As 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