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Acceptance andAcceptance andCommitment TherapyCommitment Therapy
(ACT) and Chronic Pain(ACT) and Chronic Pain
Lance M. McCracken, PhDLance M. McCracken, PhD
Centre for Pain ServicesCentre for Pain Services
Roya !ationa "ospita for Rhe#matic DiseasesRoya !ationa "ospita for Rhe#matic Diseases
Centre for Pain ResearchCentre for Pain Research$niversity of %ath$niversity of %ath
%ath $&%ath $&
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'#tine of Tak'#tine of Tak
Propose that psychooica approaches toPropose that psychooica approaches to
chronic pain are deveopinchronic pain are deveopin
Descrie an ACT mode.Descrie an ACT mode.
S#mmari*e the state of o#tcome iterat#reS#mmari*e the state of o#tcome iterat#reon ACT for chronic pain.on ACT for chronic pain.
S#est thatS#est that
o S#fferin is normaS#fferin is norma
o contro is often #n+orkaecontro is often #n+orkae
o yo#r mind cannot e tr#stedyo#r mind cannot e tr#sted
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The vo#tion of Cinica Psychooy
$nderyin-rame+ork
Processes ofPathooy
Taret TherapyProcesses
'perant Conditionin %ehavior Conditionin
Conitive%ehaviora
Conditionin,attention, coias, thinkin,eievin
%ehavior andsymptoms(physica emotiona)
Skis trainin,e/pos#re,conitivetherapy
Conte/t#a(M%SR, ACT) Avoidance,co f#sion,sef, va#es,commitment,oss of present
%ehavior Acceptance,def#sion,mindf#ness,va#es, skistrainin,reationship
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0101there is itte empirica s#pport forthere is itte empirica s#pport for
the roe of conitive chane as ca#sathe roe of conitive chane as ca#sain symptomatic improvementsin symptomatic improvements
achieved in C%T.2achieved in C%T.2
(Lonmore 3orre, 4556)(Lonmore 3orre, 4556)
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MethodMethod
! 7 4,89: peope attendin treatment! 7 4,89: peope attendin treatment
for chronic pain.for chronic pain.
Meas#res of o#tcome administeredMeas#res of o#tcome administeredpre;, post, and < month foo+;#p.pre;, post, and < month foo+;#p.
Meas#res of adherence to treatmentMeas#res of adherence to treatment
methods meas#red at < month foo+;methods meas#red at < month foo+;#p.#p.
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Res#tsRes#ts
Adherence to pacin, tho#htAdherence to pacin, tho#ht
chaenin, stretchin, and e/ercisechaenin, stretchin, and e/ercise
had very sma reations +ith o#tcomehad very sma reations +ith o#tcomevariaes.variaes.
=ariance in +eein at foo+;#p=ariance in +eein at foo+;#p
acco#nted for y adherence factorsacco#nted for y adherence factors
raned from < to 4>.raned from < to 4>.
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If taken at face value, the findingsIf taken at face value, the findings
suggest that both theory and practicesuggest that both theory and practice
of recommending adherence toof recommending adherence totreatment methods require re-treatment methods require re-
examination if not overhaul. (p !"#examination if not overhaul. (p !"#
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Therapist DriftTherapist Drift
Therapists often to not f#y impementTherapists often to not f#y impement
C%T.C%T.
This #s#ay inc#des shiftin foc#sThis #s#ay inc#des shiftin foc#sfromfrom doindointoto takintakin..
This arises from therapist conitiveThis arises from therapist conitive
distortions, emotiona reactions, anddistortions, emotiona reactions, andavoidance.avoidance.
3aer ?. vidence;ased treatment and therapist drift.
%RAT 455@ 96B
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00'#r iest sine proem in impementin C%T'#r iest sine proem in impementin C%T
is that many cinicians fai to p#sh for ehavioris that many cinicians fai to p#sh for ehavior
chane (e.., e/pos#re, ehaviora activation, 1)chane (e.., e/pos#re, ehaviora activation, 1)
despite the evidence that these eements ofdespite the evidence that these eements of
treatment are the most important.2treatment are the most important.2
00'#r ein nice to or protective of the patient'#r ein nice to or protective of the patient
can +orsen the proem.2can +orsen the proem.2
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Enternationa Fo#rna of Stress Manaement 455:B
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Suffering is Normal
o to 85> of ad#ts have chronic pain. to 85> of ad#ts have chronic pain.
o to 85> of the pop#ation s#ffers to 85> of the pop#ation s#ffers
from a dianosae psychooicafrom a dianosae psychooica
disorder in any iven year.disorder in any iven year.
o The ifetime prevaence of psychooicaThe ifetime prevaence of psychooica
disorders is neary :5>.disorders is neary :5>.
&esser et a. Arch ?en Psychiatry 455: G4B :@8;G54.
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The ACT mode of Psychopathooy
Psychooica
Enfe/iiity
Dominance of the
Concept#ai*ed Past and -eared
-#t#re
Lack of =a#es
Carity
Enaction, Emp#sivity,or Avoidant
Persistence
Attachment to the
Concept#ai*ed Sef
Conitive
-#sion
/perientia
Avoidance
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-romB "ayes et a. $ehav %es &her455G 99B
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ACT Treatment Processes
Psychological
Flexibility
Contact with the
Present Moment
Values
Committed
Action
Self as
Context
CognitiveDefusion
Acceptance
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/perience Tho#hts and -eeins/perience Tho#hts and -eeins
DetectDetect kno+ a tho#ht orkno+ a tho#ht or
feein is presentfeein is present
Reister the contentReister the content
#nderstand the#nderstand themessae of themessae of thee/periencee/perience
%eieveHheed%eieveHheed take it as tr#etake it as tr#e
-#se-#se contact it as the onycontact it as the ony
e/perience presente/perience present
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Chronic Pain and S#fferinChronic Pain and S#fferin
nwillingness
!nflexibility
Avoidance
Poor
Functioning
Distress "Discomfort
Pain
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Chronic Pain and S#fferinChronic Pain and S#fferin
nwillingness
!nflexibility
Avoidance
Poor
Functioning
Distress "Discomfort
Pain
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Chronic Pain and S#fferinChronic Pain and S#fferin
nwillingness
!nflexibility
Avoidance
Poor
Functioning
Distress "Discomfort
Pain
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ACT;%ased Treatment forACT;%ased Treatment for
Chronic PainChronic Pain
Dah et a., 4559. %ehav TherDah et a., 4559. %ehav Ther
McCracken et a., 455:. %ehav Res TherMcCracken et a., 455:. %ehav Res Ther
McCracken et a., 4556. #r F PainMcCracken et a., 4556. #r F Pain =o+es McCracken, 455I. F Cons#t Cin=o+es McCracken, 455I. F Cons#t Cin
PsychoPsycho
3ickse et a., 455I. #r F Pain3ickse et a., 455I. #r F Pain
=o+es et a. 455@. Co %ehav Practice=o+es et a. 455@. Co %ehav Practice
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8 Jear -oo+;#p S#rvey in %ath8 Jear -oo+;#p S#rvey in %ath
!oteB Thanks to &evin =o+es Fane Khao;'%rien!oteB Thanks to &evin =o+es Fane Khao;'%rien
! 7 @5 (G of those contacted)! 7 @5 (G of those contacted)
G9> +omenG9> +omen
Pain D#ration M 7
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Meas#resMeas#res 5;
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Pre;T/ 8 Jr -;#p Si ffect Si*e (d)
Pain #$%&
(.!'#
#$'&
(.!'#
O.5: .88
PhysicaDisaiity
$(%(.#
$()(.)#
O.55< .G5
PsychosociaDisaiity $)*(.*# $(*(.'# O.55< .G8
An/iety +#$,)(!.*+#
')$**(.'#
O.55< .68
'#tcome at 8 Jears'#tcome at 8 Jears
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11contin#edcontin#ed
Pre;T/ 8 Jr -;#p Si ffect Si*e (d)
Depression )&$,((."'#
(,$&+(.*#
O.55< .@4
Medica =isits ,$)&(.)*#
)$&,(.!+#
O.55< .:5
Acceptance ,-$#((.#
#%$,,(.*#
O.55< .2 small, > .5 medium, > .8 larged > .2 small, > .5 medium, > .8 large.
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Empact of C%T and ACT Modes inEmpact of C%T and ACT Modes in
Psychooy Trainee TherapistsPsychooy Trainee Therapists
Participants +ere 4I peope seekinParticipants +ere 4I peope seekintreatment for depression or interpersonatreatment for depression or interpersona
proems.proems.
Matched pairs randomy assined to eMatched pairs randomy assined to etreated for
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Therapist TraininTherapist Trainin
C%TC%T
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Primary Cient '#tcomeBPrimary Cient '#tcomeB
?SE of SCL;@5?SE of SCL;@5
?ro#p ffect at
post T/
ffect at
foo+;#pACT .8"*. (small > .2") medium > .5") large > .8"*
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'ther Res#ts'ther Res#ts
Acceptance appeared to e the mostAcceptance appeared to e the most
important process to o#tcome in othimportant process to o#tcome in oth
ro#ps.ro#ps.At the start of treatment therapistsAt the start of treatment therapists
reported ess kno+ede of ACT.reported ess kno+ede of ACT.
Therapists fear and tension d#rinTherapists fear and tension d#rintreatment decreased in C%T #t not intreatment decreased in C%T #t not in
ACT.ACT.
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More Empactf# Treatment inMore Empactf# Treatment in
the -#t#rethe -#t#re
Conte/t#aConte/t#a Ae to e/perientiay manip#ate f#nctionaAe to e/perientiay manip#ate f#nctiona
active inf#ences o#tside of takin andactive inf#ences o#tside of takin andthinkinthinkin
CompassionateCompassionate Ae to inc#de empathy, intimacy, andAe to inc#de empathy, intimacy, and
carincarin Co#raeo#sCo#raeo#s
Ae to radicay contact pain and s#fferin,Ae to radicay contact pain and s#fferin,and to earn to sit +ith it, openy, +itho#tand to earn to sit +ith it, openy, +itho#tresistance, +henever re#ired.resistance, +henever re#ired.
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S#mmary
Psychooica approaches to chronic painare deveopin and no+ inc#de the notionof psychooica fe/iiity
They emphasi*e that s#fferin is norma,
and inc#de acceptance. These approaches re#ire treatment
providers to face discomfort act +ith a+areness and fe/iiity enter carin reationships +ith peope +ith
pain.
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Thank yo#Thank yo#