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!).
Values: Qualities of living
Oh so much has been written about values…Values bring meaning to what we do every day, values give us the ‘why’ we dig deep, values guide the directions we take, and help us understand what really matters.
Apparently, the Dalai Lama is quoted as saying “Open your arms to change but don’t let go of your values” and from all the things I’ve done as an occupational therapist, this quote resonates the most. Even when the end result doesn’t look the same as the old way (form), occupational therapists are all about helping people do what matters most (function).
Describing and defining values
Most clinicians learn ‘SMART’ goals (ewww!). Specific, measurable, achievable, relevant, and time-bound… These, friends, are not values. These are actions that are intended to help people achieve goals. Things we can tick off a list and say to ourselves “I’ve done it.”
Values are directions, qualities of how we want to be in our world, what we want our lives to stand for, principles we hold dear. Many people I’ve seen in clinic tell me that ‘being reliable’, ‘being a good partner’, ‘being there for my family’ are the values they hold close.
We can never tick a value off our list and say “I’ve done it” (though we can choose to alter our values if we want).
Let me give you an example. Creativity is a value I embrace. Being able to express myself in crafts, music, dance, gardening, clothing choices – combining diverse elements in a new way so I create something unique is a guiding principle, a value in my life.
Making a piece of jewellery is a goal. I can tick that goal off my list, and say “I’ve made that, I’ve done it” and move on to the next expression of creativity. Perhaps it will be gin-making, or writing or planting a hanging basket. Each of these end results are goals. If I wanted to, I could write a SMART expression of those goals. My focus while doing them is often on the end result: did I make a piece of jewellery? did I create a nice gin? but what matters is that I’ve been creative. At least one day in every week.
And I’ve expressed my creativity in many ways. Sometimes it’s through refreshing the way I do my teaching, other times it’s in creating a handout, it could be experimenting with a new recipe. The form of my creativity comes in all sorts of ways. But the function of all these acts is to express my creativity.
How might we use values in pain rehabilitation?
When something matters to us, we dig deeply and persevere even when the going is tough. Just ask a parent! Being a good parent is a common value, and we all know that parenting a grumpy teenager is not always peachy sweet! We do the hard things because the over-riding value we have is important to us.
In therapy, we’re often asking people to do hard things. Some of the things are about moving when it feels painful, or the person is afraid. Some of them are about slowing down and not completing a job ‘the right way’ or at all! We set goals to achieve the end goal of ‘getting better’ (whatever that looks like), and all the things done in the name of recovery are intended to help the person get there.
When the end goal of ‘getting better’ is imbued with important values, we can ask the person to remember why they want to do the hard things. Doing so helps with grit, determination and perseverance. For example, if the person is a runner, and their ‘getting better’ is about resuming their 10km run, we can ask the person what it is about running that really matters. It could be ‘being outside’, ‘pushing myself hard’, ‘feeling my body being strong’, ‘social connections with the running club’, ‘dealing with my stress.‘ All of these are powerful reasons to follow the rehab plan, and they’re intrinsic for the person.
The fishhook in goal-setting
While goal-setting is something we know helps with rehabilitation, there is one fishhook that can trap us as clinicians, and the person we hope we’re helping. The negative of goal-setting is that it can focus all of our attention on the end goal. The tick of ‘yes I’ve done it.’
What’s wrong with that? It’s great to celebrate the achievement for sure, but it can take the focus away from noticing what is going on as we progress towards the goal.
The old quote ‘Life’s a journey not a destination’ might be hackneyed but oh my it applies to goals and goal-setting. The journey is life. The actions taken to progress towards a goal are also life. We can become relatively insensitive to what is going on in each moment, each action we take to achieve the goal, and once the goal is done and dusted – we go right ahead to set another goal, and once again may not pay attention to the process of achieving it. What missed opportunities to savour what is, to relish the present, to absorb all that is in the now, and to enjoy how we get from here to ‘there’ wherever that may be.
How can we combine the good that comes from structured goal-setting with the fulfillment that comes from expressing values?
I’ve dropped the old SMART goal acronym. I now talk of actions. Living well with chronic pain means making incremental changes in my actions so that my life expresses what I really value. Actions are either done – or not done. Yes or no. Not half-done, or dropped part-way because I got bored or it was hard. Living my values happens all the time, everywhere, in all that I do. I build my actions into my habits and routines, values inform the occupations (daily meaningful activities) I choose so that over time my life looks like the values I hold.
I use the Choice Point, as originally developed by Russ Harris and colleagues. After working with a person to define and prioritise their values, we work through a specific value they want to express. We identify ‘Hooks’ that can get in the way of actions to move towards what matters, and ‘Helpers’ that support making effective choices. Then many times over a day the person can check in and ask themselves “Is my next action going to take me towards what matters, or away?”
Does using values as a guide to action (instead of ‘SMART’ goals) help? Well, of course I’m going to say yes, but here are some papers that seem to show that values and actions done every day in line with values makes a difference for people with pain.
First, here’s this one from Johanneson et al., (2023) where participants with long-standing CRPS identified that values helped them prioritise what they chose to do in daily life, enhancing social connections and increasing their sense of acceptance.
Fischer-Grote and colleagues (2021) found that “perceived importance and success of life values and their related inhibitors and facilitators may differentially affect CLBP patients. Considering such individual aspects is therefore of utmost importance to improve patient care, as they enable treatment goals and the therapeutic strategies to be adapted accordingly.” Like, duh… why wouldn’t individual values influence what a person wants to spend their energy on?
And one for the records from 2006 – can you believe how long McCracken and colleagues have been looking at this stuff? And how little has got through to clinical practice… sigh… McCracken & Yang (2006) looked at values-aligned action and outcomes from chronic pain programmes, and surprise (not!), “Regression analysis showed that success at living according to values predicted variance in functioning independent of acceptance of pain, supporting its incremental utility in a contextual analysis of chronic pain and its potential importance in treatment for chronic pain.”
Points to take home
- Chronic pain erodes a person’s sense of self, their ability to do what matters in their life, while much of our rehabilitation involves asking people to do things foreign to their usual world.
- Values give life to life, add purpose and meaning to what we do.
- Goals and goal-setting can, if we’re not careful, misdirect our (and our patient’s) attention away from the process of savouring how we live. Actions taken in everyday living infuse values into daily life – and for people living with pain, help make life meaningful, even if the form of how life is lived differs.
- Clinicians: never lose sight of why people want to get better. Help people take actions that lead towards what matters to them, making sure that while the form of values-based actions may change, the function those actions play in supporting values is never forgotten.
Fischer-Grote, L., Tuechler, K., Kienbacher, T., Mair, P., Spreitzer, J., Paul, B., Ebenbichler, G., & Fehrmann, E. (2021). In-depth analysis of life values and their corresponding inhibitors and facilitators in chronic low back pain patients: A mixed-method approach. J Back Musculoskelet Rehabil, 34(2), 207-219. https://doi.org/10.3233/BMR-200034
Johannesson, C., Nehlin, C., Gordh, T., Hysing, E. B., & Bothelius, K. (2023). Patients’ experiences of treatment-relevant processes in multimodal pain rehabilitation for severe complex regional pain syndrome – a qualitative study. Disabil Rehabil, 1-8. https://doi.org/10.1080/09638288.2023.2209744
McCracken, L. M., & Yang, S.-Y. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain, 123(1-2), 137-145. https://doi.org/http://dx.doi.org/10.1016/j.pain.2006.02.021
The series:
Hexaflex 2 – Self-as-context/perspective-taking
HealthSkills Blog 
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