Acceptance and Commitment Therapy (ACT) and Chronic Pain

Lance M. McCracken, PhD Centre for Pain Services Roya !ationa "ospita for Rhe#matic Diseases Centre for Pain Research $niversity of %ath %ath $&

'#t ine of Ta k

Propose that psycho o(ica approaches to chronic pain are deve opin( Descri)e an ACT mode . S#mmari*e the state of o#tcome iterat#re on ACT for chronic pain. S#((est that
o o o

S#fferin( is norma contro is often #n+orka) e yo#r mind cannot )e tr#sted

The ,vo #tion of C inica Psycho o(y

$nder yin( -rame+ork 'perant Co(nitive %ehaviora Processes of Patho o(y Conditionin( Conditionin(, attention, co( )ias, thinkin(, )e ievin( Avoidance, co( f#sion, se f, va #es, commitment, oss of present Tar(et %ehavior %ehavior and symptoms (physica . emotiona ) %ehavior Therapy Processes Conditionin( Ski s trainin(, e/pos#re, co(nitive therapy Acceptance, def#sion, mindf# ness, va #es, ski s trainin(, re ationship

Conte/t#a (M%SR, ACT)

01there is itt e empirica s#pport for the ro e of co(nitive chan(e as ca#sa in symptomatic improvements achieved in C%T.2 (Lon(more . 3orre , 4556)

Method
! 7 4,89: peop e attendin( treatment for chronic pain. Meas#res of o#tcome administered pre;, post, and < month fo o+;#p. Meas#res of adherence to treatment methods meas#red at < month fo o+; #p.

Res# ts
Adherence to pacin(, tho#(ht cha en(in(, stretchin(, and e/ercise had very sma re ations +ith o#tcome varia) es. =ariance in +e )ein( at fo o+;#p acco#nted for )y adherence factors ran(ed from < to 4>.

If taken at face value, the findings suggest that both theory and practice of recommending adherence to treatment methods require reexamination if not overhaul. (p !"#

Therapist Drift
Therapists often to not f# y imp ement C%T. This #s#a y inc #des shiftin( foc#s from doin( to ta kin(. This arises from therapist co(nitive distortions, emotiona reactions, and avoidance.

3a er ?. ,vidence;)ased treatment and therapist drift. %RAT 455@A 96B <<@;<46.

0'#r )i((est sin( e pro) em in imp ementin( C%T is that many c inicians fai to p#sh for )ehavior chan(e (e.(., e/pos#re, )ehaviora activation, 1) despite the evidence that these e ements of treatment are the most important.2

0'#r )ein( Cnice toD or Cprotective ofD the patient can +orsen the pro) em.2

Enternationa Fo#rna of Stress Mana(ement 455:B<4B<G9;<6G.

Suffering is Normal
o o

<:> to 85> of ad# ts have chronic pain. <@> to 85> of the pop# ation s#ffers from a dia(nosa) e psycho o(ica disorder in any (iven year. The ifetime preva ence of psycho o(ica disorders is near y :5>.

&ess er et a . Arch ?en Psychiatry 455:A G4B :@8;G54.

The ACT mode of Psychopatho o(y

Dominance of the Concept#a i*ed Past and -eared -#t#re

,/perientia Avoidance

Lack of =a #es C arity

Psycho o(ica Enf e/i)i ity

Co(nitive -#sion

Enaction, Emp# sivity, or Avoidant Persistence

Attachment to the Concept#a i*ed Se f

0Psycho o(ica Enf e/i)i ity2

A process )ased in interactions of an(#a(e and co(nition +ith direct e/periences that prod#ces an ina)i ity to persist in, or chan(e, a )ehavior pattern in the service of on( term (oa s or va #es.

-romB "ayes et a . $ehav %es &her 455GA 99B <;4:.

ACT Treatment Processes

Contact with the Present Moment

Acceptance

Values

Psychological Flexibility

Cognitive Defusion Self as Context

Committed Action

,/perience Tho#(hts and -ee in(s

Detect

kno+ a tho#(ht or fee in( is present #nderstand the messa(e of the e/perience take it as tr#e contact it as the on y e/perience present

Re(ister the content

%e ieveHheed

-#se

Chronic Pain and S#fferin(

Pain

Distress " Discomfort nwillingness !nflexibility Avoidance

Poor Functioning

Chronic Pain and S#fferin(

Pain

Distress " Discomfort nwillingness !nflexibility Avoidance

Poor Functioning

Chronic Pain and S#fferin(

Pain

Distress " Discomfort nwillingness !nflexibility Avoidance

Poor Functioning

ACT;%ased Treatment for Chronic Pain

Dah et a ., 4559. %ehav Ther McCracken et a ., 455:. %ehav Res Ther McCracken et a ., 4556. ,#r F Pain =o+ es . McCracken, 455I. F Cons# t C in Psycho 3ickse et a ., 455I. ,#r F Pain =o+ es et a . 455@. Co( %ehav Practice

8 Jear -o o+;#p S#rvey in %ath

! 7 @5 (G<> of those contacted) G9> +omen Pain D#ration M 7 <8: months (SD 7 <59.

!oteB Thanks to &evin =o+ es . Fane Khao;'L%rien

Meas#res

5;<5 ratin( of pain Sickness Empact Profi e Pain An/iety Symptoms Sca e %ritish Co #m)ia MaMor Depression Enventory Medica =isits (past si/ months) Chronic Pain Acceptance N#estionnaire

'#tcome at 8 Jears
Pre;T/ Pain Physica Disa)i ity Psychosocia Disa)i ity An/iety #$%& ( .!'# $(% (. (# $)* (. *# +#$,) ( !.*+# 8 Jr -;#p #$'& ( .!'# $() (. )# $(* (. '# ')$** (((. '# Si( O.5: O.55< O.55< O.55< ,ffect Si*e (d) .88 .G5 .G8 .68

1contin#ed
Pre;T/ Depression Medica =isits Acceptance M.A/ )&$,( ( (."'# ,$)& (,.)*# ,-$#( ( ,. (# 8 Jr -;#p (,$&+ ( (.*# )$&, ((.!+# #%$,, ((,.-*# Si( O.55< O.55< O.55< ,ffect Si*e (d) .@4 .:5 <.4: .6<

d > .2 small, > .5 medium, > .8 large. large

Empact of C%T and ACT Mode s in Psycho o(y Trainee Therapists

Participants +ere 4I peop e seekin( treatment for depression or interpersona pro) ems. Matched pairs random y assi(ned to )e treated for <5 session of either ACT or C%T. TherapistsB <9 masterDs st#dents +ith 8;9 years st#dy in psycho o(y +ith itt e or no prior treatment e/perience. ,ach therapist treated one ACT and one C%T case.

Lappa ainen et a . %ehavior Modification 4556A8<B9II;:<<.

Therapist Trainin(
C%T

ACT

<4 ho#rs ect#re in C%T I: pa(es readin( +eek y (ro#p s#pervision

G ho#r ect#re in ACT 8@ pa(es readin( +eek y (ro#p s#pervision

Note: Both training conditions were embedded in a one semester ordinary Clinical eaching !rogram consisting of 2" hours lecture and #" hours clinical case Su!er$ision. he course em!hasi%ed e$idence&based a!!roaches. a!!roaches

Primary C ient '#tcomeB ?SE of SCL;@5

?ro#p ACT C%T

,ffect at post T/ <.<< .:G

,ffect at fo o+;#p <.59 .4I

Note: Calculated as Cohen's d. (small > .2") medium > .5") large > .8"*

'ther Res# ts
Acceptance appeared to )e the most important process to o#tcome in )oth (ro#ps. At the start of treatment therapists reported ess kno+ ed(e of ACT. Therapists fear and tension d#rin( treatment decreased in C%T )#t not in ACT.

More Empactf# Treatment in the -#t#re

Conte/t#a

A) e to e/perientia y manip# ate f#nctiona active inf #ences o#tside of ta kin( and thinkin( A) e to inc #de empathy, intimacy, and carin( A) e to radica y contact pain and s#fferin(, and to earn to sit +ith it, open y, +itho#t resistance, +henever reP#ired.

Compassionate

Co#ra(eo#s

S#mmary

Psycho o(ica approaches to chronic pain are deve opin( and no+ inc #de the notion of psycho o(ica f e/i)i ity They emphasi*e that s#fferin( is norma , and inc #de acceptance. These approaches reP#ire treatment providers to

face discomfort act +ith a+areness and f e/i)i ity enter carin( re ationships +ith peop e +ith pain.

Thank yo#