2. Healthy Ways to Deal with Chronic Pain: An Acceptance and Commitment Therapy Perspective Healthy Ways to Deal with Chronic Pain: An Acceptance and Commitment Therapy Perspective Steven C. Hayes University of Nevada

3. 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

4. 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

5. 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.

6. The data are hardly reassuring...

7. 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

8. 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

9. 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.

10. E.g., Physical Ability Vowles & Gross, 2003, Pain

11. 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

12. Data Like These Raise a Question... What are we treating?

13. 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

14. The Problem is That We All Normally Think PainSuffering

15. Therefore, for pain patients … “Its important to keep fighting this pain.” Is endorsed by 92% of patients! McCracken, Vowles, & Eccleston, 2004, Pain

16. 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

17. Willingness and Acceptance My tinnitus as an example

18. A Larger System Supports This Link PainSuffering

19. The System Creating Suffering Struggling with Pain Failure Lost Freedom & Opportunity Suffering Multiplied Pain

20. The Cycle of Suffering Struggling with Pain Failure Lost Freedom & Opportunity Suffering Multiplied Pain

21. The Cycle of Suffering Struggling with Pain Failure Increase Pain Focus & Lost Freedom & Opportunity Suffering Multiplied Pain More

22. Breaking the Cycle of Suffering Failure Lost Freedom & Opportunity Suffering Multiplied Pain Self- Compassion And Life Direction

23. Breaking the Cycle of Suffering Failure Freedom & Opportunity Suffering Multiplied Pain Maintained Life Direction

24. Breaking the Cycle of Suffering Success Freedom & Opportunity Suffering Multiplied Pain Maintained Life Direction

25. Breaking the Cycle of Suffering Success Freedom & Opportunity Suffering Reduced Pain Maintained Life Direction

26. Breaking the Cycle of Suffering Success Freedom & Opportunity Suffering Reduced Pain? Maintained Life Direction

27. 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)

28. 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 work- site/home  Baseline=60 days, intervention: 4 1-hr sessions over 30 days, FU 60 days  2 therapists: 1 experienced CBT, 1 nurse

29. Cohen’s d at follow-up = 1.00

30. 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

31. 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

32. 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 PostF-Up

33. Pain Interference 2 Post3.5 mo6.5 mo Pain Interference (1-10) Pre 4 6 MDT ACT

34. 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

35. Between Effect Sizes (p eta sq) Post 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

36. For Example, Life Satisfaction PrePost4 Month 25 20 15 Follow Up Satisfaction w Life Scale TAU ACT

37. 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

39. 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

40. Effect Sizes at 3-36 Mo. Follow Up.2.5.81.11.5 SmallMediumLarge Acceptance Values Success Values Discrepancy Pain Depression Pain-Related Anxiety Physical Disability Psychosocial Disability Medical Visits 3 Month Follow Up 36 Month Follow Up

41. 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

42. 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)

43. 4/29/2015 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 six- hour workshop) or diabetes education (also a six hour workshop) Pre, post, 3-month follow-up

44. Change (Pre to Follow up) AAQ (Diabetes) Ed’nACT Self- Management Ed’nACT % in Diabetic Control Ed’nACT 50% 25% 0% 50% 25% 0% 10 5 0 Level 3 Process Evidence AAQD and Self-Management mediate blood glucose outcomes

45. 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 Cancer Patients: ACT and CBT Rost, Wilson, Hildebrandt, & Mutch, in press

46. Impact on Distress (POMS) (change scores) Wilks’ Lambda=.722, F(3,29)=3.722, p=.022 Session 12 d =.9

47. 4/29/2015 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

48. Psychological Flexibility The ACT Model

49. The two-minute Persuasion Exercise

50. 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

51. 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

52. 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.

53. 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

54. 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

55. 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.”

56. Exercise – Part II Speaker: You still want to change. Listener: Listen reflectively. Speaker: Can respond with elaboration.

57. 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

58. 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

59. A Focus on Values –Form an answer to the questions: “What do you want your life to stand for?” “What brings meaning to life?”

60. Example Values Domains Friends Family Relationships Intimate Relationships Work / Career Education / Learning Self Development/Learning Recreation / Leisure Spirituality Citizenship / Community Health / Well-Being

61. 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

62. A Model for Treatment Improved willingness to have the experience of pain + More frequent engagement in valued activity over the longer term = Progress

63. Learning ACT Join ACBS www.contextualpsychology.org There are about 60 books available including three in the area of chronic pain

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