ACT in the treatment of chronic illness

JoAnne Dahl, Department of Psychology, University of Uppsala Sweden

Why do people get “stuck” in pain?

Riddle about Sweden

When pain was unavoidable, it was bearable, when pain became avoidable, it became unbearable

The solution becomes the problem.

Solutions for chronic pain

Evidence for most common medical treatments for pain is limited or non-existent

the greater the access to quick fix solutions, the greater the pain sensitivity

those societies offering most attention and solutions are those with greatest prevalence and disability

ACT and chronic illness

attempts to control negatively evaluated aspects of an experience may actually increase suffering in the long run: avoiding pain (symptoms) causes pain (suffering) and produces actions: narrow, rigid, less valued

symptoms have been allowed to get in the “drivers seat”

experiential avoidance of

symptoms predicts poorer long-term

outcome: if you can’t stand it, you’ve got it

clean symptom/dirty symptoms

clean symptoms are those directly elicited by pathology (damaged tissue, dysfunctional brain activity, low insuline, allergene)

dirty symptoms are the suffering caused by avoiding symptoms

why avoiding the problem becomes the

problemThere is a difference between avoiding a dangerous situation or avoiding the thought of a dangerous situation, the first will save you life the second will handicap you for life

Fundamental assumptions

People are capable of living a meaningful life with pain, anxiety and any other discomfort

Avoidance of pain or symptoms tends to make us loose sight of valued directions and thus a loss of life quality

Aim of Treatment

To help the person with pain to identify and act consistently with valued directions, independent of pain symptoms

To create psychological flexibility when relating to discomfort generally

Treatment principles

Valued direction in life dimensions

Exposure in valued directions: previously avoided

Acceptance of what cannot be directly changed

Defusion of thoughts which are not functional

When you alter your life in the service of reducing symptoms,

your symptoms flourish and your life quality diminishes

Creative hopelessness

Goal: freedom from pain

Cost: loss of life quality: no

friends, no job, no fun

Cost; I may fail

What happens when what is important

hurts?

Goal Life

control and avoidance cycle: moving down into struggle and away

from a values-based vital life

Life Restriction and loss: life

skrinks, present moment

disappears, vitality is lost

Relief:temporary relief, illusions that mindy solutions may work this

time

Pain

Mindy chatter: when I feel pain, reasons, predictions consequences

Entanglement: taking literally,

mindy solutions that call for escape, avoidance,

making deals, losing who you are

Control and avoidance: complying with mindy solutions and buying these thoughts

and engaging in the actual behavior they structure

ACT: moving up towards a values

basedvital life

Values: the life directions I choose, what I want my life to be about

Commitment and flexibility: choosing

to take action consistent with my values, enhancing

life flexibility

Growth and contact with barriers: as I step forward I grow and develop and feel

pain

Acceptance and being present: making

room for pain in the

moment it occurs

Mindfulness and defusion:observing my thoughts as

thoughts, taking heed if theyare helpful, staying conscous as the observer self, cognitive

flexibility

Chronic PainChronic Pain Dahl, Nilsson & Wilson, 2004Dahl, Nilsson & Wilson, 2004

20 public health caretakers at risk fordeveloping long-term pain/stress symptoms

10 TAU, 10 ACT protocol, 4 sessions at work-site/home

Baseline=60 days, intervention: 4 1-hrsessions over 30 days, FU 60 days

2 therapists: 1 experienced CBT, 1 nurse

Cumulative Sick Leave

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= 1.00

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Medical Utilization

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Mea

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its

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MTAU

Total Quality of Life

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37

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44

Pre Post 6-Mo FU

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MTAU

Chronic PainChronic Pain McCracken, Vowles, & McCracken, Vowles, & EcclestonEccleston, in press, in press

108 chronic pain patients

Average of 132 months of Chronic pain

6.3 treatment programs

Multidisciplinary in-patient program

Within subject analysis: Preassessment; 3.9months later (on average) pretreatmentassessment; 3-4 week residential program; 3month follow-up

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Impact on Chronic PainAss't to Pre (M=3.9 mo) and Pre to F-Up (M=3.9 mo)

conclusions

Acceptance based treatment compared to controlled based appears to lead to more promising long-term results

The person with chronic pain is more interested in getting his/her life back than simply getting rid of the pain.

A development and evaluation of an integrative health model in treatment of epilepsy:

Two randomized controlled trials investigating the effects of a short-term ACT intervention compared to attention control in India and South Africa.

Tobias Lundgren, JoAnne Dahl and Lennart Melin Department of psychology, Uppsala University, Sweden

DesignDesign Randomized Controlled Trial Randomized Controlled Trial Participants in South Africa = 27Participants in South Africa = 27 Two conditions, ACT and Attention Control.Two conditions, ACT and Attention Control. Inclusion criteria: Inclusion criteria: 4 seizures in the last 3 months4 seizures in the last 3 months Able and willing to participateAble and willing to participate No other ongoing illnesses No other ongoing illnesses Age 15 – 50Age 15 – 50

Application of an integrative health model, acceptance based behavior therapy in Epilepsy South Africa

Grietha Van Wyk, Tobias Lundgren & JoAnne Dahl Department of psychology, Uppsala University, Sweden

Evaluation of an empowerment program: ACT Cooperative project between Epilepsy South Africa, Uppsala UniversitySweden and the International Bureau for Epilepsy IBE

Grietha Van Wyk, Epilepsy South AfricaProf. JoAnne Dahl, Commission Chair IBE, Uppsala UniveristyTobias Lundgren, Uppsala University, Sweden

•A Simpler Version of the•Goals of ACT•A Simpler Version of the•Goals of ACT

• Accept your “tendency to seize”

• Choose your valued direction

• Take action to regain your quality of life in the face of all difficulties

Increase in life quality for ACT groupIncrease in life quality for ACT group

Life quality SWLS

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Pre post 6 month 1 year

Sco

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Control

Measure of persistency in striving for living a vital life in the face of difficulties

Measure of persistency in striving for living a vital life in the face of difficulties

Bulls-eye persistancy

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Control

Self-rating evaluation of where you place your activity level today in relation to the

bull’s eye of vitality you want

Self-rating evaluation of where you place your activity level today in relation to the

bull’s eye of vitality you want

Self rated evaluation of the degree to which epilepsy and thoughts about epilepsy is accepted or avoided

Self rated evaluation of the degree to which epilepsy and thoughts about epilepsy is accepted or avoided

Future research Future research

• Develop an integrative health model with a focus on empowerment of human resources to act consistent towards long term valued living.

• Look for the mechanism in behavior change.

• Training the trainers in ACT program in several Epilepsy South Africa Centers

• Develop an integrative health model with a focus on empowerment of human resources to act consistent towards long term valued living.

• Look for the mechanism in behavior change.

• Training the trainers in ACT program in several Epilepsy South Africa Centers

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