1. Psychological Treatments for Chronic Pain: The Example of Acceptance & Commitment Therapy for Chronic Pain Kevin E. Vowles, Ph.D. 5 th Annual A Thoughtful Approach to Pain Management Medford, OR 20 March 2016

2. Disclosures Grant Funding: Grant Funding: NIH: PI: NIH: PI: 1 R34 AT008398-01, Cons: 1 R21 AT007939 01A1 Robert Wood Johnson Foundation Center for Health Policy, Robert Wood Johnson Foundation Pfizer Independent Grants for Learning and Change, Consultant MRC, EPSRC (UK). MRC, EPSRC (UK). No other financial affiliations to disclose. No other financial affiliations to disclose.

3. Goal and Assumptions Meaningful, Effective, Vital living: Only happens when effective living happens. Only happens when effective living happens. See Vowles, 2015, Introduction to Special Issue on Modern Behavior Therapies, Current Opinion in Psychology

4. The problem of pain can be conceptualized as one of behavior (not of pain). The problem with this behavior is that it is often directed towards pain control and away from areas that bring meaning and importance to living. 1976! 2014!

5. Meaningful, Effective, Vital living: Only happens when effective living happens. Only happens when effective living happens. Does not require feeling better, good, happy – or being pain free. Does not require feeling better, good, happy – or being pain free. Is about having options for behavior - AKA a “broad behavioral repertoire” Is about having options for behavior - AKA a “broad behavioral repertoire” See Vowles, 2015, Introduction to Special Issue on Modern Behavior Therapies, Current Opinion in Psychology Goal and Assumptions

6. “I can’t go on” ThoughtAction Stopping Context Overwhelmed by private content Unwillingness to Experience Valued Behavior Failures

7. “I can’t go on” ThoughtAction Stopping Context Willingness to experience Contact with thoughts & wider experience Persistence in values-based action Carrying on or

8. Outcomes through three years

9. Effect size estimates controlled for within participant correlation N = 108

10. Does it work? “To meet this standard, well-designed studies conducted by independent investigators must converge to support a treatment’s efficacy.”

11. Unfortunately, this answer isn’t quite sufficient Statistical significance is based on average effect. Statistical significance is based on average effect. We don’t know: We don’t know: If the change is meaningful. If the change is meaningful. Who experienced treatment success and failure. Who experienced treatment success and failure. How treatment worked. How treatment worked.

12. “Clinically Significant” Change Does change in an individual patient Does change in an individual patient 1. Exceed change that could be accounted for by measurement error alone? Reliable Change Reliable Change 2. Involve a shift from a “clinical” to a “recovered” distribution? Clinical Significance Clinical Significance Jacobson & Truax, 1991, J Consult & Clin Psych Jacobson et al., 1999, J Consult & Clin Psych

14. Measure Test-retest (r) Required value for reliable change 1 Mean (SD) for comparison group 2 Required value to be classified in non-clinical distribution 3 Depression (BCMDI).8312.616.2 (12.7)24.9 Pain-related anxiety (PASS).8617.032.0 (21.1)41.1 Disability (SIP).870.100.13 (.11)0.22 Data used in the calculation of reliable and clinically significant change at three month follow-up Notes: 1 Patient score must equal or exceed this value in order to be classified as reliably changed. 2 Comparison group data from Vowles et al. (2011). 3 Patient score must equal or fall below this value in order to be classified as changed at a level of clinical significance.

15. All patients Reliable worseningNo change Reliable improvement only Clinically significant change Disability1.4%67.6%5.4%25.6% Depression3.8%59.0%11.5%25.6% Pain-related anxiety1.3%60.5%10.5%27.6% Only patients with scores within clinical range at pre-treatment Reliable worseningNo change Reliable improvement only Clinically significant change Depression3.3% 55.7%14.8%26.2% Pain-related anxiety0.0%48.9%17.0%34.0% Disability2.1%60.4%8.3%29.2%

16. In clinical range at pre-treatmentAll patients

17. Possible prerequisites for change? How does it work?

18. Decrease in Pain Intensity + Decrease in Distress

19. Interdisciplinary program of ACT Duration: ~6 hrs daily for 4 weeks, 2 days/wk Intended for highly disabled or distressed individuals The treatment program: Pain Distress *Vowles, Witkiewitz, Levell, Sowden, & Ashworth, under review.

20. 174 treated patients Growth Mixture Modeling used to assess within- and between individual trajectory of change in pain and distress in relation to improvement at 3 mo f/u. Trajectory of change in pain and distress unrelated to improvement in: physical disability, psychosocial disability, depression, pain- related fear, pain acceptance, values engagement, observed physical functioning, # pain-related medical visits *2 Exceptions, improvements in: 1. Pain-related anxiety related to pain trajectory 2. Psychosocial disability related to distress trajectory

21. Improved willingness to have the experience of pain + More frequent engagement in valued activity over the longer term = (should) WITH Pain

22. The impact of more willingness and more values-based activity Better: Current emotional and physical functioning Vowles & McCracken, 2008, Health Psych; Vowles et al., 2008, Pain; Vowles & Thompson, 2012; Vowles et al., CJP; Vowles et al., 2014, Beh Ther Future emotional and physical functioning McCracken & Vowles, 2008, Health Psych; Vowles et al., 2011, BRAT Improvements in emotional and physical functioning in the months and years following treatment Vowles et al., 2007, Eur J Pain; Vowles & McCracken, 2008, J Consult Clin Psych; Vowles et al., 2011, BRAT; Vowles et al., 2014, J Pain; Vowles et al., 2014 J Contextual Beh Psychology

23. Struggle/ Unwillingness Valued & Quality Living

26. 3 mo. Outcomes: Disability:Reliably improved Values:From 70% to 25% Discrepant Med Visits in prev 3 months : From 5 to 0

27. 3 mo. Outcomes: Disability:Reliably improved Values:From 53% to 30% Discrepant Med Visits in prev 3 months : From 15 to 2

28. 3 mo. Outcomes: Disability:Not reliably improved Values:From 60% to 43% Discrepant Med Visits in prev 3 months : From 0 to 0

29. 21 treated patients If change in struggle/values, then reliable change in f/u disability 8/10 patients; 80% “hit”/20% “miss” rate If no change in struggle/values, then no reliable change in f/u disability 9/11 patients; 82% “hit”/18% “miss” rate Vowles, Cohen, & Fink (2014). Journal of Contextual Behavioral Science.

30. Change in Pain? Decreased Pain Same PainWorse Pain +RC2 (9.5%)7 (33.3%)1 (4.8%) -RC5 (23.8%)6 (28.6%)--

31. Summary Psychosocial treatments appear to work, on average. Psychosocial treatments appear to work, on average. It seems important to: It seems important to: Explicitly state our success criteria to determine rates of “success” and “failure” Explicitly state our success criteria to determine rates of “success” and “failure” Expressly test mechanisms of treatment effect so that treatments can target them more explicitly. Expressly test mechanisms of treatment effect so that treatments can target them more explicitly.

32. From: www.flickr.com/photos/-leethal-/4296360438/ Connecting the dots... There can be an augmentation of willingness to have unpleasant and aversive experiences... in the service of what we hold to be important... and this seems to be associated with improved functioning over follow-up periods (typically 3-9 months). This is my understanding of what is referred to as Acceptance and Commitment Therapy

33. Thanks for your attention. Questions? k.e.vowles@gmail.com