title: The Mediating Role of Acceptance in Multidisciplinary Cognitive-Behavioral Therapy for Chronic Pain.
abstract: Cognitive-behavioral therapy (CBT) is the most frequently delivered psychological intervention for adults with chronic pain. The treatment yields modest effect sizes, and the mechanisms of action remain understudied and unclear. Efforts are needed to identify treatment mediators that could be used to refine CBT and improve outcomes. The primary aim of this study was to investigate whether pain-related acceptance, from the psychological flexibility model, mediates changes in outcome over time in a CBT-based treatment program. This includes comparing how this variable relates to 3 other variables posited as potential mediators in standard CBT: life control, affective distress, and social support. Participants attended a 5-week outpatient multidisciplinary program with self-report data collected at assessment, posttreatment, and 12-month follow-up. Multilevel structural equation modeling was used to test for mediation in relation to 3 outcomes: pain interference, pain intensity, and depression. Results indicate that effect sizes for the treatment were within the ranges reported in the CBT for pain literature. Pain-related acceptance was not related to pain intensity, which is in line with past empirical evidence and the treatment objectives in acceptance and commitment therapy. Otherwise, pain-related acceptance was the strongest mediator across the different indices of outcome. Accumulated results like these suggest that acceptance of pain may be a general mechanism by which CBT-based treatments achieve improvements in functioning. More specific targeting of pain-related acceptance in treatment may lead to further improvements in outcome.
  
  
  CONCLUSIONS
  Potential mediators of outcome in a CBT-based treatment for adult chronic pain were investigated using multilevel structural equation modeling. The results highlight the role of pain-related acceptance as an important treatment process even when not explicitly targeted during treatment. These data may help clinicians and researchers better understand processes of change and improve the choice and development of treatment methods.
authors.affiliation: Department of Pain Rehabilitation, Skåne University Hospital, Lund, Sweden; Department of Psychology, Lund University, Lund, Sweden. Electronic address: sophia.akerblom@psy.lu.se.
authors.forename: Sophia
authors.initials: S
authors.lastname: Åkerblom
authors.affiliation: Department of Psychology, Lund University, Lund, Sweden; King's College London, Psychology Department, Health Psychology Section, London, United Kingdom.
authors.forename: Sean
authors.initials: S
authors.lastname: Perrin
authors.affiliation: Department of Pain Rehabilitation, Skåne University Hospital, Lund, Sweden; Department of Health Sciences, Lund University, Lund, Sweden.
authors.forename: Marcelo
authors.initials: M
authors.lastname: Rivano Fischer
authors.affiliation: King's College London, Psychology Department, Health Psychology Section, London, United Kingdom.
authors.forename: Lance M
authors.initials: LM
authors.lastname: McCracken
mesh_terms: D000293:Adolescent; D000328:Adult; D059350:Chronic Pain / Q000150:complications / Q000523:psychology* / Q000534:rehabilitation*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003863:Depression / Q000209:etiology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D055815:Young Adult
keywords: Acceptance and commitment therapy; acceptance; chronic pain; cognitive-behavioral therapy; mediator; multilevel structural equation modeling