New Directions in The Psychology of Chronic Pain

Management

Lance M. McCracken, PhD

Pain Management Unit

Royal National Hospital for Rheumatic Diseases & University of Bath

Bath UK

Bath Pain Management Unit

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).

• 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).

Treatment Process in Chronic Low 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.

Is Pain Relief Necessary for Patient Satisfaction?

• N=62 patients with chronic pain followed in an Anesthesia-based specialty clinic.

• Strongest predictors of satisfaction:– Perceiving evaluation as complete.– Feeling the received explanation for treatment.– Believing that treatment improved daily activity.

McCracken et al. (2002). European Journal of Pain.

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.

History of Psychological Treatments for Chronic Pain

• Late 1960’s – 1980’s – Operant Behavioral.

• Early 1980’s to present – Cognitive Behavioral.

• Most recently – Acceptance-based, Mindfulness-based, and increasingly Contextual approaches.

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.

“Third Wave” Therapies

Therapy Approach Originators Problem area

Acceptance and Commitment Therapy

Hayes et al. 1999

General

Dialectical Behavior Therapy

Linehan 1993

Borderline Personality d/o

Functional Analytic Psychotherapy

Kohlenberg & Tsai, 1991

General

Integrative Behavioral Couples Therapy

Jacobson et al. 2000

Couples Discord

Mindfulness-Based Cognitive Therapy

Teasdale et al. 2000

Relapse of Depression after CBT

“…there is little empirical support for the role of cognitive change as causalin symptomatic improvements achieved in CBT.”

(Longmore & Worrell, 2007)

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.

“The single most remarkable fact about human existence is how hard it is for humans to be happy.”

(Hayes, Strosahl, & Wilson, 1999)

The ACT model of Psychopathology

Psychological Inflexibility

Dominance of the Conceptualized Past and Feared

Future

Lack of Values Clarity

Inaction, Impulsivity,or AvoidantPersistence

Attachment to theConceptualized Self

CognitiveFusion

ExperientialAvoidance

“Psychological Inflexibility”

• Process based in interactions of language and cognition with direct experiences that produce 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.

Radical Idea!

• In many cases of chronic pain, at least some of the time, CONTROL is not the SOLUTION; it’s the PROBLEM.

Radical Idea!

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

Treatment Processes

• Acceptance

• Present focus (mindfulness)

• Cognitive de-fusion

• Values-based action

• Committed action

• A contextual sense of self

“I can’t go on”

Thought Action

Stopping

Context

Loss of contactWith present

CognitiveFusion

ExperientialUnwillingness

ValuesFailure

“I can’t go on”

Thought Action

Stopping

Context

Mindfulness Acceptance

CognitiveDe-fusion

Values-basedAction

Carryingon

or

“Psychological Flexibility”

Dimensions of CognitionFused – Overwhelmed by thought content, loss of contact with present situation, behavioral options narrowed.

De-fused- Aware of reactions as reactions,

contact with wider situation beyond thoughts, access to

a range of responses

True Untrue

Helpful UnhelpfulRational Irrational

In Other Words

• Thoughts have a dimension of literal truth, or consistency with reality.

• They also have a dimension of the functions or influences they exert.

• Cognitive Fusion is the degree to which these influences are exclusive or response narrowing and the degree to which they produce insensitivity and inflexibility.

Cognitive De-fusion

• A process of altering the role thoughts play in relation to other behavior.

• Not about changing content of thought.

• Includes awareness of the process and not merely the content of thinking.

• Alters impact of, and need to control, thought content.

Acceptance of Chronic Pain

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

pain.

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.

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.

Mindfulness from an ACT Point of View

• Contact with the present moment.

• Acceptance.

• Cognitive defusion.

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).

Correlations of Mindfulness with Patient Functioning (N = 105)

r p <

Pain-related Anxiety -.39 .001

Depression -.51 .001

Depression Interference -.27 .05

Physical Disability -.40 .01

Psychosocial Disability -.50 .001

Alertness (SIP) -.48 .001

Regression Results: Variance Explained in Depression

6%

15%

29%

11%

39% Background

Pain

Acceptance

Mindfulness

Unexplained

Regression Results: Variance Explained in Psychosocial Disability

6%10%

27%

10%

47%

Background

Pain

Acceptance

Mindfulness

Unexplained

Regression Results: Variance Explained in Physical Disability

3%11%

18%

7%

61%

Background

Pain

Acceptance

Mindfulness

Unexplained

ACT for Disability due to Stress and Pain

• N = 19 health sector workers with daily stress and pain and 3 periods of > 7 days sick leave in the past year

• Randomized to:– Medical Treatment as Usual (MTAU)– Four 1-hour sessions of ACT plus MTAU

Dahl, Wilson, Nilsson. Dahl, Wilson, Nilsson. Behav TherBehav Ther 2004;35:785-802. 2004;35:785-802.

Results: Mean number sick days per month

02468

101214

One Month Intervals

Ave

rag

e S

ick

Day

s

ACT

MTAU

Medical Service Utilization: Physician, Specialist & Physiotherapist

0

2

4

6

8

10

12

14

16

Me

an

Me

dic

al

Vis

its

1 Month Pre Post 6 Month FU

ACT

MTAU

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

Team

• Clinical Psychologists

• Nurses

• Occupational Therapists

• Physicians

• Physiotherapists

• Psychology Assistants

Results from CCBT for Chronic Pain: Post Treatment and 3-Month

Follow-up

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Pre-post

Pre-f-up

Eff

ec

t S

ize

Reliable Change Results (N = 114)

% Reliable Decline

% Reliably Improved

Depression 0 41.8

Pain-related Anxiety 0 49.1

Disability 3.4 44.0

Vowles & McCracken (under review). J Consult Clin Psychol

Reliable Change - Continued

Number of Domains Improved

> 1 > 2 > 3

Number of Patients

86 70 16

Percent Improved 75.6 61.4 14.0

Number needed to Treat

1.34 1.65 7.14

Variance in Improvements accounted for by Changes Acceptance and Values

Outcome ∆R2 β Acceptance

β

Values

Depression .17* -.36* -.06

Anxiety .33* -.63* -.02

Disability .18* -.41* -.03

* p < .01

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.

Selected Correlation Results

Emotional Exhaustion (0-10)

Acceptance -.35**

Mindfulness -.43**

Values-based action -.50**

* p < .01; ** p < .001

Selected Correlation Results

General Health (SF-36)

Acceptance .36**

Mindfulness .30*

Values-based action .52**

* p < .01; ** p < .001

Selected Correlation Results

Vitality (SF-36)

Acceptance .52**

Mindfulness .43**

Values-based action .66**

* p < .01; ** p < .001

Selected Correlation Results

Emotional Functioning (SF-36)

Acceptance .74**

Mindfulness .40**

Values-based action .51**

* p < .01; ** p < .001

Variance in Worker Functioning Explained by Acceptance, Mindfulness,

and Values-based ActionCriterion Variable ∆R2

Emotional Exhaustion .31*

General Health .25*

Vitality .52*

Emotional Functioning .61*

* P < .001

Summary

• Current analyses of human behavior show us that language and thinking can create great problems for human beings.

• These analyses also show two ways to help: change in the content or in the context of experience.

• Contextual processes include acceptance, cognitive defusion, mindfulness, and values.

Thank you.