Feasibility randomized‐controlled trial of online Acceptance and Commitment Therapy for patients with complex chronic pain in the United Kingdom
Open accessAbstract
Background: Acceptance and Commitment Therapy (ACT) has growing support for chronic pain. However, more accessible treatment delivery is needed. This study evaluated the feasibility of online ACT for patients with complex chronic pain in the United Kingdom to determine whether a larger trial is justified. Methods: Participants with chronic pain and clinically meaningful disability and distress were randomly assigned to ACT online plus specialty medical pain management, or specialty medical management alone. Participants completed questionnaires at baseline, and 3‐ and 9‐month post‐randomization. Primary feasibility outcomes included recruitment, retention and treatment completion rates. Secondary outcomes were between‐groups effects on treatment outcomes and psychological flexibility. Results: Of 139 potential participants, 63 were eligible and randomized (45% recruitment rate). Retention rates were 76–78% for follow‐up assessments. Sixty‐one per cent of ACT online participants completed treatment. ACT online was less often completed by employed (44%) compared to unemployed (80%) participants. Fifty‐six per cent of ACT online participants rated themselves as ‘much improved’ or better on a global impression of change rating, compared to only 20 per cent of control participants. Three‐month effects favouring ACT online were small for functioning, medication and healthcare use, committed action and decentring, medium for mood, and large for acceptance. Small‐to‐medium effects were maintained for functioning, healthcare use and committed action at 9 months. Conclusions: Online ACT for patients with chronic pain in the United Kingdom appears feasible to study in a larger efficacy trial. Some adjustments to treatment and trial procedures are warranted, particularly to enhance engagement among employed participants. Significance: This study supports the feasibility of online Acceptance and Commitment Therapy for chronic pain in the United Kingdom and a larger efficacy trial. Refinements to treatment delivery, particularly to better engage employed patients, may improve treatment completion and outcomes.
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iACT may be beneficial in areas such as values, QoL and insomnia that previous internet-ACT programs have not been successful.
“iACT may be beneficial in areas-such as values, QoL and insomnia-that previous internet-ACT programs have not been successful (22)(23)(24)(25)(26).”
From Internet-delivered acceptance and commitment therapy (iACT) for chronic pain—feasibility and preliminary effects in clinical and self-referred patients (2020) · cites this paper as [22]
The Results (§3.2.1; page unavailable) report improvements in functioning, and the Methods (§2.5.2.9; page unavailable) measure pursuit of valued goals; the Discussion (§4; page unavailable) describes quality of life as an aim of ACT. But this trial does not report an insomnia outcome, and its Introduction (§1; page unavailable) describes benefits of earlier internet-ACT programs rather than establishing that they were unsuccessful in these three areas. (LLM, conf=0.82)
Experimental — accuracy not yet measuredThe findings are consistent with previous large randomized controlled trials and meta-analyses demonstrating the effectiveness of digital interventions for improving symptoms of depression, anxiety, and pain-related impairment in people with chronic pain.
“Our findings are consistent with previous large randomized controlled trials and meta-analyses that have demonstrated the effectiveness of digital interventions for improving symptoms of depression, anxiety, and even pain-related impairment in people with chronic pain who have been recruited from pain management clinics, primary care clinics, and community/internet referral sources [20,21,45-47].”
From Digital Mental Health Intervention Plus Usual Care Compared With Usual Care Only and Usual Care Plus In-Person Psychological Counseling for Orthopedic Patients With Symptoms of Depression or Anxiety: Cohort Study (2022) · cites this paper as [21]
The Introduction reports earlier randomized trials of online therapy for chronic pain, and §3.2.1 reports improvements in depression and pain-related interference in this trial. But this was a small feasibility trial recruited from one specialty pain clinic, not a large trial; it did not report an anxiety outcome or recruit directly from community or internet sources. The depression difference was also less than small at nine months (§3.2.1; §2.2 Recruitment). (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn two studies, missing standard deviations could not be retrieved; standard deviations were calculated from the 95% confidence interval or the standard error following Cochrane Handbook recommendations.
“In two studies, missing standard deviations could not be retrieved (Scott et al., 2018; Rickardsson et al., 2021).”
From Guided internet-based cognitive-behavioral therapy for patients with chronic pain: A meta-analytic review (2022) · cites this paper as Scott et al., 2018
The Data analysis section says standard deviations were computed from estimated model standard errors, and the reported outcomes include confidence intervals. The paper does not establish that the citing authors could not retrieve missing standard deviations, nor does it document their use of Cochrane Handbook recommendations. This verdict concerns Scott et al. only, not the other cited study; page numbers were unavailable in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measuredThese studies show significant increases in pain acceptance and decreases in pain interference.
“These studies show significant increases in pain acceptance and decreases in pain interference (Buhrman et al., 2013;Lin et al., 2017;Scott et al., 2018;Trompetter et al., 2014).”
From Internet-delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1-year follow-up (2021) · cites this paper as Scott et al., 2018
Section 3.2.1 reports effects favouring online ACT for pain acceptance at 3 months and improvements in pain interference at 3 and 9 months. But Section 2.7 says this feasibility trial was not powered to detect treatment effects and did not undertake significance testing, so it does not support calling either change statistically significant. The pain-acceptance difference was also less than small at 9 months. (LLM, conf=0.90)
Experimental — accuracy not yet measuredTo date, there are four published RCTs evaluating the efficacy of Internet-delivered ACT for diverse chronic pain.
“To date, there are four published RCT's evaluating the efficacy of Internet-delivered ACT for diverse chronic pain (Buhrman et al., 2013;Lin et al., 2017;Scott et al., 2018;Trompetter et al., 2014).”
From Internet-delivered acceptance and commitment therapy as microlearning for chronic pain: A randomized controlled trial with 1-year follow-up (2021) · cites this paper as Scott et al., 2018
The Introduction identifies this as a randomized trial of online ACT for chronic pain, so it supports counting Scott et al. among the published RCTs. But the Introduction and Discussion describe its purpose as testing feasibility and whether a larger efficacy trial was warranted; calling it an RCT evaluating efficacy overstates its primary aim. The cited passages do not establish the total of four trials as of the citing paper's date. (LLM, conf=0.86)
Experimental — accuracy not yet measured
Completion and follow-up rates have been found to be higher in older and unemployed populations.
“Completion and follow-up rates have also been found to be higher in older and unemployed populations.22,31”
From Design and implementation of online acceptance and commitment therapy with enhanced therapist support for chronic low back pain (ACT for PAIN) (2025) · cites this paper as [22]
Section 3.1.2 reports higher online ACT treatment completion among participants not working (80%) than among those engaged in work (44%). It also says completers did not differ significantly by age. Section 3.1.3 does not report higher follow-up completion for older or unemployed participants; medication use was the only significant difference it identified. (LLM, conf=0.90)
Experimental — accuracy not yet measuredA total of 8 studies used a blended ACT program involving both iACT and in-person ACT sessions.
“A total of 8 studies used a blended ACT program involving both iACT and in-person ACT sessions [20-27].”
From Efficacy of Internet-Based Acceptance and Commitment Therapy for Depressive Symptoms, Anxiety, Stress, Psychological Distress, and Quality of Life: Systematic Review and Meta-analysis. (2022) · cites this paper as [24]
Section 2.4.1 describes this trial as combining eight online ACT sessions with an opening and closing therapist session. Those therapist sessions could be face-to-face or by telephone, so the source does not establish that participants received in-person ACT sessions. The claim’s total of eight studies belongs to the citing paper’s group of references, not to this single source. (LLM, conf=0.86)
Experimental — accuracy not yet measuredInternet-delivered ACT programs for chronic pain have previously been evaluated for clinical populations and self-referred samples with consistently promising effects on pain interference and acceptance.
“Internet-delivered ACT programs (iACT) for chronic pain have previously been evaluated for clinical populations (22,23) as well as with self-referred samples (24)(25)(26) with consistently promising effects on pain interference and acceptance”
From Internet-delivered acceptance and commitment therapy (iACT) for chronic pain—feasibility and preliminary effects in clinical and self-referred patients (2020) · cites this paper as [22]
Completion rates were similar to what has been reported in previous studies on iACT for chronic pain.
“Completion rates were similar to what has been reported in previous studies on iACT for chronic pain (22)(23)(24)26) but leaves room for improvements.”
From Internet-delivered acceptance and commitment therapy (iACT) for chronic pain—feasibility and preliminary effects in clinical and self-referred patients (2020) · cites this paper as [22]
Thirteen included studies documented whether client engagement checks were conducted during the trial.
“Thirteen studies documented whether client engagement checks were conducted during the trial [28, 29, 46, 47, 49, 50, 52, 53, 56–60].”
From Acceptance and commitment therapy for patients with chronic pain: A systematic review and meta-analysis on psychological outcomes and quality of life (2024) · cites this paper as [52]
Online ACT for chronic pain is feasible and acceptable.
“Studies evaluating online ACT for chronic pain speci fi cally, have shown that these treatments are feasible and acceptable [25, 26].”
From A feasibility trial of online Acceptance and Commitment Therapy for women with provoked vestibulodynia (2023) · cites this paper as [25]
Studies testing online ACT interventions for chronic pain generally appear to have resulted in improvements in pain and mental health outcomes.
“which generally appear to have resulted in improvements in pain and mental health outcomes.”
From Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis (2021) · cites this paper as [44]
Two studies used TAU as comparison.
“and two used TAU”
From Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis (2021) · cites this paper as [44]
ACT for PAIN builds off previously tested versions of ACT.
“This ACT program, ACT for PAIN, builds off previously tested versions.21–23”
From Design and implementation of online acceptance and commitment therapy with enhanced therapist support for chronic low back pain (ACT for PAIN) (2025) · cites this paper as [22]
ACT for PAIN is based on content and design previously studied in general chronic pain, painful diabetic neuropathy, vulvodynia, and HIV-related pain.
“It is based on the content and design previously studied in general chronic pain,22 painful diabetic neuropathy,21 vulvodynia,24 and HIV-related pain.23”
From Design and implementation of online acceptance and commitment therapy with enhanced therapist support for chronic low back pain (ACT for PAIN) (2025) · cites this paper as [22]
Six randomized controlled trials on digitally delivered ACT for patients with chronic pain have been conducted, including one noninferiority trial comparing video teleconferencing with in-person delivery.
“All in all, six randomized controlled trials on digitally delivered ACT for patients with chronic pain have been conducted thus far; one was a noninferiority trial comparing video teleconferencing with in-person delivery [22–27].”
From ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain—A Pilot Trial. (2021) · cites this paper as [25]
The compliance rate in the present study (90%) was high compared with previous research on internet-delivered ACT for chronic pain.
“In comparison with previous research on internet-delivered (via a desktop computer) ACT treatment for chronic pain patients [20, 23–25], the compliance rate in the present study was high (90%).”
From ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain—A Pilot Trial. (2021) · cites this paper as [25]
The preliminary efficacy results support previous findings on internet-delivered ACT for chronic pain but extend them with promising effects on insomnia, values, and quality of life.
“The preliminary efficacy results of the present study support previous findings on internet-delivered (primarily using a desktop computer) ACT for chronic pain patients [22–26, 72], but our results also extend these findings, with promising effects on insomnia, values, and QoL.”
From ACTsmart: Guided Smartphone-Delivered Acceptance and Commitment Therapy for Chronic Pain—A Pilot Trial. (2021) · cites this paper as [25]
18 studies directly targeted people with depressive symptoms.
“Moreover, 18 studies directly targeted people with depressive symptoms [14,21,23-25,27,30-40].”
All studies presented adequate data analysis and statistics reporting, with the exception of Scott and colleagues.
“adequate data analysis and statistics reporting”
From Efficacy of Online-Based Acceptance and Commitment Therapy for Chronic Pain: A Systematic Review and Meta-Analysis (2021) · cites this paper as [44]
Section 2.7 (Data analysis; page unavailable) describes the trial’s statistical methods, and section 3.1.3 reports statistical results. Neither assesses whether Scott and colleagues’ analysis and reporting were adequate relative to other studies. The claimed exception is an appraisal by the citing authors that cannot be verified from this source. (LLM, conf=0.76)
Experimental — accuracy not yet measured
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“Our findings are consistent with previous large randomized controlled trials and meta-analyses that have demonstrated the effectiveness of digital interventions for improving symptoms of depression, anxiety, and even pain-related impairment in people with chronic pain who have been recruited from pain management clini…”
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Terpstra, J. A., van der Vaart, R., van Beugen, S., van Eersel, R. A., Gkika, I., Erdős, D., Schmidt, J., Radstake, C., Kloppenburg, M., van Middendorp, H., et al. (2022) · Internet Interventions · doi:10.1016/j.invent.2022.100587 · Cited by 38 · see citing works
Ye, L., Li, Y., Deng, Q., Zhao, X., Zhong, L., & Yang, L. (2024) · PLoS ONE · doi:10.1371/journal.pone.0301226 · Cited by 43 · see citing works
Scott, W., Guildford, B. J., Badenoch, J., Driscoll, E., Chilcot, J., Norton, S., Kemp, H. I., Lee, M. J., Lwanga, J., Boffito, M., et al. (2021) · European Journal of Pain · doi:10.1002/ejp.1762 · Cited by 36 · see citing works
Self-citationYu, L., Kioskli, K., & McCracken, L. (2021) · Journal of Pain · doi:10.1016/j.jpain.2021.02.011 · Cited by 36 · see citing works
Self-citationRosser, B. A., Fisher, E., Janjua, S., Eccleston, C., Keogh, E., & Duggan, G. B. (2023) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd013863.pub2 · Cited by 31 · see citing works
The role of psychological flexibility in relation to suicidal thinking in chronic pain
McCracken, L. M., Patel, S. T., & Scott, W. (2018) · European Journal of Pain · doi:10.1002/ejp.1273 · Cited by 31 · see citing works
Self-citationChisari, C., McCracken, L. M., Cruciani, F., Moss-Morris, R., & Scott, W. (2022) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2021.11.003 · Cited by 30 · see citing works
Self-citationLin, J., Scott, W., Carpenter, L., Norton, S., Domhardt, M., Baumeister, H., & McCracken, L. M. (2019) · Systematic Reviews · doi:10.1186/s13643-019-1044-2 · Cited by 30 · see citing works
Self-citationRickardsson, J., Zetterqvist, V., Gentili, C., Andersson, E., Holmström, L., Lekander, M., Persson, M., Persson, J., Ljótsson, B., & Wicksell, R. K. (2020) · mHealth · doi:10.21037/mhealth.2020.02.02 · Cited by 28 · see citing works
“…psychological flexibility, value orientation, QoL, insomnia, pain intensity, depressive symptoms and anxiety during treatment and up to 1-year follow-up, iACT may be beneficial in areas—such as values, QoL and insomnia—that previous internet-ACT programs have not been successful (22-26).”
BackgroundKarekla, M., Constantinou, P., Ioannou, M., Gloster, A. T., & Kareklas, I. (2019) · Clinical Psychology in Europe · doi:10.32872/cpe.v1i3.33058 · Cited by 29 · see citing works
Buonanno, P., Marra, A., Iacovazzo, C., Franco, M., & Simone, S. D. (2022) · Pain Medicine · doi:10.1093/pm/pnac128 · Cited by 29 · see citing works
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Kioskli, K., Scott, W., Winkley, K., Godfrey, E., & McCracken, L. M. (2020) · Pain Medicine · doi:10.1093/pm/pnaa110 · Cited by 24 · see citing works
Self-citationGentili, C., Zetterqvist, V., Rickardsson, J., Holmström, L., Simons, L. E., & Wicksell, R. K. (2021) · Pain Medicine · doi:10.1093/pm/pnaa360 · Cited by 20 · see citing works
Eastwood, F., & Godfrey, E. (2024) · British Journal of Pain · doi:10.1177/20494637231221451 · Cited by 22 · see citing works
Han, A., & Kim, T. H. (2022) · Journal of Medical Internet Research · doi:10.2196/39182 · Cited by 20 · see citing works
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Frostholm, L., & Rask, C. U. (2019) · Clinical Psychology in Europe · doi:10.32872/cpe.v1i1.32217 · Cited by 18 · see citing works
“The results from these two larger internet-based studies were generally supported by the two smaller studies (Buhrman et al., 2013; Scott et al., 2018), even though the Buhrman study (Buhrman et al.”
BackgroundResultKioskli, K., Winkley, K., & McCracken, L. M. (2019) · Journal of Contextual Behavioral Science · doi:10.1016/j.jcbs.2019.07.002 · Cited by 18 · see citing works
Self-citationBakhshaie, J., Penn, T. M., Doorley, J. D., Pham, T. V., Greenberg, J., Bannon, S. M., Saadi, A., & Vranceanu, A. (2022) · Journal of Pain · doi:10.1016/j.jpain.2022.04.013 · Cited by 18 · see citing works
Cuenca‐Martínez, F., López, L., Suso‐Martí, L., Varangot‐Reille, C., Calatayud, J., Herranz‐Gómez, A., Romero-Palau, M., & Casaña, J. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11071806 · Cited by 15 · see citing works
Assessing Psychological Flexibility in Chronic Illness
Tyndall, I., Vagos, P., Cano, S., Pinto, H., & Trindade, I. A. (2023) · The Psychological Record · doi:10.1007/s40732-023-00572-y · Cited by 12 · see citing works
Carvalho, S. A., Trindade, I. A., Duarte, J., Menezes, P. J., Patrão, B., Nogueira, M. R., Guiomar, R. N. R. M., Lapa, T. A. S. C., Pinto‐Gouveia, J., & Castilho, P. (2021) · Frontiers in Psychology · doi:10.3389/fpsyg.2021.630766 · Cited by 11 · see citing works
Maathz, P., McCracken, L. M., Eriksson, V., Säde, F., Aneblom, G., Rikner, Å., Skalkidou, A., & Buhrman, M. (2023) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2022-0146 · Cited by 10 · see citing works
“Studies evaluating online ACT for chronic pain specifically, have shown that these treatments are feasible and acceptable [25, 26].”
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Buhrman, M., Hällström, H., Fridén, A., Kettis Moden, E., Grahn, G., Carlfjord, M., Hjo, C., Gasslander, N., Bohm‐Starke, N., & McCracken, L. M. (2024) · European Journal of Pain · doi:10.1002/ejp.2253 · Cited by 8 · see citing works
“Adequate rates of adherence and retention were achieved in the current trial, with 70% of participants completing at least half of the ACT sessions and an over-all dropout rate of just 18%, similar to other recent trials (Scott et al., 2018).”
Self-citationIntegrated and Comprehensive Pain Management Programs: Effectiveness and Harms
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Telehealth and Applied Behavior Analysis: An Overview and Examples of Application
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“It is based on the content and design previously studied in general chronic pain, 22 painful diabetic neuropathy, 21 vulvodynia, 24 and HIV-related pain.”
Self-citationAcceptance and commitment therapy for prevention of chronic pain after total knee arthroplasty.
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“38,39 Delivering the treatment during the in-hospital rehabilitation period can be an efficient way to administer an ACT-based treatment, as it facilitates the formation of groups of patients with similar clinical status and reduces logistic barriers to participation.”
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Internet-Delivered Cognitive Behavioural Therapy for the Management of Chronic Non-Cancer Pain
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The Role of Psychologists in Treating Pelvic Pain Conditions
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Virtual Acceptance and Commitment Therapy (vACT) For Youth with Chronic Illnesses: A Case Report
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- Authors
- Scott, W., Chilcot, J., Guildford, B., Daly‐Eichenhardt, A., & McCracken, L. M.
- Affiliations
- King's College London (GB)
- Guy's and St Thomas' NHS Foundation Trust (GB)
- INPUT Pain Management, Guy's and St Thomas’ NHS Foundation Trust London UK
- Corresponding author
- Scott, W.
- Venue
- European Journal of Pain
- Publisher
- Wiley
- Published
- 2018-05-15
- Volume
- 22
- Issue
- 8
- Pages
- 1473-1484
- ISSN
- 1090-3801 (ISSN-L)
- 1532-2149
- OpenAlex
- W2802462572
- Cited by
- 69
- References
- 42
- Citations by year
- 2026: 3 · 2025: 5 · 2024: 3 · 2023: 12 · 2022: 17 · 2021: 15 · 2020: 8 · 2019: 4 · 2018: 2
- FWCI
- 8.50
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- Funders
- International Association for the Study of Pain
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Applied Psychology › Digital Mental Health Interventions
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Keywords
- acceptance and commitment therapy, online therapy, chronic pain, feasibility, psychological flexibility, treatment retention, participant recruitment, employment status, acceptance, health care utilization
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