Healthy Ways to Deal Healthy Ways to Deal with Chronic Pain: with Chronic Pain: An Acceptance and An Acceptance and
Commitment Therapy Commitment Therapy PerspectivePerspective
Steven C. HayesUniversity of Nevada
My GoalMy Goal
• To explore briefly our view of chronic pain
• To provide an alternative, evidence based approach that applies not just to pain but to behavioral health treatment generally
• To show some data
• To work with a very small set of methods
• To interest you in exploring the area
Is Pain the Issue or is itIs Pain the Issue or is itOur Relationship to PainOur Relationship to Pain
• In the case of acute pain, pain is clearly a focal issue
• But chronic pain may be a very different issue
Immersion in Struggle
• For many of those with chronic pain, pain intensity has been the focus of years of struggle … and yet it seems virtually untreatable.
The data are hardly reassuring. . .
Chronic Pain
• is extremely commone.g., Breivik et al., 2006; Gureje et al., 1998
• remits in only a minority of casese.g., Andersson, 2004; Elliott et al., 2002
• does not reliably respond to our clinical arsenal over the longer terme.g., Eccleston et al., 2009; Hoffman et al., 2007; Martell et al., 2007; Chou et al., 2007; Armon et al., 2007; Kemler et al., 2000; 2008
• Opioids – No evidence of long-term pain reduction (i.e., > 15 weeks).Martell et al., 2007 – Ann. of Internal Medicine – Systematic ReviewChou et al., 2007 - Ann. of Internal Medicine – Clinical Guidelines
• Surgery - Continued pain and disability are the norm following spinal surgery (i.e., discectomies & fusions).
Franklin et al., 1994; Hoffman et al., 1993; Turk, 2002; Turner et al., 1992; 1995
• Spinal Cord Stimulators - Pain reduction is relatively transient (absent @ 3, 4, & 5 year f/u). No evidence of improvement in functioning or quality of life.
Kemler et al., 2000 NEJM; 2002 J Neurosurgery; 2006 NEJM; 2008 J Neurosurgery
• Epidural Steroid Injections – – Lumbar - “Probably not” effective for long-term pain relief, for
improving functioning, or decreasing rates of surgery.– Cervical – Not enough evidence yet available upon which to base a
conclusion.Armon et al., 2007., Neurology – Systematic Review & Clinical Guidelines commissioned by
the Amer. Acad. of Neurology
Pain and Functioning
• Studies find very limited evidence for a relationship between reported pain intensity and direct measures of– daily activity– medication use– health care use, or – observed behavior.
E.g., Physical Ability
0
5
10
15
20
25
% V
aria
nce
(r-
squ
are)
∆ Floor to Waist Lift ∆ Waist to Shoulder Lift
∆ Pain-Related Fear
∆ Pain Intensity
Vowles & Gross, 2003, Pain
Future Work Status
• Following treatment (6 months later):– Degree of pain was a nonsignificant predictor (post-
treatment depression level predicted 28% of the variability)
• Vowles, Gross, & Sorrell, 2004, Euro J Pain
• In the absence of treatment (4 months later):– Pain accounted for 0.3% of variance (nonsignificant),
while pain related acceptance accounted for 14.0% (p < .001).
• McCracken & Eccleston, 2005, Pain
Data Like These Raise a Question . . .
• What are we treating?
Treatment Options
• There seem to be few evidence-based reasons to focus on pain per se
• We should focus on meaningful functioning in the context of the person’s total life situation, including pain when there is pain
• That is the ACT approach
The Problem is That We All Normally Think
Pain Suffering
Therefore, for pain patients …
• “Its important to keep fighting this pain.”
Is endorsed by 92% of patients!
McCracken, Vowles, & Eccleston, 2004, Pain
That is Shocking Because Persistent Struggling With Pain is …
• Single best predictor of, now and over several months prospectively:
– Worse Pain– Lower Levels of Activity– Greater Disability– Worse Depression– Greater Avoidance
McCracken, Eccleston & Bell, 2005, Eur J Pain McCracken, Vowles, & Gauntlett-Gilbert, 2007, J Behavioral MedVowles & McCracken, 2010, Beh Res & Therapy
Willingnessand Acceptance
• My tinnitus as an example
A Larger System Supports This Link
Pain Suffering
The System Creating Suffering
Strugglingwith Pain
Failure
Lost Freedom &Opportunity
SufferingMultiplied
Pain
The Cycle of Suffering
Strugglingwith Pain
Failure
Lost Freedom &Opportunity
SufferingMultiplied
Pain
The Cycle of Suffering
Strugglingwith Pain
Failure
Increase Pain Focus& Lost Freedom &
Opportunity
SufferingMultiplied
PainMore
Breaking the Cycle of Suffering
Failure
Lost Freedom &Opportunity
SufferingMultiplied
Pain Self-Compassion
And Life Direction
Breaking the Cycle of Suffering
Failure
Freedom &Opportunity
SufferingMultiplied
Pain MaintainedLife Direction
Breaking the Cycle of Suffering
Success
Freedom &Opportunity
SufferingMultiplied
Pain MaintainedLife Direction
Breaking the Cycle of Suffering
Success
Freedom &Opportunity
SufferingReduced
Pain MaintainedLife Direction
Breaking the Cycle of Suffering
Success
Freedom &Opportunity
SufferingReduced
Pain? MaintainedLife Direction
The Impact of That ApproachThe Impact of That Approach
• Listed by APA as having “strong research support” as a evidence-based approach
• The only approach listed by APA as generally applicable to all kinds of pain
• 7 RCTs (~ 360 patients) and 7 open trials (~950 patients, up to 3 yr follow up)
Chronic PainChronic Pain Dahl, Nilsson & Wilson, Behavior Therapy, 2004Dahl, Nilsson & Wilson, Behavior Therapy, 2004
20 public health caretakers at risk for developing long-term pain/stress symptoms
10 TAU, 10 ACT protocol, 4 sessions at work-site/home
Baseline=60 days, intervention: 4 1-hr sessions over 30 days, FU 60 days
2 therapists: 1 experienced CBT, 1 nurse
Cumulative Sick Leave
0
10
20
30
40
50
60
70
80
BL mo 1
BL mo 3
BL mo 5
Inte
rven
tion
FU mo 2
FU mo 4
FU mo 6
Ave
rag
e T
ota
l # S
ick
Day
s
ACT
TAU
Cohen’s d at follow-up =
1.00
Pediatric PainPediatric PainWicksell et al, 2009Wicksell et al, 2009
• 32 patients w/ longstanding pediatric pain
• 25 female; ~ 15 y o, 32 mo pain duration
• Randomly assigned to ACT or multidiscipinary Rx & amitriptyline (MDT). 2 drop outs.
• Pre / post / 3.5mo f-up / 6.5 mo f-up
Content of TreatmentContent of Treatment
• ACT = 10 individual, 1-2 parental over 4 mo; on average 13 sessions thru f-up
• MDT = About 10 individual + parents sessions; medication titrated and continued for 10 mo, with addition meetings with team throughout; on average 22.8 sessions through follow up
Between Effect Sizes (p eta sq)Between Effect Sizes (p eta sq)
• Fight with pain .29*** .23***• Pain intensity .13** .13**• Pain interference .16** .09• Physical health .03 .05• Mental health .15** .11*• Depression .12* .10*• Fear of movement .21*** .12*• Pain related worry .34*** .15**
* p < .1; **p < .05; *** p < .01; medium = .09; large = .25
PostPost F-UpF-Up
Pain InterferencePain Interference
2Post 3.5 mo 6.5 mo
Pai
n In
terf
eren
ce (
1-10
)
Pre
4
6
MDT
ACT
WhiplashWhiplashWicksell et al, 2008Wicksell et al, 2008
• 21 patients with whiplash associated disorder.
• 11 female; ~ 42 y o, 83 mo pain duration
• Randomly assigned to ACT or wait list. One wait list drop out.
• Pre / post / 4mo f-up / 7 mo f-up in Rx arm
Between Effect Sizes (p eta sq)Between Effect Sizes (p eta sq)Post through F-UPost through F-U
• Pain disability .44
• Life satisfaction .40
• Fear of movement .40
• Depression .60
• Pain intensity .01 n.s.
• Pain interference .31
All p < .01 except as indicated; medium = .09, large = .25
For Example, Life SatisfactionFor Example, Life Satisfaction
Pre Post 4 Month
25
20
15
Follow Up
Sat
isfa
ctio
n w
Life
Sca
le
TAU
ACT
Chronic PainChronic Pain McCracken, Vowles, & Eccleston, BRAT, 2005McCracken, Vowles, & Eccleston, BRAT, 2005
Effectiveness trial: 108 chronic pain patientsAverage of 132 months of Chronic pain6.3 treatment programsMultidisciplinary in-patient programWithin subject analysis: Preassessment; 3.9
months later (on average) pretreatment assessment; 3-4 week residential program; 3 month follow-up
-10%
0%
10%
20%
30%
40%
50%
Per
cen
t Im
pro
vem
ent
Impact on Chronic PainAss't to Pre (M=3.9 mo) and Pre to F-Up (M=3.9 mo)
Three Year Follow UpThree Year Follow Up Vowles, McCracken & O’Brien, BRAT, 2011Vowles, McCracken & O’Brien, BRAT, 2011
108 chronic pain patients treated with ACTFollow up data at three month and 3 years
Effect Sizes at 3-36 Mo. Follow UpEffect Sizes at 3-36 Mo. Follow Up
.2 .5 .8 1.1 1.5
Small Medium Large
Acceptance
Values Success
Values Discrepancy
Pain
Depression
Pain-Related Anxiety
Physical Disability
Psychosocial Disability
Medical Visits
3 MonthFollow Up
36 MonthFollow Up
A Quick Note Before We Leave DataA Quick Note Before We Leave Data
• One reason nurses may want to consider learning ACT:
• There are good effects from very short ACT interventions in the management of diabetes, exercise, weight, epilepsy, MS, cancer treatment and many other areas in addition to mental health
And by The WayAnd by The Way
• We have local projects coming together right now in post partum depression and hypertension (if you might be able to help email me: [email protected])
04/22/2304/22/23
ACT for Diabetes ManagementACT for Diabetes Management Gregg, Callaghan, Hayes, & Glenn-Lawson, 2008, JCCPGregg, Callaghan, Hayes, & Glenn-Lawson, 2008, JCCP
• Randomized controlled trial with poor, mostly minority clients
• 40 / group: ACT plus diabetes education (one six-hour workshop) or diabetes education (also a six hour workshop)
• Pre, post, 3-month follow-up
Change (Pre to Follow up)Change (Pre to Follow up)AAQ
(Diabetes)
Ed’n ACT
Self- Management
Ed’n ACT
% in Diabetic Control
Ed’n ACT
50%
25%
0%
50%
25%
0%
10
5
0
Level 3 Process Evidence
AAQD and Self-Management mediate blood glucose outcomes
• Stage 4 cancer patients randomly assigned either to ACT or to a form of traditional CBT (cognitive restructuring plus relaxation): 30 / group
• 12 sessions with each participant during chemotherapy visits: pre and sessions 4, 8, and 12.
• No follow up, in part due to the relatively high likelihood of death (12 died during the study)
Psychological Adjustment Among Psychological Adjustment Among Cancer Patients: ACT and CBTCancer Patients: ACT and CBT
Rost, Wilson, Hildebrandt, & Mutch, in press
Impact on Distress (POMS)Impact on Distress (POMS)(change scores)(change scores)
Wilks’ Lambda=.722, F(3,29)=3.722, p=.022
-40
-20
0
Pre Session 4 Session 8 Session 12
CBT
ACT
Session 12 d = .9
04/22/2304/22/23
My Point: It is Worth LearningMy Point: It is Worth Learning
• I will give to a link to a society that will help you do just that if you are interested
• Indeed, a nursing SIG is forming in that society
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
Psychological Flexibility
The ACT Model
The two-minute Persuasion Exercise
• Speaker
– Think of something you want to change, but still have some ambivalence about.
– Perhaps something related to a health area (smoking, diet, exercise), recreation (TV watching, hobby), or work (study more, change jobs).
– If none of this applies personally, role play someone you know but don’t say which is which
• Clinician:
– Put yourself in the mental state in which you have a good understanding of the speaker’s problem, and you know what he/she needs to do to address the problem.
– Even if this is not your style, play this out
The clinician’s task: Persuade the client to change!
Try strategies such as: - Explain why it is important to change. - Warn of the consequences of not changing. - Sympathize. - Reassure your client that change is possible. - Disagree if the client argues against change (confront denial). - Try to make the patient see the damage being done by her/his
current behavior. - Towards the end of the “session,” tell your client what to do.
Why a “Psychological” Approach
Not because pain:• Is a mental problem / in
people’s heads.• Is affected by moods or
thoughts• Causes distress• Leaves no other
alternative
But because:• People with pain want
to live free and full lives• Participation in life is
about action• Successful treatment
entails behavioral change
A Place to Start
• Mindful Listening – Reflective listening that fosters perspective
taking and a gradual focus on meaning and purpose
– “Is this what you meant?” – Look at the person; slow the pace; take the
time to share consciousness
Reflect and Look for Meaning
• Repetition – Repeat an element– “You want some help.”
• Rephrasing – Repeat with synonyms– “Sounds like you are really suffering and want someone to
do something about it.”
• Reflection of feeling – paraphrase emphasizing emotional dimension.– “This sounds as if its very important to you.”
• Paraphrase – best guess at meaning.– “You are hoping that the work we do here today will bring
some meaning back in to your life.”
Exercise – Part II
• Speaker: You still want to change.
• Listener: Listen reflectively.
• Speaker: Can respond with elaboration.
Listening Tips• Guess at what they mean.
– (It’s ok to be wrong)
• Experiment with statements (questions are ok too).– “Sounds like . . . ”– “You are wondering if . . . ”– “You are feeling (thinking, hoping, etc.)”– Express genuine empathy but no wallowing
• Can start w/simple reflections and then use advanced
• Repetition – Repeat an element– “You want some help.”
• Rephrasing – Repeat with synonyms– “Sounds like you are really
suffering and want someone to do something about it.”
• Reflection of feeling – paraphrase emphasizing emotional dimension.– “This sounds as if its very
important to you.”
• Paraphrase – best guess at meaning.– “You are hoping that the work we
do here today will bring some meaning back in to your life.”
• Guess at what they mean.– (It’s ok to be wrong)
• Experiment with statements (questions are ok too).– “Sounds like . . . ”– “You are wondering if ...”– “You are feeling (thinking,
hoping, etc.)”– Express empathy
• Can start w/simple reflections and then use advanced
A Focus on Values
– Form an answer to the questions:
• “What do you want your life to stand for?”
• “What brings meaning to life?”
Example Values Domains• Friends
• Family Relationships
• Intimate Relationships
• Work / Career
• Education / Learning
• Self Development/Learning
• Recreation / Leisure
• Spirituality
• Citizenship / Community
• Health / Well-Being
Exercise – Part III
• Speaker– Why is this important to you?
– If you did that, what would that allow you to do?
• Clinician – Listen, Reflect, Ask for clarification.
• Please:– Slow down
– Recognize that this is likely to be important
– Listen, don’t solve
A Model for Treatment
Improved willingness to have the experience of pain
+
More frequent engagement in valued activity over the longer term
=Progress
Learning ACTLearning ACT
Join ACBS
www.contextualpsychology.org
There are about 60 books available including three in the area of chronic pain
QUESTIONS?QUESTIONS?• Email: [email protected] • ACBS www.contextualpsychology.org• The next large conference is WorldCon X in DC, July 21-25