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A dilemma – ACT-ing Well, Living Well


ResearchBlogging.orgAs part of looking at ACT, I’ve been looking at values and committed actions that people are taking (or could take) to make their lives rich and fulfilling.  I’m currently mulling over what to do in a case where the client I’m working with is actually quite happy with his life, and given that we can’t eliminate his pain, he doesn’t really want to make any further changes.  It makes setting goals quite difficult!

I took a quick look into the journals to see whether there have been any studies using an ACT treatment framework in which the effect of looking at personal values was directly examined, and found a paper by Branstetter-Rost, Cushing and Douleh, published in the Journal of Pain in August last year.  In this study, an intervention in which individuals considered their personal values (in other words, what is important to them, what influences the direction in which they take actions) was carried out, and its influence on tolerance to a cold pressor test was evaluated.

Two previous studies have shown that low levels of experiential avoidance and high acceptance are reportedly related to higher pain tolerance, conversely one would expect that high levels of experiential avoidance and low levels of acceptance would be related to lower tolerance to pain.  A couple of definitions here: pain tolerance is about how long a person is prepared to ‘put up with’ pain before attempting to move away from it, as opposed to pain threshold which is the point at which the person identifies the stimulus as being painful.

Experiential avoidance is about trying to avoid ‘sitting with’ or allowing negative emotions, thoughts or sensations to be present, while acceptance is about allowing any and all experiences (positive and negative) to be present without judging them or necessarily responding to them.

Several treatments for chronic pain have included the use of distraction – or purposeful use of attention away from the pain – but this has recently been shown to increase the instrusiveness of thoughts about pain, and heighten the negative experience of pain.  So the major difference between an ACT ‘acceptance’ and mindfulness approach is that by using mindfulness, people are encouraged to nonjudgementally experience all that is happening ‘now’; or ‘sit with’ any and all experiences whether they’re unpleasant, or for that matter, pleasant.

Back to this study about values.  Values are thought to motivate behavior and facilitate acceptance despite the experience of painful emotions and stimuli. People commonly allow themselves to experience difficulty, challenge, struggle and yes, pain, in order to achieve something they value – think of athletes, dancers, musicians and even academics!

In this study, individuals who received an acceptance intervention were hypothesised to have greater pain tolerance than those who had no treatment. It was further hypothesized that ‘adding an ACT-consistent values exercise to the acceptance intervention would result in even greater pain tolerance.’

Students from the Missouri campus participated in this experiment for course credit – the cold pressor test is not my cup of tea, and I think I’d want something for my effort!

The control group received 20 minutes of their State Constitution read aloud by an experimenter, to give this group the same contact time as those in the other two conditions.  The Acceptance-only group received 20 minutes didactic training and experiential exercises in the concepts of ‘control as the problem’ and using exercises and metaphors such as thought suppression and attempts to forcibly change one’s feelings, along with defusion and willingness exercises.  (for more details of these, keep reading over the next few weeks!).  And finally, the experimental group, received the same 20 minute teaching as the Acceptance group, but also “the experimenter referred to the participant’s top-ranked valued-life area, and engaged the participant in a 2-minute imagery exercise involving endurance of physical pain for the purpose of that value.” The example was given of a person willingly swimming in icy-cold water to rescue a family member.

The researchers then asked participants to plunge their hand into water that was cooled to between 0 – 2 degrees celcius for up to 600 seconds.  Pain threshold was recorded when participants identified that they could first feel pain; pain tolerance was recorded in seconds from the time the person put their hands in the water, to the time they removed their hands; and pain ratings were made using a visual analogue scale anchored by faces representing various levels of pain expression, and the words ‘no pain’ and ‘worst pain’.

The results – acceptance plus values made a big difference in terms of pain tolerance, but not threshold. This is great news!  It’s not surprising that threshold isn’t different from the other groups, because threshold is simply the point at which people start to experience something as painful – it’s the tolerance to something unpleasant that makes the big difference in terms of whether someone will or won’t persist with activity (and has a direct influence IMHO on disability).

OK, so what does this mean for me and my patient?

Well, I struggle at this point because my patient, although he places a good deal of value on his family and being a good parent, doesn’t feel that his pain gets in the way of him doing so.  This is despite him not working, being unable to drive very far, carry out his own grocery shopping, or even mow his own lawns.  Perhaps I’m being very judgemental here, but for most of the people I work with, these are the sort of activities they want to be able to do as part of being a ‘good parent’, or a ‘good provider’.

Reflecting on the stages of change model of Prochaska & DiClemente, perhaps he’s simply at the precontemplative stage – maybe he lacks confidence to even consider that there may be the possibility of doing these sort of activities.  Maybe he’s fearful of the consequences – increased pain, more fatigue, loss of current routine, risk of failing, loss of his benefit, perhaps even loss of family system stability.

I’m undoubtedly a newbie at using ACT, and I’m certain this patient is experientially avoidant.  To me it does seem as though he may have adopted, or ‘fused with’ the identity of being unwell, or an invalid.  While he does appear to be ensuring values that he holds are being met, I wonder whether there are aspects of his life that he’d like to change – but isn’t ready to tell me about yet.

In the spirit of ACT I’m ‘sitting with’ my own frustration at not yet knowing how or what to do next.  My instinct is to keep the door open somehow by indicating that perhaps now isn’t the right time for him to learn about self managing his chronic pain, and let him know that when he is ready with some areas he’d like to change, we’ll be ready to see him.

In the meantime I hope the discussions we’ve had about what is important to him now and in the future will have started him pondering, and that he’ll have the opportunity to explore what we’ve discussed with someone who will support him to begin to see possibilities.

Branstetter-Rost, A., Cushing, C., & Douleh, T. (2009). Personal Values and Pain Tolerance: Does a Values Intervention Add to Acceptance? The Journal of Pain, 10 (8), 887-892 DOI: 10.1016/j.jpain.2009.01.001

5 comments

  1. I know two very similar patients to these! My own reflections have led me down a similar path (perhaps without the excellent referencing!).
    The conclusions I drew were similar (challenging my own values / judgements) but with one additional component – money! Both my patients are being financially supported – one by the state (admittedly at a pitiful level) and one by medical insurers, and this is where I get in an ethical pickle.

    I know that returning to work (in all it’s guises) is important for a whole bunch of physical and mental health reasons but if ‘the system’ is supporting some people to remain disabled then what to do? I know the patient won’t be grateful if I point out to their GP or case manager that they are physically capable of achieving employment, yet whilst that support system is in place, these patients are unwilling to move.

    I’m very much with you when you describe your patient as ‘experientally avoidant’ – this isn’t bludging, it looks to me like no confidence to change (and deal with the changes) and low importance.

    thanks for the stimulating post as ever

    P

    1. I think my position regarding people being supported to remain ‘unwell’ despite actually being capable of work is quite clear. Working is healthy for people – not working is unhealthy, and there is a heap of evidence to support this, so I’ll happily let a GP know that it’s time to move on.
      I know the patient will not be grateful, and I’m sure the GP will be ambivalent about taking action on the basis of my recommendation – but at the same time, it’s important we use what is based on evidence to challenge the status quo and the systems that support poor health. For more information, head to KendallBurton

  2. Thank you for your deeply interesting series of posts on ACT (and I love your photos)! I’ve encountered similar situations to the one you mention above. I think your observations about individuals constructing self-identity as an invalid and (albeit unwittingly or unconciously) structuring self perception to facilitate avoiding change are spot on, and are two of the hardest nuts to crack. If we take (extrapolating and generalising wildly, so I hope you’ll excuse the blunt instrument approach) anxiety about pain as the more important factor than pain itself, then finding strategies for reducing anxiety could be the key to starting a positive process. Asking people to contemplate the ‘end result’ or big picture changes before breaking down the process into ‘baby steps’ has often been frustrating in my experience – because the very idea of major change has already started the anxiety process in motion. With some people (and you have to be judicious in assessing who) presenting very, very small challenges within an extremely safe environment without explicitly clarifying the ‘end goal’ beforehand can be more successful. It’s not about being sneaky, but more about dealing with anxiety as a priority.

    1. Hi there, thanks for the compliment about the photography! Welcome to New Zealand scenery – it does the beauty for you!
      I don’t think people deliberately avoid ‘becoming well’ in terms of ‘fusing with’ the thoughts about disability, ill health etc. It’s part of being human to have this wonderful brain that just tries to ‘solve the unsolvable’, and labels everything as the same as the description. But yes, moving from being a ‘patient’ or an ‘invalid’ to being a person is the hardest but at the same time the most important move for people with any chronic health problem. I have a sneaking suspicion that most of the ‘work’ of an interdisciplinary pain management programme is not about the skills people learn, but instead about the concept of ‘yes! I can be me again!’, an attitudinal shift that shows people that change is possible and the future is not about what the person cannot do.
      I’m reminded again of that saying by John Woden: Do not let what you cannot do get in the way of what you can.
      And yes, I think we as clinicians can be smart (perhaps even sneaky!) about how we help the person gain confidence to believe that it’s possible. Although it’s not the only way, ACT seems to be a reasonably effective way to do this.

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