A Prospective Analysis of Acceptance of Pain and Values-Based Action in Patients With Chronic Pain

Lance M. McCracken and Kevin E. Vowles

These two researchers have been publishing more and more on acceptance and values and Acceptance and Commitment Therapy (ACT) and Contextual Cognitive Behavioural Therapy (CCBT), and this paper is another example of the type of work being undertaken.

The objective was to ‘prospectively investigate the combined processes of acceptance of pain and values-based action a in the emotional, physical, and social functioning of individuals with chronic pain.’

A concept I’m interested in is ‘psychological flexibility’ or the willingness individuals have to allow for ways of behaviour and goals to differ depending on the context or situation in which they occur – in other words, allow for the realities of life while all the while still aiming for things that are important to them to achieve. And by things, I mean activities that express the values of the person. ACT includes concepts such as acceptance, cognitive defusion, contact with the present moment, self-as-context, values,and committed action (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), which are construed as ‘psychological flexibility’.

Quoting from the article “Acceptance has been investigated in more than 15 studies (e.g., McCracken, Vowles, & Eccleston, 2004; Viane et al., 2003; Vowles,McCracken, & Eccleston, in press a; see McCracken & Vowles, 2006). A number of treatment studies of mindfulness-based methods support the role of the process of “contact with the present moment” (e.g., Kabat-Zinn, Lipworth, & Burney, 1985: Sephton et al., 2007), but just one study included direct assessment of mindfulness (McCracken, Gauntlett-Gilbert, & Vowles, 2007). There is just one study of values-related processes in relation to patient functioning with chronic pain (McCracken & Yang, 2006). In each of these studies the general result is that processes of acceptance, contact with the present moment, and values-based action are significantly associated with better emotional, physical, and social functioning.'[my emphasis]

Participants in this study seem familiar to me
– very similar to the chronic pain patients referred to the clinic in which I work, that is they have had pain for 77 months (8.0 – 516), in their 40’s, mostly married or in long-term relationships, mainly experiencing low back pain, lower limb pain, or whole body pain, and 60% or so not working.

They were recruited from the people referred to the Centre, and completed the questionnaires for this study when they first attended for assessment, and again roughly 18 weeks later at the commencement of their pain management programme. The questionnaires included measures of acceptance, importance and success at living according to their values, emotions, and disability.

Now as usual I’m not going into detail into the multiple regression analyses and other statistical methodology – that’s for you to read, when you read the article in depth. Suffice to say that ‘the present analyses demonstrate that measures of acceptance of pain and values-based action predict functioning later in time for patients seeking treatment for chronic pain.’

Unexpectedly, ‘there were only two of nine possible occasions where both the acceptance and values variables performed as significant predictors, in the equations for depression and psychosocial disability.’ It was thought that this would occur in every equation. The authors suggest that
‘Our inability to find these relations may have been due to the statistical control procedures that included pain intensity, a variable that shares variance with both acceptance and values, and the
overlapping variance between the acceptance and values variables, which, according to the correlation results, is estimated at 25.0%.’

They add that ‘the study interval was quite long, providing opportunity for a wide range of influences on the measures of functioning at Time 2 that could have reduced their relations with the acceptance and values measures from Time 1’.

I like this point made by the authors: Flexible and effective behavior will tend to have both qualities [of acceptance and values] and these qualities are expected to mutually enhance each other, with acceptance loosening up restrictive influences exerted by pain on behavior in the near term, and values giving direction and purpose to behavior over the longer term.

Now you know I’m going ask ‘What does that mean for us as clinicians?’
Well…people who report that they accept their situation and act to achieve things that they value in their life despite their pain present ‘better’ in terms of their results on measures of things like emotional, physical, and social functioning.

Not really rocket science in that anecdotally clinicians know that angry and resentful people rarely function as comfortably in their lives as people who are more accepting and ‘get on with life’. What is rocket science is that these concepts are based on a theoretical model that can be empirically tested, and used to help us develop ways to encourage people to become more accepting, and to live lives based on things that are important to them, rather than spend energy on seeking to return to ‘the way things were’ or ‘what might have been’.

It means that some of the work of occupational therapists whose primary focus is to help people identify important areas of activity and facilitate their achievement in these areas is validated. That perhaps over time, the urgency to ‘reduce pain’ (which in many ways constructs and reinforces disability because it implies that having pain and restrictions is not normal) may reduce. Perhaps by helping people with pain identify what is important to them, we as clinicians might look at what is important to us – making more space in our lives for things we value, like balance, family, creativity, and inquiry.

I can foresee some clinicians finding the concept of accepting pain particularly hard to reconcile with their own value system of relieving pain (almost at all costs). And this will conflict with the aims of patients who dearly want me to help them ‘remove their pain’. So, putting these concepts into therapy in an acceptable way for the people with whom I work continues to be my challenge. After all, these patients are seeking treatment – this shows that they are unhappy with their current situation, living the antithesis of acceptance. I can see this topic being discussed over and again in the next few years.

I hope you’ve enjoyed my stroll through mindfulness and acceptance over this week – have no fear, I can see that I’ll carry on this particular path many times as I continue learning and enquiring! As I discover things, I’ll be sure to post them. Keep in touch too – your comments mean a lot to me, and it’s always great to see what other people think, whether you agree or not! And if you want to subscribe, don’t forget the RSS feed link at the top right of this page – or bookmark – I post most days during the week.

McCracken, L.M., Vowles, K.E. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain.. Health Psychology, 27(2), 215-220. DOI: 10.1037/0278-6133.27.2.215
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., Lillis, J. (2006).
Acceptance and Commitment Therapy: Model, processes and outcomes.
Behaviour Research and Therapy, 44, 1–25.

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