Changes in Sleep Problems and Psychological Flexibility following Interdisciplinary Acceptance and Commitment Therapy for Chronic Pain: An Observational Cohort Study
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AIMS: Cognitive and behavioral treatments (CBT) for sleep problems and chronic pain have shown good results, although these results could improve. More recent developments based on the psychological flexibility model, the model underlying Acceptance and Commitment Therapy (ACT) may offer a useful addition to traditional CBT. The aim of this study was to examine whether an ACT-based treatment for chronic pain is associated with improved sleep. Secondly, we examined the associations between changes on measures of psychological flexibility and sleep-related outcomes. METHODS: The study used an observational cohort methodology. Participants were 252 patients (73.8% female) attending a 4-week, interdisciplinary, pain management program in London, United Kingdom. Participants completed standard self-report measures of pain and functioning, sleep outcomes, and processes of psychological flexibility. Pre- to post-treatment, and pre-treatment to follow-up measures were examined for statistically significant differences using paired samples t-tests. Secondarily, hierarchical multiple regression analyses were conducted to examine change in process measures in relation to change in treatment outcome. RESULTS: Participants showed statistically significant improvements (all p < 0.001) at post-treatment on measures of insomnia severity (d = 0.45), sleep interference (d = 0.61), and sleep efficiency (d = 0.32). Significant improvements in insomnia severity and sleep interference were also observed at 9-month follow up. Small to medium effect sizes were observed across the sleep outcomes. Statistically significant changes were also observed on measures of psychological flexibility, and these improvements were significantly associated with improvements on sleep-related outcomes, independently contributing up to 19% of unique variance. CONCLUSION: This study supports the potential usefulness of ACT-based treatments for chronic pain for addressing co-occurring sleep difficulties. Further research is needed to determine how to improve the impact of this treatment for co-morbid pain and sleep difficulties, possibly using a randomized-controlled trial design.
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Psychological inflexibility was found as a predictor of higher levels of insomnia severity.
“Psychological inflexibility was found as a predictor of higher levels of insomnia severity (Daly-Eichenhardt et al., 2016;El Rafihi-Ferreira et al., 2022;McCracken et al., 2011;McCracken et al., 2021;McCracken et al., 2022;McCracken et al., 2023;Zakiei et al., 2022), whereas psychological flexibility was found as a predictor of lower levels of insomnia severity (McCracken et al., 2022;McCracken et”
From Psychological inflexibility as a predictor associated with insomnia (2024) · cites this paper as Daly-Eichenhardt et al., 2016
The Results section reports that changes in cognitive fusion, a psychological inflexibility process, positively predicted changes in insomnia severity during treatment for chronic pain. It does not establish that psychological inflexibility predicts higher absolute levels of insomnia severity; its regression outcome was change in severity. (LLM, conf=0.85)
Experimental — accuracy not yet measuredIncreased psychological flexibility contributes to better sleep.
“At the same time, increased psychological flexibility also contributes to better sleep.15 16”
From SoundMind Trial: a study protocol for a randomised controlled trial for online acceptance and commitment therapy and sound therapy for tinnitus (2024) · cites this paper as [16]
The Results report that improvements in psychological flexibility were associated with reduced insomnia severity and sleep interference in a chronic-pain cohort. But the Discussion says this uncontrolled study cannot establish that increased psychological flexibility caused the sleep improvements; the Results also found no additional predictive contribution for sleep efficiency. The unqualified claim that it contributes to better sleep therefore overstates the evidence. (LLM, conf=0.86)
Experimental — accuracy not yet measuredACT is efficacious in treating insomnia.
“which is efficacious in treating insomnia (Daly‐Eichenhardt et al., 2016; Hertenstein et al., 2014; Lawson et al., 2023; Rafihi‐Ferreira et al., 2024; Riemann et al., 2023; Shin et al., 2023; Zakiei & Khazaie, 2019).”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Daly‐Eichenhardt et al., 2016
The Discussion reports that an interdisciplinary ACT-based program was associated with reduced insomnia severity in adults receiving treatment for chronic pain, including at nine-month follow-up. Because this was an observational study in a specific population, it does not establish that ACT is efficacious for treating insomnia generally. (LLM, conf=0.88)
Experimental — accuracy not yet measuredDaly-Eichenhardt et al. define clinically significant change of ISI in a pain context as a change of at least half a standard deviation.
“In another relevant study, Daly-Eichenhardt, et al. [35] define clinically significant change of ISI in a pain context as a change of at least half a standard deviation.”
From Is sleep disturbance in patients with chronic pain affected by physical exercise or ACT-based stress management? - A randomized controlled study (2018) · cites this paper as Daly-Eichenhardt, et al. [35]
Cognitive fusion has a direct relationship with insomnia.
“Some studies also have shown direct relationships between experiential avoidance (Hertenstein et al., 2014) and cognitive fusion (Daly‐Eichenhardt et al., 2016) with insomnia.”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Daly‐Eichenhardt et al., 2016
That inaction did not uniquely relate to sleep quality was inconsistent with the Zakiei et al. (2022) findings and with two studies examining sleep in chronic pain patients, which showed committed action was related to sleep outcomes.
“That inaction did not uniquely relate to sleep quality was inconsistent with the Zakiei et al. (2022) findings, and similarly with two studies examining sleep in chronic pain patients, which showed committed action was related to sleep outcomes (Daly‐Eichenhardt et al., 2016; McCracken et al., 2011).”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Daly‐Eichenhardt et al., 2016
Positive changes in cognitive fusion, experiential avoidance and sleep outcomes following ACT for insomnia have been reported.
“Positive changes in cognitive fusion (Daly‐Eichenhardt et al., 2016), experiential avoidance (Hertenstein et al., 2014) and sleep outcomes following ACT for insomnia also have been reported (Shin et al., 2023).”
From Associations between psychological inflexibility processes, pre‐sleep arousal and sleep quality. (2025) · cites this paper as Daly‐Eichenhardt et al., 2016
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“Positive changes in cognitive fusion (Daly-Eichenhardt et al., 2016), experiential avoidance (Hertenstein et al., 2014) and sleep outcomes following ACT for insomnia also have been reported (Shin et al., 2023).”
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- Authors
- Daly-Eichenhardt, A., Scott, W., Howard-Jones, M., Nicolaou, T., & McCracken, L. M.
- Affiliations
- Guy's and St Thomas' NHS Foundation Trust (GB)
- King's College London (GB)
- Corresponding author
- McCracken, Lance M.
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2016-08-31
- Volume
- 7
- Pages
- 1326-1326
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC5006108
- OpenAlex
- W2516518908
- Cited by
- 69
- References
- 54
- Citations by year
- 2026: 8 · 2025: 8 · 2024: 13 · 2023: 1 · 2022: 9 · 2021: 8 · 2020: 6 · 2019: 11 · 2018: 3 · 2017: 1
- FWCI
- 6.69
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Research Portal (King's College London) (acceptedVersion, other-oa)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Funders
- International Association for the Study of Pain
- King's College London
- Topics
- Social Sciences › Psychology › Clinical Psychology › Mindfulness and Compassion Interventions
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Keywords
- acceptance and commitment therapy, chronic pain, sleep disorders, insomnia, psychological flexibility, multidisciplinary pain management, sleep interference, sleep efficiency
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