Mission Statement of IASP Press速 The International Association for the Study of Pain (IASP) is a nonprofit, interdisciplinary organization devoted to understanding the mechanisms of pain and improving the care of patients with pain through research, education, and communication. The organization includes scientists and health care professionals dedicated to these goals. The IASP sponsors scientific meetings and publishes newsletters, technical bulletins, the journal Pain, and books. The goal of IASP Press is to provide the IASP membership with timely, highquality, attractive, low-cost publications relevant to the problem of pain. These publications are also intended to appeal to a wider audience of scientists and clinicians interested in the problem of pain.
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Progress in Pain Research and Management Volume 33
Contextual Cognitive-Behavioral Therapy for Chronic Pain
Lance M. McCracken, PhD Pain Management Unit, Royal National Hospital for Rheumatic Diseases, and University of Bath, Bath, United Kingdom
IASP PRESS® • SEATTLE
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息 2005 IASP Press速 International Association for the Study of Pain速 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed have not involved any verification of the findings, conclusions, and opinions by IASP速. Thus, opinions expressed in Contextual Cognitive-Behavioral Therapy for Chronic Pain do not necessarily reflect those of IASP or of the Officers and Councillors. No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent verification of diagnoses and drug dosages. Library of Congress Cataloging-in-Publication Data McCracken, Lance M., 1962Contextual cognitive-behavioral therapy for chronic pain / Lance M. McCracken. p. cm. -- (Progress in pain research and management ; v. 33) Includes bibliographical references and index. ISBN 0-931092-83-3 (alk. paper) 1. Chronic pain. 2. Cognitive therapy. I. Title. II. Series. RB127.M3965 2005 616'.0472--dc22 2005043225
Published by: IASP Press International Association for the Study of Pain 909 NE 43rd Street, Suite 306 Seattle, WA 98105-6020 USA Fax: 206-547-1703 www.iasp-pain.org www.painbooks.org Printed in the United States of America
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Contents Foreword: The Opportunities and Challenges of Acceptance-Based Approaches to Pain Foreword: Empowering the Lives of Chronic Pain Patients Preface
ix xiii xv
1.
The Problem of Chronic Pain
1
2.
Psychological Approaches to Chronic Pain
11
3.
Contextual Cognitive-Behavioral Theory
23
4.
Contextual Cognitive-Behavioral Assessment
35
5.
A Contextual Cognitive-Behavioral Model of Chronic Pain and Disability
51
6.
Acceptance of Chronic Pain
61
7.
Acceptance-Based Contextual Cognitive-Behavioral Therapy Methods
73
8.
Values and Values-Based Action
91
9.
Activity Engagement and Overt Behavior Change
101
10. The Future
111
Appendix
119
References
121
Index
129
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Foreword: The Opportunities and Challenges of Acceptance-Based Approaches to Pain Imagine have pain every waking moment of your day. Imagine that the cause of the pain cannot be determined and that health care professionals tell you there is nothing they can do to eliminate the pain. Your pain is likely to continue for the rest of your life. What would you do? How would you think and feel? How would your life change? This volume is about persons whose lives are dominated and defined by their struggle to eliminate such persistent pain. Although the struggle to eliminate pain is often the central problem in managing chronic pain, until recently it has received little attention from pain researchers and clinicians. To understand why, one needs to consider the historical context of chronic pain clinics and chronic pain management programs. It is only in the past 40 years that the scope and complexity of the problems of persons with chronic pain have become apparent. Prior to that time, pain was considered as simply an indicator of an underlying medical problem that required treatment. Pioneers such as Bonica (1953) argued that, even when underlying disease is treated effectively or is apparently absent, pain can persist. Bonica was among the first medical specialists to argue that such chronic pain, in and of itself, is a legitimate target for clinical and research efforts. He reasoned that because chronic pain was complex, it was best treated in special multidisciplinary pain clinics. In such clinics, professionals from different disciplines, each having expertise in the control of pain (e.g., anesthesiology, neurology, neurosurgery, physical medicine, psychiatry, and psychology) could evaluate a patient with chronic pain and develop an appropriate multidisciplinary pain management plan. The 1970s to early 1990s witnessed the emergence of a large number of pain clinics and pain management programs. These specialized programs mobilized hope among patients and multidisciplinary specialists that a sophisticated, multidisciplinary approach could produce substantial reductions in, and in some cases the elimination of, chronic pain. Although pain clinics and pain programs have been successful in improving the lives of persons with chronic pain, only in rare cases do they eliminate pain or reduce it to very low levels. The benefits of these programs have mainly been in enhancing quality of life and reducing painix
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related physical disability and psychological distress. In light of this observation, the titles “pain clinic” or “pain program” are probably misnomers. These titles foster the mistaken notion that the primary agenda, goal, and outcome of treatment is the abolition or substantial reduction of pain. Interestingly, most pain clinics and pain programs include an educational component where patients are told that while treatment may produce some reductions in pain, the central goal is to improve quality of life, despite the presence of persistent pain. Although pain clinics and pain programs have helped many persons, there remains an important subgroup of individuals who present for treatment in these programs who feel that the treatment is doomed to failure if it does not eliminate their pain. These individuals’ lives often center around the struggle to eliminate pain and the search for new treatments that promise to eliminate pain (McCracken et al. 2004). New medical and surgical techniques, often invasive and risky, are constantly being developed, many of which are touted in the media, and in some cases by practitioners, as cures for chronic pain. All too often, patients focused on the elimination of their chronic pain seek out and undergo these treatments, only to have their hopes for total and permanent pain relief dashed. Many patients have multiple failures with invasive surgeries and other aggressive approaches designed to eliminate pain. Unfortunately, in many cases, these treatments have major side effects and result in even more severe pain. With repeated failures of treatments designed to eliminate pain comes bitterness, hopelessness, and resignation. This volume introduces a very innovative acceptance-based approach that can help pain clinicians and researchers understand why, in some persons, struggling to eliminate persistent pain can be so problematic. This acceptance-based approach offers novel and important strategies for assessing and treating pain that may be particularly beneficial to patients who have failed to respond to more conventional biomedical and psychosocial approaches. The acceptance-based approach outlined in this book has very important implications for assessment. First, it emphasizes the importance of understanding behavior in its context. The reason that someone continues with a nonproductive struggle to eliminate pain may be due to social or environmental antecedents, such as the promptings of a spouse or the urgings of a well-intentioned health care provider, or consequences, such as avoidance of unwanted family or work responsibilities. Alternatively, this struggle may reflect a learning history in which struggles to overcome seemingly insurmountable obstacles were occasionally successful.
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Second, an acceptance-based approach highlights the need to much more fully assess an individual’s own view of his or her problems as revealed by thoughts and words. As this volume points out, we need to accept and understand this view as a starting point and be cautious about making assumptions of what that view may be. Careful interviewing done in an empathic fashion can help reveal how a person’s verbal constructions of his or her situation (“Because of this pain I can’t work and therefore I am worthless”) can motivate and drive what seems to be an incessant and fruitless search for ways to eliminate pain. All too often, pain clinicians’ attempts at pain assessment are encumbered by conceptual models, preconceptions, and pragmatic concerns that interfere with their ability to carefully listen to and fully understand how patients view their own pain. Third, an acceptance-based approach emphasizes the crucial importance of understanding avoidance as a coping strategy. When someone views chronic pain as unacceptable and intolerable, it is understandable that he or she feels it must and should be avoided at all costs. As is clear from this volume, avoidance may take many forms. It may be evident in changes in behavior (e.g., spending excessive time reclining or in bed or drinking too much alcohol) or thoughts (e.g., trying to ignore the pain or convincing oneself that it is only a temporary problem). The acceptance-based approach outlined in this book makes it clear that avoidance, while understandable as a coping strategy, has long-term consequences that are negative and selfdefeating. As is clear from reading this book, one of the most important reasons to develop an acceptance-based approach to chronic pain is that it can direct treatment efforts. With growing adoption of an acceptance-based approach will come increased use of contemporary as well as traditional meditation techniques. Kabat-Zinn’s mindfulness meditation protocol, for example, brings together a set of meditation practices that can increase awareness and acceptance of pain-related thoughts and feelings (Kabat-Zinn 1982). Loving kindness (Metta) meditation, a traditional meditation practice, fits well with an acceptance-based approach in that can help patients understand pain-related anger and resentment and develop a more compassionate and forgiving attitude toward themselves and others (Carson et al., in press). One of the most important and interesting features of this book is that it highlights the ways in which traditional cognitive-behavioral and behavioral interventions can be used within the context of an acceptance-based approach. Techniques that involve graded exposure to feared pain-related activities and events are advocated, not for reducing or controlling the fear of pain, but instead for helping patients develop a capacity to experience thoughts and feelings they may be avoiding.
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In conclusion, this book represents a very important step in the development of an acceptance-based approach to persons having chronic pain. It deserves to be read by all pain clinicians and researchers who are interested in novel, psychosocial approaches to dealing with the challenges of living with persistent pain. FRANCIS J. KEEFE, PHD Department of Psychiatry and Behavioral Sciences Duke University Medical Center Durham, North Carolina, USA
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Foreword: Empowering the Lives of Chronic Pain Patients The vast majority of treatment approaches in chronic pain target reduction in pain per se. It is remarkable how little evidence exists for this approach, despite its powerful common-sense appeal. Some of the most typical pain treatments, such as analgesics, surgery, physical therapy, manipulation, transcutaneous electrical nerve stimulation, and the like have very limited empirical support with chronic pain (Dahl et al. 2005). In area after area, physical findings fail to correlate with chronic pain or disability. For example, disk hernia is as common among patients without back pain as in those with chronic back pain (Boos et al. 1995). Reports of back pain are not correlated with objective measures of back function and general physical fitness, such as muscle strength, oxygen uptake, height, weight, body mass index, or the spinal channel as measured by ultrasound; instead they correlate most strongly with psychosocial factors (Bigos et al. 1991). This basic pattern is repeated throughout the pain literature. Whatever else one can say about such data, one thing is clear: chronic pain is not simply a physical problem. It involves profound social and psychological dimensions as well. The multidimensional nature of chronic pain probably explains why broader treatment approaches are more successful. Meta-analyses have confirmed that integrated multidisciplinary treatment regimens are notably more effective (Flor et al. 1992) and lead more patients to return to work (Cutler et al. 1994). The dominant model that underlies most psychosocial interventions for chronic pain is cognitive-behavioral therapy (CBT). Meta-analyses have confirmed the effectiveness of CBT technology, but not of the traditional CBT model. Fortunately, CBT is itself undergoing a revolutionary change, as this volume will show. Traditionally, CBT took the relatively mechanistic position that thoughts and feelings needed to change their form before behavior could change. The so-called “third wave� (Hayes 2004), interventions such as mindfulnessbased interventions or Acceptance and Commitment Therapy (Hayes et al. 1999a), take a more contextual approach: the life role of thoughts and feelings is itself a situated event and thus can change even if thoughts and feelings do not change their form. This shift from a more mechanistic to a more contextualistic form of CBT has potentially revolutionary implications for pain (Dahl et al. 2005). xiii
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This potential is now being explored empirically with good early results (e.g., Dahl et al. 2004; McCracken et al., in press). It turns out that chronic pain patients are ready to consider whether attempts at control have beneficial effects over the long term, especially if their lives need to be put on hold in the meantime. Far from invalidating the pain patient, this shift is empowering. This volume makes a powerful argument that chronic pain is in part an experiential avoidance disorder. The author’s own empirical work is especially telling: the Chronic Pain Acceptance Questionnaire (see the Appendix) shows that acceptance of pain and a willingness to act in its presence is associated with reports of lower pain intensity, less pain-related anxiety and avoidance, less depression, less physical and psychosocial disability, more daily uptime, and better work status (McCracken 1998; McCracken and Eccleston 2003; McCracken et al. 2004b). A relatively low correlation between acceptance and pain intensity shows that acceptance is not simply a function of having a low level of pain. Acceptance of pain predicts better adjustment on measures of patient function than does perceived pain intensity, and that continues to be true even when pain intensity is factored out. These powerful data are being replicated in several other disorders (Hayes et al. 2004). From a pathology-oriented perspective, it is removal of pain that is necessary to free the individual to pursue life directions. From a contextual CBT perspective, however, it is possible to move directly toward this behavioral end once one abandons the struggle to avoid or reduce pain itself. The data so far suggest that the latter perspective is closer to the truth. This volume provides an easy and skillful introduction to these newer, acceptance-based approaches (see also Dahl et al. 2005) and shows how they can be integrated into multidisciplinary treatment. Multifaceted and caring, this model has the potential to be a real step forward for the pain patient. No one likes to hurt. Human compassion calls out for us to reach out to those in pain and to help them through the difficulty they face. But as we do so, we need to make sure that what we are doing is truly helpful. In essence, the work represented in this volume shows that there are new and potentially more effective ways to be compassionate and to empower the lives of those with chronic pain. STEVEN C. HAYES, PHD Department of Psychology University of Nevada Reno, Nevada, USA
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Preface My first professional experiences with chronic pain sufferers took place at the university medical center in Morgantown, West Virginia, in 1990. Four years later I accepted my first faculty post at The University of Chicago. Around that same time I became aware of the work of a group of behaviorally oriented researchers on language, cognition, emotion, and something called Acceptance and Commitment Therapy (ACT). Shortly after beginning work in Chicago I ran across two things—a copy of an early version of a treatment manual for ACT (later expanded and published as Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change) and a doctoral dissertation on acceptance-based treatment for chronic pain completed by David Geiser, a student from the University of Nevada in Reno. I found this material both challenging and immensely exciting. At that point my colleagues and I began to expand our behavioral and cognitive-behavioral approaches and to increasingly adopt contextual and acceptance-based assessment and treatment methods. We also began to study processes related to acceptance of chronic pain, with remarkably encouraging results. Since 2000 this work has carried on with our team in Bath, United Kingdom. There are many influences on the work presented here in addition to the primary influences from ACT. These influences come from my clinical training at West Virginia University; the operant approach to chronic pain of Wilbert Fordyce; work on fear and avoidance of pain by colleagues in Belgium, Canada, the Netherlands, and Sweden; Dialectical Behavior Therapy from Marsha Linehan; and approaches to mindfulness training, including the work of Jon Kabat-Zinn. This volume was designed to introduce a different perspective on chronic pain management, to illustrate this perspective with a sample of practical clinical methods, to lead the reader to further study in the wider literature, and to encourage some expansion of current clinical methods. The chapters of this book are intended to present a theoretical and clinically useful approach to chronic pain management, albeit one that is in continuing development. The first chapter presents a social and medical perspective on chronic pain, and briefly discusses recent shifts in behavioral and cognitive therapies, shifts that are particularly applicable to the problem of pain. Chapter 2 traces developments in the operant and cognitive behavioral approaches to chronic pain that have laid part of the foundation for current work. Chapters 3 through 5 describe an integrative, functional, contextual framework for xv
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assessment and treatment of chronic pain that incorporates and extends the spirit of both operant- and cognitive-behavioral approaches. Chapter 6 further examines psychological acceptance, a key element of this framework, and reviews relevant research findings. Chapters 7 through 9 present treatment principles and illustrate treatment methods of Contextual CognitiveBehavioral Therapy (CCBT) for chronic pain. The final chapter summarizes and restates some of the key distinguishing features of CCBT and suggests directions for further development. The approach of this book, including the notion of “acceptance” and questioning the necessity for control over pain as it does, may lead to some misunderstanding. After all, pain control is now often presented as a “basic human right,” and “live life” is equated with “control pain” in slogans of our professional societies and advertisements from the pharmaceutical industry. These statements sound reasonable, and on many occasions they are; however, they may require a closer look. The notion of basic human rights is a useful one. It can add urgency to goals such as promoting appropriate funding for pain treatment services, facilitating access to these services by those who will benefit, encouraging training of pain specialists, and promoting new therapy developments, or for any purposes that reduce unnecessary suffering. Nevertheless, statements about a right to pain control may do a disservice in other ways. If they are taken to mean that all pain is controllable, they are simply untrue, may place unnecessary pressure on health care providers, and may inadvertently add to patients’ suffering. Universal access to modern medical therapies, trained specialists, interdisciplinary services, and empirically supported therapies for those who will benefit is a noble goal. Access to pain control methods, however, should not be equated with access to complete pain control. That is unrealistic. Above all, this book is about finding effective solutions for chronic pain sufferers, whether that means they “live life” as a result of pain control or “live life” in other ways. The point of this book is not to dismiss pain or to discourage attempts to alleviate it, but rather to ensure that these attempts are balanced and proportionate and do not unintentionally exacerbate patients’ problems, exclude effective ways of helping patients that do not focus on pain control, or put the quality of the patient’s life secondary to other concerns. Clearly, it is the potential to enhance the quality of the patient’s life that gives pain control efforts their justification at the start. It may be important to demote the word “acceptance” before it gets too overblown. Acceptance of all pain is not an appropriate goal. Acceptance is not intended as the primary guiding principle of therapy. It is simply one of a number of secondary processes meant above all to serve the purpose of helping pain sufferers live their lives with success, freedom, and vitality. For
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many people burdened by chronic pain, it appears to provide a sensitive, honest, and effective means for doing that. As small as the book may appear and as much I fully accept responsibility for its message, it reflects contributions from many people. I would like to express my sincere thanks to all those who helped me reach the point at which this book became possible. There are many teachers and colleagues who have given me opportunities to watch, listen, learn, and to communicate more clearly about the work I do. I am particularly grateful to Rick Gross and Jennifer Haythornthwaite for their teaching and mentoring over the years. My special thanks go to Steve Bono and Chris Eccleston for help during the writing of this book and for providing the opportunity to discuss much of the material in it. I am grateful to my excellent colleagues in Bath who have provided invaluable opportunities for learning and for developing the services we offer and share with our broader community. I would also like to thank the people from IASP Press, especially Elizabeth Endres, and the copy editor Margaret Warman, for all of their help in finally bringing this work to the reader. LANCE M. MCCRACKEN, PHD
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Contextual Cognitive-Behavioral Therapy for Chronic Pain, Vol. 33, by Lance M. McCracken, IASP Press, Seattle, © 2005.
2 Psychological Approaches to Chronic Pain The history of formal psychological approaches to pain is a short one. If one takes 1879, the year the first psychology laboratory was opened by Wilhelm Wundt, as the formal beginning of psychology as a field of study, then psychological approaches to pain cannot be older than that. For example, the first mention of the term “psychogenic pain” was not made until 1904 by Otto Binswanger, a professor of psychiatry at the University of Jena in Switzerland. Shortly afterward, around 1909, the introspectionist Edward Titchener made his observations that pain appeared to have both sensory and emotional qualities. In the 1920s Ivan Pavlov showed that dogs could be conditioned to respond to pain exposure in ways that were more usually associated with exposure to food. In 1965 Ronald Melzack and Patrick Wall published their paper on the gate control theory of pain in the journal Science, providing a working framework for understanding the remarkably variable relationship between peripheral noxious stimulation and the experience of pain. It is not the purpose of this chapter to detail the entire history of psychological thinking about chronic pain. That topic deserves treatment of its own, and the purpose here has a more specific focus. Clinical methods used most frequently today by psychologists and interdisciplinary teams are rooted in two related frameworks, the operant and the cognitive-behavioral. The theory, methods, and results of these frameworks will be briefly summarized.
AN OPERANT APPROACH
In 1976 Wilbert Fordyce published Behavioral Methods for Chronic Pain and Illness, the product of his collaborative work with colleagues at the University of Washington on the application of operant behavioral methods to chronic pain treatment. They had earlier discussed and presented treatment outcome results (Fordyce et al. 1968, 1973), but the book (Fordyce 1976) was the first complete description of this approach. It constituted a 11
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Contextual Cognitive-Behavioral Therapy for Chronic Pain, Vol. 33, by Lance M. McCracken, IASP Press, Seattle, © 2005.
3 Contextual Cognitive-Behavioral Theory It may be clear from Chapter 2 that there has been some controversy in the past arising from contrasting philosophies of psychology within pain management. This controversy concerns the relative emphasis placed on what the pain sufferer thinks and feels and the degree to which the content of these experiences should be targeted for change in treatment. Behavioral approaches in particular have been criticized for ignoring covert or private aspects of the patient’s experience and, by implication, for regarding them as unimportant. As will be seen, this criticism is not valid for behavioral approaches today. Relatively recent developments within behavioral science and practice fully consider private experiences and do so in new ways, functionally rather than structurally. Some of the history of behavioral approaches is worth reviewing, however, to help put current behavioral and cognitive approaches in perspective.
A BRIEF HISTORY
The founder of behaviorism was John B. Watson. Watson was responding to problems he saw within psychology, which at that time took mental processes and consciousness as its subject matter, and what was called “introspection” as its method. In 1913 Watson published his paper “Psychology as the behaviorist views it.” In this paper he urged that psychologists abandon introspection and adopt more suitable methods in order to advance the field as a natural science. It is important to understand what Watson was attempting to accomplish, because many of his ideas have been misrepresented. Watson believed that introspection was inadequate for the study of mental processes. He insisted that psychology could return to the study of internal mental states at some later date if methods were developed to support that endeavor, and in the meantime placed them temporarily out of bounds in favor of objectively measurable, overt behavior. His approach to psychology was pragmatic and was readily adopted by many; however, it was also greatly limited by its reliance on truth by agreement, or logical positivism, and its unit of analysis, the stimulus-response relation. Although Watson’s 23
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work was useful in creating a break from the tradition of introspectionism and was a considerable epistemological advance at that time, it was a limited approach by today’s standards. In Watson’s approach, referred to as methodological behaviorism, he defined the subject matter of psychology with the exclusion of private experience. He did not, however, deny the existence of these experiences, as is sometimes supposed. In any case, by the middle of the 1950s there was a shift in psychology. Behavioral approaches since that time have slowly but increasingly embraced private experiences as their subject matter.
RADICAL BEHAVIORISM
Radical behaviorism is the philosophy that formed a framework for the field of behavior analysis (Skinner 1974; Chiesa 1994; O’Donohue and Ferguson 2001). The term “radical” seems to connote the extreme, outlandish, or extraordinary. It was intended simply to mean thorough-going, to the root, or deep. Radical behaviorism has features that distinguish it from other approaches to the study of psychology. These include its subject matter, its model of causality, and its goals. Radical behaviorism defines behavior as its subject matter. In much of contemporary psychology this is not the case; rather, behavior is considered as a sign or manifestation of some other variable, process, or issue of primary concern, such as intelligence, memory, personality, attitude, emotion, motivation, intention, cognitive bias, or identity. Within radical behaviorism, behavior includes all the observable activity of the whole individual, even activity that is observable only by the person engaging in it. As Skinner clarified, “Mentalism kept attention away from the external antecedent events which might have explained behavior, by seeming to supply an alternate explanation. Methodological behaviorism did just the reverse: by dealing exclusively with external antecedent events it turned attention away from self observation and self knowledge. Radical behaviorism restores some kind of balance. It does not insist on truth by agreement and can therefore consider events taking place in the private world within the skin. It does not call these events unobservable, and it does not dismiss them as subjective. It simply questions the nature of the object observed and the reliability of the observations.” (Skinner 1974). The model of causality for radical behaviorism is a subtle one. It relies on selection and functional relations, selection being of three types: natural
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L.M. MCCRACKEN Table I Methods of behavioral assessment arranged in order of directness 1. Direct observation of free behavior in its actual context 2. Direct observation of instructed behavior (e.g., role-playing) in its actual context 3. Direct observation of free behavior in an analogue context 4. Direct observation of instructed behavior in an analogue context 5. Immediate self-observation or self-monitoring 6. Interview or questionnaire methods 7. Interview or questionnaire methods with significant others
HYPOTHETICAL CONSTRUCTS AND FUNCTIONAL RESPONSE CLASSES
Measures used in psychology are varied, but often include descriptions of behavior. These behaviors are considered to be signs or symptoms of some other variable, typically one of central interest that is inferred and not directly observed. The behavior clusters used to derive summary scores are grouped together for theoretical reasons, or sometimes on empirical grounds. They may have demonstrated sufficient intercorrelations to be considered to reflect the same psychological feature. For certain psychological variables it may be presumed that what ties the items of an inventory together is their shared relationship with some personal characteristic such as locus of control, self-efficacy, or neuroticism. It is useful to understand meaningful consistencies in behavior over time or across situations, although these are sometimes inferred rather than observed. Further, when a person is given a score for a variable that has traitlike features, that variable can assume unwarranted causal status and may be used to explain the very behavior pattern from which it was derived. Measures of inferred psychological processes can confuse description with explanation, leading to circular reasoning. This reliance on personal characteristics as causes of behavior inhibits a more careful examination of contextual influences. Deducing internal causes from consistent behavior patterns directs assessment and treatment efforts toward the quantifying and changing of hypothetical descriptive accounts, rather than toward the functional dependence of observable behavior on aspects of the person’s environment, including the stimulus features of thoughts and emotions and the contexts that give them their meaning. Some psychological variables of interest in chronic pain assessment could be reexamined as possibly meeting criteria for functional response classes, groups of perhaps superficially dissimilar responses that appear under the same influences or operate on the environment in the same manner (see Chapter 3). The notion of response class implies only that
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direction, and social influence can provoke resistance, strengthening behavior that is counter-therapeutic. Dialectical behavior therapy explicitly includes a contingency management component that is a useful guide (Linehan 1993b). One important concern is that patients are experimenting. They have opportunities in treatment to behave in ways that they never did before, and these may be healthy new responses likely to lead to freer and more satisfying lives. Patients may exercise despite an increase in pain, recognize a thought as an unnecessary influence on a course of action, or confront a difficult emotion without defense. These responses may show up in small ways, and we may observe them. If we respond appropriately, these useful behaviors may be repeated, but if we happen to ignore them, they may not. Methods for reinforcing healthy behavior patterns include shaping, i.e., reinforcing successive approximations or partial responses that resemble the complete behavior; finding responses that reinforce behavior in a particular individual; realizing that public praise is not always reinforcing; ensuring that praise does not become associated with a lack of support or with increasing demands; using non-arbitrary and natural reinforcers whenever possible; using punishing methods as little as possible, if at all; remembering that if one is using cues or instructions one must use consequences as well; and watching for and addressing punishing influences that may come from within the group of patients. Responses from treatment providers that reinforce healthy and functional patient behavior can take many subtle forms and need not be overdone. A smile, a thumbs-up, or a single quiet word can be all the acknowledgment needed if it arises spontaneously, sincerely, and openly, from a relationship of respect.
RELAXATION
Relaxation methods may seem discordant with an approach that entails acceptance of private experience. Ostensibly, relaxation is about changing the way one feels inside. It is often promoted as a pain reduction strategy, either as a method to reduce pain from muscle tension or as a way to reduce the emotional aspects of the pain experience (e.g., Caudill 1995). Relaxation can serve other purposes and can also be a useful experiential exposure method. If relaxation happens to work for a patient and helps him or her to actively live a meaningful life, there is no need for change. However, it can also be a form of avoidance and part of a failing agenda to control pain. For
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example, some patients enjoy relaxation because it allows them to check out from reality, and others say that relaxation does not change how their pain feels, and they therefore reject it. Some patients claim that they cannot relax due to pain, or that they can only relax when their pain is at a low level. They may say that they cannot concentrate or that they are having distressing thoughts. These responses are interesting from a psychological perspective because in these instances thoughts and feelings are functioning as barriers to a course of action; they are being taken as experiences with which to struggle, in ways that are unnecessary. These problems provide excellent opportunities for some alternate purposes of relaxation. A core assumption of acceptance-based CCBT is that behavior directed toward a meaningful life can occur in a manner that includes, but is not derailed by, potentially distracting or troubling thoughts, emotions, and sensations. Relaxation methods provide a potential experience of this process. The practice of relaxation can be tied to different goals, not aimed toward the control or reduction of unwanted private experiences but toward a willingness to have these experiences and a loosening of the influence of these experiences on action. This loosening is the process of increasingly acting in a calm and relaxed manner with the full awareness that one may not be feeling or thinking that way. A summary of some of the purposes of relaxation that may be used clinically is included in Table II. Within an acceptance-based approach it is probably more useful to expose patients to relaxation methods that have a “here and now” quality. Patients often say they enjoy guided imagery or exercises in which the therapist’s voice is used to induce calmness, or exercises with hypnotic features. These types of strategies can function as avoidance or escape from experiences and therefore can reinforce the seeking of pain relief, possibly Table II Functions of relaxation Relaxation is about focusing efforts and taking on the appearance and behavior of a person who feels calm and confident, regardless of whether you feel those things or not. The practice of relaxation enhances awareness of your body by including observation of the body in a relatively focused way. The experience of relaxation can include noticing thoughts and feelings for what they are without the natural, sometimes automatic, tendency for these things to become a concern. Appearing relaxed is useful socially because it puts others at ease and often helps you achieve what is important without you or others being distracted by something else. Relaxation exercises provide the occasion for you to observe whether some of the behavior and reactions you engage in are unnecessary and move you away from things you value.
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to the exclusion of other goals. Also, it is not always clear what the patient is learning in the passive role they often adopt during such exercises. More present-focused and less avoidance-based exercises may involve focusing on breathing, the body, sensations, or perhaps some other brief focusing device such as counting. It is possible to use a behaviorally based relaxation method focused on overt responses and breathing (Poppen 1988) and to adapt a simple version of this method for use in a chronic pain treatment context. An example of such a relaxation method is included in Table III.
OTHER METHODS
A range of other methods could be used within an acceptance-based approach. Some methods of standard behavioral activation, such as those used with depression, can be helpful (e.g., Emery 2000). Behavioral activation concepts such as faking, acting “as if,” and acting opposite to the way one feels, can be useful to demonstrate the fact that actions need not follow feelings. Actions can follow desired goals in the situation instead. When patients raise the issue that they do not want to be dishonest or hide their feelings, it can generate useful discussion. We might ask, “What does acting Table III A sample behaviorally based relaxation method Acting in a relaxed fashion can be as easy as observing your behavior that is not relaxed and making change where you can. You can simply notice that tense facial expressions, movements, postures, or breathing are not necessary, and move these behaviors in a more still, focused, and calmer direction. For each step of this task, focus your attention on the body region specified, observe unnecessary tension or tense behavior (such as raised shoulders, hands held rigidly or in a fist, clenched teeth, rapid breathing, rigid or “closed” postures), and allow the area to loosen. Keep the pace of your observation of your body by counting from 1 to 10 as you progress. You may imagine tense behavior changing and fading from the top of your head, through each subsequent region, on down to your feet. 1. Head and face 2. Neck 3. Shoulders and chest 4. Arms and hands 5. Back and abdomen 6. Waist and hips 7. Thighs 8. Knees 9. Shins and calves 10. Ankles and feet Practice being aware of whatever sensations are present, allowing change in those that are a product of your own behavior, and simply observing without reaction those, such as pain or moods, that cannot be usefully controlled.
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