The effectiveness of acceptance and commitment therapy on pain catastrophizing, pain anxiety, and resilience in cancer patients

Asgharzadeh, Fatemeh; Pourfaraj, Majid

doi:10.22034/27.2.93

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Volume 27, Issue 2 (7-2025)

EBNESINA 2025, 27(2): 93-102

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The effectiveness of acceptance and commitment therapy on pain catastrophizing, pain anxiety, and resilience in cancer patients

Fatemeh Asgharzadeh

, Majid Pourfaraj ^*

Department of psychology, Beh.c, Islamic Azad University, Behshahr, Iran , Ma.Pourfaraj@iau.ac.ir

Keywords: acceptance and commitment therapy, pain, catastrophizing, anxiety, resiliency, cancer

Full-Text [PDF 1520 kb] (69 Downloads) | Abstract (HTML) (206 Views)

Type of Study: Original | Subject: Military Psychiatry
Received: 2024/11/18 | Revised: 2025/09/29 | Accepted: 2025/07/12 | Published: 2025/07/13

Extended Abstract: (52 Views)

Introduction

Chronic pain is a pervasive and debilitating issue among cancer patients, often exacerbated by psychological factors. One such factor is pain catastrophizing, a maladaptive cognitive process characterized by an exaggerated perception of pain's threat and a sense of helplessness in managing it [2]. This cognitive distortion not only intensifies the subjective experience of pain but also contributes to emotional distress and impaired functioning.
Another critical psychological component is pain anxiety, which involves fear and avoidance behaviors related to pain. Research indicates that pain-related anxiety plays a significant role in the development and persistence of chronic pain, creating a vicious cycle where fear of pain leads to heightened sensitivity and disability [3].
In contrast to these negative psychological processes, resilience represents a protective factor. Defined as the capacity to adapt successfully to adversity or recover from traumatic experiences, resilience enables individuals to maintain psychological well-being despite challenging circumstances [5]. For cancer patients, resilience can mitigate the emotional toll of diagnosis and treatment, fostering better adherence to medical regimens and improved quality of life.
Addressing these psychological dimensions is crucial, as untreated distress can disrupt treatment adherence and worsen health outcomes. Among therapeutic approaches, Acceptance and Commitment Therapy (ACT) has emerged as a promising intervention. ACT is rooted in the principle of psychological flexibility—the ability to accept unavoidable discomfort while committing to actions aligned with personal values. Unlike traditional therapies that focus on symptom reduction, ACT encourages patients to embrace their experiences without judgment, reducing the struggle with pain and anxiety [6].
This study examined the efficacy of ACT in reducing pain catastrophizing and pain anxiety while enhancing resilience among leukemia patients. By integrating psychological and medical care, this research aimed to contribute to holistic cancer treatment strategies.

Methods

This study employed a quasi-experimental design with pre-test and post-test assessments, including a control group awaiting treatment. The design allowed for the comparison of outcomes between the intervention and control groups, ensuring robust evaluation of ACT's effects.
The study population comprised 40 leukemia patients recruited from Imam Khomeini Hospital in Behshahr city, Iran, during 2023. Participants were selected through purposive sampling, ensuring they met specific criteria, and were randomly assigned to either the experimental or control group using a lottery method.
Inclusion criteria required participants to have a definitive cancer diagnosis confirmed by a pathologist, at least one year since diagnosis, current chemotherapy treatment, no diagnosed mental disorders (as assessed by a clinical psychologist), voluntary consent to participate, and an age range of 30–60 years.
Exclusion criteria included participation in other psychological interventions, absence from more than two therapy sessions, or withdrawal of consent during the study. These measures ensured that the results were not confounded by external variables.
The experimental group underwent an 8-week ACT program based on the protocol by Hayes et al. [6]. Each session lasted 1.5 hours and was conducted in a group setting. The therapy focused on core ACT processes: 1) Cognitive Defusion: Helping patients distance themselves from distressing thoughts; 2) Acceptance: Encouraging openness to pain and discomfort; 3) Present-Moment Awareness: Cultivating mindfulness to reduce rumination; 4) Values Clarification: Identifying meaningful life goals; and 5) Committed Action: Taking steps toward value-driven behaviors.
The control group received no psychological intervention during the study period but was offered the ACT program afterward as an ethical consideration.
Three validated questionnaires were used to measure outcomes: 1) Pain Catastrophizing Scale (PCS) [11]: A 13-item tool assessing exaggerated negative thoughts about pain; 2) Pain Anxiety Symptoms Questionnaire (PASQ) [13]: A 20-item measure evaluating fear and avoidance behaviors related to pain; 3) Connor-Davidson Resilience Scale (CD-RISC) [5]: A 25-item scale measuring adaptability and coping skills.
These instruments provided reliable and quantifiable data on the psychological variables under investigation.

Results

The pre-test and post-test comparisons revealed significant improvements in the experimental group. Pain catastrophizing scores decreased from 52.55 (±4.77) to 32.29 (±3.51), indicating a substantial reduction in maladaptive thoughts about pain. Pain anxiety scores dropped from 35.66 (±4.20) to 20.98 (±3.91), reflecting diminished fear and avoidance behaviors. Resilience scores increased from 54.38 (±16.21) to 60.32 (±18.09), demonstrating enhanced coping abilities. All changes were statistically significant (p < 0.001), with effect sizes of 0.58 for pain catastrophizing, 0.53 for pain anxiety, and 0.64 for resilience. These effect sizes suggest moderate to large therapeutic impacts.
In contrast, the control group showed no significant changes in any measure, confirming that the improvements were attributable to the ACT intervention.

Discussion and Conclusion

The efficacy of ACT can be attributed to its focus on psychological flexibility. By teaching patients to accept pain without judgment, ACT reduces the cognitive and emotional amplification of pain (catastrophizing) and the associated anxiety. This aligns with Hayes et al.'s [6] model, which posits that acceptance disrupts the cycle of avoidance and distress.
These findings underscore the importance of integrating psychological therapies into cancer care. ACT's non-invasive, value-based approach makes it particularly suitable for patients undergoing rigorous medical treatments. Future research could explore its long-term effects and applicability to other cancer types.
This study had some limitations: The study's sample size was modest, and the quasi-experimental design limits causal inferences. Larger, randomized controlled trials are needed to validate these results.
This study demonstrates that ACT is an effective intervention for reducing pain catastrophizing and anxiety while boosting resilience in leukemia patients. Its success highlights the need for holistic cancer care that addresses both physical and psychological well-being.

Ethical Considerations

The study adhered to ethical guidelines, including informed consent, confidentiality, and the right to withdraw. Approval was obtained from the Ethics Committee of Islamic Azad University, Sari Branch (IR.IAU.SARI.REC.1402.280). The control group was offered the ACT program post-study to ensure equitable access to benefits.

Funding

There is no funding support.

Authors’ Contribution

Authors contributed equally to the conceptualization and writing of the article. All of the authors approved the content of the manuscript and agreed on all aspects of the work.

Conflict of Interest

Authors declared no conflict of interest.

Acknowledgments

We would like to express our sincere gratitude to all the medical staff and patients who patiently supported us in conducting this study.

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Asgharzadeh F, Pourfaraj M. The effectiveness of acceptance and commitment therapy on pain catastrophizing, pain anxiety, and resilience in cancer patients. EBNESINA 2025; 27 (2) :93-102
URL: http://ebnesina.ajaums.ac.ir/article-1-1373-en.html

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