Trying to help someone begin the process of accepting chronic pain is no easy task. My observation is that people need time to recognise that their pain problem is not acute pain (so it won’t ‘heal’), and go through the process of seeking ‘the cause’ (so the ‘cure’ can be found), then begin the long process of adjusting expectations and renegotiating the new ‘self’ as the person moves toward a life living with pain rather than fighting it.
I also recognise that this path isn’t linear, rather it’s tortuous, winding back and forth from emotion to emotion as treatments are offered, more investigations are available, as anger and resentment and deep sadness emerge when new losses are experienced. Some people may have their pain for many years without moving toward acceptance, sometimes even saying they ‘accept’ their pain while all the while railing against it.
I don’t find it easy to ask someone how willing they are to experience their pain. Perhaps this is something I’m working on in myself – I do fear the person’s anger directed at me when I suggest they might stop the search for control and instead sit with their pain and experience it fully. I’ve struggled to find suitable materials to help with the process, so today’s post is definitely a work in progress!
On the internet there are many sources for therapy. I found a couple yesterday that might be adapted for chronic pain management, and a wonderful presentation written by Dr Lance McCracken on ACT as it can be used in pain management.
So, first up is the presentation.
Take the time to go through it, there are some very interesting (and challenging) conclusions – like a quote from Longmore and Worrell “…there is little empirical support for the role of cognitive change as causal in symptomatic improvements achieved in CBT.” and the conclusion from a very large study into adherence to pain management treatment by Curran, C de C Williams, and Potts saying ‘Adherence to pacing, thought challenging, stretching, and exercise had very small relations with outcome variables. Variance in wellbeing at follow-up accounted for by adherence factors ranged from 1 to 2%.’ So if it’s not what we’re doing in pain management programmes that makes the difference – what is it?
Does this statement hit you between the eyeballs?
“Our biggest single problem in implementing CBT
is that many clinicians fail to push for behavior
change (e.g., exposure, behavioral activation, …)
despite the evidence that these elements of
treatment are the most important.”
“Our being ‘nice to’ or ‘protective of’ the patient
can worsen the problem.”
The remainder of the presentation covers the ACT case conceptualisation and some specific findings from studies conducted at Bath – well worth looking at. What this emphasises is that most of our suffering arises because we are trying to control something that actually can’t be controlled. We have an idealised view of the person we think we ‘should’ be, we hold onto it with a vicelike grip even in the face of new and altered circumstances, and so we fail to respond with flexibility and adjustment, and we continue to use previously helpful strategies far longer than is helpful.
Now for some resources.
These are not pain-specific, and unfortunately I wasn’t able to find any that resonated with me enough to use them. These are from Dr Jason Luoma, and available from his website.
The first is a case formulation format and caseoutlineworked example.
This is helpful because it works through the situations and emotions the person is avoiding – either through trying to control situations, control thoughts or control emotions. Something I like about ACT is the question ‘what is the function of the behaviour?’ – in other words, how well is this approach working? What compromises in other areas of life are being made in the effort to avoid experiencing something negative?
Finally, here are some documents that could be modified to use as worksheets for clients with chronic pain – Dr Luoma points out that these are available in published books and it’s best to buy the books. I’d like to see them modified for chronic pain, and although I’ve seen some worksheets that do this, I’m still not clear whether they’ll work well enough for me. Maybe I’m still learning about ACT and need to do some more to feel comfortable with the therapy before they completely ‘fit’ for me!
More tomorrow – metaphors and how they can help.