New directions in the psychology of chronic pain management

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

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 Teasdale et al. 2000 Jacobson et al. 2000 Kohlenberg & Tsai, 1991 Linehan 1993 H ayes et a l . 1999 Originators Relapse of Depression after CBT Mindfulness-Based Cognitive Therapy Couples Discord Integrative Behavioral Couples Therapy General Functional Analytic Psychotherapy Borderline Personality d/o Dialectical Behavior Therapy General Acceptance and Commitment Therapy Problem area Therapy Approach

“… there is little empirical support for the role of cognitive change as causal in 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 Avoidant Persistence Attachment to the Conceptualized Self Cognitive Fusion Experiential Avoidance

“ 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

Thought Action Context “ I can’t go on” Stopping Loss of contact With present Cognitive Fusion Experiential Unwillingness Values Failure

Thought Action Context or “ Psychological Flexibility” “ I can’t go on” Stopping Mindfulness Acceptance Cognitive De-fusion Values-based Action Carrying on

Dimensions of Cognition Fused – 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 Unhelpful Rational 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) .001 -.51 Depression .001 -.48 Alertness (SIP) .001 -.50 Psychosocial Disability .01 -.40 Physical Disability .05 -.27 Depression Interference .001 -.39 Pain-related Anxiety p < r

Regression Results: Variance Explained in Depression

Regression Results: Variance Explained in Psychosocial Disability

Regression Results: Variance Explained in Physical Disability

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. Behav Ther 2004;35:785-802.

Results: Mean number sick days per month

Medical Service Utilization: Physician, Specialist & Physiotherapist

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

Reliable Change Results (N = 114) Vowles & McCracken (under review). J Consult Clin Psychol 44.0 3.4 Disability 49.1 0 Pain-related Anxiety 41.8 0 Depression % Reliably Improved % Reliable Decline

Reliable Change - Continued Number of Domains Improved 7.14 1.65 1.34 Number needed to Treat 14.0 61.4 75.6 Percent Improved 16 70 86 Number of Patients > 3 > 2 > 1

Variance in Improvements accounted for by Changes Acceptance and Values * p < .01 Disability Anxiety Depression Outcome β Values β A cceptance ∆ R 2 -.03 -.41* .18* -.02 -.63* .33* -.06 -.36* .17*

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 * p < .01; ** p < .001 -.50** Values-based action -.43** Mindfulness -.35** Acceptance Emotional Exhaustion (0-10)

Selected Correlation Results * p < .01; ** p < .001 .52** Values-based action .30* Mindfulness .36** Acceptance General Health (SF-36)

Selected Correlation Results * p < .01; ** p < .001 .66** Values-based action .43** Mindfulness .52** Acceptance Vitality (SF-36)

Selected Correlation Results * p < .01; ** p < .001 .51** Values-based action .40** Mindfulness .74** Acceptance Emotional Functioning (SF-36)

Variance in Worker Functioning Explained by Acceptance, Mindfulness, and Values-based Action * P < .001 .61* Emotional Functioning .52* Vitality .25* General Health .31* Emotional Exhaustion ∆ R 2 Criterion Variable

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.

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New directions in the psychology of chronic pain management