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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 69-75

The impact of acceptance and commitment therapy on pain catastrophizing: The case of hemodialysis patients in Iran

Department of Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan, Iran

Date of Web Publication17-Mar-2016

Correspondence Address:
Dr. Gholamreza Manshaee
Assistant Prof, Department of Psychology, Isfahan (Khorasgan) Branch, Islamic Azad University, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2395-2296.178868

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In recent years, there has been an increasing interest in research and treatment of chronic pain psychological stress of the patients suffering from kidney failure and undergoing hemodialysis treatment. The present study set out to investigate the practical effectiveness of acceptance and commitment therapy on improving the pain catastrophizing of hemodialysis patients. A quasi-experimental design was used in which a target sample of 30 hemodialysis patients, who received treatment at Dolatabad Hemodialysis Center, Isfahan, Iran, volunteered to participate in this study. They were then randomly divided into two groups (i.e., control and experimental groups), 15 each. Based on acceptance and commitment approach, the experimental sample received group-based instruction during an eight session period offered twice a week. The participants in both treatment and control groups were given pain catastrophizing scale before and after the treatment. The findings revealed that participants receiving group instruction based on acceptance and commitment training approach showed remarkably lower pain catastrophizing compared with those in the control group.

Keywords: Acceptance and commitment therapy, catastrophizing pain, hemodialysis patients, chronic pain, psychological stress

How to cite this article:
Ramezanzadeh D, Manshaee G. The impact of acceptance and commitment therapy on pain catastrophizing: The case of hemodialysis patients in Iran. Int J Educ Psychol Res 2016;2:69-75

How to cite this URL:
Ramezanzadeh D, Manshaee G. The impact of acceptance and commitment therapy on pain catastrophizing: The case of hemodialysis patients in Iran. Int J Educ Psychol Res [serial online] 2016 [cited 2020 Oct 27];2:69-75. Available from: https://www.ijeprjournal.org/text.asp?2016/2/2/69/178868

  Introduction Top

Pain catastrophizing in this survey refers to the score that a person earns in Sullivan's [1] standard questionnaire. As a construct comprised of a set of mental, biological, and social symptoms, pain is considered as an index of life quality and mental health which is a sign of illness and infrastructure disorder.[2] According to the international association for studying pain (IASP), pain is defined as an unpleasant exciting experience which is associated with real or potential tissue damage.[3] Because pain is a sensation that is unpleasant, it consists of both sensory information and emotional experience.[4] There are many factors that may affect the way individual people perceive pain including individual psychological status, genetic composition, and sociocultural effects, all of which must be taken into consideration when assessing and working with people who suffer from chronic pain.

In general, pain has been divided into two categories; namely, acute pain and chronic pain. Acute pain is restricted to a short time duration and signals tissue harm or injury. The reasons for acute pain are most often known while this is not always the case with chronic pain. Chronic pain is referred to as a sort of pain that perseveres more than normally expected remedy time.[5] IASP asserts that chronic pain is complex and largely misunderstood, and it usually lasts longer than 3 months. Chronic pain often leaves multiple negative consequences, which would influence patients' biological, psychological, and sociological functioning.[6]

The results of a number of empirical studies reveal that pain catastrophizing has a significant effect on and direct and stable relationship with chronic pain experiences.[7] The main impact of pain catastrophizing on chronic pain is that the patients undertake an initial assessment of their pain which would keep them alert to painful and threatening feelings or the fear of future painful feelings.[8] As Sardá et al.[9] comment, current literature on the chronic pain emphasizes pain is catastrophizing as a significant cognitive variable.

Recently, there have been some new theories which have tried to explain the approach that direct alternation of thoughts, feelings, or physical symptoms are quite necessary for clinical developments to take place. These theories, which are referred to as the third wave of behavior therapy, are categorized as acceptance-based models. Acceptance and commitment therapy (ACT) approach is an example of these models.[10] In such treatment methods, an attempt is made to enhance the relationship between an individual's mental ability and his/her feelings and thoughts. Accepting an appropriate replacement for avoidance is based on the personal experience including active and conscious acceptance of personal events that are related to the person's background knowledge. In a commitment activity, the person is encouraged to do all his/her best in order to reach the intended goal. In fact, the main objective of such treatment is to develop mental and psychological flexibility; that is creating the ability to practically choose from among various options the most appropriate one, rather than forcing someone to do something merely for avoiding disordered thoughts, feelings, or memories.

ACT is regarded as an acceptance and mindfulness-based approach through which professionals of the field can treat many cognitive and mental problems and disorders such as chronic pain. The main principle underlying this type of therapy is that rather than trying to change thoughts and feelings, the practitioners should help clients to observe them as they are. It emphasizes the fact that it is the struggle with pain that results in suffering, not the pain itself. Accordingly, in ACT the pain is considered as an unavoidable part of living which should be accepted. There have been a number of studies in which ACT approach has revealed promising results.[11],[12],[13]

Pakenham,[13] for instance, tried to investigate the effectiveness of ACT training on stress. They found that there was a remarkable improvement in the participants' physical symptoms despite the increasing level of work stress. In the same vein, Nicholas et al.[11] set out to explore the relationship between pain catastrophizing and depression. Having controlled the effect of some other variables such as age, gender, and pain duration, the researchers concluded that catastrophizing revealed about 40 percent of depression variance while the pain intensity was not significant. In general, it is claimed that ACT will result in low scores on anxiety and reduction of cognitive distress [12] as well as in diminution of cognitive inflexibility.[10]

In order to treat people with disorder using ACT approach, the patients should be encouraged to actively encounter with their horrendous mental experiences, while at the same time change their behavior and set themselves a goal so as to make commitment to a better lifestyle. ACT approach may assist people in modifying negative behavior patterns and automatic thoughts. This would in turn lead to regulation of positive behaviors that are related to people's mental health.[14]

End-stage renal disease (ESRD) is considered as a type of chronic, irreversible illness that is untreated or complicated to treat.[15] The best possible way to save the patient from such a disease is the transplantation of a new kidney. The main problem with this treatment, however, is that most countries suffer from a lack of donated kidneys. As such, the most prevalent procedure that these countries employ for treating the ESRD is hemodialysis.[15] In this regard, Aghanwa and Morakinyo [16] maintain that although hemodialysis has been respected as an appropriate way in treating the ESRD, this type of therapy would also have some negative side effects for the patients including digestive, anemia, and/or nerve irritability. Clearly, such side effects would negatively influence the quality of patients' lives so that they may commit suicide.[17]

Based on a great deal of evidence supporting the newness of ACT approach and significance of acceptance concept in alleviating cognitive disorder experiences, and due to the lack of empirical research conducted on such understudied area, the present study sought to investigate the efficacy of group-based ACT training on the pain catastrophizing of the Iranian hemodialysis patients. Sarda, Nocholas, Asghari, and Pimenta [9] analyzed the relationship between catastrophizing, pain, and depression in a cross-sectional study with 812 patients suffering from chronic pain. After controlling the probable effects of age, gender, and time duration of the pain, catastrophizing indicated the variance of depression as 40 percent in a way that it was not a significance predictor's intense pain. Woby et al.[7] confirm that Leeuw et al.[18] proved the fact that catastrophizing might change the person's understanding of his/her pain intensity. This believes continuously impress temporal decisions which cause having a helplessness lifestyle. Furthermore, the research of Dahl et al.[19] about the effectiveness of the way of this remedy has shown that in comparison with the other normal ways of treatment, this 4 h experience of this treatment clearly causes decreasing patients' pain. These points indicate the necessity of theoretical and practical approaches in order to have a suitable reaction toward psychiatrics' problems in hemodialysis patients. Hence, far no perfect study about Iranian' patients in this field is reported. The objective of this research is analyzing pain catastrophizing after hypotension of patients and its intensifying factors and the studying the effectiveness of ACT as a group. Acceptance and commitment through a combination of freshness and the crystal clear observation of the experiences and their acceptance can cause positive changes in compatibility and welfare. The results of the present survey will use for developing the society, improving such patients exposed to the chronic disease, emotional and behavioral' disorders especially in the field of the pathology of hemodialysis' patients.

  Methods Top

The present study was an attempt to explore the potential of ACT training on pain catastrophizing of patients who suffer from kidney failure. To achieve the purpose of study, a quasi-experimental study involving a pretest-posttest control group design was utilized during which the participants, who were randomly divided into control and experimental groups were asked to respond to the pain catastrophizing scale before and after the treatment and also at the end of a postintervention period. The ACT training served as the independent variable while the dependent variable was the hemodialysis patients' scores obtained through the Sullivan's [1] pain catastrophizing questionnaire.

The researcher's teaching has been hold in hemodialysis center of Ayatallah Naseri in Dolatabad in eight sessions after introducing deputy of medical and science therapy.

The detail of these processes are shown in the following table briefly [Table 1]:
Table 1: Detail of the processes

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Patients of the experimental group were recommended to repeat their assignments and exercises beside their training class. Furthermore, they were told the beginning of every session examinants have been taken a reactive test. The plan of treatment was designed in a way that each session was divided to four parts.

In the first part, they were assigned 10 min to discuss the activities and last session assignments of participants. They were motivated to help each for solving the problem. In the second part, they got familiar with acceptance approaches and commitment based therapy which was 15 min. In the third part, which was 25 min, they figured out how should use these skills in their real life practically. They were encouraged to express their problems clearly to solve by acceptance and commitment based therapy. In the last 10 min, they were given assignments for the next session. After these sessions have finished, both control and experimental groups had posttest and then after 45 days follow-up test.

From the population of hemodialysis patients with chronic pain sent to the Dolatabad Hemodialysis Center during the Fall and Winter 2014, a total number of 30 patients were randomly selected and divided into control and experimental groups, 15 each. They were both male (65 percent) and female (35 percent) with their age ranging from 20 to 55.

The criteria for taking part in the research were as (1) Being satisfy by participating in the research, (2) having at least age range of 20–50, and (3) passing at least 3 months and at most 3 years of starting hemodialysis and being amendable to participate in the research.

The criteria of eliminating from the research were as (1) Being physically or mentally impaired, (2) having an unpleasant experience in the last 6 month and having a background of emotional disease by a psychiatric diagnosis, and (3) not having a regular present in every session.

At first, 34 people were selected for experimental and control group, 17 people for each group. Due to the absence of four people and also by taking the normal sample size which suggested 15 people in experimental research into consideration, these two groups were decreased to 15 people.

The main instrument utilized in this study was the pain catastrophizing questionnaire developed by Sullivan.[1] It is a 13-item inventory designed to measure the patients' pain catastrophizing scale. The respondents were required to respond the questionnaire items rated on a five-point scale. As such, each item was rated on the scale of 1–5 with the rate of five showing “always” and one showing “at all.” The reliability of the questionnaire was calculated based on the alpha Cronbach's coefficient, which turned out to be 0.78. The questionnaire has already been acknowledged by practitioners of the field to have a high level of validity for both clinical and nonclinical population.

The items in the questionnaire were all translated into participants' native language (i.e. Farsi). Besides, to remove the likelihood of misunderstanding, the rubric of the questionnaire was explained. Moreover, a sufficient amount of time was given to participants for answering the prompts so as to eliminate anxiety and stress, which could have an adverse effect on the quality of responses.

Finally, to analyze data gathered by the questionnaire, a repeated measure statistical technique for variance analysis was used.

  Results Top

As [Table 2] reveals, the normality of variable distribution for the dependent variable has been assumed for both pretest and posttest. Accordingly, it can be safe to use parametric tests for current data.
Table 2: Results of Kolmogorov-Smirnov test

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According to [Table 3], the equality of variable variance for the dependent variable (pain catastrophizing) has also been assumed for both pretest and posttest as well as pursuit period because P > 0.05.
Table 3: Results of Lewin test for variables

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Based on the average scores in each group [Table 4], it can be claimed that the effect of ACT on pain catastrophizing is statistically significant (P < 0.05).
Table 4: Repeated measure test results

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  Discussion Top

This study made an attempt to investigate the effectiveness of ACT on pain catastrophizing of Iranian hemodialysis patients. It was hypothesized that the increasing acceptance of chronic pain may be the means to diminish the effect of catastrophic thinking about pain. The results of data analysis revealed that the ACT had a positive effect in decreasing the pain catastrophizing of hemodialysis patients. According to McCracken and Eccleston,[20] catastrophizing is generally referred to as “an automatic, unpleasant, magnificatory, and unrealistic interpretation of feared future events.” The authors also define acceptance as “a deliberate, realistic, and openness to immediate experience.” McCracken and Eccleston argue that although both catastrophic thinking about chronic pain and acceptance of chronic pain confirm that the pain will continue, catastrophic thinking characterizes this with a feeling of haplessness, whereas with acceptance the patient acknowledge this as a willingness to live with his/her pain.[20]

The literature concerning the efficacy of ACT approach has repeatedly demonstrated its potential in guiding the efforts for changing the behavior of patients with chronic pain. This finding corroborates the results of studies conducted by Dahl et al.,[19] Swain et al.[21] and Pakenham.[13] These authors made an attempt to explore the potential of ACT for reducing the pain experience and catastrophic thoughts of patients with chronic pain. Swain et al.,[21] as an example, concluded that this type of therapy alleviates the anxiety in children and adolescents and increases the patients' quality of life. Burton et al.[22] also revealed that pain catastrophizing would be considered as a predictor of backache development in patients who suffer from chronic back trouble.

Overall, it can be claimed that, rather than focusing on removing deleterious factors, the ACT approach help patients to accept their controlled excitements and background knowledge and get rid of and stop struggling with those verbal rules that have caused them trouble. The ACT is basically process oriented and concentrates on the acceptance of cognitive experiences and commitment to increasing significant and flexible activities without considering the content of cognitive experiences. The ACT approach uses acceptance, mental concentration, commitment, and behavior changing processes in order to create flexibility. In this type of treatment, the patient is helped to experience something different based on behavioral commitments and he/she commit to carry out the action regularly. Accordingly, through recognizing their values and goals, the patients make a commitment to positive behavior changes in themselves such as pain catastrophizing.

Moreover, in this type of therapy the patient, through cognitive diffusion, learns to view the internal and private events as they really are rather than what the events show. This will make the acceptance process takes place more appropriately because diffusion of thoughts and feelings decreases the output of internal events that are considered as cognitive obstacles. In cases when the patients experience irrational and disturbing thoughts about their illness, the only way is avoidance. By practicing diffusion, the patients will be helped to interact with obsessive thinking through various methods and styles. While the degree of thinking may be the same, it occurs as something that is quite different. In fact, these thoughts are not dangerous anymore. As such, it can be claimed that acceptance and commitment through observing experiences clearly and accepting them can create positive changes in adaptation and well-being.

The results of data analysis also revealed that pain catastrophizing would change the patient's perceived pain intensity, which may continuously influence behavioral decisions. Consistent with the results of this study, Woby et al.[7] and Vlaeyen and Linton [23] also found that in order to mitigate the pain symptoms, the patients use certain responses that are present and restrain themselves from those valued activities that help them not to suffer from pain in the future. Consequently, a significant decrease in activities will most often cause the patients to experience a despairing life.

A selection of the sample was done voluntarily at the first and then it changes to a random selection in experimental and control groups. The findings of the study, however, does not support what Forman et al.[24] found. Based on the results of their study, they concluded that disappointment and depression, as a result, is a prevalent outcome from which the patients with ESRD suffer. They further argued that when clients with chronic pain disappointedly feel that they do not have sufficient ability to live a satisfactory life, the ACT approach helps them accept their personal restrictions and disabilities so that their life expectancy level would increase. There are a number of reasons why the present study did not reach this finding. First, the participants might have reported less inefficiency feeling at the outset of the treatment phase. In other words, they might have showed that they were more hopeful than they really are. Second, while the acceptance in the ACT approach is emphasized, the participant might have been reluctant to accept the fact that they would continue their lives disappointedly. The other reason might be that most of the disappointment components are objective and, as such, mental perception on which the ACT approach concentrates may not change. Acceptance and commitment mostly focuses on cognitive factors, whereas life expectancy level depends on patients' surrounding context and outsiders rather than mental and cognitive matters. Besides, because the participants' surrounding context and environment might have already been appropriate, there was no need for change and variation.

By taking the present research which has been done on the hemodialysis patients into consideration, it is suggested that the acceptance and commitment based therapy carry out about other patients affected to chronic pain.

  Conclusion Top

The results of the present survey and researches of Ardakani et al.,[25] Ebrahimi et al.,[26] Hor et al.,[27] Dahl et al.[19] have shown that this treatment clearly caused decreasing the experience of pain and catastrophizing thoughts in hemodialysis' patients. These results were in line with the result of Ebrahimi et al.[26] They have shown that this kind of therapy caused decreasing the pain related to depression and improving life quality in patients affected to the syndrome of chronic pain of pelvis; though it did not show a significant effect on pain intensity. Nicholas et al.[11] have shown that time duration of pain, and catastrophizing explained 40 percent of depression variance while it was not expected that the pain intensity is significant. Regarding the explanation of research' findings, it should be mentioned that acceptance and commitment based therapy instead of eliminating the risk factors, help patients to accept their tensions and controlled behaviors. It can help them to get rid of verbal rules which were the reason of their problems, and it causes them not to have a challenge with them.

Commitment-based therapy is mainly process-oriented and clearly emphasizes on enhancing the acceptance of psychological experiences, and commitment by increasing useful, flexible, and compatible activities without taking the contents of experiences into consideration. Acceptance and commitment based therapy is an approach which uses processes such as acceptance, mind focus, commitment, and the processes of changing the behavior in order to create the flexible position. In this therapy, the person is helped to experience something different based on behavioral commitment in commitment-based therapy. Patients are committed to do exercise regularly. When the patient is getting aware of his/her goals and values, she/he will face with the positive changes in his/her status and decrease the pain catastrophizing even without giving any support of psychologist.

Furthermore, the patients learn to see the internal events through the cognitive diffusion as they are, not as it is happening. It causes the process of acceptance would be done better. Eventually, the effectiveness of internal events as psychological obstacles would decrease through the thoughts and feelings' diffusion. In conditions that patients have the experience of illogical and unpleasing thoughts, their disease avoidance is the only solution. Patients have learned how to face with scrupulous thoughts in different ways through diffusion exercises. In this case, the level of acceptance is decreased. Therefore, thought can be a same thing but happens differently. These thoughts will not be threatening because patients consider them just as thoughts, not reality. Hence, the acceptance and commitment based therapy can make a positive change in healthy and welfare through the combination of freshness and the crystal clear observation of experiences.

One of the main problems within today's societies is chronic diseases such as ESRD, which decrease the patients' quality of life and mental health. Assessing the frequency level and factors influencing such disorders would help health specialists find more information about the mainspring of such disorders and, as a result, employ a more comprehensive approach toward treating them. Based on the findings of this study, as well as many others, it can be concluded that psychological components such as pain catastrophizing and ACT approach can play a significant role in improving the quality of life in patients with chronic pain such as hemodialysis patients. Accordingly, it seems necessary to take account of psychological variables in the treatment process of such patients and not to use merely physiological approaches.

Overall, the findings revealed that ACT can be respected as the most appropriate treatment method for treating cognitive disorders in patients with chronic pain. This type of treatment reduced the perceived stress level and pain catastrophizing in hemodialysis patients.

Chronic pain such as kidney disease is one of the most important problem of people that nowadays causes decreasing the life quality of affected people and psychological healthy of society due to its frequency and intensity. Hygienic experts can have more information about the reason of disorders by measuring the rate of the disease spread and factors caused disorders. Therefore, they are able to use perfect approaches in their planning and treatment processes. It can be concluded that based on the findings of the present research and other mentioned ones, the psychological components such as pain catastrophizing and acceptance and commitment based therapy can have a significant causal role on the life quality of chronic patients like kidney hemodialysis. Therefore, it sounds necessary that in the treatment process of these patients, they should not just rely on physiological approaches. If the role of the psychological variables have been considered in the pathology and treatment, the treatment's effects and its process would be more efficient. Psychological and physiological disorders would be cured by the cooperation of physicians and psychologists.

Ethical consideration

  • In order to ensure the examinees, writing their name in the questionnaires was not necessary. They were ensured that research nature and the result of questionnaires would be confidential and the researcher undertakes all aspects of the research
  • In order to perform the experiment and teach participants practically, the necessary cooperation and contraction with hemodialysis Center of Ayatallah Naseri had been done
  • Those people, who wanted to know the analysis of their answer in questionnaires, were justified.


This manuscript is prepared by the help of the encouraging professors in the field of psychology. I deeply appreciate the in charge people and the staff of Ayatollah Naseri Hospital of Dolatabad who were helpful in conducting this article.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4]

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