Acceptance and Commitment Therapy and Mindfulness in a Contextual Approach to Chronic Pain: Basic an

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Acceptance and Commitment Therapy and Mindfulness
in a Contextual Approach to Chronic Pain Basic
and Intermediate Methods

• Lance M. McCracken, PhD
• Pain Management Unit
• Royal National Hospital for Rheumatic Diseases
  University of Bath
• Bath UK

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Bath Pain Management Unit
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The single most remarkable fact about human
existence is how hard it is for humans to be
happy. (Hayes, Strosahl, Wilson, 1999)
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Medical Treatments for Chronic Pain

• Short trials of opioids average 33 pain relief
  (Turk 2002, Clin J Pain).
• Surgery for degenerative lumbar conditions
  There is still insufficient evidence on the
  effectiveness of surgery on clinical outcomes to
  draw any firm conclusions. (Gibson and Waddell,
  2006, Cochrane Library).

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• Regional Anesthesia There is insufficient
  evidence on the effectiveness of facet joint,
  epidural, and local injection therapy for low
  back pain. (Nelemans et al. 2001, Spine).

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Treatment Process in Functional Restoration for
Chronic Back Pain

• Decreased fear and avoidance predict improved
  mood, interference, and daily activity.
• Changes in pain or physical capacity accounted
  for relatively little or no variance in outcomes.
• McCracken Gross (1998). J Occupational
  Rehabil.
• McCracken, Gross, Eccleston (2002). Behav Res
  Ther.

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Is Pain Relief Necessary for Patient Satisfaction?

• N62 patients with chronic pain followed in an
  Anesthesia-based specialty clinic.
• Strongest predictors of satisfaction
• Perceiving evaluation as complete.
• Feeling they received explanation for treatment.
• Believing that treatment improved daily activity.
  
• McCracken et al. (2002). European Journal of Pain.

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Comprehensive Pain Programs

• 14-60 pain reduction.
• 65 increase in physical activity
• 66 return to work.
• 68 reduction in annual healthcare costs.

As reviewed in Gatchel and Okifuji (2006). The
Journal of Pain.
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The Waves of Behavioral and Cognitive Therapy

• First application of basic learning principles
  to behavior change.
• Second emphasis on cognitive processes.
• Third integration and expansion of behavioral
  and cognitive approaches in a contextual
  framework.

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Third Wave Therapies
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there is little empirical support for the role
of cognitive change as causal in symptomatic
improvements achieved in CBT. (Longmore
Worrell, 2007)
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Behavioral Activation

• Based on the notion that much of depressive
  behavior, including inactivity and rumination,
  functions as avoidance.
• Principles
• Activity leads to activity
• Change made from the outside-in
• Action toward goals not according to moods
• Patients learn to attend to experience rather
  than rumination

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• Treatment strategies
• Activity logs
• TRAP (trigger, response, avoidance pattern)
• TRAC (trigger, response, alternative coping)
• ACTION (assess, choose, try choice, integrate
  behavior, observe results, never quit)
• Examine behavior avoided by rumination, set
  goals, carry out behavior

Source Martell, Addis, Dimidjian (2004). In
Mindfulness and Acceptance Expanding the
Cognitive-Behavioral tradition
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Randomized Trial of Behavioral Activation,
Cognitive Therapy, and Antidepressant Medication
for Major Depression

• 241 patients randomized
• Results Among severely depressed patients BA was
  comparable to ADM and both outperformed CT.
• These results challenge the assumption that
  directly modifying negative beliefs is essential
  for change

Dimidjian et al. J Consult Clin Psychol 2006 74
658-670.
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A Standard CBT Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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A Standard CBT Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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A Standard CBT Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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A CONTEXTUAL Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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A CONTEXTUAL Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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A CONTEXTUAL Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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A CONTEXTUAL Approach
Moods and Emotions
Pain and other Sensations
Thoughts and Beliefs
Activity
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The ACT model of Psychopathology
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Psychological Inflexibility

• A process based in interactions of language and
  cognition with direct experiences that produces
  an inability to persist in, or change, a behavior
  pattern in the service of long term goals or
  values.

From Hayes et al. Behav Res Ther 2006 44 1-25.
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Radical Idea!

• In many cases of human suffering pain, at least
  some of the time, CONTROL is not the SOLUTION
  its the PROBLEM.

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Radical Idea!

• It may be difficult for patients to talk or think
  their way out of problems based in talking and
  thinking.

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Treatment Processes

• Acceptance
• Present focus (mindfulness)
• Cognitive de-fusion
• Values-based processes
• Committed action
• Self-as context

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The ACT Treatment Question
Contact with the Present Moment
(6) At this time, in this situation?
(2) Are you willing to have these experiences,
fully and without defence
Values
Acceptance
(5) Of your chosen values
(4) AND do what takes you in the direction
CognitiveDefusion
Committed Action
(3) As they are, and not as they say they are

• Given a distinction between
• you and the experiences you
• are struggling with

Self as Context
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Psychological Acceptance

• Processes of flexible and practical action, free
  from un-necessary restriction by psychological
  experiences.
• Engagement in activities with these experiences
  present.
• Absence of attempts to limit contact with these
  experiences.

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Values-Based Action

• Action in accord with relatively global desired
  life consequences.
• Guided by chosen directions in relation to
  family, intimate relations, friends, work,
  health, growth and learning, etc.

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Mindfulness

• Moment-to-moment non-judgemental awareness.
• A quality of behavior that includes full,
  flexible, non-defensive, non-reactive, and
  present-focused contact with experienced events.

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• Paying attention in the moment, on purpose,
  non-judgementally, as if your life depended on
  it.

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Mindfulness from an ACT Point of View

• Contact with the present moment.
• Acceptance.
• Cognitive defusion.

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Role of Mindfulness and Acceptance in Chronic
pain

• N 105 patients at assessment.
• Completed
• 0-10 ratings of pain.
• Mindful Attention Awareness Scale (Brown and
  Ryan, 2003).
• British Columbia Major Depression Inventory
• Chronic Pain Acceptance Questionnaire.
• Pain Anxiety Symptoms Scale.
• Sickness Impact Profile.

From McCracken, Gauntlett-Gilbert and Vowles.
Pain (2007).
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Correlations of Mindfulness1 with Patient
Functioning (N 105)
1 Mindful Attention Awareness Scale (Brown and
Ryan, 2003).
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Regression Results Variance Explained in
Depression
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Regression Results Variance Explained in
Psychosocial Disability
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Regression Results Variance Explained in
Physical Disability
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Factor Analyses of the MAAS in Persons with
Chronic Pain (N 150)
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Correlations of Mindfulness Factors with Patient
Functioning
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Coping with Psychotic Symptoms Bach Hayes, 2002

• Could this work even with the most horrifying
  forms of private events?
• 80 Ss hospitalized with hallucinations and/or
  delusions randomized to either ACT or TAU
• 3 hours of ACT all but one session in-patient
• ACT intervention focused on acceptance and
  defusion from hallucinations / delusions

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Impact on Rehospitalization
1.0
ACT
.9
.8
Proportion Not Hospitalized
.7
.6
Treatment as Usual
40
80
120
Days After Initial Release
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Processes of Change Symptoms
100
ACT
75
Percentage Reporting Symptoms
50
Control
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Pre
F-up
Phase
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Processes of ChangeSymptom Reporting and
Acceptance
ACT
TAU
50
40
Rehospitalization Rate
30
20
Admit
Admit
Deny
Deny
10
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Processes of ChangeBelievability
80
Control
Literal Believability of Psychotic Symptoms
(0-100)
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ACT
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Pre
F-up
Phase
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Results Mean number sick days per month
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Medical Service Utilization Physician,
Specialist Physiotherapist
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Treatment

• Patients
• N 171 highly disabled adults with chronic pain
• n 114 at follow-up
• 3 or 4 week residential treatment.
• Daily sessions
• Physical conditioning
• Psychology
• Skills training
• Education sessions

• Psychological Methods
• Exposure
• Mindfulness
• Metaphor
• Confusion
• Modelling
• Explicit non-coercion

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Team

• Clinical Psychologists
• Nurses
• Occupational Therapists
• Physicians
• Physiotherapists
• Psychology Assistants

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Results from CCBT for Chronic Pain Post
Treatment and 3-Month Follow-up
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Reliable Change Results (N 114)
Vowles McCracken (under review). J Consult Clin
Psychol
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Reliable Change - Continued
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Variance in Improvements accounted for by Changes
Acceptance and Values
p lt .01
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Randomized Trials of ACT
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Behavior Change

• Information is to behavior change like spaghetti
  to a brick wall.

- Wilbert Fordyce
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Demonstrations
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Potential Pitfalls in Treatment

• Our own unwillingness.
• Doing a lot of treatment methods.
• Talking and persuading too much.
• Coercion (de-legitimising)
• Sounding smart.
• Being right.
• Forgetting to observe and act curious.
• Losing track of our own values.

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A Contextual Analysis of Treatment Providers
Rehab Workers in Singapore

• N 98.
• 76.5 women.
• 36.7 Nurses, 12.2 Physios, 10.2 OTs, 9.2
  Physicians, 9.2 Admin, 22. other.
• Age M 35.45 yrs, sd 8.9.
• Years at work M 8.8, sd 8.5.

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Selected Correlation Results
p lt .01 p lt .001
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Selected Correlation Results
p lt .01 p lt .001
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Selected Correlation Results
p lt .01 p lt .001
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Selected Correlation Results
p lt .01 p lt .001
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Variance in Worker Functioning Explained by
Acceptance, Mindfulness, and Values-based Action
P lt .001
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Summary

• No one wants to suffer physical or emotional pain
  or to have discouraging or frightening thoughts
  or memories.

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• It appears that largely verbally-based processes
  mix with direct experiences and exert restricting
  influences on behavior that are contextually
  determined.
• The result is referred to as psychological
  inflexibility.

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• Treatment approaches to suffering can now aim
  either to alter the content of experience or the
  context by which these experiences (a) generate
  additional negatively evaluated experiences, and
  (b) occasion unworkable behavior patterns.

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Thank you.
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Contact Details
Lance.McCracken_at_RNHRD-tr.swest.nhs.uk http//ww
w.bath.ac.uk/pain-management/