Acceptance in chronic pain
It’s a truism that no-one really wants to have pain (and if they do, we probably need to ‘talk’!).  Accepting pain may be equated with ‘giving up hope’ or ‘giving in’ – perhaps acceptance is thought to be about resignation rather than acknowledgement.  In any event, very few of the people I work with seem to be ready to acknowledge the reality of having pain and at the same time being aware of the ability to also experience joy, peace, fun and all the other good things in life.

I’m not entirely surprised by this when I consider the way we’re raised to believe that:

(1) pain is bad and must be avoided

(2) doctors are all-powerful and can fix anything if only they try hard enough (except the common cold – but we can take anti-cold remedies to help)

Most of us are also taught to avoid negative things like failure, fear, desperation, and even anger.  Sadness is thought to be overwhelming so let’s medicate or at least minimise.  Even in schools, kids are taught not that someone wins and someone loses but ‘it’s all about participation’ in case their tender wee self esteem is bruised.

But it is true that bad things happen even to good people, and with limited exposure to ways of dealing with negative or unpleasant emotions, and an expectation that these things ‘should’ be fixable, many of the people I work with (including some of the therapists and doctors!) have a strong belief that ‘if only I can find the right thing, I can beat this pain’.  In CCBT or ACT terms, the efforts to fight against having these negative things is called ‘experiential avoidance’. (that’s a link to a paper about EA as a generalised vulnerability).

Experiential avoidance is defined by Hayes and others as ‘excessive negative evaluations of unwanted private thoughts, feelings, and sensations, an unwillingness to experience these private events, and deliberate efforts to control or escape from them’ – in other words, trying hard not to experience things that we don’t like by avoiding them, controlling them and even smothering them with medication or other substances.

The question has been asked as to whether this works – and the simple answer is that it can in the short term, but it has a cost.  The cost is the energy needed to maintain the control, avoidance and smothering – and the loss of other positive emotions, along with not really be fully engaged in the moment.  It might be useful if you’re trying not to show boredom in a long meeting, or pretending to be brave when you’re investigating that funny noise outside at night.  On the other hand, as a general coping strategy it’s not nearly so helpful because it actually increases the awareness of the negative feelings, and it prevents being fully aware of what’s going on.

Experiential avoidance becomes a disordered process when it is applied rigidly and inflexibly such that enormous time, effort, and energy is devoted to managing, controlling, or struggling with unwanted private events. This struggle, in turn, gets in the way of movement toward valued goals, diminishes contact with present experiences, and thus yields impairment in functioning (Kashdan, Barrios, Forsyth & Steger, 2006)

Lance McCracken and colleagues have been looking at the role of acceptance in chronic pain for some time now.  This paper examines the effect of acceptance more generally (ie not just acceptance of chronic pain) on people’s lives in a group of people with chronic pain attending a clinic for pain management.  The main problem with chronic pain is that it is chronic – and even with the best of medical input, many people continue to have pain at an intensity and interference level that makes it difficult to manage.

I don’t want to review the paper in detail – it’s one I think will be good to read in its entirety – but I do want to reflect on some of the things that were found.

This is a quote from the discussion:

General psychological acceptance remained a significant predictor of patient functioning even when tested within a wider model that included other relatively strong predictors of patient functioning, including pain, pain acceptance, and mindfulness. These findings suggest that general psychological acceptance has a significant and unique role to play in the suffering and disability of chronic pain patients.

Something I’ve noticed is that people who cope well with pain are often quite flexible in how they view their lives.  What I mean by this is that they know there is more than one way to achieve a goal.  So if they want to be a good parent they’ll do this in lots of different ways including playing sports with the kids, being there for dinner, going to the school parent-teacher meetings and so on.

They don’t stop with ‘being a good parent means playing football with the kids and I can’t do that because of my pain’ – they do other things that also mean being a good parent.

Their energy isn’t taken up completely with ‘fighting against the pain’ or looking for pain relief or going to medical appointments or scouring the internet for another gadget.  They seemingly have time to live well alongside their pain.

McCracken and Zhao-OBrien suggest that ‘It is possible that the experience of chronic pain induces low acceptance or that low acceptance is somehow a risk factor for chronic pain-related disability.’ They posit several reasons for their findings: persons with pain who habitually attempt to avoid or control difficult psychological experiences suffer from greater and longer term disability and distress. This, in turn, could lead them to seek treatment and to appear in our sample. Thus, low acceptance in our patient group could be either a result of chronic pain, a vulnerability factor of chronic pain and disability, or a result of a selection effect arising in a treatment seeking population.

I don’t know which way around it goes – but this week I’m going to review ways to encourage acceptance in people with chronic pain, to expand the range of strategies that I can bring to people who are distressed by their pain.  If you’ve got questions about this – click on the comments below (remember they’ll be seen publically after I’ve reviewed them), or if you’d rather, go to the ‘About’ tab above and send me a message that way.  If you’re keen to keep reading, use the RSS feed link above or you can bookmark and come back to visit.

McCracken, L., & Zhao-O’Brien, J. (2009). General psychological acceptance and chronic pain: There is more to accept than the pain itself European Journal of Pain DOI: 10.1016/j.ejpain.2009.03.004
KASHDAN, T., BARRIOS, V., FORSYTH, J., & STEGER, M. (2006). Experiential avoidance as a generalized psychological vulnerability: Comparisons with coping and emotion regulation strategies Behaviour Research and Therapy, 44 (9), 1301-1320 DOI: 10.1016/j.brat.2005.10.003


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