I was looking to write about a new treatment, or something that is innovative, and you know, there isn’t a whole lot new out there in pain management land. If it wasn’t for Lorimer Moseley’s work on motor imagery and Lance McCracken’s work on acceptance, I think we’d be doing pretty much what I was doing in pain management in 1990, with perhaps a little less emphasis on core stability and muscle imbalance!
Anyway, rather than finding some new treatment, what I did find was something more to add to the concept of psychological flexibility and acceptance as a really important aspect of learning to live with a persistent pain problem (or, for that matter, any negative thing that life throws at ya!).
Acceptance is not a very well-defined concept – and it’s not something we’re very good at doing in our modern society. We’re invited to go out there and get what we want, change what we don’t like and not put up with second best. We throw out our old and dated clothing, furniture, mobile phones, laptops; we upgrade our physical appearance with botox and face peels and fake tan and liposuction; and when a health problem comes along we almost take it for granted that there will be a way to alleviate or reverse or somehow fix what we’ve got. To think that there may be some things that need to be lived with and accepted doesn’t come easily.
McCracken describes acceptance of pain as including ‘a willingness to engage in activity with pain present and to allow pain to register in experience without attempts to control or avoid it.’ [emphasis mine]
The language I hear from patients and other health providers often uses words like ‘control’ or ‘fight’ or ‘overcome’ pain, as if it can be beaten into submission and life will carry on as it was before. I don’t think this is what really happens, at least not with chronic or persistent pain.
For one thing, pain doesn’t often get completely ‘beaten’ – most of the time it’s still there, albeit somewhat less intense maybe, but still present. And no-one has a pain experience without learning something from it – maybe that some of the things that used to be easy are not, and that’s unpleasant; maybe that it’s not a good idea to do specific movements; maybe that ‘next time’ it might be a good idea to try this, or that. Life is never exactly the same as it was ‘before’.
Acceptance involves being willing to recognise that pain is present – and that it’s still possible to do important or valued things without controlling or avoiding the fluctuations that occur with pain and activity.
In this paper, McCracken and Zhao-O’Brien explore whether the concept of acceptance of pain might be also related to acceptance of ‘a wider range of undesirable experiences these people may encounter, such as other physical symptoms, experiences of emotional distress, or distressing thoughts.’
It’s not uncommon for people with persistent pain to go through unpleasant investigations or procedures, to have distressing responses from other people to their predicament, to maybe have to change job (or even lose a job), to feel unhappy or to get depressed, to worry about the future and what it might bring. This study sought to look at whether the people who are more prepared to accept and be willing to ‘have undesirable psychological experiences without attempting to control them’, might be functioning better and suffer less.
The study involved a group of 144 people referred to an interdisciplinary tertiary pain management centre in the UK. Before treatment, they completed a set of questionnaires including several about acceptance. And as usual, a whole bunch of statistical things were carried out on the results. I won’t be too descriptive about these stats, but basically, multiple regression analyses were carried out to ‘establish the contribution of general psychological acceptance to patient functioning, after the variance contributed by patient background characteristics, pain intensity, pain acceptance, and mindfulness was taken into account.’
What they found was ‘a positive relationship between general psychological acceptance and functioning, suggesting that higher levels of acceptance predicted better emotional, physical, and psychosocial functioning.’
In other words, the people that were prepared to sit with, or make room for the negative experiences that people with chronic pain often experience, and not try to control or avoid them, seemed to feel better and do more.
Now there is a huge difference between ‘putting up with’ or ‘tolerating’ these negative things, and accepting them. So this is not about being stoic and uncomplaining, nor about pretending that they’re not there and they don’t affect how people feel. It is much more about recognising that these things are happening, and allowing them to register without trying to rush through them or ignore them.
I want to add a couple of points here – this finding suggests that we do know that there is some sort of association, but we don’t know the direction of this. Maybe people who are less prepared to accept unpleasant things seek treatment more. Maybe people who have chronic pain become less able to accept unpleasant events. At this stage it’s not clear.
What we can suggest is that if we can help people become more willing to experience these negative things, this may be one way to help people with chronic pain function better and feel better.
How we do this seems a little less straightforward, but ACT certainly seems to give us some clues. Being ‘mindful’, or able to experience ‘moment-to-moment awareness while in contact with whatever emerges in experience’ is one way to start that process. Allowing a gentle ‘knowing’ of an experience without judging it, controlling it, or trying to avoid it – not easy! Being aware of how our use of language, while something that has given humans such an array of helpful problem solving tools, can also be a trap that can lead us to think we are our thoughts – rather than recognise that we have thoughts that we can choose to act on – or not.
I’m a baby in terms of learning how to help people be more willing to choose to commit to an action that is important while at the same time being aware of, and able to accept, some of those not so comfortable experiences that arise. But I’m learning – and I’ll be writing about my experiences as I continue doing so. And yes, I’ll be using these same strategies in my own life too.
McCracken, L., & Zhao-O’Brien, J. (2010). General psychological acceptance and chronic pain: There is more to accept than the pain itself European Journal of Pain, 14 (2), 170-175 DOI: 10.1016/j.ejpain.2009.03.004