Lance McCracken

• BA, MA, PhD
• Professor at Uppsala University

Over 30 years ago, treatments based broadly within cognitive behavioral therapy (CBT) began a rise in prominence that eventually culminated in their widespread adoption in chronic pain treatment settings. Research into CBT has proliferated and continues today, addressing questions very similar to those addressed at the start of this enterprise. How...

Unlabelled: Scientific models are like tools, and like any tool they can be evaluated according to how well they achieve the chosen goals of the task at hand. In the science of treatment development for chronic pain, we might say that a good model ought to achieve at least 3 goals: 1) integrate current knowledge, 2) organize research and treatment...

Background and objective: Psychological treatments for chronic pain have helped many people around the world. They are among the most researched and best evidenced treatments a person can receive when they have persistent, disabling, and distressing pain. At the same time improvements in the effectiveness of these treatment appear to be at a stand...

The current study included randomized controlled trials (RCTs) to assess the benefits of Acceptance and commitment therapy (ACT) for chronic pain. Searches were conducted in Web of Science, PsycINFO, PubMed, Scopus, Cochrane Library, and Embase from inception until September 30, 2022. Thirty-three RCTs, including 2293 participants, were included. S...

Psychological flexibility is a model of human performance and well-being. It essentially entails an approach to life circumstances that includes openness, awareness, and engagement. It has roots in behavior analysis, and it is linked to a philosophy of science called functional contextualism and to a specific therapy approach called Acceptance and...

ACT-FM en français

Background People with Parkinson’s disease can experience psychological distress and have difficulties accessing face-to-face psychological support due to symptom burden and limited availability of psychological services. Digital options for psychological support can bridge this gap. We have developed an app based on acceptance and commitment thera...

This study investigates whether data from people with endometriosis (n = 58) and fibromyalgia (n = 58) exhibit what is called “ergodicity,” meaning that results from analyses of aggregated group data can be used to support conclusions about the individuals within the groups. The variables studied here are commonly investigated in chronic pain: pain...

Background: Identifying predictors for adherence and clinical response to psychological therapies is essential for improving individual treatment outcomes. Objective: To explore predictors of adherence and clinical response among individuals with co-occurring chronic low back pain (CLBP) and depression receiving cognitive behavioral therapy (CBT)....

Background The Multidimensional Psychological Flexibility Inventory (MPFI) is a measure of all facets of psychological flexibility and inflexibility, potentially important processes of change in psychological treatment for chronic pain. In some contexts, it can be considered too long. The aim of this study was, therefore, to validate a short form M...

Background: Acceptance and Commitment Therapy (ACT) has been found to be beneficial for individuals dealing with chronic pain. The theoretical mechanisms of change proposed by ACT are based on the Hexaflex model. To comprehensively reflect this model, the Multidimensional Psychological Flexibility Inventory (MPFI) and Psy-Flex have been developed....

Introduction/Aims A previous randomized controlled trial showed that guided self‐help acceptance and commitment therapy plus standard medical care (ACT+SMC) was superior to standard medical care alone (SMC) for improving quality of life (QoL) and mood at 9‐weeks post randomization in a sample of people with muscle disorders (MD). This follow‐up stu...

Background Motor neuron disease (MND) is a progressive, fatal, neurodegenerative condition that affects motor neurons in the brain and spinal cord, resulting in loss of the ability to move, speak, swallow and breathe. Acceptance and commitment therapy (ACT) is an acceptance-based behavioural therapy that may be particularly beneficial for people li...

Background: Following the successful completion of feasibility and acceptability studies of internet-delivered self-help Acceptance and Commitment Therapy for family carers of people with dementia (iACT4CARERS), a full-scale randomised controlled trial (RCT) evaluating its clinical and cost effectiveness will be conducted. This paper describes the...

Background. International guidelines have recommended cognitive behavioural therapy, including acceptance and commitment therapy (ACT), as it offers validated benefits for managing fibromyalgia; however, it is inaccessible to most patients. We aimed to evaluate the effect of a 12-week, self-guided, smartphone-delivered digital ACT programme on fibr...

Purpose The struggle with sense of self has a fundamental impact on health and wellbeing in people with chronic pain. Acceptance and Commitment Therapy (ACT) particularly includes a process related to sense of self, called self-as-context (SAC). A measure of SAC, called the Self Experiences Questionnaire-8 (SEQ-8) has been developed in people with...

Objective: This study explored the extent to which within-patient changes in processes targeted in Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD) are associated with changes within-patient in pain intensity and depressed mood and evaluated the extent that process-outcome relationships differed betwee...

This study investigates whether data from people with chronic pain conditions, including endometriosis (n = 58) and fibromyalgia (n = 58), exhibit ergodicity, a necessary condition for the generalizability of group-based research findings to individual cases. The study focused on frequently assessed variables in chronic pain, including pain intensi...

Chronic pain and depression are frequently comorbid conditions associated with significant healthcare and social costs. This study examined the cost-utility and cost-effectiveness of videoconference-based group forms of Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD), as a complement to treatment-as-u...

Background Given the degenerative nature of the condition, people living with motor neuron disease (MND) experience high levels of psychological distress. The purpose of this research was to investigate the cost‐effectiveness of acceptance and commitment therapy (ACT), adapted for the specific needs of this population, for improving quality of life...

Behavioral therapies, such as Acceptance and Commitment Therapy (ACT), have been empirically supported for treating fibromyalgia (FM). However, clinical adoption is challenging due to limited access to qualified providers. A smartphone-based, FDA cleared prescription digital therapy (FM-ACT) addresses this barrier by providing self-guided ACT for t...

Objective Fibromyalgia (FM) is a prevalent pain syndrome with significant healthcare and societal costs. The aim of the SMART-FM-SP study is to determine the effectiveness, cost-utility and physiological effects in patients with FM of a digital intervention (STANZA®) currently marketed in the United States, which delivers smartphone-based, fully se...

This study aimed to explore the views of family carers of people living with dementia from ethnic minority groups and their therapists on internet-delivered, self-help acceptance and commitment therapy for family carers (iACT4CARERS), enhanced with additional therapist guidance. To achieve this, a qualitative approach with semi-structured interview...

Objectives Cancer related pain (CRP) is among the most frequent collateral effects of cancer, with chronic CRP, lasting at least three months, affecting >40% of cancer survivors. Evidencebased treatments, including pain-focused Cognitive Behavioral Therapy (CBT) are available, but it appears that cancer patients/survivors are often poorly informed...

Background: Excessive attention to pain, or hypervigilance, is associated with negative outcomes in chronic pain conditions such as fibromyalgia. The Pain Vigilance and Awareness Questionnaire (PVAQ) is a self-report questionnaire to measure attention to pain. This study aimed to evaluate the psychometric properties of a Swedish version of the PVA...

Background: Provoked vestibulodynia (PVD) causes suffering in many women's lives due to its impact on relationships, sexual functioning and functioning in other key domains. Objective: Here, we report a randomized controlled trial conducted to examine whether Acceptance and Commitment Therapy (ACT) with a focus on values-based exposure, delivere...

Introduction Stigma adversely affects people with chronic pain. The qualities within self-compassion may be particularly useful for buffering the impact of stigma on people with pain. In the context of an Acceptance and Commitment Therapy-based (ACT) treatment for chronic pain, this study investigated the association between changes in stigma and s...

People with primary psychosis are among the most seen in inpatient psychiatry. Treatment guidelines recommend both pharmacological and psychological treatments. However, psychological treatments arenot routinely offered in many settings. There is also a lack of research on psychological treatments for this vulnerable population in the inpatient set...

Purpose: To explore the experiences of patients with chronic low back pain (CLBP) plus comorbid depressive symptoms who received a remote synchronous videoconference group form of Acceptance and Commitment Therapy (ACT) or Behavioral Activation Treatment for Depression (BATD). Methods: A qualitative study (IMPACT-Q) was nested within a randomized c...

Objective Chronic pain frequently co-occurs with clinically relevant psychological distress. A systematic review was conducted to identify the efficacy of cognitive behavioral therapy-based interventions for patients with these comorbid conditions. Methods The systematic search was carried out in Medline, PsycINFO, Web of Science, and Scopus up to...

Our understanding of the underlying psychological processes of development, maintenance, and treatments for stress-induced exhaustion disorder (ED) remains limited. Therefore, the current study aimed to explore whether sleep concerns, pathological worry, perfectionistic concerns, and psychological flexibility mediate change in exhaustion symptoms d...

Background. People with Parkinson’s disease can experience psychological distress and have difficulties accessing face-to-face psychological support due to symptom burden and limited availability of psychological services. Digital options for psychological support can bridge this gap. We have developed an app based on Acceptance and commitment ther...

Introduction In adults, muscle disease (MD) is typically a chronic long-term condition that can lead to a reduced quality of life (QoL). Previous research suggests that a psychological intervention, in particular Acceptance and Commitment Therapy (ACT), may help improve QoL for individuals living with chronic conditions such as MD. Methods This ne...

Background People with chronic pain are frequently exposed to stigma, which is typically distressing and may lead to internal stigmatizing thoughts. The thought content associated with stigma has similarities to pain catastrophizing, although these concepts differ in that stigma is arguably more social in origin. Stigma can be measured by the Stigm...

Objectives Mental health problems and persistent COVID‐19 symptoms were prevalent in the context of COVID‐19. However, despite the long‐observed association between physical symptoms and mental health problems, such association has not been adequately examined in the context of COVID‐19. Our understanding of wider patterns of risk and vulnerability...

Objectives Processes of psychological flexibility (PF) are positively associated with health and wellbeing in several chronic pain disorders. However, these processes have not been investigated in endometriosis, a chronic pain disorder affecting 5–10 % of women worldwide. This study is a preliminary investigation of the associations between PF or p...

This study examined the efficacy of adding a remote, synchronous, group, videoconference-based form of Acceptance and Commitment Therapy (ACT) or Behavioral Activation Therapy for Depression (BATD) to treatment-as-usual (TAU) in 234 patients with chronic low back pain (CLBP) plus comorbid depressive symptoms. Participants were randomly assigned to...

Elevated levels of anxiety in relation to chronic pain have been consistently associated with greater distress and disability. Thus, accurate measurement of pain-related anxiety is an important requirement in modern pain services. The Pain Anxiety Symptom Scale (PASS) was introduced over 30 years ago, with a shortened 20 item version introduced 10...

Background and purpose: This study explored the feasibility and acceptability of conducting a larger trial of a self-guided, online self-compassion and acceptance and commitment therapy (ACT) focused treatment among people with type 2 diabetes (T2D) to decrease psychological distress. Materials and methods: This study was a two-arm, parallel, fe...

Background Motor neuron disease (MND) is a fatal, progressive neurodegenerative disease that causes progressive weakening and wasting of limb, bulbar, thoracic and abdominal muscles. Clear evidence-based guidance on how psychological distress should be managed in people living with MND (plwMND) is lacking. Acceptance and Commitment Therapy (ACT) is...

Objective: In response to COVID-19, virtual, group-based interdisciplinary pain management programmes (PMPs) were rapidly implemented. This included implementing different intensities and formats of virtual PMPs to address a range of patient needs and complexity. This observational study investigated outcomes associated with virtual high and low i...

Objectives: Acceptance and Commitment Therapy (ACT) is an established treatment for chronic pain. However, it is a form of treatment that have not yet been applied much in the treatment of persistent vulvar pain disorders. This study examines the feasibility and preliminary effects of online ACT for patients with provoked vestibulodynia. Methods:...

Although empirically validated for fibromyalgia (FM), cognitive and behavioral therapies, including Acceptance and Commitment Therapy (ACT), are inaccessible to many patients. A self-guided, smartphone-based ACT program would significantly improve accessibility. The SMART-FM study assessed the feasibility of conducting a predominantly virtual clini...

Background Exhaustion due to persistent non-traumatic stress (ENTS) is a significant health problem with substantial personal, social, and economic impact. While there are increasing studies of ENTS, there is no international agreement on how it should be diagnosed and treated. This scoping review aimed to map definitions, diagnoses, treatments, ou...

Purpose of review: This review focuses on the role of psychologists in the assessment and treatment of fibromyalgia syndrome (FMS), a highly prevalent condition characterized by chronic widespread pain, fatigue, cognitive problems, distress, and disability. Recent findings: A large body of work supports the effectiveness and cost-utility of psychol...

Little is known about psychological interventions for stress-induced Exhaustion disorder (ED), and there is a need for more research to improve the outcomes obtained in treatments. The present study examines predictors of improvement, including sub-group responses, in a large sample of ED patients receiving a Multimodal intervention (MMI) based on...

Objectives: Behavioral eHealth interventions can enhance self-management and improve well-being in people with chronic pain. The development of these interventions calls for a user-centered approach to ensure that patient needs are appreciated. However, it may be challenging to involve patients; particularly during the early stages of the process....

Objectives The purpose of the current study was to investigate facets of Psychological Flexibility (PF) and Psychological Inflexibility (PI) and their relations with depression, anxiety, and insomnia in people with chronic pain during the COVID-19 pandemic. It was predicted that the full set of facets would significantly predict all three outcomes....

Objectives Awareness (being present), acceptance, and engagement (committed action) are three dimensions of psychological flexibility. Understanding these in the context of chronic pain may identify treatment targets to help refine individual treatment. Our objective was to test the predictive capacity of three dimensions within the psychological f...

Psychiatric disorders are common, and reliable measures are crucial for research and clinical practice. A cross-diagnostic construct that can be used to index treatment outcomes as well as prevalence of psychological ill health is psychological flexibility. The aim of this study was to validate a Swedish version of the Multidimensional Psychologica...

Background Studies of individuals with non-cancer-related chronic pain, find that higher levels of psychological flexibility (PF) are associated with less distress, better functioning, and a better response to treatment. People diagnosed with cancer are at significantly increased risk of developing chronic cancer-related pain, the presence of which...

Background Motor neuron disease (MND) is a rapidly progressive, fatal neurodegenerative disease that predominantly affects motor neurons from the motor cortex to the spinal cord and causes progressive wasting and weakening of bulbar, limb, abdominal and thoracic muscles. Prognosis is poor and median survival is 2–3 years following symptom onset. Ps...

Psychological flexibility (PF) is a model of well-being and daily functioning that is applied to chronic pain, and is the model behind Acceptance and Commitment Therapy (ACT). However, studies of PF in chronic pain are limited by the lack of a single measure capturing all facets. The Multidimensional Psychological Flexibility Inventory (MPFI) asses...

This chapter is meant to define the third wave of behavior therapy. This is a difficult task as it can only be done coherently be laying out at the same time what were the first and second waves – no easy task in itself. It is also difficult because there is, in a sense, no such thing as the third wave. There are many constituent therapies, each un...

Finding psychological factors that can reduce the substantial impact of COVID-19 on mental and physical health is important. Here we replicate and expand a previous study regarding the role of psychological flexibility (PF) in this context. We employed a comprehensive and well validated measure of PF and examined its role in relation to health outc...

Making sense of one's circumstances is normally regarded as helpful, including in the context of chronic pain. However, sense-making may be associated with adverse impacts in daily functioning. To better understand the functions of sense-making, the objective of the current study was to develop, validate, and preliminarily examine a measure of pote...

Objectives Patients with inflammatory arthritis report that fatigue is challenging to manage. We developed a manualised, one-to-one, cognitive–behavioural intervention, delivered by rheumatology health professionals (RHPs). The Fatigue - Reducing its Effects through individualised support Episodes in Inflammatory Arthritis (FREE-IA) study tested th...

Psychological flexibility (PF) is a general model of well-being. PF is positively associated with functioning in several chronic pain disorders. However, it has not been investigated in endometriosis, a chronic pain disorder affecting 5-10% of women worldwide. This is the first preliminary investigation of the associations between PF or psychologic...

Background: Growing evidence demonstrates the benefit of Acceptance and Commitment Therapy (ACT) for people with chronic pain. However, there remain people with chronic pain who do not benefit from ACT, and predicting treatment response is difficult. Aims: This aim of this study was to investigate if baseline psychological flexibility (PF) profi...

Personas review & case report as part of the DAHLIA project

Purpose To explore carers’ views and acceptability of internet-delivered, therapist-guided, self-help Acceptance and Commitment Therapy (ACT) for family carers of people with dementia (iACT4CARERS). Methods A qualitative approach with semi-structured interviews was employed with family carers (N = 23) taking part in a feasibility study of iACT4CAR...

Objectives Mindfulness-based approaches to treatment of sexual dysfunction associated with vulvar pain appear promising, but little is known about the specific processes of mindfulness in sexual interactions or if mindfulness may be of particular benefit to women who experience pain associated with sexual activity. This study aimed to examine the a...

Introduction Chronic pain affects about 20%–40% of the population and is linked to mental health outcomes and impaired daily functioning. Pharmacological interventions are commonly insufficient for producing relief and recovery of functioning. Behavioural health treatment is key to generate lasting benefits across outcome domains. However, most peo...

Chronic pain conditions are common and have a considerable impact on health and wellbeing. This impact can be reduced by cognitive behavioral therapy (CBT), the most commonly applied psychological approach to chronic pain. At the same time, CBT continues to develop, and now includes what is sometimes called “third wave” CBT. In this review, we exam...

Psychiatric disorders are common, and reliable measures are crucial for research and clinical practice. A cross-diagnostic construct that can be used to index treatment outcomes as well as prevalence of psychological ill health is psychological flexibility. The aim of this study was to validate a Swedish version of the Multidimensional Psychologica...

Background: Chronic muscle diseases (MD) are progressive and cause wasting and weakness in muscles and are associated with reduced quality of life (QoL). The ACTMuS trial examined whether Acceptance and Commitment Therapy (ACT) as an adjunct to usual care improved QoL for such patients as compared to usual care alone. Methods: This two-arm, rand...

Objectives: A randomized controlled trial of a new type of Physiotherapy informed by Acceptance and Commitment Therapy (PACT), found that it improved functioning in people with chronic low back pain compared to usual physiotherapy care. Fidelity evaluation is necessary to understand trial processes and outcomes. This study evaluated PACT treatment...

Objectives Self-compassion and psychological flexibility appear to benefit wellbeing and quality of life (QoL) in the general population and in people with long-term conditions like Type 2 Diabetes (T2D). However, both variables share similarities and their unique roles in relation to distress and QoL in people with diabetes over time are not clear...

Background: Although cognitive-behavioural treatments for chronic pain are delivered in groups, there is little research investigating group effects in these treatments. Purpose: The aim of this study was to investigate associations between group composition variables at the start of treatment and individual outcomes following intensive interdis...

Objectives: It is unclear how to address PTSD in the context of chronic pain management. Here we examine the potential benefits of an addition of prolonged exposure (PE) therapy for PTSD for adults attending multidisciplinary CBT for chronic pain. Methods: Four adults seeking treatment for chronic pain from a specialized pain rehabilitation serv...

This study aimed to explore therapists’ perceptions and acceptability of providing internet-delivered, therapist-guided, self-help acceptance and commitment therapy (ACT) for family carers of people with dementia (iACT4CARERS). To achieve this, a qualitative approach with semi-structured interviews was employed with eight novice therapists recruite...

Introduction Vulvodynia is a condition characterised by persistent vulval pain and includes particular impacts on sexual and emotional functioning. Acceptance and Commitment Therapy (ACT) has been successfully applied in persistent pain but has not been tested in this population. This single-case experimental design (SCED) study aimed to evaluate w...

Committed action is a fundamentally important facet of psychological flexibility and acceptance and commitment therapy (ACT). This article introduces committed action, reviews how definitions of it have evolved over time, presents a current definition, and summarizes current evidence. While the term itself has not always garnered great attention ei...

This article reflects on future directions within the field of contextual behavioral science (CBS), focusing on (1) refinement of the theory of CBS and implications for clinical practice; (2) methodological aspects, particularly the utility of individual-level analyses for understanding change processes and customized interventions; (3) how digital...

Objectives: The feasibility of research into internet-delivered guided self-help Acceptance and Commitment Therapy (ACT) for family carers of people with dementia is not known. This study assessed this in an uncontrolled feasibility study. Method: Family carers of people with dementia with mild to moderate anxiety or depression were recruited fr...

A prospective, 2-armed, parallel group randomised controlled trial (RCT) was conducted to compare the effectiveness of Acceptance and Commitment Therapy (ACT) combined with a supervised exercise programme with a supervised exercise programme alone for adults with chronic pain. One hundred seventy-five participants were individually randomised to re...

Objective: Psychosocial factors are related to pain and sex-related outcomes in provoked Vulvodynia and possibly, in mixed and spontaneous Vulvodynia. However, a broader behavioural framework, such as the psychological flexibility model, has received limited attention in this context. Recently, additional psychosocial variables have also emerged th...

Introduction: The COVID-19 pandemic has impacted individuals, communities, and whole populations. Experts across many different fields contributed their time and efforts in different ways to respond to the pandemic. Psychologists working in healthcare provided support and led many initiatives, both regionally and nationally. However, it is unknown...

Background Women with Vulvodynia experience pain, related impacts on sex and daily functioning, and depression. While psychosocial factors are associated with outcomes in Vulvodynia, longitudinal data are limited, especially in mixed/spontaneous Vulvodynia. Broad psychological models such as Psychological Flexibility (PF) and content-specific facto...

Single case designs (SCDs) represent an excellent approach for developing and testing treatments, and for generating general knowledge of treatment mechanisms and outcomes. Their ability to generate knowledge, however, will depend on their methods being reliable, valid, clearly described, and replicable. This scoping review aims to map assessment m...

Patients with inflammatory arthritis report that fatigue can be a challenging symptom to manage, with little support available. In response, we developed a brief one-to-one cognitive-behavioural manualised intervention, delivered by rheumatology health professionals (RHPs), to help patients manage their fatigue.

Background/Aims Patients with inflammatory arthritis report that fatigue can be a challenging symptom to manage, with little support available. In response, we developed a brief one-to-one cognitive-behavioural manualised intervention, delivered by rheumatology health professionals (RHPs), to help patients manage their fatigue. Methods We designe...

Background: Chronic pain affects ¬about 20% of the population and can lead to mental health issues and impaired daily functioning. Behavioural health treatment is crucial to support coping, however, this approach is currently not available for most patients with chronic pain. A digital solution might be uniquely suitable to bridge that gap. Objecti...

Background Innovations in virtual reality (VR) technologies have improved the adaptability of its use in therapeutic settings, and VR has shown to be a promising treatment for fear of medical procedures, with research increasing in this area in recent years. Purpose This review aims to collate evidence for the impact of VR on fear of medical proce...

Executive Summary Throughout its history the strategy and tactics of contextual behavioral science (CBS) research have had distinctive features as compared to traditional behavioral science approaches. Continued progress in CBS research can be facilitated by greater clarity about how its strategy and tactics can be brought to bear on current challe...

Background. Efforts to identify specific variables that impact most on outcomes from interdisciplinary pain rehabilitation are challenged by the complexity of chronic pain. Methods to manage this complexity are needed. The purpose of the study was to determine the network structure entailed in a set of self-reported variables, examine change, and l...

Aims: People with chronic pain may be particularly vulnerable to the impact of the pandemic COVID-19, and psychological flexibility may protect them. This study investigates psychological functioning in the context of COVID-19, including fear and avoidance in the context of COVID-19, specifically its association with daily functioning, and the rol...

Background Neuropathic pain negatively affects quality of life among people living with HIV (PLWH). This study examined the feasibility of conducting a full‐scale randomized‐controlled trial of online acceptance and commitment therapy (“ACT OPEN”) for neuropathic pain in PLWH. Methods Using a parallel‐groups design, thirty‐eight participants were...