Tracking Psychological Processes Involved

in Self-Management of Chronic Pain –

Measures of Psychological Flexibility

Lucie Knight, Counselling Psychologist(on behalf of Prof Lance McCracken)

INPUT Pain Management Unit

Focus of Presentation

• Measures used at INPUT to assess the

psychological underpinnings of chronic

pain.

• Processes involved in adjusting and living

with chronic pain and their assessment.

• Developing new measures: the Committed

Action Questionnaire and the Cognitive

Fusion Questionnaire.

INPUT Measures

Main outcome measures:

• SF-36

• Patient Health Questionnaire (PHQ-9)

• EQ-5D-5L; Brief Pain Inventory

• Health care visits, medication use, work status

Process measures based on ACT:

• Chronic Pain Acceptance Questionnaire (CPAQ)

• Acceptance and Action Questionnaire (AAQ-II)

• Experiences Questionnaire (EQ)

• Cognitive Fusion Questionnaire (CFQ)

• Committed Action Questionnaire (CAQ)

ACT

A form of cognitive behavioral therapy with the following features:

– Focuses on behaviour change

– Includes a primary process called psychological flexibility

– Recognizes that suffering is a normal part of the human condition

– Does not aim to eliminate pain, but offers skills to respond flexibly, in ways that enables people to follow their values in the face of challenges.

– Relies heavily on experiential exercises and metaphorical or paradoxical uses of language

– Is emotionally intensive

– Follows a philosophy called functional contextualism

– Has a direct association with “Relational Frame Theory”, a program of basic behavioral science.

ACT Treatment Processes

Psychological

Flexibility

Contact with the

Present Moment

Values

Committed

Action

Self as

Context

Cognitive

Defusion

Acceptance

Mindfulness

Randomized Trials of ACT in

Physical Health

Problem Area Authors

Work stress

Bond & Bunce, 2000

Flaxman & Bond, 2010

Brinkborg et al., 2011

Pain and stress Dahl et al., 2004

Drug refractory epilepsy Lundgren et al., 2006

Diabetes Gregg et al., 2007

Chronic pain

Wicksell et al., 2008

Johnston et al. 2010

Wetherell et al. 2011

Thorsell et al., 2011

Pediatric chronic pain Wicksell et al., 2009

Randomized Trials of ACT- Continued

Promotion of physical activity Butryn et al., 2011

Headache Dindo et al., 2012

Mo’tamedi et al, 2012

Multiple sclerosis Nordin et al., 2012

Tinnitus Hesser et al., 2012

Cancer Rost et al., 2012

Green = RCT

ACT for Chronic Pain (N = 16 Studies)

o Dahl et al. 2004

o McCracken et al. 2005

o McCracken et al. 2007

o Vowles & McCracken,

2008

o Wicksell et al. 2008

o Vowles et al. 2009

o Johnston et al. 2010

o Wetherell et al. 2011

o Thorsell et al. 2011

o McCracken & Gutierrez-

Martinez, 2011

o McCracken & Jones, 2012

o Wicksell et al., 2013

o Burhman et al., 2013

o McCracken et al., 2013

o Steiner & Bigati, 2013

o Luciano et al., 2014

Measures: Psychological Flexibility

Process Measure Publications*

Acceptance Acceptance and Action Questionnaire-IIChronic Pain Acceptance Questionnaire 219

Cognitive defusion Experiences QuestionnaireCognitive Fusion QuestionnaireDrexel Defusion Scale

11

Contact with the present

Mindful Attention Awareness Scale(most mindfulness measures) 23 (364)

Self-as-observer Experiences Questionnaire0

Values-based action Valued Living QuestionChronic Pain Values InventoryBulls EyeEngaged Living Scale

42

Committed action Committed Action QuestionnaireEngaged Living Scale 3

* Keyword Search: chronic pain + process term; Medline, Psychinfo, EMBASE; 8 November 2013.

ACT measures used at INPUT

• Chronic Pain acceptance Questionnaire – CPAQ

(McCracken et al, 2004; Vowels et al, 2008): 2 factors:

activity engagement and pain willingness

• Acceptance and Action Questionnaire - AAQ (Hayes et

al 2004; Bond et al 2011): measure of psychological

acceptance / experiential avoidance. General measure

of psychological flexibility. AAQ II includes 7 items

• Experiences Questionnaire – EQ (Fresco et al, 2007;

McCracken et al, 2014): De-centering and rumination

• Committed action questionnaire CAQ: newly developed

• Cognitive Fusion Questionniare CFQ (Gillanders et al

2013): recently validated in chronic pain

Creating a Measure

• N = 216 consecutive adults with chronic

pain at INPUT.

• 62.5% women.

• Mean age 47.5

• 12.6 years of education.

• Primary pain 88.3% back.

• Mdn pain duration 104 months.

Factor Analysis of CAQ

Correlations Including the Committed Action

Questionnaire

SF-36

Pain Acceptance

Pain(0-10)

Depression (PHQ-9)

Phys Soc Mental Health

Vital Gen Health

Committed Action (CAQ)

.49*** -.05 -.57*** .20*** .40*** .58*** .33*** .37***

Pain Acceptance (CPAQ)

-.13 -.42*** .17* .31*** .39*** .24*** .30***

* p < .05; ** p < .01; *** p < .001.

Regression Results

Block Predictors ΔR2 β (final)

AdjustedR2

Depression (PHQ-9)

1 Pain (0-10) .064** .22**

2 Committed action (CAQ) .15*** -.39*** .20***

1 Pain (0-10) .064** .20**

2 Pain acceptance (CPAQ) .15*** -.16

3 Committed action .17*** -.48*** .37***

Physical Functioning (SF-36)

1 Pain (0-10) .080** -.27**

2 Committed action (CAQ) .033* .18* .097**

1 Pain (0-10) .080** -.27**

2 Pain acceptance (CPAQ) .018 .063

3 Committed action (CAQ) .018 .15 .092**

Block Predictors ΔR2 β (final)

AdjustedR2

Social Functioning (SF-36)

1 Pain (0-10) .081** -.26**

2 Committed action (CAQ) .15*** .38*** .21***

1 Pain (0-10) .081** -.25**

2 Pain acceptance (CPAQ) .077** .12

3 Committed action .080** .32*** .22***

Mental Health (SF-36)

1 Pain (0-10) .032 -.15

2 Committed action (CAQ) .32*** .57*** .34***

1 Pain (0-10) .032 -.13

2 Pain acceptance (CPAQ) .14*** .13

3 Committed action (CAQ) .20*** .51*** .35***

Block Predictors ΔR2 β (final)

AdjustedR2

Vitality (SF-36)

1 Pain (0-10) .036* -.17

2 Committed action (CAQ) .10*** .32*** .12***

1 Pain (0-10) .036* -.16

2 Pain acceptance (CPAQ) .046* .078

3 Committed action (CAQ) .062** .29** .12***

General Health (SF-36)

1 Pain (0-10) .00 -.042

2 Committed action (CAQ) .13*** .37*** .12***

1 Pain (0-10) .00 -.027

2 Pain acceptance (CPAQ) .089** .16

3 Committed action (CAQ) .065** .29** .13***

A Preliminary Study of

Cognitive Fusion

• N = 326 people seeking treatment for

chronic pain.

• 67.8% women

• Mean age 47.4 years (sd = 11.8)

• Participants completed an interim 13-item

version of the Cognitive Fusion

Questionnaire (Gillanders et al., 2013) as

part of a treatment outcome assessment

process.

Correlations

SF-36

AAQ-II CPAQ PHQ-9 Phys Ment Soc Vital GH

Cog Fusion

(CFQ).78*** -.53*** .59*** -.10 -.54*** -.41*** -.35*** -.34***

Pain Accept

(CPAQ)-.54*** -.51*** .16** .39*** .37*** .29*** .30***

** p < .01; *** p < .001.

Regression Model for Depression

Regression Model for Mental Health

INPUT OutcomesMeasures Pre-

treatment

mean (SD)

Post-

treatment

mean (SD)

9-month

mean (SD)

F p Cohens

d (pre-

post)

Cohens

d (pre-

9month)

PHQ (N=138) 15.13 (6.34) 9.83 (6.41) 12.21 (7.19) 55.80 0.000 0.84 0.46

AAQ (N=142) 30.67 (10.97) 26.51 (11.28) 25.66 (12.70) 18.95 0.000 0.38 0.46

CFQ (N=140) 50.87 (13.79) 48.04 (15.68) 46.86 (15.28) 7.63 0.001 0.21 0.29

CPAQ (N=128) 50.58 (19.13) 63.19 (18.65) 60.88 (19.42) 27.36 0.000 0.66 0.54

Physical

functioning SF-36

(N=146)

15.18 (3.65) 17.34 (4.57) 16.31 (4.64) 23.695 0.000 0.59 0.31

Social

functioning SF-36

(N=147)

4.88 (1.86) 6.52 (2.00) 5.87 (2.33) 40.482 0.000 0.88 0.53

Outcomes for the two week pre-

Neuromodulation programme

• N = 174 in a two-week treatment course.

• All participants being considered for a

“neuromodulation” procedure.

• Neuromodulation means a spinal cord

stimulator implantation for pain relief.

• Question: Can people actively seeking

other treatment benefit from an ACT-

based treatment?

Selected Results Post Treatment

Pre M (SD) Post M (SD) t d

Physical 15.69 (3.97) 17.19 (4.51) 6.58** .38

Social 5.04 (1.85) 6.34 (1.99) 8.22** .70

Mental Health 16.63 (5.80) 20.71 (4.87) 10.96** .70

Depression 15.51 (6.86) 11.24 (6.02) 9.53** .62

Acceptance 46.61 (18.17) 56.74 (18.96) 3.02* .56

Physical, Social, and Mental Health scores are raw scores from SF-36,

depression score is from PHQ-9.

* p < .01, ** p < .001.

Empirical Studies from INPUT since 2013

McCracken, L. M. (2013). Committed action: An application of the psychological flexibility

model to activity patterns in chronic pain. The Journal of Pain, 14, 828-835.

Barker, E, & McCracken, L. M. (in press). From traditional Cognitive Behavioral Therapy

to Acceptance and Commitment Therapy for chronic pain: A mixed method study of

staff experiences of change. British Journal of Pain.

McCracken, L. M., DaSilva, P., Skillicorn, B., Doherty, R. (in press). The Cognitive Fusion

Questionnaire: a preliminary study of psychometric properties and prediction of

functioning in chronic pain. The Clinical Journal of Pain.

McCracken, L. M., Barker, E., Chilcot, J. (in press). Decentering, rumination, cognitive

defusion, and psychological flexibility in people with chronic pain. Journal of

Behavioral Medicine.

McCracken, L. M., Chilcot, J. & Notron, S. (in press). Further development in the

assessment of psychological flexibility: A shortened Committed Action Questionnaire

(CAQ-8). European Journal of Pain.

Conclusions

• A number of new measures have been developed and validated to support the assessment of psychological processes involved in adjusting to chronic pain. These complement outcome measures and provide insight into how people adjust or what impedes progress.

• The CAQ and CFQ, assessing two key ACT processes of the psychological flexibility model, Committed Action and Cognitive Fusion, have been tested and been shown to have good psychometric properties.

• Both committed action and cognitive fusion explain significant proportions of the variance in depression, mental health and social functioning.

• Shorter forms of the scales are being developed and there are plans to create further new measures, e.g. to assess self as observer.