Contextual Cognitive-Behavioral Therapy for Chronic Pain, 2005

McCracken LM. Contextual Cognitive-Behavioral Therapy for Chronic Pain, 2005. IASP Press, Seattle, Washington. ISBN 0-931092-83-3; 148 pages; $67.00.

Many people with chronic pain develop elaborate strategies to control their pain. These often involve avoidance of thoughts, activities and experiences that have been associated with increased pain or distress in the past. Paradoxically, in the long run, these strategies can restrict life enjoyment and the pursuit of meaningful goals. In the extreme, avoidance of pain can become one of the major organizing principles of daily life. This provocative new book argues that a more promising approach may be to help people with chronic, refractory pain create and experience meaningful, value-based lives despite ongoing pain. This is a powerful thesis, yet it is easy to imagine many patients and psychotherapists balking at it in favour of more traditional approaches which focus on pain control. However, as is cogently argued, waiting for complete pain relief before pursuing life goals may be unrealistic for many patients and may contribute to ongoing distress.

Dr Lance McCracken is a Consultant Clinical Psychologist and Clinical Lead of the Pain Management Unit, Royal National Hospital for Rheumatic Diseases, Bath, United Kingdom. He is the sole author of this slim volume (148 pages) in the Progress in Pain Research and Management Series. Without question, Eh- McCracken is the leading authority on the acceptance of pain. In this volume, he brings together several years of clinical and research experience on psychological approaches to pain and acceptance of pain to propose a shift from traditional cognitive behavioural pain management towards a more integrated, contextually based approach. The first chapter of the book describes the magnitude of the problem of chronic pain and highlights the need for multidisciplinary intervention. Several chapters follow which provide an excellent overview of behavioural and cognitive behavioural theories and management strategies. The second half of the book outlines the author's functional contextualist approach which he describes as an integration of some of the key features of opérant and cognitive behavioural approaches with new features such as acceptance, mindfulness, spirituality, self and willingness.

The theoretical description is supplemented with discussion of various treatment goals and group therapy techniques. However, the volume is not a treatment manual, so implementation and clinical scenarios are not described in detail. The line between describing a psychotherapeutic approach and providing a treatment manual is blurred at times; for instance, when patient activity sheets are provided. Nonetheless, it is my opinion that the complexity of this approach would require specialized training - for instance, in mindfulness meditation - and that the information provided irt the book is insufficient to allow adoption as a therapeutic tool. Ample references to empirically supported treatments, such as Acceptance and| Commitment Therapy, which inform the proposed approach are provided.

As a pain psychotherapist and researcher and a student of insight meditation, there are many additional topics that I would have liked to see Dr McCracken tackle. For instance, he focuses only on adults with chronic, nonmalignant pain; it would have been interesting to consider how the approach could be tailored to special groups including adolescents, the elderly and those with progressive disease. In addition, there is only superficial consideration of the role of the therapeutic relationship and little discussion of working with family members. Developing a new relationship with one's pain and letting go of many years' avoidance and control undoubtedly trigger changes throughout the patient's life, both positive and negative, but this issue is not addressed. Perhaps I am asking too much from a book that introduces a new approach and instead will look forward to these topics being addressed as the approach matures.

On the whole, I found Dr McCracken's book to be a valuable, thought-provoking resource. It is very well written, and the author's compassion for and understanding of people with chronic pain is evident. I highly recommend it to anyone involved in the psychology of chronic pain, whether in research or the provision of clinical services.