Values-Based Behavioral Activation for Chronic Pain in Primary Care: A Pilot Study

  • Stephanie A. HookerEmail author
  • Andrew H. Slattengren
  • Lucas Boyle
  • Michelle D. Sherman


Chronic pain is prevalent and can be complex to manage in primary care. Encouraging patients with chronic pain to engage in valued activities has been associated with reduced disability and distress. This single-arm, mixed methods pilot study examined whether adding a values-based behavioral activation intervention to a chronic pain protocol is feasible and acceptable in an urban, underserved family medicine residency clinic. Patients (N = 30) living with chronic pain completed a values assessment and co-created a plan with a psychologist to engage in values-based activities. Patients completed self-report measures of psychological health and functioning pre- and post-intervention and a qualitative interview at the follow-up visit. The intervention was considered feasible and acceptable. Patients reported high levels of satisfaction and enjoyment of the intervention and significantly less pain interference at follow-up compared to baseline. Values-based behavioral activation for chronic pain may be implemented as part of behavioral health practice in primary care.


Chronic pain Family medicine Behavioral interventions Values Integrated primary care 



This study was funded by the Minnesota Academy of Family Physicians Resident Research Grant.

Compliance with Ethical Standards

Conflict of interest

Stephanie A. Hooker, Andrew H. Slattengren, Lucas Boyle, and Michelle D. Sherman declare that they have no conflicts of interest to report.

Research Involving Human Subjects

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.


  1. Alschuler, K. N., Kratz, A. L., & Ehde, D. M. (2016). Resilience and vulnerability in individuals with chronic pain and physical disability. Rehabilitation Psychology, 61, 7–18. Scholar
  2. Anshel, M. H., & Kang, M. (2007). An outcome-based action study on changes in fitness, blood lipids, and exercise adherence, using the disconnected values (intervention) model. Behavioral Medicine, 33, 85–100. Scholar
  3. Antmann, D., Cook, K. F., Jensen, M. P., Chen, W., Choi, S., Revicki, D., … , Lai, J. (2010). Development of a PROMIS item bank to measure pain interference. Pain, 150, 173–182.
  4. Arnow, B. A., Hunkeler, E. M., Blasey, C. M., Lee, J., Constantino, M. J., Fireman, B., … , Hayward, C. (2006). Comorbid depression, chronic pain, and disability in primary care. Psychosomatic Medicine, 68(2), 262–268.
  5. Berge, J. M., Trump, L., Trudeau, S., Utržan, D. S., Mandrich, M., Slattengren, A., … , Wootten, M. (2017). Integrated care clinic: Creating enhanced clinical pathways for integrated behavioral health care in a family medicine residency clinic serving a low-income, minority population. Families, Systems, & Health, 35(3), 283–294.
  6. Bovend’Eerdt, T. J. H., Botell, R. E., & Wade, D. T. (2009). Writing SMART rehabilitation goals and achieving goal attainment scaling: A practical guide. Clinical Rehabilitation, 23, 352–361. Scholar
  7. Branstetter-Rost, A., Cushing, C., & Douleh, T. (2009). Personal values and pain tolerance: Does a values intervention add to acceptance? The Journal of Pain, 10, 887–892. Scholar
  8. Breivik, H., Collett, B., Ventafridda, V., Cohen, R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10(4), 287. Scholar
  9. Dahlhamer, J., Lucas, J., Zelaya, C., Nahin, R., Mackey, S., DeBar, L., … , Helmick, C. (2018). Prevalence of chronic pain and high-impact chronic pain among adults—United States, 2016. Morbidity and Mortality Weekly Report, 67(36), 1001–1006.
  10. Diener, E., Emmons, R., Larsen, R., & Griffin, S. (1985). The satisfaction with life scale. Journal of Personality Assessment, 49, 71–75. Scholar
  11. Dimidjian, S., Barrera, M., Jr., Martell, C., Muñoz, R. F., & Lewinsohn, P. M. (2011). The origins and current status of behavioral activation treatments for depression. Annual Review of Clinical Psychology, 7, 1–38. Scholar
  12. Dobmeyer, A. C. (2018). Psychological treatment of medical patients in integrated primary care. Washington, DC: American Psychological Association. Scholar
  13. Dobscha, S. K., Corson, K., Perrin, N. A., Hanson, G. C., Leibowitz, R. Q., Doak, M. N., …, Gerrity, M. S. (2009). Collaborative care for chronic pain in primary care: A cluster randomized trial. JAMA, 301, 1242–1252.
  14. Edmond, S. N., Heapy, A. A., & Kerns, R. D. (2019). Engaging mental health professionals in addressing pain. JAMA Psychiatry. Scholar
  15. Ehde, D. M., Dillworth, T. M., & Turner, J. A. (2014). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. American Psychologist, 69, 153–166. Scholar
  16. Hooker, S. A., & Masters, K. S. (2018). Daily meaning salience and physical activity in previously inactive exercise initiates. Health Psychology, 37, 344–354. Scholar
  17. Hooker, S. A., Masters, K. S., & Park, C. L. (2018). A meaningful life is a healthy life: A conceptual model linking meaning and meaning salience to health. Review of General Psychology, 22, 11–24. Scholar
  18. Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillan, D. (2017). Acceptance and commitment therapy (ACT) for chronic pain: A systematic review and meta-analysis. Clinical Journal of Pain, 33, 552–568. Scholar
  19. Jacobson, N. S., Martell, C. S., & Dimidjian, S. (2001). Behavioral activation treatment for depression: Returning to contextual roots. Clinical Psychology: Science and Practice, 8, 255–270. Scholar
  20. Janevic, M. R., McLaughlin, S. J., Heapy, A. A., Thacker, C., & Piette, J. D. (2017). Racial and socioeconomic disparities in disabling chronic pain: Findings from the Health and Retirement Study. The Journal of Pain, 18, 1459–1467. Scholar
  21. Kanter, J. W., Manos, R. C., Bowe, W. M., Baruch, D. E., Busch, A. M., & Rusch, L. C. (2010). What is behavioral activation? A review of empirical literature. Clinical Psychology Review, 30, 608–620. Scholar
  22. Kim, E. H., Crouch, T. B., & Olatunji, B. O. (2017). Adaptation of behavioral activation in the treatment of chronic pain. Psychotherapy, 54(3), 237–244. Scholar
  23. Ko, H., Hooker, K., Geldhof, G. J., & McAdams, D. P. (2016). Longitudinal purpose in life trajectories: Examining predictors in late midlife. Psychology and Aging, 31, 693–698. Scholar
  24. Krippendorff, K. (2004). Content analysis: An introduction to its methodology (2nd ed.). Thousand Oaks, CA: Sage.Google Scholar
  25. Kroenke, K., & Spitzer, R. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32, 509–515. Scholar
  26. Lestoquoy, A. S., Laird, L. D., Mitchell, S., Gergen-Barnett, K., Negash, N. L., McCue, K., …, Gardiner, P. (2017). Living with chronic pain: Evaluating patient experiences with a medical group visit focused on mindfulness and non-pharmacological strategies. Complementary Therapies in Medicine, 35, 33–38.
  27. Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance & commitment therapy skills-training manual for therapists. Oakland, CA: New Harbinger.Google Scholar
  28. Masters, K. S., Ross, K. M., Hooker, S. A., & Wooldridge, J. S. (2018). A psychometric approach to theory-based behavior change intervention development: Example from the Colorado Meaning-Activity Project (COMAP). Annals of Behavioral Medicine, 52, 463–473. Scholar
  29. Matthias, M. S., Parpart, A. L., Nyland, K. A., Huffman, M. A., Stubbs, D. L., Sargent, C., & Bair, M. J. (2010). The patient-provider relationship in chronic pain care: Providers’ perspectives. Pain Medicine, 11, 1688–1697. Scholar
  30. McCracken, L. M., & Yang, S. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain, 123, 137–145. Scholar
  31. Okifuji, A., & Turk, D. C. (2015). Behavioral and cognitive-behavioral approaches to treating patients with chronic pain: Thinking outside the pill box. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 33, 218–238. Scholar
  32. Richards, D. A., Ekers, D., McMillan, D., Taylor, R. S., Byford, S., Warren, F. C., … , Finning, K. (2016). Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): A randomized, controlled, non-inferiority trial. Lancet, 388, 871–880.
  33. Schappert, S. M., & Burt, C. W. (2006). Ambulatory care visits to physician offices, hospital outpatient departments, and emergency departments: United States, 2001-02. Vital and Health Statistics, 13(159), 1–66.Google Scholar
  34. Seal, K., Becker, W., Tighe, J., Li, Y., & Rife, T. (2017). Managing chronic pain in primary care: It really does take a village. Journal of General Internal Medicine, 31, 931–934. Scholar
  35. Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The Meaning in Life Questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53, 80–93. Scholar
  36. Steger, M. F., Kashdan, T. B., Sullivan, B. A., & Lorentz, D. (2008). Understanding the search for meaning in life: Personality, cognitive style, and the dynamic between seeking and experiencing meaning. Journal of Personality, 76, 199–228. Scholar
  37. Vowles, K. E., Fink, B. C., & Cohen, L. L. (2014). Acceptance and commitment therapy for chronic pain: A diary study of treatment process in relation to reliable change in disability. Journal of Contextual and Behavioral Science, 3, 74–80. Scholar
  38. Wilson, K. G., & Murrell, A. R. (2004). Values work in acceptance and commitment therapy: Setting a course for behavioral treatment. In S. C. Hayes, V. M. Follette, & M. M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 120–151). New York: Guilford Press.Google Scholar
  39. Zale, E. L., & Ditre, J. W. (2015). Pain-related fear, disability, and the fear-avoidance model of chronic pain. Current Opinion in Psychology, 5, 24–30. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Family Medicine and Community HealthUniversity of MinnesotaMinneapolisUSA
  2. 2.HealthPartners InstituteMinneapolisUSA

Personalised recommendations