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.

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.

Pain may not be what a person fears most

We all have typical ways of going about our daily routines and solving problems. Mostly these work – until we encounter a situation where they don’t. If we’re flexible enough, we’ll figure out a way to change what we do in that instance, and this will become another strategy to draw on, and might even become another habit that works – until it doesn’t.

In pain rehabilitation, there are certain patterns of activity that have received a lot of research attention. Activity avoidance is one of them, while task persistence is given rather less air time (though it’s emerging as an intriguing area to study (Hasenbring, Andrews & Ebenbichler, 2020)). But perhaps what we’ve looked into less are aspects of adjusting to life with pain that raise uncomfortable thoughts and feelings. These in turn make it more difficult for a person to change how they go about daily life.

Some examples I’ve heard from people I’ve worked with:

  • I need to keep pushing through the day because I’m the boss, and a hands-on manager. If I stop being hands-on, there’s nobody to pick up the slack. Things won’t get done.
  • I’m a mum, and I can’t let my children go off to school without them having had breakfast, and making their lunches, and there’s all the parent-teacher events. I can’t just stop.
  • When I left the lawn half-done, my partner jumped in and did it for me, then got really angry with me and I’m not doing that again!
  • I was a professional athlete. Going to the gym is horrible. I’m a failure – I’m lifting these tiny weights and I used to lift massive ones.
  • I’m going back to work on this graded programme, but I can’t fit my gym programme in, and that’s the only way I’m going to fix my core strength.

These situations are pretty common. The clash between “pain management” and the reality of daily life. Daily life is messy, and there are social factors at play, there’s the unpredictable, the real fear of criticism or loss of a job or someone not taking up the slack while the person makes changes in how he or she does life. It’s far easier to prescribe exercises in a controlled place, to track progress by weights, repetitions and cardiovascular fitness or range of movement.

Doing self management, things like pacing or setting time aside for movement, or spending time in meditation or asking someone to help: these are easy in the short-term, right? But not quite as easy if you think of these things needing to happen for life. In fact, some people with pain begin to feel like this new life isn’t really a life at all! Where’s the spontaneity?

When we begin drawing on Acceptance and Commitment Therapy (ACT) a common error is thinking the “acceptance” part is only about accepting pain, and stopping treatment, ie let’s focus on being willing to experience pain in the pursuit of what’s important. And there’s good evidence supporting the process of doing valued activities as one of the key processes in ACT, as well as being a key outcome (Vowles, Sowden, Hickman & Ashworth, 2019). All the occupational therapists say “preach it!” because, of course, this is what occupational therapy as a profession is based on!

So what else needs to be the focus if we’re using ACT in persistent pain management? As you can see from the client examples I’ve given, there are more effects from pain and self-management strategies than just being willing to experience the ouch. People hold fused beliefs about what kind of a person they are: the reliable worker; the dutiful parent; the responsible boss; the super-athlete; the compliant patient. The strategies people use to cope with persistent pain may impinge on ideas a person holds about themselves.

Furthermore, things clinicians tell people – like “your exercises will reduce your pain”, or “you must learn to fire this muscle to help stabilise”, or “meditation needs to be done this way” – can also become fused ideas. A lot like wearing a splint for years “because the therapist said I must”, or using a particular chair “because the therapist said it was the best for me.”

Any time we begin introducing new ways of doing things, we’re likely to encounter people who will find it hard to see why our perfectly reasonable solution won’t fit them in their circumstances. Consequently we can either try hard to persuade the person to do it (creating pliance), or we can decide the person isn’t cooperative and give up. I think there’s a third way: using ACT we can examine the usefulness or workability of the approach preferred by the person, and we can do the same for the new approach. By looking at the good and not-so-good in each option, we can also begin to explore the fused thoughts and emotions, experiential avoidance (what is it the person is unwilling to experience?), values, sense of self (is it me, or a story about me?) – indeed, all the ACT processes are likely to come into play.

What we need to do then will depend on your clinical orientation and the person. If the person judges that what they’re currently doing is working for them – our job is done. We can “leave the door open” for them by indicating that there are alternative strategies the person might want to experiment with in the future, but pushing against a person’s own belief that they’re doing fine just isn’t aligned with ACT.

If the person agrees that no, their current approach isn’t working – then we can begin exploring what’s going on. Occupational therapists might begin with daily activities, perhaps identifying what’s important about them, and then experimenting with (or playing with!) different ways of doing them. As an occupational therapist, I’m likely to want to understand is showing up for the person, maybe draw on other important values to help them to begin to use a coping strategy. The cool thing about ACT is that while committed action must be 100% we can adjust the demands of that action to the level of confidence a person has.

For example, if someone really has strongly fused ideas that “everything needs to be done for the children before they go to school”, we might begin by laying out the children’s lunches but asking the children to put them into their bags. Two things might be going on in this case: one might be about loosening the fused idea that “good mothers do everything for their children” while simultaneously helping the person develop skills to communicate effectively with their children – allowing the children to experience what happens if they forget! (Kids have ways of finding food, believe me)

We could be building on the mum’s value of raising independent children, and drawing on her skills of mindfulness and being in the present moment. We’d need to check in with her willingness to do this: is she 100% willing to let her kids go to school without physically putting their lunches into their bags? If she’s not, we might try making the task a little less challenging. This might look like allowing the children not to brush their hair before going to school, or putting the lunches beside the bags but not inside them. Whatever we do we’re gently allowing her to feel the shiver of anxiety that she hasn’t “done everything for the children” while also using another value “I’m raising independent children” to help her follow through.

In terms of where this example might go, if one of the fused thoughts is that “I feel guilty if I don’t do everything for my kids”, this is likely playing out in other parts of this person’s life. By helping her be willing to experience that anxiety in the pursuit of supporting her children to become independent, she’s developing more space between her thoughts and what she decides to do with them. She’s rehearsing a process where she draws on strengths (values, mindfulness, cognitive defusion) to help her commit to doing something that’s not easy. And doing this in one part of her life begins to open the possibilities for doing this in other parts of her life.

Pain rehabilitation and management is often not so much about dealing with the pain and effects of pain on life, but on life and how we live it. Life is more than whether we’re pain-free, fit or happy, it’s about moving onward in the direction of what’s important to us.

Hasenbring, M. I., Andrews, N. E., & Ebenbichler, G. (2020). Overactivity in Chronic Pain, the Role of Pain-related Endurance and Neuromuscular Activity: An Interdisciplinary, Narrative Review. The Clinical Journal of Pain, 36(3), 162-171.

Vowles, K. E., Sowden, G., Hickman, J., & Ashworth, J. (2019). An analysis of within-treatment change trajectories in valued activity in relation to treatment outcomes following interdisciplinary Acceptance and Commitment Therapy for adults with chronic pain. Behav Res Ther, 115, 46-54. doi: 10.1016/j.brat.2018.10.012

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

Musings on new learning

Over the past week I’ve been reading a book on embodied cognition, Intelligence in the Flesh: Why your mind needs your body, written by Guy Claxton. In this book, Claxton argues that we place far too much emphasis on abstract ideas of language and intelligence, and fail to recognise how intertwined our body and brain systems really are. It’s fascinating and raises many ideas and questions for me when I think of our pain experience.

To add to my musing, I had the great pleasure of attending the Australia and New Zealand Association for Contextual Behavioural Science conference in Wellington where I had the opportunity to have my mind blown by Steven Hayes and colleagues talking about a way of viewing language and behaviour from a functional contextual perspective (lots of links in this post because I can’t hope to do justice to the topics and I hope you’ll take the opportunity to click through to read more).

The truly weird thing is the links between these two aspects of being human: the one in which language is viewed in the context of whole body systems, and the one in which language (and thought) is viewed as a behaviour that develops as we grow and make connections between what is “out there” and what is “in here” – and all the abstract things in between.

I have no idea where this post will lead to, but here goes!

Let’s begin by thinking about how a baby experiences pain. Not that long ago it was believed that because babies can’t remember early life experiences and don’t have language to represent their experience, they didn’t feel pain. This, despite all of us knowing that when a baby is surprised by something external to them, when they want or need something, and times when they respond dramatically to an injection or being bumped, they react! And they react loud and clear.

Babies grow up into toddlers, and as they do we notice they develop associations between symbols and objects and experiences they interact with. Kids without hearing, in an environment where they’re surrounded by people using sign language, quickly develop the capability to represent experiences and objects with movements that mean something both to them and to those around them. Embodied cognition approach argues that the network of physiological responses flows in cycles between body and multiple parts of the brain to stamp “expected” patterns that begin to represent the world around us, and inside us. And we develop associations between internal and external objects that ultimately loop around many bits of the brain to ultimately be represented by symbols – words either spoken or gestured. Actually, according to Guy Claxton, these initial representations unfurl like ferns as a welling-up of associations and actions with multiple potential associations and actions that are either dampened down by past experience or allowed to develop dependent on intentions.

So, for example, a baby has a bunch of signals from his or her belly that flow and cycle around to various parts of the brain and endocrine system that represent what we know as “hunger”. Maybe initially it’s an urge to recapture that warm, safe, satisfied experience of having a full belly, but over time these signals develop more complex associations, with some representing “hunger”, others “milk”, “food”, “mummy”, “give me”, “want” and so on. As the baby develops, the associations between experiences and representations become far more complex and largely out of our “conscious” awareness, and these representations begin to develop a life of their own, so that as a two-year old, around dinner time, all those associations of “hungry”, “milk”, “food”, “mummy”, “give me”, “want” clamour for attention and the toddler has a melt-down! Seriously, perhaps for a toddler, being given a carrot which doesn’t fit with all those associations of  “hungry”, “milk”, “food”, “mummy”, “give me”, “want” actually doesn’t fit with the representations the toddler is trying to achieve at dinner time.

Let’s think about pain then. When a baby experiences the “yukkiness” of an empty belly – or the absence of “warm”, “mummy”, “food”, “safety” – he or she responds by crying. A baby’s whole body gets in on the act (you go watch one cry!) – and we respond. We use a bunch of words to talk to a baby when they fall down or get hurt – and they quickly learn that falling down or getting hurt isn’t nice – and that someone will come get them when they cry. Over time these experiences accumulate and the words we use for pain become associated with lots of unpleasant experiences like – cold, hungry, sad, tired, afraid, ouch, scratch, sore, comfort, abandonment, worry and so on. Soon enough any time we hear the word “ouch” or “pain”, or see a scratch or someone falling or ourselves falling, this constellation of associations are all activated, some more than others! Given how long we’ve been pairing all these associations together, it’s no wonder that pain, any pain, holds a whole bunch of meaning for us, many of which are deeply physical but also psychosocial.

At the same time as we make these connections, we’re also beginning to view “me” or “I” as somehow separate from what happens to us, and we’re all familiar with our internal narrative. This narrative contains not only the words we use to describe or narrate what’s happening, but also all those experiences and associations that go along with them. In contextual behavioural science, the representations of words, concepts, and all the associations between where, when, and how we connect these things are viewed as just as important as the words themselves.  This matters when we begin to believe that the representations (words, language) actually ARE what they “stand in for”. So, for example, if the word “pain” links with a whole bunch of experiences body processes, including perhaps not being helped to feel secure, or of fearing the worst, or of bad things happening to others around us (in life or TV even), it’s likely we’ll be experiencing those things as if they were happening in real life now. Pair that word with body experience which brings the whole to life again (in ways we can’t always express in language), and it’s no wonder many people are truly afraid of what’s going on – and act accordingly, perhaps without not really realising that this is happening. It’s like the unfurling of associations and actions occur independently of what we call “conscious thought”.

I know this is a fairly simplistic account of what I’ve been reading and learning about – and I have much more to learn and explore! But it strikes me that if our bodies are so comprehensively intertwined with the “what it is like” to be living in our world, it’s no wonder that only providing education about pain may not always be as powerful as we’d like. It helps me understand why experiencing our bodies doing things in different contexts while feeling safe/secure is so necessary. It also gives me more confidence that using metaphors (which represent our world or situations in symbols that straight words may not elicit) helps draw on these embodied representations and may elicit change more quickly than trying to “convince” or “tell” someone what’s going on.

I’d love to hear your thoughts – join in the conversation and let’s help each other make sense of this very groovy neuroscientific approach that integrates the social into our biopsychosocial framework.

Links to online CBT resources

I have occasion to look for online resources from time to time – this week it’s been anxiety and CBT self-help, so I’ve been strolling through the internet and located some really great, evidence-based sites with excellent resources.

First one  – here Over 100 downloadable worksheets, all pdf documents, including ACT, Vicious Flower circle, formulation worksheets, sheets for challenging core beliefs – and I have hardly started listing!.  Definitely worth going to if you’d like some well-designed, clear worksheets you can save onto your own computer.  For a sample, click here for the Pain and Fatigue worksheet

e-couch is a free online site for anxiety and depression, and other mood combinations.  You do need JavaScript to use the site.  It’s an off-shoot from MoodGym, run in conjunction with Australia National University.

Living Life to the Full is a UK-based site, once again it’s free, supported by the Glasgow and Clyde NHS. is a site for teens and their parents – nicely interactive, and once again, supported by the NHS

I went through the New Zealand sites, but my teenaged daughter sniffed and said they weren’t ‘cool’, so they haven’t been included – but I need to add that there are some excellent ones, just not quite as therapy-oriented as the sites I’ve listed above.

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 iii : Acceptance & Willingness
One thing that strikes me as very different about the ACT approach is the very different way therapists are encouraged to respond to difficult emotions.  Part of ACT is to encourage acceptance of, and ‘sitting with’ negative thoughts or emotions or sensations rather than attempting to change them or ignore them – and in my learning about ACT and trying to model ACT consistent behaviour in therapy, I find I need to become more mindful of my own responses to other people’s thoughts and emotions.

What I mean by this is that I initially have a response to avoid experiencing another person’s distress – so if the person I’m working with is tearful or angry or afraid, I have often tried to mop up the tears or calm the person down or reassure them.  What’s wrong with this you say?

Well, ACT views these emotions as something to acknowledge rather than alter, recognising that painful emotions are part of life and that in therapy we can demonstrate through our actions as therapists that when we make space for these emotions there is an opportunity to learn that they will pass. And by doing that, people recognise that emotions have less power than we often give them!

I’ve often reflected that many clinicians working in the area of chronic pain are quite fearful of pain, and especially, fearful of increasing someone’s pain when we ask them to do movements.  Several good studies have shown that when a clinician is fearful of pain, the recommendations he or she makes are often around avoiding fluctuations in pain.  In other words, we’re anxious about pain and we communicate to our patients that they too should be anxious about and avoid it.  Problem is, this isn’t always workable. (Vlaeyen & Linton, 2006)

Workability is a key tenet of ACT.  It means, does this approach to a situation enhance life, add to living aligned to personal values, enrich relationships, enable the person to experience all that life brings?  Or does the solution to a situation constrain life, work against things the person values, avoid and attempt to control something that can’t actually be controlled.

As I’ve pointed out before, many people with chronic pain find that medications don’t completely abolish pain – in fact, most medications provide about a 30% reduction in pain intensity. At the same time, medications have many side effects and a lot of the people I work with simply don’t want to take them.  This leaves them with the unwelcome choice of experiencing pain if they want to do anything, or, in efforts to avoid fluctuations in pain, doing very little (and often still having pain fluctuations!).  It’s very very hard to control pain – and as so many studies have shown, the thing about pain isn’t that it’s present, it’s the negative judgement and emotional distress that we have about having pain that brings grief. (McCracken, 2007)

What to do?  Well, many clinicians talk about pain management as if it’s about directly addressing the intensity of the pain.  I’m not so sure this is a good thing.  Not only is it pretty unworkable (because the pain can and will vary depending on so many variables, controlling all of them is unlikely), but it also teaches people to be afraid of pain and therefore gives pain far more power and control over life than it needs to.

I would love it if we could talk about ‘life management’ or ‘living well with pain’.  It’s the disability associated with pain that is the main problem, not the pain itself.

So over the past few months I’ve taken to asking people if they’re willing to allow their mind to wander to and from their pain during a therapy session.  Instead of offering to calm them down, or reassure them or even offer sympathy, I’ve tried to simply sit with them, and as they make a statement I may comment along the lines of ‘Your mind is telling you that it’s hard’, or ‘Can we make room for that feeling and thought as well as your pain?’. I may ask them to tell me how big their pain is, where the edges of where they feel pain and where their body feels ‘normal’, and ask them to describe the sensations.  I’ve celebrated with them their ability to commit to doing something that is normally outside of their comfort zone.

I’ve been surprised at how my behaviour has changed with patients.  I’m much less likely to be fearful of them having negative emotions, sessions feel calmer, I’m less emotionally tired, and the most important thing?  The people I’ve been working with also seem to be able to be present with their pain a little longer and be much less distressed.  They’ve been willing to treat their pain with gentleness.

It doesn’t always work well – but I’ve been surprised at how often it does help reduce that anxiety, and I haven’t done any cognitive restructuring or thought challenging, all I’ve done is simple breathing and allowing the mind to wander.

Pain can have power, yet at the heart of pain management we have often given pain even more power than it has by encouraging people to attempt to control it, or to control their actions (including thoughts) in order to control their pain.  Moving away from a control focus to a gentler, kinder way of being with pain is not easy, especially for us as therapists.  And most especially for therapists who have used ‘talk therapy’ as one way of working with people rather than experiencing or doing.

I value CBT because the approach has given many people a new way to view themselves and their thoughts and emotions.  At the same time, doing has always been a major focus for me as a therapist.  Now I’m finding a new way of behavioural change that is not mechanistic, but is instead flexible and most importantly, places what is important to the person at the heart of it.  McCracken and Vowles (2008) have been looking at the usefulness of acceptance and values-based action in pain management – I think there is something in it.

McCracken, L., & Vowles, K. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain. Health Psychology, 27 (2), 215-220 DOI: 10.1037/0278-6133.27.2.215

MCCRACKEN, L. (2007). A Contextual Analysis of Attention to Chronic Pain: What the Patient Does With Their Pain Might Be More Important Than Their Awareness or Vigilance Alone The Journal of Pain, 8 (3), 230-236 DOI: 10.1016/j.jpain.2006.08.004

VLAEYEN, J., & LINTON, S. (2006). Are we “fear-avoidant”? Pain, 124 (3), 240-241 DOI: 10.1016/j.pain.2006.06.031

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.

Accepting chronic pain
How willing are you to have persistent pain? Can you accept pain without fighting against it? If you were told your pain was going to be there forever, would you avoid important activities or would you start to get back into life again?

Recently I reviewed about 200 questionnaires completed by people attending the Pain Management Centre where I work. I was looking especially at what they’d written down as goals for coming to the Centre, and unsurprisingly, most of them were to ‘reduce my pain’ – to tolerable levels, to manageable levels, or so the person could begin ‘living a normal life’. I hate to break it to you – even the most effective medication seems to only reduce pain by about 30%, and most people wanting pain reduction are after at least a 60% reduction.

What this means is there is quite a gap between what people expect – and what they get.

Along with all those goals of reducing pain were a huge number of everyday activities that people wanted to return to – provided that their pain reduced.

I haven’t asked people those questions at the top of this post.  I must admit I’m a little wary of doing so – they’re not the sort of thing people really want to hear first off when coming to Pain Management!  Yet, it looks like they’re the sort of thing we might need to ask people at some point in their search for pain reduction.

It’s not easy to think about accepting chronic pain.  Most of the medical people I work with think it’s a horrific thing to consider – a life with pain.  And so the search for something, anything, to take the pain away.  In fact, one doctor said to me it is unethical to stop looking for pain relief, and in fact he wouldn’t dream of withdrawing something that apparently reduced pain – even if it didn’t change the person’s disability one bit.

A couple of definitions here might be helpful: pain is ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’; disability is the effect of pain on function, related to the amount of interference an individual experiences from pain on their activityPain interference is associated with depression and anxiety, amongst other factors.

Recent studies especially those from the Bath University research group of McCracken and Eccleston, are showing that acceptance of chronic pain is strongly associated with better outcomes especially in terms of activity engagement and reduced distress.  Acceptance in this context is about being willing to experience pain without trying to avoid it, control it or reduce it. The degree of acceptance is associated with engaging in activities that the person values despite experiencing pain, and ‘disengaging from the struggle to limit contact with pain’ (Fish, McGuire, Hogan, Morrison & Stewart, 2010).

In my experience, there are few people who come to a Pain Management Centre who are willing to accept their chronic pain – in fact, when someone says to me ‘I’ve come to accept my pain’, I inwardly cringe because it so often means ‘I’m resisting any accommodation of my pain into my daily life’, or ‘I’m resigned to having pain forever and life is horrid’.  Part of coming to a Pain Management Centre is an expression that life isn’t working out so well, so that something is needed to help the person cope better, feel better and start to live again.

Introducing the idea of acceptance is not always straightforward.  My warped occupational therapy/psychology background means that I find it easier to begin with looking at important values and how these are expressed behaviourally in activity.  Contextual cognitive behavioural therapy, or Acceptance & Commitment Therapy, or other variants of these two, often suggest starting with ‘cognitive defusion’, or the language that people use to describe themselves in which the ‘who’ they are is labelled directly alongside the ‘what’ they want to do.  Difficult theoretical concepts such as relational frame theory underpin this type of therapy, in which the person is helped to slightly distance themselves from the content of their thoughts (particularly negative labels).

My take on starting the journey towards acceptance is to help the person look at what is important in their life, then look at how they’re demonstrating or enacting these values.  For example, if being a good parent is important, how is the person demonstrating this?

If a mother is spending most of her time cleaning the house because this has been her usual way of showing that she cares for her family, but cleaning is demanding and she feels frustrated and irritated at herself and her family because of her pain, then maybe there can be another way to show her values.  I might suggest to her that she list all the ways she can show her family that she cares, and choose one to start doing.

While she starts to explore this, and to consider loosening up her belief that ‘the only way to be a good mother is to have a clean home’, it’s possible to help her review her thoughts that ‘only bad mothers have untidy homes’, and maybe consider a more flexible thought that ‘mothers who care for their family spend time with them’.  By doing this, and identifying an activity that she enjoys with her family, I can start to introduce the idea that she could do this activity – and bring her pain along with her.

At this point I can start to introduce the idea of mindful attention to the whole of the activity, rather than just her pain.  And we are one step closer to helping her recognise that she doesn’t need to struggle against her pain, she can instead fill her life with good things, and the pain (and especially the negative emotions around pain) can become just another aspect of her experience.

A brief questionnaire that could be used to measure this is the Chronic Pain Acceptance Questionnaire-8, an 8-item questionnaire that is derived from the 20-item CPAQ.  While the study I’ve referred to is definitely a preliminary one, and there is more work to be done on it, both the 20 and 8 item CPAQ tap into some important dimensions that examine how willing a person is to get involved in important activities, and to experience pain at the same time.

There are times when all of us will willingly go through pain – having a flu jab, running or exercising further than we’ve gone before, carrying a child when it’s too tired to walk, standing on the sideline at a football game in the cold, or waiting in a queue to pick up tickets to a good concert.  Because the end result is worth it – maybe one of our jobs as pain clinicians is to find out what’s ‘worth it’ to our patients, so they too, can start to live lives doing things that they value despite pain.

Fish, R., McGuire, B., Hogan, M., Morrison, T., & Stewart, I. (2010). Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8 Pain DOI: 10.1016/j.pain.2009.12.016

ACT – some evidence for acceptance & commitment therapy in chronic pain

ResearchBlogging.orgFor a relatively young therapy, ACT has a lot of research to support its use in chronic pain. A very quick search through PsychInfo located 51 studies since 2002 with the keyword ‘acceptance’, and the majority of these (I didn’t count them up!) were related to ACT studies.
I’m not intending to run through a review of the evidence for ACT, that’ll come later! but I do think it’s useful to have a look at one study from the Bath University colleagues of McCracken and Vowles.

This study was carried out with a group of over 100 participants attending a pain management programme.  Two measurement times were used – at the time of screening for acceptance onto the programme and at the time participants started treatment, with a period of 18 weeks or so between them.  None of the participants in the study had active treatment, so this is simply a study of the relationship between one variable at one point in time, and another variable at another point in time without intervention.  Although you could argue that assessment is an interventions, and it’s certainly something we’ve observed at Pain Management Centre.

While its a correlational analysis (remember, no conclusions about causation!), it’s notable that ‘acceptance of pain and values-based action measured at Time 1 were significantly correlated with pain, pain-related distress, pain-related  anxiety and avoidance, depression, depression-related interference with functioning, and physical and psychosocial disability measured at Time 2.’

The measures used were the Chronic Pain Acceptance Questionnaire developed by McCracken et al (2004), Chronic Pain Values Inventory (McCracken & Yang, 2006), the Pain Anxiety Symptoms Scale and British Columbia Major Depression Inventory.  To measure disability, the Sickness Impact Profile was used.

Some interesting points to note:

  • Although no treatments were carried out, and pain-related anxiety, depression, depression-related interference with functioning, physical and psychosocial disability, and uptime did not change from T1 to T2, pain intensity did reduce, distress reduced and medication use reduced.  Several people started work.  So it looks similar to the findings we’ve obtained at Pain Management Centre from simply assessing also occur in this process.

Can we conclude that assessment is an intervention? Does the impact of assessment differ depending on how the assessment is carried out and what is included in it?  Certainly something that seems intuitively important is that people have the opportunity to tell their story and feel heard as part of assessment.  It might be the first time for some of them to have the psychosocial aspects of their pain assessed, and this alone may help them make sense of their situation.  It may also be that the way in which recommendations are made from an assessment (often through a case formulation) provides both understanding and an opportunity for the person to start taking their own steps toward recovery.

  • Measures of acceptance and values also changed between T1 and T2. Each increased significantly, including activity engagement, pain willingness, total acceptance of pain, and values-based action, although the increase was quite small.

Pondering this, I wonder whether acceptance may increase as part of the process of being advised that pain is going to persist, and that there is no medical ‘fix’. It would have been helpful had some of the details of the assessment process had been included in this study – but failing that, and assuming that assessment for inclusion in the programme involves advising patient that their pain is chronic and there is a way forward, I’m thinking that some of this information alone could be helpful for people to begin the process of acceptance.

The discussion of this paper notes that ‘measures of acceptance of pain and values-based action predict functioning later in time for patients seeking treatment for chronic pain.’  It also states ‘On average, the acceptance and values scores accounted for 18.3% of the variance in the six regression equations where they accounted for significant variance in the measures of functioning.’  So, what is important to a person (values), and teh degree to which a person is prepared to accept having pain, has an influence on what that person does functionally.  As McCracken & Vowles state ‘Flexible and effective behavior will tend to have both qualities [acceptance and values] and these qualities are expected to mutually enhance each other, with acceptance loosening up restrictive influences exerted by pain on behavior in the near term, and values giving direction and purpose to behavior over the longer term.’ They also make the point that physical function and especially work-related function are less influenced by acceptance and values than emotional functioning.  Maybe there are other factors that influence physical function, unrelated to acceptance – pain-related anxiety and avoidance springs to mind.

What can we conclude from this study?

Acceptance and values, two important aspects of ACT, seem to influence patient status and functioning over time in a group of people seeking treatment from a tertiary-level pain management facility.  These patients present as quite disabled (although not a lot different from the people presenting for treatment at Pain Management Centre where I work), and they hadn’t received treatment – so this is a ‘natural’ study of processes that occur without professional input.  On its own this study can’t draw major conclusions, but it adds another level of evidence for the importance of examining the process of acceptance in helping people learn to live with persistent pain.

McCracken, L., & Vowles, K. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain. Health Psychology, 27 (2), 215-220 DOI: 10.1037/0278-6133.27.2.215
McCracken, L. M., Vowles, K. E., & Eccleston, C. (2004). Acceptance of
chronic pain: Component analysis and a revised assessment method.
Pain, 107, 159–166.
McCracken, L. M., & Yang S.-Y. (2006). The role of values in a contextual
cognitive-behavioral approach to chronic pain. Pain, 123, 137–145.