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Issues of acceptance in chronic pain populations.

Chronic pain, defined as recur- rent pain which last for longer than six months, represents a wide spread and challenging problem affecting as many as 75 million Americans and which has considerable impact on the quality of life for the people who are experiencing it (Borrica, 1987; Frymoyer & Cats-Baril, 1991). For many of these individuals no clear diagnosable etiology for their pain will be identified (Deyo, 1986; Dworkin & Massoth, 1994) and, despite substantial expenditures, in many, if not most cases, chronic pain continues to be poorly managed within traditional medical settings (Crook, Weir & Turks, 1989).

To improve treatment outcome and broaden our understanding of this complex behavior, a number of theorists have expended the conceptualization of pain to include psychological factors and indeed the official definition of pain acknowledges the presence and role of psychological factors in the experience of pain (Flor & Turk, 1984; Fordyce, 1976; Gatchel & Turk, 1996). Within the now broadly recognized biosocial model, pain is defined as a physical, emotional, and behavioral experience associated with actual or potential tissue damage (Gatchel & Turk, 1996; Melzack & Walls, 1982).

There are several important implications which follow from this definition. The foremost of which is that all pain in humans is mediated by psychological factors. Amongst other things, this means there is no such phenomena in humans as "true pain" and searching for distinctions between Psychogenic vs. Organic pain is not useful. However, there is a large variation in the type psychological factors present, the extent to which they are influencing perception and expression of pain, and the impact they are having on treatment.

By including behavioral and cognitive-behavioral treatments in pain management programs, treatment outcomes improve considerably and there is a substantial body of literature demonstrating the efficacy of multidisciplinary approaches to chronic pain management (Flor & Turk, 1984; Fordyce, 1976; Gatchel & Turk, 1996; Kerns, 1994). However, a sizable proportion of patients do not respond well even to structured multidisciplinary treatment programs (Turk, 1990; Turk & Rudy, 1991). It has been suggested that patient factors may account in part for differences in outcome (Keens, et al., 1997). One important factor that has not received extensive attention, but which may differentiate between responders and nonresponders, is acceptance of pain. In particular, acceptance of pain as a chronic condition which is going to require a different approach than that used for acute pain. As such, changing patient's level of acceptance can be an important part to effectively impacting their pain experience.

Recently, within the field of clinical behavior analysis, there has been growing interest in the role of verbal behavior in the etiology and maintenance of psychopathology. As such, a number of individuals have written about the impact of "acceptance" on a variety of clinical phenomenon (Hayes, et al., 1994). This paper examines the possible role of acceptance vs. non-acceptance within chronic pain populations.

Data from ongoing studies being performed at the University of Alabama at Birmingham School of Medicine suggest three general styles of responding to chronic pain. The first is what might be called the acute pain response. These individuals continue to be focused on seeking medical solutions to their pain. They are often in a great deal of emotional distress, are highly focused on identifying an etiology to their pain, often are seeking invasive solutions like surgery, engage in frequent "doctor shopping" seeking a total resolution and cure for their pain, see their pain as a medical problem which should be addressed solely by medical personnel, and put life goals on hold. Many Patients continue to seek treatment at high personal, as well as financial cost, which actually disrupts the chances of engaging ii a successful treatment (Amoff, 1991; Philips, 1987).

The second way individuals may respond to chronic pain might be defined as the disability response. This is characterized by accepting that their pain is likely to be chronic and that an etiology might never be found and so they give up. They tend to see them- selves as disabled and indeed ten are seeking SSI Disability, are highly sedentary, are often depressed, and have abandoned their life goals. They also view their pain as a medical problem, however they are typically seeking medication based solutions rather than interventional solutions.

These two ways of responding might be thought of as akin to responses one frequently sees to emotional pain (Hayes, et al., 1996). For example, in response to depression, people often either spend large amounts of energy trying to push it away or wallow in it. Neither is a response that involves addressing the symptoms of depression. Similarly focusing on acute pain management strategies or living a disability-focused lifestyle are both ways of responding to chronic pain that are maladaptive, avoidant, and non accepting of the current circumstances. Both of these groups of patients tend to be passive about their role in treatment and tend to see treatment outcome in black and white terms. For these patients, treatment efficacy is defined as complete return to normal functioning, otherwise treatment has been a failure. However, a large majority of chronic patients will continue to experience some level of pain even after "successful" treatment, and some pain treatments actually do more harm than good (Amoff, 1991; Crook, et al., 1989; Philips, 1987). For most individuals experiencing chronic pain, more appropriate and realistic treatment goals are aimed at stabilizing pain and maximizing function (i.e., rehabilitation strategies) rather than effecting a cure (medical strategies). In part because of this, similar to the recent movement found in the area of acceptance based psychotherapy, there has increasingly been a call to shift treatment focus away from the elimination of pain and toward effective pain management (McCraken, 1998).

The third way of responding to chronic pain, acceptance based responding, may indicate a useful direction for treatment approaches. In general, within the context of chronic pain, an acceptance based response refers to acknowledging that the pain is going to be chronic although means can be found to modify pain, accepting responsibility of self-care, use of active pain management techniques, giving up on unproductive attempts to eliminate pain, reducing reliance on healthcare professionals, and committing to working toward important life goals despite pain. To paraphrase Hayes and his colleagues (1996), acceptance means actively contacting physical as well as psychological experiences while behaving effectively.

Based on this conceptualization of acceptance as applied to chronic pain, we would predict a variety of changes for patients who adopt an attitude of acceptance. In particular, one would expect to see: a) decreased emotional distress, b) decreased reliance on the sole use of medical solutions, such as medications, further medical evaluations, and additional surgeries, and c) decreased avoidance of possibly pain-inducing situations which in turn would lead to increased activity and improved participation in physical therapy. Interestingly, based on this formulation one may or may not see a decrease in reported pain, but one should see an increase in reported quality of life.

There is a slowly building body of literature supporting the ideas put forward in this paper. Data from other medical populations such as renal failure patients suggest that continued efforts to control uncontrollable medical events is predictive of negative emotional responding (Eitel et al., 1995). Conversely, it was found that individuals who work toward goals of increased understanding of the context of their disease and acceptance of the events have fewer negative emotional responses and increased coping. Relatedly, working on controlling what is controllable has positive effects on coping and emotional responding (Rothbaum, et al., 1982). It would seem that being able to work on finding effective solutions requires acceptance of the context and pain.

Recently two studies have investigated acceptance and pain. Kerns and his research group (1997) approached the problem from the perspective of a stages of changes model. They suggested that determining a patient's stage of change could be predictive of response to pain and coping style. They found that patients who were in a stage of pre-contemplation were more likely to report poor pain control, focus on medical solutions to pain, and use more passive coping techniques. Patients who were in the action or maintenance stages reported more pain control, less focus on medical pain management, and higher use of active coping techniques.

Most recently McCracken (1998) used a questionnaire designed by Geiser and Hayes at the University of Nevada, Reno, which specifically assessed acceptance and pain (the Chronic Pain Acceptance Questionnaire), along with several other self-report measures, to investigate the relationship between acceptance and a variety of factors commonly associated with chronic pain. He found that acceptance was correlated with lower anxiety and avoidance, less depression, more activity, and less disability. Interestingly, pain intensity and acceptance had only a relatively low correlation suggesting that higher levels of acceptance were not explained simply by lower pain levels.

These studies suggest that acceptance may be an important factor to consider, but can attempting to manipulate acceptance affect actual treatment? The answer to this question is at this point tentative. The only study to date which has attempted to answer this question is an unpublished dissertation performed by Geiser at UNR in 1992. The study compares the effects of an acceptance-based intervention to those of a standard cognitive-behavioral intervention. There were methodological limitations to the study, but Geiser did find that acceptance, as measured with a questionnaire designed and standardized for pain populations, was associated with a number of positive outcomes and that the acceptance-based intervention was an effective treatment. Of note, he did not find differences between the standard treatment approach and the acceptance-based approach, but Geiser also found that both groups demonstrated improved acceptance of pain. The results imply that, although there are likely multiple treatment methods which can successfully reduce and stabilize pain, acceptance may be part of effectively providing treatments.

In closing, it does appear that acceptance may play a role in improved ability to manage pain. The extent to which acceptance is important in dealing with pain will depend on the context. For example, the nature of the pain disorder, the interventions which are still available, and their efficacy. This is analogous to different levels of acceptance in mood disorders. There is clearly a difference between better understanding and coming to terms with an abusive childhood history versus ongoing physical abuse. It should also be noted that there is not just one point at which individuals need to make a decision regarding acceptance of chronic pain versus continued pursuit of treatment (McCraken, 1998). Effective and appropriate treatment for intractable pain should involve an ongoing process of balancing acceptance with attempts to find new ways to control pain based on emerging medical technology. There is a need for ongoing dialogue between patients and treatment providers and an important part of maintaining acceptance is providing patients with honest information in a hopeful context about the limits of current practice. It should emphasize that there is still clearly a need for behavioral and cognitive-behavioral interventions within this population, as many patients do significantly benefit from training in these kinds of skills. The question becomes where to target efforts for specific patients and much work is still needed to improve our understanding of how these techniques work and with whom? Additional research is needed to better understand the role of acceptance in chronic pain and to identify and improve the effective components of different interventions for pain and acceptance.

References

Arnoff, G.M. (1991). Chronic pain and the disability epidemic. Clinical Journal of Pain, 7, 330-338.

Bonica, J.J. (1987). Importance of the problem. In S. Anderson, M. Bond, M. Mehta & M. Swerdlow (gds.) Chronic Non-cancer Pain. Lancaster, UK: MTP Press, 18.

Crook, J., Weir, R. & Turk, E. (1989) An epidemiological follow up survey of persistent pan suffers in a group family practice and specialty pain clinic. Pain, 36,49-61.

Deyo, R.A. (1986). The early diagnostic evaluation of patients with low back pain. Journal of General Internal Medicine, 1, 328-338.

Dworkin, S.F. & Massoth, D.L. (1994). Temporomandibular disorders and chronic pain: A dynamic-ecologic perspective. Annals of Behavioral Medicine. 14, 3-11.

Eitel, P, Hatchett, L., Friend, R., Griffin, K.W. & Wadhwa, N.K. (1995). Burden of self-care in seriously ill patients: Impact of adjustment. Health Psychology, 14,457-463.

Flor, H. & Turk, D.C. (1984). Etiological theories and treatment for chronic back pain. Somatic models and interventions. Pain, 19, 105-121.

Fordyce, W.E. (1976). Behavioral Methods for Chronic Pain. St. Louis: CV Mosby.

Frymoyer, J.W. & Cats-Baril, W.L. (1991). An overview of the incidences and costs of low back pain. Orthopedic Clinics of North America, 22, 263-271.

Gatchel, R.J. & Turk, D.C. (1996). Psychological Approaches to Pain Management: A Practitioner's Handbook. New York: The Guilford Press.

Geiser, D.S. (1992). A comparison of acceptance-focused and control- focused psychological treatments in a chronic pain treatment center. Unpublished doctoral dissertation. University of Nevada, Reno, NV.

Hayes, S.C., Jacobson, N.S., Follette, V.M. & Dougher, M.J. (1994). Acceptance and Change: Content and Context in Psychotherapy. Reno, NV: Context Press.

Hayes, S.C., Wilson, K.G., Gifford, E.V., Follette, V.M. & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152-1168.

Kerns, R.D. (1994). Pain management. In H. Hersen & R.T. Ammerman (gds.), Handbook of Prescriptive Treatments for Adults. New York: Plenum Press. Pp. 443-462.

Kerns, R.D., Rosenberg, R., Jamison, R.N., Caudill, M.A. & Haythomthwaite, J. (1997). Readiness to adopt a self-management approach to chronic pain: The Pain Stages of Change Questionnaire (PSOCQ). Pain, 72, 227-234.

McCracken, L.M. (1998). Learning to live with pain: Acceptance of pain predicts adjustment in persons with chronic pain. Pain, 74, 21-27.

Melzack, R. & Walls, P.D. (1982). The Challenge of Pain. New York: Basic Books.

Philips, H.C. (1987). Avoidance behavior and its role in sustaining chronic pain. Behavior Research and Therapy, 25, 273-279.

Rothbaum, F., Weisz, J.R. & Snyder, S.S. (1982). Changing the world and changing the self: A two process model of perceived control. Journal of Personality and Social Psychology, 42,5-37.

Turk, D.C. (1990). Customizing treatment for chronic pain patients: Who, what, why? Clinical Journal of Pain, 6, 255-270.

Turk, D.C. & Rudy, T.E. (1991). Neglected topics in the treatment of chronic pain patients- relapse, noncompliance, adherence enhancement. Pain, 44, 5-28.

Erik M. Augustson, Ph.D., University of Alabama at Birmingham School of Medicine
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Author:Augustson, Erik M.
Publication:The Behavior Analyst Today
Date:Jan 1, 2000
Words:2398
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