Many clients with chronic pain spend an enormous amount of time, energy and money to control or eradicate pain. The unfortunate clinical reality (for some) is that total pain relief is not always possible. When this is the unfortunate situation, a shift in approach to pain care is often necessary. Modern pain care approaches emphasize the resumption of daily activities despite—not dependent on the absence of— pain. This shift in clinical perspective requires an understanding of the psychological impact of chronic pain and a real-world integration of the knowledge into clinical practice. What types of strategies has your client tried to control or fix their chronic pain? What have they tried?
“I try to not think about the pain”
“I rest when I have pain”
“I roll on a foam roller to alleviate the pain”
“I decrease my activity”
“I listen to relaxing music”
“I take CBD oil”
“I pop a pill”
When Controlling Pain Becomes the Problem
Avoiding pain is natural.
Every human has engaged in behaviors to escape the unpleasantness of pain. But avoiding pain can actually make pain worse. And the behaviors and strategies clients use to avoid pain can lead them down a path of disuse, disability and even death (think opioids).
In Acceptance and Commitment Therapy (ACT) the persistent avoidance of painful and unpleasant events is known as experiential avoidance. These behaviors are common and relate to a naturalized way of responding– to avoid negative thoughts, memories, feelings, and physical sensations and attempt to replace them with positive thinking and distraction to make the pain go away. When these attempts don’t work, thoughts and feelings surrounding the pain experience take control.
There are countless ways experiential avoidance shows up in a client’s behavior:
“I try and put it out of my mind”
“I’ll go to my__________, they’ll fix it!”
“I have a drink”
“I smoke pot”
“I go for another opinion, they must have missed something”
When attempts to control pain repeatedly fail, self-identification with pain often becomes a defining feature interfering with a person’s ability to live a rich, full and active life.Avoiding pain is natural. Click To Tweet
Opening Up and Willingly Moving Forward
Acceptance and Commitment Therapy (ACT) is a cognitive behavioral therapy that focuses on psychological flexibility. The general goal of ACT is to increase psychological flexibility– to contact the present moment as a conscious human being, and to change or persist in behavior when doing so serves valued ends. This is a process of opening up and taking a willingness approach and embrace whatever is causing distress or suffering, and inspire commitment and behavior change and take
action toward the things that you value (1). Psychological flexibility can also be defined as:
- Coming in full contact with painful and unpleasant internal experiences while consciously choosing to take action and engage in a meaningful life.
- Contacting the present moment fully as a conscious human being, and based on what the situation, changing or persisting in behavior in the service of your chosen values.
In everyday language, this means holding unpleasant internal experiences lightly and acting on longer-term values rather than short-term impulses, thoughts, and feelings. Psychological flexibility is what you want to nurture in your clients while modeling it in yourself as a pain professional.
When applied to the treatment of chronic pain, ACT seeks to tweeze out the physical sensation (pain) from emotional (suffering). The bedrock supporting ACT is the idea that suffering can be lessened and clears a new path that emphasizes values. Values are the things people do and believe that give their lives purpose and meaning – even in the presence of pain.ACT seeks to tweeze out the physical sensation (pain) from emotional (suffering) Click To Tweet
The concept of mindfulness, central to ACT, refers to the ability to engage and experience the present moment, be it pleasant, unpleasant or neutral and acknowledge the thoughts, images, memories, emotions, feelings and physical sensations that come with it. This ‘mindful’ awareness leads to a willingness approach (acceptance), to notice and name unpleasant experiences as they are and allow them to pass (defuse) so they won’t dominate your actions and erode opportunities to live by your values.
Check out this podcast with Dr. Kevin Vowles, PhD on How To Avoid The Trap Of Negative Thinking Using ACT.
Swimming Ashore with Creative Hopelessness
A first step in targeting pain-related behaviors is helping the client notice which one(s) of her pain control behaviors are keeping them stuck. A good metaphor for the practitioner to think about is a dog chasing its own tail. Tail chasing is a common play behavior in puppies, but one in which the nature of the pursuit leads you no closer to your destination. While some clients openly and willfully identify chosen behaviors that have not worked, many clients struggling with chronic pain may be reluctant.
The purpose of creative hopelessness is to create a context where the costly and futile struggles are abandoned and new solutions can be claimed.
Creative hopelessness is a technique in the ACT model to help clients realize the unworkability of the control agenda. In other words, it aims to undermine the control agenda by gently and compassionately exposing the costs of avoidance behaviors (2).
It does not imply that the patient is hopeless!
Creative hopelessness is not a feeling: it is a liberating action of letting go of an agenda that has not worked so more productive and innovative actions can take place. (3)
Creative hopeless is not always used in the ACT model for pain. It comes in handy when you suspect or know a client is clinging tightly to the “control agenda.” This is often noticed in the rule-governed language clients use such as: “In order to exercise, the pain has to go away” or“I’ll go back to work once the pain is gone.”
It is a way to chip away at the control agenda and make room for healthier behaviors in line with the client’s values.
ACT and Creative Hopelessness in Pain Care
Pain with its adverse consequences on daily activity is the main reason people seek the care of a physical therapist or other pain professionals. As you engage your patient or client in therapeutic exercise to restore mobility and activities of daily living, ACT is a useful psychological technique to inform pain care. It can help clients drop the rope in the tug-o-war with pain. In this podcast How To Live An ACTive Life Beyond Pain Combining ACT & PT Jennifer Battles describes how to use ACT to increase adherence in physical therapy. Results of her work, available here, demonstrated that a brief ACT intervention improved patients’ physical therapy treatment and home exercise adherence, suggesting that ACT may provide wider, far-reaching effects on promoting behavior changes necessary to successfully manage pain.
Several randomized controlled clinical trials provide evidence that ACT reduces the physical and emotional impact of chronic pain including:
✓ Dahl et al. showed that workers at risk for long-term disability resulting from stress and pain symptoms were less likely to take sick leave after attending ACT sessions (4).
✓ Wetherell et al. reported that ACT and cognitive-behavioral therapy (CBT) provided similar improvements in pain interference, depression, and pain-related anxiety in chronic pain patients; patient satisfaction, however, was significantly higher with ACT (5).
✓ A systematic review and meta-analysis assessing results from acceptance-based interventions for the treatment of chronic pain concluded that ACT may be more suitable than CBT for patients with high levels of experiential avoidance and lower levels of meaning in life. (6)
✓ Another review on the same topic suggests that ACT is efficacious particularly for enhancing physical functioning and decreasing distress, compared to inactive treatment (7).
✓McCracken et al. studied 108 patients with chronic pain that went through 3-4 weeks of ACT treatment; an improvement of 34% in pain-related depression and anxiety, physical disability, medical visits, pain intensity, and pain medication was noted, and 81% of these improvements continued 3 months later (8). Moreover, at the three-year follow-up, 64.8% of patients had reliably improved in at least one key domain: acceptance of pain and values-based action (9).
✓ For the first time, an ongoing clinical trial in Ireland will evaluate the effectiveness of a combined Exercise and ACT programme (ExACT), in comparison to supervised exercise for chronic pain (10).
5 Questions to Undermine Control Strategies
The following questions can be used to grease the wheels and facilitate creative hopelessness. This can be used with a variety of pain conditions. Creative hopelessness can be used by mental health professionals (psychologists, LCSW, counselors, coaches) as well as physical medicine professionals (PTs, OTs) to help clients open up and explore where they are stuck.
1- What Have You Tried?
“What have you tried to control, get rid of or alleviate the pain?”
To help clients remember all the different things they’ve tried, therapists can use the acronym STOP, representing 4 broad categories of experiential avoidance:
- Substances: “Have you use any substances to avoid or get rid of the pain?”(foods, drinks, recreational drugs, supplements or herbal remedies, and over-the-counter or prescription medication)
- Thinking: “Have you tried to not think about the pain or change your thoughts about the pain?” (self-help books on positive thinking or worked with a therapist to try to reframe thoughts, delete thoughts or change thoughts.)
- Opting out: “What important, meaningful or enjoyable life activities, events, challenges, or people do you avoid, escape, procrastinate, or withdraw from because of chronic pain?” (work, relationships, recreation, school etc.)
- Pause:“What have you tried to press the pause button on your pain? (this often shows up in distraction techniques such as listening to music, meditation or reading. Healthy behaviors such as meditation can be used as an avoidance strategy).
2- How Has It Worked?
An important first step here is to validate your client’s response by acknowledging their efforts and go on to identify what worked and what did not in their attempts to control chronic pain.
“Did you get relief from doing/taking _______?
How long did it last?”
In this step, it is important to distinguish form from function, namely what actually works to relieve pain and what has been a short-term “fix” or avoidance strategy. You will find that most clients have a long list of treatments that have failed or only alleviated pain temporarily…but none have provided long-term relief.
3- What Has It Cost?
Compassionately, you then ask about the cost these short-term control strategies with regard to work, health, time, money, energy, relationships, missing out, giving up on important things.
“Have these efforts, and the price you’ve paid, decreased or increased over time?”
“Are the costs worth the results you’ve gotten?”
It is common for clients to say the short-term strategies have cost them lots of money and they have lost time and contact with the things that are important to them in their life such as work, family, friends, and recreation.
4- What’s That Like For You?
As the patient steps back and looks at these strategies through a new lens your aim is to cultivate a self-compassionate reflection on how clinging to the control agenda has created more suffering in the long term. Again, you want to validate your patient’s efforts: suggest that most of what they tried makes perfect sense, they’ve worked very hard, they are not lazy, and they’ve done what is only natural and what every human would do. Also help them notice that although some of these things may have worked temporarily, they ultimately did not provide consistent or long-term relief, and most have led them away from the things they enjoy, cherish and value in life. It is normal for the client to experience sadness, fear, anger or frustration. A good way to buffer this and help the patient cope is by asking them “What would you say to someone you love, if they had been caught in the same trap for so long, and they were feeling what you are feeling right now?”Validate your patient’s efforts: they’ve worked very hard, they are not lazy, and they’ve done what is only natural and what every human would do. Click To Tweet
5- Are You Open To Trying Something Different?
After helping your client realize there is little or no benefit in pursuing the same pain avoidance strategies, there is an opportunity to turn your hopelessness into creative ground. You might say… “You have tried many times and for so long to push away and to control your pain, and the results are less than ideal; are you open to trying something different, that might work better, in terms of building a better life?”
If the answer is yes, you may begin to work on simple, non-confronting willingness exercises based on the various core processes of the ACT model that include cognitive defusion, mindfulness and clarifying values.
Infusing Principles of ACT Into PT Practice
Physical therapists are in a unique position to impact change in the chronic pain epidemic that we are facing in America (11). Psychologically informed practice is a beautiful marriage between the mind and body. It is a point on an imaginary line between the narrowly focused biomedical model and the cognitive-behavioral approaches developed for the treatment of mental illness (pain and psychopathology are not synonymous). Utilizing ACT principles such as creative hopelessness in physical therapy practice is a great way to boost adherence to treatment. It is also a way to bring your patients back in contact with activities they have tossed out the window during the struggle with pain. Moreover, techniques used in ACT can also help your patients cope with feelings of anxiousness or melancholy.
To learn more about ACT, download the free ACT Starter Kit by going to www.DrJoeTatta.com/75Download.
Inside is a full explanation of the ACT model for pain, a few metaphors you can use in therapy, as well as some of the latest research about the effectiveness of ACT for chronic pain.
1- Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and commitment therapy as a unified model of behavior change. The Counseling Psychologist, 40(7), 976-1002.
2- Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. F., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.
3-Hayes, S. C., & Strosahl, K. D. (Eds.). (2004). A practical guide to acceptance and commitment therapy. Springer Science & Business Media.
4- 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(4), 785-801.
5- Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., … & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098-2107.
6- Veehof, M. M., Oskam, M. J., Schreurs, K. M., & Bohlmeijer, E. T. (2011). Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. Pain, 152(3), 533-542.
7- Hann, K. E., & McCracken, L. M. (2014). A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy. Journal of Contextual Behavioral Science, 3(4), 217-227.
8 – Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: a study of effectiveness and treatment process. Journal of Consulting and Clinical Psychology, 76, 397-407.