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

A Prospective Analysis of Acceptance of Pain and Values-Based Action in Patients With Chronic Pain
Lance M. McCracken and Kevin E. Vowles

These two researchers have been publishing more and more on acceptance and values and Acceptance and Commitment Therapy (ACT) and Contextual Cognitive Behavioural Therapy (CCBT), and this paper is another example of the type of work being undertaken.

The objective was to ‘prospectively investigate the combined processes of acceptance of pain and values-based action a in the emotional, physical, and social functioning of individuals with chronic pain.’

A concept I’m interested in is ‘psychological flexibility’ or the willingness individuals have to allow for ways of behaviour and goals to differ depending on the context or situation in which they occur – in other words, allow for the realities of life while all the while still aiming for things that are important to them to achieve. And by things, I mean activities that express the values of the person. ACT includes concepts such as acceptance, cognitive defusion, contact with the present moment, self-as-context, values,and committed action (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), which are construed as ‘psychological flexibility’.

Quoting from the article “Acceptance has been investigated in more than 15 studies (e.g., McCracken, Vowles, & Eccleston, 2004; Viane et al., 2003; Vowles,McCracken, & Eccleston, in press a; see McCracken & Vowles, 2006). A number of treatment studies of mindfulness-based methods support the role of the process of “contact with the present moment” (e.g., Kabat-Zinn, Lipworth, & Burney, 1985: Sephton et al., 2007), but just one study included direct assessment of mindfulness (McCracken, Gauntlett-Gilbert, & Vowles, 2007). There is just one study of values-related processes in relation to patient functioning with chronic pain (McCracken & Yang, 2006). In each of these studies the general result is that processes of acceptance, contact with the present moment, and values-based action are significantly associated with better emotional, physical, and social functioning.'[my emphasis]

Participants in this study seem familiar to me
– very similar to the chronic pain patients referred to the clinic in which I work, that is they have had pain for 77 months (8.0 – 516), in their 40’s, mostly married or in long-term relationships, mainly experiencing low back pain, lower limb pain, or whole body pain, and 60% or so not working.

They were recruited from the people referred to the Centre, and completed the questionnaires for this study when they first attended for assessment, and again roughly 18 weeks later at the commencement of their pain management programme. The questionnaires included measures of acceptance, importance and success at living according to their values, emotions, and disability.

Now as usual I’m not going into detail into the multiple regression analyses and other statistical methodology – that’s for you to read, when you read the article in depth. Suffice to say that ‘the present analyses demonstrate that measures of acceptance of pain and values-based action predict functioning later in time for patients seeking treatment for chronic pain.’

Unexpectedly, ‘there were only two of nine possible occasions where both the acceptance and values variables performed as significant predictors, in the equations for depression and psychosocial disability.’ It was thought that this would occur in every equation. The authors suggest that
‘Our inability to find these relations may have been due to the statistical control procedures that included pain intensity, a variable that shares variance with both acceptance and values, and the
overlapping variance between the acceptance and values variables, which, according to the correlation results, is estimated at 25.0%.’

They add that ‘the study interval was quite long, providing opportunity for a wide range of influences on the measures of functioning at Time 2 that could have reduced their relations with the acceptance and values measures from Time 1’.

I like this point made by the authors: Flexible and effective behavior will tend to have both qualities [of 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.

Now you know I’m going ask ‘What does that mean for us as clinicians?’
Well…people who report that they accept their situation and act to achieve things that they value in their life despite their pain present ‘better’ in terms of their results on measures of things like emotional, physical, and social functioning.

Not really rocket science in that anecdotally clinicians know that angry and resentful people rarely function as comfortably in their lives as people who are more accepting and ‘get on with life’. What is rocket science is that these concepts are based on a theoretical model that can be empirically tested, and used to help us develop ways to encourage people to become more accepting, and to live lives based on things that are important to them, rather than spend energy on seeking to return to ‘the way things were’ or ‘what might have been’.

It means that some of the work of occupational therapists whose primary focus is to help people identify important areas of activity and facilitate their achievement in these areas is validated. That perhaps over time, the urgency to ‘reduce pain’ (which in many ways constructs and reinforces disability because it implies that having pain and restrictions is not normal) may reduce. Perhaps by helping people with pain identify what is important to them, we as clinicians might look at what is important to us – making more space in our lives for things we value, like balance, family, creativity, and inquiry.

I can foresee some clinicians finding the concept of accepting pain particularly hard to reconcile with their own value system of relieving pain (almost at all costs). And this will conflict with the aims of patients who dearly want me to help them ‘remove their pain’. So, putting these concepts into therapy in an acceptable way for the people with whom I work continues to be my challenge. After all, these patients are seeking treatment – this shows that they are unhappy with their current situation, living the antithesis of acceptance. I can see this topic being discussed over and again in the next few years.

I hope you’ve enjoyed my stroll through mindfulness and acceptance over this week – have no fear, I can see that I’ll carry on this particular path many times as I continue learning and enquiring! As I discover things, I’ll be sure to post them. Keep in touch too – your comments mean a lot to me, and it’s always great to see what other people think, whether you agree or not! And if you want to subscribe, don’t forget the RSS feed link at the top right of this page – or bookmark – I post most days during the week.

McCracken, L.M., Vowles, K.E. (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
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., Lillis, J. (2006).
Acceptance and Commitment Therapy: Model, processes and outcomes.
Behaviour Research and Therapy, 44, 1–25.

Mindfulness effectiveness
One of the most delightful aspects of the ‘new wave’ of cognitive behavioural therapies is the continued adherence to test the effectiveness of therapy in a scientific way. There has been quite a flow of ACT (Acceptance and Commitment Therapy), CCBT (Contextual Cognitive Behavioural Therapy) and allied therapies in the psychological literature, and now it is fast appearing in interdisciplinary journals.

The official publication of the IASP (International Association for the Study of Pain) is the journal Pain. It publishes studies relevant to a broad range of disciplines involved in the study and management of pain. It’s fascinating to see the different articles that make their way to the journal – from basic science to primary prevention/public health campaigns!
This article, Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study is a good example of the type of study on ACT practices that is published in this well-read journal.

Morone, Greco and Weiner write about their pragmatic study to ‘assess the feasibility of recruitment and adherence to an eight-session mindfulness meditation program for community-dwelling older adults with chronic low back pain (CLBP) and to develop initial estimates of treatment effects.’

Now the first point to make is that mindfulness meditation alone does not equate to ACT. It does, however, form a foundation for the practice of ACT, as well as having well-documented effects from simple meditation practice on physiological arousal.

Back to the storyParticipants were 37 community-dwelling older adults aged 65 years and older with CLBP of moderate intensity occurring daily or almost every day. Participants were randomized to an 8-week mindfulness-based meditation program or to a wait-list control group. Baseline, 8-week and 3-month follow-up measures of pain, physical function, and quality of life were assessed.

This is an interesting group of participants – I work in a public hospital outpatient centre, and I notice that there are increasing numbers of people in this age group being referred to the service. I’m not sure if this is because medication prescribing has changed, that older adults are reporting chronic pain more readily than 15 – 20 years ago, whether it’s an artifact of having a larger number of people aged 65 in the community, or what it is – but it does have an impact on the type of programmes we provide. In view of the increasing growth in the over 65 year age group in the next 20 years, it is a group that we are going to see more often, and who will require more expenditure in health care especially if disability from chronic pain is not addressed effectively. Whew! that was a long sentence!

So a fairly typical methodology was employed for this study – a wait-list control, and baseline, 8-week and 3-month follow-up measures taken across several domains.

The actual intervention was over eight weeks, and included an introduction to the ‘principles and practices’ of meditation, reading materials, a recording of a ‘body scan’ meditation and a sitting meditation, discussion and problem solving around the habit of meditation, and psychoeducational material on stress, pain and the ‘mind-body’ connection was also provided. A walking meditation was introduced towards the latter part of the eight weeks, and the only major difference from ‘standard’ Mindfulness-Based Stress Reduction Programmes ((Kabat-Zinn, 1982; Kabat-Zinn et al.,1992; Kabat-Zinn, 1990; Kabat-Zinn, 2003.) was the elimination of a full-day silent meditation ‘retreat’ and the yoga component.

Now for the exciting part: what were the results?

Well, the study was a pragmatic and applied one, so the first thing I was interested in was participation rates and adherence. 19 participants were selected for the meditation group, 13 participated, one was lost at followup, leaving 12 completing. In the waiting list group, 18 were initially recruited to this group, 14 eventually participated (after a delay of 8 weeks), and 13 completed.

Allowing that these participants were specially recruited, I’m not sure we can generalise to the group of people who are usually referred to a public hospital service. However, it is interesting that these participants continued to attend what is probably seen as an ‘unusual’ type of therapy for pain.

The authors commented that these participants attended the majority of sessions, engaged in the ‘homework’ activities (meditation practice) during the programme, and reported that they maintained the practice three months later. This is great as it demonstrates that older adults understand the programme, are interested in it, find benefit from it, and as the authors quote a program participant stated it best ‘‘Mindfulness meditation has a quieting effect on me. It gives me a peaceful feeling while doing it and I am able to reduce my back and leg pain by deflecting the pain and by focusing on other parts of my body’’.

It’s also interesting that things like activity planning and exercise were not specifically included in the programme, but activity levels increased.

As expected, acceptance of their situation increased, as did quality of life measures. Pain intensity reduced and ‘global’ health and mental health as measured by the SF36 reduced.

Notable too – people who crossed over from the waiting list group also improved.

The authors are open about several aspects of this study that mean its interpretation needs to be somewhat guarded: it is a small group, a pilot study, between group differences can’t be established due to low power, and the differences between the groups were not entirely controlled for.

However, it’s the beginning of the ‘real world’ type of study that can help us as clinicians think about the people we work with and whether this therapy may be useful.

MORONE, N., GRECO, C., WEINER, D. (2008). Mindfulness meditation for the treatment of chronic low back pain in older adults: A randomized controlled pilot study☆. Pain, 134(3), 310-319. DOI: 10.1016/j.pain.2007.04.038
Kabat-Zinn J. An outpatient program in behavioral medicine for
chronic pain patients based on the practice of mindfulness
meditation: theoretical considerations and preliminary results.

General Hospital Psychiatry 1982;4:33–47.
Kabat-Zinn J. Full catastrophe living: Using the wisdom of your
body and mind to face stress, pain, and illness.
New York: Delacorte;
Kabat-Zinn J. Mindfulness-based interventions in context: past,
present, and future.
Clin Psychol: Sci Pract 2003;10:144–56.
Kabat-Zinn J, Lipworth L, et al. The clinical use of mindfulness
meditation for the self-regulation of chronic pain. J Behav Med