Acceptance and commitment therapy (ACT) - Giornale Italiano di ...
Acceptance and commitment therapy (ACT) - Giornale Italiano di ...
Acceptance and commitment therapy (ACT) - Giornale Italiano di ...
Create successful ePaper yourself
Turn your PDF publications into a flip-book with our unique Google optimized e-Paper software.
<strong>Giornale</strong> <strong>Italiano</strong> <strong>di</strong> Me<strong>di</strong>cina del Lavoro ed Ergonomia Supplemento A, Psicologia<br />
© PI-ME, Pavia 2011 2011; Vol. 33, N. 1: A53-A63<br />
http://gimle.fsm.it ISSN 1592-7830<br />
Anna Bianca Preve<strong>di</strong>ni, Giovambattista Presti, Elisa Rabitti, Giovanni Miselli, Paolo Moderato<br />
<strong>Acceptance</strong> <strong>and</strong> Commitment Therapy (<strong>ACT</strong>): the foundation<br />
of the therapeutic model <strong>and</strong> an overview of its contribution<br />
to the treatment of patients with chronic physical <strong>di</strong>seases<br />
IULM University-Milan-Italy, IESCUM, <strong>ACT</strong>-Italia<br />
ABSTR<strong>ACT</strong>. Nowadays, treatment of chronic illnesses, such as<br />
stroke, cancer, chronic heart <strong>and</strong> respiratory <strong>di</strong>seases,<br />
osteoarthritis, <strong>di</strong>abetes, <strong>and</strong> so forth, account for the largest part<br />
of expenses in western countries national health systems.<br />
Moreover, these <strong>di</strong>seases are by far the lea<strong>di</strong>ng causes<br />
of mortality in the world, representing 60% of all deaths.<br />
Any treatment aimed at targeting them might engage an<br />
in<strong>di</strong>vidual for a large portion of his/her life so that personal<br />
<strong>and</strong> environmental factors can play a crucial role in modulating<br />
the person’s quality of life <strong>and</strong> functioning, on top of any<br />
me<strong>di</strong>cal cure. Anxiety, depression, <strong>and</strong> <strong>di</strong>stress for examples<br />
are not rare in patients with chronic <strong>di</strong>seases. Therefore,<br />
Cognitive <strong>and</strong> Behavior Therapy research has largely<br />
contributed in the last decades in identifying <strong>and</strong> programming<br />
interventions on such aspects as real <strong>and</strong> perceived social<br />
<strong>and</strong> family support, coping abilities, locus of control,<br />
self-efficacy that might help patients living with their chronic<br />
<strong>di</strong>sease.<br />
More recently, third generation Cognitive-Behavior-Therapies,<br />
such as Dialectical Behavioral Therapy (DBT), Mindfulness<br />
Based Cognitive Therapy (MBCT), Functional Analytic<br />
Psycho<strong>therapy</strong> (FAP) <strong>and</strong> <strong>Acceptance</strong>, <strong>and</strong> Commitment<br />
Therapy (<strong>ACT</strong>) focused their attention <strong>and</strong> research efforts<br />
on developing intervention models targeting the needs of<br />
patients with a chronic <strong>di</strong>sease.<br />
This paper has three aims. First is to briefly introduce <strong>ACT</strong><br />
epistemological (Functional Contextualism) <strong>and</strong> theoretical<br />
(Relational Frame Theory) foundations as a st<strong>and</strong> point for<br />
underst<strong>and</strong>ing the peculiarity of <strong>ACT</strong> as a modern form of<br />
Clinical Behavior Analysis. The second aim is to introduce <strong>ACT</strong><br />
clinical model <strong>and</strong> its six core processes (acceptance, defusion,<br />
present moment, self as a context, values <strong>and</strong> committed action)<br />
as both accountable, in their continuum, for psychological<br />
flexibility <strong>and</strong> inflexibility. Third, to present a brief overview<br />
of stu<strong>di</strong>es <strong>and</strong> outcomes of <strong>ACT</strong> intervention protocols<br />
<strong>and</strong> assessment tools that have been investigated in patients<br />
with chronic physical <strong>di</strong>seases, <strong>and</strong> namely: <strong>di</strong>abetes, obesity,<br />
epilepsy, <strong>and</strong> chronic pain.<br />
Key words: Cognitive-Behavior Therapy, <strong>Acceptance</strong><br />
<strong>and</strong> Commitment Therapy, chronic <strong>di</strong>seases, Functional<br />
Contextualism, Relational Frame Theory, Chronic pain.<br />
RIASSUNTO. ACCEPTANCE AND COMMITMENT THERAPY<br />
(<strong>ACT</strong>): LE BASI DEL MODELLO TERAPEUTICO E UNA PANORAMICA<br />
DEL SUO CONTRIBUTO AL TRATTAMENTO DEI PAZIENTI CON<br />
MALATTIA FISICA CRONICA. Al momento attuale, l’intervento<br />
terapeutico rivolto a malattie croniche quali stroke, cancro,<br />
malattie car<strong>di</strong>ache e respiratorie croniche, artrosi, <strong>di</strong>abete<br />
e così via, rappresenta la spesa più gr<strong>and</strong>e che i sistemi sanitari<br />
nazionali dei paesi occidentali devono affrontare. Inoltre,<br />
queste malattie costituiscono la principale causa <strong>di</strong> morte,<br />
rappresent<strong>and</strong>o il 60% dei decessi nel mondo. Ogni intervento<br />
mirato al trattamento delle malattie croniche coinvolge<br />
la persona per gran parte della sua vita, così che i fattori<br />
personali e ambientali rivestono un ruolo cruciale nel<br />
modulare la qualità <strong>di</strong> vita e il funzionamento della persona,<br />
al <strong>di</strong> là <strong>di</strong> qualsiasi cura me<strong>di</strong>ca. Ansia, depressione e stress,<br />
per esempio, sono piuttosto frequenti in questo tipo<br />
<strong>di</strong> pazienti. Perciò, negli ultimi decenni la ricerca <strong>di</strong> stampo<br />
cognitivo-comportamentale ha contribuito ampiamente<br />
a identificare e programmare interventi mirati a quegli<br />
aspetti, quali il supporto sociale e familiare reale e percepito,<br />
le abilità <strong>di</strong> coping, il locus of control, l’autoefficacia,<br />
che possano aiutare i pazienti a convivere con la propria<br />
con<strong>di</strong>zione <strong>di</strong> salute cronica.<br />
Più <strong>di</strong> recente, le terapie cognitivo-comportamentali <strong>di</strong> terza<br />
generazione, come la Dialectical Behavioral Therapy (DBT),<br />
la Mindfulness Based Cognitive Therapy (MBCT),<br />
la Functional Analytic Psycho<strong>therapy</strong> (FAP) e l’<strong>Acceptance</strong>,<br />
<strong>and</strong> Commitment Therapy (<strong>ACT</strong>) hanno focalizzato<br />
attenzione e intenti <strong>di</strong> ricerca al fine <strong>di</strong> sviluppare modelli<br />
<strong>di</strong> intervento mirati ai bisogni <strong>di</strong> pazienti con malattia cronica.<br />
Il presente articolo ha tre obiettivi principali. Il primo è quello<br />
<strong>di</strong> introdurre le basi epistemologiche (Contestualismo<br />
Funzionale) e teoriche (Relational Frame Theory) dell’<strong>ACT</strong>,<br />
come punto <strong>di</strong> partenza per la comprensione della peculiarità<br />
dell’<strong>ACT</strong> come moderna forma <strong>di</strong> Analisi Clinica<br />
del Comportamento. Il secondo obiettivo è <strong>di</strong> introdurre<br />
il modello clinico dell’<strong>ACT</strong> e i suoi sei processi chiave<br />
(accettazione, defusione, momento presente, sé come contesto,<br />
valori e impegno all’azione) come aspetti centrali, lungo<br />
il proprio continuum, sia della flessibilità sia dell’inflessibilità<br />
psicologica. Il terzo, è quello <strong>di</strong> presentare una breve rassegna<br />
degli stu<strong>di</strong> e dei risultati relativi ai protocolli <strong>di</strong> intervento<br />
basati sull’<strong>ACT</strong> e agli strumenti <strong>di</strong> valutazione che sono stati<br />
applicati a pazienti con malattie fisiche croniche e in<br />
particolare: <strong>di</strong>abete, obesità, epilessia e dolore cronico<br />
Parole chiave: Terapia Cognitivo-Comportamentale, <strong>Acceptance</strong><br />
<strong>and</strong> Commitment Therapy, malattie croniche, Contestualismo<br />
Funzionale, Relational Frame Theory, dolore cronico.<br />
Introduction<br />
Any chronic illness, such as stroke, cancer, chronic<br />
heart <strong>and</strong> respiratory <strong>di</strong>seases, osteoarthritis, <strong>di</strong>abetes, <strong>and</strong><br />
so forth, can take decades to be fully established, <strong>and</strong> often<br />
its origin can be traced back in younger ages. Nowadays<br />
chronic <strong>di</strong>seases account for the largest part of the ex-
A54<br />
penses of the national health systems in western countries<br />
<strong>and</strong> are by far the lea<strong>di</strong>ng cause of mortality in the world,<br />
representing 60% of all deaths. The long time span for<br />
those <strong>di</strong>seases to develop implicitly points to the fact that<br />
there might be opportunities for prevention of symptoms<br />
or <strong>di</strong>sease worsening or bettering patient’s quality of life,<br />
while reducing the me<strong>di</strong>cal impact of drug therapies. Environmental<br />
con<strong>di</strong>tions <strong>and</strong> in<strong>di</strong>vidual characteristics,<br />
both in terms of lifestyles <strong>and</strong> psychological factors, can<br />
modulate the <strong>di</strong>sease’s impact on the in<strong>di</strong>vidual quality of<br />
life. Much research shows weak or no correlation between<br />
the nature <strong>and</strong> degree of physical impairment due to <strong>di</strong>fferent<br />
me<strong>di</strong>cal con<strong>di</strong>tions (e.g. ischemic heart <strong>di</strong>seases,<br />
head injuries, chronic pain, etc.), <strong>and</strong> the degree of the <strong>di</strong>sability<br />
or the getting back to normal life (1-3). Data suggest<br />
that psychological adjustments are crucial in modulating<br />
the level of functioning in people facing injuries,<br />
trauma <strong>and</strong> pain, where in western societies patients with<br />
chronic con<strong>di</strong>tions frequently are dealt with as if they were<br />
only affected by acute me<strong>di</strong>cal pathologies entailing shortterm<br />
symptom alleviation <strong>and</strong> not long-st<strong>and</strong>ing lifestyle<br />
changes. This bias not only leads to perpetuating chronic<br />
illness’ problems, both in terms of personal suffering <strong>and</strong><br />
economic burden on society (4, 5), but also increases the<br />
risk of exacerbating, stabilizing or maintaining the<br />
problem by focusing only on symptoms alleviation drugs,<br />
sick leaves, or hospitalizations (5, 6). By addressing the<br />
care of chronic patients at the physical level with drugs,<br />
only a small part of the process is taken into account,<br />
whereas it is very important what over time the patient<br />
thinks <strong>and</strong> feels about his/her illness (covert behaviors) in<br />
order to pre<strong>di</strong>ct <strong>and</strong> improve his/her adherence (overt behaviors)<br />
to any me<strong>di</strong>cal intervention (7). In pursuing this<br />
goal researchers showed that there are a number of personal<br />
factors in me<strong>di</strong>ating patient’s adaptation to the<br />
chronic <strong>di</strong>sease <strong>and</strong> adherence to the treatment that must<br />
be taken into account when working with physical impaired<br />
patients, some of which are: anxiety, depression,<br />
locus of control, self-efficacy, coping styles, real <strong>and</strong> perceived<br />
social support, etc.<br />
Cognitive-Behavior Therapy (CBT) has been demonstrated<br />
an effective psychological intervention to help both<br />
adults <strong>and</strong> children in dealing with many chronic <strong>di</strong>seases<br />
(8-10). More recently, third generation Cognitive-Behavior-Therapies<br />
(11), such as Dialectical Behavioral<br />
Therapy (DBT; 12), Mindfulness Based Cognitive Therapy<br />
(MBCT; 13), Functional Analytic Psycho<strong>therapy</strong> (FAP; 14)<br />
<strong>and</strong> <strong>Acceptance</strong> <strong>and</strong> Commitment Therapy (<strong>ACT</strong>; 15, 16)<br />
focused their attention <strong>and</strong> research efforts on developing<br />
intervention models aimed in helping those patients too.<br />
This paper has three aims. First, to briefly introduce<br />
<strong>ACT</strong> epistemological (Functional Contextualism) <strong>and</strong> theoretical<br />
(Relational Frame Theory) foundations as a st<strong>and</strong><br />
point for underst<strong>and</strong>ing the peculiarity of <strong>ACT</strong> as a<br />
modern form of Clinical Behavior Analysis. The second<br />
aim is to introduce <strong>ACT</strong> clinical model <strong>and</strong> its six core<br />
processes (acceptance, defusion, present moment, self as a<br />
context, values <strong>and</strong> committed action) as both accountable,<br />
in their continuum, for psychological flexibility <strong>and</strong><br />
inflexibility. Third, to perform a brief overview of stu<strong>di</strong>es<br />
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
<strong>and</strong> outcomes of <strong>ACT</strong> intervention protocols <strong>and</strong> assessment<br />
tools that have been investigated in patients with<br />
chronic physical <strong>di</strong>seases, <strong>and</strong> namely: <strong>di</strong>abetes, obesity,<br />
epilepsy, <strong>and</strong> chronic pain.<br />
<strong>Acceptance</strong> <strong>and</strong> Commitment Therapy (<strong>ACT</strong>) philosophical <strong>and</strong><br />
theoretical roots: Functional Contextualism <strong>and</strong> Relational Frame<br />
Theory<br />
Even if it is not possible to exhaustively tackle all the<br />
issues entailed in the philosophical <strong>and</strong> theoretical basis of<br />
<strong>Acceptance</strong> <strong>and</strong> Commitment Therapy (<strong>ACT</strong>), the authors<br />
believe it is crucial to be aware of some of their stances<br />
<strong>and</strong> implications to the construction <strong>and</strong> purpose of the<br />
clinical model (<strong>ACT</strong> itself), as a st<strong>and</strong> point for underst<strong>and</strong>ing<br />
the peculiarity of <strong>ACT</strong> as a modern form of Clinical<br />
Behavior Analysis.<br />
One of the endeavors of <strong>ACT</strong> Scholars has always<br />
been to take into account basic <strong>and</strong> applied behavioral<br />
principles <strong>and</strong> frame them in a coherent epistemological<br />
picture to avoid the risk of this <strong>therapy</strong> being misinterpreted<br />
as a mere new set of more or less older psychotherapeutic<br />
techniques. Hayes, Strosahl <strong>and</strong> Wilson (15),<br />
clearly underline the importance of making all levels of<br />
analysis explicit. They suggest that this can help an <strong>ACT</strong><br />
therapist analyzing patient’s problems, choosing a specific<br />
intervention, <strong>and</strong> underst<strong>and</strong>ing what are the <strong>ACT</strong> elements<br />
of continuity <strong>and</strong> <strong>di</strong>scontinuity with other psychological<br />
theories <strong>and</strong> models. Accor<strong>di</strong>ng to Hayes (11),<br />
<strong>ACT</strong> is grounded in Functional Contextualism, a pragmatic<br />
philosophy of science, which identifies the ongoing<br />
interactions of the whole organism with the historical <strong>and</strong><br />
actual contexts as the unit of analysis of behavior (16, 17).<br />
From this perspective:<br />
• behavior is everything that an organism can do, inclu<strong>di</strong>ng<br />
overt behaviors (thoughts are not <strong>di</strong>screte<br />
structures, nor the cause of behavior, but they are behaviors<br />
themselves) <strong>and</strong> it is what the analysis should<br />
explain (18);<br />
• context is everything, beside behavior itself, that can<br />
be analyzed <strong>and</strong> that influences the development, the<br />
expression, the mo<strong>di</strong>fication, <strong>and</strong> the maintenance of<br />
that behavior, both in the present moment <strong>and</strong> in the<br />
past history. It is what we can manipulate in the<br />
analysis (18);<br />
• the former two statements clarify the aim of the explicatory<br />
categories as pragmatic, namely the pre<strong>di</strong>ction<br />
<strong>and</strong> influence of the behavior of interest, so that “truth”<br />
is relative (e.g. patient’s values are not arguable), <strong>and</strong><br />
it is true what is workable. Truth is tied to practical<br />
consequences (committed actions), not to ontological<br />
assumptions (being sick, having a chronic <strong>di</strong>sease,<br />
having a depressed <strong>di</strong>sorder, etc.);<br />
• as a consequence, the emphasis of the analysis is on<br />
the function of behaviors rather than on their topography,<br />
shape <strong>and</strong> frequency, so that it is considered<br />
much more useful to try to change the variables of the<br />
context that are causally (either as actual or historic antecedents<br />
or consequences) linked to the “negative”
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
behaviors that an <strong>ACT</strong> therapist wishes to decrease or<br />
the “positive” behaviors he/she wishes to increase;<br />
moreover, the therapist should look at the function of<br />
behavior because events similar in topography may be<br />
<strong>di</strong>ssimilar in function <strong>and</strong> vice versa.<br />
From a theoretical point of view <strong>ACT</strong> is based on Relational<br />
Frame Theory (RFT; 19), a comprehensive theory<br />
of language <strong>and</strong> cognition rooted in basic research, which<br />
states that human language is based on the learned ability<br />
to arbitrarily relate events. Research demonstrated that<br />
human beings can learn things through relational frames,<br />
the core functions of language <strong>and</strong> cognition, without necessarily<br />
<strong>di</strong>rectly having experienced those events (20). By<br />
relational framing humans can bring behavior under the<br />
control of verbal rules (social, cultural, familiar <strong>and</strong> similar<br />
conventions) <strong>and</strong> subtract it from the <strong>di</strong>rect control of<br />
contingencies (what works in the present moment in the<br />
service of what someone values). RFT entails that the<br />
normal verbal processes that allow fragile creatures like<br />
human beings to dominate over the entire world are the<br />
same processes that can make their behavior very narrow,<br />
rigid, maintained <strong>and</strong> governed by socially constructed<br />
verbal rules, rather than by its <strong>di</strong>rect consequences (17).<br />
Therefore, psychological pain inhabits in the normal function<br />
of humans’ language processes (e.g. problem<br />
solving), when those are applied to solve private experiences<br />
(e.g. problematic thoughts, feelings, memories,<br />
body sensations, etc.), rather than to the solution of external<br />
world’s problematic events or situations, lea<strong>di</strong>ng to<br />
experiential avoidance (15, 21).<br />
Experiential Avoidance is any human behavioral pattern<br />
related to the unwillingness to stay in contact with<br />
particular painful private experiences (e.g. unpleasant sensorial<br />
<strong>and</strong> emotional reactions, thoughts <strong>and</strong> memories associated<br />
to this pain, etc.) that has the function to alter the<br />
content <strong>and</strong> frequency of these internal events <strong>and</strong> to avoid<br />
the contexts in which they occur. Human beings tend to<br />
experience language in a very literal way even when it is<br />
used to describe not objective characteristics of the world,<br />
so that the thought or the word of something (e.g. Because<br />
of my chronic <strong>di</strong>sease, if I go out I will feel pain <strong>and</strong> be a<br />
burden to my friends <strong>and</strong> family) takes the place of the actual<br />
thing (e.g. I = burden for friends <strong>and</strong> family), allowing<br />
the literal content of a thought to dominate on the<br />
in<strong>di</strong>vidual behavior (e.g. the person doesn’t go out because<br />
he/she feels to be a burden for others instead of<br />
going out AND verifying if there is or is not something<br />
he/she can do <strong>and</strong> appreciate with the family <strong>and</strong> friends).<br />
It is for those reasons that <strong>ACT</strong> never attempts to <strong>di</strong>rectly<br />
mo<strong>di</strong>fy the content of cognitions, because by doing this<br />
there’s a chance even to increase their literal function (are<br />
they true/false, rational/irrational, real/<strong>di</strong>storted?). Rather,<br />
<strong>ACT</strong> seeks to foster actions in the person’s valued <strong>di</strong>rections,<br />
changing the context (from literality to non-literality)<br />
of those cognitions, so that they are no longer barriers<br />
to these actions, regardless if they are “true” or not.<br />
Hayes et al (17) stated the following as the main implications<br />
of RFT to clinical practice <strong>and</strong> <strong>ACT</strong> interventions:<br />
1) the problem solving process <strong>and</strong> reasoning constantly<br />
going on in humans’ minds involves the same cog-<br />
A55<br />
nitive processes accountable for psychopathology so that<br />
it is not workable to either change or extinguish it, 2) because<br />
thoughts <strong>and</strong> cognitions reflect the person’s learning<br />
history, they can not be permanently mo<strong>di</strong>fied or extinguished,<br />
3) the effort to <strong>di</strong>rectly <strong>and</strong> topographically<br />
change their form or frequency can set a context in which<br />
their literal relevance <strong>and</strong> function can eventually increase,<br />
<strong>and</strong>, 4) it is possible to change internal events’<br />
function (i.e. thoughts, feelings, <strong>and</strong> body sensations, etc.)<br />
as barriers or obstacle changing the context of literality in<br />
which they normally operate, even if they consistently<br />
occur in the same form or frequency.<br />
Clinical <strong>and</strong> Applied Behavior Analysis: the Hexaflex model of <strong>ACT</strong><br />
The main aim of <strong>ACT</strong> is to increase the ability of an<br />
in<strong>di</strong>vidual to persistently pursue goals in his/her valued <strong>di</strong>rections,<br />
using experiential strategies such as metaphors,<br />
paradoxes <strong>and</strong> exercises to undermine the literal function<br />
of language <strong>and</strong> highlight its inadequacy in precisely describing<br />
the actual <strong>di</strong>rect experience. In this way, the therapist<br />
helps the patient experientially to be aware that private<br />
<strong>and</strong> covert part of behaviors (i.e. thoughts, feelings,<br />
body sensations, etc.) are simply words, images <strong>and</strong> physical<br />
reactions that have a specific evolutionary functions,<br />
but are not real <strong>and</strong> bin<strong>di</strong>ng facts.<br />
Accor<strong>di</strong>ng to <strong>ACT</strong> researchers, experiential avoidance<br />
<strong>and</strong> consequent psychological suffering occurs when long<br />
term values <strong>and</strong> meaningful life domains are systematically<br />
deserted in the service of the imme<strong>di</strong>ate relief from<br />
private negative experiences while defen<strong>di</strong>ng one’s conceptualized<br />
self. Driven by these short term purposes the<br />
behavioral patterns narrow <strong>and</strong> drive away the client from<br />
the goals he/she might value. The therapeutic work with<br />
<strong>ACT</strong> takes into account six processes to help the client<br />
reaching a more general goal: psychological flexibility,<br />
conceptualized as the ability of being in contact with the<br />
present moment, with consciousness <strong>and</strong> intention, persisting<br />
in actions or changing them when this is in the service<br />
of what the person values. The six core processes of<br />
the Hexaflex model (fig. 1) are interconnected <strong>and</strong> partially<br />
overlap. As stated above, they don’t represent real<br />
psychological construct, but processes extended on a continuum,<br />
which are accountable both for psychological<br />
flexibility <strong>and</strong> psychopathology. Processes of mindfulness<br />
<strong>and</strong> acceptance (i.e. acceptance, defusion, contact with<br />
the present moment <strong>and</strong> self as a context) lay on the left<br />
part of the Hexaflex, while processes of behavior change<br />
<strong>and</strong> <strong>commitment</strong> (i.e. values, committed action, contact<br />
with the present moment <strong>and</strong> self as a context) are on the<br />
right side (17).<br />
An exhaustive <strong>and</strong> thorough description of the six<br />
Hexaflex processes <strong>and</strong> supportive data from basic research<br />
goes beyond the intent of this paper <strong>and</strong> can be<br />
found elsewhere (15, 19, 21, 22). Briefly summarized the<br />
six <strong>ACT</strong> core processes deal with:<br />
• <strong>Acceptance</strong> (Experiential avoidance): it is the willingness<br />
to make room for <strong>and</strong> embrace the inner unwanted<br />
experiences, leaving the fight against them
A56<br />
Figure 1. The Hexaflex model of <strong>ACT</strong> for psychological flexibility <strong>and</strong> inflexibility<br />
Legend: between brackets are the processes responsible for psychopathology<br />
without attempting to change nor eliminate them; it is<br />
the opposite of Experiential avoidance represented by<br />
those behaviors aimed at flying away form <strong>di</strong>fficult<br />
thoughts, emotions <strong>and</strong> physical sensations.<br />
• Defusion (Fusion): it is the process of <strong>di</strong>stancing from<br />
the literal products of language <strong>and</strong> cognitions<br />
(thoughts, beliefs, memories, words, judgments, etc.),<br />
learned through defusion techniques (metaphors, paradoxes<br />
<strong>and</strong> experiential exercises), to see them for what<br />
they are <strong>and</strong> not as unquestionable truths <strong>and</strong> reasons<br />
for action or inaction; the aim is to bring the person’s<br />
behavior back to the control of <strong>di</strong>rect contingencies<br />
(the five senses) rather than of language.<br />
• Contact with the present moment (conceptualized past<br />
<strong>and</strong> feared future): it refers to be psychologically present<br />
to what is happening in the here <strong>and</strong> now, being<br />
aware of <strong>and</strong> committing to what one is doing <strong>and</strong><br />
living, instead of lingering in a conceptualized past or<br />
being afraid of the future; the aim is to bring the person<br />
in contact non-judgmentally with the environmental<br />
events for what they are.<br />
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
• Self as context (Attachment to a conceptualized self): it is<br />
the process of stepping back from all the definitions <strong>and</strong><br />
the stories about one’s self, without <strong>di</strong>sputing them but<br />
learning to observe them; the propose is to undermine<br />
the definition of the self as a few <strong>and</strong> very narrowing labels<br />
<strong>and</strong> verbal rules that everybody has because of one’s<br />
own past experiences <strong>and</strong> social environment <strong>and</strong> that<br />
can become the only reasons for action or inaction.<br />
• Values (Lack of values clarity): they are what one believes<br />
it is important in his/her <strong>di</strong>fferent life’s domains,<br />
beyond ethical <strong>and</strong> moral <strong>di</strong>ctates; the aim is to bring<br />
the person in contact with personal meaningful <strong>di</strong>rections<br />
that give the person a <strong>di</strong>gnified context for the<br />
therapeutic <strong>and</strong> life <strong>di</strong>fficult experiences.<br />
• Committed action (Inaction, impulsivity, avoidance): it<br />
is the ability of pursuing, or interrupting, behaviors<br />
when this is in the service of the person’s meaningful<br />
<strong>di</strong>rections; many behavioral interventions (e.g. behavioral<br />
activation, skills training, etc.) are used to help<br />
the person in defining <strong>and</strong> planning realistic <strong>and</strong> effective<br />
plans of actions in line with his/her own values.
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
This model is useful in conceptualizing patients with<br />
chronic <strong>di</strong>seases <strong>and</strong> working with them to build psychological<br />
flexibility. One of the crucial aspects is that <strong>ACT</strong><br />
challenges the patient’s avoidance <strong>and</strong> control agenda on<br />
private experiences, confronting the person with his or<br />
her past experience (e.g. Did your control attempts work<br />
in the past <strong>and</strong> brought you towards the things you<br />
value?), helping the patient experiencing how to accept<br />
<strong>and</strong> embrace private experiences in the service of chosen<br />
values. Learning mindfulness <strong>and</strong> defusion behaviors<br />
might offer a realistic alternative to experiential avoidance.<br />
Those might offer these patients <strong>di</strong>fferent contexts<br />
in which these stressful <strong>and</strong> painful internal experiences<br />
related to their illness is looked at, rather than looked<br />
from (e.g. past <strong>and</strong> narrow definitions of the self the patient<br />
is very attached to <strong>and</strong> that now are at risk because<br />
of the limitations due to the <strong>di</strong>sease). Those “now” contexts<br />
may foster the capability to see thinking <strong>and</strong> feeling<br />
as ongoing processes, both useful <strong>and</strong> fallible tools, rather<br />
than unquestionable representations of reality. This is<br />
done without any attempt of reducing or changing the<br />
form <strong>and</strong> the content of those inner events but by undermining<br />
their role as reasons for action or inaction. This is<br />
particularly important for these patients, who have to deal<br />
with chronic <strong>and</strong> physical symptoms. By using experiential<br />
exercises <strong>and</strong> metaphors, informed by the six core<br />
processes of psychological flexibility, the therapist works<br />
to help the client to clarify personally chosen values (e.g.<br />
social interactions, family, work, etc.) that have been neglected<br />
for a long time because of illness-related problems<br />
<strong>and</strong> are re-<strong>di</strong>scovered as <strong>di</strong>gnified context for <strong>commitment</strong><br />
actions (e.g. exposure to physically <strong>and</strong> psychologically<br />
painful activities, such as physio<strong>therapy</strong>, life<br />
styles mo<strong>di</strong>fication, etc.).<br />
<strong>ACT</strong> with physical chronic <strong>di</strong>seases: an overview of the current<br />
empirical evidence <strong>and</strong> assessment tools<br />
<strong>ACT</strong>-based protocols, interventions, <strong>and</strong> assessment<br />
tools have been investigated with <strong>di</strong>fferent chronic <strong>di</strong>seases.<br />
We summarize below the main outcomes <strong>and</strong> assessment<br />
tools. In table I a summary of the controlled<br />
comparison trials with <strong>ACT</strong> in patients affected by physical<br />
chronic <strong>di</strong>seases is reported.<br />
<strong>ACT</strong> oriented assessment tools for chronic <strong>di</strong>seases<br />
The <strong>Acceptance</strong> <strong>and</strong> Action Questionnaire - II (AAQ-<br />
II) (23), is a 10-item self-report measure of psychological<br />
flexibility, conceptualized as a continuum from acceptance<br />
to experiential avoidance, with questions assessing<br />
the ability to stay in contact with emotions without behaving<br />
in order to get rid of them; there is also an AAQ-II<br />
Italian version (24). The AAQ (nine-item version) (25) has<br />
been used also in me<strong>di</strong>cal rehabilitation settings with patients<br />
with spinal cord dysfunction, stroke, amputation, or<br />
orthope<strong>di</strong>c surgery, <strong>and</strong> data support that it is a reliable<br />
<strong>and</strong> valid measure also in me<strong>di</strong>cal populations <strong>and</strong> that<br />
avoidance plays an important role in rehabilitation outcomes<br />
(26). So far, <strong>di</strong>fferent versions of this questionnaire<br />
A57<br />
are available for assessing psychological flexibility <strong>and</strong><br />
acceptance-experiential avoidance process related to<br />
many <strong>di</strong>fferent health con<strong>di</strong>tions, specifically:<br />
• <strong>Acceptance</strong> <strong>and</strong> Actions Diabetes Questionnaire<br />
(AADQ) (27), an 11-item Likert-type self-report scale<br />
(Cronbach’s α = .94), which measures acceptance of<br />
<strong>di</strong>abetes-related thoughts <strong>and</strong> feelings <strong>and</strong> the degree<br />
to which they interfere with valued action.<br />
• Diabetes <strong>Acceptance</strong> <strong>and</strong> Action Scale (DAAS) (28), a<br />
42-item Likert-type self-report scale that is used to in<strong>di</strong>cate<br />
levels of psychological flexibility in youth with<br />
type 1 <strong>di</strong>abetes. The authors are still in the process of<br />
collecting psychometric data.<br />
• <strong>Acceptance</strong> <strong>and</strong> Action Epilepsy Questionnaire<br />
(AAEpQ) (29), an 8-item Likert-type self-report scale<br />
for epilepsy related problems (Cronbach’s α = .65-.76;<br />
these alpha values are considered acceptable for a<br />
scale in early use, particularly one with few items).<br />
• Chronic Pain <strong>Acceptance</strong> Questionnaire (CPAQ) (30),<br />
a 20-item Likert-type self-report scale, which has two<br />
subscales that assess activity engagement (11items) <strong>and</strong><br />
pain willingness (9 reversed-key items). The subscales<br />
<strong>and</strong> total scale are internally consistent (Cronbach’s α<br />
= .78-.82) <strong>and</strong> reliably pre<strong>di</strong>ct patient functioning. The<br />
questionnaire is also validated in Italian language (31).<br />
• <strong>Acceptance</strong> <strong>and</strong> Action Questionnaire for Weight-Related<br />
Difficulties (AAQW) (32), a 22 items Likert-type<br />
self-report scale, designed to measure acceptance of<br />
weight-related feelings, defusion from weight related<br />
thoughts, <strong>and</strong> the degree to which thoughts <strong>and</strong> feelings<br />
interfere with valued action. The mean score for<br />
the sample was 88.9 (sd = 19.8, range 49 to 124) <strong>and</strong><br />
the internal consistency is good (Cronbach’s α = .88).<br />
• Psychological Inflexibility in Pain Scale (PIPS) (33): a<br />
12-item Likert-type self-report instrument to assess psychological<br />
inflexibility in people with chronic pain.<br />
Analyses support the reliability <strong>and</strong> vali<strong>di</strong>ty of a two factors<br />
solution: the avoidance subscale (8 items) measuring<br />
the tendency to engage in behaviors that lead to avoid<br />
pain <strong>and</strong> related <strong>di</strong>stress, <strong>and</strong> the cognitive fusion subscale<br />
(4 items) assessing the experience of thoughts as if<br />
they were true. The questionnaire demonstrates good internal<br />
consistencies (Cronbach’s α = .87 for the total<br />
scale, .89 <strong>and</strong> .66 for the two subscales respectively).<br />
<strong>ACT</strong> <strong>and</strong> <strong>di</strong>abetes<br />
Diabetes is a chronic illness entailing a high risk of<br />
<strong>di</strong>sability <strong>and</strong> death, when life styles are not adjusted <strong>and</strong><br />
the adherence to me<strong>di</strong>cal treatments is low or not regular.<br />
Interventions aimed to manage <strong>di</strong>abetes-related <strong>di</strong>stress<br />
may help people in dealing with its emotional challenges<br />
<strong>and</strong> to improve self-management skills.<br />
Gregg et al (27) r<strong>and</strong>omly assigned 81 type-II <strong>di</strong>abetes<br />
patients to a 7 hours education group (n = 38, following a<br />
patient education manual; 34) <strong>and</strong> to a group where education<br />
(same as above but in an abbreviated 4 hours form)<br />
was associated with a mindfulness <strong>and</strong> acceptance training<br />
on <strong>di</strong>fficult thoughts <strong>and</strong> feelings about <strong>di</strong>abetes, an exploration<br />
of personal values related to <strong>di</strong>abetes, <strong>and</strong> a<br />
focus on the ability to act in a valued <strong>di</strong>rection while con-
A58<br />
Study<br />
tacting <strong>di</strong>fficult experiences (n = 43) (35). At three months<br />
follow up, in the group where 3 of the 7 hours <strong>di</strong>abetes<br />
workshop were focused on <strong>ACT</strong> processes, patients reported<br />
<strong>di</strong>abetes self-management improved significantly<br />
more (Mann-Whitney U = 331.5, z = -2.40, p
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
17.2% loss, SD = 4.49) between baseline <strong>and</strong> post-treatment<br />
<strong>and</strong> an average of 9.6% (range = 4.5% gain to 25.9%<br />
loss, SD = 7.34) after six months. Further, participants’<br />
ratings of the extent to which their weight was having a<br />
negative impact on their quality of life (measured by the<br />
Impact of Weight on Quality of Life-Lite; IWQOL-Lit)<br />
(40) decreased significantly from baseline (M = 61.13) to<br />
both post-treatment (M = 47.56, t = 5.83, p
A60<br />
.043). The study, though conducted with a small sample of<br />
patients <strong>and</strong> for a short period of observation, nevertheless<br />
provides preliminary evidence of the efficacy of a short (4<br />
hours) <strong>ACT</strong> intervention in preventing sick-leave <strong>and</strong><br />
me<strong>di</strong>cal access in people with chronic pain. Moreover,<br />
further stu<strong>di</strong>es are needed to clarify the putative change<br />
processes, also analyzing the separate contribution of the<br />
<strong>di</strong>fferent therapeutic components.<br />
McCracken et al (49) followed 108 chronic pain patients<br />
with a long history of treatment (average 10 years)<br />
through an <strong>ACT</strong>-based 3-4 weeks residential treatment<br />
program. In this multi-<strong>di</strong>sciplinary <strong>and</strong> intensive protocol<br />
physiotherapists, occupational therapists, nurses, physicians,<br />
<strong>and</strong> psychologists all worked together on an <strong>ACT</strong>based<br />
program delivered approximately 6 hours a day,<br />
with daily in<strong>di</strong>vidual psychological sessions. The program<br />
included exposures <strong>and</strong> explicitly targeted the role of feelings<br />
<strong>and</strong> thoughts as reasons for action (or inaction),<br />
without attempting to change the form or reduce the frequency<br />
of the feared internal experiences. In the run-in period<br />
measures improved from initial assessment to pretreatment<br />
on average only by 3% (average of 3.9 month<br />
wait), but improved on average by 34% following treatment.<br />
81% of these gains were maintained at 3 months<br />
follow up. Further, positive changes in acceptance of pain<br />
measured by the CPAQ co-varied with improvement in<br />
depression, pain related anxiety, physical <strong>di</strong>sability, psychosocial<br />
<strong>di</strong>sability, <strong>and</strong> the ability to st<strong>and</strong>. Positive outcomes<br />
were also seen in a timed walk, decreased me<strong>di</strong>cal<br />
visits, daily rest due to pain, pain intensity, <strong>and</strong> decreased<br />
pain me<strong>di</strong>cation use. Although there was no r<strong>and</strong>omization<br />
to treatment, the waiting period of each subject before<br />
treatment worked as his/her own comparison con<strong>di</strong>tion.<br />
McCracken et al (50) also compared the impact of an<br />
intensive <strong>and</strong> multi-<strong>di</strong>sciplinary three-week treatment<br />
(total time 80h, inclu<strong>di</strong>ng principles of exposure, acceptance,<br />
cognitive defusion, mindfulness, <strong>and</strong> values based<br />
approaches) with two groups of highly <strong>di</strong>sabled (n = 53)<br />
<strong>and</strong> st<strong>and</strong>ard patients (n = 234) with chronic pain. The<br />
highly <strong>di</strong>sabled patients showed significant changes (t-test<br />
p
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
found at post-intervention (F(1,170) = 50.16, p
A62<br />
12) Linehan MM. Cognitive-behavioral treatment of borderline personality<br />
<strong>di</strong>sorder. New York: Guilford Press, 1993.<br />
13) Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive<br />
<strong>therapy</strong> for depression: A new approach to preventing relapse. New<br />
York: Guilford Press, 2001.<br />
14) Tsai M, Kohlenberg RJ, Kanter JW, Kohlenberg B, Follette WC,<br />
Callaghan GM. A Guide to functional analytic psycho<strong>therapy</strong>: awareness,<br />
courage, love, <strong>and</strong> behaviorism. New York: Springer, 2008.<br />
15) Hayes SC, Strosahl KD, Wilson KG. <strong>Acceptance</strong> <strong>and</strong> <strong>commitment</strong><br />
<strong>therapy</strong>: an experiential approach to behavior change. New York:<br />
Guilford Press, 1999.<br />
16) Moderato P, Presti G, Chase PN, e<strong>di</strong>tors. Pensieri, parole e comportamento:<br />
un’analisi funzionale delle relazioni linguistiche. Milano:<br />
McGraw-Hill; 2002.<br />
17) Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. <strong>Acceptance</strong> <strong>and</strong><br />
<strong>commitment</strong> <strong>therapy</strong>: Model, processes <strong>and</strong> outcomes. Behav Res<br />
Ther 2006; 44: 1-25.<br />
18) Wilson KG, DuFrene T. Mindfulness for Two: An <strong>Acceptance</strong> <strong>and</strong><br />
Commitment Therapy Approach to Mindfulness in Psycho<strong>therapy</strong>.<br />
Oakl<strong>and</strong>, CA: New Harbinger, 2009.<br />
19) Hayes SC, Barnes-Holmes D, Roche B, e<strong>di</strong>tors. Relational frame<br />
theory: a post Skinnerian account of human language <strong>and</strong> cognition.<br />
New York: Plenum Press, 2001.<br />
20) Dougher MJ, Hamilton DA, Fink BC, Harrington J. Transformation<br />
of the <strong>di</strong>scriminative <strong>and</strong> eliciting functions of generalized relational<br />
stimuli. J Exp Anal Behav 2007; 88: 179-97.<br />
21) Hayes SC, Smith S. Get out of your mind <strong>and</strong> into your life: The new<br />
<strong>Acceptance</strong> <strong>and</strong> Commitment Therapy. Oakl<strong>and</strong>, CA: New<br />
Harbinger; 2005. [Tr. It. Smetti <strong>di</strong> soffrire, inizia a vivere. Impara a<br />
superare il dolore emotivo, a liberarti dai pensieri negativi e vivi una<br />
vita che vale la pena <strong>di</strong> vivere. Milano: Franco Angeli, 2010].<br />
22) Harris R. <strong>ACT</strong> Made Simple: An Easy-To-Read Primer on <strong>Acceptance</strong><br />
<strong>and</strong> Commitment Therapy. Oakl<strong>and</strong>, CA: New Harbinger,<br />
2009.<br />
23) Hayes S. <strong>Acceptance</strong> <strong>and</strong> Action Questionnaire - II (AAQ-II) [internet].<br />
2009 [cited 2009 Dec 27]. Available from: http: //contextualpsychology.org/acceptance_action_questionnaire_aaq_<strong>and</strong>_variations.<br />
24) Moderato P, Presti G, Miselli G, Rabitti E. Linking clinical <strong>and</strong> academic<br />
research in Italy: Italian version <strong>and</strong> validation research project<br />
of the <strong>Acceptance</strong> <strong>and</strong> Action Questionnaire. Paper presented at:<br />
The <strong>ACT</strong> Summer Institute IV; 2008 May 28-30; Chicago, USA.<br />
25) Hayes SC, Strosahl KD, Wilson KG, Bissett RT, Pistorello J,<br />
Toarmino D, Polusny MA, Dykstra TA, Batten SV, Bergan J, Stewart<br />
SH, Zvolensky MJ, Eifert GH, Bond FW, Forsyth JP, Karekla M,<br />
McCurry SM. Measuring experiential avoidance: a preliminary test<br />
of a working model. Psychol Rec 2004; 54: 553-78.<br />
26) Kortte KB, Veiel L, Batten SV, Wegener ST. Measuring avoidance in<br />
me<strong>di</strong>cal rehabilitation. Rehabil Psychol 2009; 54: 91-8.<br />
27) Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL. Improving<br />
<strong>di</strong>abetes self-management through acceptance, mindfulness, <strong>and</strong><br />
values: A r<strong>and</strong>omized controlled trial. J Consult Clin Psychol 2007;<br />
75: 336-43.<br />
28) Greco L, Hayes, SC, e<strong>di</strong>tors. <strong>Acceptance</strong> <strong>and</strong> mindfulness treatments<br />
for children <strong>and</strong> adolescents: A practitioner’s guide. Oakl<strong>and</strong>:<br />
New Harbinger; 2008.<br />
29) Lundgren T, Dahl J, Hayes, SC. Evaluation of me<strong>di</strong>ators of change<br />
in the treatment of epilepsy with <strong>Acceptance</strong> <strong>and</strong> Commitment<br />
Therapy. J Behav Med 2008; 31: 225-35.<br />
30) McCracken LM, Vowles KE, Eccleston C. <strong>Acceptance</strong> of chronic<br />
pain: Component analysis <strong>and</strong> a revised assessment method. Pain<br />
2004; 107: 159-66.<br />
31) Bernini O, Pennato T, Cosci F, Berrocal C. The psychometric properties<br />
of the Chronic Pain <strong>Acceptance</strong> Questionnaire revisited<br />
among Italian patients with chronic pain. J Health Psychol 2010; 15:<br />
1236-45.<br />
32) Lillis J, Hayes SC. Measuring avoidance <strong>and</strong> inflexibility in weight<br />
related problems. Int J Behav Consult Ther 2008; 4: 348-54.<br />
33) Wicksell RK, Lek<strong>and</strong>er M, Sorjonen K, Olsson GL. The Psychological<br />
Inflexibility in Pain Scale (PIPS) - Statistical properties <strong>and</strong><br />
model fit of an instrument to assess change processes in pain related<br />
<strong>di</strong>sability. Eur J Pain 2010; doi: 10.1016/j.ejpain.2009.11.015.<br />
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
34) Callaghan GM, Gregg JA, Ortega E, Berlin K. Psychosocial interventions<br />
with patients with type 1 <strong>and</strong> 2 <strong>di</strong>abetes. In: O’Donohue<br />
WT, Byrd M, Henderson D, Cummings N, eds. Behavioral integrative<br />
care: treatments that work in the primary care setting. New<br />
York: Brunner-Routledge, 2005: 323-39.<br />
35) Gregg J, Callaghan G, Hayes SC. The <strong>di</strong>abetes lifestyle book:<br />
Facing your fears <strong>and</strong> making changes for a long <strong>and</strong> healthy life.<br />
Oakl<strong>and</strong>, CA: New Harbinger; 2007.<br />
36) Lundgren T, Dahl J, Melin L, Kies B. Evaluation of acceptance <strong>and</strong><br />
<strong>commitment</strong> <strong>therapy</strong> for drug refractory epilepsy: a r<strong>and</strong>omized controlled<br />
trial in South Africa - a pilot study. Epilepsia 2006; 47: 2173-79.<br />
37) Lundgren T, Dahl J, Yar<strong>di</strong> N, Melin J. <strong>Acceptance</strong> <strong>and</strong> Commitment<br />
Therapy <strong>and</strong> Yoga for drug refractory epilepsy: a r<strong>and</strong>omized controlled<br />
trial. Epilepsy Behav 2008; 13: 102-8.<br />
38) World Health Organization Global Report. Preventing chronic <strong>di</strong>seases:<br />
a vital investment. Geneva: World Health Organization; 2005.<br />
39) Forman M, Butryn ML, Hoffman KL, Herbert JD. An Open Trial of<br />
an <strong>Acceptance</strong>-Based Behavioral Intervention for Weight Loss.<br />
Cogn Behav Pract 2008. doi: 10.1016/j.cbpra.2008.09.005.<br />
40) Kolotkin RL, Crosby RD. Psychometric evaluation of the Impact of<br />
Weight on Quality of Life-lite questionnaire (IWQOL-lite) in a<br />
community sample. Qual Life Res 2002; 11: 157-71.<br />
41) Tapper K, Shaw C, Ilsley J, Hill AJ, Bond FW, Moore L. Exploratory<br />
r<strong>and</strong>omised controlled trial of a mindfulness-based weight loss intervention<br />
for women. Appetite 2009; 52: 396-404.<br />
42) Smith BJ, Marshall AL, Huang N. Screening for physical activity in<br />
family practice. Evaluation of two brief assessment tools. Am J Prev<br />
Med 2005; 29: 256-64.<br />
43) Lillis J, Hayes SC, Bunting K, Masuda A. Teaching acceptance <strong>and</strong><br />
mindfulness to improve the lives of the obese: a preliminary test of<br />
a theoretical model. Ann Behav Med 2009; 37: 58-69.<br />
44) Lillis J. <strong>Acceptance</strong> <strong>and</strong> Commitment Therapy for the treatment of<br />
obesity-related stigma <strong>and</strong> weight control. [PhD thesis]. Reno, NV:<br />
University of Nevada, 2007.<br />
45) Mannucci E, Ricca V, Barciulli E, Di Bernardo M, Travaglini R,<br />
Cabras PL, Rotella CM. Quality of life <strong>and</strong> overweight: the obesity<br />
related well-being (Orwell 97) questionnaire. Ad<strong>di</strong>ct Behav 1999;<br />
24: 345-57.<br />
46) Goldberg DP. The detection of psychiatric illness by questionnaire.<br />
London: Oxford University Press; 1972.<br />
47) Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk, DC. The biopsychosocial<br />
approach to chronic pain: scientific advances <strong>and</strong> future<br />
<strong>di</strong>rections. Psychol Bull 2007; 133: 581-624.<br />
48) Dahl, JC, Wilson KG, Nilsson A. <strong>Acceptance</strong> <strong>and</strong> Commitment<br />
Therapy <strong>and</strong> the treatment of persons at risk for long-term <strong>di</strong>sability<br />
resulting from stress <strong>and</strong> pain symptoms: a preliminary r<strong>and</strong>omized<br />
trial. Behav Ther 2004; 35: 785-802.<br />
49) McCracken LM, Vowles KE, Eccleston C. <strong>Acceptance</strong>-based treatment<br />
for persons with complex, long-st<strong>and</strong>ing chronic pain: A preliminary<br />
analysis of treatment outcome in comparison to a waiting<br />
phase. Behav Res Ther 2005; 43: 1335-46.<br />
50) McCracken LM, MacKichan F, Eccleston C. Contextual cognitivebehavioral<br />
<strong>therapy</strong> for severely <strong>di</strong>sabled chronic pain sufferers: effectiveness<br />
<strong>and</strong> clinically significant change. Eur J Pain 2007; 11:<br />
314-22.<br />
51) Wicksell RK, Melin L, Olsson GL. Exposure <strong>and</strong> acceptance in the<br />
rehabilitation of adolescents with i<strong>di</strong>opathic chronic pain - A pilot<br />
study. Eur J Pain 2007; 11: 267-74.<br />
52) Wicksell RK, Melin L, Lek<strong>and</strong>er M, Olsson GL. Evaluating the effectiveness<br />
of exposure <strong>and</strong> acceptance strategies to improve functioning<br />
<strong>and</strong> quality of life in longst<strong>and</strong>ing pe<strong>di</strong>atric pain - A r<strong>and</strong>omized<br />
controlled trial. Pain 2009; 141: 248-57.<br />
53) Slater MA, Hall HF, Atkinson JH, Garfin SR. Pain <strong>and</strong> impairment<br />
beliefs in chronic low back pain: validation of the pain <strong>and</strong> impairment<br />
relationship scale (PAIRS). Pain 1991; 44: 51-6.<br />
54) Swinkels-Meewisse EJ, Swinkels RA, Verbeek AL, Vlaeyen JW,<br />
Oostendorp RA. Psychometric properties of the Tampa Scale for kinesiophobia<br />
<strong>and</strong> the fearavoidance beliefs questionnaire in acute low<br />
back pain. Man Ther 2003; 8: 29-36.<br />
55) Ware Jr JE, Sherbourne CD. The MOS 36-item short-form health<br />
survey (SF-36). Conceptual framework <strong>and</strong> item selection. Med<br />
Care 1992; 30: 473-83.
G Ital Med Lav Erg 2011; 33:1, Suppl A, Psicol<br />
http://gimle.fsm.it<br />
56) Wicksell RK, Ahlqvist J, Bring A, Melin L, Olsson GL. Can exposure<br />
<strong>and</strong> acceptance strategies improve functioning <strong>and</strong> life satisfaction in<br />
people with chronic pain <strong>and</strong> whiplash-associated <strong>di</strong>sorders (WAD)?<br />
A r<strong>and</strong>omized controlled trial. Cogn Behav Ther 2008; 37: 169-82.<br />
57) Söderlund A, Lindberg P. Cognitive behavioural components in<br />
physio<strong>therapy</strong> management of chronic whiplash associated <strong>di</strong>sorders<br />
(WAD) - a r<strong>and</strong>omised group study. G Ital Med Lav Ergon 2007;<br />
29(1 Suppl A): A5-11.<br />
58) Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The Pain<br />
Disability Index: psychometric <strong>and</strong> vali<strong>di</strong>ty data. Arch Phys Med Rehabil<br />
1987; 68: 438-41.<br />
59) Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With<br />
Life Scale. J Pers Assess 1985; 49: 71-75.<br />
60) Zigmond AS, Snaith RP. The hospital anxiety <strong>and</strong> depression scale.<br />
Acta Psychiatr Sc<strong>and</strong> 1983; 67: 361-70.<br />
61) Vowles KE, McCracken LM. <strong>Acceptance</strong> <strong>and</strong> values-based action in<br />
chronic pain: A study of treatment effectiveness <strong>and</strong> process. J Consult<br />
Clin Psychol, 2008; 76, 397-407.<br />
A63<br />
62) Johnston M, Foster M, Shennan J, Starkey NJ, Johnson A. The Effectiveness<br />
of an <strong>Acceptance</strong> <strong>and</strong> Commitment Therapy Self-help<br />
Intervention for Chronic Pain. Clin J Pain, 2010; 26: 393-402.<br />
63) Vowles KE, McNeil W, Gross RT, McDaniel ML, Mouse A, Bates<br />
M, Gallimore P, McCall C. Effects of pain acceptance <strong>and</strong> pain control<br />
strategies on physical impairment in in<strong>di</strong>viduals with chronic<br />
low back pain. Behav Ther 2007; 38: 412-25.<br />
64) Vowles KE, Wetherell JL, Sorrell JT. Targeting acceptance, mindfulness,<br />
<strong>and</strong> values-based action in chronic pain: Fin<strong>di</strong>ngs of two preliminary<br />
trials of an outpatient group-based intervention. Cogn<br />
Behav Pract 2009; 16: 49-58.<br />
65) Kendel F, Gelbrich G, Wirtz M, Lehmkuhl E, Knoll N, Hetzer R, Regitz-Zagrosek<br />
V. Pre<strong>di</strong>ctive relationship between depression <strong>and</strong><br />
physical functioning after coronary surgery. Arch Intern Med 2010;<br />
170: 1717-21.<br />
66) Bianconi G, Poggioli E, Merelli E, Razzaboni E, Comelli D. Aspetti<br />
psicologici della sclerosi multipla. [Psychological issues related to<br />
multiple sclerosis]. G Ital Med Lav Ergon 2006; 28(1 Suppl 1): 22-8.<br />
Reprint request: Anna Bianca Preve<strong>di</strong>ni - Istituto Comunicazione, Comportamento e Consumi, Università IULM-Milano, Via C. Bò<br />
1/2, 21143 Milano, Italy - Cell.: +39 347 9305235, E-mail: annapreve<strong>di</strong>ni@gmail.com