Welcome back to the Healing Pain Podcast with Lance McCracken, PhD

As always, it’s an honor to be spending this time with you. If you read episode 187, then you met psychologist, Louise Sharpe, who shared her research and discuss these central components of psychological therapy for effective pain management. Her research distilled over 50 components of psychological treatment for pain into three essentials, which were psychoeducation, cognitive approaches and strategies to increase physical activity. In her paper, she named these three as the gold standard for pain care. I enjoyed this episode with Professor Sharpe. I believe her research and interview is useful and can help inform clinical practice. Make sure to give it a read before you dive into this episode.

While I was doing some research, I came across a commentary in response to the paper Professor Sharpe published. This commentary was written by Professor Lance McCracken and published in the European Journal of Pain. For those of you who may not know Lance McCracken, he is a professor of clinical psychology and Head of Division of Clinical Psychology at Uppsala University in Sweden. He has worked as a clinician and conducted research into chronic pain treatment for more than 30 years. He actively contributes to the evidence base on Acceptance and Commitment Therapy for chronic pain.

The title of his commentary was Necessary Components of Psychological Treatment for Chronic Pain: More Packages for Groups or Process-Based Therapy for Individuals. In his commentary, Professor McCracken proposes that instead of studying the components of psychological treatment, if we want better treatments for pain, what we mainly need to identify is the processes of change known to have an impact on outcomes. I was interested in Lance’s commentary and his perspective, so I invited him to come to speak to us. This leads us to the episode where Professor McCracken discusses Process-Based Therapy.

Process-Based approaches have been growing. Some say that Process-Based Therapy should be the new gold standard of care because they can target a broader range of problems. In diagnosis-based protocols can target multiple problems at once and a more easily individualized and minister to the client. In this episode, you’ll learn all about Process-Based Therapy, the science and evidence behind Process-Based Therapy, how it can help clinicians more effectively treat pain, and how it differs from protocols that focus on specific syndromes. Without further ado, let me introduce Professor Lance McCracken, and learn all about Process-Based Therapy.

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Process-Based Therapy And Chronic Pain With Lance McCracken, PhD

Lance, thanks for joining me for the show. 

Joe, how are you?

It’s great to have you here. I’ve been looking forward to our chat. I came across a commentary that you wrote in the European Journal of Pain, which talks about maybe potentially moving from components of psychological treatment, talking more about the process. I’m excited to talk to you about it. Probably a good place to start is you’ve dedicated over 30 years to researching the psychology of pain. Give us your view of what’s the status of chronic pain treatment.

Thank you for reading the commentary and for inviting me to be here. I appreciate it. Where things are at, I always say that it’s a good time to be interested in psychology, chronic pain, and treatment development because we’ve already achieved a lot. CBT and various versions of CBT we know work well. They produce benefits for people with chronic pain. We’re over that hurdle. We have evidence, we know that there’s a benefit. We have these other interesting questions, like, “Who benefits and what do they benefit from? How do they benefit? How can we make it last and how can we make the benefits even greater?” We have a job to do or many jobs to do, but we already have a success story. That’s where we’re at.

We also have a lot of innovative and interesting new options. Things like new psychological processes that we didn’t use to appreciate to the same degree. We have more modes of delivery that we know can be effective. We have a new technology. We can use people’s smartphones. We could monitor people in more ways than we used to be able to do. There’s a lot of science and evidence behind us and a lot of opportunities. We have some serious questions that we still need to answer. Those are these things that are always called the who, how, what, where, when, or whatever you want to call it. For whom, what circumstances? What methods? By what mechanism? Those questions are what we’re wrestling with.

It’s the 10,000-foot view you were saying that cognitive-behavioral therapy has come a long way and there’s good evidence to support it for the treatment of chronic pain. You’re talking more along the lines of Process-Based Therapy, which is what the title of this episode is about. Somewhere potentially in the middle of those two are the components and that’s what your colleague, Louise Sharpe, wrote a paper on the Necessary Components of Psychological Treatments and Chronic Pain Management: A Delphi Study. That’s what your commentary was in relation to. She boiled down those components into three categories. If I remember correctly, it’s Psychoeducation, CBT, and some type of Activity Engagement. Our study is interesting because it took a whole lot of different types of components and boiled it down to three. From your view, what are the potential pros and cons of that?

I agree with the spirit of what Louise and her colleagues are meaning to do. We’re all trying to do the same thing in a sense. We all want to refine treatments and make them more impactful. One way to do it is to think about all of the components that have been delivered historically, but then find the ones that exert the most impact and find it by asking the people who researched the treatments and the people who deliver the treatments to produce a consensus. This is a way to do it. The intention is right on if you ask me, but there are also certain limitations here. One limitation for me is that this approach brings us back to things that we’ve already done to review them and then select from them to pick the ones that we think will work the best. It’s a little bit backward-looking. To me, it doesn’t begin with a formulation of treatment as a whole. It is a must find the right parts approach.

I don’t think it radically reorganizes what we could do nor does it give a great organization to how to do that better. It is what it is. It could produce better treatments, but there are other ways to innovate and produce the next treatment prototypes and things such as that. That’s what we’ll talk about. There are pluses and minuses. I don’t want to put down what they’ve done because the intention is right on. I do think for many people who read it, they’ll take learning from it and they’ll be able to apply it. Practical benefits could come from that, but the view I have is that we could do this in a more radical way. We could more deeply get underneath how we have been delivering treatment and then more radically reorganize it outside of the confines of where we’ve been in the past.

Does it potentially run the risk of someone reading the paper and taking those three components, let’s say psychoeducation, CBT and some type of activity engagement and say, “That’s what our entire program is going to be like?” Whether it’s an inpatient program or whether it’s an app on a phone where it boils it down to that, it takes away the individuality of care.

What I wrote in my commentary is that there is a risk that people will take those three things than focus too much on them. Maybe rely on those components as their guide too much and will take too much comfort or confidence in the delivery of those thinking, “If I can hit those, I’m doing a good job.” As you yourself mentioned right there. In a way that all by itself leaves out tracking the individual, noticing the difference between what different individuals might need. The fact that this summary comes from group data, group delivery experience boiled down by consensus. There’s a lot of heterogeneity. There are a lot of individual patient circumstances and a lot of individual patients need to be hidden inside that summarizing effects of consensus group delivery and group data.

You take the lesson from what they’ve got there, and then if you could add these other pieces, detecting individual needs, making sure you keep tracking the data of the individual. Don’t choose a component from group data with the belief that will necessarily apply to a person. The point is probably becoming obvious already to your readers, that this focus on components is a way to organize what one does next, and another way to do that would be Process-Based Therapy. How does that contrast? That’s where we’re getting to, in a sense.

The term Process-Based Therapy is new to some people. I’ve even asked a couple of colleagues of mine who work in mental health and they weren’t able to articulate it to me. I had to do a lot of reading on my own to get a good grasp of it, even though I’ve read some of them myself, but tell us how Process-Based Therapy is an evolution from the components.

For one thing, it’s evolutionary because it is different. If you think about how evolution works are you have to have variability. Without any variability, you can’t get selection. Without selection and retention, you don’t have different forms down the line. You can’t create increasingly more effective forms because you don’t have any variability. One thing we can say about Process-Based Therapy, whatever it is if it is different from what we’re doing that alone could be a good thing because it’s variability.

We let that run in the environment and we see what works better and what works better gets selected for use, and things could be good. There’s no apology needed in this issue here and finding difficulty in uncovering what is Process-Based Therapy. Although the term has been known, I wouldn’t say it’s been widely known, and it’s probably only entering people’s vocabulary. You don’t have to track down a few particular people by main, probably to read about it in any volume. Those who are speaking about it the most probably would be Stephan Hofmann, Steven Hayes, and others, but there’s a relatively small number of people who are promoting the virtues.

As you mentioned, Steven Hayes, so ACT itself is a Process-Based Therapy at heart. 

It would be called by many people an early prototype of a Process-Based Therapy. It has to be said that ACT began to be used and tested a bit in the ’80s. There was a full-length book in 1999. At that time, you’d be hard-pressed to have found the term, Process-Based Therapy, in the book, although it is inherently process-based. I’m not sure that the term was popularly used but it certainly is. It’s of known therapies. It is one that certainly fits the mantle, fits the picture of what is a Process-Based Therapy.

For other practitioners who are reading, if we pull out a little bit and widen the lens, there are processes that are at work and other types of therapies. ACT has six processes that people familiar with. If they’re familiar with ACT, what are the types of processes might a practitioner relates to or start to become aware of from that?

The first thing to say is if there’s any treatment that’s happening that is generating any impact, intrinsically, inherently, essentially inside there is a process. That process may be that it is not being consciously, intentionally, incrementally manipulated to produce the outcome desired, but there will be a process. If there’s change, there’s a process. If there’s an incremental change directly at the end of the methods applied that in turn is related to an incremental change in the outcomes of interest, then it’s processed. It’s not process-based unless it is the intention, the purposeful choice of the person delivering the treatment to make those processes, the heart, the focus, the organizing component of the treatment. It’s that intentionality you could say.

For example, from a physiotherapist perspective, the primary cognitive-behavioral intervention they’re using is probably pain education. The reconceptualization of pain, that would be a process that they would intentionally be applying to care. Likewise, let’s say more from a traditional cognitive-behavioral intervention, cognitive restructuring itself is the procedure or the component, but the re-appraisal would be the process.

At this stage in history, we’ve not had a history of being careful with our statements of what is a process and what’s not, and you nicely hit on one issue. That is for a lot of the terms they’re used interchangeably as method and process like mindfulness. Is the mindfulness method or process exposure? Is exposure something you do or is it something that happens when you do what you do? Is it the process or the method? Education, what is that? Is education the process, is the process of knowledge enhancement or what? We have some ways to go to refine our terms to nail down our processes so that the ways we named them to have precision.

They’re only what they say they are, and can’t be confused with something else. We’ll need to move ahead with developing criteria for what makes something a process compared to something that isn’t the process. We are where we are in a slightly sloppy stage of process and mechanism. We’re making progress. We know that some of these challenges are there, but physiotherapists have their processes in what they do. Some of them when they’re seeking psychological behavioral change, and then your other ones, which would be more within your domain that are non-psychological processes.

As a pain practitioner, it starts to make me think, do we have an adequate set of processes identified for chronic pain yet? Which ones do we potentially know a little bit about?

What we’ve done a couple of times in this discussion is to walk backward a little bit and you think about, what are we talking about here? For any individual that we see, we’re going to have outcomes of interest. In pain management, we have some conventional ones like pain interference, disability, depression or pain intensity. We’ll have a range of variables that we know are correlated with those and where the presumption is if you manipulate that correlated variable it’ll impact on your outcome of interest. If you then add to that, we’ve said another thing, which is these links are individual.

They’re based on a person’s learning history and their situation. If you add a couple of other features to their individual and you say, they may be bi-directional, the relationships between these process type variables and outcomes go in both directions. They’re dynamic, they change during the course of treatment. They may go back and forth to strength or they may strengthen in their impact or lessen in their impact. Saying these few things, they’re multi-variate, bi-directional, dynamic, and individual, and they are the things that we’ve said. They are things like something about catastrophizing. For example, something about avoidance or by the same token, something about behavioral engagement or behavioral activation.

I’d say there’s going to be an intentional process domain we need to nail down something about awareness and attention. We don’t have that many more. ACT is based on psychological flexibility, six-facet or three-dimension, open aware and engaged model. People interested in psychological flexibility and ACT will see evidence for these facets, but not everyone would agree with that. You have to begin to ask questions about what’s enough evidence to call something, an evidence-based process, but that’s a little bit all over the place. There’s some that look pretty strong. Most people would agree, but we’re still populating this space of evidence-based processes.

We’re trying to figure out the procedures that have an impact on the process that impacts behavior change ultimately, and that has to be individualized for the person that you’re treating.

We haven’t talked a lot about the method, but if you’ve got processes in there, one thing that you want them to be is empirically related to your outcomes of interest. They have empirically demonstrated a relationship with your outcomes. In the other direction, they have an empirically demonstrated relationship with the methods that you would intend to use to operate on your processes. You get those links into directions and that’s what supports the function and influence makes the processes relevant.

It’s interesting because that fits well with personalized and precision medicine. Although then it makes me think, does Process-Based Therapy not fit or not fit as well with group therapy?

You may need another show on that topic. I would say, without trying to start any trouble that it’s hard for group treatment to be individualized around every single individual in the group. There’s one point of delivery in the room, a therapist. You’ll get other points of delivery, the other patients, or the other participants. For any person, everyone else in the room is a potential point of delivery but not all of the therapist’s behavior or the other people’s behavior, whether it’s therapeutic or counter therapeutic can even possibly be calibrated individualistically to any one person in the room. I wouldn’t stack up group treatment delivery as the prototype process base, because process-based means doing what for this individual in these circumstances, what is done to impact on their priority outcome issues. Even the outcomes, they have to be idiographic. Meaning, they have to be pertinent, and based on this individual’s priorities. It’s hard to swing that in group treatment and aggregated group data.

It starts to blow your mind after a while if you start to think about all the different levels that can have an impact on. For example, protocols, which are popular, especially for newer therapists, because it gives them a little bit of confidence and almost a roadmap and a how-to guide. Can you protocolize Process-Based Therapy then?

You can lay down design but you can’t pre-orchestrate moment by moment, because that defied the purpose. You have to have dynamic customizability. If all your sessions are pre-ordained and all of the minutes during your session are already spoken for, you don’t have any customize ability anymore. You could say that we need it. You could have a protocol that said what you need as your instruments. “Are these instruments the list of empirically supported processes of change?” Your methods that you’re competent in utilizing. Your tracking methods for processes that may be relevant and probably your outcomes to know when you got there. A process of feeding the process information to the delivery, to the therapist, to select the next method based on the process being targeted. In a way that’s an unusual protocol, but if you say a protocol is a list of your tools, yes. An instruction set, which says, what we’ve been talking about so far individual, customizable, dynamic watch out for bi-directional relations, multi-variate, be situational and individual and be contextual. It’s a nice set of flexible reminders, but not a session by session protocol.

If a clinician is reading this and they want to start to practice in this way more from a Process-Based approach, are there process measures they can start to use in clinical practice to measure certain processes that may have an influence on the patients they’re treating?

Yes and no. I’d say one of our challenges in our field if we want to equip ourselves to do Process-Based Therapy is the development of brief methods that are useful for repeated application, use, and an administration that could be used daily or more than once daily. You need that fine-grained, detailed, dense, and intensive assessment over time. Skilled clinicians with training and the development of measures can design their own, can pilot them, and use them. Clinicians already do this. I must say we are not overflowing with all validated instruments that anyone can select for use. You can read, and you could find what people have used, get copies of what they use.

You will find that many people are using instruments like daily diaries that they were developed for the study that they’re doing weren’t validated in a study of their own in a unique and new way, specifically suited to intensive longitudinal data. There are examples out there. I know I’ve read there are single-case experimental studies and have one replicated and have one series and they get their data in a repeated fashion. They graph it. They are using measures, but we haven’t reached the point where we have a whole treasure trove of validated measures to pick from. It’s more made for a purpose now you’re borrowing them for something else.

If we had that, then it may influence a practitioner’s not only evaluation but then the goal setting and what happens in the care of that patient.

If you’re not tracking the process, it’s hard to calibrate and choose the process. It’s hard to know what you did hit the target you intended to target. You are saying in some ways, a slightly discouraging thing because of what I said before, but it’s right on. If we can’t track measure, reflect these things, it’s going to be hard for that information to guide a choice.

They’re still tracking, let’s say interventions, components, in essence, symptoms and potentially functional outcomes.

Implicitly they have the protocol, they have the list of methods. They know the methods for this session. They are tracking because they’re checking off. “Yes. I did psychoeducation. I did education on depression or I did a goal setting. I did smart goals.” That’s exactly right. Historically, we have tracked method. The protocol says do these methods and then we implicitly check them off when we have done. That doesn’t mean that the impact of the method we’ve measured the delivery. We don’t know if functionally the method hit home or not.

How do you see yourself integrating Process-Based Therapy into your future research with your group?

We are putting our heads together and trying to drill down into the things that we’re talking about. We are scouring literature to understand that we’re doing a scoping review. We’re interested in idiographic methods and of one single case experimental design method for those individual approaches. What measures do people use when they test and examine these approaches? We’d like to understand the lay of the land, all of the territory the scope of what is used, how those measures are developed and validated? What domains are represented and what’s best practice? That’s a step. We know that we have used some platforms to get daily data on people’s phones. We’re still working on finding maybe the best platform to do that.

We want to examine mediation, mechanism, and replicated single-case data. We know there are some methods for doing that. That’s something else we’re looking into. If you remember where we’ve been, RCTs with mediation and moderation analysis, pre and post-follow-up data, not a lot of intensive daily data, but that’s classic. This is what we’ve done. We’re trying to move away from that smaller number, more intensive data. Not as many people, more data over time and then adopting our measures, our analytic approach, our approach to mediation, and moderation accordingly. We are at the beginning phase. We’re piloting things and reading our butts off.

I’m noticing you’re almost going in the reverse of evidence-based research in a way, which makes sense. You’re much more versed in research than I am but there may be more potential for a single subject design or a case study with regard to Process-Based Therapy since it is individualized.

I’ll tell you a short story about one thing that we tried hard to do because most of my experiences, not in RCTs, we’ve done some RCTs, but what we’ve done is a lot of studies in actual clinical practice. A lot of effectiveness studies, like what happens in actual treatment. We’ve tried rather hard to be processed based on our approach to that and tried to find potential mechanisms and potential moderators variables from the baseline that can be used to determine how to customize. We’ve had such a miserable time specifically with that last one.

How do you identify variables at baseline that are related to whether people are going to do well in one thing or another? The customizing or individualizing information, and we’ve completely not been able to find anything. It finally dawned on us, our hypothesis, which is when you have a heterogeneity within groups, heterogeneity between groups added together into larger groups of aggregated data, you have treatment teams that vary and incompetency and fidelity. You have cross center changes. You have differences in people’s pain conditions, the personal history, and relevant psychological processes. You are buried in heterogeneity.

How could you expect to find predictors, moderators or even clean mechanisms and all of this extreme heterogeneity? It dawned on us that can’t be possible. It can’t be that processes change in an even meat tidy, linear fashion over exactly a three-week period of time in everyone to the same extent. If that’s your model of mechanism, it can’t work. Your model of moderators can’t work either because if you can’t figure out mechanism or mediation, you don’t have a hope of nailing predictors of outcome. That’s what has brought us around to this. It does sound like going in historically in the wrong direction because we’ve hit the pinnacle of treatment outcome assessment research larger RCTs with moderation, mediation, and health economic analysis. That stuff never needs to be canceled. I don’t think it’s bad. We shouldn’t stop it, but our argument would be, we better start complimenting that. Adding to that or extending that with a different way to look at the data to make sure that if there is something obscured and all of that aggregated data that we learn about it. We learn what it is.

I attended an ACT bootcamp and I sat next to a social worker who worked at one of the VAs in the United States. She had mentioned to me that to work at the VA, I believe she was working in a trauma setting that they had to be competent in eighteen different psychotherapies. I’ve not trained psychotherapy, but I’m like, “That sounds like a lot to me for any human being to maintain over the course of a long period of time.” I’m wondering if maybe in some ways, Process-Based Therapy could be simpler for practitioners to apply in practice versus the multitude of different theories that almost all our professions have. 

One thing that is a complaint about many practicing clinicians is that we seem to have been told in the past that the way to do evidence-based therapy was to find the protocol that was tested on multiple RCTs and verified as the protocol that produces the good effect. If you do that protocol, you’re doing evidence-based practice. We seem to have been told that that’s the way to do it. The trouble is, these are all disorders specific. If you want to get into this game of protocols, there are a lot of protocols, panic disorder, depression, social anxiety, generalized anxiety disorder, headache, low back pain, and fibromyalgia. The list goes on and that’s too much to memorize. It becomes too many. The secret hidden behind all those numerous protocols is that many of them are based on the same therapeutic processes inside. Let’s skip a step. Let’s learn the processes and then produce the clinical technology needed to know when they are needed and do it that way instead of memorizing protocols or keeping a huge drawer full of protocols, a shelf, or a library.

It sounds like it simplifies things for a practitioner and maybe in a way, it gives them a little bit more confidence, especially maybe at the beginning of their career where they’re looking at, “What protocol do I use for depression, fibromyalgia, and OCD?” This is more common in psychology than other fields, but even in physical therapy, there are multiple protocols for different types of conditions and the list keeps growing and growing. Most practitioners don’t follow those protocols to the tee. There should be something at work in all of them that has a commonality and hopefully, Process-Based Therapy is that. We’ll be watching your work, following you on PubMed. Let people know how they can follow you and learn more about your work as you venture into this.

I encourage people to either look me up at Uppsala University in the Psychology Department. You can see some of the stuff that’s coming out of our group. Our research group is growing. I only arrived in Uppsala in 2018 and we’ve taken on three PhD students. We have high hopes for the future. I’m where you find most people are, ResearchGate and Google Citations and Twitter, popping my name somewhere. Following me on Twitter might encourage me to tweet more, which wouldn’t be a bad thing. I have a goal to be more frequent on Twitter and to write clearer, more clever quality tweets. I could use the help on the traditional places.

At the end of every episode, I ask you to show this with your friends, family and colleagues on Facebook, Twitter, LinkedIn, wherever you have people who are hanging out, talking about the psychology of chronic pain and Process-Based Therapy. I want to thank Lance for joining us. We’ll see you.

Important Links:

• Louise Sharpe – Previous episode
• Professor Lance McCracken – LinkedIn
• Necessary Components of Psychological Treatment for Chronic Pain: More Packages for Groups or Process-Based Therapy for Individuals
• Necessary Components of Psychological Treatments and Chronic Pain Management: A Delphi Study
• ResearchGate – Lance McCracken
• @Lance_McCracken – Twitter
• https://OnlineLibrary.Wiley.com/doi/full/10.1002/ejp.1568
• https://OnlineLibrary.Wiley.com/doi/abs/10.1002/ejp.1561

About Lance McCracken

Lance McCracken is Professor of Clinical Psychology and Head of the Division of Clinical Psychology at Uppsala University in Sweden. He has worked as a clinician and conducted research into chronic pain treatment for almost 30 years. Among other things he published the first study on psychological flexibility in chronic pain, in 1998, and led the first specialty chronic pain service in the world designed around Acceptance and Commitment Therapy, beginning in 2000.