For some time I’ve been learning more about ACT – Acceptance and Commitment Therapy (normally pronounced ‘act’, not A – C – T). While I have to admit that I have been flummoxed by relational frame theory, a behavioural theory of human language and cognitionthat underpins ACT (go here for a tutorial that may enlighten somewhat), there are some very simple principles that ACT employs that I’ve found useful in my own life – and in the lives of people I work with.
Over the next few days I want to outline a bit more about ACT and how I use it within pain management – I’ll be referring to journal papers that explore the use of ACT in pain management, but a lot of what I’ll cover comes more from my own experiences with moving from a CBT approach to ACT.
There are loads of resources on the internet and in books and journals for ACT – it’s one of the most generous forms of therapy I’ve found, with people readily sharing their knowledge and experience with others. I appreciate this along with the strong adherence to an evidence-based, research-supported theory and practice, that is at the same time incredibly pragmatic.
OK, so what is ACT? Simply put, ACT involves accepting what is out of your personal control, while committing to taking action that makes your life rich and full. Most introductions to ACT start with the concept of ‘cognitive defusion’, or recognising that our thoughts and emotions are not ‘us’. In fact we tend to ‘observe’ our thoughts – but often remain stuck with the effects or labels our thoughts have attached to our sense of self. So to break with tradition, and because it works well for me from my occupational therapy background, I want to start with ‘valued actions’.
Valued action involves working with the person to identify just what they think is important in their life, then helping them do it. Sounds like what occupational therapists have been doing since the profession’s inception! It can be summed up as ‘Do what matters’.
There is a ‘provided that’ clause in this though, and that is to ensure that when doing what matters the process does not help the person avoid experiences that are negative.
Three definitions here: Values are the qualities we want from what we do, sometimes called ‘chosen life direction’. Values involve spending time thinking about what we want our lives to be about, what we want to stand for, how we want to behave over time. ACT describes values as being like a compass because they provide direction and help keep us ‘on track’.
The second definition is ‘committed action’ which means doing what it takes to live by our values, even if it, at times, involves negative experiences. Committed action means taking action, doing things in the real world, behaviours, that need to be repeated again and again to help move you in the direction you have chosen. It’s not just doing something once, haphazardly, or as a strategy to avoid experiencing something negative. It may involve setting goals, working on time management, learning to persist and wait for delayed gratification, being assertive, taking care of yourself, relaxation and so on.
Experiential avoidance is about trying to avoid, get rid of, distract from, ignore or escape from unwanted thoughts or emotions – ACT calls these ‘private experiences’ or things that no-one else knows about unless you tell them. It’s what we often do naturally to try and ‘problem solve’ how to get rid of these unwanted experiences. What we end up doing, very often, is working so hard to avoid feeling or thinking or experiencing these unwanted experiences that we replace what we actually do want and value, and especially actions that take us along the road in the direction of our values. An example might help:
Alex is 20, he wants to take off on his motorbike and ride the open road. Last time he took his bike out, though, his back pain really bothered him, and he ended up coming home before going very far.
He’s now really worried that if he goes out on his bike, his back will play up again, so he’s spent the last two years stripping and rebuilding his bike, going to the gym to ‘get strong’, seeing doctors and physiotherapists, even going in a car instead of his motorbike, but never actually taking it out on the open road just in case he has trouble with his back again. The problems are his anxiety that his back will let him down, as well as his continual search to ‘find the cause of the pain and fix it’ – and for two years he hasn’t gone out on the bike!
Now he could take off on his bike but keep on worrying that his back will let him down – how much will he enjoy his ride, do you think? Or he could take medication, or even drink alcohol or smoke cannabis to reduce his fearof having a sore back while riding – but again, at what cost? What do you think he learns about his fear or his pain? My bet is that his anxiety won’t reduce if he takes either of these options, and he will actually get more anxious about having this anxious feeling (and feeling the pain) – and all the time he will be working very hard to control the problem of his anxiety AND his pain.
What if there was another way?
This is where ACT opens up another option – acceptance. Not, you’ll note, tolerating the negative feelings, or putting up with them! Instead, actually allowing them to come along for the ride as well as the good and joyful and energising experiences we have in life. More about acceptance later this week.
Why would an occupational therapist consider using ACT?
In the process of helping people do what is important in their lives, occupational therapists have always attempted to be ‘client centred’ and ensure the activities chosen are valued by the person. Often, however, therapists have found strategies that increase experiential avoidance – think of the multiple gadgets that are handed out to ‘reduce pain’, or the relaxation training that is used to ‘reduce pain’, or the planning and activity pacing that is used to ‘reduce pain’. At the same time, many of these strategies trigger negative emotions in the patient who doesn’t want to ‘leave a job half-done’, or ‘look like an idiot with that raised toilet seat’, or ‘be selfish and rest’. Occupational therapists may use motivational interviewing techniques, or cognitive behavioural therapy to help people overcome their reluctance – but at the same time, fail to address the underlying problem of experiential avoidance.
Helping people engage in what they really want to do is a fundamental part of occupational therapy – ACT provides a very clear, evidence-based approach to enable living well. It does mean a shift for therapists, though. Referrals for occupational therapy may be driven by the patient/client’s desire to avoid the negative experiences of fluctutations in pain intensity, or anxiety about having pain, or frustration at having to acknowledge the limitations pain places on the pace of life. But at least occupational therapists already have foundation skills in identifying values and actions that the person believes are important. This gives occupational therapists a great way to begin to discover, with the client, what they want to put in place in their lives and why.
The paper below nicely describes the balance that people want to achieve – doing activities but also having pain or avoiding activities and being unable to fulfil valued actions.
Satink, T., Winding, K., & Jonsson, H. (2004). Daily Occupations With or Without Pain: Dilemmas in Occupational Performance. OTJR: Occup Particip Health, 24(4), 144-150.