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Mission Statement of IASP Press®

The International Association for the Study of Pain (IASP) is a nonprofit, inter-disciplinary organization devoted to understanding the mechanisms of pain andimproving the care of patients with pain through research, education, and communi-cation. The organization includes scientists and health care professionals dedicatedto these goals. The IASP sponsors scientific meetings and publishes newsletters, tech-nical bulletins, the journal Pain, and books.

The goal of IASP Press is to provide the IASP membership with timely, high-quality, attractive, low-cost publications relevant to the problem of pain. These publi-cations are also intended to appeal to a wider audience of scientists and cliniciansinterested in the problem of pain.

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Progress in Pain Research and ManagementVolume 33

Contextual Cognitive-BehavioralTherapy for Chronic Pain

Lance M. McCracken, PhD

Pain Management Unit, Royal National Hospital for RheumaticDiseases, and University of Bath, Bath, United Kingdom

IASP PRESS® • SEATTLE

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© 2005 IASP Press®

International Association for the Study of Pain®

All rights reserved. No part of this publication may be reproduced, stored in a retrievalsystem, or transmitted, in any form or by any means, electronic, mechanical, photocopy-ing, recording, or otherwise, without the prior written permission of the publisher.

Timely topics in pain research and treatment have been selected for publication, but theinformation provided and opinions expressed have not involved any verification of thefindings, conclusions, and opinions by IASP®. Thus, opinions expressed in ContextualCognitive-Behavioral Therapy for Chronic Pain do not necessarily reflect those of IASPor of the Officers and Councillors.

No responsibility is assumed by IASP for any injury and/or damage to persons orproperty 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 rapidadvances in the medical sciences, the publisher recommends that there should beindependent verification of diagnoses and drug dosages.

Published by:

IASP PressInternational Association for the Study of Pain909 NE 43rd Street, Suite 306Seattle, WA 98105-6020 USAFax: 206-547-1703www.iasp-pain.orgwww.painbooks.org

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

McCracken, Lance M., 1962- Contextual 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

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Foreword: The Opportunities and Challenges of Acceptance-BasedApproaches to Pain ix

Foreword: Empowering the Lives of Chronic Pain Patients xiii

Preface 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 Painand 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

Contents

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Foreword: The Opportunities andChallenges of Acceptance-Based

Approaches to Pain

Imagine have pain every waking moment of your day. Imagine that thecause of the pain cannot be determined and that health care professionals tellyou there is nothing they can do to eliminate the pain. Your pain is likely tocontinue for the rest of your life. What would you do? How would you thinkand feel? How would your life change? This volume is about persons whoselives are dominated and defined by their struggle to eliminate such persis-tent pain.

Although the struggle to eliminate pain is often the central problem inmanaging chronic pain, until recently it has received little attention frompain researchers and clinicians. To understand why, one needs to considerthe historical context of chronic pain clinics and chronic pain managementprograms. It is only in the past 40 years that the scope and complexity of theproblems of persons with chronic pain have become apparent. Prior to thattime, pain was considered as simply an indicator of an underlying medicalproblem that required treatment. Pioneers such as Bonica (1953) arguedthat, even when underlying disease is treated effectively or is apparentlyabsent, pain can persist. Bonica was among the first medical specialists toargue that such chronic pain, in and of itself, is a legitimate target forclinical and research efforts. He reasoned that because chronic pain wascomplex, it was best treated in special multidisciplinary pain clinics. In suchclinics, professionals from different disciplines, each having expertise in thecontrol of pain (e.g., anesthesiology, neurology, neurosurgery, physical medi-cine, psychiatry, and psychology) could evaluate a patient with chronic painand develop an appropriate multidisciplinary pain management plan. The1970s to early 1990s witnessed the emergence of a large number of painclinics and pain management programs. These specialized programs mobi-lized hope among patients and multidisciplinary specialists that a sophisti-cated, 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 im-proving the lives of persons with chronic pain, only in rare cases do theyeliminate pain or reduce it to very low levels. The benefits of these pro-grams have mainly been in enhancing quality of life and reducing pain-

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related physical disability and psychological distress. In light of this obser-vation, the titles “pain clinic” or “pain program” are probably misnomers.These titles foster the mistaken notion that the primary agenda, goal, andoutcome of treatment is the abolition or substantial reduction of pain. Inter-estingly, most pain clinics and pain programs include an educational compo-nent where patients are told that while treatment may produce some reductionsin pain, the central goal is to improve quality of life, despite the presence ofpersistent pain.

Although pain clinics and pain programs have helped many persons,there remains an important subgroup of individuals who present for treat-ment in these programs who feel that the treatment is doomed to failure if itdoes not eliminate their pain. These individuals’ lives often center aroundthe struggle to eliminate pain and the search for new treatments that promiseto eliminate pain (McCracken et al. 2004). New medical and surgical tech-niques, often invasive and risky, are constantly being developed, many ofwhich are touted in the media, and in some cases by practitioners, as curesfor chronic pain. All too often, patients focused on the elimination of theirchronic pain seek out and undergo these treatments, only to have their hopesfor total and permanent pain relief dashed. Many patients have multiplefailures with invasive surgeries and other aggressive approaches designed toeliminate pain. Unfortunately, in many cases, these treatments have majorside effects and result in even more severe pain. With repeated failures oftreatments designed to eliminate pain comes bitterness, hopelessness, andresignation.

This volume introduces a very innovative acceptance-based approachthat can help pain clinicians and researchers understand why, in some per-sons, struggling to eliminate persistent pain can be so problematic. Thisacceptance-based approach offers novel and important strategies for assess-ing and treating pain that may be particularly beneficial to patients who havefailed to respond to more conventional biomedical and psychosocial ap-proaches.

The acceptance-based approach outlined in this book has very importantimplications for assessment. First, it emphasizes the importance of under-standing behavior in its context. The reason that someone continues with anonproductive struggle to eliminate pain may be due to social or environ-mental antecedents, such as the promptings of a spouse or the urgings of awell-intentioned health care provider, or consequences, such as avoidance ofunwanted family or work responsibilities. Alternatively, this struggle mayreflect a learning history in which struggles to overcome seemingly insur-mountable obstacles were occasionally successful.

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Second, an acceptance-based approach highlights the need to much morefully assess an individual’s own view of his or her problems as revealed bythoughts and words. As this volume points out, we need to accept andunderstand this view as a starting point and be cautious about making as-sumptions of what that view may be. Careful interviewing done in an em-pathic fashion can help reveal how a person’s verbal constructions of his orher situation (“Because of this pain I can’t work and therefore I am worth-less”) can motivate and drive what seems to be an incessant and fruitlesssearch for ways to eliminate pain. All too often, pain clinicians’ attempts atpain assessment are encumbered by conceptual models, preconceptions, andpragmatic concerns that interfere with their ability to carefully listen to andfully understand how patients view their own pain.

Third, an acceptance-based approach emphasizes the crucial importanceof understanding avoidance as a coping strategy. When someone viewschronic pain as unacceptable and intolerable, it is understandable that he orshe feels it must and should be avoided at all costs. As is clear from thisvolume, avoidance may take many forms. It may be evident in changes inbehavior (e.g., spending excessive time reclining or in bed or drinking toomuch alcohol) or thoughts (e.g., trying to ignore the pain or convincingoneself that it is only a temporary problem). The acceptance-based approachoutlined in this book makes it clear that avoidance, while understandable asa coping strategy, has long-term consequences that are negative and self-defeating.

As is clear from reading this book, one of the most important reasons todevelop an acceptance-based approach to chronic pain is that it can directtreatment efforts. With growing adoption of an acceptance-based approachwill come increased use of contemporary as well as traditional meditationtechniques. Kabat-Zinn’s mindfulness meditation protocol, for example, bringstogether a set of meditation practices that can increase awareness and accep-tance of pain-related thoughts and feelings (Kabat-Zinn 1982). Loving kind-ness (Metta) meditation, a traditional meditation practice, fits well with anacceptance-based approach in that can help patients understand pain-relatedanger and resentment and develop a more compassionate and forgiving atti-tude toward themselves and others (Carson et al., in press).

One of the most important and interesting features of this book is that ithighlights the ways in which traditional cognitive-behavioral and behavioralinterventions can be used within the context of an acceptance-based ap-proach. Techniques that involve graded exposure to feared pain-related ac-tivities and events are advocated, not for reducing or controlling the fear ofpain, but instead for helping patients develop a capacity to experience thoughtsand feelings they may be avoiding.

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In conclusion, this book represents a very important step in the develop-ment of an acceptance-based approach to persons having chronic pain. Itdeserves to be read by all pain clinicians and researchers who are interestedin novel, psychosocial approaches to dealing with the challenges of livingwith persistent pain.

FRANCIS J. KEEFE, PHD Department of Psychiatry and Behavioral Sciences

Duke University Medical Center Durham, North Carolina, USA

xii FOREWORD

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Foreword: Empowering the Livesof Chronic Pain Patients

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The vast majority of treatment approaches in chronic pain target reduc-tion in pain per se. It is remarkable how little evidence exists for this ap-proach, despite its powerful common-sense appeal. Some of the most typicalpain treatments, such as analgesics, surgery, physical therapy, manipulation,transcutaneous electrical nerve stimulation, and the like have very limitedempirical support with chronic pain (Dahl et al. 2005). In area after area,physical findings fail to correlate with chronic pain or disability. For ex-ample, disk hernia is as common among patients without back pain as inthose with chronic back pain (Boos et al. 1995). Reports of back pain are notcorrelated with objective measures of back function and general physicalfitness, such as muscle strength, oxygen uptake, height, weight, body massindex, or the spinal channel as measured by ultrasound; instead they corre-late most strongly with psychosocial factors (Bigos et al. 1991). This basicpattern is repeated throughout the pain literature. Whatever else one can sayabout such data, one thing is clear: chronic pain is not simply a physicalproblem. It involves profound social and psychological dimensions as well.

The multidimensional nature of chronic pain probably explains whybroader treatment approaches are more successful. Meta-analyses have con-firmed that integrated multidisciplinary treatment regimens are notably moreeffective (Flor et al. 1992) and lead more patients to return to work (Cutleret al. 1994).

The dominant model that underlies most psychosocial interventions forchronic pain is cognitive-behavioral therapy (CBT). Meta-analyses have con-firmed the effectiveness of CBT technology, but not of the traditional CBTmodel. Fortunately, CBT is itself undergoing a revolutionary change, as thisvolume will show.

Traditionally, CBT took the relatively mechanistic position that thoughtsand feelings needed to change their form before behavior could change. Theso-called “third wave” (Hayes 2004), interventions such as mindfulness-based interventions or Acceptance and Commitment Therapy (Hayes et al.1999a), take a more contextual approach: the life role of thoughts and feel-ings is itself a situated event and thus can change even if thoughts andfeelings do not change their form.

This shift from a more mechanistic to a more contextualistic form ofCBT has potentially revolutionary implications for pain (Dahl et al. 2005).

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xiv CONTRIBUTIxiv FOREWORD

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 chronicpain patients are ready to consider whether attempts at control have benefi-cial effects over the long term, especially if their lives need to be put onhold in the meantime. Far from invalidating the pain patient, this shift is em-powering.

This volume makes a powerful argument that chronic pain is in part anexperiential avoidance disorder. The author’s own empirical work is espe-cially telling: the Chronic Pain Acceptance Questionnaire (see the Appen-dix) shows that acceptance of pain and a willingness to act in its presence isassociated with reports of lower pain intensity, less pain-related anxiety andavoidance, less depression, less physical and psychosocial disability, moredaily uptime, and better work status (McCracken 1998; McCracken andEccleston 2003; McCracken et al. 2004b). A relatively low correlation be-tween acceptance and pain intensity shows that acceptance is not simply afunction of having a low level of pain. Acceptance of pain predicts betteradjustment on measures of patient function than does perceived pain inten-sity, and that continues to be true even when pain intensity is factored out.

These powerful data are being replicated in several other disorders (Hayeset al. 2004). From a pathology-oriented perspective, it is removal of painthat is necessary to free the individual to pursue life directions. From acontextual CBT perspective, however, it is possible to move directly towardthis behavioral end once one abandons the struggle to avoid or reduce painitself. 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 howthey can be integrated into multidisciplinary treatment. Multifaceted andcaring, this model has the potential to be a real step forward for the painpatient.

No one likes to hurt. Human compassion calls out for us to reach out tothose 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, thework represented in this volume shows that there are new and potentiallymore effective ways to be compassionate and to empower the lives of thosewith chronic pain.

STEVEN C. HAYES, PHDDepartment of Psychology

University of NevadaReno, Nevada, USA

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Preface

My first professional experiences with chronic pain sufferers took placeat the university medical center in Morgantown, West Virginia, in 1990.Four years later I accepted my first faculty post at The University of Chi-cago. Around that same time I became aware of the work of a group ofbehaviorally oriented researchers on language, cognition, emotion, and some-thing called Acceptance and Commitment Therapy (ACT). Shortly afterbeginning work in Chicago I ran across two things—a copy of an earlyversion of a treatment manual for ACT (later expanded and published asAcceptance and Commitment Therapy: An Experiential Approach to Behav-ior Change) and a doctoral dissertation on acceptance-based treatment forchronic pain completed by David Geiser, a student from the University ofNevada in Reno. I found this material both challenging and immenselyexciting. At that point my colleagues and I began to expand our behavioraland cognitive-behavioral approaches and to increasingly adopt contextualand acceptance-based assessment and treatment methods. We also began tostudy processes related to acceptance of chronic pain, with remarkably en-couraging results. Since 2000 this work has carried on with our team inBath, United Kingdom.

There are many influences on the work presented here in addition to theprimary influences from ACT. These influences come from my clinical train-ing at West Virginia University; the operant approach to chronic pain ofWilbert Fordyce; work on fear and avoidance of pain by colleagues in Bel-gium, Canada, the Netherlands, and Sweden; Dialectical Behavior Therapyfrom Marsha Linehan; and approaches to mindfulness training, including thework of Jon Kabat-Zinn.

This volume was designed to introduce a different perspective on chronicpain management, to illustrate this perspective with a sample of practicalclinical methods, to lead the reader to further study in the wider literature,and to encourage some expansion of current clinical methods. The chaptersof this book are intended to present a theoretical and clinically useful ap-proach to chronic pain management, albeit one that is in continuing develop-ment. The first chapter presents a social and medical perspective on chronicpain, and briefly discusses recent shifts in behavioral and cognitive thera-pies, shifts that are particularly applicable to the problem of pain. Chapter 2traces developments in the operant and cognitive behavioral approaches tochronic pain that have laid part of the foundation for current work. Chapters3 through 5 describe an integrative, functional, contextual framework for

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xvi PREFACE

assessment and treatment of chronic pain that incorporates and extends thespirit of both operant- and cognitive-behavioral approaches. Chapter 6 fur-ther examines psychological acceptance, a key element of this framework,and reviews relevant research findings. Chapters 7 through 9 present treat-ment principles and illustrate treatment methods of Contextual Cognitive-Behavioral Therapy (CCBT) for chronic pain. The final chapter summarizesand restates some of the key distinguishing features of CCBT and suggestsdirections for further development.

The approach of this book, including the notion of “acceptance” andquestioning the necessity for control over pain as it does, may lead to somemisunderstanding. After all, pain control is now often presented as a “basichuman right,” and “live life” is equated with “control pain” in slogans of ourprofessional societies and advertisements from the pharmaceutical industry.These statements sound reasonable, and on many occasions they are; how-ever, they may require a closer look. The notion of basic human rights is auseful one. It can add urgency to goals such as promoting appropriate fund-ing for pain treatment services, facilitating access to these services by thosewho will benefit, encouraging training of pain specialists, and promotingnew therapy developments, or for any purposes that reduce unnecessarysuffering. Nevertheless, statements about a right to pain control may do adisservice in other ways. If they are taken to mean that all pain is control-lable, they are simply untrue, may place unnecessary pressure on health careproviders, and may inadvertently add to patients’ suffering.

Universal access to modern medical therapies, trained specialists, inter-disciplinary services, and empirically supported therapies for those who willbenefit is a noble goal. Access to pain control methods, however, should notbe equated with access to complete pain control. That is unrealistic. Aboveall, 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” inother ways.

The point of this book is not to dismiss pain or to discourage attempts toalleviate it, but rather to ensure that these attempts are balanced and propor-tionate and do not unintentionally exacerbate patients’ problems, excludeeffective ways of helping patients that do not focus on pain control, or putthe quality of the patient’s life secondary to other concerns. Clearly, it is thepotential to enhance the quality of the patient’s life that gives pain controlefforts their justification at the start.

It may be important to demote the word “acceptance” before it gets toooverblown. Acceptance of all pain is not an appropriate goal. Acceptance isnot intended as the primary guiding principle of therapy. It is simply one ofa number of secondary processes meant above all to serve the purpose ofhelping 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 responsibil-ity for its message, it reflects contributions from many people. I would liketo express my sincere thanks to all those who helped me reach the point atwhich this book became possible. There are many teachers and colleagueswho have given me opportunities to watch, listen, learn, and to communi-cate more clearly about the work I do. I am particularly grateful to RickGross and Jennifer Haythornthwaite for their teaching and mentoring overthe years. My special thanks go to Steve Bono and Chris Eccleston for helpduring the writing of this book and for providing the opportunity to discussmuch of the material in it. I am grateful to my excellent colleagues in Bathwho have provided invaluable opportunities for learning and for developingthe services we offer and share with our broader community. I would alsolike to thank the people from IASP Press, especially Elizabeth Endres, andthe copy editor Margaret Warman, for all of their help in finally bringingthis work to the reader.

LANCE M. MCCRACKEN, PHD

PREFACE xvii

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Contextual Cognitive-Behavioral Therapy forChronic Pain, Vol. 33, by Lance M. McCracken,IASP Press, Seattle, © 2005.

Psychological Approachesto Chronic Pain

The history of formal psychological approaches to pain is a short one. Ifone takes 1879, the year the first psychology laboratory was opened byWilhelm Wundt, as the formal beginning of psychology as a field of study,then psychological approaches to pain cannot be older than that. For ex-ample, the first mention of the term “psychogenic pain” was not made until1904 by Otto Binswanger, a professor of psychiatry at the University of Jenain Switzerland. Shortly afterward, around 1909, the introspectionist EdwardTitchener made his observations that pain appeared to have both sensoryand emotional qualities. In the 1920s Ivan Pavlov showed that dogs could beconditioned to respond to pain exposure in ways that were more usuallyassociated with exposure to food. In 1965 Ronald Melzack and Patrick Wallpublished their paper on the gate control theory of pain in the journal Sci-ence, providing a working framework for understanding the remarkably vari-able relationship between peripheral noxious stimulation and the experienceof pain.

It is not the purpose of this chapter to detail the entire history of psycho-logical thinking about chronic pain. That topic deserves treatment of itsown, and the purpose here has a more specific focus. Clinical methods usedmost frequently today by psychologists and interdisciplinary teams are rootedin two related frameworks, the operant and the cognitive-behavioral. Thetheory, methods, and results of these frameworks will be briefly summa-rized.

AN OPERANT APPROACH

In 1976 Wilbert Fordyce published Behavioral Methods for ChronicPain and Illness, the product of his collaborative work with colleagues atthe University of Washington on the application of operant behavioral meth-ods to chronic pain treatment. They had earlier discussed and presentedtreatment outcome results (Fordyce et al. 1968, 1973), but the book (Fordyce1976) was the first complete description of this approach. It constituted a

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Contextual Cognitive-Behavioral Therapy forChronic Pain, Vol. 33, by Lance M. McCracken,IASP Press, Seattle, © 2005.

Contextual Cognitive-Behavioral Theory

It may be clear from Chapter 2 that there has been some controversy inthe past arising from contrasting philosophies of psychology within painmanagement. This controversy concerns the relative emphasis placed onwhat the pain sufferer thinks and feels and the degree to which the contentof these experiences should be targeted for change in treatment. Behavioralapproaches in particular have been criticized for ignoring covert or privateaspects of the patient’s experience and, by implication, for regarding themas unimportant. As will be seen, this criticism is not valid for behavioralapproaches today. Relatively recent developments within behavioral scienceand practice fully consider private experiences and do so in new ways,functionally rather than structurally. Some of the history of behavioral ap-proaches is worth reviewing, however, to help put current behavioral andcognitive approaches in perspective.

A BRIEF HISTORY

The founder of behaviorism was John B. Watson. Watson was respond-ing to problems he saw within psychology, which at that time took mentalprocesses and consciousness as its subject matter, and what was called “in-trospection” as its method. In 1913 Watson published his paper “Psychologyas the behaviorist views it.” In this paper he urged that psychologists aban-don introspection and adopt more suitable methods in order to advance thefield as a natural science. It is important to understand what Watson wasattempting to accomplish, because many of his ideas have been misrepre-sented.

Watson believed that introspection was inadequate for the study of men-tal processes. He insisted that psychology could return to the study of inter-nal mental states at some later date if methods were developed to supportthat endeavor, and in the meantime placed them temporarily out of boundsin favor of objectively measurable, overt behavior. His approach to psychol-ogy was pragmatic and was readily adopted by many; however, it was alsogreatly limited by its reliance on truth by agreement, or logical positivism,and its unit of analysis, the stimulus-response relation. Although Watson’s

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work was useful in creating a break from the tradition of introspectionismand was a considerable epistemological advance at that time, it was a limitedapproach by today’s standards.

In Watson’s approach, referred to as methodological behaviorism, hedefined the subject matter of psychology with the exclusion of private expe-rience. He did not, however, deny the existence of these experiences, as issometimes supposed. In any case, by the middle of the 1950s there was ashift in psychology. Behavioral approaches since that time have slowly butincreasingly embraced private experiences as their subject matter.

RADICAL BEHAVIORISM

Radical behaviorism is the philosophy that formed a framework for thefield of behavior analysis (Skinner 1974; Chiesa 1994; O’Donohue andFerguson 2001). The term “radical” seems to connote the extreme, outland-ish, or extraordinary. It was intended simply to mean thorough-going, to theroot, or deep. Radical behaviorism has features that distinguish it from otherapproaches to the study of psychology. These include its subject matter, itsmodel of causality, and its goals.

Radical behaviorism defines behavior as its subject matter. In much ofcontemporary psychology this is not the case; rather, behavior is consideredas a sign or manifestation of some other variable, process, or issue of pri-mary concern, such as intelligence, memory, personality, attitude, emotion,motivation, intention, cognitive bias, or identity. Within radical behavior-ism, behavior includes all the observable activity of the whole individual,even activity that is observable only by the person engaging in it. As Skin-ner clarified,

“Mentalism kept attention away from the external antecedent events whichmight have explained behavior, by seeming to supply an alternate explana-tion. Methodological behaviorism did just the reverse: by dealing exclu-sively with external antecedent events it turned attention away from selfobservation and self knowledge. Radical behaviorism restores some kindof balance. It does not insist on truth by agreement and can thereforeconsider events taking place in the private world within the skin. It does notcall these events unobservable, and it does not dismiss them as subjective.It simply questions the nature of the object observed and the reliability ofthe observations.” (Skinner 1974).

The model of causality for radical behaviorism is a subtle one. It relieson selection and functional relations, selection being of three types: natural

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HYPOTHETICAL CONSTRUCTS AND FUNCTIONALRESPONSE CLASSES

Measures used in psychology are varied, but often include descriptionsof behavior. These behaviors are considered to be signs or symptoms ofsome other variable, typically one of central interest that is inferred and notdirectly observed. The behavior clusters used to derive summary scores aregrouped together for theoretical reasons, or sometimes on empirical grounds.They may have demonstrated sufficient intercorrelations to be considered toreflect the same psychological feature. For certain psychological variables itmay be presumed that what ties the items of an inventory together is theirshared relationship with some personal characteristic such as locus of con-trol, self-efficacy, or neuroticism.

It is useful to understand meaningful consistencies in behavior over timeor across situations, although these are sometimes inferred rather than ob-served. Further, when a person is given a score for a variable that has trait-like features, that variable can assume unwarranted causal status and may beused to explain the very behavior pattern from which it was derived. Mea-sures of inferred psychological processes can confuse description with ex-planation, leading to circular reasoning. This reliance on personal character-istics as causes of behavior inhibits a more careful examination of contextualinfluences. Deducing internal causes from consistent behavior patterns di-rects assessment and treatment efforts toward the quantifying and changingof hypothetical descriptive accounts, rather than toward the functional de-pendence of observable behavior on aspects of the person’s environment,including the stimulus features of thoughts and emotions and the contextsthat give them their meaning.

Some psychological variables of interest in chronic pain assessmentcould be reexamined as possibly meeting criteria for functional responseclasses, groups of perhaps superficially dissimilar responses that appearunder the same influences or operate on the environment in the same man-ner (see Chapter 3). The notion of response class implies only that

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

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ACTIVITY ENGAGEMENT AND BEHAVIOR CHANGE 105

direction, and social influence can provoke resistance, strengthening behav-ior that is counter-therapeutic.

Dialectical behavior therapy explicitly includes a contingency manage-ment component that is a useful guide (Linehan 1993b). One importantconcern is that patients are experimenting. They have opportunities in treat-ment to behave in ways that they never did before, and these may be healthynew responses likely to lead to freer and more satisfying lives. Patients mayexercise despite an increase in pain, recognize a thought as an unnecessaryinfluence on a course of action, or confront a difficult emotion withoutdefense. These responses may show up in small ways, and we may observethem. 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 thecomplete behavior; finding responses that reinforce behavior in a particularindividual; realizing that public praise is not always reinforcing; ensuringthat praise does not become associated with a lack of support or with in-creasing demands; using non-arbitrary and natural reinforcers whenever pos-sible; using punishing methods as little as possible, if at all; rememberingthat if one is using cues or instructions one must use consequences as well;and watching for and addressing punishing influences that may come fromwithin the group of patients.

Responses from treatment providers that reinforce healthy and func-tional patient behavior can take many subtle forms and need not be over-done. A smile, a thumbs-up, or a single quiet word can be all the acknowl-edgment needed if it arises spontaneously, sincerely, and openly, from arelationship of respect.

RELAXATION

Relaxation methods may seem discordant with an approach that entailsacceptance of private experience. Ostensibly, relaxation is about changingthe 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 reducethe emotional aspects of the pain experience (e.g., Caudill 1995). Relaxationcan serve other purposes and can also be a useful experiential exposuremethod.

If relaxation happens to work for a patient and helps him or her toactively live a meaningful life, there is no need for change. However, it canalso 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 outfrom reality, and others say that relaxation does not change how their painfeels, and they therefore reject it. Some patients claim that they cannot relaxdue 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 distress-ing thoughts. These responses are interesting from a psychological perspec-tive because in these instances thoughts and feelings are functioning asbarriers to a course of action; they are being taken as experiences withwhich to struggle, in ways that are unnecessary. These problems provideexcellent opportunities for some alternate purposes of relaxation.

A core assumption of acceptance-based CCBT is that behavior directedtoward a meaningful life can occur in a manner that includes, but is notderailed by, potentially distracting or troubling thoughts, emotions, and sen-sations. Relaxation methods provide a potential experience of this process.The practice of relaxation can be tied to different goals, not aimed towardthe control or reduction of unwanted private experiences but toward a will-ingness to have these experiences and a loosening of the influence of theseexperiences on action. This loosening is the process of increasingly acting ina calm and relaxed manner with the full awareness that one may not befeeling or thinking that way. A summary of some of the purposes of relax-ation that may be used clinically is included in Table II.

Within an acceptance-based approach it is probably more useful to ex-pose patients to relaxation methods that have a “here and now” quality.Patients often say they enjoy guided imagery or exercises in which thetherapist’s voice is used to induce calmness, or exercises with hypnoticfeatures. These types of strategies can function as avoidance or escape fromexperiences 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 patientis learning in the passive role they often adopt during such exercises. Morepresent-focused and less avoidance-based exercises may involve focusingon breathing, the body, sensations, or perhaps some other brief focusingdevice such as counting. It is possible to use a behaviorally based relaxationmethod focused on overt responses and breathing (Poppen 1988) and toadapt a simple version of this method for use in a chronic pain treatmentcontext. 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-basedapproach. Some methods of standard behavioral activation, such as thoseused with depression, can be helpful (e.g., Emery 2000). Behavioral activa-tion concepts such as faking, acting “as if,” and acting opposite to the wayone feels, can be useful to demonstrate the fact that actions need not followfeelings. Actions can follow desired goals in the situation instead. Whenpatients raise the issue that they do not want to be dishonest or hide theirfeelings, 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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