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Act-ing Well, living well ii


The second in a series about ACT and its use in pain management from an occupational therapy point of view.
My last post (here) talked about ACT and ‘doing what matters’, or ‘valued action’ – this involves identifying what is important to a person, then helping them do it, while being careful not to encourage ‘experiential avoidance’, or avoiding coming into contact with experiences we’d rather not.

Here’s the ‘hexaflex’ or diagram that provides an overview of ACT.  What ACT tries to develop in people is ‘psychological flexibility’, or the ability to be in the here and now, open to experiences (even negative ones) and do what matters to live a life in alignment with what is important.  In people who lack psychological flexibility, it might be possible to see:

  1. The same old strategies being used over and again while not achieving the desired result (eg working incredibly hard to ‘get things done’ so that family are cared for, even though that leaves the person with pain exhausted and completely unable to emotionally care for the family).
  2. People trying all sorts of methods to avoid experiencing something they don’t want (eg stopping all enjoyable activities because it increases chronic pain, or attending multiple treatments to get rid of pain, or only doing activities in a certain way to make sure that pain doesn’t become overwhelming)
  3. Carrying on with activities despite pain, but ‘enduring’ the pain and feeling distressed or under strain when doing so.

The problem with presenting ACT to people is that if I ask a patient ‘would you be willing to accept having your pain’, they’re likely to hit me.  It goes against all of the usual therapeutic approaches in health.  Everyone ‘knows’ that pain is bad, and it’s our job as humans to prevent it, treat it or at least reduce it.  The problem is that in chronic pain, the efforts that go into struggling with pain, trying to control it or get rid of it or so often get in the way of living well – and what’s more, they rarely work.  In fact, some studies suggest that the ‘best’ results from pharmacology for chronic pain provide only a 30% reduction in pain intensity.

Acceptance is a concept that ACT embraces – but it’s not an all or nothing acceptance, far from it.  Acceptance is used when it’s almost impossible to control thoughts and feelings, and when control is possible but doing so erodes what makes life wonderful anyway.

The basic rule of thumb for an ACT practitioner to decide whether the strategies a person is using needs changing is whether the strategies are workable.  Now that’s a concept I really like.  Workability refers to whether the ways the person is living helps them achieve what is important in life in the long run. This is a concept that I think occupational therapists will find resonates with the way occupational therapy intervenes, and helps put into context some of the short-term ‘adaptive’ strategies that fail in the long term.  Here’s an example:

Belinda has been in hospital for a hip replacement.  The day she is expecting to go home she is visited by an occupational therapist who advises her of the various post-surgical precautions she must take to avoid dislocation.  Yes! A raised toilet seat and shower stool are duly provided, and she also receives a kitchen trolley because she’ll be on crutches for at least six weeks before she can put weight fully through her new hip.  These gadgets allow her to get out of hospital and back into home where she can begin to eat her normal meals, sleep in her usual bed, and be with her family.  The solutions provided to help her get out of hospital are very ‘workable’ and help her re-establish her independence.

Do they involve experiential avoidance? Oh yes indeed – they help her to feel more confident, reduce her pain (and the risk of dislocation), and ensure she doesn’t need to ask for help.  They help her avoid experiencing helplessness.   Without them she can’t use a normal toilet without worrying that she’ll dislocate, or do her cooking without leaning on the kitchen trolley.

There are risks inherent in providing gadgets, as any clinician knows.  In this case, when the danger of dislocation is over for Belinda she may continue using the gadgets to avoid the pain of moving through the range of movement. If she strongly believes this, Belinda may be limited in her ability to do some of the things she feels are important to her, like go to the shopping mall, see a movie at the theatre, or take a bath – she can’t exactly carry her toilet seat to the mall, or push her kitchen trolley around the supermarket! Now this is unhelpful, unworkable experiential avoidance.  Not such a good thing.

Clinicians may use strategies in acute healthcare settings to enable people to avoid certain experiences – this helps people return to other aspects of their lives that they do value, such as independence and living in their own home.  If these solutions remain in place, though, they’ll get in the way of the person living well in other aspects of their life.  Perhaps something all clinicians need to stop and consider, especially when considering the use of pain reduction approaches such as injections or infusions.

My focus in pain management is to help people who have chronic pain and want to think of themselves as ‘well’.  I can’t judge whether the strategies they use are ‘workable’ against my own values, but need to instead help people to look at the function of their strategies and help them examine the long and short-term workability of what they do in light of what is important to them.  I’ve used motivational interviewing skills as one way to help people look at their choices, and weigh up options.  Identifying values features strongly in MI, and it’s great to see them as part of ACT.   More about values next time I post.

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