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Contextual Cognitive-Behavioral Therapy for Chronic pain (Progress in Pain Research and Management, Volume 33)

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You do not actually have to read the whole book. You can skip straight to chapter 7, then do values based action (which is covered in chapter 8).

I am told that Acceptance And Commitment Therapy For Chronic Pain is about as good. I have not read it and ordered the book I reviewed because it is shorter. Chapter 7 was only 18 pages long; more good news.

The material in this book is somewhat incompatable with the pain chapter in Mindfulness and Psychotherapy. Mindfulness and Psychotherapy seemed to want to use mindfulness as a way of relaxing and therby decreasing pain. I suppose, but I do not know for sure, that the approach of Mindfulness and Psychotherapy is compatible with MBST.

Much of the early chapters of the book are a comentary about ACT, rather than a description of what it is. The book goes very close to describing what relational frame theory is, but does not quite get there. It wouldn't have killed McCracken to put in a few pages about this. At least I now know that "functional contextualism" is a posh phrase way of saying "behaviorism" (pg. 26).

My own experience is that CBT and rational emotive therapy is a good foundation for ACT. There are two problems with going straight to ACT, a) you do not have to bypass a thougght if you can modify it and b) going straight to ACT is too much of a leap without the framwork of CBT. If you wanted to do CBT for chronic pain, perhaps you could use Cognitive Therapy for Chronic Pain: A Step-by-Step Guide. I find that Cognitive Therapy for Chronic Pain: A Step-by-Step Guide is a little hearltess and does not bring much to the CBT tablet that Beck et al had not already put there.

Below is a summary that I did for my own benefit.

Contextual Cognitive Behavioural Therapy for Chronic Pain
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Lance M. McCracken. 2005. IASP Press.

Foreword
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Bonica (1953) argued that even if the underlying disease was absent, pain could persist. Graded exposure is not used to control fear but to help patients develop a capacity to experience thoughts and feelings they may be avoiding.

Foreword
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The life role of thoughts and feelings can change even if the thoughts and feelings themselves do not change. Thoughts and feelings are situated events. So, the shift is from the content of the thoughts to the context and functioning of the thoughts and feelings.

1. The Problem of Chronic Pain
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Psychological variables such as depression and perception of work are the strongest predictors of treatment outcome.

The first wave of CBT used operant and stimulus-response theories. Second wave: social learning, cognitive processes and meditational models.

2. Psychological Approaches to Chronic Pain
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1879 was the year the first psychological laboratory was opened by Wilhelm Wundt. "Psychogenic pain": Otto Binswanger, 1904. Pain has both sensory and emotional qualities: Edward Tichener, 1909. Pavlov, 1920s. Gate control theory, Melzack and Wall, 1965.

Fordyce defined chronic pain as an excess of pain behavior and relative absence of well behaviour. All that was needed was the passage of time and exposure to systematic contingencies of reinforcement in the environment.

Some experiences of pain may occur to a discrimination problem: pain, anxiety, depression frequently occur at the same time.

Avoidance. Other things causing withdrawal include limitations in social skills, problem solving or neuropsychological deficits. Other things are family members, health care providers, emotional support, financial gain.

The "dead man test": if a dead man can do it, it can not be a behaviour. Over time, the operant approach included relaxation and biofeedback. There is little correlation between what people say about their pain and what they actually do. Spousal supportive behaviour important. A reinforcer must be measured to be a reinforcer - the definition should be functional rather than formal.

New approach: "Pain and Behavioural Medicine: A Cognitive Behavioural Perspective", by Turk, 1983. Two types: reappraisal and divert attention.

3. Contextual Cognitive-Behavioral Therapy
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"Psychology as the Behaviourist Sees It": 1913, Watson, rejected introspection completely; limited by truth by agreement or logical positivism.

Radical behaviorism restores some king of balance... does not dismiss them as subjective... It simply questions the nature of the object observed and the reliability of the observations: Skinner 1974.

Intermittently the environment elicits reflexive responses (respondents), but more frequently, on a moment-to-moment basis, it provides occasions for behaviours (operants) and consequences for those behaviours. There is a reciprocal relationship between the individual and the environment.

The term `behaviorism' does not always convey clear meaning in conversation... post-Skinnerian behaviorists instead use the term "functional contextualism." It expands on behaviorism of the past. The subject matter is the act in context. The context means the history of relevant events leading up to and including the current situation. Temporal and situational. Functionally, not structurally (what they mean and not what they look like). Cause is rules/verbal and past learning experiences.

Responses with different forms but the same function will gain strength in the process. For a pain sufferer, being irritable, complaining of pain, sleeping excessively and refusing invitations, may all have the same function - avoiding social occasions. The above are a response class because they are functionally similar but structurally different.

Functional antecedents form the basis for what is referred to as stimulus control, also known as discriminative stimulus control or cuing.

Some recon thoughts control behaviour and some recon the environment does. The both do. "I can't stand this pain" at their daughter's wedding.

Rule governed behaviour. Rules have been defined as antecedent, verbal, contingency-specifying stimuli. The rule does not have to be in awareness. Many behaviours persist despite problems with the outcomes.

There are three main classes of rule following: 1) because of past correlation between rule-following and contingencies, 2) socially mediated consequences and 3) changing the effectiveness of a reinforcing consequence. Examples of rules are "pain of exercise will help in the long term" and "pain means damage."

Verbal stimuli participate in events that they represent. Functional contextualism ' RFT ' ACT.

Relational frame theory is the broader theory that encompasses stimulus equivalence. Relational frame theory offers an account of how verbal stimuli come to acquire influences (cueing, evoking emotion, motivating, reinforcing) over other behaviour by participation in relations with the events they represent. Words that describe life events can readily take on the psychological properties and influences inherent in those events. These behaviour-influencing functions can then be readily transferred without direct training to other related stimuli. Importantly, these derived relations are arbitrary, not necessarily relying on any formal similarity between similarity between the related events. Once a class of related events is established, behaviour-influencing functions trained for one event can transfer to all members of the class. These transfers are contextually determined, such that the function of an event may be relationally determined in one situation but not in another. Behaviour that is acquired by these verbal processes can be extremely durable. Once derived relations are formed, further training does not eliminate them, and behaviour change can only occur by adding further relations not subtracting.

Verbal processes can add meaning and therefore suffering to experiences of chronic pain. Depression... Dougher and Hackbert 1994. Consequences that have never been directly encountered can nonetheless exert powerful influences in such as way that pain with movement can produce responses as if that pain means paralysis, a crumbling spine, repeated injury, death, insanity, or other conditions bearing no necessary relationship to the pain itself, leading for example, to what we see as pain-related fear and avoidance.

4. Contextual Cognitive-Behavioral Assessment
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Usual domains: severity, disability, emotional distress, social factors and coping. Coping includes overt and covert measures. Disability is a molar construct and not a patient behaviour. A patient can not be observed "doing disability." There are limitations that come with working at the level of inferred categories of functioning rather than behaviour itself. Topographical assessment can be misleading.

A psychological trait can be an effect rather than a cause. Description can be confused with explanation.

Generalizability vs. reliability and validity vs. treatment utility.

5. A Contextual Cognitive-Behavioral Model of Chronic Pain and Disability
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Human suffering is, to a great extent, a natural product of language and the highly verbal world in which we live. Verbal processed include avoidance, cognitive fusion, reason-giving, and other social processes.

Some methods are tested and discarded. Some methods are persisted with in spite of failure. The external world is more amenable to control than the internal world.

Being unwilling to be anxious or depressed with add to the suffering. They may say that their mood is tucked away and the just want to deal with the pain.

Avoid social stuff or guilt, embarrassment or shame. Avoidance is pejorative, control is less pejorative. Relationship between control and functioning is limited. You can measure beliefs about control. Control and avoidance are persistent behaviours because they work immediately.

Fusion: thoughts are blended together with the events they describe or the people who have them.

Treatment can include demonstrating that behaviours are not dangerous or harmful.

Feelings and thoughts are accepted as legitimate reasons for actions. Resting and avoidance of activity is perceived as a legitimate way of dealing with pain. Possible "causes" include psychological, stress, weather, aging, emotional problem. There can be stubborn behaviour patterns in the service of being right about the pain.

6. Acceptance of Chronic Pain
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Experimentally, acceptance gives better pain tolerance than psychological avoidance/control or general education.

The goal of mindfulness for chronic pain is to help the patient observe feelings in the body as bare sensation and to see mental processes, such as alarm reactions or evaluations, as separate, and no more accurate or important than any other thoughts passing through the mind. During the practice of mindfulness, pain sensations are seen for only what they are in the moment without added meaning from, for example, negative evaluations, catastrophic thinking or worries about the future. Similarly, urges to avoid or control pain-related experiences are seen as not requiring action.

MBSR consisted of 10 two-hour classes once weekly including body scan, breathing and yoga-based mindfulness exercises. All participants ere encouraged to practice formal medication for at least 45 minutes per day, six days per week.

ACT for people with psychotic symptoms (Bach and Hayes 2002). Explore previous attemtps to manage symptoms, possibility of observing thoughts and perceptiosn without believing or acting on them, accepting symptoms whithout having to like them, and accompishing valuable goals.

7. Acceptance-Based Contextual Cognitive Behavioural Therapy Methods
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0. Collaborative environment where the patient is not struggling to be heard and believed.

1. Creative hopelessnes: what have you tried and what have you learnt from that? (Table 1). Therefore, avoid giving specific advice. 4 columns: What have you tried to reduce or control your pain and other symptoms. Short-Term Results; Were the symptoms reduced? Long-Term Results; Did you move closer to the way you want to live your life? What Does Your Experience Tell You?

2. Decrease the univariate view of pain with emotional awareness training for pain.

3. Stop trying to eliminate unwanted thoughts. Do behavioural analysis to recognise the links between thoughst, feelings, sensations and behaviours.

4. Thoght log/hot thoughts. "Anyone who had delivered this type of treatment [thought records] has probably noticed that one of the results of this process is that many patients become better observers of their thoughts and more aware of the distinction between thoughts and reality" - see - I said that CBT was essential preparation for ACT. If you don't do CBT first, ACT is too invalidating.

4A. Don't do 4. in case the patient assumes the the task of restructuring too inflexibly and/or fails.

5. Tablet II: Emotion and Behaviour Record
Identify a current or recent emotional reaction and complete as much of this worksheet as you can...

Feelings:
Overall Intensity (0-100):
Situation (Who, what, where, when):
Thoughts:
Physical reactions:
Action urges:
Behaviour (do or say):
Consequences (happened and feelings about same):
Alternative behaviour (what could you do in the future to get better results:

(This is a combination of emotional awareness training, Stop Think Do, rational emotive therapy and behavioural analysis. And, it increases the experience of the observing self. And, it causes desensetisation and verbal overshadowing. See, it's all one song.) It doing the record is distressing, do the exercise about doing the exercse (That should get the metacognition going).

6. Have the patient act out their pain behaviours. This helps people realise how they communicate their pain to other people (consciously and unconsciously), trying to not feel pain can communicate more pain, and create a sence of choice over actions.

7. Then discuss the reaction of others to the pain behaviour and their own response to the response (conscious and unconscious).

8. Discuss the role of the pain patient.

9. The consequences of their behaviour might be at odds with their goals, therefore.

6A. Do 6-9 later.

10. Mindfulness exercises: breathing, body scan, walking mediation, leaves on a stream, just noticing thoughts. Observing the present moment and seeing that wandering of the mind does not have to break the continuing contact with the present moment. This causes increased observing self, nondefensive approach to stuff and space between the observer and the experience and allows things to be seen without added meaning. De-fusion means decreasing the influence of thougths on other activities. This increases the ability to act on goals and less on private experiences.

11. "Blones have more..." "Jack and the..." "Mary had a little..." First you give the automatic response and then you see if the automatic response was correct. Histories. "I can't stand this." "This is killing me." "I have to stop."

12. Get Off Your Butts. Except for the fact. The second phrase limits the first phrase. Mutually exclusive.

"I love my partner but I am angry at her." "I want to be a good friend but I have no patience." "I would go out with my friends tonight but I have pain." The contradiciton is implied but in reality the two things are happening at once. So, say and instead.

13. Rememeber three numbers as if would win $1 000 000. Test with recall. Then say that, acually, the prize money does not exist. Then see if they forget the numbers. The brain works by addition rather than by subtraction. Find out if programmed to believe "I can't..." "I will never work again." "I am useless." "This situation is hopeless." They may be no more meaningful than the numbers.

14. Willingness. Active exposure to pain and related private experiences in the service of living a meaningful life. It is contact with pain along with an absence of attemtps to control or avoid the experience. It is not exposure to pain for the sake of it or for having less pain. Dispell the myth that the benefits of exercise is that you get less pain from it. The problem with fear is that people try to avoid the thoughts or feelings they dislike. Exercise includes stretching, rhythmic, balancing, complex, simple, repetative, short and long and low-intensity and high-intensity movements. Exposure is used to reduce attempts at avoidance, not to extinguish the experiences.

15. Group discussion and individual discussion can desensetise.

8. Values and Values-Based Action
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17. What do you want your life to be about? A compas.

The Values Assessment Rating Form
Re: Family, intimate relations, friends, work, health, growth/learning: valued direction, importance, success, rank.

The value of feeling less pain will conflict with other vaules. Chose values as if no one else were aware what direction they were taking.

What eulogy or epitaph.

Going away minduflness exercise: Imaning... time in the future, very important trip, send-off party, just put yourself in the room and find out what it feels like to be there, hear them say stuff, children, good friend, co-worker.

Look at goals that are to achieve values. Frequent small steps are best. This will bring them in contact with pain, worries and discouraging thoughts or feelings. Some barriers will be re willingness. Some barriers witll be to due to problems that need problem-solving strategies and skills.

Goals Actions, Barriers Form: Re: Family, intimate relations, friends, work, health, growth/learning: goals, actioons, barriers.

People rigidly follow rules about what they can and can not do. Chose pain.

9. Acitivty Engagement and Overt Behaviour Change
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You need to review if they did the stuff they said they would. But don't get them to do it to please you.

Habit reversal: increase awareness of the habit, develop an incompatible alternative, remain mindful of the consequences.

Sensate focus: poistion, visceral, senses, sight, hearing, touch, taste and smell. Visual (etc) imagery of an enjoyed-but-not-done-for-a-while activity. This illustrates that the activity can be done in the presence of pain.

Contingency management: make sure family are on side. Make aware that thougths might not be helpful consequences.

Relazation: but present focussed rather than avoidance focussed.

Behavioural activation.

Acting As If.

Acceptance is compatible with the belief that cure is possible.

10. The Future
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Acceptance does not mean that acceptance is the only form of treatment. Rule-based behaviour is less flexible than contingency-based behaviour. Treatment needs to be experienced based. Treatment should be seen as adding to experience, rather than adding a toolbox.

Instructions to coping with transient pain may be ineffective without the added social influcences of needing to reach a publically set standard. Clarify the social influences!

If the conceptualised self is at risk of desrtuction, the person might be concerned that they are at risk of destruction, because of the fact of verbal equivelance. The threat is reduced when the self is redefined as the observing self. This allows behaviour that is consistent with values rather than attaining the old self. Return to the old self may contain several unreaslistic elements such as not being able to, differenc economy and RTW contingent on 100% relief from pain.

Appendix. Chronic Pain Acceptance Quesionaire
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Never true, very rarely true, seldom true, sometimes true, often true, almost always true, always true.

1. I am getting on with the business of living no matter what my level of pain is.
2. My life is going well, even though I have chronic pain.
3. It's ok to experience pain.
4. I would gladly sacrifice important things in my life to control this pain better.
5. It's not necessary for me to control my pain in order to handle my life well.
6. Althought things have changed, I am living a normal life despite my chronic pain.
7. I need to concentrate on getting rid of my pain.
8. There are many activities I do when I feel pain.
9. I lead a full life even thougth I have chronic pain.
10. Controlling pain is less important than other goals in my life.
11. My thoughts and feelings about pain must change before I can take important steps in my life.
12. Despite the pain, I am now sticking to a certan course in my life.
13. Keeping my pain level under control takes first priority whenever I am doing something.
14. Before I can make any serious plans, I have to get some control over my pain.
15. When my pain increases, I can still take care of my responsabilities.
16. I will have better cotrol over my life if I can cotrol may negative thougths about pain.
17. I avoid putting msyelf in situations where pain might increase.
18. My worries and fears about what paion will do to me are ture.
19. It's a relief to realize that I don't have to change my paion to get on with my life.
20. I have to struggle to do things when I have pain.