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Current and future trends in psychology and chronic pain: time for a change?
Practice Points
Lance M McCracken*1 & Francisco Montesinos Marin2 Psychological approaches to chronic pain, often delivered in a multidisciplinary context, make an
important contribution to overall clinical management. As with all current approaches to chronic pain psychological approaches can, and probably should,
improve. One way to facilitate the improvement of psychological approaches to chronic pain would be for
research and treatment development activities to follow better, more precise and more integrative theoretical models. The psychological flexibility model with its focus on cognitive, emotional, social and motivational factors,
and its link to newly evolving treatment approaches, may provide a helpful guide for the next generation of developments.
SUMMARY Psychological approaches to chronic pain have produced significant success and are widely accepted. Yet it can be difficult for those outside the field to understand the many different variables, processes and methods that are a part of these approaches. This is partly because these approaches are characterized by a wide variety of models, each with its own primary focus and background assumptions, and these can change over time. It may be difficult to create greater consistency and integration between currently disparate psychological approaches, but there may be advantages to doing so. This integration could be helped by an appropriately designed and appropriately organizing theoretical model. It is suggested that what is called the psychological flexibility model could provide such a point of integration. Chronic pain creates significant difficulties for many people, and can reduce quality of life. Here ‘chronic pain’ is pain that typically per‑ sists past normal healing times and can be due to any sources, typically within the musculoskeletal system, nerve tissues, or viscera. In these situa‑ tions the person with pain is often not merely
a passive victim but an active participant. They play their part by looking for solutions, through attempts to suppress or ease the experience, and sometimes literally and figuratively fighting for control. They may look for information from physicians or the internet, trying to under‑ stand why they have pain. They may see many
Health Psychology Section, Psychology Department, King’s College London & INPUT Pain Management, Guy’s & St Thomas’ NHS Foundation Trust, London, UK 2 Departamento de Especialidades Médicas, Psicología y Pedagogía aplicadas, Facultad de Ciencias Biomédicas, Universidad Europea, Madrid, Spain *Author for correspondence: Fax: +44 207 1885410; [email protected] 1
10.2217/PMT.13.76 © 2014 Future Medicine Ltd
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MANAGEMENT PERSPECTIVE McCracken & Marin professionals and try many different medical treatments. They may adopt patterns of check‑ ing their body for signs of a change, or of worsen‑ ing pain, and ruminate about their health prob‑ lems. They may dwell on the past and imagine possible consequences of pain in the future, all as a part of trying to find out what went wrong and how to prevent further trouble. All of the different ways that people attempt to understand, solve, or reduce pain are in most ways quite natural. Quite naturally, people with pain want to stop feeling pain and start feeling happy, but they get stuck. Sometimes attempts to understand, solve, or reduce pain are success‑ ful, but sometimes they are not. In these cir‑ cumstances it is perhaps not just the presence of pain but the dominance of pain, the complex ways that pain and related experiences over‑ shadow over all other experiences, that becomes important. It seems there is an unexamined assumption behind a great deal of pain research: that the goal of the enterprise is to eradicate pain. That seems like an impossible goal, akin to aiming to eradicate sadness or anxiety. As loss and uncer‑ tainly are inevitable human experiences, so are sadness and anxiety. This is not to equate pain with emotion, but the analogy seems apt. In any case, this is perhaps partly why within the devel‑ opment of psychological treatments we create a shift of focus on reducing ‘impacts’, and as we say, on reducing the dominance of pain, and not the pain experience itself. Truly, chronic pain presents a conundrum. Pain is a huge problem. Yet, if there were no more pain, even if there were no more chronic pain, the world might be a strange place. Pain is built into the design of the human body and into the normal psychology of human experience. As much as pain is undesirable in many circum‑ stances, and certainly not an issue to take lightly, it may be inevitable to some degree. Regardless on one’s view of this matter, there is one point on which we can probably agree: pain that takes quality of life away deserves better understand‑ ing and better approaches to reduce its impacts. Where this understanding and these better approaches will emerge is anyone’s guess right now, whether it will come from studying the brain, the spinal cord, nerves, neurotransmitters, genes, the mind, the person, society, or some combination of these. Today the best treatment approaches for chronic pain are multidisciplinary or interdisciplinary.
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These treatments can include medications, interventional procedures, and physiotherapy. Particularly when these treatments are unified by a model that focuses them on improving func‑ tioning, they are known to be clinically effective and cost effective. In this context psychological research and treatment developments have con‑ tributed significantly to addressing the problems of chronic pain, and appear likely to continue to do so. In this short article we will selectively review and comment on the current status and the future of this one part of the wider effort to reduce the impact of chronic pain. Where are we? If one were trying to track the direction of psy‑ chological applications to chronic pain right now, this could be challenging. This is because the field lacks the uniformity of a single dominant theoretical model [1]. There are in fact many dif‑ ferent approaches, vying for the lead, or perhaps vying to be an incorporated piece in a successful model. In a sense this variability is good. This may reflect a period of creativity. Also, without variability there can be no ‘selection of the fit‑ test’, to use an evolutionary metaphor. Some researchers and clinicians may regard the ‘cognitive–behavioral model’ as a model. They may also regard cognitive–behavioral therapy (CBT) as a fairly precisely defined treatment approach based on this model. There are some ways, however, in which these views are not accurate. It is probably more accurate to say that the cognitive–behavioral model is many models and, perhaps accordingly, the treatments that emerge from these many mod‑ els are also very diverse. In fact, there are many different methods under the umbrella of CBT today. To add to this diversity, these are typically combined in many unique ways, depending on the skill and preferences of the therapist, the specific design of treatment in the service where they work, and often, but not always, guided by ongoing assessment and conceptualization of the person or group being provided with treatment. Sometimes treatment is designed or customized each time it is delivered, leading it to take on somewhat different features during each outing. Certainly, whatever the status of its under‑ lying model or models and however precisely defined or diverse its methods, CBT has been remarkably successful. During its approximately 30‑year history is has become a widely accepted
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Current & future trends in psychology & chronic pain: time for a change? approach to chronic pain and regarded as evi‑ dence-based [2]. The question now, is how to build on this success. While the most recent systematic reviews of CBT approaches conclude that they are effec‑ tive for chronic pain, the evidence is in some cases inconsistent, showing effects for some out‑ comes but not for others, and effect sizes are mostly small [3]. The current state of the science of psychological treatments for chronic pain has led to calls for radical change, on the scale of a paradigm shift [4]. One of the issues raised in this call for a paradigm shift is the need to base treatment development on a coherent theoretical model. Current models Out of numerous available current models we suggest that there are two that may be espe‑ cially best placed to guide further progress in the field. One of these is well-known and the other is less well-known. The well-known one is the fear-avoidance (FA) model [5,6]. The less well-known one is the psychological flexibility (PF) model [7,8]. Both can be considered specific developments of a general cognitive–behavioral model. The FA model was perhaps formally intro‑ duced in full form in 2000, although it has been in development since the late 1980s [9]. The FA model prominently features the role of the patients’ beliefs and thoughts in promot‑ ing disabling fear and avoidance. Within this model, some people with pain misinterpret pain as a catastrophe, as a sign of serious injury and pathology, and these catastrophizing thoughts lead to pain-related fear and hypervigilance, and then to a cycle of avoidance, disability and continuing distress. Other people do not interpret their pain as a catastrophe, and this is regarded as the start of their pathway to recov‑ ery. Treatments for chronic pain and disability associated with the FA model include primar‑ ily methods to modify maladaptive interpreta‑ tions of pain. This specific targeting of patient interpretations fits within an overall therapeutic focus on reducing fearful thoughts and feelings as mediators of avoidance and disability. The FA model has led to a virtual explosion of research in the field of chronic pain [5,10,11]. There are probably several reasons for this. For one the model has great intuitive appeal. It is also consistent with a long history that stresses the importance of avoidance behavior in the
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adverse impacts of chronic pain. The FA model also integrates cognitive, emotional and behav‑ ioral elements, another desirable characteristic. So far it has led to the introduction of what is called graded in vivo exposure for chronic pain related disability, essentially an adaptation of a treatment method for anxiety disorders. These methods have gained impressive preliminary evidence [12], including surprising evidence for the capacity reduce signs and symptoms of cer‑ tain pain disorders [13]. This has been a great innovation. Any good model will garner support for itself and, just as importantly; it will eventually reveal weaknesses and gaps in understanding. Over the past several years a number of critiques and proposed revisions of the FA model have appeared [14–16]. One limitation of the model, for example, is that its focus has been narrow, on specific forms of cognitive and emotional elements. After all, its focus has been on cata‑ strophizing and fear rather exclusively. It has been suggested that other pathways to disability need to be included, such as pathways that do not include fear [14]. Others have commented that the FA model lacks an emphasis on pro‑ cesses of ‘normal psychology’; a ‘motivational perspective’, which would help to understand patients’ behavior in the context of competing goals; and does not specify process of recovery or therapeutic change very well [10]. Nonethe‑ less, once again, the FA model has been a suc‑ cessful model: it is specific, has created a focus on processes of pathology that led directly to the design of treatments, and has encouraged a considerable number of studies focused on methods of graded exposure, including a focus on cognitive change [11]. So, what does the PF model have to offer and how would it stack up against a similar analysis? PF is the capacity to persist or to change behav‑ ior in a way that includes conscious and open contact with thoughts and feelings, is attuned to what the situation affords, and is guided by goals and values [8]. This means, when the capacity of psychological flexibility is present, the person can act in line with their goals, including occa‑ sions where pain, thoughts, and other feelings might otherwise have blocked their ability to do that. As noted at the start, the presence of pain easily coordinates struggling to control or suppress related experiences, and it is easy for this to intrude in or dominate all other actions. In simplest terms, with psychological flexibility
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MANAGEMENT PERSPECTIVE McCracken & Marin one can struggle or not struggle; one can seek a goal related to pain or unrelated to pain; one can operate in avoidance mode, so to speak, or in approach mode. Psychological flexibility includes multiple processes of psychological pathology and each of these has an associated process of treatment. For the problems of avoidance and defending oneself against one’s own experiences, there is the therapeutic process of acceptance. For the problem of being dominated and stuck in painful or dysfunctional thoughts, there is cognitive defusion. For having one’s focus stuck in the past or the future, there is flexible moment-to-moment awareness. For problems of ‘the self ’ under threat or imposing limits based on stories about the self, there is self-as-observer. For a lack of positive directions and motivation, there is values-clarification and values-based action. And, for inaction or impulsive persis‑ tence there is committed action. Each of the key therapeutic process from the PF model is presented and defined in Table 1. The PF model has a specific approach to treatment. It is called Acceptance and Com‑ mitment Therapy (ACT) [17]. The primary dis‑ tinguishing feature of ACT is that it focuses on PF and is organized around increasing this quality of action in patient behavior. In line with the multiple subprocesses of ACT, it is
sometimes referred to as a therapy that focuses in tandem on mindfulness related processes and activation or activity engagement related processes. ACT includes a range of methods that are primarily experiential, can be psycho‑ logically intensive, and are conducted in the context of a psychologically active therapeu‑ tic relationship. The methods in ACT include exposure-based methods, metaphor, mindful‑ ness-related exercises, and can include para‑ dox and confusion. These types of methods are used as ways to reduce the dominance of highly verbal and analytic ways of interacting with the world and to bring direct environmental contingencies into play. Other methods from traditional behavior therapy are often used too, such as skills training, role play, goal-setting, shaping and direct practice. Methods such as relaxation, distraction and cognitive restruc‑ turing tend not to be used so often by therapist delivering ACT-based methods [18]. The limitations of the FA model, which it is relatively narrow, that it is based on an abnormal psychology model, does not include competing goals, and does not specify processes of recovery [10] cannot be leveled against the FP model. The PF model is a model of nor‑ mal human behavior, as equally applicable to those with chronic pain as those without, in contexts of exceptional achievement, in normal
Table 1. Key therapeutic processes in the Psychological Flexibility Model. Process
Definition
Acceptance
The ability to openly embrace unwanted experiences, such as pain, when doing so allows one to seek one’s goals; also, the ability to engage in activities that include pain without struggling to control or reduce that pain The ability to experience the difference between thoughts and the experiences, objects or people they describe; the ability to have thoughts without having one’s experience and actions dominated by the content of the thoughts The ability to notice when one is stuck in thoughts about other times, including the past or future, and to return to experiences that are directly present in the moment of noticing them; the ability to track moment-to-moment experience The ability to experience a point of view where one has thoughts and feelings but is not defined by these thoughts and feelings; the ability to observe all of the content of one’s experience, including the ‘stories’ about who we are without needing to defend, fight against nor experience the limits imposed by these experiences Desired aims, purposes or qualities of living that are freely chosen, provide a guide for actions, inform goals and are ongoing The ability to choose a course of action, that is guided by one’s values, stick to it when it is difficult and let go of it when it is directly experienced as not serving one’s values
Cognitive defusion
Flexible present-focused attention
Self-as-observer
Values Committed action
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Current & future trends in psychology & chronic pain: time for a change? daily life, in schools, in corporations and in healthcare, equally [8]. The PF model includes competing avoidance and values-based goals and, thus, addresses motivational influences. And, again, for every process of pathology it specifies a process of therapy and wellness, so it cannot be said that it does not provide a model of recovery. The PF model is based on specific philoso‑ phy of science, a contemporary version of behav‑ iorism, known as functional contextualism. Although this has important implications for the study and development of PF and is certainly germane to the topics of this review, it is beyond the scope of this paper to discuss this philoso‑ phy in detail, and readers are referred to other sources for a more complete account [7,8,17]. The future: organize & integrate Stepping back from the mad dash to find the next most predictive variable of interest or the next brand of therapy, one might ask what steps forward could be taken to create progress. One normal human instinct seems to be to compete. This competitive instinct, however, nudges us toward certain strategies and away from oth‑ ers. It makes it easier to consider head-to-head trials as the way to determine the next therapy to carry out. It makes it easy for us to carry out studies that include massive numbers of poten‑ tial predictor variables to find the one that is the best [19]. This winner take all approach is waste‑ ful, however. An approach that runs somewhat contrary to our natural competitive streak is to seek to integrate across the competing camps, camps that in this case represent therapy types and the key variables of interest that underlie them. A possible goal could be to integrate around a single model that is able to subsume most of the psychological elements needed. From a point of view of influence exerted on behavior, how different are thinking patterns called catastrophizing, hopelessness, helpless‑ ness, low self-efficacy, lack of confidence, and perceptions of low controllability? How differ‑ ent or similar are fear, anxiety, guilt, embarrass‑ ment, sadness, and frustration? How similar or different are the behavior patterns we call avoid‑ ance, problem-solving, treatment-seeking, med‑ ication-use, sense-making and hypervigilance? Certainly in individual cases and under par‑ ticular circumstances there are unifying, func‑ tional, psychological dimensions that underlie the elements in each of these clusters.
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There are many variables now in play in chronic pain research, probably too many, and it could be useful to reduce these [20]. Although the PF model has added its set to this evergrowing list, it has not itself created additional new variables as it develops and as it is increas‑ ingly applied. It has just six processes integrated into one primary overarching dimension. The processes built into psychological flexibility are particularly integrating. For example, acceptance is a therapeutic process designed for any experi‑ ences that coordinate unhelpful, disabling, avoid‑ ance. This can include fear, anxiety, depression, guilt, embarrassment, and also failure, confusion, ‘being wrong’ and others. Cognitive defusion is similar in that it is highly integrating too. For cognitive defusion to be a relevant therapeutic process it does not matter so much what form thoughts take or in a sense ‘what they say’. What matters is whether the thoughts are experienced in a way that creates unhealthy limitations in daily functioning. Difficulties created by many varieties of thoughts, including thoughts of catas‑ trophe, hopelessness, self-criticism, terror, defeat, or discouragement, can be successfully targeted with methods that essentially create a separation between thoughts and events, or ‘defuse’ the thoughts from the events or people they over‑ whelm. Each of the processes from PF is itself a generic kind of functional dimension underling the coordinating influences on behavior. Further‑ more, these functional dimensions are generally applicable, according to the model, playing a key role in chronic pain, but also a wide-ranging role in many forms of human behavior problems, including depression, anxiety disorders, addic‑ tion, personality disorders, insomnia and in other domains of work performance, education, par‑ enting and general human wellbeing [21,22]. In its ability to integrate and cut across dis‑ tinctions that are not differences, the PF model can help us to understand the phenomenon described at the beginning of the paper. From the perspective of this model the vicious circle of increasing pain and disability that traps the patient in their thoughts, interpretations, feel‑ ings and failing behavior patterns, are patterns of avoidance, disengagement, dominance of verbal processes that impose restrictions on the range of behavior, and a lack of connection to goals and values. The way to address these therapeutically includes acceptance, cognitive defusion, flexible present-focused attention, self-as-observer, values and committed action [8].
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MANAGEMENT PERSPECTIVE McCracken & Marin Evidence In recent years the PF model and ACT have spread quickly in the chronic pain field and there are now numerous studies supporting the benefits of the treatment. Besides numerous case studies, pilot studies, and partly controlled trials, seven randomized controlled trials of ACT in chronic pain and several larger scale effectiveness studies have been published [23–29], including a large uncontrolled treatment trial with good results at 3 years p ost-treatment [30]. ACT has been deemed a promising approach for pain related-fear and avoidance in a systematic review [11]. In meta-analysis acceptance-based treatments like ACT appear equally effective to standard CBT for chronic pain [31]. ACT now has accumulating evidence for effectiveness across numerous types of health problems [22]. How to create change in the field In the USA, the period from 2001 to 2011 was officially designated by congress “The decade of pain control and research.” Near to the start of that decade there was a published paper in a top psychology journal that nicely summarized the contributions of psychological research to pain management and predicted that both “evolu‑ tion and revolution” would continue in the field [32]. We have now left that particular decade behind; however, we remain looking forward to further evolution and revolution. A shift in model toward greater consensus and adop‑ tion of a single more unifying psychological model within the multidisciplinary context of pain management certainly would constitute a revolution. In the meantime what can we do to facilitate further evolution? Ultimately researcher and therapist choices of variables, and persistence with particular meth‑ ods, are patterns of behavior. Influences like the promotion of evidence-based practice represent potentially unifying factors on these patterns, and could provide a progressive way forward. However, the state of evidence in pain man‑ agement does not indicate a single best model to guide treatment delivery. The evidence itself is fragmented. One approach to this is to sim‑ ply get more evidence that helps us to fill gaps and refine our knowledge, or to systematically review and meta-analyze the evidence. These may not always be the most efficient means for creating evolution or revolution all by them‑ selves. This is partly because the gathering and reviewing of evidence requires models and
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guidance so that better integration and fewer, new, disintegrated fragments are created. If the goal for the field is greater integration and the process includes evolution and revo‑ lution in our own behavior, perhaps the next question is about how to address inevitable barriers to change. It may be among research‑ ers that this integration is most difficult. Research groups tend to work thematically or programmatically, each study leading to the next and retaining a relation to an underlying framework, theory or guiding question. These frameworks often carry specific assumptions about the underlying subject matter than can create either differences in emphasis or even contradictions between different ones. This is where differences in primary variables of inter‑ est, branding and competitive influences play out again, making it difficult for researchers to integrate their work with others. Those who reach across to join hands with members of another group have just taken their hand off their own steering wheel, so to speak. Nonethe‑ less, it seems a key strategy would be collabo‑ ration, people from differing research groups planning, designing and completing projects together. Creating change in practice may be easier, but perhaps not much easier. Even in other areas of psychology where there is good consensus from research on effective therapy methods, such as in anxiety disorders, clinicians are not trained in these methods and patients do not receive them [33]. Even when therapists are properly trained this does not guarantee implementa‑ tion. Therapists are known to deviate or drift from doing treatment the way the evidencebased guidelines would suggest, influenced by their own thoughts and feelings, and to avoid discomfort [34]. Change in methods of treat‑ ment delivery includes uncertainty and anxi‑ ety as a part of the process of progress [35]. The uncertainty and anxiety can become blocks to progress unless the model guiding the process of change and the methods used to implement this change somehow incorporates means for addressing these. In addition to anxiety and discomfort, blocks to the adoption of new methods can arise from practical matters, such as the time and cost needed to learn new methods, and also from not seeing the adoption of these methods as important [36]. If clinicians are not trained to incorporate research and evidence as a guide in
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Current & future trends in psychology & chronic pain: time for a change? their work, for example, this may represent an important barrier to adopting evidence-based practice that is difficult to shift later, after years in practice [36,37], and as we say, both the time to learn and the training resource will need to be provided. In addition to influences based in time and training needs, however, there may be current setting factors as well, such as per‑ ceived openness of the clinic setting toward the practices in question [37]. The role of professional organizations in leading new initiatives, supporting networking, collaboration, implementation of new interven‑ tions, or even in supporting ‘culture change’ can be important [38]. Organizations and units may need to find ways to support creativity, risktaking, teamwork, and tolerance for mistakes, with are each associated with a receptive and open context [39]. Changes in practice that track with find‑ ings in research, and vice versa, ultimately will require alliances between research-oriented and practice-oriented professionals. It will require that those who conduct research produce research findings in a format that is specifically designed for those who directly provide treat‑ ment but do no research. Greater chances for direct interaction between those who deliver research results and those who deliver treat‑ ments also would help [40]. As for how to ini‑ tiate change, small steps may be best. Starting with requests for practitioners to initially adopt specific methods may be more realistic and use‑ ful than asking them to completely change all of their methods and embrace the whole model from the beginning [35,40]. References Papers of special note have been highlighted as: of interest of considerable interest n
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Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. impact of the model on recent research and issues that need to be tackled in future research.
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Conclusion & future perspective Chronic pain is a difficult problem imposing a great burden in world health. Psychological approaches are at the same time effective and developing in new directions. There is most certainly evolution here but perhaps not yet revolution. Some might say that is it time for a revolution. One feature of the landscape of psychological approaches to chronic pain is a lack of an integrat‑ ing model that helps tie together, organize, and guide further development. In many ways this is entirely normal and even a reflection of creative processes at work, an abundance of varied per‑ spectives, and great opportunity. Still, in order to progress at some point it may be required to organize this landscape [41]. The PF model is already an established model that is helping researchers to increase our under‑ standing of the psychology of chronic pain, offering innovative therapeutic methods, includ‑ ing ACT, and providing alternative framework on which further work could be based. As with any change there are goals and barriers, there is anxiety and confusion, and a step-by-step approach may be required.
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of a brief group-based form of Acceptance and Commitment Therapy (ACT) for chronic pain in general practice: pilot
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Very interesting critique of current cognitive–behavioral therapy practice that calls the reader’s attention to sources of influence on treatment delivery that are just like the problematic influences on patient behavior that the treatments are designed to address.
35 Barker E, McCracken LM. From traditional
cognitive behavioral therapy to acceptance and commitment therapy for chronic pain: a mixed method study of staff experiences of change. Br. J. Pain doi:10.1177/2049463713498865 (2013) (Epub ahead of print). 36 Stewart RE, Chambless DL, Baron J.
Theoretical and practical barriers to practitioners’ willingness to seek training in empirically supported treatments. J. Clin. Psychol. 68(1), 8–23 (2012). 37 Nelson TD, Steele RG. Predictors of
practitioner self-reported use of evidence-based practices: practitioner training, clinical setting, and attitudes toward research. Adm. Policy Ment. Health Ment. Health Serv. Res. 34, 319–330 (2007). 38 Aarons GA, Hurlburt M, Horwitz SM.
Advancing a conceptual model of evidence-based practice implementation in public service sectors. Adm. Policy Ment. Health 38, 4–23 (2011). 39 Caldwell DF, O’Reilly CA III.
The determinants of team-based innovation in organizations: the role of social influence. Small Gr. Res. 34, 497–517 (2003). 40 Lilienfeld SO, Ritschel LA, Lynn SJ, Cautin
RL, Latzman RD. Why many clinical
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Current & future trends in psychology & chronic pain: time for a change? psychologists are resistant to evidence-based practice: root causes and constructive remedies. Clin. Psychol. Rev. doi:10.1016/j. cpr.09.008 (2013) (Epub ahead of print). 41 McCracken LM, Morley SJ. The
psychological flexibility model: a basis for
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integration and progress in psychological approaches to chronic pain management. J. Pain (2013) (In Press). n n
Paper like the current one, in that it addresses the problem of varied models and no clear unifying theory in treatment
Management Perspective development for chronic pain. It differs from the current one in that it goes into greater depth, marshals more relevant literature to substantiate the points raised and looks at greater detail around the topic of therapy mechanism.
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Current and future trends in psychology and chronic pain: time for a change?
Practice Points
Lance M McCracken*1 & Francisco Montesinos Marin2 Psychological approaches to chronic pain, often delivered in a multidisciplinary context, make an
important contribution to overall clinical management. As with all current approaches to chronic pain psychological approaches can, and probably should,
improve. One way to facilitate the improvement of psychological approaches to chronic pain would be for
research and treatment development activities to follow better, more precise and more integrative theoretical models. The psychological flexibility model with its focus on cognitive, emotional, social and motivational factors,
and its link to newly evolving treatment approaches, may provide a helpful guide for the next generation of developments.
SUMMARY Psychological approaches to chronic pain have produced significant success and are widely accepted. Yet it can be difficult for those outside the field to understand the many different variables, processes and methods that are a part of these approaches. This is partly because these approaches are characterized by a wide variety of models, each with its own primary focus and background assumptions, and these can change over time. It may be difficult to create greater consistency and integration between currently disparate psychological approaches, but there may be advantages to doing so. This integration could be helped by an appropriately designed and appropriately organizing theoretical model. It is suggested that what is called the psychological flexibility model could provide such a point of integration. Chronic pain creates significant difficulties for many people, and can reduce quality of life. Here ‘chronic pain’ is pain that typically per‑ sists past normal healing times and can be due to any sources, typically within the musculoskeletal system, nerve tissues, or viscera. In these situa‑ tions the person with pain is often not merely
a passive victim but an active participant. They play their part by looking for solutions, through attempts to suppress or ease the experience, and sometimes literally and figuratively fighting for control. They may look for information from physicians or the internet, trying to under‑ stand why they have pain. They may see many
Health Psychology Section, Psychology Department, King’s College London & INPUT Pain Management, Guy’s & St Thomas’ NHS Foundation Trust, London, UK 2 Departamento de Especialidades Médicas, Psicología y Pedagogía aplicadas, Facultad de Ciencias Biomédicas, Universidad Europea, Madrid, Spain *Author for correspondence: Fax: +44 207 1885410; [email protected] 1
10.2217/PMT.13.76 © 2014 Future Medicine Ltd
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MANAGEMENT PERSPECTIVE McCracken & Marin professionals and try many different medical treatments. They may adopt patterns of check‑ ing their body for signs of a change, or of worsen‑ ing pain, and ruminate about their health prob‑ lems. They may dwell on the past and imagine possible consequences of pain in the future, all as a part of trying to find out what went wrong and how to prevent further trouble. All of the different ways that people attempt to understand, solve, or reduce pain are in most ways quite natural. Quite naturally, people with pain want to stop feeling pain and start feeling happy, but they get stuck. Sometimes attempts to understand, solve, or reduce pain are success‑ ful, but sometimes they are not. In these cir‑ cumstances it is perhaps not just the presence of pain but the dominance of pain, the complex ways that pain and related experiences over‑ shadow over all other experiences, that becomes important. It seems there is an unexamined assumption behind a great deal of pain research: that the goal of the enterprise is to eradicate pain. That seems like an impossible goal, akin to aiming to eradicate sadness or anxiety. As loss and uncer‑ tainly are inevitable human experiences, so are sadness and anxiety. This is not to equate pain with emotion, but the analogy seems apt. In any case, this is perhaps partly why within the devel‑ opment of psychological treatments we create a shift of focus on reducing ‘impacts’, and as we say, on reducing the dominance of pain, and not the pain experience itself. Truly, chronic pain presents a conundrum. Pain is a huge problem. Yet, if there were no more pain, even if there were no more chronic pain, the world might be a strange place. Pain is built into the design of the human body and into the normal psychology of human experience. As much as pain is undesirable in many circum‑ stances, and certainly not an issue to take lightly, it may be inevitable to some degree. Regardless on one’s view of this matter, there is one point on which we can probably agree: pain that takes quality of life away deserves better understand‑ ing and better approaches to reduce its impacts. Where this understanding and these better approaches will emerge is anyone’s guess right now, whether it will come from studying the brain, the spinal cord, nerves, neurotransmitters, genes, the mind, the person, society, or some combination of these. Today the best treatment approaches for chronic pain are multidisciplinary or interdisciplinary.
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These treatments can include medications, interventional procedures, and physiotherapy. Particularly when these treatments are unified by a model that focuses them on improving func‑ tioning, they are known to be clinically effective and cost effective. In this context psychological research and treatment developments have con‑ tributed significantly to addressing the problems of chronic pain, and appear likely to continue to do so. In this short article we will selectively review and comment on the current status and the future of this one part of the wider effort to reduce the impact of chronic pain. Where are we? If one were trying to track the direction of psy‑ chological applications to chronic pain right now, this could be challenging. This is because the field lacks the uniformity of a single dominant theoretical model [1]. There are in fact many dif‑ ferent approaches, vying for the lead, or perhaps vying to be an incorporated piece in a successful model. In a sense this variability is good. This may reflect a period of creativity. Also, without variability there can be no ‘selection of the fit‑ test’, to use an evolutionary metaphor. Some researchers and clinicians may regard the ‘cognitive–behavioral model’ as a model. They may also regard cognitive–behavioral therapy (CBT) as a fairly precisely defined treatment approach based on this model. There are some ways, however, in which these views are not accurate. It is probably more accurate to say that the cognitive–behavioral model is many models and, perhaps accordingly, the treatments that emerge from these many mod‑ els are also very diverse. In fact, there are many different methods under the umbrella of CBT today. To add to this diversity, these are typically combined in many unique ways, depending on the skill and preferences of the therapist, the specific design of treatment in the service where they work, and often, but not always, guided by ongoing assessment and conceptualization of the person or group being provided with treatment. Sometimes treatment is designed or customized each time it is delivered, leading it to take on somewhat different features during each outing. Certainly, whatever the status of its under‑ lying model or models and however precisely defined or diverse its methods, CBT has been remarkably successful. During its approximately 30‑year history is has become a widely accepted
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Current & future trends in psychology & chronic pain: time for a change? approach to chronic pain and regarded as evi‑ dence-based [2]. The question now, is how to build on this success. While the most recent systematic reviews of CBT approaches conclude that they are effec‑ tive for chronic pain, the evidence is in some cases inconsistent, showing effects for some out‑ comes but not for others, and effect sizes are mostly small [3]. The current state of the science of psychological treatments for chronic pain has led to calls for radical change, on the scale of a paradigm shift [4]. One of the issues raised in this call for a paradigm shift is the need to base treatment development on a coherent theoretical model. Current models Out of numerous available current models we suggest that there are two that may be espe‑ cially best placed to guide further progress in the field. One of these is well-known and the other is less well-known. The well-known one is the fear-avoidance (FA) model [5,6]. The less well-known one is the psychological flexibility (PF) model [7,8]. Both can be considered specific developments of a general cognitive–behavioral model. The FA model was perhaps formally intro‑ duced in full form in 2000, although it has been in development since the late 1980s [9]. The FA model prominently features the role of the patients’ beliefs and thoughts in promot‑ ing disabling fear and avoidance. Within this model, some people with pain misinterpret pain as a catastrophe, as a sign of serious injury and pathology, and these catastrophizing thoughts lead to pain-related fear and hypervigilance, and then to a cycle of avoidance, disability and continuing distress. Other people do not interpret their pain as a catastrophe, and this is regarded as the start of their pathway to recov‑ ery. Treatments for chronic pain and disability associated with the FA model include primar‑ ily methods to modify maladaptive interpreta‑ tions of pain. This specific targeting of patient interpretations fits within an overall therapeutic focus on reducing fearful thoughts and feelings as mediators of avoidance and disability. The FA model has led to a virtual explosion of research in the field of chronic pain [5,10,11]. There are probably several reasons for this. For one the model has great intuitive appeal. It is also consistent with a long history that stresses the importance of avoidance behavior in the
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adverse impacts of chronic pain. The FA model also integrates cognitive, emotional and behav‑ ioral elements, another desirable characteristic. So far it has led to the introduction of what is called graded in vivo exposure for chronic pain related disability, essentially an adaptation of a treatment method for anxiety disorders. These methods have gained impressive preliminary evidence [12], including surprising evidence for the capacity reduce signs and symptoms of cer‑ tain pain disorders [13]. This has been a great innovation. Any good model will garner support for itself and, just as importantly; it will eventually reveal weaknesses and gaps in understanding. Over the past several years a number of critiques and proposed revisions of the FA model have appeared [14–16]. One limitation of the model, for example, is that its focus has been narrow, on specific forms of cognitive and emotional elements. After all, its focus has been on cata‑ strophizing and fear rather exclusively. It has been suggested that other pathways to disability need to be included, such as pathways that do not include fear [14]. Others have commented that the FA model lacks an emphasis on pro‑ cesses of ‘normal psychology’; a ‘motivational perspective’, which would help to understand patients’ behavior in the context of competing goals; and does not specify process of recovery or therapeutic change very well [10]. Nonethe‑ less, once again, the FA model has been a suc‑ cessful model: it is specific, has created a focus on processes of pathology that led directly to the design of treatments, and has encouraged a considerable number of studies focused on methods of graded exposure, including a focus on cognitive change [11]. So, what does the PF model have to offer and how would it stack up against a similar analysis? PF is the capacity to persist or to change behav‑ ior in a way that includes conscious and open contact with thoughts and feelings, is attuned to what the situation affords, and is guided by goals and values [8]. This means, when the capacity of psychological flexibility is present, the person can act in line with their goals, including occa‑ sions where pain, thoughts, and other feelings might otherwise have blocked their ability to do that. As noted at the start, the presence of pain easily coordinates struggling to control or suppress related experiences, and it is easy for this to intrude in or dominate all other actions. In simplest terms, with psychological flexibility
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MANAGEMENT PERSPECTIVE McCracken & Marin one can struggle or not struggle; one can seek a goal related to pain or unrelated to pain; one can operate in avoidance mode, so to speak, or in approach mode. Psychological flexibility includes multiple processes of psychological pathology and each of these has an associated process of treatment. For the problems of avoidance and defending oneself against one’s own experiences, there is the therapeutic process of acceptance. For the problem of being dominated and stuck in painful or dysfunctional thoughts, there is cognitive defusion. For having one’s focus stuck in the past or the future, there is flexible moment-to-moment awareness. For problems of ‘the self ’ under threat or imposing limits based on stories about the self, there is self-as-observer. For a lack of positive directions and motivation, there is values-clarification and values-based action. And, for inaction or impulsive persis‑ tence there is committed action. Each of the key therapeutic process from the PF model is presented and defined in Table 1. The PF model has a specific approach to treatment. It is called Acceptance and Com‑ mitment Therapy (ACT) [17]. The primary dis‑ tinguishing feature of ACT is that it focuses on PF and is organized around increasing this quality of action in patient behavior. In line with the multiple subprocesses of ACT, it is
sometimes referred to as a therapy that focuses in tandem on mindfulness related processes and activation or activity engagement related processes. ACT includes a range of methods that are primarily experiential, can be psycho‑ logically intensive, and are conducted in the context of a psychologically active therapeu‑ tic relationship. The methods in ACT include exposure-based methods, metaphor, mindful‑ ness-related exercises, and can include para‑ dox and confusion. These types of methods are used as ways to reduce the dominance of highly verbal and analytic ways of interacting with the world and to bring direct environmental contingencies into play. Other methods from traditional behavior therapy are often used too, such as skills training, role play, goal-setting, shaping and direct practice. Methods such as relaxation, distraction and cognitive restruc‑ turing tend not to be used so often by therapist delivering ACT-based methods [18]. The limitations of the FA model, which it is relatively narrow, that it is based on an abnormal psychology model, does not include competing goals, and does not specify processes of recovery [10] cannot be leveled against the FP model. The PF model is a model of nor‑ mal human behavior, as equally applicable to those with chronic pain as those without, in contexts of exceptional achievement, in normal
Table 1. Key therapeutic processes in the Psychological Flexibility Model. Process
Definition
Acceptance
The ability to openly embrace unwanted experiences, such as pain, when doing so allows one to seek one’s goals; also, the ability to engage in activities that include pain without struggling to control or reduce that pain The ability to experience the difference between thoughts and the experiences, objects or people they describe; the ability to have thoughts without having one’s experience and actions dominated by the content of the thoughts The ability to notice when one is stuck in thoughts about other times, including the past or future, and to return to experiences that are directly present in the moment of noticing them; the ability to track moment-to-moment experience The ability to experience a point of view where one has thoughts and feelings but is not defined by these thoughts and feelings; the ability to observe all of the content of one’s experience, including the ‘stories’ about who we are without needing to defend, fight against nor experience the limits imposed by these experiences Desired aims, purposes or qualities of living that are freely chosen, provide a guide for actions, inform goals and are ongoing The ability to choose a course of action, that is guided by one’s values, stick to it when it is difficult and let go of it when it is directly experienced as not serving one’s values
Cognitive defusion
Flexible present-focused attention
Self-as-observer
Values Committed action
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Current & future trends in psychology & chronic pain: time for a change? daily life, in schools, in corporations and in healthcare, equally [8]. The PF model includes competing avoidance and values-based goals and, thus, addresses motivational influences. And, again, for every process of pathology it specifies a process of therapy and wellness, so it cannot be said that it does not provide a model of recovery. The PF model is based on specific philoso‑ phy of science, a contemporary version of behav‑ iorism, known as functional contextualism. Although this has important implications for the study and development of PF and is certainly germane to the topics of this review, it is beyond the scope of this paper to discuss this philoso‑ phy in detail, and readers are referred to other sources for a more complete account [7,8,17]. The future: organize & integrate Stepping back from the mad dash to find the next most predictive variable of interest or the next brand of therapy, one might ask what steps forward could be taken to create progress. One normal human instinct seems to be to compete. This competitive instinct, however, nudges us toward certain strategies and away from oth‑ ers. It makes it easier to consider head-to-head trials as the way to determine the next therapy to carry out. It makes it easy for us to carry out studies that include massive numbers of poten‑ tial predictor variables to find the one that is the best [19]. This winner take all approach is waste‑ ful, however. An approach that runs somewhat contrary to our natural competitive streak is to seek to integrate across the competing camps, camps that in this case represent therapy types and the key variables of interest that underlie them. A possible goal could be to integrate around a single model that is able to subsume most of the psychological elements needed. From a point of view of influence exerted on behavior, how different are thinking patterns called catastrophizing, hopelessness, helpless‑ ness, low self-efficacy, lack of confidence, and perceptions of low controllability? How differ‑ ent or similar are fear, anxiety, guilt, embarrass‑ ment, sadness, and frustration? How similar or different are the behavior patterns we call avoid‑ ance, problem-solving, treatment-seeking, med‑ ication-use, sense-making and hypervigilance? Certainly in individual cases and under par‑ ticular circumstances there are unifying, func‑ tional, psychological dimensions that underlie the elements in each of these clusters.
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There are many variables now in play in chronic pain research, probably too many, and it could be useful to reduce these [20]. Although the PF model has added its set to this evergrowing list, it has not itself created additional new variables as it develops and as it is increas‑ ingly applied. It has just six processes integrated into one primary overarching dimension. The processes built into psychological flexibility are particularly integrating. For example, acceptance is a therapeutic process designed for any experi‑ ences that coordinate unhelpful, disabling, avoid‑ ance. This can include fear, anxiety, depression, guilt, embarrassment, and also failure, confusion, ‘being wrong’ and others. Cognitive defusion is similar in that it is highly integrating too. For cognitive defusion to be a relevant therapeutic process it does not matter so much what form thoughts take or in a sense ‘what they say’. What matters is whether the thoughts are experienced in a way that creates unhealthy limitations in daily functioning. Difficulties created by many varieties of thoughts, including thoughts of catas‑ trophe, hopelessness, self-criticism, terror, defeat, or discouragement, can be successfully targeted with methods that essentially create a separation between thoughts and events, or ‘defuse’ the thoughts from the events or people they over‑ whelm. Each of the processes from PF is itself a generic kind of functional dimension underling the coordinating influences on behavior. Further‑ more, these functional dimensions are generally applicable, according to the model, playing a key role in chronic pain, but also a wide-ranging role in many forms of human behavior problems, including depression, anxiety disorders, addic‑ tion, personality disorders, insomnia and in other domains of work performance, education, par‑ enting and general human wellbeing [21,22]. In its ability to integrate and cut across dis‑ tinctions that are not differences, the PF model can help us to understand the phenomenon described at the beginning of the paper. From the perspective of this model the vicious circle of increasing pain and disability that traps the patient in their thoughts, interpretations, feel‑ ings and failing behavior patterns, are patterns of avoidance, disengagement, dominance of verbal processes that impose restrictions on the range of behavior, and a lack of connection to goals and values. The way to address these therapeutically includes acceptance, cognitive defusion, flexible present-focused attention, self-as-observer, values and committed action [8].
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MANAGEMENT PERSPECTIVE McCracken & Marin Evidence In recent years the PF model and ACT have spread quickly in the chronic pain field and there are now numerous studies supporting the benefits of the treatment. Besides numerous case studies, pilot studies, and partly controlled trials, seven randomized controlled trials of ACT in chronic pain and several larger scale effectiveness studies have been published [23–29], including a large uncontrolled treatment trial with good results at 3 years p ost-treatment [30]. ACT has been deemed a promising approach for pain related-fear and avoidance in a systematic review [11]. In meta-analysis acceptance-based treatments like ACT appear equally effective to standard CBT for chronic pain [31]. ACT now has accumulating evidence for effectiveness across numerous types of health problems [22]. How to create change in the field In the USA, the period from 2001 to 2011 was officially designated by congress “The decade of pain control and research.” Near to the start of that decade there was a published paper in a top psychology journal that nicely summarized the contributions of psychological research to pain management and predicted that both “evolu‑ tion and revolution” would continue in the field [32]. We have now left that particular decade behind; however, we remain looking forward to further evolution and revolution. A shift in model toward greater consensus and adop‑ tion of a single more unifying psychological model within the multidisciplinary context of pain management certainly would constitute a revolution. In the meantime what can we do to facilitate further evolution? Ultimately researcher and therapist choices of variables, and persistence with particular meth‑ ods, are patterns of behavior. Influences like the promotion of evidence-based practice represent potentially unifying factors on these patterns, and could provide a progressive way forward. However, the state of evidence in pain man‑ agement does not indicate a single best model to guide treatment delivery. The evidence itself is fragmented. One approach to this is to sim‑ ply get more evidence that helps us to fill gaps and refine our knowledge, or to systematically review and meta-analyze the evidence. These may not always be the most efficient means for creating evolution or revolution all by them‑ selves. This is partly because the gathering and reviewing of evidence requires models and
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guidance so that better integration and fewer, new, disintegrated fragments are created. If the goal for the field is greater integration and the process includes evolution and revo‑ lution in our own behavior, perhaps the next question is about how to address inevitable barriers to change. It may be among research‑ ers that this integration is most difficult. Research groups tend to work thematically or programmatically, each study leading to the next and retaining a relation to an underlying framework, theory or guiding question. These frameworks often carry specific assumptions about the underlying subject matter than can create either differences in emphasis or even contradictions between different ones. This is where differences in primary variables of inter‑ est, branding and competitive influences play out again, making it difficult for researchers to integrate their work with others. Those who reach across to join hands with members of another group have just taken their hand off their own steering wheel, so to speak. Nonethe‑ less, it seems a key strategy would be collabo‑ ration, people from differing research groups planning, designing and completing projects together. Creating change in practice may be easier, but perhaps not much easier. Even in other areas of psychology where there is good consensus from research on effective therapy methods, such as in anxiety disorders, clinicians are not trained in these methods and patients do not receive them [33]. Even when therapists are properly trained this does not guarantee implementa‑ tion. Therapists are known to deviate or drift from doing treatment the way the evidencebased guidelines would suggest, influenced by their own thoughts and feelings, and to avoid discomfort [34]. Change in methods of treat‑ ment delivery includes uncertainty and anxi‑ ety as a part of the process of progress [35]. The uncertainty and anxiety can become blocks to progress unless the model guiding the process of change and the methods used to implement this change somehow incorporates means for addressing these. In addition to anxiety and discomfort, blocks to the adoption of new methods can arise from practical matters, such as the time and cost needed to learn new methods, and also from not seeing the adoption of these methods as important [36]. If clinicians are not trained to incorporate research and evidence as a guide in
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Current & future trends in psychology & chronic pain: time for a change? their work, for example, this may represent an important barrier to adopting evidence-based practice that is difficult to shift later, after years in practice [36,37], and as we say, both the time to learn and the training resource will need to be provided. In addition to influences based in time and training needs, however, there may be current setting factors as well, such as per‑ ceived openness of the clinic setting toward the practices in question [37]. The role of professional organizations in leading new initiatives, supporting networking, collaboration, implementation of new interven‑ tions, or even in supporting ‘culture change’ can be important [38]. Organizations and units may need to find ways to support creativity, risktaking, teamwork, and tolerance for mistakes, with are each associated with a receptive and open context [39]. Changes in practice that track with find‑ ings in research, and vice versa, ultimately will require alliances between research-oriented and practice-oriented professionals. It will require that those who conduct research produce research findings in a format that is specifically designed for those who directly provide treat‑ ment but do no research. Greater chances for direct interaction between those who deliver research results and those who deliver treat‑ ments also would help [40]. As for how to ini‑ tiate change, small steps may be best. Starting with requests for practitioners to initially adopt specific methods may be more realistic and use‑ ful than asking them to completely change all of their methods and embrace the whole model from the beginning [35,40]. References Papers of special note have been highlighted as: of interest of considerable interest n
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Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. impact of the model on recent research and issues that need to be tackled in future research.
paradigm shift? Pain 154(10), 1929–1931 (2013). 5
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Conclusion & future perspective Chronic pain is a difficult problem imposing a great burden in world health. Psychological approaches are at the same time effective and developing in new directions. There is most certainly evolution here but perhaps not yet revolution. Some might say that is it time for a revolution. One feature of the landscape of psychological approaches to chronic pain is a lack of an integrat‑ ing model that helps tie together, organize, and guide further development. In many ways this is entirely normal and even a reflection of creative processes at work, an abundance of varied per‑ spectives, and great opportunity. Still, in order to progress at some point it may be required to organize this landscape [41]. The PF model is already an established model that is helping researchers to increase our under‑ standing of the psychology of chronic pain, offering innovative therapeutic methods, includ‑ ing ACT, and providing alternative framework on which further work could be based. As with any change there are goals and barriers, there is anxiety and confusion, and a step-by-step approach may be required.
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Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 85, 317–332 (2000). ‘Must read’ paper for anyone interested in recent and current psychological models of chronic pain.
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Vlaeyen JW, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain 12 years on. Pain 153, 1144–1147 (2012). Again, as with the original 2000 reference by Vlaeyen and Linton, this brief update on progress in the area of the fearavoidance model of chronic pain is necessary reading for understanding the
8
Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and Commitment Therapy: model, processes, and outcomes. Behav. Res. Ther. 44, 1–25 (2006). Good overview of Acceptance and Commitment Therapy and psychological flexibility without the need to read an entire book, although the evidence is accumulating quickly and the evidence review in this one is, therefore, out of date. Hayes SC, Strosahl KD, Wilson KG. Acceptance and Commitment Therapy: the Process and Practice of Mindful Change. The Guilford Press, London, UK (2012).
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Latest edition of the main text on Acceptance and Commitment Therapy, written as an update of the book these authors published in 1999. This latest book is just as comprehensive as the first, but written in a more accessible style for readers without a significant prior knowledge of behavior analysis. Lethem J, Slade PD, Troup JDG, Bentley G. Outline of a fear-avoidance model of exaggerated pain perceptions. Behav. Res. Ther. 21, 401–408 (1983).
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Pain Manage. (2014) 4(2)
n
Very interesting critique of current cognitive–behavioral therapy practice that calls the reader’s attention to sources of influence on treatment delivery that are just like the problematic influences on patient behavior that the treatments are designed to address.
35 Barker E, McCracken LM. From traditional
cognitive behavioral therapy to acceptance and commitment therapy for chronic pain: a mixed method study of staff experiences of change. Br. J. Pain doi:10.1177/2049463713498865 (2013) (Epub ahead of print). 36 Stewart RE, Chambless DL, Baron J.
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RL, Latzman RD. Why many clinical
future science group
Current & future trends in psychology & chronic pain: time for a change? psychologists are resistant to evidence-based practice: root causes and constructive remedies. Clin. Psychol. Rev. doi:10.1016/j. cpr.09.008 (2013) (Epub ahead of print). 41 McCracken LM, Morley SJ. The
psychological flexibility model: a basis for
future science group
integration and progress in psychological approaches to chronic pain management. J. Pain (2013) (In Press). n n
Paper like the current one, in that it addresses the problem of varied models and no clear unifying theory in treatment
Management Perspective development for chronic pain. It differs from the current one in that it goes into greater depth, marshals more relevant literature to substantiate the points raised and looks at greater detail around the topic of therapy mechanism.
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