Acceptance. Ask a person living with chronic pain whether they accept their pain and the answer is highly probably a resounding “No!”. It’s a word that evokes resignation, feeling helpless and giving up. Or at least that’s what many qualitative papers seem to show (Afrell, Biguet, Rudebeck, 2007; Baker, Gallois, Driedger & Santesso, 2011; Budge, Carryer & Boddy, 2012; Clarke & Iphofen, 2007; Lachapelle, Lavoie & Boudreau, 2008; Risdon, Eccleston, Crombez & McCracken, 2003). I remember when hearing a person tell me “Oh I accept my pain” thinking that this was often a clear indication that underneath it all, the person was pretty angry about the unfairness of pain impacting on their life.
Acceptance is defined in Acceptance and Commitment Therapy (ACT) as “a willingness to remain in contact with and to actively experience particular private experiences (Hayes, Jacobson, Follette, Dougher, 1994) (eds): Acceptance and Change: Content and Context in Psychotherapy. Reno, Context Press, 1994), and from this Lance McCracken and colleagues developed the Chronic Pain Acceptance Questionnaire. This measure has two dimensions: willingness to experience pain and engaging in values-directed activity despite pain. The other way acceptance has been defined draws from self-regulation, and argues that withdrawing from goals that can’t be achieved, in order to turn to goals that can be achieved is a positive way to cope with life – acceptance is defined as disengaging from a goal to get rid of pain and instead, re-engaging in other goals that aren’t affected as much by pain.
Lauwerier, Caes, Van Damme, Goubert and Rosseel (2015) have recently published a paper reviewing the various instruments that purport to measure pain acceptance. In their analysis, a coding scheme was developed consisting of the three main aspects of acceptance that seem to represent the concept: disengaging from controlling pain, pain willingness (in certain circumstances), and engaging in other valued activities. These three concepts were drawn from the literature – and then there were the left-over concepts that were also present in measures of acceptance. These are the interesting ones!
The addition five codes were: controlling pain, pain costs, pain benefits, unclear and no fit.
They identified 18 difference instruments, of which five didn’t specifically measure acceptance of chronic pain or illness and were therefore excluded from the study, leaving 13 measures to review. The one mentioned the most in the studies reviewed was the Chronic Pain Acceptance Questionnaire-2o.
Moving on to the results, what did these researchers find? And of course, why does it matter
Well, most of the instruments were measuring aspects of acceptance – the Brief Pain Coping Inventory, Chronic Pain Acceptance Questionnaire-A and CPAQ-20, and the Pain Solutions Questionnaire. The original CPAQ and the PASOL were the only two measures with moderate (but the highest percentage) of items with all three acceptance features (disengagement from pain control, pain willingness, and engaging in activity other than pain control), and interestingly, most instruments included “engaging in activities other than pain control”, while the other two factors were less well-represented.
Even more interesting is that many of the items in these instruments were classified as “controlling pain” – in other words, measuring how willing individuals are to carry on with life without trying to control pain. At the same time, many of the instruments also measured “pain costs” – such as “because of my illness, I miss the things I like to do best”.
Then these researchers did some pretty fancy analysis, looking at dimensions contained within all the items from all the measures. What they found was a 2-dimensional solution, with one dimension going from “fully engaged in valued activities” (my description!) to “pain costs”, and the other axis going from “pain willingness” to “controlling pain”.
Conclusions and why this is important
Most of the assessment measures contained some of the concepts thought to be important in pain acceptance, but the aspect most commonly found was engaging in activities other than controlling pain. Items measuring disengaging from trying to control pain, and pain willingness were found less often, while many measures incorporate pain control, and some that reflected pain costs or were unclear. This research seems to show that engagement in activities other than pain control and pain willingness are key features of items measuring acceptance, but at the same time show that not many measures look at both of these concepts together. Additionally, this research shows that many supposedly “acceptance” instruments actually measure attempts to control pain but then reverse score these items – this can mean that people using these measures interpret them as avoidance measures rather than willingness to experience pain – appealing to quite a different theoretical model (the avoidance or fear-avoidance model) rather than a pain acceptance model.
Why is this research important? Well, acceptance is still a relatively new concept in pain research and clinical practice. While it has been talked about a great deal, and there are numerous studies of acceptance, the instruments developed for such research have not been around very long, and as we can see, don’t always adequately represent the fullness of the theoretical domains. Some aspects are not well-represented or are at risk of being misinterpreted. What works in a research setting may not always be accurately transferred to a clinical setting, especially if clinicians pick up a new measure without reading the theoretical basis for its development.
I also argue on the basis of my research that “disengaging from trying to control pain” doesn’t only need to be represented by items suggesting that people no longer seek treatment. From my findings based on people who live well with chronic pain, treatment is still a feature – but the investment in the outcome of treatment is far less. It’s less important that the pain is removed, treatment is “an option” rather than a necessary part of “returning to normal”.
I also argue that pain willingness is conditional upon the values placed on the activities the individual wants to do. So, if the activity is boring, unpleasant, hard work or doesn’t have rewards to the individual, the person is more than likely to avoid it, but if it’s highly valued then pain becomes a less dominant factor in the decision to do it.
Why should clinicians care? Because acceptance is an exciting and fruitful aspect of living well with pain that we can incorporate into our treatments. Acceptance is about learning to live well, “being with” or “making space” for the presence of pain, so that the other aspects of life are able to be engaged in. That’s important given how few people can have their pain completely reduced.
Lauwerier, E., Caes, L., Van Damme, S., Goubert, L., Rosseel, Y., & Crombez, G. (2015). Acceptance: What’s in a Name? A Content Analysis of Acceptance Instruments in Individuals With Chronic Pain The Journal of Pain, 16 (4), 306-317 DOI: 10.1016/j.jpain.2015.01.001
Afrell, M., Biguet, G., & Rudebeck, C.E. (2007). Living with a body in pain — between acceptance and denial. Scandinavian Journal of Caring Sciences, 21(3), 291-296.
Baker, S.C., Gallois, C., Driedger, S., & Santesso, N. (2011). Communication accommodation and managing musculoskeletal disorders: Doctors’ and patients’ perspectives. Health Communication, 26(4), 379-388. doi: http://dx.doi.org/10.1080/10410236.2010.551583
Budge, C., Carryer, J., & Boddy, J. (2012). Learning from people with chronic pain: Messages for primary care practitioners. Journal of Primary Health Care, 4(4), 306-312.
Clarke, K.A., & Iphofen, R. (2007). Accepting pain management or seeking pain cure: An exploration of patients’ attitudes to chronic pain. Pain Management Nursing, 8(2), 102-110.
Eccleston C, Crombez G. (2007). Worry and chronic pain: A misdirected problem solving model. Pain, 132(3), 233-236.
Hayes, Jacobson, Follette, Dougher. (eds)(1994). Acceptance and Change: Content and Context in Psychotherapy. Reno, Context Press.
Lachapelle, D.L., Lavoie, S., & Boudreau, A. (2008). The meaning and process of pain acceptance. Perceptions of women living with arthritis and fibromyalgia. Pain Research & Management, 13(3), 201-210.
Risdon, A., Eccleston, C., Crombez, G., & McCracken, L. (2003). How can we learn to live with pain?: A q-methodological analysis of the diverse understandings of acceptance of chronic pain. Social Science & Medicine, 56(2), 375-386. doi: dx.doi.org/10.1016/S0277-9536(02)00043-6