Digital Acceptance and Commitment Therapy for Chronic Pain

Evidence, Potential and Open Questions

Editorial to accompany the article: “Digital acceptance and commitment therapy for the treatment of chronic pain: Findings of a randomized controlled efficacy trial” by Anne Etzelmüller and Antonia Barke et al. in this issue of Deutsches Ärzteblatt International

Chronic pain ranks among the leading causes of impaired physical functioning and interference with participation in daily life worldwide. National and international guidelines recommend using a biopsychosocial, interdisciplinary approach to treatment. In many healthcare systems, however, access to this type of care is limited and often fraught with long waiting times and a lack of cross-sectoral care structures. For this reason, digital therapy programs are gaining in importance.

Psychotherapeutic interventions, such as cognitive behavioral therapy and acceptance and commitment therapy (ACT), are an integral part of interdisciplinary, multimodal pain therapy (IMPT). In recent years, ACT has established itself as particularly effective in the treatment of chronic pain (1). ACT aims to reduce pain- and emotion-related avoidance processes and to support a values-oriented life, despite persistent pain.

ACT for chronic pain

The randomized controlled trial by Etzelmüller and Barke et al. (2) provides important evidence on the effectiveness of a digital ACT-based intervention for chronic pain. The HelloBetter Chronic Pain program has been approved as a digital health application (DiGA) and can be prescribed by doctors and psychotherapists. It comprises seven modules, each building on the previous one, with multimedia and interactive elements. Across Germany, patients with confirmed pain-related diagnoses were recruited over an eight-month period to participate in the randomized controlled efficacy trial. Clinical endpoints were assessed online at baseline, at 12 weeks and at 6 and 12 months. Standardized written guidance (vial email) was provided by psychotherapists in training.

The primary intention-to-treat (ITT) analysis found a significant reduction in pain-related interference in the intervention group compared to the waiting-list control group (treatment as usual). Sensitivity analyses confirmed the robustness of the findings, and the effects remained stable across the follow-up assessments. In addition, exploratory analysis revealed an improvement in pain acceptance. The effect size for pain-related interference was in the moderate range (SMD = 0.65) and thus consistent with the effects reported in meta-analyses, which are typically moderate for ACT (1) and even somewhat smaller, on average, for digital interventions (SMD about 0.2–0.4) (3, 4). However, due to the current lack of studies comparing digital programs directly with multimodal face-to-face programs, the relative importance of digital offerings compared to the IMPT reference standard remains to be seen.

Methodological limitations

When looking at the methodology used in the trial by Etzelmüller and Barke et al. (2), it should be taken into account that the effect size may have been influenced by expectation effects and the use of waiting-list control groups. Future studies should compare digital interventions with active control groups and adjust for expectation effects. Furthermore, only about 50% of the participants completed all modules, a finding that highlights the well-known challenges associated with adherence to digital interventions. In psychotherapy, adherence is considered a key predictor of treatment success. Thus, low usage rates and early dropouts from the program constitute a significant limitation of digital interventions (5). On the other hand, commitment and personalized support—as implemented in this trial (2)—are considered key predictors of effectiveness (6).

The preponderance of women in the sample (86.5%) reflects a well-known pattern: Men make significantly less use of both digital and face-to-face psychotherapy services, which limits the generalizability of the findings. Therefore, gender-sensitive approaches, such as target group-specific outreach formats or closer integration of digital interventions into somatic care, may be required to make digital pain therapy programs more effective on a broader scale.

Mechanisms of action of digital therapies

While digital psychotherapy offers structural advantages, such as flexibility of time and place as well as lower barriers to access, there has been only limited research into its mechanisms of action to date. The digital ACT program evaluated in this trial covers concepts such as mindfulness and acceptance, whereas relationship-oriented factors, such as empathy and validation, could only be given limited consideration due to the predominantly automated nature of the interactions. Given the concomitant use of face-to-face outpatient psychotherapy (in approximately 50% of the participants), key factors of effective psychotherapy, which are bound to interpersonal processes, may have had an additional effect (7). Thus, it is likely that the observed effects reflect the synergy between digital and traditional face-to-face psychotherapy services. Future research should seek to clarify which mechanisms of digital interventions act independently and how they interact with face-to-face therapies.

Target groups for digital interventions

The question of which groups of people stand to benefit most from digital interventions still needs to be answered. Utilizing such services requires a certain level of proficiency in using digital media as well as an intrinsic motivation. Chronic pain is often embedded in complex biopsychosocial dynamics where pain can take over functions in the regulation of emotional needs (8). Subgroup analyses of this trial (2) indicate that the evaluated intervention is particularly beneficial to patients with, for example, a somatoform pain disorder, a chronic pain disorder with somatic and psychological factors (F45.41), or fibromyalgia. One reason for this could be that digital ACT modules mostly reach affected individuals who (already) exhibit a greater openness to the role of psychological factors. In patients with predominantly somatic pain syndromes, this is often not (yet) the case. This speaks in favor of integrating digital psychotherapy into multimodal treatment pathways in an indication-specific and individualized manner.

Element of multimodal pain management

Based on the current body of evidence, digital psychotherapeutic interventions should be viewed as a scalable complement to hybrid or tiered multimodal care models which can help reduce waiting times and gaps in care. Digital ACT-based programs can prepare for, support or stabilize psychotherapeutic processes. At the same time, there is a need for further research into the effective design of individualized support models and their structured integration into existing care settings. The extent to which patients with complex motivational or psychosocial problems also benefit remains unclear.

Conclusion

Given the fact that chronic pain continues to place a heavy burden on individuals, the healthcare system and society, the most pressing task now is to determine how, for whom and under what conditions digital therapies can be used most effectively. The trial by Etzelmüller and Barke et al. (2) represents an important step in that direction and shows both the potential of digital interventions and the need for their ongoing critical evaluation along the path from innovation to routine care.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 3 February 2026; revised version accepted on 3 February 2026

Translated from the original German by Ralf Thoene, M.D.

Corresponding author
Prof. Dr. med. Frank Petzke

Cite this as:
Kästner A, Petzke F: Digital acceptance and commitment therapy in chronic pain: Evidence, potential, and open questions. Dtsch Arztebl Int 2026; 123: 147–8. DOI: 10.3238/arztebl.m2026.0018

References

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