1. Building our Tower: Evidence for Acceptance, Mindfulness, and Values in the Treatment of Chronic Pain Kevin E. Vowles, Ph.D. University of Bath Association for Contextual Behavioral Science 01 July 2009

2. My take on science Its slow....Its slow.... And its methodicalAnd its methodical

3. And its possible to get something pretty cool

4. Ideas for today Give some theoretical background.Give some theoretical background. Review and rate the evidence to date.Review and rate the evidence to date. –Including our “hot off the presses” 3 year follow-up data.

5. Radical Idea? For many with chronic pain, pain intensity may be viewed as an untreatable symptom.For many with chronic pain, pain intensity may be viewed as an untreatable symptom.

6. Consider this: Chronic pain is frequent.Chronic pain is frequent. For approx 85% of chronic pain sufferers, pain appears permanent.For approx 85% of chronic pain sufferers, pain appears permanent. There are no medical interventions available that reliably reduce the severity of pain (or improve functioning).There are no medical interventions available that reliably reduce the severity of pain (or improve functioning).

7. A question then... What are we treating?

8. Pain and Suffering PainSuffering

9. The Natural Response to Pain “Its important to keep fighting this pain.”“Its important to keep fighting this pain.” –Endorsed as “Always True” or “Almost Always True” by 92% of patients McCracken, Vowles, & Eccleston, 2004, Pain

10. The Impact of Frequent Struggling Single best predictor of:Single best predictor of: –Worse Pain –Poorer Activity –Greater Disability –Worse Depression –Greater Avoidance Both at one point in time and at ~4 months in the futureBoth at one point in time and at ~4 months in the future McCracken, Eccleston & Bell, 2005, Eur J Pain McCracken, Vowles, & Gauntlett-Gilbert, 2007, J Behavioral Medicine J Behavioral Medicine Vowles & McCracken, under review

11. Pain and Suffering PainSuffering

12. Pain and Suffering Struggling with Pain Failure Lost Freedom & Opportunity Suffering Multiplied Pain

13. Pain and Suffering Struggling with Pain Failure Lost Freedom & Opportunity Suffering Multiplied Pain

14. Pain and Suffering Struggling with Pain Failure Lost Freedom & Opportunity Suffering Multiplied Pain

15. Pain and Suffering Maintained Life Direction Failure Lost Freedom & Opportunity Suffering Multiplied Pain

16. Pain and Suffering Maintained Life Direction Success Lost Freedom & Opportunity Suffering Multiplied Pain

17. Pain and Suffering Maintained Life Direction Success Freedom & Opportunity Suffering Multiplied Pain

18. Pain and Suffering Maintained Life Direction Success Freedom & Opportunity Suffering Reduced Pain

19. Willingness will·ing (adj.) will·ing (adj.) Disposed or inclined; prepared: I am willing to overlook your mistakes.Disposed or inclined; prepared: I am willing to overlook your mistakes. Done, given, accepted, or borne voluntarily or ungrudgingly. See Synonyms at voluntary.Done, given, accepted, or borne voluntarily or ungrudgingly. See Synonyms at voluntary.voluntary Of or relating to exercise of the will; volitional.Of or relating to exercise of the will; volitional. Will (noun) The mental faculty by which one deliberately chooses or decides upon a course of action: championed freedom of will against a doctrine of predetermination.The mental faculty by which one deliberately chooses or decides upon a course of action: championed freedom of will against a doctrine of predetermination. The American Heritage® Dictionary of the English Language, Fourth Edition. Ret 05 Feb 2008, from: http://dictionary.reference.com/browse/willing

20. A treatment approach

21. Key Processes Acceptance and Mindfulness:Acceptance and Mindfulness: –Involves decreasing the influence of problematic thoughts, feelings, and sensations on living. –Includes a willingness to experience pain/distress without attempts to control them. –A quality of action occurring while in contact with these experiences. Values-based Action:Values-based Action: –Actions directed towards personally meaningful purposes, rather than towards the elimination of unwanted experiences

22. Treatment Outcomes 10 published studies10 published studies Improvements in:Improvements in: –Pain –Disability –Distress (i.e. Depression, Anxiety) –Healthcare Utilization –Physical Performance –Work & School Attendance –Acceptance –Mindfulness –Values-based action –In comparison to “treatment as usual” or waitlists. –Gains persist (i.e., 3-6 months) Dahl et al., 2004; McCracken et al., 2005; 2007; Vowles et al., 2007a; 2007b; 2008; 2009; Wicksell et al., 2007, 2008, 2009.

23. Treatment effect size Vowles & McCracken, 2008; J Consulting and Clinical Psychology

24. Adding another block: 3 year follow-up data

26. State of Evidence? GeneralizabilityGeneralizability ReliabilityReliability StabilityStability ValidityValidity

27. Thanks for your attention k.vowles@bath.ac.uk www.bath.ac.uk/pain-management/