Welcome back to the Healing Pain Podcast with Diana Hill, PhD
When people are faced with long-term chronic pain and the challenges it often brings, it can be easy to lose track of what’s important and chronic pain has a way of keeping people stuck in a rut. Even when people make a strong commitment to care for their pain and find a solution, the real world sometimes has a way of driving a wedge between you, your pain, and deeper and more meaningful life. When this happens, instead of moving toward one’s life goals and purpose, people feel completely stagnant and stuck. This is where the feelings of hopelessness and helplessness begin to set in, but there are ways that people can figure out not only why they’re stuck but also how they can get motivated and excited again about living life.
Here to talk to us about psychological strategies for getting unstuck and finding pain relief is Dr. Diana Hill. She is a clinical psychologist, a fellow podcaster, and an expert in Acceptance and Commitment Therapy, which is a cutting-edge, evidence-based therapy that helps people develop psychological flexibility. In this episode, we discussed daily habits that can begin to help you get unstuck from both physical and emotional pain. She also has a great book called the ACT Daily Journal. Make sure you take a moment to check that out on Amazon. Let’s learn more about psychological strategies to get unstuck and find pain relief with Dr. Diana Hill.
Watch the episode here:
Psychological Strategies To Get Unstuck And Find Pain Relief With Diana Hill, PhD
Diana, thanks for joining me on the show.
Thanks, Joe. It’s a pleasure to be here.
I’m always excited to speak with practitioners who not only have written their resources on the ACT and the ACT model but people who live the ACT model because you have to live the ACT model to be able to use it in practice and write a book on it, which is called ACT Daily Journal. A good question to start off with is, as a psychologist, you’ve studied lots of different methods, techniques and approaches to help people both with their physical as well as emotional pain. Why is it that the ACT model stuck for you so much, both personally as well as professionally?
My journey to ACT was in graduate school and I was in a Cognitive-Behavioral program. I was studying eating disorders at that time. I found my way to ACT through DBT, which is another acceptance-based approach. I had a long background in my mindfulness practice. I had studied with Thich Nhat Hanh at Plum Village and had my yoga practice. When I got to this cognitive-behavioral model, I felt boxed in. There were a lot of benefits to an evidence-based approach and I believe in the Science of Psychology, but I needed a little bit more room to move.
Finding in my own life this component of acceptance-based approaches that incorporate more of these Eastern principles of acceptance with Western science was where I got interested. For me, over time, ACT has evolved. In the beginning, it was using ACT in an outpatient setting where I ran a treatment center for eating disorders. Now, I see ACT as less about symptoms and diagnoses and more about how to live more fully, whether you are a parent, leader in the workplace or practitioner helping patients. Psychological flexibility at its core is about being able to function optimally and flourish in your daily life.
The idea of being boxed in speaks to me specifically because one of the reasons why I gravitated toward ACT was I studied Pain Education approaches. Pain Education approaches are used to help people reconceptualized pain away from something wrong with their body to there being other psychological factors specifically. These pain education approaches grew out of traditional CBT. They focus on changing people’s thoughts and beliefs about physical pain, their body and the cause of their pain.
There’s some good research that helps with things like pain catastrophizing and kinesiophobia which is fear of movement. As a professional, I felt boxed into it because I realized, “This works well with a certain type of patient.” It worked well with a high school Biology teacher I had as a patient who had chronic low back pain because he understood in some way about the function of the human body. With other people, they were looking for something that was a little loose, flexible or moldable. Is that similar to what you say when you say you felt boxed in?
I felt boxed in by first the protocols that are often generated in research settings, and then you get into the real world with a patient or client, and they’re coming in with a whole lot of slew of things. It’s not just their pain, but it’s also how their stress or the experiences in the workplace are impacting their pain. ACT is a Contextual-Behavioral Psychology. The contextual part matters in the sense that the context that we’re in influences our behaviors. It’s much more holistic of a model than this narrowed-in symptom that we’re targeting.
What’s interesting about ACT is that it’s about how humans function. What’s interesting about pain is that very similar areas of the brain are activated when we are in physical pain or emotional pain. It’s the somatosensory cortex, it’s the arcuate nucleus. Our response to emotional pain and physical pain is similar. We have a way of responding to pain which is evolutionarily what made us survive. We are the ancestors of people that ran from painful things. That’s how we got here and we have that in our bodies. Our response to pain, whether it’s emotional pain or physical pain, is to try and control it in a lot of different ways. Either we control it mentally like we get caught up in our thoughts about pain or we can often narrow down our lives to control our pain.
I’ve worked with clients who have something like a body dysmorphic disorder. They have a lot of pain around the way that they view their face or body, and they don’t leave their house. That’s a very narrowed way to live. You could see the same with a chronic pain patient. How the research is panning out is the United Kingdom’s NICE guidelines, which dictate a lot of healthcare in Europe, which then spreads eventually down in the US, have said that ACT is a recommended treatment for chronic pain and trauma. The reason behind that is because underneath it is our attempt to control pain and suppress our thoughts. They have this paradoxical effect that leads to them coming back stronger and narrowing our lives.
ACT is about these six core processes. I like to think or talk about them when talking with clients like the sides of the Rubik’s Cube. There are six sides to a cube and sometimes we’ll focus on one side. Maybe we’ll be focusing on values or cognitive defusion, stepping back from your thoughts. Altogether these six sides of the Rubik’s Cube, when you work on them, help you live more fully, open up your life and move towards what matters to you, even with pain, trauma and obsessive thoughts, that we can still continue to have a full and meaningful life.
I like the visual of the Rubik’s Cube. That’s good because if you look at the ACT model, it’s very flat, the Hexaflex. The Rubik’s Cube is almost something you can grab, twist around, and see different parts of it. Sometimes if you’re looking at the front side, you may be focused on 1 or 2 processes but the other four are always working in the back.
It would be helpful for those that aren’t familiar with the six core processes of ACT. We’ll lay them out and we can go in more deeply. It’s helpful to keep in mind as a practitioner these six processes because you’re on the lookout for, “Where is my client or patient stuck?” The first process is about thoughts and the process in the ACT is called cognitive defusion. Sometimes if I’m working with a pain patient, I have them imagine like, “Imagine you have some thoughts about your pain written across your hand like, ‘I don’t have enough energy. I feel too bad to do this thing. The pain is too much to handle.’ You would hold those thoughts close up to your face and then how well you can move about your life, read to your kid or see your partner when you’re this close to your thoughts.”
With cognitive defusion, we step back from our thoughts and get a little space from them. It’s almost like moving your hand away from your face so that you can take a look at your thought and see if it’s helpful to you or not, but then you can also engage with the world. What’s different with this one side of the Rubik’s Cube is that we’re not writing a different thought on your hand or tying your hand behind your back. We’re getting space met. One side of that Rubik’s Cube is how we respond to thoughts with pain and we can get entangled in them. They can be very convincing, push us around, and bully us in our lives.
The other five are values, what you care about. Acceptance, being able to open up and allow for discomfort. There’s perspective taking, being able to step out and look at the bigger picture and view, seeing ourselves as having a transcendent self that moves across time. There’s mindfulness or being present. ACT takes a little bit of a different approach to mindfulness that it’s about being mindful where it matters. There are committed actions, which are taking tiny behavioral-based moves towards what you care about. Those are the six sides of the Rubik’s Cube. As a practitioner, you’re looking for where people are stuck, and then where you’re stuck is the side that you may go to and tinker with.
The key is that we’re not trying to get to a perfect Rubik’s Cube because if I have young kids when you solve a Rubik’s Cube, it sits on your counter. You’re like, “No one touches the Rubik’s Cube. It’s perfect.” Rather it’s tinkering, moving and flexible. We all get caught up in our thoughts and move away from our values over the course of our day. We’re like instruments that get out of tune. With ACT, it’s about the flexibility to return over and over again to these six core processes, be able to see them in yourself and your clients so that you can use the skills and apply them in your life.
Through those six processes, you mentioned having a lot of research behind them with regard to helping people with chronic pain. They are acceptance and values. I was flipping through the ACT Daily Journal and you have a nice way to describe acceptance from the context of living courageously. That word, courageous, left off the page and hit me square in the face. I was like, “That’s a beautiful way to describe acceptance.” We are asking patients to do very courageous things. With physical and mental health, it’s all the same after a while. How did you come about that courageous stance that you have there?
Debbie Sorensen is my co-author. We’re mothers and therapists. We’ve been moved by our clients who have these touching moments where they’ve lived so courageously and to be able to witness that and be part of it. Any practitioner knows that. You feel this sense of, “That was such a big move for you and I can see how hard it was.” Sometimes the moves are so hard. I had a client once who used to have panic attacks in Trader Joe’s. I personally think of Trader Joe’s as a happy place. You wear Hawaiian shirts and they always acknowledge you as a person. For this client, walking into Trader Joe’s to go get her groceries was terrifying. I celebrated in a courageous move of her going in, buying some groceries for herself, and getting her Chinese chicken salad.
When we start to frame acceptance in the realm of courage, willingness or curiosity, and there’s some good neuroscience around curiosity now. I interviewed Jud Brewer who studies cravings and addictions. Taking a curious stance towards your craving changes how it shows up in your brain. Those words are much more accessible to people than the word acceptance. If you start off your session with like, “I’m practicing ACT and I’m going to get my client or patient to accept their pain,” I will guarantee you, you will get either pushback, resistance or somebody that feels belittled. We don’t want to make the statement, “Your pain isn’t painful or isn’t excruciating.” There are reasons why you have hunkered down around this thing and got so caught in it. Words like courageous, willing, open and curious have a lot more movement to them in the treatment room.
The question I always ask myself as I watch new professionals, specifically physical therapists who are learning about these third–wave type therapies, what they mean and what’s happening, “Does it take an equal amount of courage for a practitioner to adopt a new model like this where maybe they’ve studied a traditional cognitive model before and it was very focused on symptom reduction?” Traditional CBT for chronic pain is primarily focused on symptom reduction, similar to those Pain Education approaches I mentioned. How much courage does it take for a professional to say, “It’s different for me to take this perspective and help someone become resilient with what they have and who they are instead of changing what they have and who they are?”
It’s a tremendous amount of courage because not only do you have to be psychologically flexible as a provider, but you’re going to get pushback. When people come into therapy with me, the most common three requests I have are, “Help me stop feeling, thinking and remembering this.” As an ACT therapist, I have to respond with, “I can’t do that. I’m not that type of therapist. That’s not what I do.” Your attempts to not think, feel and remember are keeping you in what we call in the book, the experiential avoidance roundabout. I use the word roundabout intentionally because I live in Santa Barbara, California and they started plopping roundabouts to deal with traffic. They’re a very effective way to deal with traffic. Californians are traditionally terrible drivers. If you get a Californian in a roundabout, what we do is we go around and around.
If you think about your struggle with your pain, anxiety or thoughts, you feel caught. How do you get out of a roundabout? You have to move over a lane and you got to exit the thing. It’s incredibly scary, uncomfortable and nerve-wracking to do that if this is the first time you’re in a roundabout. That is what we’re asking our patients and ourselves to do when we’re entering into a new protocol, treatment program or do something that’s a little out of the box is to exit this roundabout of familiarity and comfort. Here’s the deal about roundabouts. Once you exit, then you can go on any street you want in town and you have freedom.
I train a lot of practitioners. When I’m working with a supervisee, what I focus on is that feeling that is linked to their values of being an effective provider. This is where the science part of ACT is helpful. We have the science to back it up. We don’t have the science to show that ACT is better than CBT for chronic pain. When they look at randomized controlled trials and reviews, ACT is about equivalent. What we do see with ACT studies is that in comparison to CBT, there’s a bit more accessibility to it, both therapist and client acceptability. ACT will help you not only get a little bit more wiggle room with your pain, but it will have spillover effects into all domains of your life.
I am interested in that. I believe in values-rich living, where how I live as a therapist, I’m sitting on the ground because I’m taking care of my body. I follow a biomechanist named Katy Bowman. I have scoliosis and chronic pain in my spine. For me, sitting on a couch or a chair is painful. I take care of my body when I’m doing a podcast. As a practitioner, I’m thinking about, “How can I do practices where I’m embodying and living out ACT while I’m helping my clients do it as well?”
In that values-living, there’s action people have to take, so the little steps along the way. Most people who teach ACT are like, “These are the little steps to building blocks, the little rocks along the path.” In your book, committed action, you have falling on purpose. As a physical therapist, this rings so true because so much of what we do is physical and the falling nature stuck with me again. To me, it’s this idea that we’re going to help you cultivate these skills and connect to values-based living, but that road maybe a little bit bumpy along the way.
In our book, it’s an eight-week program and each week is dedicated to one of the six core processes, each of those sides of the Rubik’s Cube. We also include a chapter on self-compassion to start the whole thing off like, “Compassion is the rich soil in which we plant these seeds of psychological flexibility.” We share little vignettes in the book. I could read the one about falling on purpose. This is what I wrote. “I’ve always been afraid of falling. As a kid, I wouldn’t climb trees and never made it past the bunny slope skiing. In yoga, I conveniently step out to use the bathroom when it’s time for headstands, and then I learned that falling is part of committed action. In an ACT workshop, Kelly Wilson stood wobbling in a yoga tree pose and said, ‘What if falling were part of the pose?’ Falling on purpose was radically freeing for me. If I fell on purpose and then I could try all sorts of things, surfing, a podcast, homeschooling, starting new friendships. Today, committing to falling on purpose opens my life to fresh opportunities.”
That’s where I feel like a lot of times, we get goal-oriented as opposed to process-based. ACT is a process-based approach, which means we’re not trying to get to that perfect Rubik’s Cube. We’re enjoying the process of tinkering with the cube. That means when we engage in taking these steps outside of our comfort zone, we’re strengthening our ability to move outside of our comfort zone, but we’re also holding it lightly that we don’t have to take everything so seriously, even our own recoveries from chronic pain. Falling on purpose frees you up.
We still use the science of committed action or behaviorism in ACT. I teach through Instagram, imagery, and also my blog. Some of the things that I’ve been teaching are the concepts of how to set up a habit cycle. A habit cycle in behaviorism is there’s a cue, behavior and reward. If you’re looking at a habit cycle with something like chronic pain, the cue maybe, “I feel pain in my body.” The behavior maybe, “I go back to bed. The back pain so I stay in bed,” and then the reward is, “I feel short-term relief from that pain.” We see those habit loops and behavior cycles keeping us in that roundabout.
I’m interested in setting up habit loops that are linked to values-rich behaviors. A cue maybe, “I feel pain in my back,” and then the behavior would be, “How do I want to be this day? What is important to me about my relationships or work? How do I want to be in a relationship with my kids or career?” We engage in that behavior, and the reward is intrinsic. It’s a deeper reward that is longer-lasting when you’re aligned with how you want to be in the world. That’s where we start to look at behaviorism and this committed action component of falling on purpose, but you’re falling on purpose because you’re falling towards what you care about.
You’ve started to touch on this already. You’re talking a little bit about psychological flexibility and what it looks like. Can you give us some examples of what psychological flexibility has looked like in some of your patients as you’ve seen them start to grow with this model that you’re teaching them?
Due to confidentiality, when I talk about patients, I disguise and combine them into some new version of them to honor that that’s an important part of my work. I can think about a combined patient of mine that had a lot of social anxiety. When you have social anxiety, you feel like there’s a spotlight on you and everyone is paying attention to all the details of your mind. Their particular roundabout around social anxiety is that they would never put themselves out there. This was a therapist. They wouldn’t ever want to go into a group practice or any of the team meetings. They kept their lives narrow.
When we got in touch with what are the deeper values of how they want to be as a therapist, why being a therapist was important to them, and then we took these little tiny mini-moves, they were able to move into areas of discomfort, even with that anxiety there. Panic attacks still showed up every once in a while. When you experience anxiety, it’s like a horrible feeling inside of your body, but turning towards that feeling like, “Where is it?” You can do this with pain too, “If it had a shape, what would the shape be? How is it moving? Is it moving up or down? Is it heavy or prickly?” Turning towards with curiosity, opening up, and allowing for that sensation to be there while still moving your body in the direction of what you care about. When you do that, you start to see people’s lives open up. The anxiety doesn’t necessarily go away. It might go away. That’s a great side effect but that’s not the goal.
I’m so happy you brought up a practitioner story into the mix. In my experience, I believe a lot of professionals come into ACT. They love it, are excited by it, embrace it, and have a lot of anxiety about starting their change. Changing the type of practitioner, their approach and stance, or things that they agreed to do with their patients. As you mentioned, “I have no control over your pain necessarily. I can help you cope with it and teach you techniques in different ways but ultimately, that’s not the type of work that we’re doing together.” How it looks like to us as professionals, it’s in line with what you would ask most professionals, “Why did you become a psychologist or a physical therapist?” “I want to help people, make their lives better, and help them return back to living.” All of that is embedded in the model and the book that you’re talking about.
The fuller life that you have, the more likely you’re going to experience pain. As a parent or pet owner, you know that this is part of living fully, the pain and values. Debbie and I say, “They are joined at the hip. They come together.” If you think about anything in your life that you’ve gone for that has been important to you, not a bowling game that you lose, like when you apply for something, put yourself out there in a way, a relationship you’re pursuing, or a relationship that you’re uncertain about but you like that person, it’s painful. The size of our life is dependent on the size of our willingness. Bigger, willingness, bigger life. That can be psychological pain or physical pain.
It’s changing our relationship and perspective around it. What’s hard is that because the human mind is so designed to avoid pain for evolutionary reasons and seek out hedonic pleasure, we’re also working against our biology here. It’s a bit of retraining and a process over and over again. Some of the strategies are subtle that we engage in when we’re experientially avoiding. Some of them are obvious like, “I feel lonely or stressed at night, so I drink alcohol.” You can see that would be an obvious one, numbing out with substances, but some are more subtle. It’s the subtle ones that are interesting, in particular with chronic pain, things like bracing or tensing around painful spots.
I know I do that for myself around my back pain or when I’m practicing yoga. If I have some discomfort, I’ll put one shoulder up to brace against the back. It has this cumulative effect over time, the bracing with our bodies and holding of our breath. How important it is in our pain work to be able to breathe. I’m a yoga practitioner. I believe in the breath and the power of breath from the inside out. It has so many different benefits for us psychologically, physically and spiritually. We hold our breath. Here’s another one that people don’t see a lot that I’ve gotten interested in. We avoid pain by pushing through and striving. We overwork, do more, accomplish more, rush through, and speed up quickly through things.
If you move through something quickly, you’re more likely to get yourself injured, but you’re moving through it because you don’t want to feel the pain of it. Whether that’s physical or psychological, these are mirrored with each other in the physical and psychological realm. Working with your patients can be helpful and we make a list in our book of some of these common emotional avoidance strategies. It is to help them start to see, “When I do this short-term, I get relief but long-term, what are the consequences for me? Either consequences that are negative for me physically or not helpful that I don’t end up moving towards that free roam of the streets that I want to have in my life.”
What can someone begin to do now or this week to help them move toward their personally chosen values?
There are different avenues into your values. One avenue in and I think about this with clients a lot is through looking at where you feel energized and lit up. You feel that sense of almost flow in your life or longing in the heart space. When I’m working with clients, I’ll pay attention to when they’re talking about things. If you’re working with a paying client, pay attention to when they’re talking about their pain. Don’t pay attention to the pain part. Pay attention to when they’re talking about the parts that they miss. That can be an avenue in of like, “What is it that energizes them but also where is the loss?” Often, the loss is things around relationships.
I used to have a client that I’ve worked with for years that loves to hike and knee pain has gotten the way of that. We work on like, “What if you were to go there and just be in nature?” It doesn’t have to be a hike. It can be like you go, get out of the car, and start by sitting by the stream that’s right at the trailhead. Looking for both sides of it, look for where people feel energized and be a highlighter for that, but also look for where people feel loss, longing and that their lives have gotten narrow because that can often be an arrow that’s pointing towards values. Once you get that going, you start to highlight it and use that as the rich material to help motivate people. That’s the motivation of the why behind why we’re doing this work.
There’s a couple of resources of simple questionnaires that you could use to help with this. There’s the Chronic Pain Values Inventory by McCracken. It’s a simple one where people look at different domains like family, intimate relationships, friends, work and health. They rate how important those domains are to them and then they rate the degree to which they feel like they’re successful in living out their values in those domains. You start to look at this discrepancy like, “Here’s this domain that’s important to me, but I feel like I’m not living out my values in it.” That can get a conversation going about what it is that maybe we want to be more willing or courageous around so that we can get a little bit more aligned with how we want to be in the world.
When you write a book on ACT, things start to change both for yourself and the people who pick up your book, start to read it and discover ACT and your approach to it. How has the ACT Daily Journal changed your life?
Debbie and I wrote a book about psychological flexibility as parents during the pandemic. We got to start with compassion. That’s going to be our first chapter. We were very much, “Let’s try this on while we are doing it.” Writing with her taught me a lot about interconnection, community and friendship. I’m a solo player. I ran cross country. I had my private practice. Working in groups is uncomfortable for me. Striving is my emotional avoidance strategy. Working with Debbie during this time taught me about the compassion that’s needed. I do believe that compassion, the ability to be present with ourselves and others in the face of suffering and the desire to alleviate suffering are at the foundation of this work.
I learned about that in a very intimate way that I cannot do everything that I want to do all the time. I have to prioritize based on my values and sometimes that’s sharing the load and saying, “Debbie, I can’t do it all this week. Can you take the edits?” It takes a lot of humility to recognize our limits and also to do some boundary setting. ACT Daily Journal taught me about that. My favorite part was the last chapter. We talked about integration. I’m a beekeeper and homesteader. I love bees and what bees have to teach us about working together for a greater whole. Ultimately, this work isn’t just about me, the client or the patient that I’m in the room with but this spreads.
When I work on psychological flexibility with this person or even in this interview, having this conversation with you, Joe, it’s going to spread to others that are reading, and then those that are reading will spread it to others that are reading. All of a sudden, we’re starting to spread something that’s good. As a species, we are interconnected. If you are living well and flourishing in your life, it feeds back to me and all of us. We have a lot to learn from other prosocial species like bees about that.
Diana, thanks so much for being here with us and talking about ACT and all the great work that you’re doing. Share with us how we can follow you and learn more about your work.
I do some teachings through Instagram. If you’re a social media person and you want to see some pictures of my beekeeping, you can go there. I teach ACT there. I also offer a lot of ACT workshops and training for both professionals and laypeople. You can find those through my website at DrDianaHill.com. I also offer a free Tuesday Teaching. We’ll incorporate movement, ACT and meditation into my teachings. You can find that on my website as well. Finally, for people that want to learn more about how I incorporate these ACT principles into body-based practices which I’m interested in, if you go to my website and sign up for the six strategies for body-based practicing ACT with your body, that would be a great way to learn that skill.
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About Diana Hill, PhD
Diana Hill, PhD is a clinical psychologist and co-author of ACT Daily Journal: Get unstuck and live fully with Acceptance and Commitment Therapy. She is also a co-host of the popular podcast, Psychologists Off the Clock and offers regular teachings in compassion and ACT through Insight LA and Mindful Heart Programs.
Through her online teachings, executive coaching, clinical supervision, and private therapy practice, Diana encourages clients to build psychological flexibility so that they can live more meaningful and fulfilling lives.
Diana has a knack for unpacking complex, science-based concepts and making them applicable to daily life in work, parenting, relationships and health. She completed her undergraduate work at UC Santa Barbara, majoring in Biopsychology, followed by a PhD in Clinical Psychology at CU Boulder where she researched mindfulness and acceptance-based approaches for eating disorders.
Diana practices what she preaches in her daily life as a mom of two, homesteader, and yoga teacher. Learn more about her latest offerings here and follow her on Instagram, Facebook, and Twitter to get tools to build psychological flexibility into your daily life.
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