Association for Contextual Behavioral Science

Gutierrez, O., Luciano, M. C., Rodríguez. M., & Fink. B. (2004). Comparison between an Acceptance-based and a Cognitive-Control-Based Protocol for coping with pain. Behavior Therapy, 35, 767-783. PROTOCOLS FROM GUTIÉRREZ ET AL. (2004) STUDY A) INSTRUCTIONS GIVEN TO ALL SUBJECTS BEFORE GOING TO TEST 1 IN THE PAIN TASK. “ This one is an study about pain and the strategies for coping pain. First, we would like to thank you for your participation because it is indispensable for our research. This one intends to help people who suffer with highly disabled pain, so your collaboration in this preliminary study is very important to do further studies where patients who suffer natural pain will participate. For this reason, the experimental procedures that we are using will be unpleasant because the only way to find out what strategies are useful for people suffering is to do a research where participants have an unpleasant time. Are you willing?... The study involves receiving an electric shock at different times. Every security measures have been adopted. The study lasts approximately two hours and it is important if you are willing to participate. Are you agreed?...” (If participant agreed, he should sign a informed consent form for research -available by requesting from the authors- where experimenter declared her commitment to adhere to ethical guidelines in their dealings with participants and the collection and handling of data and the participant was informed about: a) the general nature of the study; b) his/her right to withdraw from the study at any time; c) no risks associated with participation; d) confidentiality to treat all data. Then, participants were given specific written instructions about the pain task that included information about the matching-to-sample-trials, b) the choices that participants could make when the red asterisk was presented, c) the duration and frequency of electric shocks, d) tokens and rewards that the participants would receive for continued participation. When participants read the instructions, the experimenter said…) “ You must remember that we want to find out what people may do when they suffer pain so it is very important you maintain yourself in the task all time that you can. Perhaps, the task is monotonous, boring and not a bit creative but its purpose is just to reproduce the conditions of people who suffer non-continuous pain and they must work or do other things that they do not like. We seek to study the coping strategies that may be helpful for these people who live under those conditions. Do you know some people who suffer with pain and live under these conditions? ... Have you ever gone through a similar situation?... Besides, you should remember that the more tokens you accumulate, better rewards you can get. Please, come with me to the rewards room. (In the rewards room) As you can see, there are three categories of rewards depending of its “price” in tokens (A, B, C). Now, you cannot know how many tokens you need to choose one reward. The only thing that for the moment I can say you is that a reward in Category A need more tokens than a reward in Category B and than Category C. When you finish all the procedure, come to this room and you can exchange the accumulated tokens” Participants answered some questions regarding the understanding of the pain task instructions given so far. If everything had been understood properly, the participant started the pain task (TEST 1) INSTRUCTIONS GIVEN TO ALL SUBJECTS BEFORE GOING TO TEST 2 IN THE PAIN TASK “ ... Now, I am teaching you some strategies for coping with pain-related thoughts and feelings so you can use them when you perform the second Pain Task in some minutes, ok? Our minds sometimes tell us things that are helpful. For example, if I want to go to the town hall, my mind tell me that I must turn to the right, then to the left... and I finally reach my purpose: to arrive to the town hall. But, our minds sometimes tell us things that move ourselves away the important things for us. For example, imagine a person who is about to do an important conference but s/he starts to think: “I am not able, I do not remember anything, I am very anxious, I will mistake, etc. and s/he finally decided not to do the conference. See it with more examples. Perhaps, you have had different pain-related thoughts and feelings while you performed the first Pain Task (It is too painful, this task has not any sense, it is boring, I am afraid for the shocks, etc.) and you have decided not to receive more shocks and not to continue with the task. The thing is that something different can be done with our thoughts and feelings… Just now, we are going to practice in that direction …” SPECIFIC PROTOCOL FOR THE ACT-BASED CONDITION BEFORE GOING TO TEST 2 - “I can’t get up” exercise (based on cards exercise in Hayes, Strosahl & Wilson, 1999, p. 162) Tell me a thought that showed up when you decided to quit the Pain-Task and thus to avoid receiving any more shocks... (the thought is written on a piece of paper in capital letters, and the paper is then left aside on the table; this is done twice more, with another two thoughts; after that, the participant is given a folded piece of paper with a sentence written on it, though they can’t read it). Imagine that this (folded paper) were a thought you had. Now, with that thought in your hand, please get up and walk around the room... Now you can sit down. Please read whatever is written on that piece of paper (on the folded paper the participant could read ‘I can’t get up’). Then, is it possible to continue with the Pain-Task though you think that...? (they take the first paper written by the participant and read the thought written on it). Is it possible for you to think (they take the second paper-thought of the participant and read its content) and to keep yourself performing the Pain Task? ...Is it possible to have the thought of... (they take the third paper-thought and read it) and continue performing the task while having that thought...? The thing is you can keep performing the Pain-Task and thus get more tokens just by noticing the thoughts that show up and all the distress they carry with them... Whatever thoughts show up, no matter how much distress you feel, you can keep performing the Pain-Task... you can act in a certain way even though you have thoughts you don’t like... - The “dirty swamp” metaphor (Hayes, Strosahl, et al., 1999, pp. 247-248) ‘Imagine that the only way to reach something that’s important for you is to go across a swamp full of dirt, rubbish, leftovers, that smells so badly, that really stinks... to go across the swamp and arrive at the other shore. What kind of thoughts do you think that are going to appear in such a situation? ...It’s likely that thoughts like “I can’t stand this”, “This s unbearable”, “I can’t do anything so unpleasant and disgusting”, “It’s not worth the effort, it’s nonsense”...The best way you could possibly cross the swamp would be to notice all those thoughts and the distress they carry with them and let them be, to notice them and make room for them while you keep crossing the swamp... It’s about being open to all the thoughts that may show up and the distress associated to them, about carrying them with you while you keep doing what’s important in that moment: crossing the swamp and reaching the other shore... Notice all the thoughts that show up while you perform the Pain-Task and carry them with you, because you can have whatever thoughts and act differently to what you think or feel...’ SPECIFIC PROTOCOL FOR THE COGNITIVE-CONTROL-BASED CONDITION BEFORE GOING TO TEST 2. - Distraction exercise. It has been proved that trying to distract oneself and to think of other things is an effective way of dealing with our negative feelings and thoughts (e.g. thoughts related to pain, distress...). Right now, what you are going to do is to learn a strategy in order to eliminate the thoughts related to pain and distress that appear while you are performing the Pain-Task, so that you can keep performing it for longer, and thus obtain more tokens. For instance, whenever these thoughts appear, you can try to focus in a pleasant scene that you lived in your past, and so continue with the Pain-Task. Now I want you to think of that scene of your life. I will help you to imagine it and to place yourself there so that later, while performing the Pain-Task, you can focus on it easily. Please, close your eyes and raise your finger when you’ve got that situation. Now, notice where you were in that situation... Notice what you were doing... Focus on how well you were feeling then, notice the clothes you were wearing... (This exercise took place for 3 minutes, from the moment when the subject raised their finger; after those 3 minutes...) Now you can open your eyes. What you have to do when you perform the Pain-Task is to distract yourself with either this scene or with another pleasant scene, in order to avoid thinking of pain, and thus to continue in the task for longer and to obtain more tokens... Let’s practice this exercise... Tell me what you were thinking of when you decided to stop with the Pain-Task and thus to avoid receiving any more shocks. Please, evoke that thought and try to distract yourself with the scene we’ve been practicing or with another pleasant scene... Has it been difficult? ...Tell me another thought you had while doing the task... Try to evoke it and then try again to distract yourself with a pleasant scene... Finally, tell me another thought of that sort and try to distract yourself with the pleasant scene... Did you have any problems to do that? ...The thing is that you can continue with the Pain-Task if you try to eliminate your negative thoughts and the distress they carry with them, and you can distract yourself with different thoughts and pleasant scenes. - The “dirty swamp” metaphor. ‘Imagine that the only way to reach something that’s important for you is to go across a swamp full of dirt, rubbish, leftovers, that smells so badly, that really stinks... to go across the swamp and arrive at the other shore. What kind of thoughts do you think that are going to appear in such a situation? ...It’s likely that thoughts like “I can’t stand this”, “This s unbearable”, “I can’t do anything so unpleasant and disgusting”, “It’s not worth the effort, it’s nonsense”...The best way you could possibly cross the swamp would be to try to think of more pleasant things, to imagine, for instance, that you are in a lovely landscape, and meanwhile to keep crossing the swamp... It’s about removing distress and unpleasant thoughts, and thinking of more positive things, so that you can do what you have to: cross the swamp and reach the other side... Whilst you’re performing the Pain-Task, try to remove pain-related thoughts that show up and think of more pleasant things, positive things, because those thoughts will help you to keep performing the task... As shown, both experimental protocols were equal in: (a) rhetoric components (both involved initial examples, one metaphor and one exercise), (b) duration (near 20 minutes), (c) number of instructions concerning the acceptance vs. control-based strategies, (d) number of opportunities to practice the strategies, (e) number of connections between participant’s pain-related thoughts in the first Pain-Task and the components of the protocols and (f) the number of instructions given to encourage continuation in the second pain task for as long as possible. MESSAGES DELIVERED DURING PERFORMANCE (THROUGH THE HEADPHONES) IN THE SECOND PAIN-TASK (POST-TEST). * Messages delivered to the participants in the ACT condition. - You can keep performing the task regardless of whatever thoughts you have while doing it. - Whatever thoughts show up, notice them and let them stay. - Remember that you can make room for your thoughts and act differently to what they tell you. - Notice all the thoughts that show up and carry them with you. - Remember that having certain thoughts doesn’t imply acting in accordance with them. * Messages delivered to the participants in the COGNITIVE-CONTROL condition. - You can keep performing the task by distracting yourself and thinking of positive things. - Try to focus in positive thoughts or images. - Remember that if you think of pleasant and positive things you’ll be able to act in the direction you want. - Try to distract yourself with pleasant thoughts or images. - Focus in a pleasant scene of your life and you’ll be able to keep performing the task.