Reflections on ACT case formulation in chronic pain


I’ve been reviewing ACT and contextual cognitive behavioural therapy in chronic pain management over the past year or so, and it’s really interesting reflecting on the different way in which I see people after being exposed to the ACT approach.

Just to recap, some of the main precepts of ACT and CCBT are:

  • people’s attempts to control their negative emotions lead them to avoid encountering these emotions
  • but in doing so they often increase the intensity and frequency with which they experience them
  • and their attempts to avoid the experiences also lead them away from pursuing activities that enable them to achieve things that are important to them (eg values)
  • this becomes evident through ‘cognitive inflexibility’ or the difficulty to do things in different ways in order to maintain value-aligned behaviour
  • human use of language provides a lot of wonderful things, but at the same time people often confuse the words they describe an experience with, with the actual experience. (What I mean here is that in calling a situation ‘hopeless’ they behave as if it really is ‘hopeless’ and act accordingly.  In a similar way, they may say ‘I could never cope with X, Y, Z’ – but avoid encountering them, and believe that they ‘could never cope’ – but have not ever defined what ‘not coping with’ actually looks like.)
  • the de-fusion (or decoupling) of the words we use and their reality is a very effective way to review assumptions that a person has about the way the world (and themselves) really is.
  • One way of doing this is to become effective at ‘mindfulness’ where being in touch with NOW rather than judging it, or remembering the past, or predicting the future, is the focus.
  • in addition, the usual behavioural factors that maintain unhelpful ways of thinking and doing are considered
  • and then people are helped to move into living the life they really want to live – aligned with their values

In chronic pain, ‘control’ and experiential avoidance (ie trying very hard to control or avoid experiencing pain fluctuations) is often the focus of people, especially at the beginning of the transition between sub-acute and chronic pain.  And it can persist for many, many years, if it goes at all in some of the people I’ve seen.  Other patients I’ve seen have moved from trying to control their pain into accepting and moving with their pain fluctuations with relative ease – it’s simply been a process of helping them gain confidence that doing this is a good idea.

I am still uncertain whether ACT is the ‘right’ approach for all patients – perhaps.  And I’m still learning.  I do, however, think that anything that helps people move from being passive to LIVING has to be a good thing.  So I was really pleased to find a book to use as a ‘basic’ text for developing my skills in ACT.   Not that there is any shortage of books for learning ACT!  So today I thought it would reflect on some of the things that I’ve found useful when developing an ACT case formulation.  (thanks to Jay Luoma, Outline of ACT Assessment/Case Formulation Process, and he references Chapter 3 of the A Practical Guide to Acceptance and Commitment Therapy (2004), by Steve Hayes and Kirk Strosahl.)

What are the functional effects of the problem on the person?

This is the first question to ask when starting to develop an ACT case formulation.  It means looking beyond the person’s diagnosis, especially their medical diagnosis of ‘pain’, and into the problems the person has as a result of pain – and then the problems they have developed as a result of their attempts to control the pain.

What this means is listening carefully to what the person says they cannot do, and what they say they ‘have’ to do to control their pain.  It also means listening to the things they say others have told them to do, and the efforts they have taken to work hard to reduce or eliminate the pain.

I’ve found that it usually takes some time to learn what the functional effects are – and often it’s not so much the pain, as the efforts the person takes to either maintain behaviour that they think ‘must’ or ‘should’ be maintained (eg ‘I must clean all the house so it is immaculate’, ‘I must always be available to my family’), or to avoid experiencing the pain (eg ‘I must take medications and eliminate the pain’, or ‘I must find a cure’).  It’s helpful to keep your mind open and look beyond the immediate problems the person presents until the experiential avoidance and the conflict between values and the strategies employed to avoid negative experiences are more clearly seen.

Two key questions from an ACT perspective is:

  1. What private experiences is the client attempting to avoid?
  2. What avoidance behaviors are being used and how pervasive are they? This might mean asking the question ‘if you had a magic wand and your pain was gone, what would you be doing that you’re not doing now?’, or ‘what are you doing to get rid of your pain?’, and in-session avoidance or emotional control behaviors (e.g., topic changes, counterpliance, aggressiveness – these come from Jay Luoma).

Motivation – what is moving the person to seek a change of some sort?

Reviewing the factors that are either supporting change, or impeding change is really helpful.  It may be that ACC or an insurance or treatment funder is providing some external motivation which can be helpful – but at the same time internal motivations provide more impetus for change.  Reviewing the cost of trying to control the uncontrollable, or the amount of energy obtaining treatments that don’t provide lasting pain reduction – or have unpleasant side effects – or the reduction in valued activities also provides motivation.

Other factors that are known to contribute to inflexibility include:
Cognitive entanglement/fusion – as I indicated above, believing that the words used to describe a situation equate with reality: ‘right’ and ‘wrong’ approaches even though they don’t help the person progress towards valued goals (eg my therapist said I ‘should’ use this method of lifting, but you can’t do it at work because…. so I need to stay off work)
Out of contact with the present moment – Some people seem to be often ‘Phasing out’ during sessions to avoid unpleasant experiences, or try to deflect from being challenged or feeling uncomfortable (or even reporting on ‘failures’ during home learning) by telling long stories about the past, or dreaming about the future.
Out of contact with values – some people have never spent time really considering what is important in their lives.  This might be out of being subassertive, or from living a life where making deliberate choices has seemed dangerous. In people experiencing chronic pain, it can arise from a long time without achieving progress towards a goal, as I’ve described before, becoming ‘demoralised’.  People who don’t see that they have choices, or have always lived under the control of others and haven’t revisited their own values may need to be helped to establish and clarify what they really want in life – I find this most often in return to work, where people with chronic pain may never have seen that they can choose a job that is more than simply a paycheck.

Ability to build patterns of committed action – can the person see the link between what they do now and achieving a long-term goal?  Do they persist in unhelpful behaviours thinking ‘if at first I don’t succeed, try, try, try again – even if it hasn’t worked ever since they developed persistent pain?

Some of the people I work with haven’t ever had long term plans, they’ve lived simply from day to day – so being committed to anything other than NOW is really difficult.  As a result, they change tack or become diverted from activities as new events or crises develop.  This doesn’t help people with pain develop a sense of confidence or self efficacy, and increases the difficulty we, as health providers have in helping people move from helplessness (ie being ‘patients’) to being confident and moving towards what they want in life (ie being ‘people).

Consider specific treatment implications/foci based on particular patterns of client behaviour

What this means in pain management is that we need to identify, with the patient, what is diverting them from achieving their valued goals. This could be helping them identifying the things they’re avoiding – and helping them gently face their fears.  It could mean helping them identify the things they’re actively doing that are distracting them from their goals – such as treatments that take up time that could be used doing more helpful things, medications that have unhelpful side effects etc

Consider factors contributing to psychological flexibility (i.e., client strengths). This is an area often forgotten in pain management – what has helped the person achieve goals that are embody their values despite their pain?  perhaps it’s an attitude change, or the recognition that by ‘letting go’ or ‘going with’ their pain they sometimes recover more quickly, or even where they decided to make and carry out plans to achieve something important in a step-by-step fashion despite adverse events.

The following ACT ‘steps’ can be helpful (again, courtesy of Jay Luoma)

Given the functions that have been identified in this assessment consider the relevant contributions of:
1. Generating creative hopelessness (helping the person to look at the unworkable nature of the current agenda)
2. Understanding that control is the problem (helping the person understand experientially the paradoxical effects of control – the more you try to control and avoid something, the more you are likely to experience exactly what you’re trying to control!)
3. Developing willingness (helping the person face their concerns because of fear about the consequences of doing so)
4. Experiential exposure to the less-than-expected ‘sting’ of pain through acceptance and defusion (helping the person to experience pain because of beliefs about the consequences of facing feared events – such as ‘I can’t cope with a pain flare-up’ – what does ‘can’t cope with’ actually mean?)
5. Generate experiences of ‘me’ as separate from ‘my thoughts and feelings’ to help the person face feared experiences (helping the person to recognise that pain is a sensation AND a judgement, and becoming aware of the judgements as the generator of negative emotions)
6. Make contact with the present moment/mindfulness (helping the person be ‘in the now’ rather than dwelling on the past, or anticipating the future)
7. Values exploration (heping the person identify a set of values for their life, or is out of contact with their values)
8. Engage in committed action based on chosen values (Helping the person take action to achieve goals that are consistent with values, moving away from unhelpful activities that divert from living a life aligned with important values)

Some great web resources for ACT and CCBT are:

The Association for Contextual Behavioural Science – the authoritative resource

Act Mindfully

A nice social work summary of ACT

A slide presentation on the use of ACT in chronic pain, by Dr Lance McCracken

A paper written by Dr Steven Hayes, in 2007: Hello darkness: Discovering our values by confronting our fears. Psychotherapy Networker, 31 (5), 46-52.

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