Journal of Consulting and Clinical Psychology Copyright 2008 by the American Psychological Association

2008, Vol. 76, No. 3, 397– 407 0022-006X/08/$12.00 DOI: 10.1037/0022-006X.76.3.397

Acceptance and Values-Based Action in Chronic Pain: A Study of

Treatment Effectiveness and Process
Kevin E. Vowles and Lance M. McCracken
University of Bath and Royal National Hospital for Rheumatic Diseases

Developing approaches within cognitive behavioral therapy are increasingly process-oriented and based
on a functional and contextual framework that differs from the focus of earlier work. The present study
investigated the effectiveness of acceptance and commitment therapy (S. C. Hayes, K. Strosahl, & K. G.
Wilson, 1999) in the treatment of chronic pain and also examined 2 processes from this model,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

acceptance and values-based action. Participants included 171 completers of an interdisciplinary treat-
This document is copyrighted by the American Psychological Association or one of its allied publishers.

ment program, 66.7% of whom completed a 3-month follow-up assessment as well. Results indicated
significant improvements for pain, depression, pain-related anxiety, disability, medical visits, work
status, and physical performance. Effect size statistics were uniformly medium or larger. According to
reliable change analyses, 75.4% of patients demonstrated improvement in at least one key domain. Both
acceptance of pain and values-based action improved, and increases in these processes were associated
with improvements in the primary outcome domains.

Keywords: acceptance, values, chronic pain, contextual cognitive-behavioral treatment, acceptance and
commitment therapy

Chronic pain is a prevalent health concern (Breivik, Collett,
Ventafridda, Cohen, & Gallacher, 2006; Verhaak, Kerssens, Dek-
ker, Sorbi, & Bensing, 1998) involving considerable costs in terms
of healthcare, lost work productivity, and disability compensation
(see Gatchel & Okifuji, 2006, for a review). The experience of
chronic pain is also associated with significant disability, emo-
tional distress, and suffering, including pain-related fears, depres-
sion, and other psychiatric conditions (Breivik et al., 2006; Dersh,
Polatin, & Gatchel, 2002; Von Korff et al., 2005). There is no
doubt that chronic pain represents a serious problem for the indi-
vidual, their family, their community, and our societies in general.
Integrative biopsychosocial approaches have become a mainstay
treatment for chronic pain, as they seem well-suited to address the
complexities involved in these conditions (Turk & Monarch,
2002). Associated cognitive behavioral therapy (CBT) programs
have a substantial evidence base supporting their effectiveness.
Recent reviews suggest that CBT for chronic pain results in
reduced pain, emotional distress, disability, medication use, and
healthcare utilization, as well as improved physical, social, and
work-related activities (Hoffman, Papas, Chatkoff, & Kerns, 2007;
McCracken & Turk, 2002; Morley, Eccleston, & Williams, 1999).
Furthermore, these treatments are cost effective, regardless of
whether treatment is provided via a single discipline (e.g., clinical
psychology) or an interdisciplinary team of providers (Gatchel &
Okifuji, 2006; Turk, 2002). These results mirror the degree of
Kevin E. Vowles and Lance M. McCracken, Centre for Pain Research,
School for Health, University of Bath, Bath, United Kingdom, and Centre
for Pain Services, Royal National Hospital for Rheumatic Diseases, NHS
Foundation Trust, Bath.
Correspondence concerning this article should be addressed to Kevin E.
Vowles, Centre for Pain Research, School for Health, University of Bath,
Bath BA2 7AY United Kingdom. E-mail: K.Vowles@Bath.ac.uk
success CBT has achieved within medical care settings in general
(Compas, Haage, Keefe, Leitenberg, & Williams, 1999; Shadish et
al., 1997).
Although CBT has documented efficacy, the processes under-
lying treatment effects remain unclear (Keefe, Rumble, Scipio,
Giordano, & Perri, 2004; Morley, 2004). CBT, as an organized
system, has traditionally placed significant emphasis on the im-
portance of changes in the content of thoughts and beliefs in the
treatment process (e.g., Clark, 1995; DeRubeis, Tang, & Beck,
2001). This is true in chronic pain-related applications as well,
where the central roles of catastrophic thinking, cognitive coping
styles, and beliefs about pain are frequently emphasized (e.g., Turk
& Rudy, 1992; Vlaeyen & Linton, 2000).
More recently, there has been increasing interest in refining our
account of how thoughts, beliefs, and other psychological experi-
ences have their impact on behavior. Some of this interest has
come from studies that have failed to find an independent contri-
bution of cognitive strategies on beneficial treatment outcomes.
For example, at least five treatment trials for major depression,
including a total of 442 participants, have found that specifically
targeting maladaptive or illogical cognitions is not necessary to
achieve short- or long-term improvements (Dimidjian et al., 2006;
Gortner, Gollan, Jacobson, & Dobson, 1998; Jacobson et al., 1996;
Jarrett & Nelson, 1987; Zettle & Hayes, 1987). This pattern of
results is also found in treatment trials for anxiety, including
generalized anxiety disorder, social phobia, posttraumatic stress
disorder, and obsessive-compulsive disorder, where component
studies have established that cognitive components are neither
superior to behavioral components in achievement of outcomes
nor necessary to achieve treatment success (see Longmore &
Worrell, 2007, for a review).
On the basis of current research, it has been argued that treat-
ment may not need to focus on the logic or semantic meaning of
thoughts and beliefs in order to be effective, but rather may focus

397
 398 VOWLES AND MCCRACKEN
on the ways in which thoughts and beliefs have their impact on
functioning (Hayes, Strosahl, & Wilson, 1999; Linehan, 1993;
Segal, Williams, & Teasdale, 2002; Teasdale, 1997). These theo-
retical arguments emphasize the importance of the historical and
situational context where distressing or discouraging psychologi-
cal experiences occur as a way to understand their “functions” or
interrelations with patient behavior (Hayes, 2004).
Developing treatment approaches that may address these gaps in
the empirical literature and theory are referred to as third wave, to
note their relationship to earlier operant and cognitive behavioral
developments (Hayes, 2004). One of the more actively researched
approaches from among these developing therapies is acceptance
and commitment therapy (ACT; Hayes et al., 1999; see Hayes,
Luoma, Bond, Masuda, & Lillis, 2006, for a review). Key thera-
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peutic processes of this treatment model differ from traditional
CBT and include acceptance, or the willingness to experience pain
or other distressing events without attempts to control them, and
values-based action, or the aligning of actions with desired, per-
sonally meaningful purposes rather than with the elimination of
unwanted experiences (Hayes et al., 1999, 2006). Treatment meth-
ods for establishing these processes involve undermining the ways
that language and cognitive processes interact with other nonver-
bal contingencies in ways that limit healthy functioning. These
methods include exposure-based and experiential exercises, met-
aphorical uses of language, and methods such as mindfulness
training. Overall, there is good evidence for the efficacy of ACT-
based approaches across a variety of healthcare concerns, includ-
ing controlled trials of depression (Zettle & Hayes, 1987; Zettle &
Rains, 1989), psychosis (Bach & Hayes, 2002; Gaudiano & Her-
bert, 2006), diabetes (Gregg, Callaghan, Hayes, & Glenn-Lawson,
2007), worksite stress (Bond & Bunce, 2000), and polysubstance
abuse (Hayes et al., 2004), as well as uncontrolled trials for a
number of other conditions (see Hayes et al., 2006, for a review).
It appears that the ACT model leads to effective treatment for
pain as well. A small controlled trial by Dahl, Wilson, and Nilsson
(2004) showed that 4 hr of ACT substantially reduced sick leave
and healthcare use in comparison to usual medical treatment in a
group of workers at risk of prolonged work absence due to pain or
stress. A case series of 14 adolescents with chronic pain indicated
that an ACT-consistent treatment was associated with improve-
ments in school attendance and physical and emotional function-
ing, as well as reductions in interference due to pain and medica-
tion use (Wicksell, Melin, & Olsson, 2007). The findings of a trial
of contextual cognitive-behavioral therapy (CCBT), an application
of the ACT treatment model to chronic pain (McCracken, 2005),
indicated significant improvements in emotional and physical
functioning, medication use, and pain-related healthcare visits
during treatment in comparison to a no-treatment waiting phase in
a sample of 108 adults with chronic pain (McCracken, Vowles, &
Eccleston, 2005). Subsequently, it was reported that highly dis-
abled patients requiring inpatient hospitalization for treatment
achieved outcomes comparable to a less disabled group not requir-
ing hospitalization (McCracken, MacKichan, & Eccleston, 2007).
Three additional sets of analyses support the contention that ac-
ceptance is a key process in treatment outcome and behavior
change in individuals with chronic pain. The first found that
changes in acceptance over the course of treatment were related to
changes in depression, pain-related anxiety, physical and psycho-
social disability, and physical task persistence (McCracken et al.,
2005). These findings were replicated in a second study that used
an expanded sample wherein changes in acceptance were found to
account for significant and unique variance in changes in outcome
measures above and beyond the variance accounted for by changes
in pain intensity and frequency of catastrophic thinking (Vowles,
McCracken, & Eccleston, 2007). Finally, a third analysis found
that a brief ACT-consistent experimental manipulation produced
short-term improvements in performance in comparison to a ma-
nipulation focusing on control of pain in adults seeking treatment
for chronic pain (Vowles, McNeil, et al., 2007).
The previous treatment findings with regard to chronic pain
suggest that treatment approaches based on the model underlying
ACT are effective, associated with the processes identified by the
treatment model (i.e., acceptance of pain), and fertile ground for
continuing development, particularly in relation to other processes
from the treatment model. Therefore, the present analyses had two
purposes. First, we sought to perform a detailed examination of
treatment outcomes, including tests of statistical significance and
analyses of effect size and reliable change (Jacobson, Roberts,
Berns, & McGlinchey, 1999) in an entirely new sample of pain
sufferers. Second, we sought to extend previous process analysis
research by the inclusion of another process, values-based action,
in addition to acceptance. We hypothesized that statistically sig-
nificant improvements in outcomes would be observed at treat-
ment conclusion and at follow-up, in comparison to treatment
onset. Furthermore, we expected that the results of the effect size
and reliable change analyses would support the clinical relevance
of these improvements. Finally, we expected that changes in
acceptance and values-based action would be associated with one
another and with changes in the outcome variables in support of
the treatment model.
Method
Participants
Participants were consecutive referrals accepted for treatment at
a tertiary care pain rehabilitation unit in southwest England who
began treatment between January 2005 and July 2006. This sample
was entirely separate from those used in previous analyses involv-
ing treatment outcome data (i.e., McCracken, MacKichan, & Ec-
cleston, 2007; McCracken et al., 2005; Vowles, McCracken, &
Eccleston, 2007). Selection criteria for treatment included persis-
tent pain of longer than 3 months duration, significant levels of
pain-related distress and disability, and agreement with the reha-
bilitative (as opposed to curative) goals of treatment. In addition,
patients who required further medical tests or procedures or who
had conditions that could interfere with participation in a group-
based treatment program (i.e., impaired neuropsychological func-
tioning, poorly controlled psychiatric conditions) were excluded.
A total of 187 patients began treatment. Of these individuals,
145 (77.5%) were enrolled in a 3-week course of treatment, while
the remaining 42 individuals (22.5%) were enrolled in a 4-week
course for more complex or disabled cases. Across the entire
sample, treatment dropouts were relatively rare; only 16 (8.6%)
individuals discontinued treatment voluntarily or were discharged
early. The remaining 171 individuals provided data before and
after treatment, and 114 (66.7% of treatment completers) also
provided data at a 3-month follow-up appointment.
 ACCEPTANCE AND VALUES-BASED ACTION
The sample of individuals beginning treatment averaged 47.3
years of age (SD ! 11.4) and 12.5 years of education (SD ! 3.0).
The majority were women (64.2%) and White European (98.4%).
Most were married or cohabitating (68.4%; divorced, 15.5%; sin-
gle, 13.4%; widowed, 2.7%). Most were unemployed (76.3%) and
receiving some type of disability or wage replacement allowance
(76.6%). Median pain duration was 96.0 months (range: 8.0 to
516.0 months). The most frequently identified pain site was low
back (45.9%), followed by shoulder/arms (18.4%), full body
(16.8%), legs/pelvic region (11.8%), neck (2.7%), mid-back
(2.2%), and other (e.g., head, abdominal; 2.2%). The majority of
patients also identified additional pain sites (57.2%). The diagnos-
tic status of most patients (51.2%) was not firmly established or
was of a general, nonspecific nature (e.g., “chronic pain syn-
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drome,” “musculoskeletal pain,” “postsurgical pain”). In the re-
mainder of patients, most identified a diagnosis of fibromyalgia
(35.7%), while smaller proportions of patients (all " 4.0%) re-
ported other diagnoses (e.g., complex regional pain syndrome,
arthritis).
Measures
Patients completed a standard set of measures at the beginning
and end of treatment, as well as at the 3-month follow-up visit.
Demographic information was collected as part of a brief back-
ground inventory, which asked patients to report on prescribed
medications, usual pain intensity on a 0 (none) to 10 (worst
imaginable) numeric rating scale, work status, and number of
primary care, specialist, and emergency department visits for pain
attended in the previous 6 months. The medication information
was used to calculate a summary score for number of different
medication classes being taken for pain (i.e., weak opioids, strong
opioids, nonsteroidal anti-inflammatory drugs, tricyclic antide-
pressants, muscle relaxants, sedatives, anticonvulsants, selective
serotonin reuptake inhibitors, and over-the-counter analgesics).
The three types of medical visits were also summed to provide an
overall index of healthcare use related to pain.
Self-report measures were completed in pen-and-paper format.
Research assistants supervised the assessments to aid in comple-
tion and to ensure complete and usable data. Performance mea-
sures were collected by a qualified physical therapist. Incomplete
data were rare; missing responses occurred in less than 5.8% of
cases on any single questionnaire.
Chronic Pain Acceptance Questionnaire (CPAQ). The CPAQ
(McCracken, Vowles, & Eccleston, 2004) is a 20-item measure of
pain-related acceptance. It has two subscales. The first, Activity
Engagement, measures the degree to which pain and related ex-
periences restrict behaviors (11 items; e.g., “I am getting on with
the business of living no matter what my level of pain is”; “It’s a
relief to realize that I don’t have to change my pain to get on with
my life”), and the second, Pain Willingness, measures the extent to
which efforts are put in to controlling pain (9 items; e.g., “I would
gladly sacrifice important things in my life to control this pain
better” [reverse scored]; “I have to struggle to do things when I
have pain” [reverse scored]). A total score is calculated by sum-
ming scores for all items. Respondents were asked to rate the truth
of each statement as it applied to them on a 0 (never true) to 6
(always true) scale; higher scores indicate greater acceptance. The
399
total and subscale scores have demonstrated internal consistency,
reliability over time, and significant relations with measures of
emotional and physical functioning (McCracken & Eccleston,
2005; McCracken et al., 2004, 2005).
Chronic Pain Values Inventory (CPVI). The CPVI (Mc-
Cracken & Yang, 2006) is designed to assess importance and
success in six domains of personal values. Values domains include
family, intimate relations, friends, work, health, and growth or
learning. Respondents are asked to rate the importance of their
values in each domain and success in living according to them on
a 0 (not at all important/successful) to 5 (extremely important/
successful) scale. Previous analyses of this measure have indicated
good internal consistency, concurrent validity, and utility in the
prediction of daily functioning in a sample of chronic pain suffer-
ers (McCracken & Yang, 2006). For the purposes of the present
study, we used the Values Success subscale score as a measure of
values-based action.
British Columbia Major Depression Inventory (BCMDI). The
BCMDI (Iverson & Remick, 2004) was used as an index of
depression. The measure contains 20 items modeled after the
Diagnostic and Statistical Manual of Mental Disorders (4th ed.;
American Psychiatric Association, 1994) criteria for major de-
pressive disorder; the first 16 items pertain to symptom severity
and, when endorsed, are rated on a 1 (very mild problem) to 5
(very severe problem) scale. The last 4 items pertain to the
impact of symptoms on areas of work or school, family, and
social life. The symptom score has demonstrated adequate
internal consistency, test–retest reliability, and good sensitivity
and specificity for a diagnosis of major depressive disorder
(Iverson & Remick, 2004). Only the symptom summary score
was used in this study.
Pain Anxiety Symptoms Scale-20 (PASS). The PASS (Mc-
Cracken & Dhingra, 2002) is a 20-item measure of pain-related
fear and avoidance. Each item is rated on a 0 (never) to 5 (always)
scale. The measure has good internal consistency, a stable factor
structure, and strong correlations with the original 40-item PASS
(McCracken, Zayfert, & Gross, 1992) and other measures of
functioning (McCracken & Dhingra, 2002; Roelofs et al., 2004).
Sickness Impact Profile (SIP). The SIP (Bergner, Bobbitt,
Carter, & Gilson, 1981) is a 136-item measure of the effects of
health on daily functioning. It includes 12 domains, which are
combined to form a total score and three composite scores, phys-
ical disability, psychosocial disability, and “other” disability. The
SIP has been widely used in rehabilitation and other health care
settings (Battié & May, 2001; Bergner et al., 1981). The present
analyses used the Physical and Psychosocial Disability subscales,
as well as the total score.
Physical performance measures. Two direct measures of
physical performance were also collected. These included a 2-min
walking task, which measured walking speed and yielded a mea-
sure of distance traveled, and a sit-to-stand task, which measured
strength and activity tolerance and yielded the number of repeti-
tions performed within the space of 60 s using an armless chair and
without the use of hands or arms for assistance. Previous analyses
have suggested that these tasks have acceptable test–retest reliabil-
ity and relations with self-reports of functioning (Harding et al.,
1994; Lee, Simmonds, Novy, & Jones, 2001).
 400 VOWLES AND MCCRACKEN
Treatment Program
The treatment program was an adaptation of ACT principles and
treatment methods (Hayes et al., 1999), as well as mindfulness-
based methods (e.g., Kabat-Zinn, 1990), to an interdisciplinary
rehabilitation treatment setting (McCracken, 2005). Treatment was
delivered by a team of psychologists, physical therapists, occupa-
tional therapists, nurses, and physicians. Treatment methods ex-
plicitly targeted the key processes of the ACT model and were
used in the promotion of flexible and effective daily functioning
and not to reduce or change pain or other physical or emotional
symptoms. These methods included mindfulness training, values
clarification, exposure-based techniques, and cognitive defusion
exercises to raise awareness of cognitive content and its potential
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influences on action and to increase contact with direct experience
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outside of this content. Treatment did not include explicit cognitive
restructuring or self-statement analysis exercises, methods for en-
hancing thoughts of self-efficacy, or training in relaxation and
distraction. Details of treatment methods can be found in Hayes et
al. (1999), McCracken (2005), and McCracken et al. (2005), and
similar methods can be found in Dahl, Wilson, Luciano, and Hayes
(2005).
As noted, treatment courses were 3 or 4 weeks in duration.
Treatment was provided in a group format and consisted of 5 days
of treatment per week for 6.5 hr each day. Each day had approx-
imately 2.25 hr of physical conditioning sessions and 1.5 hr of
psychological session content, including mindfulness training. The
remaining time was devoted to activity skills management and
health/medical education. While in treatment, patients lived in
normal, unassisted apartment accommodations adjacent to the
hospital. Treatment integrity was maintained by manualization,
supervision, three clinical team meetings per week, and a once-
weekly clinical seminar.
Analytic Approach
Initially, we performed analyses to assess for potential differ-
ences among treatment completers and noncompleters and among
those who attended and did not attend the follow-up appointment.
Statistical methods included analyses of variance (ANOVAs) and
chi-square tests.
Second, we evaluated treatment outcomes immediately follow-
ing treatment and at the follow-up. We used repeated measures
ANOVAs to test statistical significance for all variables with the
exception of the work status variable, for which we performed a
Wilcoxon signed ranks test.
Next, we calculated uncontrolled within-subjects effect sizes
(Cohen’s d) by calculating the difference between Time 2 (post-
treatment or follow-up) and Time 1 (pretreatment) mean scores
and then dividing the result by the standard deviation of Time 1.
Cohen (1988) suggested that effect sizes should be interpreted as
small when above 0.2, medium when above 0.5, and large when
above 0.8.
Fourth, we assessed reliable change between pretreatment and
follow-up. Reliable change is one aspect of clinical significance
that involves using temporal stability data (i.e., test–retest reliabil-
ity) to test whether scores change to an extent that exceeds change
that could be accounted for by measurement error. We calculated
reliable change indexes using the formula suggested by Jacobson
et al. (1999), which involves calculating a standard error of the
difference between assessment points (Sdiff) and then using that
score to determine confidence intervals for assessing measurement
error. The Sdiff is calculated as follows:
SEM1 ! SD1 !1 " r12
(standard deviation from Time 1 multiplied by the
square root of 1 minus the test–retest coefficient),
SEM2 ! SD2 !1 " r12
(standard deviation from Time 2 multiplied by the
square root of 1 minus the test–retest coefficient),
Sdiff ! !SEM 21 # SEM 22
#square root of the sum of the squared SEMs$.
We then multiplied the Sdiff by 1.64 to obtain a confidence interval
of .90 (excluding the 5.0% of the distribution in each tail). If the
magnitude of change for a certain individual exceeds the confi-
dence interval, that individual can be classified as reliably
changed. We performed reliable change analyses for three out-
come measures considered to be core domains in chronic pain
(e.g., Dworkin et al., 2005), which were depression (BCMDI),
disability (SIP), and pain-related anxiety and avoidance (PASS). In
addition, test–retest information is available for these measures,
which is necessary to assess reliable change.1
Finally, we examined relations among changes in outcomes and
changes in acceptance and values-based action. We computed
residualized change scores for all measures for two time periods,
pre- to posttreatment and pretreatment to follow-up. First, we
calculated an overall correlation matrix of these change scores.
Next, we conducted multiple regression analyses to determine how
changes in acceptance and values-based action, considered to-
gether, related to changes in outcome measures, after controlling
for relevant background variables. We performed these regression
analyses for both time periods.
Results
Preliminary Analyses
In comparison to those who did not complete treatment (n !
16), treatment completers (n ! 171) were younger (M ! 46.8
years, SD ! 11.1 vs. M ! 53.4 years, SD ! 12.6), F(1, 186) !
5.08, p " .05, and their pain duration was shorter (M ! 119.3
months, SD ! 89.8 vs. M ! 195.5 months, SD ! 139.1), F(1,
186) ! 8.90, p " .005. No other differences were found on any
other measure, including usual pain intensity, number of pain
related surgeries, medical visits in the 6 months prior to beginning
1
We did not test the other aspect of clinical significance, which is to
determine whether the score of a particular case has moved significantly
from a “clinical” distribution to a “normal” or “recovered” distribution, as
these calculations require normative data from an appropriate sample for
comparison (Jacobson et al., 1999). To our knowledge, there are no data
available or appropriate for use as a recovered sample of chronic pain
sufferers.
 ACCEPTANCE AND VALUES-BASED ACTION 401

treatment, gender distribution, marital status, work status, or any of
the self-report measures; for ANOVAs, all Fs $ 2.40, all ps % .12;
for chi-square analyses, all %s $ 2.4, all ps % .49. With regard to
the comparisons among those who attended follow-up and those
who did not attend, all comparisons were nonsignificant, all Fs $
2.79, all ps % .10 at posttreatment, and all Fs $ 1.99, all ps % .16
in residualized change from pre- to posttreatment.
Outcome at Treatment Conclusion and 3-Month
Follow-Up
Descriptive information for measures of treatment process and
outcome is displayed in Table 1. Observed pretreatment values on
these measures appear to be consistent with those observed in
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ps $ .001. Descriptive information is displayed in Table 1. For work
status (not shown in Table 1), the results of the Wilcoxon test
indicated a significant difference, Z ! '2.24, p " .05. Of those who
provided data at the follow-up appointment, 15 had returned to work,
5 had discontinued work, and the work status of the remaining
individuals remained unchanged. Descriptively, 29.7% of patients
were working at the beginning of treatment and 38.1% were working
at follow-up.
Effect Size Calculations
From pre- to posttreatment, the average effect size was 1.07
(range: 0.67–1.76). From pretreatment to follow-up, average effect
size was 0.89 (range: 0.48 –1.51). Specific effect size magnitudes

other samples of chronic pain patients in that they indicate that for all measures are displayed in Figure 1. Using Cohen’s (1988)
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patients were complex and, on average, suffering from moderate
depressive symptoms, moderate to severe disability and functional
impairment, and elevated pain-related fear (e.g., McCracken,
Gross, & Eccleston, 2002; Spinhoven et al., 2004; Turner-Stokes
et al., 2003; Vowles, Gross, & Sorrell, 2004). Observed physical
performance was generally consistent with the studies of Harding
et al. (1994) and Lee et al. (2001).
Significance Testing
Repeated measures ANOVAs indicated significant improvement
across all measures of outcome for both time periods, all Fs(1, 170) %
50.16, all ps $ .001 for pre- to posttreatment, all Fs(1, 113) % 5.57,
all ps $ .02 for pretreatment to follow-up. If a more stringent alpha
level were applied to control for Type I error (i.e., .05 & number of
tests performed or .05 & 13 ! .004), all analyses would continue to
be significant with the exception of reduction in number of medica-
tions from pretreatment to follow-up; all other Fs(1, 113) % 11.45, all
suggested interpretive guidelines, we found that changes for all
measures were of a large size over the pre- to posttreatment period,
with the exception of change in pain intensity, which was medium
sized. During the pretreatment to follow-up period, effect sizes
remained large for acceptance, depression, pain-related anxiety,
walking distance, and sit-to-stand performance, whereas effect
sizes were medium for values-based action, pain intensity, physi-
cal disability, and psychosocial disability. Finally, the effect size
for medical visits was just below medium (d ! 0.48), in part due
to the large baseline standard deviation.
Reliable Change Analyses
Table 2 shows the results of the reliable change analyses from
pretreatment to follow-up at the 90% confidence interval for
depression, pain-related anxiety, and disability. Because we were
unable to find published test–retest data for the physical and
psychosocial subscales of the SIP, we used the SIP total score

Table 1
Mean Values (Standard Deviations) for Outcome and Process Measures at Assessment Points

3-month
Pretreatment Posttreatmenta follow-upa
Measure (N ! 171) (N ! 171) (N ! 114)

Acceptance (total) 50.4 (14.8) 76.4 (17.3) 73.3 (19.3)

Activity engagement 30.0 (10.1) 45.2 (10.9) 41.7 (12.0)
Pain willingness 20.5 (8.4) 31.2 (10.0) 31.8 (10.5)
Values-based action 2.0 (1.0) 3.2 (1.1) 2.7 (1.1)
Usual pain intensity 7.0 (1.8) 5.8 (1.9) 5.9 (2.1)
Depression 27.4 (12.7) 11.8 (10.7) 15.5 (13.4)
Pain-related anxiety 46.3 (18.3) 27.6 (18.5) 27.7 (19.8)
Physical disability 0.19 (0.11) 0.10 (0.09) 0.11 (0.10)
Psychosocial disability 0.28 (0.16) 0.14 (0.14) 0.17 (0.16)
Walking distance (meters/2 min) 95.9 (41.0) 130.1 (46.7) 136.0 (50.0)
Sit-to-stand task (frequency/1 min) 10.7 (7.1) 19.7 (9.4) 20.8 (11.3)
Medication classes 2.6 (1.4) — 2.4 (1.5)
Medical visits (past 6 months) 5.4 (4.6) — 3.2 (3.4)

Note. Acceptance was measured with the Chronic Pain Acceptance Questionnaire, values-based action with the
Chronic Pain Values Inventory, pain with a 0-10 numerical rating scale, depression with the British Columbia
Major Depression Inventory, pain-related anxiety with the Pain Anxiety Symptoms Scale-20, and disability with
the Sickness Impact Profile. Medication classes was a summation of classes of medications being taken for pain.
Medical visits were calculated by summing pain-related primary care, specialist, and emergency department
visits from the previous 6 months.
a
Pairwise comparisons all significant at a Bonferroni-corrected alpha of .004, with the exception of the
medication classes variable.
 402 VOWLES AND MCCRACKEN

1.8
Pre-Post
Pre-F ollow-up
1.6

1.4

1.2

1
E ff e c t S iz e
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

0.8

0.6

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Figure 1. Uncontrolled within-subjects effect size statistics (Cohen’s d) for outcome measures. Horizontal
reference lines in the figure represent small (0.2), medium (0.5), and large (0.8) effect sizes.

instead. Rates of reliable improvement were similar across the
three measures, averaging 45.0% (range: 41.8%– 49.1%). Reliable
decline occurred only for the SIP and in only 3.4% of cases. When
evaluated on a case-by-case basis, 75.4% (n ! 86) of patients
reliably improved on at least one measure, 61.4% (n ! 70) reliably
improved on at least two, and 14.0% (n ! 16) reliably improved
on all three. On the basis of these results, 1.34 patients would need
to be treated to see reliable change on one measure, 1.65 for
reliable change on two, and 7.14 for reliable change on all three.
Treatment Process Analysis
Correlations among residualized change scores for acceptance
and values-based action with residualized changes in outcome

Table 2
Results From the Reliable Change Analyses From Pretreatment to 3-Month Follow-Up

Test-retest % reliable % reliable

Measure (r) Sdiff decline improvement

Depression (BCMDI) .83 12.5 0.0 41.8

Pain-related anxiety (PASS) .86 16.5 0.0 49.1
Total disability (SIP) .87 0.092 3.4 44.0

Note. Sdiff ! standard error of the difference between pretreatment and 3-month follow-up. Reliable decline
and reliable improvement are the percentage of patients completing the follow-up assessment whose scores can
be classified as reliably changed according to the formula of Jacobson et al. (1999) at a 90% confidence interval.
BCMDI ! British Columbia Major Depression Inventory; PASS ! Pain Anxiety Symptoms Scale-20; SIP !
Sickness Impact Profile.
 ACCEPTANCE AND VALUES-BASED ACTION
variables are shown in Table 3. Across the treatment interval,
changes in acceptance were significantly correlated with changes
in all measures of outcome, including pain intensity, depression,
pain-related anxiety, disability, and both performance measures,
such that greater increases in acceptance were associated with
greater reductions in distress and disability and greater improve-
ments in performance. Changes in values-based action were only
moderately associated with improvements in depression, pain-
related anxiety, and sit-to-stand performance. In addition, changes
in values-based action and acceptance were significantly related to
one another, but this relation was not strong, with overlapping
variance of 6.3%, which suggests that these measures were tapping
related, but distinct constructs.
When residualized changes through follow-up were examined,
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acceptance remained significantly associated with changes in six
of eight outcome measures, again in a direction suggesting that
greater increases in acceptance were associated with greater im-
provements in functioning. Changes in values-based action gener-
ally appeared to have stronger relations with changes in outcomes
over this interval in comparison to the pre- to posttreatment inter-
val, as relations were larger and significant in relation to changes
in five outcome measures. These relations were also in the pre-
dicted direction. The relation between changes in the two process
measures at follow-up suggested 27.0% overlapping variance.
Next, we conducted multiple linear regressions to investigate the
unique and combined contributions of changes in acceptance and
values-based action in accounting for changes in outcome mea-
sures. Variance estimates ((r2) and standardized regression coef-
ficients ()) for these analyses are displayed in Table 4.
We tested demographic variables, including gender, age, edu-
cation, and pain duration, as predictor variables first, using a
statistical entry procedure ( p " .05 for entry and p * .10 for
removal). In general, these variables were not significant predic-
tors of changes in treatment outcome, accounting for significant
variance in outcome in only 3 of 15 equations and for $ 5%
variance each time.
Following the demographic variables, changes in acceptance
and values-based action were simultaneously entered. Over the
treatment interval, changes in these measures accounted for sig-
nificant variance in changes across all measures of outcome (range
(r2 ! .04 –.41, average (r2 ! .15). On each occasion in the pre-
Table 3
Correlations Among Residualized Change Scores of Acceptance and Values-Based Action With
Treatment Outcome Measures
Pre- to posttreatment
Measure Acceptance
Values-based action .25**
Usual pain intensity '.23**
Depression '.39***
Pain-related anxiety '.66***
Physical disability '.43***
Psychosocial disability '.36***
Walking distance .21**
Sit-to-stand task .24**
Medical visits — —
* ** ***
p " .05. p " .01. p " .001.
403
to posttreatment analyses, the magnitude of regression coefficients
was significant only for changes in acceptance, which was consis-
tent with the correlation results. Over the treatment to follow-up
interval, changes in acceptance and values-based action accounted
for significant variance in changes in six of eight outcome mea-
sures (range (r2 ! .10 –.33, average (r2 ! .17). Only variance
accounted for in the performance measures failed to achieve sig-
nificance. Significant regression coefficients were found for either
values-based action or acceptance in each of the same six equa-
tions. Regression coefficients were significant for acceptance on
two occasions, for pain-related anxiety and medical visits, and for
values-based action on four occasions, for pain, depression, and
both disability measures.
Discussion
The present analyses involved an in-depth assessment of the
effectiveness of a contextual, ACT-consistent, interdisciplinary
group treatment for chronic pain. In addition, two processes from
the treatment model, acceptance and values-based action, were
examined for their contributions in relation to changes in out-
comes. In sum, our hypotheses were supported, and the results
provide additional evidence for the treatment model.
Immediately following treatment and at follow-up, our sample
of complex pain sufferers achieved significant reductions in de-
pression, pain-related anxiety, disability, and healthcare use and
significant improvements in physical performance measures. Av-
erage improvement on outcome measures at posttreatment was
47.3% (range: 17.1% for pain to 84.1% for sit-to-stand perfor-
mance) and at follow-up was 40.6% (range: 7.7% for medication
use to 94.4% for sit-to-stand performance). Effect sizes were
uniformly of a medium size or larger, with the sole exception of
number of medical visits, which was of a small size. Furthermore,
the percentage of individuals working improved by just under 10%
from pretreatment to follow-up. These outcome findings mirror
results from other ACT-focused interventions for chronic pain
(i.e., Dahl et al., 2004; McCracken et al., 2005; McCracken,
MacKichan, & Eccleston, 2007; Vowles, McCracken, & Ec-
cleston, 2007; Wicksell et al., 2007) and add to the overall pool of
data supporting the effectiveness of this treatment approach
(Hayes et al., 2006).
Pretreatment to follow-up
Values-based action Acceptance Values-based action
— .52*** —
'.04 '.28** '.30**
'.19* '.30** '.41***
'.17* '.56*** '.44***
'.09 '.30** '.39***
'.13 '.35*** '.40***
.09 .14 .14
.17* .12 .16
'.32*** '.15
 404 VOWLES AND MCCRACKEN

Table 4 two thirds of these patients demonstrated reliable improvement in

Regression Results Using Residualized Changes in Acceptance, two of these domains. Given the longstanding nature of the pain
Values-Based Action, and Treatment Outcomes From Pre- to experienced by these patients, the lack of benefit from previous
Posttreatment and Pretreatment to Follow-Up treatments, and the stringent statistical criteria that must be met to
achieve reliable change (Jacobson et al., 1999), the fact that the
Pre- to Pretreatment to
posttreatment follow-up
majority achieved reliable change in two of three measures of
functioning is important and reinforces claims regarding the effi-
) ) cacy of the treatment provided, as well as the efficacy of the
Step and predictor (r2 (final) (r2 (final) broadly behavioral and cognitive treatments for chronic pain
(Gatchel & Okifuji, 2006; Hoffman et al., 2007). Second, the
Pain intensity
reduction in medical visits and unemployment all have real-world
Step 1 .04* .10** value in that these reductions directly translate into cost savings,
Acceptance '.21* '.13 increasingly important given the numerous strains on healthcare
Values-based action .05 '.22* financing and disability compensation systems (Gatchel & Okifuji,
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Depression 2006; Turk, 2002).

Both acceptance and values-based action improved significantly
Step 1 .05* — over the time periods analyzed. In relation to pretreatment scores,
Pain duration '.23** — acceptance improved by 51.6% and 45.4% at posttreatment and
Step 2 .19*** .17***
Acceptance '.36*** '.15
follow-up, respectively, whereas values-based action improved by
Values-based action '.06 '.32** 60.0% and 35.0% at posttreatment and follow-up, respectively.
Effect sizes for both measures were uniformly above 0.7. In
Pain-related anxiety particular, the effect sizes for acceptance are notable, as they were
the largest across all assessed variables. On average, acceptance
Step 1 .41*** .33***
Acceptance '.63** '.46*** scores improved by over 1.5 SDs relative to pretreatment. One
Values-based action '.02 '.17 explicit goal of treatment was to increase acceptance; the large
shifts in this measure demonstrate that treatment effectively
Physical disability achieved that goal. The effect size for values-based action was
Step 1 .04* — large immediately following treatment and medium at follow-up,
Education '.21** — where there may be additional practical and psychological factors
Step 2 .18*** .14*** influencing the success of values-based action. As far as we know,
***
Acceptance '.41 '.13 this is the first and only study to examine values-related processes
Values-based action '.03 '.32**
in treatment for chronic pain. In the future, it will be interesting to
Psychosocial disability further investigate patterns of change in values-based action in
treatment and how these relate to patient functioning over the
Step 1 .04* — longer term.
Education '.22** —
In the analyses of treatment process, changes in acceptance and
Step 2 .16** .17**
Acceptance '.30*** '.21 values-based action were related to changes in outcomes in ex-
Values-based action '.12 '.27* pected directions, such that increases in these processes were
associated with improvements in functioning. Acceptance and
Walking distance values-based action accounted for a fair to moderate proportion of
Step 1 .04* .02 variance in improvements following treatment, averaging 15.4%
Acceptance .20* .06 when using the pre- to posttreatment interval and 16.8% using the
Values-based action .01 .11 pretreatment to follow-up interval. The pattern of results over these
two time periods, however, was different. Changes in acceptance
Sit-to-stand task
appeared to dominate in the process of treatment over the pre- to
Step 1 .06* .02 posttreatment interval, while changes in values-based action ap-
Acceptance .21* .03 peared to dominate over the pretreatment to follow-up interval.
Values-based action .10 .12 Changes in acceptance at follow-up remained important for pain-
Medical visits
related fear and medical visits.
This pattern of findings from the regression analyses suggests an
Step 1 — .10** interesting and theoretically plausible interpretation. In short, an
Acceptance — '.32** early focus in treatment on acceptance may facilitate the role of
Values-based action — '.01 later values-based action. For example, one aspect of acceptance
*
p " .05. **
p " .01. ***
p " .001. involves a redirection of the struggle to control pain and all the
related aversive experiences that go along with it (e.g., emotions
Two sets of outcome findings, in particular, are noteworthy. and other symptoms). As long as behavioral efforts are directed at
First, the reliable change analyses suggested that three fourths of avoiding aversive and unpleasant experiences, actions may be
patients treated demonstrated reliable improvement in depression, limited to those that do not involve discomfort, which is not always
pain-related anxiety, or overall disability at follow-up and almost a practical option for those with chronic pain. It may be sensible to
 ACCEPTANCE AND VALUES-BASED ACTION
address the problem relating to avoidance of discomfort in the
earlier stages of treatment, as this may aid in the development of
increased flexibility in behavior and create more opportunities for
values-based action to occur. This explanation is consistent with
that of Hayes et al. (2006), who noted that fostering acceptance in
treatment is not itself an end but that it is fostered as a means of
increasing values-based action.
A specific strength of the ACT model is its identification of six
interrelated therapeutic processes: acceptance, values
identification/values-based action, contact with the present mo-
ment (e.g., an aspect of mindfulness), cognitive defusion, self as
context, and committed action (Hayes et al., 2006). The explicit
focus on these particular processes within ACT is what distin-
guishes it from other approaches within the broadly cognitive and
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behavioral therapies. Previous research in chronic pain has focused
on four of these processes: acceptance (see McCracken & Vowles,
2006, for a review), values (McCracken & Yang, 2006), mindful-
ness (McCracken, Gauntlett-Gilbert, & Vowles, 2007; Sephton et
al., 2007), and cognitive defusion (Vowles, McCracken, & Ec-
cleston, in press). In each study, as in the present one, the model
has been supported. As behavior is influenced less by the struggle
to think correctly or feel good, more in contact with direct expe-
rience, less entangled with verbally constructed versions of reality,
and more successfully guided by values, then improved social,
emotional, and physical functioning is observed. There is a need to
continue to study the ACT model, as a whole, with each of its
constituent parts considered together.
To further clarify, acceptance is not a matter of how one is
thinking or feeling per se. It is in the quality of action in contact
with thinking or feeling, particularly in relation to uncomfortable
or negatively evaluated experiences (Hayes et al., 1999; Mc-
Cracken, 2005). This quality includes a willingness to have, and
not struggle with, these experiences. Likewise, engaging in values-
based action is not regarded as contingent on thinking logically or
positively, nor on feeling good, confident, or relaxed. Values-
based action includes qualities that give behavior patterns a posi-
tive and meaningful direction, even when, or especially when,
other concurrent experiences might urge a different action. In each
case, the focus is not particularly on the content of thoughts or
beliefs, but on the interaction of thoughts and beliefs, and verbally
based influences in general, with nonverbally based influences, as
well as the contexts within which these interactions occur.
No randomization to a control condition was included in the
present treatment trial, which can appear as a significant limitation.
However, this limitation is mitigated in several ways. First, there
are previous trials of ACT-based treatment for pain that included
control conditions and each demonstrated positive results (Dahl et
al., 2004; McCracken et al., 2005; McCracken, MacKichan, &
Eccleston, 2007). Second, the patients treated in the present study
had complex longstanding problems, and they showed moderate to
large improvements at posttreatment and 3 months later, results
that would be highly unlikely to occur except from some specific
process of treatment. Third, changes were demonstrated across
multiple domains and on self-report and objective measures of
functioning, again, results not likely to occur in the absence of an
actual treatment effect. Finally, the treatment examined here oc-
curred in a “real life” clinical situation with a group of relatively
unselected patients suffering from substantial distress and disabil-
ity and with a history of many ineffectual treatments. Taken
405
together, these circumstances make it highly unlikely that the
patients treated in this study would have made similar improve-
ments solely with the passage of time or due to demand charac-
teristics alone, to name just a couple potential threats to internal
validity.
There are at least three other limitations that deserve consider-
ation. First, the current results were obtained under highly specific
conditions. Treatment was interdisciplinary, intensive, residential,
provided in a tertiary care setting, and followed a clearly specified
theoretical model. It is possible that the present findings may not
generalize to chronic pain patients treated under different circum-
stances. Second, although treatment gains persisted at the 3-month
follow-up appointment, the longer term effectiveness is unclear.
Finally, the amount of change in analgesic medication use was
small and nonsignificant when a Bonferroni-corrected alpha was
used. Although analgesic use is a complex behavior and not always
maladaptive, it is intriguing that use continued relatively un-
changed even after substantial improvements occurred in the other
measures. It may be that our method of quantifying medication use
was not sensitive enough to detect changes or that our treatment
methods were not directly focused on medication use with enough
intensity to generate a significant impact. The process of change in
medication use will require further study to determine how to alter
these patterns of behavior and if continued medication use impacts
on longer term functioning after treatment.
In summary, an intensive, group-based program of treatment for
chronic pain that is based on the model underlying ACT was
associated with significant and clinically reliable change across a
number of areas of functioning. Shifts in two hypothesized treat-
ment processes, acceptance and values-based action, were related
to shifts in outcomes. These findings provide support for the ACT
model of treatment (Hayes et al., 1999) and a specific application
of it to chronic pain, CCBT (McCracken, 2005). Future investiga-
tions attempting to replicate and extend these results may benefit
from the addition of comparison conditions, the inclusion of other
process variables from within the same treatment model, longer
term follow-up assessments, and perhaps tests of generalizability
to other settings, formats, and patient groups.
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Received March 2, 2007
Revision received March 6, 2008
Accepted March 12, 2008 !