ACT in the treatment of Chronic Pain

Transcription

1 ACT in the treatment of Chronic Pain ACT and the treatment of chronic pain JoAnne Dahl Department of Psychology, Uppsala University, JoAnne Dahl & Tobias Lundgren, Department Uppsala Sweden of Psychology, University of Uppsala, Sweden

2 Riddle????? Citizens of Sweden enjoy one of the highest standards of living and best working environments in the world, and everyone is fully covered by free and high quality health care, excellent free education through university. No one has more vacation time, number of holidays or maternity/paternity leave.

3 Riddle?? The Swedish health care system offers more solutions to the with chronic pain and those on long term sick leave than any other system in the world. No where in the world is this problem so great and so costly.

4 Pathololgy model of pain When pain was unavoidable it was bearable, when it became avoidable, it became unbearable

5 One Message No relief, no life

6 where there is pain, there is NO life

7 chronic pain cannot exist in happy moments

8 What is Relief? Relief?

9 Merriam-Webster Main Entry: 1 re lief Pronunciation: ri-'lef Function: noun Etymology: Middle English relef, relief, from Anglo-French from relever to relieve 1 : a payment made by a male feudal tenant to his lord on succeeding to an inherited estate 2 a : removal or lightening of something oppressive, painful, or distressing b : WELFARE 2a c : military assistance to an endangered post or force d : means of breaking or avoiding monotony or boredom : DIVERSION 3 : release from a post or from the performance of duty 4 : one that takes the place of another on duty

10 SBU: metaanalysis of all pain treatments The best a primary care physician can do for a person with chronic pain is nothing. Nothing is better than anything that is done today.

11 Solutions are the problem health care provides simple quick fix solutions to complicated human problems that are mostly unsolvable.

12 Persistency in the face of difficulties Another Message

13 Our clients have real pain have tried to fight their pain have tried to control their pain have tried to ignore their pain have failed just keep on trying

14 About 95% is unexplanable Chronic pain Causal models for chronic pain fail in reliabilty and validity Humans dont like unexplanable things Humans have a neocortex that generates ideas and solutions for problems whether its useful or not

15 From an alien pt of view Humans and their cortexes from an alien point of view Cortexes generate solutions If solutions do not work think harder! Conlusion: Humans are slaves of their cortexes!! Cortexes cannot stop doing this, even when harmful

16 Their Agenda It s important to keep fighting this pain. 98%

17 Bad news is Chronic pain is a unsolvable problem Chronic pain is a unsolvable problem Chronic pain is a unsolvable problem Chronic pain is a unsolvable problem

18 How does that make you feel right now??? CREATIVE HOPELESSNESS

19 The Primary ACT Model of Psychopathology Dominance of the Conceptualized Past and Feared Future Experiential Avoidance Lack of Values Clarity; Dominance of Pliance & Avoidant Tracking Psychological Inflexibility Cognitive Fusion Inaction, Impulsivity, or Avoidant Persistence Attachment to the Conceptualized Self

20 Dimensions of Cognition Fused Overwhelmed by thought content, loss of contact with present, behavioral options narrowed. Belief Disbelief De-fused- Aware of reactions as reactions, contact with wider situation beyond thoughts, access to a range of responses

21 The Roots of Suffering and Disability from Pain: A Contextual Approach Experiential avoidance Cognitive fusion Loss of contact with present situation Values failures Dominance of self as content

22 Contact with the Present Moment Acceptance Values Psychological Flexibility Defusion Committed Action Self as Context

23 Acceptance of Chronic Pain Processes of flexible and practical action, free from un-necessary restriction by pain. Engagement to activities with pain present. Absence of attempts to limit contact with pain.

24 Summary Acceptance of pain predicts better adjustment on all measures. Acceptance is relatively independent of perceived pain and accounts for more variance than pain in relation to emotional, social, and physical functioning.

25 Question Why would anyone choose to face pain? Why would anyone do treatment that includes pain, uncertainty, fear, frustration, memories, fatigue, confusion?

26 Answer Because painful experiences lay between where we are and where we want to go.

27 Values Chosen life directions, or guides for living, in relation to family, intimate relations, friends, work, health, growth and learning. Assessed by the Chronic Pain Values Inventory (CPVI).

28 Summary No one wants pain. However, pain is not always what it looks like, or what our thoughts say it is; does not need to be restricting, and does not need to be fought. There are developing approaches to pain that aim not to change pain but to change how pain is experienced.

29 Elisabeth

30 When you alter your life in the service of reducing symptoms, your symptoms flourish and your life quality diminishes

31

32 Life Restriction and loss: life skrinks, present moment disappears, vitality is lost Relief:temporary elief, illusions that mindy lutions may work this time Pain Mindy chatter: when I feel pain, reasons, predictions consequences control and avoidance cycle: moving down into struggle and away from a values-based vital life Entanglement: taking literally, mindy solutions that call for escape, avoidance, making deals, losing who you are Control and avoidance: complying with mindy solutions and buying these thoughts and engaging in the actual behavior they structure

33 Values: the life directions I choose, what I want my life to be about Commitment and flexibility: choosing to take action consistent with my values, enhancing life flexibility ACT: moving up towards a values based vital life Acceptance and being present: making room for pain in the moment it occurs Growth and contact with barriers: as I step forward I grow and develop and feel pain Mindfulness and defusion: observing my thoughts as thoughts, taking heed if they are helpful, staying conscous as the observer self, cognitive flexibility

34 Chronic Pain Dahl, Nilsson & Wilson, public health caretakers at risk for developing long-term pain/stress symptoms 10 TAU, 10 ACT protocol, 4 sessions at worksite/home Baseline=60 days, intervention: 4 1-hr sessions over 30 days, FU 60 days 2 therapists: 1 experienced CBT, 1 nurse

35 Cumulative Sick Leave 80 Average Total # Sick Days ACT TAU Cohen s d at follow-up = BL mo 1 BL mo 3 BL mo 5 Intervention FU mo 2 FU mo 4 FU mo 6

36 Medical Service Utilization: Physician, Specialist & Physiotherapist Mean Medical Visits Month Pre Post 6 Month FU ACT MTAU

37 Total Quality of Life Mean QOL Score ACT MTAU Pre Post 6-Mo FU

38 conclusions Acceptance based treatment compared to controlled based appears to lead to more promising long-term results The person with chronic pain is more interested in getting his/her life back than simply getting rid of the pain.