Intended for healthcare professionals

Clinical Review State of the Art Review

New generation psychological treatments in chronic pain

BMJ 2022; 376 doi: (Published 28 February 2022) Cite this as: BMJ 2022;376:e057212
  1. Lance M McCracken, professor of clinical psychology1,
  2. Lin Yu, lecturer in psychology2,
  3. Kevin E Vowles, professor of clinical health psychology3
  1. 1Department of Psychology, Uppsala University, Uppsala, Sweden
  2. 2Department of Psychology, Middlesex University, London, UK
  3. 3School of Psychology, Queens University Belfast, Belfast, UK
  1. Correspondence to LM McCracken Lance.McCracken{at}


Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called “third wave” CBT. In this review, we examine the evidence for application of acceptance and commitment therapy (ACT), a principal example of this new wave or latest generation of treatment approaches, in people with chronic pain. We identified 25 randomized controlled trials of ACT for adults with chronic pain. Across the included trials, small to large effect sizes favoring ACT were reported for key outcomes including pain interference, disability, depression, and quality of life. Evidence from three studies provided some support for the cost effectiveness of ACT for chronic pain. Evidence also supported the mediating role of theoretically consistent processes of change (psychological flexibility) in relation to treatment outcomes. Investigation of moderators and predictors of outcomes was limited and inconsistent. In future, a greater focus on process based treatments is recommended. This should include continued identification of evidence based processes of change, and research methods more suited to understanding the experience and needs of individual people.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: none.

  • Contributors: All authors participated in formulating the search queries, reviewing the literature, and drafting and revising the manuscript. All authors accept full responsibility for the work, had access to the data, and controlled the decision to publish. LMM is the guarantor.

  • Patient involvement: No patients were involved in the drafting of this manuscript.

  • Provenance and peer review: Commissioned; externally peer reviewed.

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