Week 7-Psychological Therapy for Pain (incl. mindfulness)

Question 1

Define mindfulness

Answer 1

Intentional, non-judgmental focus on the present moment (Shapiro et al., 2006)

Question 2

Give examples of mindfulness techniques

Answer 2

Formal meditation:
1. Mindfulness Based Stress Reduction
(MBSR) (Kabat-Zinn, 1985)
2. Mindfulness Based Cognitive Therapy
(MBCT) (Segal, Williams, & Teasdale, 2002)

Other exercises that promote mindfulness:
1. Acceptance and Commitment Therapy (ACT) (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).

Question 3

What are the Commonalities between MBSR and MBCT? (Day et al., 2014)

Answer 3

 Group setting consisting of 4 to 8 sessions.

 Provided with guided MM audio files
and are instructed to practice daily for
45 minutes.

 Practice progression: body scan, seated meditations, mindful movement/yoga/walking, sharing experiences.

 Encouraged to infuse mindful practices into everyday tasks.

Question 4

What are the Advantages of mindfulness meditation?

Answer 4

 Just as effective as CBT and hypnosis

 Additionally, suitable for delivery in large groups (in uncomplicated cases)

 Can be delivered via internet or apps

 Many opportunities for ongoing support (e.g., meditation retreats)

Question 5

What are the Disadvantages of mindfulness meditation?

Answer 5

 Requires preparedness of the patient

 “McMindfulness” (hype, over-marketing,
unrealistic expectation)

Question 6

What’s the IAA model of mindfulness? (Shapiro et al., 2006)

Answer 6

-Intentional, non-judgmental [Attitude] focus [Attention] on the present moment

Intention:
1. Self-regulation (behaviour/symptom change)
2. Self-exploration (curiosity)
3. Self-liberation (spiritual)

Attitude (qualities of attention/intention):
1. Open/accepting
2. Kindly
3. Curious

Attention:
1. Shifting attention
2. Sustaining attention

Question 7

IAA: What’s Decentring as a “meta-mechanism”?

Answer 7

“Subject” becomes “Object” of attention
* Shapiro: Re-perceiving
* MBCT: Decentring
* ACT: Cognitive de-fusion (and “self-as-context”)

Question 8

What’s Acceptance and Commitment Therapy (ACT)?

Answer 8

■ “ACT is a therapeutic approach that uses
acceptance and mindfulness processes, and
commitment and behaviour change processes, to produce greater psychological flexibility.” (Hayes, Wilson, Strosahl, 1999)

■ ACT is an evolution of Cognitive-Behavioural Therapy, with the key difference between the incorporation of mindfulness practices (McCracken and Vowles, 2014)

Question 9

What’s The ACT Hexaflex? (Hayes, Strosahl & Wilson, 1999)

Answer 9

Psychological flexibility is linked with:
-Contact with the present moment
-Values
-Acceptance
-Cognitive Defusion
-Committed Action
-Self as Context

Question 10

ACT Hexaflex: Defusion, Self as Context, “Decentering”

Answer 10

Bennett, et al. Transl Psychiatry (2021):
* “Allows individuals to experience distressing inner events as imperfect
models of the real-world rather than
precise reflections.”

• Article provides up-to-date overview
  of different models and methods to
  measure decentring; takes developmental perspective (Example: McCracken, et al., 2014).

Decentring has a two factor structure:
(1) Self-as-context - intentionally
disengage/disidentify from the content
of inner events
(2) Cognitive defusion - reduced
emotional reactivity to those events

Question 11

What are some Key learning points?

Answer 11

■ Mindfulness is a well-defined construct, but implemented differently in different therapeutic models, and with different terminology.

■ The IAA model captures both the definition and core qualities of mindfulness; Decentring is the core cognitive mechanism.

■ The ACT model: Mindfulness is core, but supplemented by values clarification and committed action and is therefore more focused on behaviour change.

Question 12

What are Specific and non-specific therapeutic components of mindfulness analgesia? (Enck and Zipfel, 2019)

Question 13

What is the Theoretical basis of specific effects of mindfulness (vs. non-specific placebo effects)?

Answer 13

Mindfulness and placebo have theoretically distinct cognitive mechanisms:
■ Expectation:
– Placebo relies on the cognition fusion of expectations with reality (internal model of the world-dominating over the senses)
– Mindfulness aims for cognitive de-fusion (“coming to your senses”)

■ Conditioning:
– Placebo relies on conditioning mechanisms to induce pain relief
– Mindfulness aims to recognise / bring awareness to the person’s conditioning history to undermine conditioned responses (e.g. acceptance of pain undermines threat-related conditioning)

Question 14

What is the Specific effectiveness of mindfulness on pain: study designs

Answer 14

• Active control conditions are crucial for filtering out non-specific effects, notably the placebo effect (expectation of benefit, not the treatment itself)
• Most active controls in mindfulness studies were not other established treatments, but rather minimally effective interventions (“shams”)

Study types:
Acute pain:
Short-term effects
* Randomised clinical trials
* Sham controlled studies available
Long-term effects
* Between-subject designs available
* Longitudinal designs not available
* Sham control impossible

Chronic pain:
Short-term effects
* Randomised clinical trials
* Few studies using sham controls
Long-term effects
* Lack of published data