Behaviour therapy

From Wikipedia, the free encyclopedia

 

Behaviour therapy
ICD-9-CM	94.33
MeSH	D001521

Behavior therapy or behavioral psychotherapy is a broad term referring to clinical psychotherapy that uses techniques derived from behaviorism. Those who practice behavior therapy tend to look at specific, learned behaviors and how the environment influences those behaviors. Those who practice behavior therapy are called behaviourists, or behavior analysts. They tend to look for treatment outcomes that are objectively measurable. Behavior therapy does not involve one specific method but it has a wide range of techniques that can be used to treat a person's psychological problems. Traditional behavior therapy draws from respondent conditioning and operant conditioning to solve patients problems.

Behavioral psychotherapy is sometimes juxtaposed with cognitive psychotherapy, while cognitive behavioral therapy integrates aspects of both approaches.

Applied behavior analysis (ABA) is the application of behavior analysis that focuses on assessing how environmental variables influence learning principles, particularly respondent and operant conditioning, to identify potential behavior-change procedures, which are frequently used throughout clinical therapy. Cognitive-behavior therapy views cognition and emotions as preceding overt behavior with treatment plans in psychotherapy to lessen the issue. Hallmark techniques of behaviour therapies are overlapping components of cognitive psychology, in addition to behaviour analytic principles of counterconditioning, punishment, habituation, and functional analysis (FA).

History

Precursors of certain fundamental aspects of behaviour therapy have been identified in various ancient philosophical traditions, particularly Stoicism. For example, Wolpe and Lazarus wrote,

While the modern behavior therapist deliberately applies principles of learning to this therapeutic operations, empirical behavior therapy is probably as old as civilization – if we consider civilization as having started when man first did things to further the well-being of other men. From the time that this became a feature of human life there must have been occasions when a man complained of his ills to another who advised or persuaded him of a course of action. In a broad sense, this could be called behavior therapy whenever the behavior itself was conceived as the therapeutic agent. Ancient writings contain innumerable behavioral prescriptions that accord with this broad conception of behavior therapy.

The first use of the term behaviour modification appears to have been by Edward Thorndike in 1911. His article Provisional Laws of Acquired Behavior or Learning makes frequent use of the term "modifying behavior". Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe's research group. The experimental tradition in clinical psychology used it to refer to psycho-therapeutic techniques derived from empirical research. It has since come to refer mainly to techniques for increasing adaptive behaviour through reinforcement and decreasing maladaptive behaviour through extinction or punishment (with emphasis on the former). Two related terms are behaviour therapy and applied behaviour analysis. Since techniques derived from behavioural psychology tend to be the most effective in altering behaviour, most practitioners consider behaviour modification along with behaviour therapy and applied behaviour analysis to be founded in behaviourism. While behaviour modification and applied behaviour analysis typically uses interventions based on the same behavioural principles, many behaviour modifiers who are not applied behaviour analysts tend to use packages of interventions and do not conduct functional assessments before intervening.

Possibly the first occurrence of the term "behavior therapy" was in a 1953 research project by B.F. Skinner, Ogden Lindsley, Nathan H. Azrin and Harry C. Solomon. The paper talked about operant conditioning and how it could be used to help improve the functioning of people who were diagnosed with chronic schizophrenia. Early pioneers in behaviour therapy include Joseph Wolpe and Hans Eysenck.

In general, behaviour therapy is seen as having three distinct points of origin: South Africa (Wolpe's group), The United States (Skinner), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behaviour problems. Eysenck in particular viewed behaviour problems as an interplay between personality characteristics, environment, and behaviour. Skinner's group in the United States took more of an operant conditioning focus. The operant focus created a functional approach to assessment and interventions focused on contingency management such as the token economy and behavioural activation. Skinner's student Ogden Lindsley is credited with forming a movement called precision teaching, which developed a particular type of graphing program called the standard celeration chart to monitor the progress of clients. Skinner became interested in the individualising of programs for improved learning in those with or without disabilities and worked with Fred S. Keller to develop programmed instruction. Programmed instruction had some clinical success in aphasia rehabilitation. Gerald Patterson used programme instruction to develop his parenting text for children with conduct problems. With age, respondent conditioning appears to slow but operant conditioning remains relatively stable. While the concept had its share of advocates and critics in the west, its introduction in the Asian setting, particularly in India in the early 1970s and its grand success were testament to the famous Indian psychologist H. Narayan Murthy's enduring commitment to the principles of behavioural therapy and biofeedback. 

While many behaviour therapists remain staunchly committed to the basic operant and respondent paradigm, in the second half of the 20th century, many therapists coupled behaviour therapy with the cognitive therapy, of Aaron Beck, Albert Ellis, and [Donald Meichenbaum (psychologist)]]to form cognitive behaviour therapy. In some areas the cognitive component had an additive effect (for example, evidence suggests that cognitive interventions improve the result of social phobia treatment.) but in other areas it did not enhance the treatment, which led to the pursuit of third generation behaviour therapies. Third generation behaviour therapy uses basic principles of operant and respondent psychology but couples them with functional analysis and a clinical formulation/case conceptualisation of verbal behaviour more inline with view of the behaviour analysts. Some research supports these therapies as being more effective in some cases than cognitive therapy, but overall the question is still in need of answers.

Theoretical basis

The behavioural approach to therapy assumes that behaviour that is associated with psychological problems develops through the same processes of learning that affects the development of other behaviours. Therefore, behaviourists see personality problems in the way that personality was developed. They do not look at behaviour disorders as something a person has but that it reflects how learning has influenced certain people to behave in a certain way in certain situations.

Behaviour therapy is based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. Classical conditioning happens when a neutral stimulus comes right before another stimulus that triggers a reflexive response. The idea is that if the neutral stimulus and whatever other stimulus that triggers a response is paired together often enough that the neutral stimulus will produce the reflexive response. Operant conditioning has to do with rewards and punishments and how they can either strengthen or weaken certain behaviours.

Contingency management programs are a direct product of research from operant conditioning. These programs have been highly successful with those suffering from panic disorders, anxiety disorders, and phobias.

Systematic desensitisation and exposure and response prevention both evolved from respondent conditioning and have also received considerable research.

Behavior avoidance test (BAT) is a behavioural procedure in which the therapist measures how long the client can tolerate an anxiety-inducing stimulus. The BAT falls under the exposure-based methods of behaviour therapy. Exposure-based methods of behavioural therapy are well suited to the treatment of phobias, which include intense and unreasonable fears (e.g., of spiders, blood, public speaking). The therapist needs some type of behavioural assessment to record the continuing progress of a client undergoing an exposure-based treatment for phobia. One simple assessment approach for this is the BAT. The BAT approach is predicted on the assumption that the client's fear is the main determinant of behaviour in the testing situation. BAT can be conducted visual, virtually, or physically, depending on the clients' maladaptive behaviour. Its application is not limited to phobias, it is applied to various disorders such as post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD).

Current forms

Behavioral therapy based on operant and respondent principles has considerable evidence base to support its usage. This approach remains a vital area of clinical psychology and is often termed clinical behavior analysis. Behavioral psychotherapy has become increasingly contextual in recent years. Behavioral psychotherapy has developed greater interest in recent years in personality disorders as well as a greater focus on acceptance and complex case conceptualizations.

Functional analytic psychotherapy

One current form of behavioral psychotherapy is functional analytic psychotherapy. Functional analytic psychotherapy is a longer duration behavior therapy. Functional analytic therapy focuses on in-session use of reinforcement and is primarily a relationally-based therapy. As with most of the behavioral psychotherapies, functional analytic psychotherapy is contextual in its origins and nature. and draws heavily on radical behaviorism and functional contextualism. 

Functional analytic psychotherapy holds to a process model of research, which makes it unique compared to traditional behavior therapy and cognitive behavioral therapy.

Functional analytic psychotherapy has a strong research support. Recent functional analytic psychotherapy research efforts are focusing on management of aggressive inpatients.

Assessment

Behaviour therapists complete a functional analysis or a functional assessment that looks at four important areas: stimulus, organism, response and consequences. The stimulus is the condition or environmental trigger that causes behaviour. An organism involves the internal responses of a person, like physiological responses, emotions and cognition. A response is the behaviour that a person exhibits and the consequences are the result of the behaviour. These four things are incorporated into an assessment done by the behaviour therapist.

Most behaviour therapists use objective assessment methods like structured interviews, objective psychological tests or different behavioural rating forms. These types of assessments are used so that the behaviour therapist can determine exactly what a client's problem may be and establish a baseline for any maladaptive responses that the client may have. By having this baseline, as therapy continues this same measure can be used to check a client's progress, which can help determine if the therapy is working. Behaviour therapists do not typically ask the why questions but tend to be more focused on the how, when, where and what questions. Tests such as the Rorschach inkblot test or personality tests like the MMPI (Minnesota Multiphasic Personality Inventory) are not commonly used for behavioural assessment because they are based on personality trait theory assuming that a person's answer to these methods can predict behaviour. Behaviour assessment is more focused on the observations of a persons behaviour in their natural environment.

Behavioural assessment specifically attempts to find out what the environmental and self-imposed variables are. These variables are the things that are allowing a person to maintain their maladaptive feelings, thoughts and behaviours. In a behavioural assessment "person variables" are also considered. These "person variables" come from a person's social learning history and they effect the way in which the environment affects that person's behaviour. An example of a person variable would be behavioural competence. Behavioural competence looks at whether a person has the appropriate skills and behaviours that are necessary when performing a specific response to a certain situation or stimuli.

When making a behavioural assessment the behaviour therapist wants to answer two questions: (1) what are the different factors (environmental or psychological) that are maintaining the maladaptive behaviour and (2) what type of behaviour therapy or technique that can help the individual improve most effectively. The first question involves looking at all aspects of a person, which can be summed up by the acronym BASIC ID. This acronym stands for behaviour, affective responses, sensory reactions, imagery, cognitive processes, interpersonal relationships and drug use.

Clinical applications

Behaviour therapy based its core interventions on functional analysis. Just a few of the many problems that behaviour therapy have functionally analysed include intimacy in couples relationships, forgiveness in couples, chronic pain, stress-related behaviour problems of being an adult child of an alcoholic, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia, and obesity.

Functional analysis has even been applied to problems that therapists commonly encounter like client resistance, partially engaged clients and involuntary clients. Applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness. One way to enhance therapeutic effectiveness is to use positive reinforcement or operant conditioning. Although behaviour therapy is based on the general learning model, it can be applied in a lot of different treatment packages that can be specifically developed to deal with problematic behaviours. Some of the more well known types of treatments are: Relaxation training, systematic desensitization, virtual reality exposure, exposure and response prevention techniques, social skills training, modeling, behavioural rehearsal and homework, and aversion therapy and punishment.

Relaxation training involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Systematic desensitization is a treatment in which the client slowly substitutes a new learned response for a maladaptive response by moving up a hierarchy of situations involving fear. Systematic desensitization is based in part on counter conditioning. Counter conditioning is learning new ways to change one response for another and in the case of desensitization it is substituting that maladaptive behaviour for a more relaxing behaviour. Exposure and response prevention techniques (also known as flooding and response prevention) is the general technique in which a therapist exposes an individual to anxiety-provoking stimuli while keeping them from having any avoidance responses.

Virtual reality therapy provides realistic, computer-based simulations of troublesome situations. The modeling process involves a person being subjected to watching other individuals who demonstrate behaviour that is considered adaptive and that should be adopted by the client. This exposure involves not only the cues of the "model person" as well as the situations of a certain behaviour that way the relationship can be seen between the appropriateness of a certain behaviour and situation in which that behaviour occurs is demonstrated. With the behavioural rehearsal and homework treatment a client gets a desired behaviour during a therapy session and then they practice and record that behaviour between their sessions. Aversion therapy and punishment is a technique in which an aversive (painful or unpleasant) stimulus is used to decrease unwanted behaviours from occurring. It is concerned with two procedures: 1) the procedures are used to decrease the likelihood of the frequency of a certain behaviour and 2) procedures that will reduce the attractiveness of certain behaviours and the stimuli that elicit them. The punishment side of aversion therapy is when an aversive stimulus is presented at the same time that a negative stimulus and then they are stopped at the same time when a positive stimulus or response is presented. Examples of the type of negative stimulus or punishment that can be used is shock therapy treatments, aversive drug treatments as well as response cost contingent punishment which involves taking away a reward. 

Applied behaviour analysis is using behavioural methods to modify certain behaviours that are seen as being important socially or personally. There are four main characteristics of applied behaviour analysis. First behaviour analysis is focused mainly on overt behaviours in an applied setting. Treatments are developed as a way to alter the relationship between those overt behaviours and their consequences.

Another characteristic of applied behaviour analysis is how it(behaviour analysis) goes about evaluating treatment effects. The individual subject is where the focus of study is on, the investigation is centered on the one individual being treated. A third characteristic is that it focuses on what the environment does to cause significant behaviour changes. Finally the last characteristic of applied behaviour analysis is the use of those techniques that stem from operant and classical conditioning such as providing reinforcement, punishment, stimulus control and any other learning principles that may apply.

Social skills training teaches clients skills to access reinforcers and lessen life punishment. Operant conditioning procedures in meta-analysis had the largest effect size for training social skills, followed by modelling, coaching, and social cognitive techniques in that order. Social skills training has some empirical support particularly for schizophrenia. However, with schizophrenia, behavioural programs have generally lost favor.

Some other techniques that have been used in behaviour therapy are contingency contracting, response costs, token economies, biofeedback, and using shaping and grading task assignments.

Shaping and graded task assignments are used when behaviour that needs to be learned is complex. The complex behaviours that need to be learned are broken down into simpler steps where the person can achieve small things gradually building up to the more complex behaviour. Each step approximates the eventual goal and helps the person to expand their activities in a gradual way. This behaviour is used when a person feels that something in their lives can not be changed and life's tasks appear to be overwhelming.

Another technique of behaviour therapy involves holding a client or patient accountable of their behaviours in an effort to change them. This is called a contingency contract, which is a formal written contract between two or more people that defines the specific expected behaviours that you wish to change and the rewards and punishments that go along with that behaviour. In order for a contingency contract to be official it needs to have five elements. First it must state what each person will get if they successfully complete the desired behaviour. Secondly those people involved have to monitor the behaviours. Third, if the desired behaviour is not being performed in the way that was agreed upon in the contract the punishments that were defined in the contract must be done. Fourth if the persons involved are complying with the contract they must receive bonuses. The last element involves documenting the compliance and noncompliance while using this treatment in order to give the persons involved consistent feedback about the target behaviour and the provision of reinforcers.

Token economies is a behaviour therapy technique where clients are reinforced with tokens that are considered a type of currency that can be used to purchase desired rewards, like being able to watch television or getting a snack that they want when they perform designated behaviours. Token economies are mainly used in institutional and therapeutic settings. In order for a token economy to be effective their must be consistency in administering the program by the entire staff. Procedures must be clearly defined so that there is no confusion among the clients. Instead of looking for ways to punish the patients or to deny them of rewards, the staff has to reinforce the positive behaviours so that the clients will increase the occurrence of the desired behaviour. Over time the tokens need to be replaced with less tangible rewards such as compliments so that the client will be prepared when they leave the institution and won't expect to get something every time they perform a desired behaviour.

Closely related to token economies is a technique called response costs. This technique can either be used with or without token economies. Response costs is the punishment side of token economies where there is a loss of a reward or privilege after someone performs an undesirable behaviour. Like token economies this technique is used mainly in institutional and therapeutic settings.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy, habit reversal training, has been found to be highly effective for treating tics.

In rehabilitation

Currently, there is a greater call for behavioral psychologists to be involved in rehabilitation efforts.

Treatment of mental disorders

Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that both behaviour therapy and cognitive-behavioural therapy (CBT) are equally effective for OCD. CBT has been shown to perform slightly better at treating co-occurring depression.

Considerable policy implications have been inspired by behavioural views of various forms of psychopathology. One form of behaviour therapy (habit reversal training) has been found to be highly effective for treating tics. 

There has been a development towards combining techniques to treat psychiatric disorders. Cognitive interventions are used to enhance the effects of more established behavioural interventions based on operant and classical conditioning. An increased effort has also been placed to address the interpersonal context of behaviour.

Behaviour therapy can be applied to a number of mental disorders and in many cases is more effective for specific disorders as compared to others. Behaviour therapy techniques can be used to deal with any phobias that a person may have. Desensitization has also been applied to other issues such as dealing with anger, if a person has trouble sleeping and certain speech disorders. Desensitization does not occur over night, there is a process of treatment. Desensitization is done on a hierarchy and happens over a number of sessions. The hierarchy goes from situations that make a person less anxious or nervous up to things that are considered to be extreme for the patient.

Modeling has been used in dealing with fears and phobias. Modeling has been used in the treatment of fear of snakes as well as a fear of water.

Aversive therapy techniques have been used to treat sexual deviations as well as alcoholism.

Exposure and prevention procedure techniques can be used to treat people who have anxiety problems as well as any fears or phobias. These procedures have also been used to help people dealing with any anger issues as well as pathological grievers (people who have distressing thoughts about a deceased person).

Virtual reality therapy deals with fear of heights, fear of flying, and a variety of other anxiety disorders. VRT has also been applied to help people with substance abuse problems reduce their responsiveness to certain cues that trigger their need to use drugs.

Shaping and graded task assignments has been used in dealing with suicide and depressed or inhibited individuals. This is used when a patient feel hopeless and they have no way of changing their lives. This hopelessness involves how the person reacts and responds to someone else and certain situations and their perceived powerlessness to change that situation that adds to the hopelessness. For a person with suicidal ideation, it is important to start with small steps. Because that person may perceive everything as being a big step, the smaller you start the easier it will be for the person to master each step. This technique has also been applied to people dealing with agoraphobia, or fear of being in public places or doing something embarrassing.

Contingency contracting has been used to deal with behaviour problems in delinquents and when dealing with on task behaviours in students.

Token economies are used in controlled environments and are found mostly in psychiatric hospitals. They can be used to help patients with different mental illnesses but it doesn't focus on the treatment of the mental illness but instead on the behavioural aspects of a patient. The response cost technique has been used to address a variety of behaviours such as smoking, overeating, stuttering, and psychotic talk.

Treatment outcomes

Systematic desensitization has been shown to successfully treat phobias about heights, driving, insects as well as any anxiety that a person may have. Anxiety can include social anxiety, anxiety about public speaking as well as test anxiety. It has been shown that the use of systematic desensitization is an effective technique that can be applied to a number of problems that a person may have.

When using modeling procedures this technique is often compared to another behavioural therapy technique. When compared to desensitization, the modeling technique does appear to be less effective. However it is clear that the greater the interaction between the patient and the subject he is modeling the greater the effectiveness of the treatment.

While undergoing exposure therapy a person usually needs five sessions to see if the treatment is working. After five sessions exposure treatment is seen to benefit the patient and help with their problems. However even after five sessions it is recommended that the patient or client should still continue treatment.

Virtual Reality treatment has shown to be effective for a fear of heights. It has also been shown to help with the treatment of a variety of anxiety disorders. Virtual reality therapy can be very costly so therapists are still awaiting results of controlled trials for VR treatment to see which applications show the best results.

For those with suicidal ideation treatment depends on how severe the person's depression and feeling of hopelessness is. If these things are severe the person's response to completing small steps will not be of importance to them because they don't consider it to be a big deal. Generally those who aren't severely depressed or fearful, this technique has been successful because the completion of simpler activities build up their confidences and allows them to continue on to more complex situations.

Contingency contracts have been seen to be effective in changing any undesired behaviours of individuals. It has been seen to be effective in treating behaviour problems in delinquents regardless of the specific characteristics of the contract.

Token economies have been shown to be effective when treating patients in psychiatric wards who had chronic schizophrenia. The results showed that the contingent tokens were controlling the behaviour of the patients.

Response costs has been shown to work in suppressing a variety of behaviours such as smoking, overeating or stuttering with a diverse group of clinical populations ranging from sociopaths to school children. These behaviours that have been suppressed using this technique often do not recover when the punishment contingency is withdrawn. Also undesirable side effects that are usually seen with punishment are not typically found when using the response cost technique.

Third generation

The third-generation behaviour therapy movement has been called clinical behavior analysis because it represents a movement away from cognitivism and back toward radical behaviourism and other forms of behaviourism, in particular functional analysis and behavioural models of verbal behaviour. This area includes acceptance and commitment therapy (ACT), cognitive behavioral analysis system of psychotherapy (CBASP) (McCullough, 2000), behavioural activation (BA), functional analytic psychotherapy (FAP), integrative behavioural couples therapy and dialectical behavioural therapy. These approaches are squarely within the applied behaviour analysis tradition of behaviour therapy.

ACT may be the most well-researched of all the third-generation behaviour therapy models. It is based on relational frame theory. Other authors object to the term "third generation" or "third wave" and incorporate many of the "third wave" therapeutic techniques under the general umbrella term of modern cognitive behavioral therapies.

Functional analytic psychotherapy is based on a functional analysis of the therapeutic relationship. It places a greater emphasis on the therapeutic context and returns to the use of in-session reinforcement. In general, 40 years of research supports the idea that in-session reinforcement of behaviour can lead to behavioural change.

Behavioural activation emerged from a component analysis of cognitive behaviour therapy. This research found no additive effect for the cognitive component. Behavioural activation is based on a matching model of reinforcement. A recent review of the research, supports the notion that the use of behavioural activation is clinically important for the treatment of depression.

Integrative behavioural couples therapy developed from dissatisfaction with traditional behavioural couples therapy. Integrative behavioural couples therapy looks to Skinner (1966) for the difference between contingency-shaped and rule-governed behaviour. It couples this analysis with a thorough functional assessment of the couple's relationship. Recent efforts have used radical behavioural concepts to interpret a number of clinical phenomena including forgiveness.

Organizations

Many organisations exist for behaviour therapists around the world. The Association for Behavior Analysis International (ABAI) provides accreditation for training programs in behaviour therapy. The ABAI has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. ABAI has larger special interest groups for autism and its peculiar and narrow interpretation of behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. ABAI sponsors two conferences/year – one in the U.S. and one international. 

In the United States, the American Psychological Association's Division 25 is the division for behaviour analysis. The Association for Contextual Behavior Therapy is another professional organisation. ACBS is home to many clinicians with specific interest in third generation behaviour therapy. Doctoral-level behavior analysts who are psychologists belong to American Psychological Association's division 25 – Behavior analysis. APA offers a diplomate in behavioral psychology. 

The Association for Behavioral and Cognitive Therapies (formerly the Association for the Advancement of Behavior Therapy) is for those with a more cognitive orientation. The ABCT also has an interest group in behavior analysis, which focuses on clinical behavior analysis. In addition, the Association for Behavioral an Cognitive Therapies has a special interest group on addictions. 

The World Association for Behavior Analysis offers a certification in behavior therapy.

Characteristics

By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind–body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).

Behavioural therapy develops, adds and provides behavioural intervention strategies and programs for clients, and training to people who care to facilitate successful lives in the communities.

Training

Recent efforts in behavioral psychotherapy have focused on the supervision process. A key point of behavioral models of supervision is that the supervisory process parallels the behavioral psychotherapy.

Methods

• Behaviour management
• Behaviour modification
• Clinical behavior analysis
• Contingency management
• Covert conditioning
• Exposure and response prevention
• Flooding
• Habit reversal training
• Matching law
• Modeling
• Observational learning
• Operant conditioning
• Professional practice of behavior analysis
• Respondent conditioning
• Systematic desensitisation

Acceptance and commitment therapy

From Wikipedia, the free encyclopedia

 

Acceptance and commitment therapy
MeSH	D064869

Acceptance and commitment therapy (ACT, typically pronounced as the word "act") is a form of counseling and a branch of clinical behavior analysis. It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behavior-change strategies, to increase psychological flexibility. The approach was originally called comprehensive distancing. Steven C. Hayes developed Acceptance and Commitment Therapy in 1982 in order to create a mixed approach which integrates both cognitive and behavioral therapy. There are a variety of protocols for ACT, depending on the target behavior or setting. For example, in behavioral health areas a brief version of ACT is called focused acceptance and commitment therapy (FACT).

The objective of ACT is not elimination of difficult feelings; rather, it is to be present with what life brings us and to "move toward valued behavior". Acceptance and commitment therapy invites people to open up to unpleasant feelings, and learn not to overreact to them, and not avoid situations where they are invoked. Its therapeutic effect is a positive spiral where feeling better leads to a better understanding of the truth. In ACT, 'truth' is measured through the concept of 'workability', or what works to take another step toward what matters (e.g. values, meaning).

Technique

Basics

ACT is developed within a pragmatic philosophy called functional contextualism. ACT is based on relational frame theory (RFT), a comprehensive theory of language and cognition that is an offshoot of behavior analysis. Both ACT and RFT are based on B. F. Skinner's philosophy of Radical Behaviorism.

ACT differs from traditional cognitive behavioral therapy (CBT) in that rather than trying to teach people to better control their thoughts, feelings, sensations, memories and other private events, ACT teaches them to "just notice," accept, and embrace their private events, especially previously unwanted ones. ACT helps the individual get in contact with a transcendent sense of self known as "self-as-context"—the you who is always there observing and experiencing and yet distinct from one's thoughts, feelings, sensations, and memories. ACT aims to help the individual clarify their personal values and to take action on them, bringing more vitality and meaning to their life in the process, increasing their psychological flexibility.

While Western psychology has typically operated under the "healthy normality" assumption which states that by their nature, humans are psychologically healthy, ACT assumes, rather, that psychological processes of a normal human mind are often destructive. The core conception of ACT is that psychological suffering is usually caused by experiential avoidance, cognitive entanglement, and resulting psychological rigidity that leads to a failure to take needed behavioral steps in accord with core values. As a simple way to summarize the model, ACT views the core of many problems to be due to the concepts represented in the acronym, FEAR:

Cards used as a therapeutic activity in ACT treatment.

• Fusion with your thoughts
• Evaluation of experience
• Avoidance of your experience
• Reason-giving for your behavior

And the healthy alternative is to ACT:

• Accept your reactions and be present
• Choose a valued direction
• Take action

Core principles

ACT commonly employs six core principles to help clients develop psychological flexibility:

1. Cognitive defusion: Learning methods to reduce the tendency to reify thoughts, images, emotions, and memories.
2. Acceptance: Allowing unwanted private experiences (thoughts, feelings and urges) to come and go without struggling with them.
3. Contact with the present moment: Awareness of the here and now, experienced with openness, interest, and receptiveness. (e.g., mindfulness)
4. The observing self: Accessing a transcendent sense of self, a continuity of consciousness which is unchanging.
5. Values: Discovering what is most important to oneself.
6. Committed action: Setting goals according to values and carrying them out responsibly, in the service of a meaningful life.

Correlational evidence has found that absence of psychological flexibility predicts many forms of psychopathology. A 2005 meta-analysis showed that the six ACT principles, on average, account for 16–29% of the variance in psychopathology (general mental health, depression, anxiety) at baseline, depending on the measure, using correlational methods. A 2012 meta-analysis of 68 laboratory-based studies on ACT components has also provided support for the link between psychological flexibility concepts and specific components.

Research

A 2008 meta-analysis concluded that the evidence was still too limited for ACT to be considered a supported treatment, and raised methodological concerns about the research base. A 2009 meta-analysis found that ACT was more effective than placebo and "treatment as usual" for most problems (with the exception of anxiety and depression), but not more effective than CBT and other traditional therapies. A 2012 meta-analysis was more positive and reported that ACT outperformed CBT, except for treating depression and anxiety.

A 2015 review found that ACT was better than placebo and typical treatment for anxiety disorders, depression, and addiction. Its effectiveness was similar to traditional treatments like cognitive behavioral therapy (CBT). The authors suggested that the CBT comparison of the previous 2012 meta-analysis may have been compromised by the inclusion of nonrandomized trials with small sample sizes. They also noted that research methodologies had improved since the studies described in the 2008 meta-analysis.

The number of randomized clinical trials and controlled time series evaluating ACT for a variety of problems is growing. In 2006, only about 30 such studies were known, but in 2011 the number had approximately doubled. The website of the Association for Contextual Behavioral Science states that there were 171 randomized controlled trials (RCTs) of ACT published as of December 2016, and over 20 meta-analyses and 45 mediational studies of the ACT literature as of Spring 2016. Most studies of ACT so far have been conducted on adults and therefore the knowledge of its effectiveness when applied to children and adolescents is limited.

Similarities

ACT, dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP), mindfulness-based cognitive therapy (MBCT) and other acceptance- and mindfulness-based approaches are commonly grouped under the name "the third wave of cognitive behavior therapy". The first wave, behaviour therapy, commenced in the 1920s based on Pavlov's classical (respondent) conditioning and operant conditioning that was correlated to reinforcing consequences. The second wave emerged in the 1970s and included cognition in the form of irrational beliefs, dysfunctional attitudes or depressogenic attributions. In the late 1980s empirical limitations and philosophical misgivings of the second wave gave rise to Steven Hayes' ACT theory which modified the focus of abnormal behaviour away from the content or form towards the context in which it occurs. ACT research has suggested that many of the emotional defenses individuals use with conviction to try to solve their problems actually entangle humans into greater suffering. Rigid ideas about themselves, lack of focus on what is important in their life and struggling to change sensations, feelings or thoughts that are troublesome only serve to create greater distress.

Steven C. Hayes described this group in his ABCT President Address as follows:

Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experiential change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcomes.

ACT has also been adapted to create a non-therapy version of the same processes called Acceptance and Commitment Training. This training process, oriented towards the development of mindfulness, acceptance, and valued skills in non-clinical settings such as businesses or schools, has also been investigated in a handful of research studies with good preliminary results. This is somewhat similar to the awareness–management movement in business training programs, where mindfulness and cognitive-shifting techniques are employed.

The emphasis of ACT on ongoing present moment awareness, valued directions and committed action is similar to other psycho-therapeutic approaches that, unlike ACT, are not as focused on outcome research or consciously linked to a basic behavioral science program, including approaches such as Gestalt therapy, Morita therapy and Voice Dialogue, IFS and others.

Wilson, Hayes & Byrd explore at length the compatibilities between ACT and the 12-step treatment of addictions and argue that, unlike most other psychotherapies, both approaches can be implicitly or explicitly integrated due to their broad commonalities. Both approaches endorse acceptance as an alternative to unproductive control. ACT emphasizes the hopelessness of relying on ineffectual strategies to control private experience, similarly the 12-step approach emphasizes the acceptance of powerlessness over addiction. Both approaches encourage a broad life-reorientation, rather than a narrow focus on the elimination of substance use, and both place great value on the long-term project of building of a meaningful life aligned with the clients' values. ACT and 12-step both encourage the pragmatic utility of cultivating a transcendent sense of self (higher power) within an unconventional, individualized spirituality. Finally they both openly accept the paradox that acceptance is a necessary condition for change and both encourage a playful awareness of the limitations of human thinking.

Criticisms

Some published empirical studies in clinical psychology have argued that ACT is not different from other interventions. Stefan Hofmann argued that ACT is similar to the much older Morita therapy.

A meta-analysis by Öst in 2008 concluded that ACT did not yet qualify as an "empirically supported treatment", that the research methodology for ACT was less stringent than cognitive behavioral therapy, and that the mean effect size was moderate. Supporters of ACT have challenged those conclusions by showing that the quality difference in Öst's review was accounted for by the larger number of funded trials in the CBT comparison group.

Several concerns, both theoretical and empirical, have arisen in response to the ascendancy of ACT. One major theoretical concern is that the primary authors of ACT and of the corresponding theories of human behavior, relational frame theory (RFT) and functional contextualism (FC), recommend their approach as the proverbial holy grail of psychological therapies. Psychologist James C. Coyne, in a discussion of "disappointments and embarrassments in the branding of psychotherapies as evidence supported", said: "Whether or not ACT is more efficacious than other therapies, as its proponents sometimes claim, or whether it is efficacious for psychosis, is debatable". The textbook Systems of Psychotherapy: A Transtheoretical Analysis provides criticisms of third-wave behaviour therapies including ACT from the perspectives of other systems of psychotherapy.

Psychologist Jonathan W. Kanter said that Hayes and colleagues "argue that empirical clinical psychology is hampered in its efforts to alleviate human suffering and present contextual behavioral science (CBS) to address the basic philosophical, theoretical and methodological shortcomings of the field. CBS represents a host of good ideas but at times the promise of CBS is obscured by excessive promotion of Acceptance and Commitment Therapy (ACT) and Relational Frame Theory (RFT) and demotion of earlier cognitive and behavior change techniques in the absence of clear logic and empirical support." Nevertheless, Kanter concluded that "the ideas of CBS, RFT, and ACT deserve serious consideration by the mainstream community and have great potential to shape a truly progressive clinical science to guide clinical practice."

ACT currently appears to be about as effective as standard CBT, with some meta-analyses showing small differences in favor of ACT and others not. For example, a meta-analysis published by Francisco Ruiz in 2012 looked at 16 studies comparing ACT to standard CBT. ACT failed to separate from CBT on effect sizes for anxiety, however modest benefits were found with ACT compare to CBT for anxiety and quality of life. The author did find separation between ACT and CBT on the "primary outcome" – a heterogeneous class of 14 separate outcome measures that were aggregated into the effect size analysis. This analysis however is limited by the highly heterogeneous nature of the outcome variables used in the analysis, which has the tendency to increase the number needed to treat (NNT) to replicate the effect size reported. More limited measures, such as depression, anxiety and quality of life decrease the NNT, making the analysis more clinically relevant, and on these measures ACT did not outperform CBT. 

A 2013 paper comparing ACT to cognitive therapy (CT) concluded that "like CT, ACT cannot yet make strong claims that its unique and theory-driven intervention components are active ingredients in its effects." The authors of the paper suggested that many of the assumptions of ACT and CT "are pre-analytical, and cannot be directly pitted against one another in experimental tests."

Professional organizations

The Association for Contextual Behavioral Science is committed to research and development in the area of ACT, RFT, and contextual behavioral science more generally. As of 2017 it had over 7,600 members worldwide, about half outside of the United States. It holds annual "world conference" meetings: The 16th will be held in Montreal, in July 2018.

The Association for Behavior Analysis International (ABAI) has a special interest group for practitioner issues, behavioral counseling, and clinical behavior analysis ABA:I. ABAI has larger special interest groups for autism and behavioral medicine. ABAI serves as the core intellectual home for behavior analysts. ABAI sponsors three conferences/year—one multi-track in the U.S., one specific to Autism and one international.

The Association for Behavioral and Cognitive Therapies (ABCT) also has an interest group in behavior analysis, which focuses on clinical behavior analysis. ACT work is commonly presented at ABCT and other mainstream CBT organizations. 

The British Association for Behavioural and Cognitive Psychotherapies (BABCP) has a large special interest group in ACT, with over 1,200 members. 

Doctoral-level behavior analysts who are psychologists belong to the American Psychological Association's (APA) Division 25—Behavior analysis. ACT has been called a "commonly used treatment with empirical support" within the APA-recognized specialty of behavioral and cognitive psychology.

Chronic pain

From Wikipedia, the free encyclopedia

 

Chronic pain
Specialty	Pain management

Chronic pain is pain that lasts a long time. In medicine, the distinction between acute and chronic pain is sometimes determined by an arbitrary interval of time since onset; the two most commonly used markers being 3 months and 6 months since onset, though some theorists and researchers have placed the transition from acute to chronic pain at 12 months. Others apply acute to pain that lasts less than 30 days, chronic to pain of more than six months duration, and subacute to pain that lasts from one to six months. A popular alternative definition of chronic pain, involving no arbitrarily fixed duration, is "pain that extends beyond the expected period of healing". Epidemiological studies have found that 10.1% to 55.2% of people in various countries have chronic pain.

Chronic pain may originate in the body, or in the brain or spinal cord. It is often difficult to treat. Various nonopioid medicines are recommended initially, depending on whether the pain originates from tissue damage or is neuropathic. Psychological treatments including cognitive behavioral therapy and acceptance and commitment therapy may be effective for improving quality of life in those with chronic pain. Some people with chronic pain may benefit from opioid treatment while others are harmed. In people with non-cancer pain, a trial of opioids is only recommended if there is no history of either mental illness or substance use disorder and should be stopped if not effective.

Severe chronic pain is associated with increased 10-year mortality, particularly from heart disease and respiratory disease. People with chronic pain tend to have higher rates of depression, anxiety, and sleep disturbances; these are correlations and it is often not clear which factor causes another. Chronic pain may contribute to decreased physical activity due to fear of exacerbating pain, often resulting in weight gain. Pain intensity, pain control, and resiliency to pain are influenced by different levels and types of social support that a person with chronic pain receives.

Classification

The International Association for the study of pain defines chronic pain as pain with no biological value, that persists past normal tissue healing. The DSM-5 recognizes one chronic pain disorder, somatic symptom disorders, a reduction from the three previously recognized pain disorders. The criteria include it lasting for greater than six months.

The suggested ICD-11 chronic pain classification suggests 7 categories for chronic pain.

1. Chronic primary pain: defined by 3 months of persistent pain in one or more anatomical regions that is unexplainable by another pain condition.
2. Chronic cancer pain: defined as cancer or treatment related visceral, musculoskeletal, or bony pain.
3. Chronic posttraumatic pain: pain lasting 3 months post trauma or surgery, excluding infectious or preexisting conditions.
4. Chronic neuropathic pain: pain caused by damage to the somatosensory nervous system.
5. Chronic headache and orofacial pain: pain that originates in the head or face, and occurs for 50% or more days over a 3 months period.
6. Chronic visceral pain: pain originating in an internal organ.
7. Chronic musculoskeletal pain: pain originating in the bones, muscles, joints or connective tissue.

Chronic pain may be divided into "nociceptive" (caused by inflamed or damaged tissue activating specialised pain sensors called nociceptors), and "neuropathic" (caused by damage to or malfunction of the nervous system).

Nociceptive pain may be divided into "superficial" and "deep", and deep pain into "deep somatic" and "visceral". Superficial pain is initiated by activation of nociceptors in the skin or superficial tissues. Deep somatic pain is initiated by stimulation of nociceptors in ligaments, tendons, bones, blood vessels, fasciae and muscles, and is dull, aching, poorly-localized pain. Visceral pain originates in the viscera (organs). Visceral pain may be well-localized, but often it is extremely difficult to locate, and several visceral regions produce "referred" pain when damaged or inflamed, where the sensation is located in an area distant from the site of pathology or injury.

Neuropathic pain is divided into "peripheral" (originating in the peripheral nervous system) and "central" (originating in the brain or spinal cord). Peripheral neuropathic pain is often described as "burning", "tingling", "electrical", "stabbing", or "pins and needles".

Causes

Pathophysiology

Under persistent activation nociceptive transmission to the dorsal horn may induce a pain wind-up phenomenon. This induces pathological changes that lower the threshold for pain signals to be transmitted. In addition it may generate nonnociceptive nerve fibers to respond to pain signals. Nonnociceptive nerve fibers may also be able to generate and transmit pain signals. The type of nerve fibers that are believed to propagate the pain signals are the C-fibers, since they have a slow conductivity and give rise to a painful sensation that persists over a long time. In chronic pain this process is difficult to reverse or eradicate once established. In some cases, chronic pain can be caused by genetic factors which interfere with neuronal differentiation, leading to a permanent reduction in the threshold for pain.

Chronic pain of different etiologies has been characterized as a disease affecting brain structure and function. Magnetic resonance imaging studies have shown abnormal anatomical and functional connectivity, even during rest involving areas related to the processing of pain. Also, persistent pain has been shown to cause grey matter loss, reversible once the pain has resolved.

These structural changes can be explained by the phenomenon known as neuroplasticity. In the case of chronic pain, the somatotopic representation of the body is inappropriately reorganized following peripheral and central sensitization. This maladaptive change results in the experience of allodynia or hyperalgesia. Brain activity in individuals with chronic pain, measured via electroencephalogram (EEG), has been demonstrated to be altered, suggesting pain-induced neuroplastic changes. More specifically, the relative beta activity (compared to the rest of the brain) is increased, the relative alpha activity is decreased, and the theta activity both absolutely and relatively is diminished.

Dopaminergic dysfunction has been hypothesized to act as a shared mechanism between chronic pain, insomnia and major depressive disorder. Increased tonic dopamine activity and a compensatory decrease in phasic dopamine activity, which is important in inhibiting pain. This is supported by the implication of COMT in fibromyalgia and temporomandibular joint syndrome. Astrocytes, microglia, and Satellite glial cells have been found to be dysfunctional in chronic pain. Increased activity of microglia, alterations of microglial networks as well as increased production of chemokines and cytokines by microglia are proposed to act to potentiate pain. Astrocytes have been observed to lose their ability to regulate the excitability of neurons, increasing spontaneous neural activity in pain circuits.

Management

Pain management is the branch of medicine employing an interdisciplinary approach to the relief of pain and improvement in the quality of life of those living with pain. The typical pain management team includes medical practitioners (particularly anesthesiologists), rehabilitation psychologists, physiotherapists, occupational therapists, physician assistants, and nurse practitioners. Acute pain usually resolves with the efforts of one practitioner; however, the management of chronic pain frequently requires the coordinated efforts of the treatment team. Complete and sustained remission of many types of chronic pain is rare, though some can be done to improve quality of life.

Nonopioids

Initially recommended efforts are non opioid based therapies.

Various nonopioid medicines are used, depending on whether the pain originates from tissue damage or is neuropathic. Limited evidence suggests that chronic pain from tissue inflammation or damage (as in rheumatoid arthritis and cancer pain) is best treated with opioids, while for neuropathic pain (pain caused by a damaged or dysfunctional nervous system) other drugs may be more effective, such as tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants. Because of weak evidence, the best approach is not clear when treating many types of pain, and doctors must rely on their own clinical experience. Doctors often cannot predict who will use opioids just for pain management and who will go on to develop addiction, and cannot always distinguish between those who are and those who are not seeking opioids due primarily to an existing addiction. Withholding, interrupting or withdrawing opioid treatment in people who benefit from it can cause harm.

Interventional pain management may be appropriate, including techniques such as trigger point injections, neurolytic blocks, and radiotherapy. While there is no high quality evidence to support ultrasound, it has been found to have a small effect on improving function in non-specific chronic low back pain.

Psychological treatments, including cognitive behavioral therapy and acceptance and commitment therapy have been shown effective for improving quality of life and reducing pain interference in those with chronic pain. 

While exercise has been offered as a method to lessen chronic pain and there is some evidence of benefit, this evidence is tentative. Side effects from exercise are few in this population.

Opioids

In those who have not benefited from other measures and have no history of either mental illness or substance use disorder treatment with opioids may be tried. If significant benefit does not occur it is recommended that they be stopped. In those on opioids, stopping or decreasing their use may improve outcomes including pain.

Some people with chronic pain benefit from opioid treatment and others do not; some are harmed by the treatment. Possible harms include reduced sex hormone production, hypogonadism, infertility, impaired immune system, falls and fractures in older adults, neonatal abstinence syndrome, heart problems, sleep-disordered breathing, opioid-induced hyperalgesia, physical dependence, addiction, and overdose.

Alternative medicine

Hypnosis, including self-hypnosis, has tentative evidence. Evidence does not support hypnosis for chronic pain due to a spinal cord injury.

Preliminary studies have found medical marijuana to be beneficial in treating neuropathic pain, but not other kinds of long term pain. As of 2018 even for neuropathic pain the evidence is not strong for any benefit and further research is needed.

Tai Chi has been shown to improve pain, stiffness, and quality of life in chronic conditions such as osteoarthritis, low back pain, and osteoporosis. Acupuncture has also been found to be an effective and safe treatment in reducing pain and improving quality of life in chronic pain including chronic pelvic pain syndrome.

Transcranial magnetic stimulation for reduction of chronic pain is not supported by high quality evidence, and the demonstrated effects are small and short-term.

Epidemiology

A systematic literature review of chronic pain found that the prevalence of chronic pain varied in various countries from 10.1% to 55.2% of the population, affected women at a higher rate than men, and that chronic pain consumes a large amount of healthcare resources around the globe.

A large-scale telephone survey of 15 European countries and Israel, 19% of respondents over 18 years of age had suffered pain for more than 6 months, including the last month, and more than twice in the last week, with pain intensity of 5 or more for the last episode, on a scale of 1 (no pain) to 10 (worst imaginable). 4839 of these respondents with chronic pain were interviewed in depth. Sixty six percent scored their pain intensity at moderate (5–7), and 34% at severe (8–10); 46% had constant pain, 56% intermittent; 49% had suffered pain for 2–15 years; and 21% had been diagnosed with depression due to the pain. Sixty one percent were unable or less able to work outside the home, 19% had lost a job, and 13% had changed jobs due to their pain. Forty percent had inadequate pain management and less than 2% were seeing a pain management specialist.

In the United States, the prevalence of chronic pain has been estimated to be approximately 35%, with approximately 50 million Americans experiencing partial or total disability as a consequence. According to the Institute of Medicine, there are about 116 million Americans living with chronic pain, which suggests that approximately half of American adults have some chronic pain condition. The Mayday Fund estimate of 70 million Americans with chronic pain is slightly more conservative. In an internet study, the prevalence of chronic pain in the United States was calculated to be 30.7% of the population: 34.3% for women and 26.7% for men.

Outcomes

Sleep disturbance, and insomnia due to medication and illness symptoms are often experienced by those with chronic pain. Such co-morbidities can be difficult to treat due to the high potential of medication interactions, especially when the conditions are treated by different doctors.

Severe chronic pain is associated with increased 10 year mortality, particularly from heart disease and respiratory disease. Several mechanisms have been proposed for the increased mortality, e.g. abnormal endocrine stress response. Additionally, chronic stress seems to affect cardiovascular risk by acceleration of the atherosclerotic process. However, further research is needed to clarify the relationship between severe chronic pain, stress and cardiovascular health.

Psychology

Personality

Two of the most frequent personality profiles found in people with chronic pain by the Minnesota Multiphasic Personality Inventory (MMPI) are the conversion V and the neurotic triad. The conversion V personality, so called because the higher scores on MMPI scales 1 and 3, relative to scale 2, form a "V" shape on the graph, expresses exaggerated concern over body feelings, develops bodily symptoms in response to stress, and often fails to recognize their own emotional state, including depression. The neurotic triad personality, scoring high on scales 1, 2 and 3, also expresses exaggerated concern over body feelings and develops bodily symptoms in response to stress, but is demanding and complaining.

Some investigators have argued that it is this neuroticism that causes acute pain to turn chronic, but clinical evidence points the other way, to chronic pain causing neuroticism. When long term pain is relieved by therapeutic intervention, scores on the neurotic triad and anxiety fall, often to normal levels. Self-esteem, often low in people with chronic pain, also shows striking improvement once pain has resolved.

It has been suggested that catastrophizing may play a role in the experience of pain. Pain catastrophizing is the tendency to describe a pain experience in more exaggerated terms than the average person, to think a great deal more about the pain when it occurs, or to feel more helpless about the experience. People who score highly on measures of catastrophization are likely to rate a pain experience as more intense than those who score low on such measures. It is often reasoned that the tendency to catastrophize causes the person to experience the pain as more intense. One suggestion is that catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain. However, at least some aspects of catastrophization may be the product of an intense pain experience, rather than its cause. That is, the more intense the pain feels to the person, the more likely they are to have thoughts about it that fit the definition of catastrophization.

Social support

Social support has important consequences for individuals with chronic pain. In particular, pain intensity, pain control, and resiliency to pain has been implicated as outcomes influenced by different levels and types of social support. Much of this research has focused on emotional, instrumental, tangible and informational social support. People with persistent pain conditions tend to rely on their social support as a coping mechanism and therefore have better outcomes when they are a part of larger more supportive social networks. Across a majority of studies investigated, there was a direct significant association between social activities or social support and pain. Higher levels of pain were associated with a decrease in social activities, lower levels of social support, and reduced social functioning.

Effect on cognition

Chronic pain's impact on cognition is an under-researched area, but several tentative conclusions have been published. Most people with chronic pain complain of cognitive impairment, such as forgetfulness, difficulty with attention, and difficulty completing tasks. Objective testing has found that people in chronic pain tend to experience impairment in attention, memory, mental flexibility, verbal ability, speed of response in a cognitive task, and speed in executing structured tasks.