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: hayes@unr.edu)

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: hayes@unr.edu • ACBS www.contextualpsychology.org• The next large conference is WorldCon X in DC, July 21-25