Dancing around the hexaflex: Using ACT in practice 4

Acceptance and commitment therapy (ACT) can be slippery to describe. It’s an approach that doesn’t aim to change thought content, but instead to help us shift the way we relate to what our mind tells us. It’s also an approach focused on workability: pragmatic and context-specific analysis of how well a strategy is working to achieve being able to do what matters. Over the next few posts I want to give some examples of how non-psychologists can use ACT in session (remember ACT is open for anyone to use it!).

Willingess (Acceptance) – Choosing to experience it all

Do you remember the poignancy of a beloved pet dying? ‘Crossing the Rainbow Bridge‘ was written by 82-year-old Edna Clyne-Rekhy, who wrote the poem at age 19 in 1959, at the passing of her beloved dog, Major (Wikipedia entry) and tells of the reunion of pet and pawrent years later when the pawrent dies. It’s sweet and sad at the same time, and while I’m not convinced there is a Rainbow Bridge, the loss of a pet is a time of heart-wrenching grief. And yet the years of unparalleled love of a pet leads inevitably to this time. If you love, you hurt when that love isn’t there any more.

Willingness is like that. It’s about recognising that for every ‘up’ emotion, there are equivalent ‘down’ emotions. And that by feeling all the feels that life offers, we move through life moment by moment.

Willingness for pain

Willingness in pain management and rehabilitation often focuses on people being willing to experience pain. Willingness in this sense being quite different from resignation to, or giving up, or resenting, or ‘getting on with it despite’. Willingness is about choosing to make room for pain to be there without trying to change, control or avoid it – because it’s worth it. And like all ACT processes, willingness is a process we can work towards, titrating the difficulty to suit where we’re at in the moment.

By drawing on what is important to the person (their values) and using the other processes, being willing to do things with pain along for the ride is possible. We use this a lot in acute pain: people volunteer to have surgery (painful) so that a better health outcome is possible; women go through childbirth (painful) so they have a new life to raise; runners train (painful) so they can enter races or keep fit. The ‘so what’ gives meaning to pain and people are willing to do what it takes, even if it’s painful, so they can achieve it.

In persistent pain, it’s not quite as straightforward. The pain may not change a lot, so the promise of ‘do X to get Y’ isn’t quite as clear cut, especially if as a clinician you don’t feel terribly confident that it’s OK to experience pain. Some people really don’t want to experience pain even though they can do all the things they need and want to do. That can be confronting especially if there is no certainty that pain will reduce or go. I’m not sure I have a remedy for that, because it’s predicated on the idea that pain should not be present. And yet, there it is in at least 22% of New Zealanders, and there are many painful problems for which we have very little we can do to reduce pain. Willingness acknowledges the reality that pain is there.

Willingness is a yes or no thing.

And we’re willing (yes or no) depending on context. I’m willing to have a flare-up after gardening at the beginning of the season because:

(a) I know it’s not a sign of harm (cognitive defusion)

(b) It’s worth it getting my garden ready for spring (values)

(c) I’ve set my target intensity to something I can handle (committed action)

(d) I’ve done it before and I know I’ll get over it (self-as-context)

(e) Along with the achey bits, I also have the sensory experiences of freesias blooming, the texture of compost as I spread it over the garden, the tiny pink buds of blossom just starting to show, the birds (except the blackbirds and thrushes digging my poor wee seedlings up!!), and at the end of the day I savour the achievement. AND I know that as I keep gardening my tendency to flare will settle.

I’m less willing to hurt just to vacuum the house.

Willingness isn’t just about pain

But it’s not just about being willing to experience pain. It’s also about being willing to experience other negative emotions that show up because we have to adopt new and different ways of doing to accommodate pain. For example, I don’t weed my entire garden in one day. That’s frustrating – and I would rather not be frustrated! Willingness means being OK to do less – and feel frustrated – because I know I want to do other things this week, such as write this blog.

Willingness means being OK to be vulnerable enough to ask people for help – and risk rejection. To say no to things – and risk censure. To take time for yourself – and risk criticism for ‘being selfish’. To do new and unfamiliar practices like meditation, or take medication regularly, or develop priorities, or seek accommodations at work. People need to be willing to do things differently at work – and face negative comments from colleagues. They may be repeatedly asked why they haven’t been asking for an MRI – when they’ve been told it’s not needed.

ALL of these actions might be uncomfortable, even lead to negative consequences at first. Any time clinicians ask someone to do something that’s not familiar to the person in their life, that person risks feeling uncomfortable and needing to be willing to stick to their guns. This means clinicians, we need to look at ways to help the person use the other processes in the hexaflex, and titrate the demands, so they can do the things. And we need to be oh so careful not to assume that the person is ‘unmotivated’ if they struggle to do the things.

Tips for beginning willingness

• Remember it’s a process, so start by dipping in to willingness: 5 minutes of being willing to do a body scan and experience pain; one request for help today; 5 minutes break having a coffee (instead of continuing to work at your desk); a 5 minute walk
• Rehearse what to say, if it’s about asking someone to do something, or make accommodations for you, or to say no to something.
• Dig deeply into the values doing this thing draws on: remember the why! “It’s important to do only this part of the garden because I want to make tea for my family tonight”
• Use cues to remember how much, how long, why – and if you like monitoring yourself, these can be great progress reports so you can see that you are moving forwards.
• Give yourself permission to do things differently because ‘It’s part of your rehabilitation’ (self-as-context AND cognitive defusion).
• Nudge into new things gently – it’s OK to start, monitor, review and repeat.
• Acknowledging that this is not easy helps you remember and be compassionate towards yourself. You are bravely being present with what is. This is courage.

An exercise for willingness is here: click

Some cool web-based resources:

Willingness Skills for More Regulated Emotions

Willingness in difficult times: Holding the cactus gently

Thompson, M., & McCracken, L. M. (2011). Acceptance and related processes in adjustment to chronic pain [Review]. Current Pain & Headache Reports, 15(2), 144-151.

Foulk, M., Montagnini, M., Fitzgerald, J., & Ingersoll-Dayton, B. (2023). Mindfulness-Based Group Therapy for Chronic Pain Management in Older Adults. Clinical Gerontology, 1-10. https://doi.org/10.1080/07317115.2023.2229307

Pester, B. D., Crouch, T. B., Christon, L., Rodes, J., Wedin, S., Kilpatrick, R., Pester, M. S., Borckardt, J., & Barth, K. (2022). Gender differences in multidisciplinary pain rehabilitation: The mediating role of pain acceptance. Journal of Contextual Behavioral Science, 117-124. https://doi.org/10.1016/j.jcbs.2022.01.002