Tracking Psychological Processes Involved in Self … · 2017-06-22 · Tracking Psychological...
-
Upload
hoangduong -
Category
Documents
-
view
219 -
download
0
Transcript of Tracking Psychological Processes Involved in Self … · 2017-06-22 · Tracking Psychological...
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.
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.
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.