Experiences of occupational therapists within an ACT-based interdisciplinary pain management program

Abstract

Background

Acceptance and Commitment Therapy (ACT)-based interdisciplinary pain rehabilitation programs have shown effective results. While occupational therapy within these programs has made a unique contribution to pain management because of its focus on occupation and use of group activities, little is known about occupational therapists’ own experiences of it.

Aim

The aim of this study was to describe the occupational therapists’ experiences of working in a manual-based interdisciplinary pain management program grounded in ACT.

Material and methods

Six occupational therapists at a pain rehabilitation clinic were interviewed. Data were analysed using Braun and Clark’s thematic analysis.

Results

The occupational therapists experienced that ACT and occupational therapy complement each other and that ACT facilitated comprehension of occupational therapy interventions. With ACT, the team gained a common language, which made teamwork and patient comprehension more efficient. A behavioural analysis (SORC) served as a link between occupational therapy and ACT.

Conclusions

Manual-based occupational therapy activity group interventions with elements of ACT were felt to enhance the patient’s understanding of their rehabilitation and supported teamwork.

Significance

This study provides further support for use of ACT in occupational therapy within interdisciplinary pain management programs. Occupational therapistsˈ use of SORC is an area of development.

Keywords:

• Acceptance and commitment therapy
• occupational therapy

Introduction

Acceptance and Commitment Therapy (ACT) is a third-wave Cognitive Behavioural Therapy (CBT). ACT was developed in the United States during the 80s and is based on functional contextualism and relational frame theory. ACT aims to increase psychological flexibility through six core processes: acceptance (allowing and accepting unwanted thoughts and feelings), cognitive defusion (observing one’s thoughts without letting them rule), contact with the present moment (flexibly directing attention in the moment), self-as-context (being able to consider oneself), values (knowing what is important in life) and committed action (to act appropriately based on one’s values) [1].

ACT has similarities to occupational therapy and has been described as well-matched with occupational therapy practice [2,3]. American Occupational Therapy Association [AOTA] describes in their continuing education program Acceptance and Commitment Therapy for Occupational Therapy Practitioners that the main relationship ACT has with the practice occupational therapy framework is the client-centred approach. AOTA also compares core processes of ACT with components of the Model of Human Occupation (MOHO) [4], such as focus on values and the aim to engage in meaningful occupations.

Studies where occupational therapy is described as part of ACT-based multidisciplinary and interdisciplinary chronic pain rehabilitation programs have been shown to be effective, even though occupational therapy treatment has not been specifically evaluated [5–7].

Effective pain rehabilitation benefits both indivi­duals and society [8]. For example, in 2020, 82% of the individuals that participated in multimodal pain rehabilitation in specialist care in Sweden experienced an improved ability to manage their life situation one year after completion of the rehabilitation [9]. To address large and complex needs of an individual, it is common that multimodal pain rehabilitation is performed by an interdisciplinary team of several professionals working together. The individual in need is considered part of the team [10].

Chronic pain, defined as pain lasting more than three months, is characterized by significant emotional distress and/or significant disability [11,12]. Chronic pain is often multifactorial, in which biological, psychological, and social factors contribute to the pain syndrome [13]. A model that argues that all factors are of importance to understand the pain syndrome and determining proper treatment is the biopsychosocial model, where the interactions between the factors can set the pain behaviour into a vicious spiral [14]. Evaluations show that multimodal rehabilitation based on the biopsychosocial model is a successful treatment method for people with chronic pain [15,16]. Breeden and Rowe [17] argue that occupational therapy may contribute significantly to make pain rehabilitation effective based on this model, since occupational therapy theory concepts, such as occupational performance and occupational engagement, are influenced by biopsychosocial factors. Lagueux et al. [18], in turn, highlight that occupational therapy uniquely contributes to pain management because of its focus on occupational performance and occupational engagement. On the other hand, Griffiths et al. [19] describe difficulties in proving beneficial effects from occupational therapy interventions in pain rehabilitation. One reason is that the complexity of occupational therapy interventions makes it difficult to isolate and study the effect. Another reason is that occupational therapy interventions are often carried out in a multi-professional context [20].

In Sweden, it is common for multimodal rehabilitation programs to be based on CBT (or ACT) consisting of group activities [10]. This is also the case in the present study. Occupational therapy groups are unique with their combination of activities and group processes [21]. According to AOTA [2], research on how occupational therapists can incorporate ACT is important since ACT operationalizes concept of value further. Moreover, ACT also offers concepts that are not clearly defined in occupational therapy (acceptance and defusion). Therefore, taking into consideration occupational therapists’ unique experiences while working with ACT is of importance to future pain rehabilitation programs. How ACT can enrich occupational therapy interventions in pain rehabilitation has to our knowledge not been investigated before. Nor in combination with an interprofessional manual. Therefore, the aim of this study was to describe the occupational therapists’ experiences of working in a manual-based interdisciplinary pain management program grounded in ACT. Answering the following research questions: What can ACT add to occupational therapy and, what can occupational therapy interventions and ACT in combination add to the pain management program and, how is interdisciplinary teamwork experienced to be influenced by the common ground in ACT?

Material and methods

Study design

To answer the research questions a qualitative approach was used. Qualitative research methods can provide rich descriptions of a phenomenon [22]. Semi-structured interviews were applied to obtain the participants experiences [23] and thematic analysis [24] was used to analyze the qualitative data.

Context

At a pain rehabilitation clinic in Sweden, two interdisciplinary pain management programs based on ACT, a basic program, and an intensive program, are conducted. Both programs include occupational therapy treatment in groups. The present study focused on the intensive program, as it has been used for longer than the basic program. The intensive program was the first program to be developed and has served as knowledge base for shorter programs needed for patients that were not ready for the intensive program. The multimodal team at the pain rehabilitation clinic consists of an occupational therapist, physiotherapist, social worker, physician, and psychologist.

Patients

The patients who are offered pain rehabilitation at the clinic have chronic complex non-malignant pain. For those who completed rehabilitation programs in 2021, the average age was 44 years and 87% were women.

The intensive pain management program

An initial pain assessment is performed by a physician, physiotherapist, and psychologist in the team, who decides which interventions the patient needs. If the patient proceeds to the intensive program, an occupational therapist and a social worker make further assessment. An individual rehabilitation plan is established together with the patient and the team. The Canadian Occupational Performance Measure (COPM) [25] is used to set goals for the rehabilitation plan. The intensive program starts with three half-day meetings providing information about the program, chronic pain, and pain management. This is followed by an intensive phase of rehabilitation for six weeks with full-time schedule, two or three times a week. The rehabilitation period is followed by a practical application phase of nine weeks where patients apply what they have learned in their home environments, at work and during leisure time. After the application phase, follow-up meetings take place at the clinic.

The occupational therapy intervention

An occupational therapy manual for the intensive program was designed in conjunction with the implementation of ACT at the clinic and was completed in 2017. All parts of the manual were validated by the team. The occupational therapy sessions are integrated into the intensive program and planned to complement other professionals’ sessions. The manual brings a uniform language between team members and continuity of the planned order of sessions, which is important for the team members to be able to relate to each other’s treatments within the program.

The occupational therapy intervention consists of group sessions that include experience-based rehabilitation, e.g. silk painting, activity with clay, cooking, and computer work, in combination with elements of ACT aiming towards psychological flexibility by being open to change, be present and engaged through the six core processes [1]. After activity sessions, patients perform a functional behavioural analysis according to the SORC model [26]. SORC stands for Stimuli (current activity), Organism (inner experiences), Response (behaviour) and Consequences (short term and long-term). The analysis aims to aid patients in paying attention to their inner experiences and behaviours during the performance of an activity and become aware of the consequences of the behaviour. SORC is often used by phycologists and is not part of ACT. At the pain clinic several team members use SORC.

Participants

The sample was purposive and the six participants in this study were selected from occupational therapists who currently worked or had worked at the pain rehabilitation clinic. Five out of six occupational therapists currently working chose to participate in this study, covering all possible participants at the clinic. A feeling of being too new to the programme was the reason for not participating. An occupational therapist who recently had worked at the clinic was also selected to participate in this study, based on her extensive knowledge and many years at the clinic. The age of the participants were 38–67 years and they had worked with pain rehabilitation for 3–32 years.

Data collection

Data was collected in the spring of 2022. A semi-structured interview guide [23] was designed with question areas based on the research questions with supplementary questions highlighting factors such as the occupational therapist perception of which strategies were used to work with ACT core processes and how the interdisciplinary team worked together with ACT.

A test interview with the occupational therapist who had worked at the clinic was conducted and recorded by the first author. No changes were made to the interview guide after the test interview. Conducted by the first author, all interviews, including the test interview, were made through the videoconferencing software program Zoom and lasted about 45 min each. All participants were interviewed once.

Neither of the authors worked at the pain rehabilitation clinic or with ACT before the study was conducted. To incorporate knowledge about the work at the clinic the authors read manuals, educational materials, and other relevant documents. The authors also had discussions with the occupational therapists and participated in occupational therapy interventions with patients at the clinic to gain a better understanding of their work and the results of this study.

Data analysis

The recorded interviews were transcribed verbatim, generating 62 A4 pages of text. The first author transcribed two interviews herself, but then chose to transcribe the rest of the interviews with the support of the transcription functionality in Microsoft Word. These transcriptions were checked against the recordings and inaccuracies were adjusted. In the present study, Braun and Clark’s [24] thematic analysis was used. The authors chose an inductive approach and identified themes at a semantic level. Braun and Clark’s six steps in a thematic analysis were conducted by the first author with the support of the second author (triangulation) as follows: the first author familiarized herself with the transcribed material and noted down initial ideas and started to generate initial codes. After that the codes were collated into potential themes. In this step Microsoft Excel was used to sort text into themes using colour codes [27]. The themes were discussed with the second author. After that the themes were reviewed and clear definitions and names for each theme were generated. In the final step, the result of the analysis was written in relation to the aim with quotes from the participants.

As support when conducting these six steps, Braun and Clarke’s [24] 15-point checklist of criteria for good thematic analysis was used. The first author has kept a reflection diary throughout the study for traceability (audit trail) and member checking has been performed with one of the participants.

Ethical considerations

Ethical vetting was not required according to the Swedish Law of Human Research Ethics [28] because the study did not fulfil any of the legal criteria for such examination. Nevertheless, ethical guidelines and recommendations for good research practice were followed [29]. The participants gave their informed consent to participate in the study by reading information provided by email and then provided written or verbal informed consent before the online interview. All data were confidentially treated and stored. Confidentiality has been preserved as only the authors know who participated and who is who in the interviews. In the results, the participants are referred to by the letters A to F. No risks could be foreseen for participation in the study and the benefits of the study lie at the professional and societal level.

Results

Interviews showed that the occupational therapists experienced that ACT facilitated comprehension of occupational therapy interventions for the patients and the team and that ACT and occupational therapy interventions reinforced each other. The result consists of two main themes, and seven sub-themes presented in Table 1.

Table 1. Themes and Sub-themes in the thematic analysis.

Themes	Combining ACT and occupational therapy enhances pain rehabilitation	An ACT-based pain management program provides benefits for the team
Sub-themes	ACT and occupational therapy complement each other	With ACT the team gain a common foundation and a common language
	Together ACT and occupational therapy increase the likelihood of behavioural change and the understanding of both therapies	Teamwork becomes more efficient with occupational therapy activity group sessions
	ACT and occupational therapy enhance reflection on behaviour for both therapists and patients	The behavioural analysis SORC as a link between occupational therapy and ACT and a source of understanding between team members
	A group-based ACT-occupational therapy manual provides support, structure and more in-depth treatment

Combining ACT and occupational therapy enhances pain rehabilitation

This combination helped team members to understand each other and bridge nicely to each other’s interventions and enhanced the chance for patients to understand the pain management program, when explained coherently in different professional sessions.

The occupational therapists experienced that working with a manual, together with the fact that the occupational therapy intervention was delivered in a group format, increased likelihood for the patients’ behaviour to change.

ACT and occupational therapy complement each other

The occupational therapists experienced similarities between occupational therapy theory and ACT core processes. They perceived occupational therapy theory to be in line with ACT and they experienced that ACT and occupational therapy complemented each other. The occupational therapists were positive about combining occupational therapy with ACT core processes but saw a risk in missing the environmental perspective found in occupational therapy theories, but not in ACT, if the occupational therapist focused more on ACT.

The occupational therapists felt that three of ACT’s core processes were close to occupational therapy: contact with the present moment, values and committed action. The processes: defusion, acceptance, and self-as context, they experienced as being less close to occupational therapy, but they considered these processes important in pain rehabilitation. With knowledge of ACT’s core processes, the occupational therapists also experienced that it was easier to understand the patients’ pain management process.

… when we as therapists gained knowledge about the core processes, I thought it was easier to sort of understand the patients’ processes in some way and that we could also apply to… in an activity training, that is, that you kind of worked with more focus on working with strategies. (Participant A)

ACT core processes was experienced as easy to add to occupational therapy treatment because of similarities with the therapies, ʻIt is still a form that is easy to embrace as an occupational therapist. It is easy to kind of start applying it to what you are already doing, and it is easy to understand it somehow, I thinkʼ (Participant E). The occupational therapists experienced that their knowledge within occupational therapy theory was an advantage in the team when working with ACT. ACT reinforced and made visible to the team the occupational therapist’s way of working client-centred with what was valuable to the patient. It was noted that occupational therapy and ACT fused together in a good way, ʻAnd sometimes I feel like ACT and occupational therapy they kind of, so intertwined that I feel: Is this ACT? Is this occupational therapy?ʼ (Participant D).

With ACT, the occupational therapists got another therapeutic tool to use. They experienced that ACT focused on thoughts and feelings connected to behaviours to a greater extent than occupational therapy, which added another dimension, ʻ… I probably haven’t been in there as much in thoughts and feelings as I am now with ACTʼ (Participant D).

Together ACT and occupational therapy increase the likelihood to behavioural change and the understanding of both therapies

The occupational therapists experienced that ACT-based programs were more demanding for patients who had tried many different methods and strategies in the past without success. It was difficult for those patients who were focused on getting rid of the pain, to make behavioural changes.

… it is difficult for patients when they are stuck in the pretence that the pain is dangerous, that the pain depends on something else, something external. And it is going to be hard with that group of patients… (Participant A)

For those patients who had been in pain for a long time, it was difficult to get used to doing things differently, ʻ… it is a long journey the patient must makeʼ (Participant B). The patients need to approach the pain in a different, more accepting way and one of ACTs core processes is acceptance. With ACT, the occupational therapists experienced that they began to work more with the patients’ behavioural changes. During the occupational therapy sessions, the patients could be in the present moment, and pay attention to thoughts and feelings that were experienced during the activity and talk about it.

… I feel that the patients understood in a clearer way why you should be active in an activity at the occupational therapy. In the past, there was a lot more focus on accomplishment for the patients, like, now we’re going to paint or now we’re going to cook… But you didn’t have this deepening that we actually got with ACT. (Participant A)

Developed in relation to the implementation of ACT in the clinic, the occupational therapy manual helped the occupational therapists to more clearly explain the purpose of the activities, to highlight the thoughts and feelings experienced during the activities and how the patients acted on them.

An example of how ACT facilitated the patients’ understanding of the purpose of occupational therapy was in an activity with clay. The theme before implementing ACT was that patients were free to create what they wanted, which made the patients want to perform a good result. In the manual, the theme was changed to ʻshape one’s pain in clayʼ which removed the outcome requirements and increased focus on allowing and accepting unwanted thoughts and feelings and observing one’s thoughts without letting them rule.

ACT and occupational therapy enhance reflection on behaviour for both therapists and patients

With ACT, the occupational therapists as well as the patients got the opportunity to stop, reflect and observe themselves, ʻwe help the patients to reflect, and somewhere there will be a reflection. They help us reflect in some way through their reflectionsʼ (Participant E). The occupational therapists experienced that it was easier to communicate ACT to patients if they had personal experience of using ACT-processes on themselves in their own lives. They felt that they became better therapists with this experience and knowledge of ACT. ʻIt is kind of impossible to talk about something that you do not have experience ofʼʼ (Participant A). The occupational therapists were also reminded of what was important and valuable in their own lives when collaborating with patients.

The occupational therapists stated that they had the same goal as before, that patients would increase their engagement in individually meaningful activities despite pain. However, the way to reach the goal was strengthened with the help of ACT processes, ʻ… that the goal is the same…I feel more competent to take the patients there… it has kind of strengthened my occupational therapist role working with ACTʼ (Participant D).

The occupational therapists experienced that while they needed to practice ACT-based skills, they also learned to pay attention to their own feelings and behaviours, which was helpful in their occupational therapy interventions.

… to…dare to be in the moment…of course to practice it…to endure discomfort with the patients…is something you have to practice and experience yourself, I think … to dare to be there in the room and not to go into flight-behaviour… to practice paying attention when it happens. (Participant B)

A group-based ACT/occupational therapy manual provides support, structure and in-depth treatment

The occupational therapists perceived that working with manualized group activities had advantages. With the manual it became clear what to do and why to do it. The teamwork became more synchronized and occupational therapy more visualized within the team. It was perceived as if the patients saw the team members interventions to be connected in a good way. The occupational therapy manual provided support in ways to ʻexplain so it becomes clearer to patients why we do this and what the meaning of it is and how we can benefit from it in our everyday livesʼ (Participant A). The manual saved time and energy because the occupational therapists did not have to prepare new activities for each session. The manual provided structure for the group interventions that was perceived to bring patients to deeper understanding of the interventions.

The occupational therapists experienced that the manualized program worked for most patients, except patients limited by severe physical and mental disabilities who had difficulties in attending the intensive program. The occupational therapists felt that group treatment had benefits and added therapeutic value when sharing experiences with others. However, the occupational therapy manual could in some cases be perceived as a limitation, as it gave less flexibility to adapt the treatment to the patients with more needs.

An ACT-based pain management program provides benefits for the team

The occupational therapists found that the team and the patients benefited from the common language of ACT and that the patients seemed to find that the activities they did with others in the group occupational therapy sessions allowed them to observe their own behaviour through the eyes of others and that much of the knowledge they gained from the rest of the team in the program fell into place.

With ACT the team gain a common foundation and a common language

ACT as the common foundation and language for the team was perceived as important, positive, and facilitating teamwork. ʻ…we work in harmony with something (ACT) that fits very well with occupational therapyʼ (Participant C). With ACT the team got a framework, which led to stability and security for the team and the patients, ʻ… Now the patients get a common language with all of us that makes it easier to understand. Before, we spoke one language and the psychologist another… ʼ (Participant C).

Before implementation of ACT, the occupational therapists perceived it was difficult to communicate to the team what an occupational therapist do. Now, occupational therapy was perceived to support ACT processes and the occupational therapy instrument COPM acted as a foundation for the teams’ interventions. COPM highlighted activities the patients thought to be important, and goals were set from an activity perspective. By using ACT’s core processes: values and committed action, the occupational therapists were able to share the results of COPM to the team in their common language, which made it easier to understand for team members.

The occupational therapists felt that it was important to be true to occupational therapy theory when the team focused on ACT, ʻ… (there is a) risk of losing the occupational therapy… one must not become a psychologistʼ (Participant A).

Teamwork becomes more efficient with occupational therapy activity group sessions

Since occupational therapy sessions were experience-based, patients had the opportunity to experience the theory they learned for instance with the psychologist, in practice. The occupational therapists experienced that they brought something special based on occupational therapy to the teamwork. The in-depth knowledge of the processes involved when a person performs an activity was perceived as an important contribution to teamwork, ʻ…that we meet the patients in activities and when they actually do things, there is a lot that happens that we can communicate (to the team)ʼ (Participant E). During activities, the occupational therapists were able to observe patients’ behaviours that could be communicated to the patients and the team.

… (in activity) we see what happens when they experience pain, if they back off or if they face the situation, or stop breathing and do new things that they’ve never done before, is it (the activity) fun or is it scary? So, we see a lot more than the others (team members) do. (Participant F)

The occupational therapists experienced that it was during the activities in the occupational therapy sessions that the patients started to understand the purpose of ACT processes.

… It (ACT) often dawned on the patients during the practical occupational therapy sessions when they worked in an activity, and we followed up with in-depth questions. Then usually quite a lot (of understanding) happened to my experience. The patients sort of seemed to understand.

(Participant A)

The behavioural analysis SORC as a link between occupational therapy and ACT and a source of understanding between team members

The behavioural analysis SORC is not part of ACT, but the occupational therapists experienced that SORC linked ACT and occupational therapy together when capturing the thoughts and feelings in the activity and making them more visible to the patients.

… we’ve done as a bridge I think between SORC, if you know this behavioural analysis, and it’s close to the PEO model I think… it’s a type of analysis that’s close to each other and then we’ve put it a bit like a bridge between occupational therapy and ACT, somehow. That they (the patients) get to do an activity and then we capture thoughts and feelings in the SORC. (Participant B)

After each occupational therapy session, the patients performed the behavioural analysis SORC and analysed their behaviours with the support of the occupational therapist. These behaviours were then related to everyday activities by the occupational therapist. SORC was perceived as a good tool to capture ACT core processes less close to occupational therapy. The behavioural analysis was also used by other professionals and was shared and discussed in the team. Through the behavioural analyses, the occupational therapists focus on activity and occupation were made visible to the team.

Discussion

The results show that occupational therapists saw similarities between ACT core processes and occupational therapy theory, which is consistent with what AOTA [2] and Thompson [3] have described. The similarities made it easier for occupational therapists to understand ACT and enabled them to explain occupational therapy to the team based on a common foundation and language in ACT.

According to AOTA [2], ACT can further operationalize the theoretical value concept for occupational therapists, which was confirmed in this study as ACT was perceived to reinforce the importance of working with what the patients valued as meaningful activities. The occupational therapists felt that the knowledge of ACT’s core processes increased their understanding of what patients were going through, which may be due to ACT adding core processes that are not clearly defined in occupational therapy theories [2].

Occupational therapists use related knowledge in their practice, which has been described as necessary to work effectively as an occupational therapist [30]. The occupational therapists experienced that ACT, as related knowledge, supported their therapeutic work with thoughts, feelings, and behaviours, which increased the understanding of patients’ ability to perform activities. Kielhofner [30] described CBT as a related knowledge that occupational therapists often use in practice. ACT, which is a third-wave CBT, indicate to be a useful related knowledge for occupational therapists in pain rehabilitation, based on present study results.

Robinson et al. [31] describe that there is a risk that occupational therapists who use CBT only duplicate the psychological interventions of other team members without sufficient attention to occupational therapy’s professional domain. This study demonstrates the importance of an occupational therapy manual that is integrated with other professions’ manuals to increase understanding of each other’s work methods in this regard. The implementation of ACT and the development of an occupational therapy manual for the interdisciplinary intensive program entailed a clearer anchoring to occupational therapy theory and ACT’s core processes in the treatment process. The occupational therapy interventions were clarified, which the occupational therapists perceived affected the patients positively and made the occupational therapy interventions more visible to the team. Manual-based occupational therapy has many advantages that are worth mentioning and using group interventions adds another dimension. Cole [21] has described that occupational therapy groups are a unique combination of activities and group processes. Manualized occupational therapy, also using activity group therapy as a strong feature, are programs such as ReDO® [32], Lifestyle Redesign® [33], Redesigning your everyday activities and lifestyle with occupational therapy (REVEAL(OT)) [34], Active in my home (AiMH) [35,36], Balancing everyday life (BEL) [37,38] and Managing Fatigue [39,40]. However, knowledge about how the manualized occupational therapy group intervention including ACT would work in other team settings and how it is perceived by patients is needed in future studies.

An interesting result is that the occupational therapists experienced the behavioural analysis SORC as a link between occupational therapy, ACT, patient, and team. There are few studies that has examined occupational therapists’ use of behavioural analysis. Welch and Polatajko [41] studied the link between applied behaviour analysis, autism, and occupational therapy. Their results show that applied behavioural analysis and occupational therapy are compatible and that the use of behavioural analysis can expand occupational therapy. The present study indicates that the behavioural analysis SORC captures behaviours that occupational therapists can link both to ACT’s core processes and activity analysis in occupational therapy.

The instrument COPM is widely used by occupational therapists working with pain rehabilitation [17] and is particularly suitable in team-based pain management programs [42,43]. With COPM, the occupational therapists experienced a clear connection to ACT’s core processes: values and committed action, which could be communicated to the team. With the above reasoning, COPM and SORC were significant for the link between ACT and occupational therapy and the understanding of occupational therapy in the team. This is important knowledge as the difficulties the occupational therapists ex­perienced in explaining occupational therapy to the team could be reasoned to be well in line with Erlandsson and Persson’s [44] description of how the occupational therapy’s paradigm clash with the medical approach because of different epistemological foundations.

Occupational therapists have specific knowledge about activities and that “doing” has a major impact on health and well-being [44,45]. The connection between activity and behaviour needs to be clarified for occupational therapists to feel more confident explaining this connection. The occupational therapist’s interventions were a valuable contribution to the team because they made ACT processes visible to the patients in a practical way during activities. That ACT processes become comprehensible during occupational therapy group activities is something new and exciting. ACT has been shown to be significant in individual therapy [5]. The current study shows that ACT treatment within occupational therapy group activities has the potential to provide additional value for patients which is a phenomenon in need of further exploration. One part of this additional value seems to be the potential to increase their “doing” despite being afraid of pain. This may be due to reflection with others in the group may increase acceptance of what is and provide a more meaningful everyday life and thereby lead to better health. This can be related to Erlandsson and Persson’s [44] theory, which describes that individuals experience occupational value (in this case the additional value of group treatment) when they perform activities together, meaningfulness is created that is a prerequisite for experiencing health.

The occupational therapists’ positive experiences of using ACT in their own everyday life are supported by Gale and Schröder’s [46] meta-synthesis, which showed that self-practice of CBT techniques is a valuable training strategy for therapists. Self-awareness made it easier to understand the patient’s situation, and the benefits and problems they may encounter during therapy. The occupational therapists’ experiences implies that self-practice is valuable to strengthen the professional role when using related knowledge such as ACT. According to Gale and Schröder [46] self-practice leads to therapists feeling more comfortable with themselves and more competent as therapists. Self-practice/self-reflection in ACT can be a useful training strategy and contribute to professional development. The present study also indicate that ACT can bring knowledge and practical strategies to occupational therapy and vice versa which needs to be further explored.

Methodological considerations

A qualitative design was chosen to capture occupational therapists’ experiences. A qualitative method is suitable for seeking understanding and gaining more knowledge about a phenomenon [22]. A purposive sample provided opportunity for detailed descriptions that answered the aim of this study [22]. The study is limited by a small number of participants, but this unique way of working with manualized ACT-based occupational therapy within pain rehabilitation could inform future studies and development of treatment.

The authors found that the thematic analysis was suitable for analyzing the transcribed relatively rich data material. According to Braun and Clark [47], thematic analysis offers an approach to qualitative research that is reflective and thorough. The approach is easy to learn and does not require much experience in qualitative research.

Discussion of method

To describe trustworthiness in studies with qualitative design, the terms credibility, dependability, confirmability, and transferability are used [48]. To establish trustworthiness during each phase of the thematic analysis, the steps described by Nowell et al. [49], which meet the criteria outlined by Lincoln and Guba [48], were used. To ensure quality and increase credibility, triangulation and member checking can be used [48]. Triangulation was used on several occasions during the process with the second author who has knowledge of the subject area. The use of Microsoft Excel in the analysis according to Bree and Gallagher [27] increased the possibility of collaboration and understanding in the triangulation process. Member checking with one of the participants confirmed the authenticity.

Since the authors had not worked at the pain clinic before the study, they had no prior knowledge of working with the manual or in a team grounded in ACT. This objectivity enabled openness to all relevant aspects during the interviews and analysis.

To ensure dependability and confirmability, the first author has recorded all raw data, notes, transcriptions and kept a reflection diary. According to Lincoln and Guba [48], a clear audit trail through detailed accounting of the research process can increase confirmability. A detailed description of the method and the context has been made to enable the reader to assess the transferability [48]. However, the transferability of the results is limited as the study is made on a small sample and in a specific context with a manual that is tailored to the clinic. Further studies are needed to investigate whether the manual works in similar contexts.

To summarize: the occupational therapists perceived that ACT and occupational therapy have many things in common and complement each other. The manual was perceived to save time and energy and helped the team and the patient to have a common language that improved rehabilitation. The occupational therapists experienced that ACT facilitated the understanding of the purpose of occupational therapy interventions for the patients while occupational therapy group activities increased the understanding of the purpose of ACT processes. The team’s common foundation in ACT was perceived to improve the work within the team and with the patients. The occupational therapists experienced that using COPM and the behavioural analysis SORC linked occupational therapy and ACT and contributed to more efficient teamwork.

Implications

The present study provides additional support for manual-based occupational therapy group interventions and ACT within interdisciplinary pain management programs for chronic pain. ACT as related knowledge has been shown in this study to be valuable for occupational therapists in pain rehabilitation. The combination of ACT and occupational therapy can even deepen the patients’ understanding of their treatment. Further studies are needed to explore the effect of ACT-based occupational therapy manuals for group interventions in pain rehabilitation, from a patient and team perspective. Further developing the teams’ and the occupational therapists’ use of the behavioural analysis SORC is both interesting for pain rehabilitation, occupational therapy practice in general and in research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This study has been conducted with the support of the Swedish Occupational Therapists’ Scholarship Fund.