Acceptance and
Commitment Therapy
(ACT) and Chronic Pain
Lance M. McCracken, PhD
Centre for Pain Services
Royal National Hospital for Rheumatic Diseases
Centre for Pain Research
University of Bath
Bath UK
Outline of Talk
Propose that psychological approaches to
chronic pain are developing
Describe an ACT model.
Summarize the state of outcome literature
on ACT for chronic pain.
Suggest that
o Suffering is normal
o control is often unworkable
o your mind cannot be trusted
The Evolution of Clinical Psychology
Underlying Processes of Target Therapy
Framework Pathology Processes
Operant Conditioning Behavior Conditioning
Cognitive Conditioning, Behavior and Skills training,
Behavioral attention, cog symptoms exposure,
bias, thinking, (physical & cognitive
believing emotional) therapy
Contextual Avoidance, Behavior Acceptance,
(MBSR, ACT) cog fusion, defusion,
self, values, mindfulness,
commitment, values, skills
loss of present training,
relationship
“…there is little empirical support for
the role of cognitive change as causal
in symptomatic improvements
achieved in CBT.”
(Longmore & Worrell, 2007)
Method
N = 2,345 people attending treatment
for chronic pain.
Measures of outcome administered
pre-, post, and 1 month follow-up.
Measures of adherence to treatment
methods measured at 1 month follow-
up.
Results
Adherence to pacing, thought
challenging, stretching, and exercise
had very small relations with outcome
variables.
Variance in wellbeing at follow-up
accounted for by adherence factors
ranged from 1 to 2%.
“If taken at face value, the findings
suggest that both theory and practice
of recommending adherence to
treatment methods require re-
examination if not overhaul.” (p 187)
Therapist Drift
Therapists often to not fully implement
CBT.
This usually includes shifting focus
from doing to talking.
This arises from therapist cognitive
distortions, emotional reactions, and
avoidance.
Waller G. Evidence-based treatment and therapist drift.
BRAT 2009; 47: 119-127.
“Our biggest single problem in implementing CBT
is that many clinicians fail to push for behavior
change (e.g., exposure, behavioral activation, …)
despite the evidence that these elements of
treatment are the most important.”
“Our being ‘nice to’ or ‘protective of’ the patient
can worsen the problem.”
International Journal of Stress Management 2005:12:164-176.
Suffering is Normal
o 15% to 30% of adults have chronic pain.
o 19% to 30% of the population suffers
from a diagnosable psychological
disorder in any given year.
o The lifetime prevalence of psychological
disorders is nearly 50%.
Kessler et al. Arch Gen Psychiatry 2005; 62: 593-602.
The ACT model of Psychopathology
Dominance of the
Conceptualized Past and Feared
Future
Experiential Lack of Values
Avoidance Clarity
Psychological
Inflexibility
Cognitive Inaction, Impulsivity,
Fusion or Avoidant
Persistence
Attachment to the
Conceptualized Self
“Psychological Inflexibility”
A process based in interactions of
language and cognition with direct
experiences that produces 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.
ACT Treatment Processes
Contact with the
Present Moment
Acceptance Values
Psychological
Flexibility
Cognitive Committed
Defusion Action
Self as
Context
Experience Thoughts and Feelings
Detect
know a thought or
feeling is present
Register the content
understand the
message of the
experience
Believe/heed
take it as true
Fuse
contact it as the only
experience present
Chronic Pain and Suffering
Pain Distress &
Discomfort
Poor Unwillingness
Functioning Inflexibility
Avoidance
Chronic Pain and Suffering
Pain Distress &
Discomfort
Poor Unwillingness
Functioning Inflexibility
Avoidance
Chronic Pain and Suffering
Pain Distress &
Discomfort
Poor Unwillingness
Functioning Inflexibility
Avoidance
ACT-Based Treatment for
Chronic Pain
Dahl et al., 2004. Behav Ther
McCracken et al., 2005. Behav Res Ther
McCracken et al., 2007. Eur J Pain
Vowles & McCracken, 2008. J Consult Clin
Psychol
Wicksell et al., 2008. Eur J Pain
Vowles et al. 2009. Cog Behav Practice
3 Year Follow-up Survey in Bath
N = 90 (61% of those contacted)
64% women
Pain Duration M = 135 months (SD =
104.
Note: Thanks to Kevin Vowles & Jane Zhao-O'Brien
Measures
0-10 rating of pain
Sickness Impact Profile
Pain Anxiety Symptoms Scale
British Columbia Major Depression
Inventory
Medical Visits (past six months)
Chronic Pain Acceptance Questionnaire
Outcome at 3 Years
Pre-Tx 3 Yr F-up Sig Effect Size (d)
Pain 6.97 6.37 .2 small, > .5 medium, > .8 large.
large
Impact of CBT and ACT Models in
Psychology Trainee Therapists
Participants were 28 people seeking
treatment for depression or interpersonal
problems.
Matched pairs randomly assigned to be
treated for 10 session of either ACT or CBT.
Therapists: 14 master’s students with 3-4
years study in psychology with little or no
prior treatment experience.
Each therapist treated one ACT and one
CBT case.
Lappalainen et al. Behavior Modification 2007;31:488-511.
Therapist Training
CBT ACT
12 hours lecture in 6 hour lecture in ACT
CBT 39 pages reading
85 pages reading weekly group
weekly group supervision
supervision
Note: Both training conditions were embedded in a one semester ordinary
Clinical Teaching program consisting of 20 hours lecture and 30 hours
clinical case Supervision. The course emphasized evidence-based approaches.
approaches
Primary Client Outcome:
GSI of SCL-90
Group Effect at Effect at
post Tx follow-up
ACT 1.11 1.04
CBT .56 .28
Note: Calculated as Cohen’s d. (small > .20; medium > .50; large > .80)
Other Results
Acceptance appeared to be the most
important process to outcome in both
groups.
At the start of treatment therapists
reported less knowledge of ACT.
Therapists fear and tension during
treatment decreased in CBT but not in
ACT.
More Impactful Treatment in
the Future
Contextual
Able to experientially manipulate functional
active influences outside of talking and
thinking
Compassionate
Able to include empathy, intimacy, and
caring
Courageous
Able to radically contact pain and suffering,
and to learn to sit with it, openly, without
resistance, whenever required.
Summary
Psychological approaches to chronic pain
are developing and now include the notion
of psychological flexibility
They emphasize that suffering is normal,
and include acceptance.
These approaches require treatment
providers to
face discomfort
act with awareness and flexibility
enter caring relationships with people with
pain.
Thank you