acceptance and commitment therapy

Guide, don’t instruct: how we talk within sessions

Do you remember your favourite teacher in school? Mine was Mrs Jackson, teacher of my Form 2 class (I think I was 12 years old). She was an outstanding teacher because she expected that we’d do well. She also didn’t tell us what to do – she helped us explore. And if there was one thing I’d like to have happen in therapy sessions with clients, it would be that we learn how to guide instead of instructing.

It’s only recently that I’ve learned why guiding and facilitating is so much more helpful than telling or instructing, and yes it’s because I’ve been reading Villatte, Villatte & Hayes Mastering the Clinical Conversation.

Have you ever noticed that when we give an instruction like “Sit up straight” or “Use your core” our clients attend to how well they’re doing just that – sitting up straight, or using the core – and at the very same time, they no longer attend to other aspects of their movement (or the context, or even the purpose of the movement). It’s a human tendency to focus on a particular set of features of our environment – and it certainly helps us cognitively because it means we don’t have to attend to everything all at once. BUT at the same time, it means we become relatively insensitive to other features occurring at the same time.

Rules or instructions have their place, or they wouldn’t still be being used in therapy – but their utility depends on how rigidly they’re applied. It makes sense for a super athlete to really focus on certain aspects of their performance, especially when they’re training, and especially when there’s one particular set of movements that will maximise their performance. For people living with pain, however, life is not about a set of performance goals. Instead, it’s about being able to respond adeptly to the constantly changing demands of their lives. And one thing people living with pain often have trouble with is being able to notice what’s happening in their own bodies.

Let’s unpack this. People living with chronic pain live with ongoing pain in certain parts of the body – and human tendencies being what they are, we try to avoid experiencing those sore bits, so our attention either skips over the painful area or it focuses almost exclusively on the sore bits and not on other parts (technically this could be called experiential avoidance). By working hard to avoid experiencing the sore bits, or alternatively focusing entirely on those sore bits, people living with pain often fail to notice what actually happens during movement.

As therapists, we can complicate this. We can instruct people (give them rules) about the movements they “should” be doing. We try to ‘correct’ posture. We advise people to use specific lifting techniques. We say “use your core”.

The effect of these instructions is to further lead our patients away from experiencing what is happening in their body. Instead of becoming aware of the way their bodies move, they attend to how well they’re following our instructions. Which is fine – until the person experiences a flare-up, or moves into a new environment with different demands, or perhaps we complete our sessions and discharge them into the wild blue yonder.

So, people with chronic pain can progressively become less aware of how their body actually feels as they do movements, and at the same time, try to apply rules we’ve given them that may not be all that helpful in different contexts.

We end up with the plumber trying hard to crawl under a house, carrying all her tools, while at the same time being worried that she’s not “using her core”. Or the piano teacher trying to “sit up properly” while working with a student on a duet. And the nurse, working one day in a busy ward with heavy patients, and another day in a paediatric ward, trying to “lift properly” using the same technique.

If we want to help people respond effectively to the widely differing contexts they’ll experience in everyday life, perhaps we need to take some time to help people learn to trust their own body, to experience both painful areas – and those that aren’t painful. We might need to help people work out fundamental principles of movement to enable them to have movement variability and flexibility – and to adjust and adapt when the contexts change.

To do this, we need to think about the way we help people learn new ways of moving. There are two fundamentals, I think.

  1. Guiding people to attend to, or notice, what is – including being OK about noticing painful parts of the body. The purpose behind this is to help people become aware of the various movement options they have, and the effect of those options on how they feel. We might need to guide people to consider not only pain, but also feelings of strength, stability, responsiveness, reach, movement refinement, subtlety, delicacy and power. To achieve this, we might need to spend time developing mindfulness skills so people can experience rather than attempting to change what they experience. The art of being willing to make room for whatever experience is present – learning to feel pain AND feel strength; feel pain AND relaxation; feel comfort AND power.
  2. Guiding people to use their own experience as their guide to “good movement”. In part, this is more of the same. I use words like “experiment” as in “let’s try this as an experiment, what does it feel like to you?”, or “let’s give it a go and see what you think”, or “I wonder what would happen if….” For example, if a person tries to move a box on a ledge that’s just out of reach, how many of you have told the person “stand a bit closer?” While that’s one way of helping someone work out that they might be stronger if they’re close to a load, what happens if the ground underfoot is unstable? The box still needs to be moved but the “rule” of standing close to a box doesn’t work – what do you think might happen if the person was guided to “Let’s try working out how you can move the box. What’s happening in your body when you reach for it?” then “What do you think you might change to make you feel more confident?” (or strong, or stable, or able to change position?).

When we try guiding rather than instructing, we honour the person’s own choices and contexts while we’re also allowing them to develop a superior skill: that of learning to experience their own body and to trust their own judgement. This ultimately gives them more awareness of how their body functions, and the gift of being flexible in how they approach any movement task.

Villatte, M., Viullatte, J., & Hayes, S. (2016). Mastering the clinical conversation: Language as intervention. The Guilford Press: New York. ISBN: 9781462523061

An accidental form of control: when mindfulness produces happiness ACTing Well, Living Well iv

I’ve had some success while working with a man I’ll call Peter.  He’s got chronic pain, and has been incredibly fearful of what it might mean – in fact, you’d probably call him a classic catastrophiser because each time his pain flared up he immediately thought it was something like cancer and he would rush off to his GP or the Emergency Department to have it checked out.  Luckily any scans he’s had haven’t shown anything operable because I’m sure with the amount of distress he was been experiencing, he would have been able to persuade a surgeon to operate had there been anything odd-but-common found.

We’ve been using mindful breathing as a way to get in touch with the sensations, emotions and thoughts that occur to him, and especially ‘making room for’ the thoughts his mind has been telling him of needing to check his body for symptoms, for the nauseous feeling he gets when his mind starts to worry, and for the painful sensations that he experiences throughout his body.  It’s been a real learning experience for him to find that he can be willing to experience these symptoms without judging them, and, as seems to happen for many people, he’s been finding that they disappear or reduce over the five minutes or so we do the exercise.

Now this is a trap for young players and older ones too.  While it’s nice to find that sometimes mindfulness can produce peace, relaxation and calm – that’s not the point of being mindful!  The point of being mindful is to be open to experience whatever happens.  And for those people who do experience a reduction in negative emotions, sensations or thoughts, the very reduction can begin to form a subtle type of control.  The thinking goes something like this

“I feel uncomfortable.  Quick! I’ll do some mindful breathing – and then that feeling will go!”

Sounds a lot like ‘experiential avoidance’ – although perhaps slightly more effective than running around keeping busy to avoid the negative feeling, or trying very hard to ignore the feeling, or perhaps catastrophising.

Why would we worry about this?  Does it really matter if someone does start to use ‘mindful breathing’ as a way to reduce symptoms?

Well yes.  There will be times when even though the person is using mindful breathing to ‘sit with’ something negative, the negative experience doesn’t reduce, doesn’t fade, and may even increase.  That’s not the point of mindfulness – it’s about accepting whatever happens, allowing it to be there AND CONTINUING TO COMMIT TO ACTIONS that move in valued directions.

The problem with hoping that mindfulness will reduce symptoms or thoughts is that when it doesn’t reduce these, the temptation can be to feel distressed – and stop the mindfulness.  And after stopping the mindfulness it can be very difficult to carry on doing the actions that will ultimately enact values.  That wonderful mind can kick in and accuse the person of ‘being stupid’, ‘wasting time’, ‘doing this dumb thing that doesn’t even work’ – this usually brings more negative emotion along for the ride, and ultimately doesn’t help.

So what to do?

I’m still learning this, but I think I’m going to mention that mindfulness is about allowing what will be to be.  And being ready to carry on with valued actions despite this.

I think this might be one of the hardest things to do – I’ll let you know how I go!

Act-ing Well, living well ii

The second in a series about ACT and its use in pain management from an occupational therapy point of view.
My last post (here) talked about ACT and ‘doing what matters’, or ‘valued action’ – this involves identifying what is important to a person, then helping them do it, while being careful not to encourage ‘experiential avoidance’, or avoiding coming into contact with experiences we’d rather not.

Here’s the ‘hexaflex’ or diagram that provides an overview of ACT.  What ACT tries to develop in people is ‘psychological flexibility’, or the ability to be in the here and now, open to experiences (even negative ones) and do what matters to live a life in alignment with what is important.  In people who lack psychological flexibility, it might be possible to see:

  1. The same old strategies being used over and again while not achieving the desired result (eg working incredibly hard to ‘get things done’ so that family are cared for, even though that leaves the person with pain exhausted and completely unable to emotionally care for the family).
  2. People trying all sorts of methods to avoid experiencing something they don’t want (eg stopping all enjoyable activities because it increases chronic pain, or attending multiple treatments to get rid of pain, or only doing activities in a certain way to make sure that pain doesn’t become overwhelming)
  3. Carrying on with activities despite pain, but ‘enduring’ the pain and feeling distressed or under strain when doing so.

The problem with presenting ACT to people is that if I ask a patient ‘would you be willing to accept having your pain’, they’re likely to hit me.  It goes against all of the usual therapeutic approaches in health.  Everyone ‘knows’ that pain is bad, and it’s our job as humans to prevent it, treat it or at least reduce it.  The problem is that in chronic pain, the efforts that go into struggling with pain, trying to control it or get rid of it or so often get in the way of living well – and what’s more, they rarely work.  In fact, some studies suggest that the ‘best’ results from pharmacology for chronic pain provide only a 30% reduction in pain intensity.

Acceptance is a concept that ACT embraces – but it’s not an all or nothing acceptance, far from it.  Acceptance is used when it’s almost impossible to control thoughts and feelings, and when control is possible but doing so erodes what makes life wonderful anyway.

The basic rule of thumb for an ACT practitioner to decide whether the strategies a person is using needs changing is whether the strategies are workable.  Now that’s a concept I really like.  Workability refers to whether the ways the person is living helps them achieve what is important in life in the long run. This is a concept that I think occupational therapists will find resonates with the way occupational therapy intervenes, and helps put into context some of the short-term ‘adaptive’ strategies that fail in the long term.  Here’s an example:

Belinda has been in hospital for a hip replacement.  The day she is expecting to go home she is visited by an occupational therapist who advises her of the various post-surgical precautions she must take to avoid dislocation.  Yes! A raised toilet seat and shower stool are duly provided, and she also receives a kitchen trolley because she’ll be on crutches for at least six weeks before she can put weight fully through her new hip.  These gadgets allow her to get out of hospital and back into home where she can begin to eat her normal meals, sleep in her usual bed, and be with her family.  The solutions provided to help her get out of hospital are very ‘workable’ and help her re-establish her independence.

Do they involve experiential avoidance? Oh yes indeed – they help her to feel more confident, reduce her pain (and the risk of dislocation), and ensure she doesn’t need to ask for help.  They help her avoid experiencing helplessness.   Without them she can’t use a normal toilet without worrying that she’ll dislocate, or do her cooking without leaning on the kitchen trolley.

There are risks inherent in providing gadgets, as any clinician knows.  In this case, when the danger of dislocation is over for Belinda she may continue using the gadgets to avoid the pain of moving through the range of movement. If she strongly believes this, Belinda may be limited in her ability to do some of the things she feels are important to her, like go to the shopping mall, see a movie at the theatre, or take a bath – she can’t exactly carry her toilet seat to the mall, or push her kitchen trolley around the supermarket! Now this is unhelpful, unworkable experiential avoidance.  Not such a good thing.

Clinicians may use strategies in acute healthcare settings to enable people to avoid certain experiences – this helps people return to other aspects of their lives that they do value, such as independence and living in their own home.  If these solutions remain in place, though, they’ll get in the way of the person living well in other aspects of their life.  Perhaps something all clinicians need to stop and consider, especially when considering the use of pain reduction approaches such as injections or infusions.

My focus in pain management is to help people who have chronic pain and want to think of themselves as ‘well’.  I can’t judge whether the strategies they use are ‘workable’ against my own values, but need to instead help people to look at the function of their strategies and help them examine the long and short-term workability of what they do in light of what is important to them.  I’ve used motivational interviewing skills as one way to help people look at their choices, and weigh up options.  Identifying values features strongly in MI, and it’s great to see them as part of ACT.   More about values next time I post.

Carrying on with self-management strategies doesn’t make a difference

Continuing in the vein of yesterday’s post where I discussed a study showing no additional benefit from adding graded exposure or graded activity to treatment by classification, today I want to discuss a recent finding showing that all the hard work put into helping people develop and use self management may not make a difference to their recovery in the end.  It’s this study (doi:10.1016/j.ejpain.2008.06.009) by Charlotte Curran, Amanda C. de C. Williams, and Henry W.W. Potts – Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain

What?! Shock and panic around the world! Pain management skills are not used!

The whole basis of self management lies with the idea that people develop practical skills they can use in the ‘real world’ so that when they experience pain, they have a range of strategies that improves their ability to cope.  So if they’re not actually using these skills after six months, what on earth are we doing all this treatment for? (more…)

Control or acceptance?

I’ve been reading a wee bit of ACT, acceptance and commitment therapy recently. I’m trying to find a relatively simple way to explain ACT to my patients, many of whom just don’t do reading, and prefer living life in a practical way, rather than an intellectual or even spiritual way. I’m not sure I’ve found an explanation that works terribly well yet.

So this is my attempt at a ‘simple’ explanation of ACT – and I’m keen to hear what others think of it!

The first step in ACT seems to be about recognising that the previous attempts we have made to control our thoughts and feelings about a situation seem to fail. Or they need an awful lot of energy. Or they compromise other important things in our lives. I can’t remember who described it as ‘creative helplessness’, but it is a great term!

The second step is to acknowledge that we have emotions, and that they don’t respond well to either being ignored or to be focused on. But emotions are part of us, and are present when we make judgements about a situation.

It’s natural to make judgements about things – this is how we simplify our lives, by making up ‘rules of thumb’ about how we think the world works based on what we’ve experienced, been taught, or seen happen to others. And the rules we live with we just don’t seem to revisit unless we have to.

Some of us are very rigid about our rules – the world just is this way, and there is no other way… others of us are more flexible and recognise that much of life is chaotic and random, and although we would prefer to have life happen in a much more orderly way, often it doesn’t. It seems that people who live according to the second way are more able to accept situations than people who live according to the first.

So if we’ve lived rather orderly lives, where everything happens the way it ‘should’, we may be secure but our world gets rocked when something unexpected happens. And perhaps some of us are more fundamentally able to be flexible about this, while others of us are not, but it seems that people who can work out a way to flow with an unexpected situation deal with it rather better than people who strongly want it to follow the rules. People who can deal with the unexpected deviation from a script also seem less emotional about it – happy when good things happen, but not awfully distressed when bad things happen.

So what I think mindfulness does is provide a way for us to flow with a situation by enjoying things that move in a direction that we ‘want’ but also allowing us to flow with a situation that doesn’t move the way we want by releasing our emotions, giving them some space to be – then recognising that they soon dissipate.

The tools that mindfulness uses, instead of being incredibly ‘talky’ involve lots of imagery and metaphor – which works really well for a visual creature like me – but I’m not so sure that it works as well for practical types. Mindfulness uses words like ‘gentleness’, ‘flow’, ‘moving with’, ‘openness’ and so on… Not that easy to describe to my practical blokes who are more familiar with a spanner than a book!

Some of the tools of mindfulness are awareness of breathing (not control), awareness of sounds (not naming them), awareness of sensations (not judging them), visualisation (such as putting judgements into ‘bubbles’ and allowing them to float away).

I wonder how I can translate this into ‘blokespeak’!

So my focus for this week’s series of posts is attempting to find some ways to help practical people understand how to become ‘mindful’ rather than ‘judgemental’, work with emotional flow rather than cognitive labelling, and finding out what is important and whether what happens is allowing what is valued in life to occur.