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Accepting what life throws at ya


ResearchBlogging.org
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

10 comments

  1. Great post Bronwyn
    I see what you are saying about language – fighting, struggling, overcoming pain,..
    I believe this situation is one of those in which AND is key, rather than OR.
    Maybe I’m wrong, but I understood acceptance to be about find a way to be ‘at peace’ with the present and continuing efforts to improve.
    Maybe the difference here is what the person works to improve – is it function and quality of life, or is it also pain.
    Possibly the best overall strategy for a person in pain is to find acceptance and continue working towards less pain , better function and living well again.

    I gather from your writing that you have found many people in pain are unable to find ways to decrease their pain. As such, it would make sense to focus on this view of acceptance, and on theoretical premises consistent with mindfulness and some Buddhist practices.

    Please don’t misunderstand…I am not criticising you, these practices or theories. I guess the reason for this email is that I have come to a very similar place as you in treating people in pain – it’s all I do as a physiotherapist. From reading your posts it seems we approach helping people with pain self-management in almost identical ways (who knows, there may be loads of differences that are not obvious), yet there is this one key difference I perceive.
    Do we approach the person in pain from the view that the way to help is to intervene between the spark and the flame, or do we also work on decreasing the spark?
    Do we view pain as inevitable, and therefore as immutable? or when we consider changing the suffering do we also consider that this is possible by changing the suffering and by changing the pain?

    And just to throw more into the dynamic and fluid nature of pain, is it possible that things such as our beliefs about what is possible and our readiness to accept require us to learn and practice different techniques/strategies at different points in our experience? It certainly seems easier for mot people to take an approach closer to an extreme than closer to the middle path, so forcing them to the middle too soon could detrimentally impact success in pain management approaches and techniques that promote AND.

    Hmmm…reading back on what I have written…realizing the complexity of this all and that these thoughts are evolving slowly into a more imteresting premise. I’ll need to try them out more in my practise.

    neil

    1. Hi Neil
      I can understand where you’re coming from in terms of reducing pain or helping people live alongside their pain. I guess there are several reasons I’ve arrived at where I have. The first is recognising the reality that for many people, achieving a reduction or abolition of pain is not possible.
      Even the best medications seem to reduce pain by around 30% – and for many people this isn’t achieved either for a long time, if at all.
      The second is that for many people the search for some sort of pain reduction becomes their goal rather than living life, and in the process they can lose sight of what is good in life along the way.
      The third is that by living a full and good life, people can do what the brain really needs – normal activity. Normal input and a normal range of experiences going into a brain that has changed through mindfulness and acceptance to reduce the sensitivity and irritability.
      And I guess a final reason is that there is such a focus on pain reduction everywhere in life that I think people have a mindset that it’s not possible to live wonderfully well despite pain. And there is research showing that a significant proportion of people live well in the community despite having pain – undistressed, nondisabled and having a good life. Is the mindset that to have pain inevitably means suffering actually promoting suffering because we expect never to have pain?
      When the research supports that so much of the difficulty with disability and distress associated with pain is about psychosocial variables, and when we recall that everyone processes their experiences and integrates them into who they are and what they expect, could the focus on reducing pain be getting in the way of either addressing the psychosocial factors, or perhaps even contributing to those factors?

      And because I am not qualified to do hands-on therapy – I leave that to people like you! – I help those people who haven’t found pain reduction effective, but who also want to have something else to live for.

      I’m glad to have provoked some thought, and I do thank you for getting me to ponder my philosophy!
      cheers
      Bronnie

  2. Here is what I have started doing. I use the word ‘dynamic acceptance.’ it seems to go over better, connoting something active rather than passive. Works especially well (so far) with guys.

  3. I really like the ‘dynamic acceptance’ …..who knows with this attitude things may be more malleable and fluid …..Neil I like your site and approach !
    Bronnie , I enjoyed your thoughtful encompassing approach , particularly the comments on cultural influences. Often I find it may be an age related and societal attitude in some circumstances …..Many older Scottish people I see have had hardship in their lives and have experiences of adaptability as a consequence. Obviously this is a broad generalisation but a NZ Physiotherapist and Psychologist looking at coping in emigrees into the S Island sheep farming areas described similar observations.
    Modern society views health and health care as some kind of material external ‘product’ and perhaps when the product does not deliver the expected benefits it may result in a challenge to ones world view?.A lady recently paid a top notch surgeon for her meniscal intervention and was not happy at my ‘active’ and graded pain education approach as this didn’t seem to fit what was expected (wish i had shone the bright light or ultra machine for a few visits …) Perhaps if I had charged it may have been a different matter….
    Being more positive I am still moved by Havi Carel’s book Illness discussed in this well written review here http://heroesnotzombies.wordpress.com/2009/01/21/illness-by-havi-carel/
    I find the philosophical , phenemenological approach to living well with illness refreshing. . Havi Carel uses philosophy as ‘therapy’ and with the adaptation imposed by the lung impairment still considers herself ‘well’ as she constructs a meaningful life – meaningful for her. This is the dilemma of health and the dilemma of pain in many ways…….Here is a link to Havi Carel’s work which may add to this discussion?http://www.uwe.ac.uk/hlss/courses/philosophy/staff_hcarel.shtml
    Ian

    1. Thank you so much for sending this link, it’s great. I hadn’t thought of it as a philosophical approach, but I suppose it is – at least it is about experiencing life in all its momentary glory.

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