Lecture followed audience discussion on contextual cognitive behaviour therapy and acceptance and commitment therapy in the management of chronic pain from the West of Scotland Pain Group on Wednesday 5th December 2007. The speaker is Lance M. McCracken PhD, of the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases & University of Bath, Bath UK. www.wspg.org.uk Further reading: DAHL, J., & LUNDGREN, T. (2006). Living beyond your pain using acceptance and commitment therapy to ease chronic pain. Oakland, CA, New Harbinger Publications. http://www.worldcat.org/oclc/63472470 HAYES, S. C., STROSAHL, K., & WILSON, K. G. (1999). Acceptance and commitment therapy an experiential approach to behavior change. New York, Guilford Press. http://www.worldcat.org/oclc/41712470 MCCRACKEN, L. M. (2005). Contextual cognitive-behavioral therapy for chronic pain. Progress in pain research and management, v. 33. Seattle, IASP Press. http://www.worldcat.org/oclc/57564664

1. New Directions in The Psychology of Chronic Pain Management Lance M. McCracken, PhD Pain Management Unit Royal National Hospital for Rheumatic Diseases & University of Bath Bath UK

2. Bath Pain Management Unit

10. “ Third Wave” Therapies Teasdale et al. 2000 Jacobson et al. 2000 Kohlenberg & Tsai, 1991 Linehan 1993 H ayes et a l . 1999 Originators Relapse of Depression after CBT Mindfulness-Based Cognitive Therapy Couples Discord Integrative Behavioral Couples Therapy General Functional Analytic Psychotherapy Borderline Personality d/o Dialectical Behavior Therapy General Acceptance and Commitment Therapy Problem area Therapy Approach

12. “… there is little empirical support for the role of cognitive change as causal in symptomatic improvements achieved in CBT.” (Longmore & Worrell, 2007)

14. “ The single most remarkable fact about human existence is how hard it is for humans to be happy.” (Hayes, Strosahl, & Wilson, 1999)

15. The ACT model of Psychopathology Psychological Inflexibility Dominance of the Conceptualized Past and Feared Future Lack of Values Clarity Inaction, Impulsivity, or Avoidant Persistence Attachment to the Conceptualized Self Cognitive Fusion Experiential Avoidance

20. Thought Action Context “ I can’t go on” Stopping Loss of contact With present Cognitive Fusion Experiential Unwillingness Values Failure

21. Thought Action Context or “ Psychological Flexibility” “ I can’t go on” Stopping Mindfulness Acceptance Cognitive De-fusion Values-based Action Carrying on

22. Dimensions of Cognition Fused – Overwhelmed by thought content, loss of contact with present situation, behavioral options narrowed. De-fused - Aware of reactions as reactions, contact with wider situation beyond thoughts, access to a range of responses True Untrue Helpful Unhelpful Rational Irrational

30. Correlations of Mindfulness with Patient Functioning (N = 105) .001 -.51 Depression .001 -.48 Alertness (SIP) .001 -.50 Psychosocial Disability .01 -.40 Physical Disability .05 -.27 Depression Interference .001 -.39 Pain-related Anxiety p < r

31. Regression Results: Variance Explained in Depression

32. Regression Results: Variance Explained in Psychosocial Disability

33. Regression Results: Variance Explained in Physical Disability

35. Results: Mean number sick days per month

36. Medical Service Utilization: Physician, Specialist & Physiotherapist

39. Results from CCBT for Chronic Pain: Post Treatment and 3-Month Follow-up

40. Reliable Change Results (N = 114) Vowles & McCracken (under review). J Consult Clin Psychol 44.0 3.4 Disability 49.1 0 Pain-related Anxiety 41.8 0 Depression % Reliably Improved % Reliable Decline

41. Reliable Change - Continued Number of Domains Improved 7.14 1.65 1.34 Number needed to Treat 14.0 61.4 75.6 Percent Improved 16 70 86 Number of Patients > 3 > 2 > 1

42. Variance in Improvements accounted for by Changes Acceptance and Values * p < .01 Disability Anxiety Depression Outcome β Values β A cceptance ∆ R 2 -.03 -.41* .18* -.02 -.63* .33* -.06 -.36* .17*

44. Selected Correlation Results * p < .01; ** p < .001 -.50** Values-based action -.43** Mindfulness -.35** Acceptance Emotional Exhaustion (0-10)

45. Selected Correlation Results * p < .01; ** p < .001 .52** Values-based action .30* Mindfulness .36** Acceptance General Health (SF-36)

46. Selected Correlation Results * p < .01; ** p < .001 .66** Values-based action .43** Mindfulness .52** Acceptance Vitality (SF-36)

47. Selected Correlation Results * p < .01; ** p < .001 .51** Values-based action .40** Mindfulness .74** Acceptance Emotional Functioning (SF-36)

48. Variance in Worker Functioning Explained by Acceptance, Mindfulness, and Values-based Action * P < .001 .61* Emotional Functioning .52* Vitality .25* General Health .31* Emotional Exhaustion ∆ R 2 Criterion Variable

51. Thank you.