16 - An Exploration of the Implications of Sequencing Order on Group Pain Interventions

Jesse Brown VA Medical Center, Chicago, IL, USA

Purpose
As both Acceptance and Commitment Therapy (ACT) and Cognitive-Behavioral Therapy (CBT) have been found to be effective in treating chronic, non-cancer pain, there is a need to explore how to optimally apply these treatments to improve patient outcomes.The primary aim of this study was to evaluate whether a sequential approach to treatment, where acceptance based coping strategies are taught prior to problem-focused coping strategies, improves pain-related outcomes.As a basis for evaluating the effects of sequencing order, we also tested the hypothesis that Veterans receiving both treatments (ACT and CBT) would show significantly greater improvement in pain outcome measures than those receiving just one of the treatments.
Methods
A sample of 168 Veterans participated in the current study at a Midwestern Department of Veterans Affairs (VA) Medical Center between November 1, 2009 and November 30, 2012. All participants self-selected to participate in manualized ACT, CBT, or both interventions, and were administered a standard pre- and post-intervention assessment battery. The battery of measures in the current study included the Readiness Questionnaire (M. Jensen, personal communication, August 23, 2004), the Brief Pain Inventory-Short Form (BPI; Cleeland & Ryan, 1994), the Oswestry Disability Index © (ODI; Fairbank, Davies, Couper, & O’Brien, 1980), the Coping Strategies Questionnaire-Catastrophizing Scale (CSQ; Rosenstiel & Keefe, 1983), the Chronic Pain Coping Inventory-Short Form (CPCI; Jensen, Turner, Romano, & Strom, 1995), and the Brief Symptom Inventory^® 18 (BSI-18; Derogatis, 1975). These measures were chosen based on their brevity and ease of administration as well as their reliability and validity in prior research.
Results
A 4 x 2 RM MANOVA did not find a significant interaction effect or a significant main effect for type of intervention. Significant univariate main effects for time were obtained for both primary measures of pain severity, F(1,152)=5.02, p=0.03, n²=.03,and pain interference, F (1,152)=7.75, p=.01, n²=.05. In addition, significant main effects for time were noted for secondary outcome measures of illness-focused coping, F (1,152)=4.58, p=.03, n²=.03, global distress, F (1,152)=16.57, p<.001, n²=.10, and catastrophizing, F (1,152)=18.98, p<.001, n²=.11. There was no significant main effect for time found for wellness-focused coping, F (1,152)=104.19, p=.27, or disability, F (1,152)=1.01, p=.32 (see Table 2). These findings largely replicate those from a previous study (Cosio, 2015), though the significant effects in pain severity are unique to this study.
Conclusions
Participation in both groups did not produce significantly different pain-related outcomes than participation in just one group. These findings reinforce common factors theory in psychotherapy and provide insight into treatment dosage for patients with chronic pain. Considering that outcomes are similar regardless of which modality of treatment is received, providers can encourage patient collaboration in establishing a treatment plan and help them select an intervention that is most in line with their goals and values. At sites where both treatments are available, though patients may elect to receive both treatments based on personal preference, this approach may only benefit them in the sense of increasing patient-provider alliance. As treatment for chronic pain emphasizes the importance for patients of assuming an active self-management approach to their healthcare, providers should be judicious when helping patients select interventions that will be most likely to facilitate this goal as opposed to encouraging dependence on treatment.