We are experiencing a revolution in the understanding of human pain and suffering. One of the most promising and rapidly growing therapies to address human pain and suffering is Acceptance and Commitment Therapy (pronounced as “ACT” in one word). ACT is one of the third wave cognitive behavioral therapies, a group of approaches that evolved from traditional cognitive behavioral therapy (CBT). Empirically based, ACT is a psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. The ultimate goal in ACT for chronic pain is to clarify values and return to a rich, full life.
In many ways ACT for pain breaks with conventional notions of pain management, where the focus is on pain reduction and other “feel good” approaches. ACT for chronic pain is contrary to almost every biomedical approach— including analgesic medication (opioids, NSAIDS, etc.) that work to alleviate painful and unpleasant sensations. These approaches teach that pain is bad and it must be completely eliminated before you can return to your life.
A modern exploration into the understanding human suffering suggests chronic pain isn’t the enemy and therefore doesn’t need to be “stopped”, “fought” or “controlled.” Acceptance and Commitment Therapy is supported by research in the fields of Relational Frame Theory and Functional Contextualism. The ACT model believes psychological suffering is usually caused by the interface between human language and cognition, and the control of human behavior through direct experience. ACT protocols target the processes of language that are hypothesized to be involved in suffering and its improvement.
ACT believes that while pain hurts, it is the struggle with pain that causes suffering (1).
The ACT approach to living with chronic pain is different and refreshing. It helps a patient open up and accept that pain may be unpleasant but your life doesn’t need to be placed on hold or paused. In many ways ACT works to reverse the downward spiral so many pain patients have been caught in for years. In fact, attempts to avoid pain can often cause more harm than good, both to your body and to your peace of mind.
How ACT Can Help Patients Drop the Struggle with Chronic Pain
Acceptance and Commitment Therapy (ACT) emphasizes acceptance and mindfulness paired with commitment action to make changes that will lead to a rich and full life. The three tenets of ACT are:
- Accepting experiences instead of rejecting them because they may cause chronic pain.
- Choosing behaviors mindfully versus allowing automatic or conditioned responses.
- Taking action and having agency in your life rather than becoming paralyzed by unpleasant thoughts, memories, emotions or sensations.
ACT and Chronic Pain
Chronic pain often leads to fear, anxiety, and avoidance behaviors or what is known as experiential avoidance in ACT. Patients stop engaging in any activities they associate with potentially causing or increasing pain, often abandoning hobbies they enjoy. Unfortunately, these very behaviors that patients hope will reduce their pain actually wind up causing patients to focus even more on their pain, as they begin to spend all of their time working to find a way to eliminate or control pain by trying many different treatments and medications. Pain becomes the center of their life and the focus of all of their attention. They put their life on hold, as managing their pain becomes a full-time job. Ultimately, this results in even greater dissatisfaction with life, endless frustration, and more pain.Attempts to avoid pain can often cause more harm than good, both to your body and to your peace of mind Click To Tweet
ACT for pain aims to increase patients’ activity and function, enabling patients to see how they can improve and enjoy their lives without necessarily eliminating their pain. The goal is no longer to reduce pain but rather to live a full and rich life in spite of persistent pain. At the core of ACT is the intention to encourage patients to think about what their life could look like without pain and then help then to conceptualize that you can still live a rich full life…even with some pain. Essentially, ACT helps patients to open-up to pain using mindfulness exercises and a commitment to changing behaviors. Committed action is a key part of the treatment and is tied into the patient’s personal values. Positive outcomes of ACT include an increase in physical and social activity and a decrease in pain-related medical visits. Acceptance of pain is also linked to decreased anxiety, depression, and disability (2).
Psychological Flexibility— The Heart of ACT
Psychological flexibility encourages patients to stop trying to control their pain and have the flexibility to accept that unpleasant experiences are a part of life. The practitioner does not try to change the patient’s thoughts or feelings about pain. Instead, he or she encourages the patient to take a willingness approach to unpleasant thoughts, emotions, memories, and sensations. The goal of ACT is to increase psychological flexibility – contact the present moment more fully as a conscious human being, and to change or persist in behavior when doing so serves valued ends. In this manner, treatment encourages patients to allow negative feelings such as fear, anxiety, or frustration instead of constantly struggling against them or trying to avoid them. Psychological flexibility teaches patients how to remain grounded in the present and not get hooked by unpleasant thoughts and feelings. Unpleasant internal and external experiences no longer bully or inhibit behavior change or pursuing meaningful activities. Psychological flexibility is targeted through six core ACT processes (3).
The Six Core ACT Processes
- Cognitive Defusion
- Present Moment Awareness
- Self as Context
- Committed Action
When using ACT with chronic pain patients, it’s important for practitioners to express genuine compassion for their clients and tailor their exercises and metaphors to each individual patient’s needs. Practitioners must openly accept and validate their patients’ feelings and take a compassion-focused and shared perspective. The word acceptance is not used in therapy but instead, a skilled therapist guides the patient to clarify their values and points them in the direction to take action.
The first part of the ACT therapeutic model lies in acceptance. Before any further progress can be made, the patient must demonstrate a willingness to have some pain while still living the life he or she chooses. Rather than trying to escape pain or its associated unpleasantries the patient remains flexible and open (4). The patient learns to see pain, anxiety, and fear as normal. Acceptance methods promote the engagement in goal-directed action that may include unwanted feelings and refraining from attempts to control feelings.
Exercise: Build willingness skills
Practitioners help their patients to “build willingness skills.” The goal in this part of the treatment is to show patients that their thoughts and emotions are a natural response to their pain, to teach them to experience them as no more than that, to help them understand that resistance to these feelings only heightens suffering, and to enable them to feel these difficult emotions without adopting avoidance behavior when they are linked with a meaningful activity or value the patient wishes to pursue.
Asking your patients to write down an activity they have wanted to do but have not been able to because of their pain or their feelings surrounding their pain. Ask patients to consider what exactly is holding them back. Have them focus specifically on their emotions and body sensations. Then ask them if there were other times in their life when they felt this way but overcame the emotion for something important. This exercise helps patients learn to understand from actual experience that they do not have to be controlled by their painful feelings. A common example of this is public speaking. Metaphors can often help patients to better understand acceptance and can be tailored to each individual patient.
Thoughts can feel automatic and we don’t even realize their impact on our behavior. Part of diminishing the power of thoughts lies in detaching from them (5). During this step, patients learn to simply notice thoughts as they occur without attaching any significance to them. Thoughts are no longer judged as “good” or “bad” or “right” or “wrong.” Patients simply acknowledge a thought without any judgment. They begin to differentiate between having a thought and getting wrapped up in a thought.Part of diminishing the power of thoughts lies in detaching from them Click To Tweet
Patients practice skills to get out of their head or mind, rather than being dominated by it and absorbed in their negative thoughts. To help them do this, you can show them how to see thoughts simply as words without the power we assign to them. In this case, patients are not actually changing or challenging thoughts (traditional CBT) but noticing them and choosing not to allow them to influence or control their behavior. Through this step, they begin to recognize the difference between “thoughts” and “truth or reality.”
Exercise: Adding Labels to Your Thoughts
Sometimes labeling thoughts and feelings can help create emotional distance between you and your thoughts and feelings. For example, instead of thinking “I have unbearable pain today,” you can label this thought by adding the phrase “I am having the thought” in front of it. For example, “I am having the thought that I have unbearable pain today.” What thoughts have you been having lately that are related to your pain?
Focus on an especially difficult thought and really try to believe that it’s true. How does this make you feel? Let’s return to the idea of labeling thoughts. Take the same thought you were just believing and add the phrase “I am having the thought that . . . “ in front of it. How do you feel now? Do you believe the thought more or less? You can add more layers to this, by adding more phrases in front of the thought. For example, “I am realizing that I am having the thought that . . . ” How does this make you feel? Do you still believe the thought or does it feel less a part of you?
Present Moment Awareness
It can be hard to live in the present moment when suffering from pain. During this step of ACT, the patient works at remaining present in the “now,” instead of replaying the events of the past that may be filled with regret, such as the incident that caused the pain, or worrying about future possibilities and feeling anxiety about how a forthcoming activity could exacerbate pain. The patient begins to actively focus on experiences as they are occurring in the moment, in real time, developing an awareness of when his or her focus begins to drift into the past or future and then consciously shifting attention to the present moment.
Exercise: Using Your Senses to Connect with Your Environment
When you are trying to be mindful of the present, it can help to use your senses to focus in on your surroundings. Take a deep breath and try to relax your body and focus on your breathing. Look in front of you and identify three objects in your line of sight. For example, perhaps you see a tree out your window or a framed photograph nearby. Now take another deep breath and relax and pay attention to the sounds in your environment. Can you hear three different sounds if you really focus your attention? Perhaps you can hear birds chirping outside or the sounds of traffic. Take another deep breath and relax and see if you can feel three different things in or near your body. For example, is the carpet below your feet soft? Or do you notice an itch on your leg? When you perform this exercise, it forces you into the present moment as you pay attention to exactly what is around you in your environment.
Self as Context
Besides accepting pain, unpleasant thoughts, and feelings and remaining aware of the present moment, patients must also learn to notice “self as context” or “the observer self.” Essentially, this means recognizing that their “self” is separate from their thoughts, emotions, or even their physical body. This shift in perspective challenges the self the patient has created—especially when it inhibits positive behavioral change. For example, when a patient allows his or her identity to become entwined with his or her pain. With this practice, patients can learn how to observe their pain without becoming their pain.
Mindfulness is an extremely important practice to the core process of ACT. It helps establish a sense of self that is greater than one’s thoughts, feelings, body and other private events. Adopting this point of view also helps with cognitive defusion and enables patients to detach from their own thoughts without being overly influenced by them. Mindfulness exercises can help reduce “pain mindscripts.” For example, I can’t work because of my pain, Any form of exercise will exacerbate my pain, or My pain has to be my priority above all else. When patients learn the “observer self” perspective—as someone who is separate from his or her thoughts—then they can begin to release the mindscripts that are holding them back from the behavior changes that align with their values. Notice your patient’s pain mindscripts so that they can learn to consciously let go of them.
During this part of ACT, patients can learn to eliminate the labels and self-judgments they have created that are not helpful. The following brief exercise which can help patients to develop their observer skills.
Exercise: Becoming an Observer Self
In order to better observe your thoughts and feelings and see yourself as a separate entity from them, try the following exercise. Close your eyes and take a deep breath. Become aware of any feelings in your body, whether that’s a pain in your back, an itch on your arm, or simply a feeling of deep relaxation. What thoughts are you having? Simply notice them without judgment. What sounds do you hear going on around you? Recognize that you are paying attention to the feelings in your body, the thoughts in your mind, and the sounds in your environment. Acknowledge that you are separate from each of these things and are simply observing them. Notice the separation from the one who is thinking the thoughts and the one observing the thoughts.
One of the greatest goals of ACT is to help patients pursue their valued activities instead of avoiding them. This happens because of the fear that they will cause more pain or they are wrapped up in controlling or pursuing pain alleviation that they fall to the wayside. Valued activities can include things like exercise, socializing with friends, intimacy with a spouse or partner, going to work, playing with their kids, or being involved in community events. Actions that align with a patient’s values are what bring meaning to that patient’s life. When patients forsake valued activities for pain control, it often causes them to become depressed. Helping patients identify their values and establish those activities associated with these values enables them to refocus their priorities away from pain and toward doing more of what they enjoy.
To begin this part of the ACT treatment process, have patients define their values in major life areas, such as career, family, intimate relationships, friendships, health, and spirituality. Ask them to reflect on what is most important to them.Helping patients identify their values enables them to refocus their priorities away from pain and toward doing more of what they enjoy. Click To Tweet
The challenge of identifying values is that patients are likely to notice how far they are from actually living those values. The practitioner can then show how positive behavior changes can lead patients to better live their values. Following their values helps patients adhere to the behavioral changes that will improve their life.
Committed Action is the final step of ACT, where patients commit to changing their behavior and taking actions that are related to their values, in spite of their pain. At this stage, patients begin to develop goals that align with their values. For example, if the “friend” domain was extremely important to one patient, she may choose to engage in more social activities. If the “growth and learning” domain was important to another patient, he may set a goal of taking guitar lessons once a week.
One of the primary issues that arise during this part of the ACT treatment process is dealing with barriers. Perhaps the woman who made a commitment to socializing with friends feels increased anxiety before a lunch date because she fears her back pain will flare up. Or the man who decided to learn a new instrument nearly cancels his guitar lesson because he starts to worry that lessons will conflict with doctor’s appointments and that playing the guitar may worsen his arthritis.
When psychological barriers crop up, it’s important for patients to utilize some of the other ACT steps, such as Cognitive Defusion, Present Moment Awareness, and Self as Context in order to remember that they are not their thoughts and feelings and to remain focused on the present and not project fears into the future. Have patients identify when barriers do arise in order to help them see what actions they can take to move beyond those barriers.
ACT for Pain Research
Meta-analyses of ACT for chronic pain show improvements in depression, anxiety, pain intensity, physical functioning and quality of life (6,7). Acceptance and commitment therapy for chronic pain is spreading through the mental health and pain psychology fields like wildfire and fast becoming the crowd favorite. There is even some data favoring ACT over traditional CBT!
Combing ACT with Physical Therapy and Other Disciplines
Combining physical therapy with ACT is one way to create an evidence-based and psychologically informed treatment for patients with pain. A qualitative study investigated potential barriers and facilitators to embedding ACT within a physical therapist-led pain rehabilitation program (8). Findings suggested this combination presented both challenges and opportunities, but overall was a positive experience when sufficient training was provided. Physical therapist-delivered treatment, guided by principles of ACT, creates a biopsychosocial treatment for chronic pain that is both evidence-based and innovative (9). Along with CBT and mindfulness, ACT is a psychological intervention a physical therapist, or other pain practitioners can use as part of an integrative pain management program (10). The Importance of Embracing Psychosocial Factors of Pain for Physiotherapists will continue to grow.
Studies on physical therapy informed by ACT are just now blossoming and will infuse the physical therapy profession. ACT can seamlessly be integrated into a physical therapy clinical practice and will likely promote better outcomes of pain relief. ACT interventions have also informed the practice of primary care physicians, occupational therapist, nursing, social work, counseling, corporate health, fitness coaching, health coaching and more (11).
To learn more about ACT for Pain and training for practitioners click here!
Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and Commitment Therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior Therapy, 35, 785-802.
Serbic, D., & Pincus, T. (2017). The relationship between pain, disability, guilt and acceptance in low back pain: a mediation analysis. Journal of Behavioral Medicine, 40(4), 651–658. http://doi.org/10.1007/s10865-017-9826-2
McCracken, L. M., & Vowles, K. E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69(2), 178-187.
What is acceptance of pain and why would anyone want it?
McCracken, L.M., Barker, E. & Chilcot, J. J Behav Med (2014) 37: 1215. https://doi-org.uws.idm.oclc.org/10.1007/s10865-014-9570-9
- M. Veehof, H. R. Trompetter, E. T. Bohlmeijer & K. M. G. Schreurs (2016) Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review, Cognitive Behaviour Therapy, 45:1, 5-31, DOI: 10.1080/16506073.2015.1098724
Öst L-G. The efficacy of Acceptance and Commitment Therapy: an updated systematic review and meta-analysis. Behav Res Ther 2014; 61:105–21. doi:10.1016/j.brat.2014.07.018
Godfrey E, Galea Holmes M, Wileman V, et al. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain BMJ Open 2016;6:e011548. doi: 10.1136/bmjopen-2016-011548
Critchley, D.J. et al. “A light bulb moment!” Physiotherapists’ experiences of delivering Physiotherapy informed by Acceptance and Commitment Therapy (PACT)Physiotherapy , Volume 102 , e230 – e231
Mandy Nielsen, Francis J. Keefe, Kim Bennell, Gwendolen A. Jull; Physical Therapist–Delivered Cognitive-Behavioral Therapy: A Qualitative Study of Physical Therapists’ Perceptions and Experiences, Physical Therapy, Volume 94, Issue 2, 1 February 2014, Pages 197–209, https://doi.org/10.2522/ptj.20130047
Glover, N. G., Sylvers, P. D., Shearer, E. M., Kane, M.-C., Clasen, P. C., Epler, A. J., . . . Jakupcak, M. (2016). The efficacy of Focused Acceptance and Commitment Therapy in VA primary care. Psychological Services, 13(2), 156-161. http://dx.doi.org/10.1037/ser0000062