One thing that strikes me as very different about the ACT approach is the very different way therapists are encouraged to respond to difficult emotions. Part of ACT is to encourage acceptance of, and ‘sitting with’ negative thoughts or emotions or sensations rather than attempting to change them or ignore them – and in my learning about ACT and trying to model ACT consistent behaviour in therapy, I find I need to become more mindful of my own responses to other people’s thoughts and emotions.
What I mean by this is that I initially have a response to avoid experiencing another person’s distress – so if the person I’m working with is tearful or angry or afraid, I have often tried to mop up the tears or calm the person down or reassure them. What’s wrong with this you say?
Well, ACT views these emotions as something to acknowledge rather than alter, recognising that painful emotions are part of life and that in therapy we can demonstrate through our actions as therapists that when we make space for these emotions there is an opportunity to learn that they will pass. And by doing that, people recognise that emotions have less power than we often give them!
I’ve often reflected that many clinicians working in the area of chronic pain are quite fearful of pain, and especially, fearful of increasing someone’s pain when we ask them to do movements. Several good studies have shown that when a clinician is fearful of pain, the recommendations he or she makes are often around avoiding fluctuations in pain. In other words, we’re anxious about pain and we communicate to our patients that they too should be anxious about and avoid it. Problem is, this isn’t always workable. (Vlaeyen & Linton, 2006)
Workability is a key tenet of ACT. It means, does this approach to a situation enhance life, add to living aligned to personal values, enrich relationships, enable the person to experience all that life brings? Or does the solution to a situation constrain life, work against things the person values, avoid and attempt to control something that can’t actually be controlled.
As I’ve pointed out before, many people with chronic pain find that medications don’t completely abolish pain – in fact, most medications provide about a 30% reduction in pain intensity. At the same time, medications have many side effects and a lot of the people I work with simply don’t want to take them. This leaves them with the unwelcome choice of experiencing pain if they want to do anything, or, in efforts to avoid fluctuations in pain, doing very little (and often still having pain fluctuations!). It’s very very hard to control pain – and as so many studies have shown, the thing about pain isn’t that it’s present, it’s the negative judgement and emotional distress that we have about having pain that brings grief. (McCracken, 2007)
What to do? Well, many clinicians talk about pain management as if it’s about directly addressing the intensity of the pain. I’m not so sure this is a good thing. Not only is it pretty unworkable (because the pain can and will vary depending on so many variables, controlling all of them is unlikely), but it also teaches people to be afraid of pain and therefore gives pain far more power and control over life than it needs to.
I would love it if we could talk about ‘life management’ or ‘living well with pain’. It’s the disability associated with pain that is the main problem, not the pain itself.
So over the past few months I’ve taken to asking people if they’re willing to allow their mind to wander to and from their pain during a therapy session. Instead of offering to calm them down, or reassure them or even offer sympathy, I’ve tried to simply sit with them, and as they make a statement I may comment along the lines of ‘Your mind is telling you that it’s hard’, or ‘Can we make room for that feeling and thought as well as your pain?’. I may ask them to tell me how big their pain is, where the edges of where they feel pain and where their body feels ‘normal’, and ask them to describe the sensations. I’ve celebrated with them their ability to commit to doing something that is normally outside of their comfort zone.
I’ve been surprised at how my behaviour has changed with patients. I’m much less likely to be fearful of them having negative emotions, sessions feel calmer, I’m less emotionally tired, and the most important thing? The people I’ve been working with also seem to be able to be present with their pain a little longer and be much less distressed. They’ve been willing to treat their pain with gentleness.
It doesn’t always work well – but I’ve been surprised at how often it does help reduce that anxiety, and I haven’t done any cognitive restructuring or thought challenging, all I’ve done is simple breathing and allowing the mind to wander.
Pain can have power, yet at the heart of pain management we have often given pain even more power than it has by encouraging people to attempt to control it, or to control their actions (including thoughts) in order to control their pain. Moving away from a control focus to a gentler, kinder way of being with pain is not easy, especially for us as therapists. And most especially for therapists who have used ‘talk therapy’ as one way of working with people rather than experiencing or doing.
I value CBT because the approach has given many people a new way to view themselves and their thoughts and emotions. At the same time, doing has always been a major focus for me as a therapist. Now I’m finding a new way of behavioural change that is not mechanistic, but is instead flexible and most importantly, places what is important to the person at the heart of it. McCracken and Vowles (2008) have been looking at the usefulness of acceptance and values-based action in pain management – I think there is something in it.
McCracken, L., & Vowles, K. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain. Health Psychology, 27 (2), 215-220 DOI: 10.1037/0278-622.214.171.124
MCCRACKEN, L. (2007). A Contextual Analysis of Attention to Chronic Pain: What the Patient Does With Their Pain Might Be More Important Than Their Awareness or Vigilance Alone The Journal of Pain, 8 (3), 230-236 DOI: 10.1016/j.jpain.2006.08.004
VLAEYEN, J., & LINTON, S. (2006). Are we “fear-avoidant”? Pain, 124 (3), 240-241 DOI: 10.1016/j.pain.2006.06.031