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Acceptance, Cognitive Restructuring, and Distraction as Coping

Strategies for Acute Pain

Annika Kohl, Winfried Rief, and Julia Anna GlombiewskiDepartment of Clinical Psychology and Psychotherapy, Philipps-University of Marburg, Marburg, Germany.

Abstract: Little is known about treatment mechanisms underlying acceptance strategies. Accep-tance is a strategy that is expected to increase pain tolerance more than distraction, while distraction

should lead to lower pain intensity. The effect of cognitive restructuring on experimental pain has

not yet been investigated. The present study aimed to explore differential short-term effects of

acceptance, distraction, and cognitive restructuring on pain tolerance and intensity. Pain was induced

in a sample of 109 female students using a thermode. We conducted analyses of covariance with in-

struction as the independent variable and posttest scores on pain variables as dependent variables,

covarying for pretest scores. In addition, adherence to instructions and credibility of instructions

were included as covariates. Acceptance led to a higher increase in pain tolerance than did cognitive

restructuring of pain-related thoughts. No differences were detected between either acceptance and

distraction or distraction and cognitive restructuring with respect to pain tolerance. Distraction led to

lower pain intensity compared to acceptance. Cognitive restructuring did not differ from either ac-

ceptance or distraction with respect to pain intensity. As a short-term strategy, cognitive restructur-

ing was not as useful as acceptance in increasing pain tolerance. Further studies should evaluate the

preconditions under which different strategies are most effective.

Perspective: This study demonstrated that acceptance was superior to cognitive restructuring inincreasing tolerance for experimentally induced pain, but was inferior to distraction with respect

to decreasing pain intensity. Knowledge about the types of strategies that are useful in targeting di-

verse pain-related outcome measures is important for efforts to refine the treatment of chronic pain.

2013 by the American Pain Society

Key words: Acceptance, cognitive restructuring, distraction, pain tolerance, pain intensity, acute pain,

short-term strategies.

Numerous studies have investigated the effects ofacceptance-based interventions for chronic

pain.37,39,40 Although the theoretical concept ofacceptance has existed for many years and has beenextensively described by the developers of Acceptanceand Commitment Therapy (ACT),16 the mechanismsthrough which acceptance exerts its effects remain un-clear. Furthermore, little is known about the relative ef-ficacy of acceptance strategies compared to otherstrategies used in established treatments for chronicpain, such as distraction and cognitive restructuring.

Experimental studies are needed to better evaluatethe mechanisms of these strategies. Therefore, the pres-

ent study used an experimental design to compare vari-ous short-term coping strategies with respect to theireffects on pain tolerance and pain intensity.

In the context of treatment for pain, acceptance isintended to disrupt the link between thoughts andbehaviors such that participants are willing to toleratepainful stimulation for longer periods of time (withnegative thoughts and feelings) in order to pursuevalues-based activities. The majority of experimentalstudies support this hypothesis: an acceptance strategyhas been shown to be more effective at increasingpain tolerance than were other pain-regulationstrategies, for example distraction or suppres-sion.3,13,15,24,26,30 About half of the studies inducedpain through thermal stimuli, and the remainingstudies applied electrical stimulation. Only 1 studyinvestigated influences on pain tolerance andintensity in a clinical sample.38 A meta-analytic reviewfound a statistical advantage of acceptance strategies

Received September 19, 2012; Revised November 26, 2012; AcceptedDecember 7, 2012.The study was funded by Philipps-University of Marburg.There is no actual or potential conflict of interest for any of the authors.Address reprint requests to Dr. Julia Anna Glombiewski, Departmentof Clinical Psychology and Psychotherapy, Philipps-University ofMarburg, Gutenbergstrasse 18, Marburg, Germany. E-mail: [email protected]

1526-5900/$36.00

2013 by the American Pain Society

http://dx.doi.org/10.1016/j.jpain.2012.12.005

305

The Journal of Pain, Vol 14, No 3 (March), 2013: pp 305-315

Available online atwww.jpain.organdwww.sciencedirect.com
mailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.jpain.2012.12.005http://www.jpain.org/http://www.sciencedirect.com/http://www.sciencedirect.com/http://www.jpain.org/http://dx.doi.org/10.1016/j.jpain.2012.12.005mailto:[email protected]:[email protected]

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compared to other pain regulation strategies for paintolerance.20

Distraction aims to shift the attentional focus awayfrom painful stimulation and thereby to lessen pain in-tensity. Some studies indicate that strategies such as dis-traction or suppression are more effective at reducingpain intensity relative to an acceptance strategy.3,13,30

On the other hand, a meta-analytic review indicatedthat distraction and suppression were not superior to ac-ceptance strategies at reducing pain intensity.20 Due tothe fact that studies came to contradictory results, dis-traction was included as an adaptive and well-knowncontrol group for acceptance strategies.

In addition to distraction, cognitive-behavioral treat-ments (CBT) for chronic pain implement cognitive re-structuring.18,28 Patients are trained to alter theappraisal of dysfunctional pain-related thoughts in orderto improve coping with pain. Some studies also suggestinfluences of cognitive variables on pain intensity.4,8

Based on the theoretical assumptions of the CBT

model, it appears that restructuring of pain-relatedthoughts may affect disability-related behavior such aswithdrawing from painful stimuli. One study investigat-ing anxiety found that a reappraisal strategy was moreeffective at moderating the subjective feeling of anxietycompared to an acceptance strategy, while for other out-come measures no significant differences were found.17

A study on anger found a greater reduction in the reap-praisal condition than in the acceptance condition, andparticipants in the reappraisal condition tolerated a frus-tration task longer than those in the acceptance condi-tion.35

To the best of our knowledge, no experimental study

to date has compared the effects of acceptance, distrac-tion, and cognitive restructuring on pain tolerance andpain intensity.

Therefore, we aimed to investigate whether thesestrategies differentially affect pain tolerance and pain in-tensity.

Methods

ParticipantsAn a priori power analysis was performed with

G*Power 3.1.3. The power analysis indicated that givenan effect-size (f) of .3, 3 groups and 2 degrees of free-dom, and 3 covariates, a sample of 111 participants wasexpected to be suitable for detecting main and interac-tion effects with a power of .8 and an alpha criterionof .05. We expected an effect size of .3 because previousstudies showed medium effect sizes.13,20,26

Participants were German first-year female undergrad-uate psychology students recruited through announce-ments at the Philipps-University of Marburg and via the

internet. Students received course credit for participa-tion. Exclusion criteria were male gender, chronic andacute pain conditions, Raynauds disease, high bloodpressure, neuropathy, coronary diseases, diabetes,insufficient knowledge of German language, and cur-rent pain-medication use. We excluded male participants

because several recommendations suggest investigatingfemales (eg12) due to the greater prevalence of pain con-ditions in women and differences in pain sensitivity. Fur-thermore, men and women differ in pain sensations,5,34

and therefore including both genders could producemore subgroups or confounding variables. Moreover,we excluded men in order to prevent any interaction

effect of experimenter gender and participant genderon pain tolerance.22 We chose female experimenters toavoid potential influences of a cross-gender interaction.

One hundred fifteen participants completed onlinequestionnaires. Five participants were excluded due topain medication intake, chronic or acute pain, or Ray-nauds disease. One hundred ten participants were ran-domly allocated to 1 of the 3 conditions: acceptance,distraction, or cognitive restructuring. One participantwas excluded after randomization due to insufficientlanguage skills (total N = 109). Participants ages rangedfrom 19 to 30 years (mean = 22.1, SD = 2.38).

The research project was approved by the Ethics Com-

mittee of The German Psychological Society (DeutscheGesellschaft fur Psychologie, DGPs, WR032010). Partici-pants were informed of the procedure and had the op-portunity to withdraw from the study at any time.

Study DesignA mixed between-within design with 3 factors was

employed. The between-group factor was instructioncondition (acceptance, distraction, and restructuring).The within-group factor was time point (pretest versusposttest).

Procedure

Self-Report Measures

All participants completed 3 questionnaires assessinghabitual coping strategies corresponding to the 3 differ-ent instructions. This procedure allows testing regardingwhether group differences existed in habitual copingstrategies due to unsuccessful randomization.

Questionnaires were completed at home prior to theexperimental session. Habitual cognitive restructuringof pain-related thoughts and mental distraction from

pain-related thoughts were assessed using the CopingStrategies and Pain-Related Distress Questionnaire(FESV; Cronbachs a= .77, test re-test reliability = .79).10

An example item assessing cognitive restructuring isWhen I am in pain, I say to myself that because ofpain, I learn to appreciate painless conditions. An exam-ple item assessing mental distraction is When I am inpain, I distract myself by listening to good music. Habit-ual acceptance of pain was measured using a question-naire created by the authors with 10 items rated ona 5-point Likert scale. Items were generated by adapting

items fromthe Chronic Pain Acceptance Questionnaire(CPAQ),25,29 the Acceptance and Action Questionnaire(AAQ II),2 and the Difficulties in Emotion RegulationScale (DERS).11 Items were reformulated to refer topain conditions and to be appropriate for use in healthysamples (I accept when I am in pain or I do a lot of

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activities when I am in pain). Furthermore, consultationwith experts in the field of acceptance-based treatmentsas well as pain suggested that our questionnaire has highface validity. Each item was also discussed within ourworking group. Participants also completed the DERSand the AAQ II in order to validate the newly createdquestionnaire. Data for these measures are not reported

within this article because these questionnaires were notused in analyses. The measure of habitual coping strate-gies (acceptance) showed good internal consistency(Cronbachs a= .76). It was significantly correlated withmeasures of similar constructs such as the AAQ II (r =.39; P< .01) and the Non-Acceptance subscale of theDERS(r = .3; P< .01). The questionnaire assessing habit-ual coping strategies (acceptance) was not significantlycorrelated with measures of theoretically distinct con-structs such as the cognitive restructuring subscale ofthe FESV (r = .06; P= .55) and the mental distraction sub-scale of the FESV (r = .02,P= .8).

In addition, participants completed the German ver-

sion of the Beck Depression Inventory (BDI-II)14

and thePain Sensitivity Questionnaire(PSQ; Cronbachs a= .92,test re-test reliability = .83).33 In the PSQ, respondentsrate the degree of pain associated with various scenarios(eg, Imagine you burn your tongue on a very hot drink)on an 11-point Likert scale. We also assessed level of paincatastrophizing using the German version of the PainCatastrophizing Scale (PCS; Cronbachs a= .92).27 An ex-ample item is I worry all the time about whether thepain will end.

Estimates of internal consistency and reliability ratingsare drawn from prior research, with the exception of the

data from the questionnaire designed by the authors

(habitual acceptance of pain).

Pretest

Two different female experimenters conducted the ex-perimental sessions. Participants signed an informedconsent form. They were given the opportunity to askquestions and were informed about the procedure andthe application of the thermode. Before the pretest, par-ticipants had the opportunity to familiarize themselveswith the procedure and to practice stopping the heatstimulus.

Participants underwent the same assessment twice:pain tolerance and pain intensity were measured at pre-

test and at posttest.

Stimulus Material and Outcome Measures

We employed thermal stimuli between 32 and 50C toinduce pain. Stimuli were delivered to the dominantforearm via a 3- 3-cm peltier-based thermode (TSA II:Thermal Sensory Analyzer; Medoc Ltd, Ramat Yishai,Israel). The thermal stimulus started at 32C and rosewith a slope of .5C per second. The thermode remainedat the same place on the skin for pretest and posttest.

Participants were asked to tolerate stimuli as long as pos-sible and to stop the stimulus by clicking a computermouse. Pain tolerance was determined by the tempera-

ture at which the participant stopped the thermal stimu-

lus. When the maximum temperature was reached, thesoftware automatically returned the thermode to thebaseline temperature of 32C.

Pain intensity was assessed with a 10-cm visual analogscale (VAS) immediately after the termination of eachthermal stimulus. The minimum anchor was no painand the maximum anchor was worst imaginable pain.

Instructional Set

Participants listened to 1 of the 3 instructions via head-

phones. Instructions were based on those used in severalprior studies.13,31,32,38 All instructions were approved byseveral experts on pain treatments, mindfulness-basedtreatments, and CBT. Several pilot tests were conductedand instructions were modified after each trial accordingto experts ratings.

All instructions were approximately the same length(5.5 minutes) and followed the same structure: partici-pants were asked to write down 3 thoughts that hadled to termination of pretest stimuli in order to work

on these thoughts using the specific strategies. Next,a description of the strategy was given, followed by anexample of successful application of the strategy (a pain-ful situation at a dentists office was used as an example).Participants were given the opportunity to practice thestrategy before the concrete instructions for the secondtrial (posttest) were provided.

Acceptance Instruction. It was explained thatthoughts often initiate behavior, but that it is also possi-ble to disengage oneself from these thoughts (defusion)through nonjudgmental awareness (mindfulness) or ac-ceptance. The strategy of regarding thoughts as cloudsin the sky was discussed as an example of defusion. If

thoughts can be accepted, they no longer control behav-ioral tendencies and do not inhibit personal goals.Within the exercise, participants were asked to imaginethat they were experiencing the thermal stimulus andto regard their thoughts as clouds in the sky passing by.

Cognitive Restructuring Instruction. It was explainedthat thoughts, feelings, and actions are related. It is pos-sible to alter the appraisal of a situation so that feelingsand behavior tendencies also change according to the re-appraisal. Negative and dysfunctional thoughts can bereplaced by more functional ones, and the new pointof view results in increased freedom of action. Withinthe exercise, participants were asked to imagine the ap-

plication of the thermode and to develop alternativethoughts such as this painful experience does notmean that my skin will be damaged or toleratingpain is a challenge and I have already overcome worsepain.

Distraction Instruction. It was explained that distrac-tion can lead to reduced perception of thoughts andfeelings. Attention can work like a spotlight: depending

on which thoughts and feelings come into focus, otherthoughts and feelings may be blanked out. It is possi-ble to distract oneself internally or externally. Internaldistraction may take place via imagination or recallingpast experiences, while external distraction may involve

increasing attention to environmental stimuli. Within

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the exercise, participants were asked to imagine feelingthe heat stimulus and to distract themselves by imaginga pleasant scene. For further details, see the Appendix.

Posttest

Following the instructions (approximately 6 minutesafter pretest), the heat stimulus was applied again. Par-

ticipants stopped the thermal stimulus by a mouse clickwhen no longer willing to tolerate it and were askedto rate pain intensity on the VAS afterward.

Manipulation Check and Pain Threshold

After the posttest, participants received a manipula-tion check questionnaire assessing the extent to whichthe instructions were applied (rated as a percentage).Participants also rated the credibility of the instructionson a 4-point scale ranging from very much to notat all.

Furthermore, pain thresholds were determined by themean value of 3 trials for the heat stimulus, in which

participants were instructed to stop the stimulus whenit became painful. The interstimulus interval betweeneach of the trials was set to 4 seconds. Pain thresholdwas determined after pre- and posttest assessment ofpain tolerance and intensity in order to avoid habitua-tion to the heat stimulus.

Results

Statistical AnalysisThree participants were able to tolerate the maximum

of heat of 50C during the pretest and were excludedfrom further analyses of pain tolerance. We also

excluded 1 outlier with pain tolerance levels for bothpretest and posttest that were >2.5 SD below the meanpain tolerance level (seeTable 1).

All analyses were performed using the Statistical Pack-age for Social Sciences (SPSS, Windows v.19: SPSS Inc,Chicago, IL).

To assess the differential effects of instructions on paintolerance and pain intensity, we performed separateanalyses of covariance (ANCOVAs) for each outcomemeasure. Instruction condition was entered as theindependent variable, posttest data as the dependent

variable, and pretest data as a covariate. In these ANCO-VAs, we also controlled for the information gathered viathe manipulation check (the percentage rating of adher-ence to instructions and the rated credibility of the in-structions). We assumed the instructions to be morepowerful when rated as more credible. Post hoc pairwisecomparisons were performed to identify differences be-

tween the 3 types of instructions.

Baseline CharacteristicsNo significant differences were found in any of the

baseline measures (eg, age or self-report measures);thus, we concluded that the randomization was success-ful. For further details seeTable 2. There were no signif-

icant effects of experimenter on outcome measures.We explored whether adherence to instructions

differed across groups using an analysis of variance(ANOVA) with instruction group as the independent var-iable and adherence to instructions as the dependentvariable. Significant group differences were found (F[2,

106] = 3.48,P< .05). Pairwise post hoc analyses indicatedthat participants in the distraction condition showedhigher adherence to instruction compared to those inthe acceptance (P < .05) and cognitive restructuring(P< .05) conditions, while acceptance and cognitive re-

structuring did not differ (P= .731).Furthermore, we calculated an ANOVA to test whether

instruction conditions differed with respect to credibility.The effect was nonsignificant (F[2, 106] = 2.16,P= .121).

Pain ToleranceMeans and standard deviations for pain tolerance

(temperature in C) at pretest and posttest for the 3 con-

ditions are shown inTable 3.The ANCOVA identified a significant effect of instruc-

tion condition on pain tolerance at posttest (F[2,99] = 3.2,P< .05, partial Eta2 = .061), when controllingfor pretest scores. According to Ferguson,7 Eta2 can be

interpreted as follows: .04 = small; .25 = moderate;and .64 strong. Furthermore, Ferguson notes that thedistinction between Eta2 and partial Eta2 tend to besmall in large samples. Pairwise post hoc analyses indi-cated that acceptance was significantly more effectivethan cognitive restructuring at increasing pain

Table 1. Outlier Analysis

CONDITION BDI PSQ PCS FESV-KU * FESV-MAy

HABITUAL

ACCEPTANCE

OFPAINz DERS-NONACC.x AAQ-II{

Ceiling effects

No. 1 Distraction 2 4.14 28 5 10 28 16 58

No. 2 Restructuring 18 3.86 32 7 8 29 8 48

No. 3 Distraction 8 3.21 20 10 10 34 19 55

Outlier6 2.5 SD

No. 1 Acceptance 4 2.14 27 7 16 23 6 52

*FESV, cognitive restructuring subscale.

yFESV, mental distraction subscale.

zPain Acceptance Questionnaire.

xDifficulties in Emotion Regulation Scale, subscale Nonacceptance.

{Acceptance and Acton Questionnaire.

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tolerance (P< .05). Pain tolerance at posttest did notdiffer between the acceptance and distraction condi-tions (P= .058) or between the distraction and cognitiverestructuring conditions (P= .692) when controlling for

pretest scores (seeFig 1). In sum, instructions to acceptthoughts and feelings related to painful stimuli pro-longed the tolerance of these stimuli relative to an in-struction to cognitively restructure pain-relatedthoughts and feelings. In addition, there was a trendfor acceptance to be superior to distraction in increas-ing tolerance for thermal stimuli.

The effect of the covariate pretest was also significant(F[1, 99] = 316.7,P< .01). This finding indicates that pre-test and posttest data were highly correlated.

In addition to the main effects for instruction condi-tion and for pretest, credibility of instructions was signif-icantly related to posttest scores (F[1, 99] = 10.49, P< .01).

The interaction between credibility and instruction con-dition was nonsignificant.

A post hoc analysis revealed a significant partial corre-lation between credibility and pain tolerance at posttest(r = .25,P< .05), when controlling for pain tolerance atpretest.

Pain IntensityTable 4shows means and standard deviations for pain

intensity (VAS) at pretest and posttest for the 3 instruc-tion conditions. Examination of means indicated thatpain intensity increased during posttest compared topretest scores.

Controlling for pretest scores, the ANCOVA showeda significant effect for instruction condition on pain in-

tensity from pretest to posttest (F[2, 103] = 3.97,P< .05,partial Eta2 = .073). Post hoc pairwise comparisons indi-cated significant differences between acceptance anddistraction (P < .01), favoring distraction. In other

words, participants who received the distraction in-structions had lower pain ratings compared to partici-pants who were instructed to accept painful thoughtsand feelings. No significant differences in posttestpain intensity were found between the acceptanceand cognitive restructuring conditions (P = .098) orthe cognitive restructuring and distraction conditions(P = .244) when controlling for pretest scores (seeFig 2).

Moreover, the effect of the covariate pretest was sig-nificant (F[1, 103] = 155.26, P< .01), indicating that pre-test and posttest data were highly correlated.

Credibility of instructions was not significantly re-

lated to posttest pain intensity (F[1, 102] = .013,P= .908).

DiscussionThe present study investigated the effects of differ-

ent short-term pain regulation strategies (acceptance,distraction, and cognitive restructuring) on experimen-tally induced heat pain tolerance and pain intensity.We found that acceptance led to increased pain toler-ance relative to cognitive restructuring. Distraction ledto lower pain intensity compared to acceptance.

Table 2. Sample Characteristics

ACCEPTANCE(N= 38) DISTRACTION(N= 36) C OGNITIVERESTRUCTURING(N= 35) F VALUE*

Age (mean, SD) 22.53 (2.28) 21.39 (1.83) 22.43 (2.84) 2.624

BDI (mean, SD) 8.71 (6.79) 11.39 (8.43) 9.31 (8.77) 1.123

PSQ (mean, SD) 3.40 (1.18) 3.35 (.92) 3.25 (1.05) .190

PCS (mean, SD) 24.63 (7.87) 24.39 (8.72) 22.4 (10.37) .66

Room temperature (mean, SD) 24.36 (3.84) 23.72 (3.52) 24 (4.04) .258

Habitual acceptance of painy(mean, SD) 30.61 (5.94) 30.33 (5.45) 29.57 (5.19) .336

FESV-cognitive restructuring (mean, SD) 12.05 (3.35) 13.31 (3.99) 12.6 (3.45) 1.12

FESV-mental distraction (mean, SD) 15.18 (4.81) 13.33 (5.09) 14.09 (3.58) 1.549

Pain thresholdz(mean, SD) 44.13 (3.24) 43.50 (2.68) 43.87 (2.73) .437

*All F values are nonsignificant (P> .05).

yPain Acceptance Questionnaire.

zPain threshold was assessed after posttest.

Table 3. Means and Standard Deviations forPretest and Posttest for Pain Tolerance

PAINTOLERANCE(C)

ACCEPTANCE

(N= 37)

DISTRACTION

(N= 34)

COGNITIVE

RESTRUCTURING

(N= 34)

Pretest 44.91 (3.02) 44.79 (2.55) 44.46 (2.54)

Posttest 47.38 (2.14) 46.97 (1.61) 46.63 (2.22)

Estimated marginal

means*

47.34 (.17)y 46.87 (.18) 46.77 (.17)

*Standard errors in parentheses.

yF(2, 99) = 3.2, P< .05, favoring acceptance over cognitive restructuring.Figure 1. Estimated marginal means and standard errors forpain tolerance (assessed in the range between 32 and 50C).

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Pain ToleranceTolerance time went up for all participants across the

instructional sets. We found that acceptance was more

effective at increasing pain tolerance than was cognitiverestructuring, with a small effect size. Previous studieshave also shown that acceptance is especially effectivewhen participants perceive high discomfort during ex-perimental pain procedures.13,30 For instance, a priorexperimental study of food cravings found thatacceptance was only superior to cognitive restructuringamong participants reporting a high susceptibility tofood.9

We considered the possibility that the ineffectivenessof cognitive restructuring might have been due to an in-

sufficient level of pain catastrophizing in healthy volun-teers. Interestingly, our results indicate that the meanvalue of pain catastrophizing was higher than in anotherstudy with low back pain patients.27

Nevertheless,although participants endorsed relatively

high levels of pain catastrophizing in a questionnaire, theexperimental pain might have not been sufficient to pro-voke catastrophizing in this particular situation.

Our results contrast with those of previous studies ofcoping strategies for anxiety and anger.17,35 However,comparisons between anxiety or anger and paintolerance are limited, because pain tolerance is

a behavior and anxiety and anger are experiences.Differences between the present and prior results may

have occurred due to the use of different outcome mea-

sures or because the instructions differed in content. Inaddition, some studies have suggested that acceptancestrategies may have the greatest impact when the strat-egy is embedded in a values-based context3,30 or whenacceptance instructions involve metaphors andexercises,26 such as the present studys use of the exampleof thoughts as clouds in the sky.

No significant differences were detected between dis-traction and acceptance with respect to pain tolerance.Our results are in line with those of a previous studythat also failed to find significant differences betweenacceptance and distraction.19 Our results run counter tothe results of another study that found that acceptancewas superior to distraction at increasing pain toler-ance.13 Our findings are also consistent with the resultsof a recent meta-analysis indicating that acceptancestrategies appear to be more effective than other strate-gies at increasing pain tolerance.20 When acceptancewas compared to control groups that are consideredless powerful, such as suppression,24,30 or to conditions

that did not involve 1 specific strategy, significantdifferences were more easily detected.3,15,32

With respect to pain tolerance, we can draw the pre-liminary conclusion that cognitive restructuring is no dif-ferent from distraction in increasing pain tolerance.

Interestingly, we found that credibility had an effecton the extent of pain tolerance, with higher credibilityof instructions accompanied by greater tolerance forpainful stimuli.

To summarize, acceptance strategies can change theway of responding to pain-related thoughts and feelingsand offer a broader scope of behavior. Cognitive restruc-

turing does not appear to change pain-related behavior

as much as acceptance. Nevertheless, it can be an impor-tant tool for other clinically relevant experiences, ie, anx-iety or anger.

Pain IntensityIn line with a previous study,13 distraction proved to be

more effective than acceptance with respect to pain in-tensity ratings, with a small effect size. Because accep-tance strategies do not seek to alter inner experiences,it is reasonable that an acceptance strategy did not im-pact a sensory nociception. Previous studies comparingthe effects of acceptance versus distraction or suppres-sion on pain intensity have yielded mixed find-

ings.3,19,26,30,31

Furthermore, a meta-analysis found nosignificant differences in the effects of acceptanceandother pain regulation strategies on pain intensity.20 Di-vergent results may have emerged due to different oper-ationalizations of constructs in the instructions or type of

comparison condition. Distraction was not more effec-tive than cognitive restructuring at regulating pain in-tensity in the present study.

In line with the results of a previous study, pain inten-sity increased from pretest to posttest across all groups.32

It is possible that the skin surface became sensitized toadditional exposure to warm stimuli, such that partici-pants perceived stimulation as more painful at posttest.

It is not surprising that the acceptance group had thehighest pain ratings, because participants in this group

Table 4. Means and Standard Deviations forPretest and Posttest for Pain Intensity

PAININTENSITY(VAS)

ACCEPTANCE

(N= 38)

DISTRACTION

(N= 36)

COGNITIVE

RESTRUCTURING

(N= 35)

Pretest 68.63 (15.62) 60.39 (16.18) 59.80 (16.59)

Posttest 78.39 (14.90) 65.33 (16.82) 67.34 (17.32)

Estimated marginal

means*

74.33 (1.75) 67.16 (1.78)y 69.88 (1.79)

*Standard errors in parentheses.

yF(2, 102) = 4.01, P< .05 favoring distraction over acceptance.

40

45

50

55

60

65

70

75

80

AcceptanceN=38

DistractionN=36

CognitiveRestructuring

N=35

Pain

intensity

(VAS)

*F(2, 102) = 4.01;partial Eta2=0.073

Figure 2. Estimated marginal means and standard errors forpain intensity assessed by the VAS ranging from no pain = 0to worst imaginable pain = 100.

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tolerated stimuli for a longer period of time than par-ticipants in the other 2 groups. We suggest that pain in-tensity and pain tolerance are based on a commonlatent factor, and therefore we decided not to covaryeither pain tolerance or pain intensity in analyses ofthe other.

Advantages of This StudyThis is the first study to test the effects of different cop-ing instructions within a highly standardized thermalpain induction procedure. Previous studies have notcompared acceptance strategies with cognitive restruc-turing in the context of experimentally induced pain.The sample size in our study was larger than in most ofthe other studies and was adequately powered to detectsignificant differences. Moreover, we assessed potentialpreexisting differences in habitual coping strategiesand tested the credibility of our manipulation and thedegree of adherence to instructions. Results highlightthe importance of experimental research investigating

mechanisms of therapeutic interventions. The presentstudy indicated that differences emerge between short-term strategies, and that advantages of simple andunique strategies should be better disentangled.

LimitationsThe generalizability of our results to males might be

limited because of gender-specific effects on pain thresh-old andpain tolerance5,19,34;inaddition,resultsmightnotgeneralize to other age cohorts due to the restricted agerange. Generalizability to chronic pain patients may alsobe limited. Pain stimuli might have a different meaningor affective valence for chronic pain patients than for

a sample of students. It is unclear to what extentexperimentally induced pain is comparable to chronicpain conditions. Nevertheless, conducting a study withhealthy participants to detect patterns in pain behaviorand pain sensations independently of chronic conditionsrepresents an important initial step.

Because participants level of catastrophizing was rela-

tively high, the cognitive restructuring instruction mighthave been insufficient to significantly reduce the level ofcatastrophizing. Cognitive restructuring is a very com-plex strategy that requires practice. The instructionswithin the present study lacked some elements of cogni-tive restructuring such as rational rebuttal to automatic

thoughts. On the other hand, experimental studieswith even shorter reappraisal instructions have shownbeneficial effects.17,35

Furthermore, distraction was associated with greateradherence to instruction than cognitive restructuring

or acceptance. Distraction may be the most commonlyknown strategy for coping with pain. Therefore, peoplemight find it easier to apply such a strategy. This pointadds weight to the argument that cognitive restructur-ing and acceptance might require more training to opti-mize effectiveness.

One might argue that the lack of a control condition isanother limitation. However, several studies have al-

ready demonstrated the effectiveness of strategies suchas distraction and acceptance in comparison to a control

group.1,20 In line with the rationale for randomizedcontrolled trials, which allows the comparison of newtreatments to established ones without a controlgroup, we decided not to include a control group.

Another limitation of our study is that the proceduredid not allow all participants to reach the limit of theirpain tolerance, because the thermode stops at 50C for

ethical reasons. However, we were able to includemore than 95% of participants in analyses for heat paintolerance.

Some research suggests that previous knowledgeabout a specific coping strategy might influence the ad-equate application of this strategy.6,9,21,23 It should benoted that our study is not a comparison between ACTand CBT, because we tested only isolated strategiesfrom a larger toolbox for both treatment types.

Clinical ImplicationsAlthough it is difficult to translate the present results

into clear clinical recommendations for chronic pain pa-

tients, we know that the willingness to tolerate painfor longer periods of time is crucial for chronic pain pa-tients. Attempting to avoid pain results in disability, re-duced participation in daily life activities, and lowerfunctioning. Furthermore, chronic pain patients sufferenormously from pain and therefore may benefit fromstrategies that lead to reduced pain intensity. Thus, it isuseful to know that distraction may be more helpfulthan acceptance in decreasing the nociceptive sensationof pain, and that cognitive restructuring seemed to be asuseful as distraction. In sum, we recommend applyinga range of strategies for managing chronic pain in orderto influence both pain tolerance and pain intensity. Thefact that credibility of instructions was related to out-come variables demonstrates the importance of present-ing strategies convincingly. This finding suggests that itmight be beneficial to allocate patients to the treat-ments they rate as the most credible.

Implications for Future ResearchFuture studies should evaluate the usefulness of the

various coping strategies at modifying a wider range ofclinically relevant outcome variables. Expectanciesmaybe important moderators of treatment outcomes,36 andourfindings indicate the importance of assessing this var-

iable within experimental and clinical trials, especially intrials of procedures that aim to alter behavior. We recom-mend assessing credibility immediately after the instruc-tions rather than after posttest, because experiencesduring posttest might influence credibility ratings.

Future research should address whether different in-structions are associated with different effects withinchronic pain populations. Further studies are needed todraw conclusions about long-term effectiveness of thevarious strategies.

The majority of research in this field is conducted withhealthy participants, such that replicating results inclinical samples is a priority. Furthermore, it is important

to investigate the circumstances under which particularstrategies are most effective for differenttarget variables.


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Appendix

Complete Instructions1. Acceptance: Please list three different thoughts

which urged you to stop the painful stimulus.(break of 1 minute)

Now I would like you to put down your pencil.

(short break)Sometimes our thoughts control our behavior. Howeverthis connection between thoughts and actions can beloosened. Sometimes it is even very important to ignoreour thoughts if we want to achieve our goals. It isa good strategyto merely perceive your thoughts without

judging or changing them. You may think of thoughtslikeclouds in the sky. If you do not regard your thoughts as tobe of importance but just observe them, they will pass bylike clouds in the sky. The acceptance of unpleasantthoughts mayleadto different actions thanyour thoughtswant you to act. Thus your thoughts do not control yourlife because they are not the cause of your behavior, and

because it is important to pursue certain goals.Example: Imagine one of your last visits to the dentist.

Maybe at one of those visits you had to experience pain.However you have accepted the pain because you pur-sued the goal to preserve your teeth as long as possible.Maybe there have been thoughts which urged you tostop the treatment. And maybe you have not concededthem spontaneously but just noticed and acceptedthem, and finally let them go. Thus you just kept sittingthere and endured the pain.

Exercise: Please read again through your thoughtswhich urged you to stop the stimulus. Close your eyesand imagine the thermode is causing you pain again.

Try to perceive these thoughts neutrally and let thempass by like clouds in the sky. Please note that you areable to act independently of your thoughts if you merelyperceive your thoughts without any judgments. (breakof 1 minute)

Specific instruction: Now I would like you to openyour eyes. Please try to increase the duration of thehot and cold stimulus by accepting all your thoughtsand sensations. Let go of the thoughts you had in thebeginning which urged you to stop the stimulus. Beready to experience the pain without any attempt tochange them.

2. Distraction: Please list three different thoughts

which urged you to stop the painful stimulus.(break of 1 minute)

Now I would like you to put down your pencil.(short break)

If you try to distract yourselves from these thoughtsyou might perceive them less intense than before. Some-times you have to distract yourself from disturbing influ-ences in order to achieve your goals. Our attention workslike a spotlight. Depending on which thoughts and feel-ings come into focus, other thoughts and feelings areblanked out. Thus we are able to shift our attention toother aspects to avoid unpleasant thoughts and feelings.On the one hand you are able to distract yourself inter-

nally, for example by recalling a pleasant situation. Onthe other hand you are able to distract yourself exter-

nally, for example by concentrating on your environ-ment.

Example: Imagine one of your last visits to the dentist.Maybe at one of those visits you had to experience pain.To endurethis pain, youpossibly concentratedon a paint-ing on the wall. Perhaps you even tried to look at thatpainting very closely in order to use your attention to ca-

pacity. And maybe in your thoughts you planned the restof the day and were thinking about the things you can doafter your visit at the dentist. By means of the distractionyou were able to cope with the treatment.

Exercise: Please read again through your thoughtswhich urged you to stop the stimulus. Close your eyesand imagine the thermode is causing you pain again.Imagine you are lying on a lawn on a warm summerday. You are watching other people who are lying onthe lawn as well, looking at the clouds und listening tothe singing birds. Try to imagine this scene and distractyourself from the thoughts which have urged you tostop the stimulus.(break of 1 minute)

Specific Instruction: Now I would likeyou to open youreyes. Please try to increase the duration of the hot andcold stimulus by distracting yourself from all yourthoughts and feelings. Imagine the scene where youare lying on a lawn. Thus you may distract yourselffrom the pain and the thoughts which urge you to stopthe stimulus.

3. Cognitive restructuring: Please list three differentthoughts which urged you to stop the painful stim-ulus.(break of 1 minute)Now I would like you to put down your pencil.(short break)

Sometimes it helps to view a situation from a different

angle and to develop another point of view. Dependingon how we judge a certain situation, we show differentfeelings and behavior tendencies. On the one hand neg-ative thoughts and appraisals may cause dejection anduncertainty, and may influence bodily sensations ina negative way. On the other hand positive thoughtsmay cause pleasant bodily sensations. Thus the same sit-uation can lead to completely different appraisals. Theway you feel and the way your body responds dependson how you judge the situation. Unpleasant thoughts

can be replaced by helpful thoughts. As a consequenceyou act differently depending on your point of view.

Example: Imagine one of your last visits to the dentist.

Maybe at one of those visits you had to experience pain.And maybe you viewed the pain from another point ofview: For example, you were thinking that you have toendure just a little pain in order to avoid much worsepain in the future, and that the dentist knows what heis doing. Or perhaps you took the pain as a challengeand were thinking that you can be proud of yourself ifyou master this challenge.

Exercise: Please read again through your thoughtswhich urged you to stop the stimulus. Close your eyesand imagine the thermode is causing you pain again.Now you may develop alternative points of views. For ex-ample you may think something like I have already

overcome worse pain, or this painful experience lastsjust a short period of time, compared to all the things I


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will be doing afterwards, or this pain is unpleasant butdoes not indicate any serious injury. Maybe you comeup with even more revaluations.(break of 1 minute)

Specific Instruction: Now I would like you to open youreyes. Please try to increase the duration of the hot and

cold stimulus by developing another point of view ofthe pain. Please restructure your thoughts to alternativeand helpful thoughts which will make it easier for you toendure the pain. You may use the thoughts you just de-veloped.


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