Healthy Ways to Deal
with Chronic Pain:
An Acceptance and
Commitment Therapy
Perspective
Steven C. Hayes
University of Nevada
My 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 it
Our 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 common
e.g., Breivik et al., 2006; Gureje et al., 1998
• remits in only a minority of cases
e.g., Andersson, 2004; Elliott et al., 2002
• does not reliably respond to our clinical
arsenal over the longer term
e.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 Review
Chou 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
∆ Pain-Related Fear
∆ Pain Intensity
25
% Variance (r-square)
20
15
10
5
0
∆ Floor to Waist Lift
Vowles & Gross, 2003, Pain
∆ Waist to Shoulder Lift
Future Work Status
• Following treatment (6 months later):
– Degree of pain was a nonsignificant predictor (posttreatment 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 Med
Vowles & McCracken, 2010, Beh Res & Therapy
Willingness
and Acceptance
• My tinnitus as an example
A Larger System
Supports This Link
Pain
Suffering
The System Creating Suffering
Pain
Suffering
Multiplied
Struggling
with Pain
Lost Freedom &
Opportunity
Failure
The Cycle of Suffering
Pain
Suffering
Multiplied
Struggling
with Pain
Lost Freedom &
Opportunity
Failure
The Cycle of Suffering
More
Pain
Suffering
Multiplied
Struggling
with Pain
Increase Pain Focus
& Lost Freedom &
Opportunity
Failure
Breaking the Cycle of Suffering
SelfCompassion
And Life Direction
Lost Freedom &
Suffering
Opportunity
Multiplied
Pain
Failure
Breaking the Cycle of Suffering
Pain
Maintained
Life Direction
Freedom &
Opportunity
Suffering
Multiplied
Failure
Breaking the Cycle of Suffering
Pain
Maintained
Life Direction
Freedom &
Opportunity
Suffering
Multiplied
Success
Breaking the Cycle of Suffering
Pain
Maintained
Life Direction
Freedom &
Opportunity
Suffering
Reduced
Success
Breaking the Cycle of Suffering
Pain?
Maintained
Life Direction
Freedom &
Opportunity
Suffering
Reduced
Success
The 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 Pain
Dahl, 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 worksite/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
Average Total # Sick Days
80
70
60
ACT
TAU
50
Cohen’s d at
follow-up =
1.00
40
30
20
10
6
FU
m
o
4
FU
m
o
2
o
m
FU
rv
en
ti o
n
5
In
te
B
L
m
o
3
o
m
L
B
B
L
m
o
1
0
Pediatric Pain
Wicksell 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 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)
Post
•
•
•
•
•
•
•
•
Fight with pain
Pain intensity
Pain interference
Physical health
Mental health
Depression
Fear of movement
Pain related worry
.29***
.13**
.16**
.03
.15**
.12*
.21***
.34***
* p < .1; **p < .05; *** p < .01; medium = .09; large = .25
F-Up
.23***
.13**
.09
.05
.11*
.10*
.12*
.15**
Pain Interference
6
MDT
4
ACT
2
Pre
Post
3.5 mo
6.5 mo
Whiplash
Wicksell 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)
Post through F-U
•
•
•
•
•
•
Pain disability
Life satisfaction
Fear of movement
Depression
Pain intensity
Pain interference
All p < .01 except as indicated; medium = .09, large = .25
.44
.40
.40
.60
.01 n.s.
.31
Satisfaction w Life Scale
For Example, Life Satisfaction
25
ACT
20
TAU
15
Pre
Post
4 Month
Follow Up
Chronic Pain
McCracken, Vowles, & Eccleston, BRAT, 2005
Effectiveness trial: 108 chronic pain patients
Average of 132 months of Chronic pain
6.3 treatment programs
Multidisciplinary in-patient program
Within subject analysis: Preassessment; 3.9
months later (on average) pretreatment
assessment; 3-4 week residential program; 3
month follow-up
Pa
in
De
I
pre n ten
sity
Pa
s si
inon
r el
( BD
ate
I)
Ph
da
ys i
n
Ps
x ie
ca
y ch
lD
ty
os
is a
oc
bili
ial
ty
Dis
ab
Pa
ility
Pa
in
in
Re
Me
s tin
dic
g
a ti
on
Us
e
GP
v is
it s
Tim
ed
Wa
S it
lk
- St
an
d /m
in
Percent Improvement
Impact on Chronic Pain
Ass't to Pre (M=3.9 mo) and Pre to F-Up (M=3.9 mo)
50%
40%
30%
20%
10%
0%
-10%
Three Year Follow Up
Vowles, McCracken & O’Brien, BRAT, 2011
108 chronic pain patients treated with ACT
Follow up data at three month and 3 years
Effect Sizes at 3-36 Mo. Follow Up
Small
Medium
Large
Acceptance
3 Month
Follow Up
Values Success
36 Month
Follow Up
Values Discrepancy
Pain
Depression
Pain-Related Anxiety
Physical Disability
Psychosocial Disability
Medical Visits
.2
.5
.8
1.1
1.5
A 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 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)
ACT for Diabetes Management
Gregg, Callaghan, Hayes, & Glenn-Lawson, 2008, JCCP
• Randomized controlled trial with poor, mostly
minority clients
• 40 / group: ACT plus diabetes education (one sixhour workshop) or diabetes education (also a six
hour workshop)
• Pre, post, 3-month follow-up
3/12/2016
Level 3
Process
Evidence
Change (Pre to Follow up)
AAQ
(Diabetes)
% in
Diabetic
Control
SelfManagement
10
50%
50%
5
25%
25%
0
0%
0%
Ed’n ACT
Ed’n ACT
AAQD and Self-Management mediate
blood glucose outcomes
Ed’n ACT
Psychological Adjustment Among
Cancer Patients: ACT and CBT
Rost, Wilson, Hildebrandt, & Mutch, in press
• 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)
Impact on Distress (POMS)
(change scores)
CBT
0
Session 12
d = .9
-20
ACT
-40
Pre
Session 4
Session 8 Session 12
Wilks’ Lambda=.722, F(3,29)=3.722, p=.022
My 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
3/12/2016
The ACT
Model
Contact with the
Present Moment
Acceptance
Values
Psychological
Flexibility
Defusion
Committed
Action
Self as
Context
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
• Guess at what they mean.
– (It’s ok to be wrong)
– “You want some help.”
• Experiment with statements
(questions are ok too).
synonyms
– “Sounds like . . . ”
– “Sounds like you are really
– “You are wondering if ...”
suffering and want someone to do
something about it.”
– “You are feeling (thinking,
hoping, etc.)”
Reflection of feeling –
– Express empathy
paraphrase emphasizing
emotional dimension.
• Can start w/simple reflections
– “This sounds as if its very
important to you.”
and then use advanced
• Rephrasing – Repeat with
•
• Paraphrase – best guess at
meaning.
– “You are hoping that the work we
do here today will bring some
meaning back in to your life.”
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
• Self Development/Learning
• Family Relationships
• Recreation / Leisure
• Intimate Relationships
• Spirituality
• Work / Career
• Citizenship / Community
• Education / Learning
• 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 ACT
Join ACBS
www.contextualpsychology.org
There are about 60 books available
including three in the area of chronic pain
QUESTIONS?
• Email: hayes@unr.edu
• ACBS
www.contextualpsychology.org
• The next large conference is
WorldCon X in DC, July 21-25