ACT – Acceptance & Commitment Therapy

ACT plus exercise, vs exercise alone…

and what a shame there was no ACT alone group…

No secret here, I like ACT (Acceptance and Commitment Therapy) as an approach for living well with chronic pain. I like it for many reasons, but probably the most compelling ones are that the hierarchy between therapist and person living with pain is minimised (we’re both humans finding our way through life) and that it doesn’t require the person to delve into challenging or disputing thoughts – this in turn enhances adherence to the core elements of ACT: living a life aligned with what really matters to this person. People seem to find using ACT more appealing than other forms of therapy for chronic pain.

Anyway, just recently a new study investigating ACT plus an additional exercise component (for eight weeks of physiotherapy supervised exercise, and ACT led by a psychologist), vs a supervised exercise programme only. This recent publication is a 12 month follow-up from the original (Casey et al., 2022).

The design of this study involved participants referred to an outpatient musculoskeletal clinic living with any chronic pain condition. Participants were excluded from the trial if they needed further diagnosis, experienced a major medical or psychiatric diagnosis, had cancer, an ‘unstable’ inflammatory condition, substance misuse, some kind of surgical or interventional procedure in the previous 3 months, were part of another supervised exercise programme or were taking part in psychological or physiotherapy treatment, or had attended a previous multidisciplinary pain programme – or couldn’t exercise because of some contraindication.

The two approaches were: (1) an ACT programme with exercise – 8 weeks of once a week two hours of ACT, then a 1.5 hour of exercise led by a physiotherapist who had not undertaken ACT training; and (2) 8 in-person supervised physiotherapy exercise sessions that followed the same structure as the ACT plus exercise. The same therapist led both groups of participants in the exercise component.

The primary outcome was pain interference as measured by the Brief Pain Inventory at 12 months follow-up, with secondary outcomes of pain intensity (BPI), the Patient Health Questionnaire-9 for depression, and the General Anxiety Disorder-7 to assess anxiety. Patient satisfaction was measured, along with the Patient Global Impression of Change. “Process” oriented measures (designed to measure factors thought to change over time and influence outcome) of pain self efficacy, pain catastrophising and the TSK were also taken, along with two measures from ACT, the Chronic Pain Acceptance Questionnaire and the Committed Action Questionnaire.

There were some intriguing changes to the original protocol including redefining some of the measures from outcomes into process measures, and the exercise intervention wasn’t fidelity tested.

What did they find? Well, a bit underwhelming for a person who likes ACT, to be honest! Both groups showed the same amount of pain interference, though with a slight tendency towards the ACT + exercise group which became significant only at one year. No other differences between the two groups were identified with the exception of slightly reduced pain catastrophising in the ACT + exercise group. Participants were happy with the ACT + exercise programme vs the exercise only, and the same participants reported positive responses to the global impression of change question.

Interestingly, there were more drop-outs from the exercise-only group, and the authors also report that the therapist contact time wasn’t equivalent. With a very low follow-up response rate (slightly higher for the ACT + ex group), again it’s not really possible to definitively know just how effective either approach was. The authors also point out that participants weren’t encouraged to use ACT approaches during the exercise part of the ACT + exercise programme because the physiotherapist wasn’t trained in ACT.

Some unanswered questions for me from this study, which was well-conducted within the confines of funding and patient availability.

One big question for me is why movement practices aren’t routinely part of ACT for chronic pain anyway. Certainly the way I practice, and the way physiotherapists I know who have learned ACT and use it routintely, wouldn’t add a non-ACT-based movement intervention into the mix. Given we know that movement practices are an ideal context for employing ACT methods, I’m curious as to why the principles that have been part of CBT approaches to pain management (ie all the team adopt the same over-arching model, employ the same strategies) weren’t adopted here. It’s during movement practices that sticky thoughts arise, and when leaning in to discomfort with pain and anxiety and sadness is highly relevant. They’re also a great time to work with self-as-context given how relevant self-concept is when setting movement practice challenge intensity. Of course, I’d still argue that movement practices can be decontextualised from daily life, and there is always a need to get out of the clinic and into the real world, however even in a ‘gym’ or ‘exercise class’ setting there are opportunities for physiotherapists (and other movement practitioners) to apply ACT strategies.

That the team members didn’t share skills across the team raises yet again the problem we have with siloed treatment. Interprofessionalism is sorely needed to ensure consistent practice of any kind of approach, whether it’s a physio using ACT to work with sticky thoughts and mindlessness, or it’s a psychologist understanding enough about movement and bodies to reinforce that movement is a good thing. It’s like the interprofessional nature of chronic pain management hasn’t yet gone very far, and I wonder why given how many decades it’s been since this was first proposed (at least since 2005, see McCallin, 2005).

Arguing for exercise (about which we know a reasonable amount) head-to-head with ACT + exercise feels a bit redundant to me. We know movement is a good thing. We know the effect sizes are small on both pain intensity and disability, and we know these are consistent findings for almost any treatment approach for chronic pain. We also know that ACT for chronic pain is slightly better adhered to than other forms of therapy, and that it seems especially helpful for people who avoid and are freaked out (though not so much as to make us use it everywhere). What we don’t know, and this study, along with many others, can’t tell us, is whether it made a big difference to the unique and individual daily lives of participants.

Some other missing information that I’ve commented on before. We don’t know the regular movement practices of participants prior to entering these programmes. We don’t know whether participants maintained their movement practices beyond the end of the eight week programme. We have no idea whether the movement practices were enjoyed by participants although we do know that people attending the ACT + exercise were more satisfied than those just attending exercise. We don’t know anything about their lifestyles before, during or after the study, so we don’t know whether the gym or hydrotherapy were exercise practices they valued. We also don’t know whether they transferred any of the learning from the movement practices into other parts of their lives – step counts do not equal daily life. We don’t know anything about the participants family life, their sense of curiosity and joy, or even whether participants who weren’t working during this study were able to return to work or find work.

If we are going to be serious about helping people with persistent pain live lives they value, isn’t it important to find out what people want to be able to do in their worlds? If we want to know how well a therapy works, shouldn’t we attempt to find out a bit more about the person’s world so that anything we offer can actually be done long-term? Life is more than a series of exercise programmes and psychotherapy – life is full of surprises, awe, devastation, busy periods, slow times, grief, love, births, deaths and other health problems. While designing studies is hard, I wonder if we’ve come to the end of the usefulness of further studies exploring movement/exercise for chronic pain. The studies don’t seem to be adding much – just that movement practices are good for health. We kinda know that. Let’s get far more creative and work out how people can integrate all sorts of movement practices for the entirety of their life, throughout all of their life contexts, in all that they do. And let’s do the same for ‘psychological’ approaches. In fact, can we move from siloed ‘physio, psychology, OT, nursing’ and into ‘pain therapists’ and remove the death grip we seem to have for ‘our unique contribution.’ We have far more in common than not in pain therapies, and there is considerably more power in a united approach than a fragmented one.

Casey, M. B., Smart, K. M., Segurado, R., Hearty, C., Gopal, H., Lowry, D., Flanagan, D., McCracken, L., & Doody, C. (2022). Exercise combined with Acceptance and Commitment Therapy compared with a standalone supervised exercise programme for adults with chronic pain: A randomised controlled trial. Pain, 163, 1158–1171. https:// doi. org/ 10. 1097/j. pain. 00000 00000 002487

Casey, M. B., Takemasa, S., O’Reilly, T., Leamy, M., Mc Kearney, E., Buckley, M., Smart, K. M., Segurado, R., Lowry, D., Flanagan, D., Gopal, H., Hearty, C., & Doody, C. (2024). Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial. European Journal of Pain. https://doi.org/10.1002/ejp.2229

McCallin, A. (2005). Interprofessional practice: learning how to collaborate. Contemp Nurse, 20(1), 28-37. https://doi.org/10.5172/conu.20.1.28

Dancing around the hexaflex: Using ACT in practice 6

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 (remember ACT is open for anyone to use it!) can use ACT in session.

Actions: It’s what we’re about

You know the old saying “All talk, no action”? There are times I think people with pain get much more talk-talk-talk than action, and the actions that get done are those to please other people. Let’s unpack the ‘committed action’ part of the ACT hexaflex.

Actions are either done – or not. No half-actions here! Goals, as I mentioned in Using ACT in practice 5, can take our focus away from what we are doing to what we hope we’ll achieve. In other words, goals can take us away from the intrinsic experiences of moving towards something that matters. If we’re only looking at ticking the goal off our to do list it becomes hard to be in the moment as we journey towards that result.

But if we look at rehabilitation practice, particularly if we’re funded by an insurer who wants to see ‘outcomes’ because they’re paying for it, often we see a list of ‘goals’ the person must achieve for therapy to be considered a ‘success.’ Do these goals help the person move towards what matters long after the therapy programme is done and dusted? Do people still do those things when they’re discharged from our care? And for chronic pain management, surely most of the self-management options are exactly those things the person will need to do for life?

Actions done differently

I hope it goes without saying that actions need to align with a person’s values.
People must know why their actions are important. People also need to know that they can achieve them, or that they can achieve them with a push.

You see, rehabilitation is a scaffolding process. We simplify aspects of a task so the person can achieve it, then we progress the tasks until the person reaches as far as they can. By simplifying, I mean we modify movements, or weight, or speed, or the environment; we remove unpredictability and complexity so the person can focus on just the parts they need to, maybe we include ourselves as a safety net, so the person knows we won’t let them come to harm. We celebrate as they achieve the task. And we always must remember that scaffolding eventually comes down.

I like the way FACT therapists are taught to establish actions. They’re called ‘behavioural experiments’ – opportunities for the person to do an action and observe the result. The way this is done is pretty cool.

Firstly the person has identified what matters to them. The therapist has carried out a case formulation and identified the person’s strengths and vulnerabilities on the three pillars (Openness, Awareness, and Engagement), and with the person develops two actions they can choose from. One action has less effort and less risk and has more certain results, while the other requires greater effort and potentially can promote more radical change.

Now these actions can use SMART features (you know – specific, measurable, achievable, relevant and timely), but the key is that they’re tied to helping the person move towards what matters, to enhancing psychological flexibility – and the best part is that the person can choose which one they’d like to do.

Importantly, obstacles to doing these actions are always discussed and there’s a good deal of problem-solving about how to make sure they do fit in to the person’s life. At the same time, the person is invited to draw on the other parts of the hexaflex (or three pillars) as they do this action. They’re asked to notice (mindfulness), to be willing (even if it’s a bit scary), to put their mind’s chatter to one side so they can choose for themselves (defusion), and to be willing to take a different perspective as they give it a go.

More than this, when they’ve tried the action, they get to debrief. They’re supported to review what they did (action), how it felt (mindfulness/noticing), whether the action took them towards or away from what matters (values), how else they could do it (variation), and what their next step might be.

Even more cool: if the person ‘didn’t do it’ this is not a failure! Instead, it’s an opportunity to:

Give credit to the person for being willing to show up and tell you they didn’t do it (it’s an unpleasant feeling to know you’ve not followed through)
Establish what mattered more, what was it about the action or the context, or other parts of the hexaflex that might have either hindered or helped
Reconsider the values underpinning that action – and did you as therapist mistake what was important
Be flexible about what the action looked like. How else could the person do it? There is always more than one way to move towards…

A bit far from the old ‘do what I advise because I’m the therapist’!

Actions are ongoing

An action is one event, and life is usually not isolated into single events. If we want to go towards the mountains, there’s often a river or a swamp to get through before we start going uphill. We need to make decisions about how we’re going to get through the river or swamp – and some of the actions we subsequently take look like they’re moving us away from getting to the mountain. We could choose to wade thigh-high across the river to head directly to the mountain, or we could do a detour and go over the bridge, then head towards the mountain.

This is life. Therapists will need to help people keep their eyes on the prize – and often to help funding agencies recognise that getting towards the mountain without wading across the river means doing a detour. It’s part of the journey. If we have a bird’s eye view or we’ve used a map, we can see why doing the detour is important. We have a different perspective – and sharing that perspective both with the person and their whānau/family and the funding agency – can help them see why the detour is relevant and necessary.

When the person finds the journey hard, the detour weird, can’t see the mountain because the swamp reeds are way too high, our job as therapists is to help them see the map. Remind the person of their values – why they wanted to go towards the mountain. It’s not our job to just advise on the next road to take, or that the detour is necessary. It’s our obligation to help keep the person’s eyes on the prize while also helping them savour the journey getting there.

In other words, while we might offer advice about how a person moves towards what matters in their life, it’s not our job to focus only on that. We’re there to help them do what matters to them. Sometimes that means we need to recognise we’re not the right guide for this part of the journey. This is where teamwork comes in.

Points to take home

Actions are what we do – we can’t predict outcomes, but we can decide to do, or not do, actions.
A move towards what matters is progress, even if it’s small.
Notice what happened when taking that action. Bring awareness to all that happens when doing the action – even the uncomfortable, awkward newness of it.
Draw on why that direction is important.
Take a bird’s eye view if it feels like you’re taking a detour. Get someone else’s perspective because they might have a bigger map.
It’s OK to drop an action if it no longer serves you. If it’s not helping you move towards living your values, and you can’t see how it fits in – maybe it’s scaffolding you don’t need any more. You can always pick it up again if you find that it was helping.
There are usually lots of different ways to move towards what matters. You don’t have to be stuck doing the same old, same old – try some variations!

For some thought-provoking papers on goal-setting in rehabilitation, this one by Gibson and colleagues makes me ponder: Gibson, B. E., Terry, G., Setchell, J., Bright, F. A. S., Cummins, C., & Kayes, N. M. (2020). The micro-politics of caring: tinkering with person-centered rehabilitation. Disability & Rehabilitation, 42(11), 1529-1538. https://doi.org/10.1080/09638288.2019.1587793

This paper by Crawford and colleagues details barriers and facilitators for person-centred goal-setting: Crawford, L., Maxwell, J., Colquhoun, H., Kingsnorth, S., Fehlings, D., Zarshenas, S., McFarland, S., & Fayed, N. (2022). Facilitators and barriers to patient-centred goal-setting in rehabilitation: A scoping review. Clinical Rehabilitation, 36(12), 1694-1704. https://doi.org/10.1177/02692155221121006

The series:

Hexaflex 1 – Mindfulness

Hexaflex 2 – Self-as-context/perspective-taking

Hexaflex 3 – Cognitive defusion

Hexaflex 4 – Willingness

Hexaflex 5 – Values

Dancing around the hexaflex: Using ACT in practice 5

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 1 – Mindfulness

Hexaflex 2 – Self-as-context/perspective-taking

Hexaflex 3 – Cognitive defusion

Hexaflex 4 – Willingness

Hexaflex 5 – Values

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)

(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

Dancing around the hexaflex: Using ACT in practice 3

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!).

Cognitive defusion

I’m guessing that for psychologists and those who primarily work with thoughts, it feels natural to begin here, but maybe all humans jump to talking rather than doing because this is the biggest distinction between us and other animals.

Cognitive defusion refers to making some space between a thought or belief, and what we do next. It’s not just about actions we take, but also how seriously we hold on to the opinions of our mind.

The language theory underpinning ACT is relational frame theory. This theory explains how humans rapidly acquire an understanding of relationships between concepts, and why these learned relationships become so ‘sticky.’

For a full description of RFT, this is a great place to begin [Youtube playlist]. If you’re a reader, not a video watcher, I love the paper by Beeckman and colleagues (2019) (listed below).
The topic is pretty technical, so I’ll simplify it and just say that humans learn to relate to one concept (stimulus) based on how it is related to another stimulus (concept). We do this directly through our personal experiences, but we also do this by arbitrarily relating concepts (stimuli) to other concepts using language, and from these relationships we develop relationships between those associations to even more associations that have never been experienced or been talked about!

Some of these verbal rules make sense – in some contexts. For example we know that Geoff, going for knee surgery might be told ‘walking is not as painful as cycling, and cycling is not as painful than climbing a ladder.’ Geoff has surgery, and the knee is painful during initial mobilising. Because Geoff has also been told that cycling will be more painful than walking, and that climbing a ladder is even more painful than that, during his recovery he will avoid both cycling and walking. Why? Because he’s combined the ideas of ‘walking=ouch‘ with ‘cycling=OUCH‘ and ‘ladder climbing=OUCH.’ Even though cycling and ladder climbing don’t look like walking, and even though he hasn’t ever personally experienced pain while either cycling or climbing a ladder since his surgery. AND it makes sense not to go nuts and cycle or climb ladders in the early days of recovery.

Some of the verbal rules hang around longer than helpful. If Geoff follows the rule of not cycling or climbing ladders – it’s initially helpful, but if he’s later advised it’s OK to now go cycling and climbing ladders but his wife is worried and instead keeps telling him not to do these things, he may not try them out and continue avoiding. Following the rules that were relevant early after surgery helped, but the negative consequences of annoying Geoff’s partner stops him from ‘disobeying.’ And Geoff never experiences what really happens if he tries cycling or climbing a ladder: the verbal rules win!

What can we do about these really sticky verbal rules?

One of the most popular approaches to getting people on board with pain rehabilitation is explaining pain neurobiology and the poor relationships between pain intensity and what’s going on in the tissues. Information, like ‘explaining pain’ or drawing a network diagram showing links between thoughts, emotions, physiological arousal, pain and activity can help give people a bit of distance between their immediate thoughts (based on initially useful rules), and being OK to begin therapy. It’s pretty helpful, has been part of pain management and rehabilitation ever since Fordyce and Main and the early pain psychology researchers. It doesn’t change pain very much, but then it wasn’t intended to! It’s meant to help people feel more confident about doing their movement-based therapy.

So that’s one thing we can offer. But what do we do if the person just does not believe us? If the rules the person’s learned are really sticky – like ‘I have a disc prolapse and that jelly stuff is oozing out of my disc’, or ‘I have a weak core and if I don’t hold it in my vertebrae will go out of alignment’? What do we do then?

Doing beats talking

This is where therapists can draw on strengths the person has in other processes of the hexaflex. For example, I often use values (and I’ll bet many of you do!). We might say ‘Geoff, if you want to recover, we’ll have to do these exercises first – they’ll be in the ‘orange zone’ where they’re a bit uncomfortable, but you’ll be safe.’ We’re drawing on the value Geoff places on recovery to help him be willing to something that goes against the ‘rule’ he’s learned, and making the initial actions relatively easy to do so he achieves success and the anxiety isn’t too high, using ‘behaviour under appetitive control.’

We might use mindfulness, as I suggested in the first article in this series. We might say ‘Geoff, would it be OK to mess about with attention for a bit while we start experimenting with some little movements – can you bring your mind to your breathing? And can you step up on this wee box? What do you notice in your breath right now?’ In doing this, we’re bringing his attention away from the rule he’s learned and towards his own sensory experience. This helps anchor him to the here and now, and with our guidance, helps him to use his own experience to guide both his actions and how closely he follows the rules he’s learned.

We can also draw on self as context by reminding him that during the early days of his recovery, he was a patient, and now he is becoming himself again: see how far he has come from the early days after surgery!

The cool thing about using the other parts of the hexaflex is that we’re not arguing with them and instead we’re helping them develop a different relationship to those thoughts. So it can be fun to give the thoughts names: ‘ooh that’s my mind being my dictator!’ , ‘the devil on my shoulder’ or ‘the parrot’. Some people think of what their mind tells them as a lot like an off-station radio, or the passengers in a car all having an opinion but the driver gets to make the decision about whether their conversations are worth listening to.

Literally hundreds of metaphors and ways of developing a different relationship with thoughts have been written about in ACT. Some great resources include the Big Book of ACT Metaphors (Stoddard and Afari, New Harbinger Press, 2014); examples from Radical Relief by Joe Tatta , and content on the ACBS website .

But I have two wishes: 1) that we stop reverting to talking just because it’s easy and doesn’t make us feel too uncomfortable and instead 2) we draw on experiential learning and use the other processes in the hexaflex. Doing is so much more potent than talking, and from my experience, transfers to life outside the clinic much more readily. And that, folks, is where life is lived.

Beeckman, M., Hughes, S., Kissi, A., Simons, L. E., & Goubert, L. (2019). How an Understanding of Our Ability to Adhere to Verbal Rules Can Increase Insight Into (Mal)adaptive Functioning in Chronic Pain. Journal of Pain, 20(10), 1141-1154. https://doi.org/10.1016/j.jpain.2019.02.013

Fordyce, W. E. (1984). Behavioural science and chronic pain. Postgraduate Medical Journal, 60(710), 865. https://doi.org/10.1136/pgmj.60.710.865

Kendall, N. A., Linton, S. J., Main, C. J. (1997). Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain: Risk Factors for Long-Term Disability and Work Loss. Wellington, NZ

Waddell, G., Main, C. J., Morris, E. W., Paola, M. D. I., & Gray, I. C. (1984). Chronic Low-Back Pain, Psychologic Distress, and Illness Behavior. Spine, 9(2), 209-213.

Dancing around the hexaflex: Using ACT in practice 2

Self as context

From my experience, this process is possibly the least well understood of the ACT hexaflex processes. This is my interpretation, drawn from listening to people like Kevin Vowles, Lance McCracken, Steven Hayes and Kirk Strosahl.

Essentially this process is about stepping back from assumptions and requirements of socially constructed ideas of who we should be. It reflects the ability to see another perspective without having to take that perspective as your own. I see it has having two facets: (1) who am I being in this moment? and (2) what other perspectives might I be able to understand in this moment?

When I’m working with someone living with pain I often see a deep sense of shame and alienation from what the person views as their sense of self. I might see grief and anger about what the person must do in everyday life. Things like having to move slowly, take medications, stop doing things they love, and follow administrative processes just to get treatment and/or compensation. Initially, at least, these feel completely alien – and while for a time adopting the ‘sick role’ is socially sanctioned way, as pain lingers this becomes less OK both to the person and those around them. The sick role doesn’t fit well with the old self – but the old self is so far away, the sick role sticks.

I also see efforts to retain parts of the ‘old self’ – this might look like using the same old ‘grit your teeth and burn through it’ because the old self was a really hard worker, or a competitive athlete, or a strong person who never gives up. It might also look like seeking help from all manner of clinicians because the ‘old self’ is always successful, always finds the problems and fixes them.

As time goes on, people can take on the ‘self’ that’s imposed on them by compensation organisations, or clinicians – the ‘compliant’ patient, the ‘litigant’, the ‘victim’. These might be foreign to the person’s usual sense of self, but often build upon other long-held attitudes and beliefs and seem to coalesce into a ‘new me’. They may blame others for their predicament, they may be helpless, they may not do what they’ve agreed to – and it may stem from this sense of ‘I’m not me, I’m this [sad, sorry, angry, victim, patient, feared-self]‘.

People may find it hard to resume doing things that matter to them not because they don’t want to, but because it’s so incredibly sad to have to start at a significantly lower level than the self-concept they hold about themselves: ‘I’m an athlete’ means being able to work at a high level of physical strength, and here they are just walking around the block and that’s hard.

The second expression of self as concept, as I understand it, is being able to take another person’s perspective – to try it on for a moment to gain a new understanding of the situation, or what to do. A bit like the exercise ‘what would you say to your neighbour, if they were in your shoes?’ We can be a lot kinder to other people than we are with ourselves, right? We can also use this perspective-taking as a way to view a future self, or to understand or nurture a younger self. If the person is telling you what seems like an old story of ‘being the carer for a parent’, helping them take the perspective of their younger self, but with the wisdom of now being an older and wiser self, can help them have compassion for their younger self while also showing that they are strong and capable, even if they currently feel overwhelmed and weak.

How can we use self as concept in therapy?

Apart from the ‘what would you say to your neighbour’ exercise, or the self compassion for their younger self, there are a heap of ways we can use this process. One I like to use is time – let’s measure progress from when you were at the very beginning of your rehab, not from when you were at your very best.

We don’t need to have warm and fuzzy feelings about our current self – because that can turn into a rule ‘I must be better at loving myself, so I must work hard at feeling loving towards myself.’ Remember, ACT is about action – not feelings! If you want to show yourself (and your patient/client) how hard it is to change feelings, just try asking yourself to feel genuine, warm and compassionate feelings towards someone you just don’t like very much! Yep, it doesn’t happen.

And if we can’t manufacture loving feelings towards someone else, why would we think we can do it towards ourselves, if we don’t like ourselves very much? If the person is a parent, or even a pawrent of a pet, I like to draw parallels with the actions we take that demonstrate our love for our children (or furbabies). There are times when we just don’t feel that charitable towards our kids: I remember the horror and anger I felt when one of my children drew on, and cut into, the fabric of my sofa! And yet I still cooked tea for them, washed their clothes, got them off to school and did all those ‘parental’ things – in the name of love and being a good parent.

What actions could this person take to show love for their ‘self’? Perhaps acknowledging that although it’s hard, they did the mindfulness they agreed to do. Maybe they gave themselves the gift of 5 minutes not doing anything. It could be any small act of compassion towards themselves.

Rehabilitation is also a time of reflecting on what matters in life – and this can include ‘who I want to be’. Now might be a good time to consider what rules about ‘self’ have been in place, and consider how well they’re serving the life they want. Considering and then expressing the things that really matter (values) helps begin developing a new sense of self – and as my PhD studies showed, people want to ‘re-occupy’ a sense of self that feels like them. In part, people want to still express those underlying values through the way they live their life. While the form, or how they do this might differ, what matters is that they can express those values functionally. It might look different, but it functions in the same ways the person has always valued. For example, if someone has always been an outdoors person and values being out in the wilderness but feels they can’t because they’re not the fit young buck they were, they can still go to wild places and maybe do a short walk, take some photographs, do a meditation, record the birdsong, sort through their old hunting gear and clean it up, go visit a mate and reminisce (and perhaps even plan a new trip!).

If a good part of rehabilitation is, according to people living with pain, about ‘returning to myself’ isn’t it time we considered how people live their lives before we decide to thrust unfamiliar and therapist-centred practices on them? Let’s stop judging people for failing to do their home exercise programme if they’ve never wanted to exercise before. Let’s give people kudos for all the things they now have to do that are unfamiliar – like attend appointments (on time, of course, and usually in work time); take medications (again, on time, despite side effects, and often with limited impact on pain); navigate administrative paperwork (perfectly, no mistakes, and submitted on time every time) – and fit these things into a life that was already busy before pain came on. Being a patient is hard work, clinicians we need to appreciate this, and take the perspectives of the people we seek to serve.

Some readings on self and pain…

Carrasquillo, N., Zettle, R.D. Comparing a Brief Self-as-Context Exercise to Control-Based and Attention Placebo Protocols for Coping with Induced Pain. Psychological Record, 64, 659–669 (2014). https://doi.org/10.1007/s40732-014-0074-3

Lennox Thompson, B., Gage, J., & Kirk, R. (2019). Living well with chronic pain: a classical grounded theory. Disability and Rehabilitation, 1-12. https://doi.org/10.1080/09638288.2018.1517195

Van Niekerk, L. M., Dell, B., Johnstone, L., Matthewson, M., & Quinn, M. (2023). Examining the associations between self and body compassion and health related quality of life in people diagnosed with endometriosis. Journal of Psychosomatic Research, 167, 111202. https://doi.org/10.1016/j.jpsychores.2023.111202

Yu, L., Norton, S., & McCracken, L. M. (2017). Change in “Self-as-Context” (“Perspective-Taking”) Occurs in Acceptance and Commitment Therapy for People With Chronic Pain and Is Associated With Improved Functioning. The Journal of Pain, 18(6), 664-672. https://doi.org/https://doi.org/10.1016/j.jpain.2017.01.005

Yu, L., Scott, W., Goodman, R., Driscoll, L., & McCracken, L. M. (2021). Measuring ‘self’: preliminary validation of a short form of the Self Experiences Questionnaire in people with chronic pain. British Journal of Pain, 15(4), 474-485. https://doi.org/10.1177/2049463721994863

Dancing around the hexaflex: Using ACT in practice 1

Mindfulness – messing about with attention

Thanks to Kevin Vowles, I’m adopting the term ‘messing about with attention’ for the ‘present moment awareness’ or ‘mindfulness’ part of ACT. We can get caught up in how we define mindfulness – they all have value – but make the doing of mindfulness less practical.

Why use present moment awareness? Paying attention, on purpose, and without judgement (one of many definitions! This one from Kabat-Zinn, 2003) serves to disentangle us from thoughts about the past and predictions for the future; has been shown to reduce cortical arousal (Day, et al., 2021); and importantly for this post, comes in many forms.

We know that repeated practice, especially over extended periods of time (say, for 20 – 40 minutes or longer) results in alterations in how parts of the brain respond both when anticipating pain, and during painful experiences (Lutz, et al., 2013), but getting to where extended practice is even achievable can be difficult (Birtwell et al., 2019). ‘Messing about with attention’ can be used, however, anywhere and any time. I’m definitely not suggesting clinicians dissuade people from using long meditations because the results are pretty profound for most people (and most RCTs use around 40 – 45 minutes), but we shouldn’t ignore the usefulness of briefer forms of mindfulness.

During movement or occupation (daily activity)

If you’re a physio, osteo, chiro, exercise physiologist or occupational therapist, you have the most awesome opportunity to bring mindfulness into your sessions. It requires a shift in your thinking, though, because mindfulness used during movement or occupation isn’t quite the same as the usual sitting or even a ‘movement’ meditation. For one, it’s not scripted!

Your mindset

Mindfulness is about noticing, paying attention and being curious, but in many movement practices the aim is to develop ‘proper’ form. To move in a pre-determined manner. Perhaps to strengthen, or to relax, various muscle groups. To create a body movement that conforms to some ideal.

If you’d like to bring mindfulness into your movement session, would it be possible to put these ideas to one side for a moment?

Would you be willing to explore what it feels like to move – maybe in one way, and then in another? Would you be willing to experiment? To play with movement and notice how it feels in the body?

The invitation

To create an environment for practicing this kind of paying attention, the person will need an invitation. The invitation might be something like “I wonder if you feel OK to bring your mind to this part of your body for a moment?” or “If you were to close your eyes right now, what part of your body would you notice first?”

You may want to have a quiet environment, one that’s not distracting, no music or other people talking, somewhere where it’s OK to focus on how the body feels.

The guidance

If the person you’re working with hasn’t used mindfulness like this before, you might want to offer them some guidance about what to pay attention to. Something like “You’ve brought your mind to this part of your body, and as you move, what do you notice changing?” or “As you move, where does your weight shift through the soles of your feet?” or “As you move, can you bring your attention away from that part of your body [the first part you suggested they notice] and on to your breathing?”

Bring their attention to any shifts in position, changes in weight distribution, changes in breath, head position, stance, contact with the floor….

Throughout, your job is NOT to suggest what the person might notice, or experience. Your job is to help them explore, with purpose, and without judging. Guide them to play with movements as they do this: perhaps make tiny movements, or shift weight forward and back, or make big movements, speed up or slow down, add ‘purpose’ by making the movement purposeful – if they’re reaching forward, add in reaching for a cup, a pen, a book, a flower, a cloth. Ask them to notice what happens as they reach for these items. Let them repeat or alternate or otherwise change the way they do the movement.

The closure

End this by returning to the breath. It’s not a rule, and you can end in another way if you like, but I find giving some space to stopping and just breathing gives room for people to let their attention go back to something very familiar (and portable!).

Debrief

Your choice: you can ask the person “what did you notice?” or you can let them spontaneously tell you (or not). During the debrief your approach is to model acceptance of their experience, again without judgement. Let their experience be their experience.

If they say “Oh my mind wandered all over the place” ask them “were you able to bring your mind back?” and if they were (and they usually do!) let them know that’s all that’s needed.

You may want to explore which movement was most free, fluid, comfortable, stable. Which felt best, and can the person replicate it?

It’s not about what you think is ‘good’ form, this approach is about the mindful experiencing for the purpose of experiencing.

Rationale

While there are a billion reasons for using mindfulness, in today’s post my intention is to show that mindfulness offers a way for people to pay attention to their own bodily experiences, and to draw their own conclusions about how their body responds to movement.

My argument is that when people leave our care, they will probably have periods where their body ‘reverts’ to how it was when they first sought treatment. If our job is only to help people return to ‘normal’ without also furnishing people with skills to build resilience, we’re only doing half a job. It might be great for repeat customers, but I believe healthcare has enough to do without searching for ways to get people to come back – and failing to help people get in tune with what their body likes to do and how this feels, seems pretty unhelpful to me.

Showing people ways to really inhabit their own body, becoming skilled at noticing how their body feels during movement, being able to experiment and play with different movement patterns, to adjust and notice how it feels: these are powerful tools for helping people gain confidence in how incredibly versatile their body is. Our job might be less about ‘physical fitness’ or ‘strength’, ‘flexibility’ or even ‘function’, it might be about teaching people meta-cognitive skills of noticing and reflecting on what happens as they move throughout the various life contexts they inhabit.

Birtwell, K., Williams, K., van Marwijk, H., Armitage, C. J., & Sheffield, D. (2019). An Exploration of Formal and Informal Mindfulness Practice and Associations with Wellbeing. Mindfulness (N Y), 10(1), 89-99. https://doi.org/10.1007/s12671-018-0951-y

Day, M. A., Matthews, N., Mattingley, J. B., Ehde, D. M., Turner, A. P., Williams, R. M., & Jensen, M. P. (2021). Change in Brain Oscillations as a Mechanism of Mindfulness-Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain. Pain Medicine, 22(8), 1804-1813. https://doi.org/10.1093/pm/pnab049

Kabat-Zinn, J. (2003). Mindfulness-Based Interventions in Context: Past, Present, and Future . Clinical Psychology: Science & Practice, 10(2), 144-156.

Lutz, A., McFarlin, D. R., Perlman, D. M., Salomons, T. V., & Davidson, R. J. (2013). Altered anterior insula activation during anticipation and experience of painful stimuli in expert meditators. Neuroimage, 64(1), 538-546.

Acceptance and Commitment Therapy: It’s not about giving up

Last week someone asked how I can reconcile using Acceptance and Commitment Therapy (ACT) alongside hypnosis, because ACT is all about giving up on pain reduction. This belief is common I suppose because ‘acceptance’ is in the name, and acceptance means ‘giving up’ (Biguet et al., 2015). It might also come about because ACT is so often helpful for people with chronic or persistent pain, though I’ve heard some commentators argue that ACT is unhelpfully used with people who may still have pain resolution or reduction available to them.

I can’t comment on when or how ACT is used, but I can point out misinterpretations – and in this post, I will.

The basis of ACT is found in its philosophy. ACT draws on functional contextualism, which is aligned with pragmatism (Pepper, 1942), and concerns itself with establishing ways to predict and influence behavioural phenomenon with precision, scope, and depth. ‘Behaviour’ in this context is the ‘act in context’ and the purpose of analysis is to predict and influence ‘successful working’ (Biglan & Hayes, 1996).

A therapy developed from functional contextualism and employing relational frame theory (RFT) is ACT. There are other variants, and increasingly, Hayes and colleagues are calling for us to employ process-based therapy where particular processes are influenced, rather than applying a generic recipe (see Hayes et al., 2023). ACT aims to help people develop ‘successful working’ so that their lives move in the direction of what matters to them (values) irrespective of what life throws at them.

A good question to ask, then, is whether ACT really implies that people need to stop looking for pain reduction – and in my usual time-honoured way of course I’m going to say ‘it depends.’ The contextual nature of ACT requires this answer, because whether an action is ‘good’ or ‘not so good’ depends on – you guessed it – context.

You see, the ‘workability’ measure matters from an ACT perspective. The critical question is whether this action in this context by this person ‘works’ to move them towards what they value.

This way of thinking is quite different from the black and white rules often applied in musculoskeletal and pain management. Rules in these fields are based on the idea that there is a single Truth ‘out there’ and independent from the contexts where they are applied. It’s a philosophical stance that’s so common it’s rarely overtly stated. Most biomedical research is carried out with the assumption that Truth is independent of context – it’s reductive, considers that the whole can only be made up of the parts, and there is nothing else. Unfortunately, as Schrodinger’s cat thought experiment showed, this way of thinking doesn’t explain all. Darn.

If we adopt a functional contextual perspective, the question is not whether someone should stop seeking pain relief or whether they should turn to accommodating pain. Should there be a single answer? Are there a set of circumstances that apply to all people, all the time, everywhere? Or is it like everything else, complex and nuanced and contextual. It depends.

The Oxford dictionary states that acceptance is “the action of consenting to receive or undertake something offered.” Acceptance is about consenting to something, being willing to do something, or being willing to acknowledge something. ACT as therapy always asks whether something is ‘worth it’ – does it help this person move towards what matters in their life?

When using ACT, the challenge for us as clinicians is often the ‘permissive’ stance that ACT fosters. There are no outright, black and white rules. Each choice depends on purpose, context, workability.

My take on ACT is that it turns us away from the need to constantly be working to avoid or control what we don’t enjoy and instead turns us towards doing what matters in our lives. Sometimes doing what matters to me does result in a flare-up. That’s not my favourite thing, but it happens (flare-ups can come out of the blue, too). The difference is that I know I can manage even with a flare, AND if I’ve done what matters, the positive that comes from that over-rides any negative from a flare.

And you know what? If I have a big flare, I can use hypnosis to have an effective, efficient way to down-regulate my nervous system. The rule of thumb is: how well did that work for me? And more: What was my goal? Why did I do what I did and how well did I weigh up all the options for getting this thing done? Would I do anything differently next time?

The more options we offer people with pain, the more flexibility they can have in the way they live their lives. Let them do the deciding.

Biglan, A., & Hayes, S. C. (1996). Should the behavioral sciences become more pragmatic? The case for functional contextualism in research on human behavior. Applied & Preventive Psychology, 5(1), 47-57. https://doi.org/10.1016/S0962-1849(96)80026-6

Biguet, G., Nilsson Wikmar, L., Bullington, J., Flink, B., & Lofgren, M. (2016). Meanings of “acceptance” for patients with long-term pain when starting rehabilitation. Disability and Rehabilitation, 38(13), 1257-1267. https://doi.org/10.3109/09638288.2015.1076529

Hayes, S. C., Hofmann, S. G., & Ciarrochi, J. (2023). The Idionomic Future of Cognitive Behavioral Therapy: What Stands Out from Criticisms of ACT Development. Behavior Therapy. https://doi.org/10.1016/j.beth.2023.07.011

Pepper,S.C. (1942). World hypotheses: A study in evidence. University of California Press, Berkeley

The power of being present

I’ve been listening to Prof Kevin Vowles recently, as he presents his approach to pain using ACT. He made an important point about mindfulness that resonated with me: it’s that when learning to be fully present, it’s not how long we stray from our point of focus, nor even how many times we come back, the learning is that we can come back. Again and again and again.

There are arguments about what mindfulness is, and I’m certain these will continue, but for the purposes of this post and for people just learning mindfulness, I’m defining it as the deliberate practice of attending to a focus (this could be a single point of focus, or it could be broader – the practice is about being deliberate and self-regulating where attention is being placed), and ‘orienting’ towards sensory experiences in the moment with curiosity, openness and willingness to accept what shows up. This is a definition broadly adopted from Bishop et al., (2004).

A review by Leca and Tavares (2022) looked at mindfulness for people living with fibromyalgia and found, albeit with reservations brought about by study design, that mindfulness does have promise for this pain problem. They used fairly stringent criteria for selecting the studies included in their analysis, resulting in only seven eligible studies, from an initial 160 results.

What they found was that mindfulness helped participants experience better quality of life, and this was influenced by better sleep, less distress, and improved functioning. Not enormous effect sizes, but this is common for chronic pain outcomes of any kind. They also found flaws in the methods used to study mindfulness, including that participants’ experience with mindfulness prior to the research was often omitted, there was limited reporting on the teachers’ experiences or training, and there were a lot of drop-outs, programmes were quite onerous and brief and follow-ups were short. Again, not uncommon in chronic pain research.

Mindfulness is intriguing to study. From the outside there is nothing to see – a person usually sitting quietly, breathing. BUT there is converging evidence that those regularly using mindfulness show some interesting effects on how the brain functions. De Benedittis (2021) compared mindfulness and hypnosis and the brain networks thought to be at play, and found that while both share similar activity in the neural networks, they activate quite differently. Both hypnosis and mindfulness engage the frontal cortex (click here for an update on your neuroanatomy of the frontal cortex) but activate areas differently. De Benedittis found that the anterior cingulate cortex is a key area, the dorsolateral prefrontal cortex is activated in response to hypnotic suggestion in hypnosis, while in meditation, the same area is activated as the person gets more proficient.

So what?

I first started using hypnosis in the mid-1990s, as I needed help with my sleep. I regularly used a hypnotic induction to reduce the time it took me to fall asleep. I have a very active mind that starts to chat to me at night, possibly because I don’t slow down enough through the day for it to get a word in edgeways! Since childhood it’s always taken me at least 45 minutes to settle into bed and eventually fall asleep – and the delay in falling asleep gets worse if I’m tussling over a situation or a problem that I can’t readily find a solution for. There have been times in my life when I haven’t slept until the very wee hours – 4.ooam…. and I still wake (often) for short periods during the night.

Hypnosis helped me retrain my falling asleep practice to where now I can fall asleep most night in about 15 minutes.

As I became more drawn to ACT, I found myself turning to mindfulness rather than hypnosis. With hypnosis I have an outcome in mind: deep relaxation, achieving a trance state that makes it easy to let go and fall asleep. With mindfulness I have no particular destination. I’m willing to be present with whatever sensations and thoughts turn up.

With mindfulness I gently and consistently turn my attention to whatever the target is for that mindfulness practice. It could be my breath (because it’s boring, it’s always there, it’s a rhythm, and there’s a lot to notice!). It could be the contact of my body on the bed (similar reasons to breathing!).

My attention is taken away by thoughts. By weird and fleeting sensations – sharp pin-like stabs in my calves, a feeling like my toes are encased in a gently prickly sock, that my shoulder is being gripped by a large hand and squeezed, that aching in my lower back….

The practice of finding out that my attention has gone there and not my breath and then bringing my attention back to my breath: that is a key part of my mindfulness practice. And doing this without getting irritated by how often this happens!

When I’m particularly sore my mindfulness practice is such a gift. It doesn’t reduce my pain, let me be clear about that. It doesn’t change pain intensity or qualities, at least not for me. What mindfulness gives me is curiosity. My pain is never just one sensation. The more I explore an area where I’m sore, the more complex is my pain. There are areas of hot pain. Areas of no pain. Areas that pulse. Areas that are almost absent – I can’t ‘feel’ them in my mind. Areas that are tingling, and areas that are like tiny needles. And the weirdest thing of all is as I go to explore them in my mind, they slide away and change and metamorphose into another sensation. Pain is a slippery sucker!

Curiosity is, as I’ve written before, associated with willingness to not know. Curiosity is part of openness to experience (Silvia & Christensen, 2020), it’s essential for human growth because it leads to exploring our world and developing an understanding of what is currently unknown. My mindfulness practice unleashes my curiosity – what am I experiencing in my body at this moment? Curiosity has a tiny frisson of anxiety – I don’t know what I will find out – but tempered with a kind of calm knowledge that whatever I notice will likely change. That particular pain won’t last forever, even if my overall pain continues to be present. I would never have known this if I hadn’t explored, in minute detail, areas where I’m sore.

Mindfulness has given me the ability to manage that anxiety, and we need this kind of self-regulation when we live with pains that are negatively valenced – and all pain, by definition, is ‘unpleasant’ and ‘sensory’ and ’emotional’.

As a clinician, mindfulness has given me the skills to be present as I listen to distressing stories from people who haven’t had the kind of healthcare experience they deserve. Mindfulness means I can check in with what is happening here and now, rather than letting my mind head off in the direction of ‘how long will this take?’ or ‘let’s just cut to the chase: what’s wrong’ or ‘what a tragic tale, how dare this happen.’ Even brief dips in and out of mindfulness can give me a chance to notice that I’m not listening fully. And gives me a chance to come back to who I am here for. Mindfulness removes me from my mindiness, and steps me towards curiosity.

You see, while extended mindfulness meditation is part of my life, these brief moments of mindfulness are my mainstay as I go about my everyday living.

I invite you, whether you live with pain, or you’re a clinician – or both – to stop right now and pay attention to the contact of your body on whatever support you’re on. The chair. My feet on my footstool. The weight of my forearms on my computer keyboard. The pressure of my clothing on my legs, the cool areas where the air is circulating, the warmth where my legs touch the chair.

Notice that you can bring your attention back again and again and again.

You can’t do it wrong. Just bring your attention back to what is being sensed now.

And see how often you can do this throughout today.

And notice how it feels.

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., et al. (2004). Mindfulness: a proposed operational definition. Clinical Psychology Science & Practice, 11, 230–241.

De Benedittis, G. (2021). Neural Mechanisms of Hypnosis and Meditation-Induced Analgesia: A Narrative Review. International Journal of Clinical & Experimental Hypnosis, 69(3), 363-382. https://doi.org/10.1080/00207144.2021.1917294

Kashdan, T. B., Stiksma, M. C., Disabato, D. J., McKnight, P. E., Bekier, J., Kaji, J., & Lazarus, R. (2018). The five-dimensional curiosity scale: Capturing the bandwidth of curiosity and identifying four unique subgroups of curious people. Journal of Research in Personality, 73, 130-149. https://doi.org/10.1016/j.jrp.2017.11.011

Leca, S., & Tavares, I. (2022). Research in Mindfulness Interventions for Patients With Fibromyalgia: A Critical Review. Frontiers in Integrative Neuroscience, 16, 920271. https://doi.org/10.3389/fnint.2022.920271

Silvia, P. J., & Christensen, A. P. (2020). Looking up at the curious personality: individual differences in curiosity and openness to experience. Current Opinion in Behavioral Sciences, 35, 1-6. https://doi.org/10.1016/j.cobeha.2020.05.013

Learning ACT (acceptance and commitment therapy)

Around 2001 I read what I believe is the first randomised controlled trial of ACT for people living with chronic pain (McCracken, 1998). I quickly dived into this ‘new’ therapy – it appealed to me because it resonated with my own experiences with psychological therapies for depression, and in the way I had learned to live alongside my own pain. For those who don’t know, I developed chronic pain around the age of 22ish (dates are hard to remember!) and after seeing a pain specialist was given those fateful words ‘I’m sorry, there’s nothing we can do from a medical perspective.’

Why did ACT resonate so well? Because I’d tried to do the things that CBT offered. All the ‘maladaptive thoughts’ (stinkin’ thinkin’), the reframing (no, life doesn’t suck completely, it just sucks here, and here…), the behavioural activation (just keep on doing, even though it’s not rewarding) – all the things I was supposed to do to ‘fix’ my depression and my pain, but actually made me focus more on my thoughts, and more on the reality of being a single mother with two small children working full-time, studying part-time, and yes, feeling overwhelmed and at times pretty desperate.

ACT was different. ACT focused on noticing first. Noticing what was here and now. And when I was being present in the moment I could see my children as wonderful, quirky, loving kids (who also made a horrendous mess that I could never keep on top of!). I could see the colours in the flowers and trees in the nearby Botanic Gardens. I could notice my left earlobe (it doesn’t get sore – neither does my belly button!).

Learning ACT was not easy. ACT is a slippery therapy for anyone who wants a step-by-step protocol. There are common parts to ACT as an approach, like creating a sense of ‘these things don’t work – but it’s not for want of trying, it’s because humans don’t work this way’ (because the harder we struggle to control a thought or a feeling, the more it sticks to us), like being present and noticing, choosing actions that align with what matters: these were relatively familiar to me because of my occupational therapy background. Occupational therapists often start by asking people about what they want and need to do, then begin by setting actions that help the person do those things, but ACT can start anywhere on that darned hexaflex.

How might I go about learning ACT today? Because I know me, I would begin by looking at the end. What’s the end goal with ACT? It’s about being able to continue doing what matters (making our lives count in the ways we want them to), despite what life throws at us. I take this to mean that although the form or outer expression of what matters to us might change over our lives, the intent or values underpinning those actions is retained. And sometimes the values might change a little as we focus on one for a time, and others step back.

The thing is, changing how we do things is hard! I’ve often said to people with pain that I can teach the skills of pacing, for example, in an hour. What’s difficult is dealing with what our minds say, the reactions from other people, our own feelings about making changes and dealing with these other reactions, and the inner sense of wrongness that can come up – like ‘what kind of a person stops half-way through a task just to go take a break?’ And this is why ‘education’ for pain has to go beyond telling someone what to do.

As a total nerd, I like to know the theory or the organising structure supporting a therapy. ACT is based on solid science and I don’t just mean relational frame theory! ACT is a cognitive behavioural therapy, with the major distinction between ACT and CBT being how language is viewed. This means knowing about behaviour change from a Skinnerian perspective. It really does help to understand classical and operant conditioning. It moves us away from working hard to avoid things we don’t like, and towards things that are rewarding to us. The influence of moving in the direction of things we want has a different flavour from avoiding things we don’t want.

For example, if I work hard to avoid feeling my pain, I'll notice my pain whenever I do anything. This makes pain so much more present to me! If, instead, I want to enjoy the delights of what my body can do because I love to move to music, there are so many ways I can do this! I can tap my toes and my fingers in time to the music. I can hum along. I can chair dance. I can sit and internally dance to it. I can stand up and do a wiggle. I can even get up and dance! I can walk in time to the music, I can choose the tempo of the music I move to... the world opens up to me.

I do ACT as I understand it. I try to use ‘doing’ as the vehicle for working through the various processes because how we do anything is how we do everything. I try not to just talk about ACT. ACT is a doing therapy where, by paying attention to what happens in the moment and bypassing the commentary our minds make (and the stories we hold onto about who we are), the effects of what we do become the guidance we need.

For example, if I feel better in my body by doing chunks of activity then doing a stretch or a walk or a dance or a body scan, my mind can leap in and tell me I'm being lazy, ineffective, sloppy, and never get anything done. Following the guidance of my mind would lead me away from relishing the lightness and reduced pain I get from chunking my day into bits. If I'm willing to notice how my mind likes to nag AND to notice how wonderful my body feels, guess which one is a better guide? Especially if what really matters to me is how I can be calm at the end of the day when I spend time with my partner! By noticing how my body is, and letting my mind do its thing without buying into the content, I'm much more likely to keep doing the pacing.

There are many courses teaching ACT, and loads of freely accessible material on ACT throughout the interwebs. That’s due in large part to the ethos of ACT and those researching and using ACT-aligned approaches. Unlike CBT which can be tightly regulated, particularly in the USA, ACT is far more generous and open. Anyone can use ACT, it’s intended to view people as people, not bundles of psychopathology. I like this, especially in pain where so many people have already been given unhelpful names and treated with disdain and stigma. It won’t breach your scope of practice because it is about humans being practical about how our minds work, and what trips us up when we hit a life snag. Life snags are everywhere, and being human is, well, who we are!

The challenge for therapists not familiar with psychological approaches is to learn ACT from the perspective of your profession. If you’re a physiotherapist, ACT is done differently from when ACT is used by an occupational therapist or a social worker or a psychologist. We might deal with the same stuff, but our entry point to ACT is often different from a psychologist. I like to begin with actions aligned with values and watch what happens as people begin to do the things. It’s once people begin doing that our minds, beliefs about who we are, our desire not to feel uncomfortable, our memories and expectations all begin to wreak havoc on being guided by what actually happens in real time.

This is why I’m preparing my own online ACT course for therapists who work with people living with pain. The solid foundations of ACT will be there – but we’ll begin by doing the doing. ACT is a different way of being with people, and the best person to experiment with is —– yep, yourself. Keep watching for ACT for pain therapists, coming soon!

BTW this study by Lai et al., (2023) shows 33 ACT RCTs (bearing in mind my reservations about RCTs), with 2293 participants, showing (as usual) small to medium effect sizes for physical function and pain intensity at follow-up; and on depression, anxiety and improved quality of life. Interestingly, people with difficult-to-treat pains like chronic headache and fibromyalgia showed greater benefit than those wioth nonspecific or mixed pain, and again as usual, results were smaller over time. ACT is helpful – so let’s do it!

Lai, L., Liu, Y., McCracken, L. M., Li, Y., & Ren, Z. (2023). The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials. Behav Res Ther, 165, 104308. https://doi.org/10.1016/j.brat.2023.104308

McCracken, L. M. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain, 74(1), 21-27. https://doi.org/10.1016/s0304-3959(97)00146-2

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For health professionals supporting chronic pain self management