-efficacy, activity engagement, pain intensity, and interference.¹⁹

• iACT is a telehealth-ACT intervention that uses microlearning and focuses on treating pain interference. It includes seven themed chapters each with audio and video files, two telephone contacts, and weekly online contact with a provider. Treatment demonstrated improvement in pain acceptance, and all participants reported positive behavior change with gains maintained at 12-month follow-up.²⁰

The recent pandemic provided a need for psychotherapists to adapt traditional in-person ACT interventions to telehealth delivery. To ensure the intervention is engaging, it is helpful to provide visual and tactile learning opportunities, such as by mailing a participant a hard copy of a booklet, and/or using the share screen option on video conferencing platforms to share additional information about the ACT theoretical framework. In addition, the use of metaphors, videos, and at-home exercises, clinicians can provide a highly experiential treatment through telephone, videoconferencing, and internet platforms.

An important initial task of treatment is to develop a trusting relationship and orient the patient to the theoretical framework of the ACT intervention, which focuses on perspective change, pain acceptance, and learning to observe thoughts so as to uncouple thoughts and feelings/behaviors. One way to do this is by having the person with chronic pain watch a video titled, Small Pleasures/ Μικρές Χαρές (2008), which can be found on YouTube.²¹

The video tells the story of Eftichis, a boy who many years ago had an experience that made him see life from a different perspective. Additional ACT metaphors that are helpful to use during the initial phase of treatment include the “Two Mountains Metaphor,” which explains how the provider is not guiding from the top of the mountain but rather from a mountain across from the participant’s. Further, the “Roller Coaster Metaphor” normalizes the ups and downs of treatment.

The hexagon used to explain the ACT theoretical framework begins at the top with being mindfully present in the moment (see Figure 1). Providers can define and explain mindfulness to patients, but it may be helpful to also have the person with chronic pain watch a video titled, “Why Mindfulness is a Superpower: An Animation,” which can be found on YouTube.²² This may also be paired with a discussion about “experiential avoidance,” which includes the person with chronic pain exploring how they have taken steps to escape pain or numb feelings brought up by their pain in the past.

Such a discussion can be augmented with the use of the “Person in the Hole” metaphor. This metaphor highlights the need for the right tools and the right instrument training to get out of a hole. People with chronic pain often compare other people’s external appearance to their internal experience because things seem to be working for them. Control works when manipulating external systems, but can backfire when applied to private experiences. Again, this discussion can be augmented with the use of several additional metaphors.

The “Quicksand Trap” metaphor highlights the paradox of how working hard not to sink in the sand actually makes it so. It shows how a lot of energy can be spent in self-protection rather than what is valued. Similarly, the “Tug of War with a Monster” metaphor demonstrates that the effort to battle with the “monster” of pain is far more exhausting compared to simply observing it. This metaphor can be demonstrated with an at-home exercise. In this exercise the patient is asked to push a stress ball, which is a stand-in for the monster, against a wall with their hand, and then compare that effort to just watching the ball lay on their lap.

Perhaps the most popular metaphor to demonstrate the importance of acceptance and surrender is the “Chinese Finger Trap.” Providers may actually keep some of these bamboo finger traps on hand to demonstrate how the struggle actually tightens the trap around the finger, whereas relaxing loosens the trap so that the fingers can be released. For telehealth delivery, the bamboo finger traps can be mailed to the patient and demonstrated together via a videoconferencing session, or with instructions for a self-paced intervention.

When pivoting to the right of the hexagon, one comes across the valued living and choice principles. These concepts can be explained to the person with chronic pain, but it may be helpful to also have them watch a video, “Values vs. Goals by Dr. Russ Harris,” on YouTube.²³

If you pivot further to the right, the person with chronic pain moves away from a lack of action to setting goals according to values and carrying them out responsibly. The concept of committed action can be discussed, but providers may also want to use the “Pen” at-home exercise. In this exercise the patient is asked to try as hard as they can to pick up a pen. What happens? They either pick up the pen or they don’t. This is compared to their commitment to action, they do it or they don’t – there is no in between.

When pivoting to the left of the hexagon, the person with chronic pain moves away from their avoidance and toward allowing experiences to come and go without struggling with them. Often, providers can explain the “Joe the Bum” metaphor and/or have patients watch the video, The Unwelcome Party Guest: an Acceptance & Commitment Therapy (ACT) Metaphor, on YouTube.²⁴ This video depicts a main character throwing a party where an unwelcome guest arrives and the different outcomes one may face dealing with them. Providers can use the “Garbage Can” at-home exercise to illustrate how additional suffering is added to their pain when they do not learn to accept it. Participants are asked to use a small garbage can, or other object, and hold it away from their body and compare that experience to embracing it close to their body.

Pivoting further to the left in the hexagon, the person with chronic pain moves away from cognitive defusion – seeing thoughts and feelings as fused – toward learning to perceive thoughts, images, emotions, and memories as what they are, not what they appear to be. Providers can explain the concept of cognitive defusion but may also want to use the “Arm Raise” at-home exercise. The person with chronic pain is asked to raise their arm while saying “I can’t lift my arm.” This action illustrates the separation of thoughts from the body. Thoughts are just thoughts, physical sensations are just physical sensations, nothing more, nothing less. Essentially, just because you think it, doesn’t make it true.

Another at-home exercise asks participants to cover their eyes with their hands and look at what they see, then to move the hands about a foot away from their face and look at what they see, and then again lay their hands on their lap and look at what they see. This action illustrates how focusing so closely on pain can distort one’s perceptions. The distance offers a more accurate, clearer perception. Mindfulness encourages cognitive defusion, and it may be helpful to have them follow along by watching a video on YouTube titled Leaves on a Stream, which encourages observation of thoughts where the patient experiences themselves not as the thinker, but rather as the curious witness of the thoughts.²⁵

The hexagon used to explain the ACT theoretical framework ends at the bottom with self-as-context versus content. When pivoting down, the person with chronic pain moves away from using one perspective to accessing a transcendent sense of self, a continuity of consciousness that is ever changing. This principle is perhaps the most difficult to understand in ACT and is best explained through experiential activities at-home. One activity instructs the patient to put an object in front of them, close their eyes, and then asks them to switch opening one eye then the other, which switches their perspective without changing the object.

It may also be helpful to have them watch these additional videos (all accessible on YouTube): Passengers on a Bus: an Acceptance & Commitment Therapy (ACT) Metaphor,²⁶ Demons on the Boat – an Acceptance & Commitment Therapy (ACT) Metaphor,²⁷ and Struggling with Internal Hijackers?²⁸

Practical Takeaways

Telehealth-ACT interventions are demonstrating promising outcomes with individuals with chronic pain. They have been shown to be as effective as traditional treatment delivery models, as long as interventions aren’t too time consuming and patients have access to stable internet and dependable technology devices. Online treatments also provide an alternative to traditional treatment and may increase treatment attendance and adherence, but providers need to reassure patients that telehealth treatments are effective and normal.²⁹

While these approaches show promise for chronic pain in general, future studies should be developed and investigate telehealth-ACT programs tailored for specific types of chronic pain.³⁰ Overall, clinicians recommending virtual acceptance and commitment therapy as part of self-care for chronic pain should keep in mind that:

• The benefits for telehealth delivery of psychological interventions include flexibility, a lack of transportation barriers, and less provider burden.

• Telehealth-ACT for chronic pain performs just as well as traditional, in-person treatment models.

• Patients in online telehealth-ACT treatments report impersonal relationships with providers and are apprehensive about treatment efficacy. It is important to develop trusting relationships with patients and for providers to normalize online treatment delivery.

• Telehealth-ACT is not for every individual – sometimes an in-person appointment is necessary when symptoms are complex or changing and for patients for which oppressive systems, such as systemic racism and cycles of poverty, place them at greater risk.