Welcome back to the Healing Pain Podcast with JoAnne Dahl, PhD
We are discussing the importance of values in pain care and how values are approached through the lens of acceptance and commitment therapy. In acceptance and commitment therapy, the term values refers to activities that give your life meaning. Values can be looked upon as the people, the causes and the activities that are deeply important to you. When you connect to your values, you’re able to move your life forward in meaningful directions even in the face of very difficult and very painful experiences. This is why values are so important because in clinical trials, values are associated with lots of positive outcomes. Even if pain itself does not change, you can have less anxiety, less depression and improved physical function and enjoy a much richer, full and active life.
The best part of values is that you choose your own values. Often people can confuse a value with a goal. Values are not goals and you never accomplish a value. Instead, values act like a compass that helps you make choices and move you in the direction that you want to go. Values keep you on track with a rich, full and active life, even if you have some pain. Joining us is JoAnne Dahl. She is a Professor of Psychology at Uppsala University in Sweden and a clinical psychologist specializing in behavioral medicine. She is the co-author of the book, The Art and Science of Valuing in Psychotherapy, Acceptance and Commitment Therapy for Chronic Pain, Living Beyond Your Pain and Acceptance and Commitment Therapy and Relational Frame Theory in Relationships.
We’ll discuss many types of values or what are known as value domains and acceptance and commitment therapy. Values can be a huge topic that many people spend lots and lots of years studying. Values work can be distilled or focus into ten categories. These ten value domains for you to think about are parenting, family and friends, intimate relationships, work, leisure, citizenship, personal growth, health, spirituality and community. As you participate, take a moment to notice what’s essential in your life when you hear one of these value domains mentioned. For example, we’ll discuss the domain of personal care. Personal care can also be looked upon as your personal health which is an important topic for people overcoming chronic pain.
Think about how you would like to take care of your body or how you’d like to take care of your health when it comes to exercise or diet under the ideal circumstances. See if you can connect this to a deeper health value that’s personal to you. For example, you may think, “I want to feel healthy and strong when it comes to exercise.” That’s great and it’s important but then I want you to take that one level deeper and I want you to know or I want you to ask yourself, “Why is this important? Why is it important for me to be healthy and strong?” Notice what comes up for you. You may notice, “I want to be healthy and strong so I can coach my son’s baseball games,” or “I want to be healthy and strong so I can be the PTA President at my daughter’s elementary school,” or possibly, “I want to be healthy and strong so I can be a loving and supportive daughter for my mom who is getting older and is not able to take care of herself anymore.”
There are lots of reasons why you value being healthy and strong. To accompany this episode, I’ve included the Bull’s Eye Values worksheet for you to download. The Bull’s Eye is a values clarification exercise you can use whether you are somewhat with pain or you’re a practitioner and you’re interested in implementing values work during your therapy sessions. The Bull’s Eye worksheet is a one-page handout and a useful tool that you can use in practice whether you’re a physical medicine professional or a mental health professional. To download the Bull’s Eye worksheet, all you have to do is text the word 152Download to the number 44222 or you can go to IntegrativePainScienceInstitute.com/152download. There are specific instructions on how you can use it and you’ll also learn a lot in this episode. Let’s meet JoAnne Dahl as we discuss values and pain care.
Watch the episode here:
The Art And Science Of Values In Pain Care Using Acceptance And Commitment Therapy (ACT) with JoAnne Dahl, PhD
Hi, JoAnne, welcome to the Healing Pain Podcast. It’s a great honor to have you here.
Thank you for having me.
I’m excited to talk to you about ACT, valuing, pain and all the things that you’ve been working on for decades as a psychologist. You live and practice in Sweden but as you speak, you’re fluent in English, so you’re from the United States. Tell us a little bit about your story of living in the US and leaving the US and heading over to Sweden and working on a professional career there.
I went to Quaker College in the United States in the ‘70s. There was a program there for Scandinavia. I thought Scandinavia was a fascinating country. I was actually interested in the criminal system because I volunteered at the Indiana State Penitentiary, which was a scary place. I was just fascinated by Scandinavian prisons that seemed like, “Why are they in prisons?” I went with a group of students from that college and they were interested in healthcare. We went to hospitals and prisons there and I met a guy there. They had a free graduate school and all schools were free. Scandinavia is a great place to live and my kids all live here and they all go to school here. I recommend coming here for a visit. It’s such a radically different place than the United States.
A hot topic now in the US is education and the cost of education. Not to be political and get on on a topic, but is school still free in Sweden?
Yes, completely and even if you choose a private school like a Montessori school, it’s also free. The PhD level is completely free. The healthcare system is also free. I think having companies that are private and are looking for profits do influence the way we get care.
It sure does, especially in the world of pain. You mentioned you went to school in the US. Obviously you have a PhD in Psychology. Did you do your undergrad in psychology in the US and then did your PhD in Sweden?
No, I did a BA in the States but in Sweden, I had to start over again. They have something called professional programs so you start over again. It’s five years to become a psychologist and then ten more years to get your PhD, so it’s a long way to go.
Tell me about your early practice and your early career in pain care as a pain psychologist in Sweden. What did that look like?
My very first job as a psychologist was at a rehab. It was the very beginning and that was 1978. You’re younger Joe, but with the model that was from Washington, that was the first time psychology was ever practiced with pain. It was a revolution and this is what became what’s also called the Swedish back schools. It was done in groups and essentially it looked exactly like it is now. That was 40 years ago. The idea was work hardening. You desensitize yourself to pain, do what it hurts and it’s the “no gain, no pain” type of thing. I don’t know if you remember the Dallas Model. That was a model where essentially you stay on machines and work your way through the pain. A lot of things were maybe unethical we would say now, but I think it was mechanical looking.
It sounded more operant-conditioning, not even CBT-based. Would you say that’s true?
It was called CBT-based, but the physiotherapists at that time were working a lot with orthopedic medicine. There weren’t so many physiotherapists and we’re like cheerleaders cheering on people. We did guided the practice where you’d measure them and then we’d sit and clap, “You made it, you made a centimeter more.” There were a lot of graphs.
This is more like the CBT run. You did that for how many decades?
For about 25 years I worked with CBT like that in groups. You probably know yourself, Joe, all of us, whoever worked with these things, there are a lot of burnout because you essentially were convincing people to do things they didn’t want to do. For example, if they came in and you say, “Where’s your pain?” They say neck and shoulders. You say, “Okay, what are you avoiding?” “I can’t do this movement.” “Let’s start there.” They’d say, “Hello, I said that it hurts.” We ignored that. We were taught to turn our faces away if they were talking about pain. It was harsh. That’s why we were getting burned out, because it was so tiring to people to do what they did not want to do.
It can be very demoralizing to the patient as well.
That hurts too that you are demoralizing people. It was not good.
Tell me how you ran into or came about acceptance and commitment therapy.
Being a tired person working in public health, I listened to Kelly Wilson when he came to Sweden and talked at one of our conventions on Behavior Therapy. He talked about values. I thought, “What if I could not be the cheerleader? What if people could find their own motivations?” I liked that idea. I worked with Kelly and we did some work together and I saw that the patients inspired me. It wasn’t me pulling them and I got back my joy again of being a therapist because I was not pulling them anymore. Swedish people are careful and as Americans, we compliment people. We give validation, which they don’t do here. I was even more so doing it as an American. I have to curb my enthusiasm to learn.Values are associated with lots of positive outcomes, even when pain itself does not change! Click To Tweet
I didn’t think about the cultural aspect of the interactions like that. That’s interesting. You were introduced to Kelly Wilson and some of his work. His work is pivotal in the world of values. Values start to open you up as a professional as well and with that, you opened your patients up to values. I’ve done a couple of ACT episodes already. I did one with Steve Hayes, but tell people what ACT is and how it might be different from traditional CBT. We’ve already talked about it a little bit, but talk about it in your words and in your experience.
Kelly Wilson and I did a study together and it was mentioned in Steve Hay’s book. It was from 2004 with the public health workers who were tired and they were at risk for sick leave. That’s what we worked up together and when I did the values compass with them which was asking them not what they were avoiding but what they wanted their life to be about, you saw that motivation and that life come back to them. It makes such a change so quickly without any effort on my part. I got mesmerized by the values part first and then adding in this diffusion rather than changing thoughts. We’re playing with thoughts. We laughed at how silly these stereotypes simplifications are. It became so much more playful and fun at work.
Essentially, the big difference is you’re teaching people to relate differently to the pain that they’re learning a different relationship. I think that’s the main big difference with CBT. Bigger changes were required. You’re asking them that the pain should go down and you’re asking them to control the pain. It’s the same as the medical model. I compare that to epilepsy when I worked with epilepsy. In the first few years, we’ve worked with the control of seizures and then after that we worked more with acceptance of seizures. That was much simpler and a lot more fun.
You mentioned the study that you did with Kelly Wilson on Swedish workers. You discussed in this study that there is a myth that people are stressed out because they’re doing too many things. In that particular study, you found out that’s not why people are stressed and in pain. They’re not stressed and in pain because they’re doing too much. Can you talk about that a little bit?
There are a lot of selfish concepts where you build up a story about things. You know yourself with the work you do that when we start getting into resistance and getting behind things, we were doing it more because we are forcing ourselves to do it. We’re losing the quality and we’re making ourselves do things and that’s where you get into trouble. You know much more than I do what happens in the body but I’m sure it’s not good because it’s so aversive. When you choose to do things and you’d land in the actual quality and the integrity of an activity, then you can never do too much.
It’s because you’re enjoying the activity.
You’re choosing it and you’re landing at it. Sometimes it like you’re taking a whip and you’re whipping your body to do things. Anything you do with that intention would be too much.
You’re touching on the fact of reinforcers in human behavior. It’s a technical topic and it’s one that psychologists understand a lot better than other types of practitioners. Can you explain to us why values are reinforcing?
A very common thing is when you think about burned out or chronic pain, often people think, “I’m helping people too much, so I’m not thinking about myself,” or “I’m too kind.” That’s sad because there can never be too much kindness in this world. If you were good at helping people, that’s fantastic. Can you keep doing it? When we say that you, Joe, have a sibling that you want to help that’s maybe in trouble, you choose to help that person, your brother, because you want to, because it’s important. Somehow in your everyday life, it becomes a routine and an expectation. You thought, “Oh no, I got to do that.” That becomes what we call a negative reinforcer. Those are the things that will tire you out or dry you up if you have a lot of, “I have to do that.” As long it becomes a positive reinforcement of the values in it, it can totally without any limits at all. We should never say no. We should just learn to say yes. There should be no limit to loving and caring.
There are also primary and secondary reinforces that people work within life and develop. The primary reinforces are something more evolutionary that we have as humans.
In our values book, we become natural reinforcers. That would come for all of us human beings, but topographically, they could look very different. In principle, for example, what Steve takes up in his book is these yearnings for community and for competency. That’s what we would call values.
JoAnne, let’s talk about a book that you wrote on values, it’s called The Art and Science of Valuing in Psychotherapy. It’s an excellent book if you’re interested in the topic of valuing and psychotherapy and how to help clients identify their values and work with values in care. On that topic as a practitioner, is there an ideal moment or a session where values should come into the therapy room?
If you asked different ACT trainers, they would say different things. I like to bring it right in the front at the start. When I look at someone, I’d like to know “Why are you here? What is it? There’s something that you are yearning for or something you want.” I’d like to get at that rather than go through what’s wrong with you or what’s your problem? We just cut to the chase if you can go to values.
If you read different ACT trainers and different ACT protocols, they may insert values in the middle or more toward the end, but people in the world of pain care like to work with them in the beginning. You mentioned that you’re interested in what someone is looking for or what they’re yearning for on a deeper level. If someone with pain is reading this and they’d say, “If I’m going to see a pain psychologist or maybe a physiotherapist, I’m interested in pain and relief. That’s why I’m there.” How would you answer that question to someone?
You could take a few steps further. “If you were in pain, what then?” If you came to me with a migraine and I said, “What difference does it make if you have a migraine or not?” “It makes a difference because I can’t go meet my friends.” You get to those things. When you work with someone overweight, “Is that what you want on your gravestone? “Joe lost those five kilos at the end.” Freeing up things is not a good criterion for value.
As you start to look at values and you start to unwind values and help people clarify their values in the therapy room, how many different types of values are there? Are there major categories that one can work with?
If we think of evolutionary, we need variation. We need diversity in values. Just like in biology, we need a lot of variation because if you put all your eggs in one basket, you’re going to be vulnerable. Topographically and principally, we need to have a great variation. If you think about how you live your life in New York, I have been a guest of you in New York and I thought you lived a very big, huge variation in your life. You have friends. You’ve got intimate relationships. You’ve got family and you spent time with all them. You’re taking care of your body, eating and culture. All those things would help you if something were to go wrong. It’s like the spokes of a wheel. A wheel will go round if you lose the spokes, but it runs best if you have all the spokes in good condition. If you do lose the spoke, if you have the other things working, you’ll have reserved. With chronic pain, when people start putting their life on hold and their mission in life is to get rid of pain, you can see that that will lead to depression.
I like that metaphor of the wheel and spokes. Another example of that is if a particular individual says, “I’m just going to be a good mother,” or “I’m just going to be a CEO.” You may be feeling one of those ten domains. The ten domains are our family, intimate relationships, parenting, friendship, work, education, recreation, spirituality, citizenship and self-care. Self-care is also sometimes broken down to health care or care of oneself. If someone says, “I’m just going to be a CEO. My main value is I am a leader in a company,” what you’re saying is that if they lack attention or clarity in some of the other values of their relationship, if they should ever lose that position or that status, it could be devastating for them because they have nothing else that they lean on in their life.
Yes, that’s right. I just retired and I can say that people who have done that are in trouble. Let’s say you’re only together with your partner and he leaves you. You need to think that you need variety and diversity, so that you’re not that vulnerable if you were to lose something. Through life we are going to lose things. We need to always think about that and prepare ourselves to be flexible about finding new ways to express that.
How does helping people explore those domains? Of course, unless I have to always do all ten but people are moving in and out as you mentioned. How does that relate to what’s called in ACT self as context? How can that help with self as context? It can be a difficult term and concept for many practitioners to understand and start to integrate into their care.
Within RFT, self as the context is usually called the most important of all the psychological ingredients. It’s this thing about lifting yourself up above your conceptualized self. A lot of people think of that in terms of spirituality and transformation. On a simple level, we do this all the time. It’s the ability to say that you and I were arguing about something and then we suddenly think about, “What do we want to happen here?” “I want to have a meaningful meeting with Joe.” That would be more important to lift myself up rather than saying who’s right or wrong. You’re bigger and we’re connecting over something greater than just the concepts we are at.
I have a good example. I had a guy who was a soccer player. If you ask him what’s important, it was just soccer. He goes down to Spain with his family and his little three-year-old runs in front of a car and he dives in front of the car to save his son, which he did but he was run over and became paralyzed. No more soccer. That’s just an example, but things happen to us all the time where we all of a sudden can not express ourselves in this particular, the physical of soccer. At the hospital, they asked him, “What was so much fun about soccer?” He’d say playing in a team, playing with other guys, competition, fresh air, a ball. You’re much higher there and there can be many expressions from that point on how to now express. You don’t get stuck on a concept which you can lift yourself up. It gives you a little more flexibility.
You’re also helping him explore how he can find similar values but in different contexts?
We have to do that all our lives. As you age, you think about your parents in Florida, they can’t do that. They do something else, but not stop and say, “Okay, if I can’t do that, forget It.” You have to find new ways of doing things continuously.
If I can give an example to that as well, I was a competitive gymnast. I have a lot of friends who are still gymnasts. They’re in their 30s, 40s, 50s, some are even in their 60s and they’re still doing gymnastics. One of their great values is being a gymnast and being part of that gym is culture. Gymnastics is a relatively young sport, meaning it is physically more difficult to do as you get older. I’ve tried to help a lot of my friends. A lot of my athlete friends find similar context whether it’s finding a yoga class, a Pilates class or a ski club where you’re still part of an activity. You’re still an athlete, but it’s a little bit of a different context. It works well for people. It takes a little bit of time in the beginning to make that transfer. Once they make it, the value changes for them a little bit as far as the context has changed for them, but the meaning is still there on a deep level.
Another thing that’s important to say about values is also the pro-social part. In the beginning of ACT, when we looked at the values, we’d looked at more, “What do I want? What do I want to get out of this?” Now, in the last few years, we’re talking more about, “What can I contribute?” That is a shortcut because let’s say one of your friends is depressed because she can’t do gymnastics, but maybe she could be a mentor to someone else. Maybe somebody else would like to learn gymnastics and you could maybe help. Pro-socially you can get at these values.
Let’s talk about pro-social behavior for a minute because I was never introduced to it until I started learning and studying ACT. Pro-social behavior is an important topic to talk about now in so many different climates, whether it’s healthcare or politics. As a practitioner working with people with chronic pain, I may help them clarify their deep values and meaning in their life. How could that help us as a society overcome our chronic pain epidemic?
There’s nothing about being egocentric that is helpful to yourself or to others. We are not naturally alone. For example, let’s say in your fields, in different activities, if you can help someone else take care of their body or if you could be maybe a teacher in gymnastics, you automatically get your own needs fulfilled. I grew up in the United States. We all went to the same public school and everything but now things are a little more individualistic, “What about me?” That’s not good for us as a society and we need to be more collective. When we help others, we get our own needs met. The more we give away, the more we get back. We have to trust that. I don’t know if I answered your question.
What you’re saying is that as a practitioner, no matter what kind of practitioner you are, a psychologist, an occupational therapist or physical therapist, if you’re working with values, you may help someone overcome pain, but oftentimes, people’s deepest values are their need to help others. With the epic and biblical amount of chronic pain that we have in the world both emotional and physical, we know that in a lot of ways those two are really just one. If we can help people help other people, that may be the quickest way to overcome our pain epidemic. It’s not necessarily training herds and herds of psychologists and physical therapists. Maybe the way to do it is helping people with pain help other people with pain.
Absolutely. I believe that. When a person comes to you and says, “I feel empty, I’m depressed, I’m alone,” our answer should be, “How can I help you help someone else?” That would be the quickest way for you, but it’s not so easy when people are filled with themselves. We have this idea that we’ve had for some time that you got to put on your own oxygen mask before you help somebody else. What’s something most people would say they believe is you have to help yourself first and then you can help somebody else. I don’t think so. You need to start with helping somebody else and that will help you because we’re social animals. It’s easier. If you’re depressed, you’re laying in bed and you say to me, “There’s no meaning for me to get out of bed.” The truth is you have no meaning in yourself, but if your neighbor has a dog that needs to go out, there’s a meaning.”
It can be a difficult topic in our world of social media where everything, to a certain extent, is very me-oriented. Just the idea of a selfie, meaning I’m taking pictures of myself and I’m constantly broadcasting to the world what I’m doing. In some ways, are we training people to be less pro-social?
I don’t think the pendulum can go in different directions and in your own work, I don’t know how long would you say we’ve had this more mindfulness. We’ve had other types of things that are a little more collective thinking. This pendulum is going in the other direction.
It’s a great point. We once have these two funnels happening. We have the more mindfulness, aware and open to what we’re all experiencing together. There’s another almost like, “I am the center and from there, things radiate.” They’re interesting to think about. They’re important when we talk about pain and people with chronic pain. I mentioned before that there are ten domains for values and I read them off. Some practitioners may be thinking ten is a lot. I don’t know where I would squeeze that into to an initial evaluation or how many sessions it could take me. Let’s say fourteen sessions just to work on ten different domains of values and the insurance companies are only reimbursing four. I know you’ve worked on a tool which is the Bull’s Eye. Can you talk about the four domains in the Bull’s Eye and how they were whittled down to those four domains?
There was a student of mine who did a factor analysis on the ten and it turns out that they gathered together into those four.
Those four domains are work education, relationships, personal growth, health and leisure.
You could cook them down to one thing and that’s the sense of belonging. The number one fear and longing is to belong. If you see someone who is in chronic pain and have trouble working, not being able or competent to work, it’s devastating for a human being because that means you’re not good enough to belong. I had a terrible example. I was up North and there was a woman up there. She went out even in the newspapers and saying that she had these sores that were so painful and nobody could help her rid them. They were special sores and she had all kinds of help. No one could help her. Finally, the pain clinic got tired of this and treated her sores. They were healed and she went out and she jumped in front of a train and killed herself. I saw that you also were in Steve Hayes’ education. I’m talking about the pride of pathology like, “I am so special.” If I can’t be special doing a job and being in a career, I can be special in another way. It’s the same function to be in the sense of competency and belonging. We have to be very careful not to take that away from people. It’s like, “What function does this fill?”
That’s a form versus function as I talk about it in ACT, in behavioral therapy.
If you don’t meet the criteria, we laugh and say, “This person’s making this up,” instead of thinking there’s a serious meaning behind this and this person needs to feel that they belong.
You’ve raised an interesting topic that literally gave me the chills. That is that as most pain practitioners, no matter who they are; psychologists, physical therapists, physicians, social workers, we have this yearning to “cure” people’s pain. In that case, from a very biomedical perspective, her sores were cured. In some ways, we failed. We didn’t serve her at all.
I had another example from Vermont. He was a young intern that worked with a pain specialist in Vermont. The neurologist told him to tell a patient that he can go home. There’s nothing wrong and there’s nothing on his neurological exam. He goes happily down to the guy to tell him he’s fine. The guy left and he went home and shot himself. They decided from then on to work with pain to try to understand the person. We are robbing them by putting them into these very simplistic models and we’re not understanding the complexity.
Let’s say a practitioner had a yearning to go to school to help people. They went through their education where they were told, “When you do this, you’re going to cure someone’s back pain, fibromyalgia, depression, anxiety, PTSD.” How does a practitioner begin to drop their own struggle with needing to fix and cure everybody?
When you’re younger, it’s quite a vanity to cure and help someone and we can’t solve most problems. I don’t know if you’d agree with that as a physical therapist. Most things have to be lived through and finding new ways, but you can’t solve life. We have to get over that in ourselves. You’re going to have to suffer with this person. There’s going to be a lot of pain as you go through it with this person and you need to be willing to do that.
It could be very difficult for a practitioner to be willing to do that with people when they want to fix it.
Often in traditional CBT, if a kid was acting up in school, “He just wants some attention. Ignore him.” That’s what we did with pain. They just want our attention. This would be the opposite of that with ACT. If you sense that somebody needs to feel special, then you give that to them 100%. Let them feel special, “This is a very special thing and you are a special person.” You give them that acceptance so they can get the flexibility to see it. This is something they are using to protect themselves. How could we get to the next level? How could we let that go and show vulnerability? It’s a sensitive and delicate job.
Pain care is a sensitive and delicate job and it’s an important job. I’m glad you’re here talking to us about it. People are reading this and they’re saying, “Value sounds like this is something that needs to be doing and it’s something that’s going to help people. This is what’s missing from my practice. This is what’s missing from my conversations with people with pain.” What are the traps that either practitioners or people with pain can fall in when they start to explore and clarify their values and research what they want in their life as far as values go?
A big stumbling block is this difference between what we would call function and form. A lot of things sound good and you may have associations. I started CrossFit that I really like. I’m so enthusiastic about CrossFit. If somebody told me, “I’m going to CrossFit,” I was like, “That’s great,” but I’m not listening to this person because I already know. That’s how we get fooled with typography, the form of something. You say you’re going to yoga and say, “That’s great,” but you might be going to yoga to get rid of your stress. You might be going there to look good at other people’s eyes. I don’t know what your intention is. I need to understand why are you doing those things. Otherwise, it’s just a checklist. Looking at the actual quality of the activity, what intention do you go to the gym? “Because I want to lose some weight.” That’s not a value.
CrossFit is a great example because when you told me that you went to CrossFit and you loved it, the look on your face was of a kid in a candy store. You’re so happy. My first thought was I wouldn’t expect that JoAnne would be a CrossFit enthusiast. It’s a totally wrong assumption on my account. If applying this to values, how does CrossFit fit into those domains for you? What domains does it feel for you?
It has most domains actually because in CrossFit, what are we trying to achieve? What is this movement about? We do have movement. Is what’s happening what you want to be happening here? How would you know? How would you know you’ve gone too far? It’s a very delicate learning about being present in what you’re doing and all the time being, is this coinciding? The opposite would be you put on your earphones and you go to the gym. You go on the machines and you don’t know, somebody just told you to do it. That’s been lacking in my life. I love that I am learning. This is new to me.
It’s a great example though because we have gyms in our culture. We have something even in hospitals or outpatient clinics called the physical therapy gym, which in certain cases could be a very cold thing. People don’t really enjoy being there. They don’t see why this is important to them, but CrossFit in many ways has figured out we can create an environment that fosters family, friendships and it’s a leisure activity. It’s health and self-care. There may be even aspects of spirituality and citizenship that come up there.
It’s very pro-social too.
People are working in teams. It’s a great example for practitioners to look at the environments they work in. For instance, the psychotherapy room where there’s one chair that the psychotherapist sits in and there’s another chair that the client sits in and maybe there are some pretty pictures on a wall. Is that an optimal environment?
No, it’s not because it’s not versatile and it’s not flexible.
What recommendations would you have for psychologists or other mental health professionals to make their environment more pro-social and open up to more values type work?
People should think more like they do in Japan. A room should be very flexible. You should be able to move your chairs and get rooms. You can do all kinds of different things. It can be on the floor and you shouldn’t put a room with designer furniture. Otherwise, it’s very boring to sit.
It’s bad for your health.
You should get out of your chair and by getting out of your chair and being playful and doing things, it’s more fun for you. If you’re having more fun, it’s contagious for the other person. To involve physical movements in anything you do can be better learning.
You’ve done some of this work in your own practice and you’ve even done some of it in Africa on missions where instead of doing psychotherapy when you’re sitting in a chair, you’re up and about with clients working on diffusion in a way that uses the body as a physical metaphor and working on selfless context and values using the body, which is very rare. Not many mental health professionals are up doing things like that. One of the ways you do that is through The Life Line. Can you talk about that work a little bit?
I worked with physical therapists and I have learned to use the body. I’m not educated in the body but it’s so much better. It’s a way to connect to people and you get so much more variation in the response. If somebody’s just sitting by themselves, it’s very little behavior. You’re up on the floor and The Life Line is used as a functional analysis that looks for behavior patterns. It’s much easier if they’re up moving because then you see the patterns in the relational frames of do they have a sympathetic response? What kind of behavior am I seeing? What are the thoughts? Movement gives that and so Life Line is behavior sampling of trying to find these patterns of the operating conditioning as to how are they relating to unpleasantness, whatever they’re calling it. What are the behavior patterns here? Once you’ve established it and find them, you can help people to be aware and also how can we add to those patterns to make them more helpful for you.
You’ve done some work with regard to exposure in ACT and it’s different than what you might find in traditional CBT. Can you talk about how exposure in ACT is different than exposure in traditional Cognitive Behavioral Therapy?
In traditional CBT, exposure is more of going back to places that are hurtful. There’s different exposure where you go through and there’s a lot of different views on that and different branches of how you do that. The ACT is pretty simple and when you use the word acceptance, we’re talking about exposure. Anything that comes up in me, if it’s a painful thought, a feeling, a pain, whatever happens within me, can I make room for it? Can I have it? Am I big enough to have it? It could be anything. You can practice daily with opening up. I usually use my hands for giving oxytocin, not just standing it, but can I show care? Anything I have is okay and I’m big enough for it. This is a selfless context but for pain, often we would lie people down and try to find actual pain. It’s being playful and finding ways of relating to it. Can you be curious about it? Can you and I be curious researchers? Can we lay down flat and look at it, to be curious and let it be however it wants to be? We’re taking away the threat in that. It makes it easier for you and me. Together, we will be going to watch this. Whenever I stimulate the person to get to that activity, you can see that it comes and goes. That’s what’s the true nature of pain is; it comes and goes. What people are calling pain is often the resistance thing. Resistance, we can do something about, the other we can’t. That’s life.
You’re eliciting pain which for most people is naturally an aversive experience. It’s aversive to us on a biological level but you’re helping them to elicit pain and that by creating curiosity or interest, you’re changing the stimulus of that particular function for that person.
We’re adding more stimulus. You’re like, “Come; I want to see you.” When you change that relationship and I’ve seen this in other things like epilepsy or migraine as well. If you welcome it to come, it takes the edge job from the whole thing and it takes a lot. I would guess, 90% of what we feel in pain is probably the resistance part and if you let that go, it’s not more than what you can take.
It’s a completely different perspective of what most practitioners do. Most practitioners ask, “Where’s the pain? What’s the intensity? What is the pain present like? Is it numbness, tingling, burning, shooting, radiating? What is it on a scale of 1 to 10?” We’re hoping all of those things can tract down to zero, but you’re saying, “I want to know all the different qualities of the pain. I want to teach you how to relate to the pain in a different way.” Through changing their relationship to pain is eventually how the pain may change. It doesn’t mean that the pain is going to go away 100% but that’s a healthier way to respond to the pain than what we’re currently doing.
It’s funny because every once in a while I hear a patient say, “I have no idea what I did this weekend. I don’t know if it was the golf game I played or if it was playing with my grandson on the floor. For some reason, my knee hurts more than usual and I really can’t figure it out.” In that person’s conversation with themselves and with me, there’s a little bit of curiosity there. It shows they’re not fearful of it. In a lot of ways you’re changing that which is more of behavioral perspective, that fear avoidance. You’re now turning into that curiosity and the approach to pain and ultimately that willingness to have this pain right here as it is now, instead of completely changing it.
You could get that pain to see if you can get that pain in the room and then just watch what they’re doing. “Oh no, it’s going to be like that again.” You can see these catastrophic thoughts or whatever. There are some physical therapists that use the word edge. You go to the edge of the pain and you maybe can expand and see if you can be a little playful with those edges.
Ideally, we want to be a bit beyond the edge because if you’re just going up to the edge then a lot of ways you’re telling people to stop before you feel pain.
That’s a very common thing people say.
It’s very common, even with graded activity or even with graded exposure which is used by both physical therapists and psychologists. If they’re stopping before they have any aversive sensation, whether its thoughts, feelings, emotions, physical sensations in their body, different types of interoceptive processes that people feel, they were not teaching willingness or what is also known as acceptance.
That’s really true. You can see that if you do the breath-holding exercise where you hold your breath. This pain as a warning signal is always exaggerated. That’s why I think that edge is arbitrary.
Ultimately, from that work, you’re leading people right back into their values because values are what creates the context for willingness and acceptance. JoAnne, you have decades of wonderful work and insight to helping many different types of conditions. What are you working on? What are the passion projects that you have going on?
I’ve been very interested in refugee problems. There’s a part in Stockholm that a lot of refugees have come into the country. The public health wants to give them some help, but they don’t speak Swedish. We’ve been working on different ways on how we can work with their pain with very little language. We’ve been working on that, going to their houses, doing something very simple and finding anything that works. We’re not talking at all about any problems. Is there any constellation of anything that works for like somebody breaks bread or somebody who mixes tea? They’re all women, and then we use our telephones in creating variation. If you did this in one context, is there somebody who could do it for them? For a lady who baked bread, there are some children’s groups maybe that would. Is there another group outside of this area that are Swedish people? We tried to create variation so we could get them to come out. Using anything working and building on it, that’s what I’ve been working.
It’s important work. You’ve done some refugee work in the past, haven’t you? Tell us about that because I know that work is very important to you. It’s helped shaped who you are as a psychologist.
I got commissioned in different developing countries to work where there is no medication. It gives me so much creativity when you’re in a situation where there’s no protocol and there’s no language. It shows you that the most important is human connectedness and that we are exactly the same. It’s finding the likeness between us rather than what’s topographically different. I get joy from working in this type of creative areas.
JoAnne, it’s been a pleasure speaking with you and thank you for your time. Can you tell everyone how they can learn more information about you? I mentioned the book, The Art and Science of Valuing in Psychotherapy. Tell us how they can reach out to you and learn more about you.
You and I have done this course in the ACT in Pain. That’s a good example of working physically. That’s the only course there is on that. I also have a podcast, about I think 62 episodes.
You did a podcast and there are some great speakers you have on there.
I haven’t done it. It was a few years ago. I stopped doing it, but that’s another way too if you’re interested in ACT.
It was called Taking Hurt to Hope. People can reach out to you on your website at JoAnneDahl.com. Thank you again for being with us. As always, make sure to share it with your friends and colleagues who are interested in pain care. It’s a really important topic talking about the art and science of valuing and the care of people with pain and other challenges. Share it out on Facebook, Twitter, LinkedIn and maybe your favorite Facebook group where people are interested in talking about chronic pain. I’m Dr. Joe Tatta. It has always been a tremendous honor to be here.
- The Art and Science of Valuing in Psychotherapy
- Acceptance and Commitment Therapy for Chronic Pain
- Living Beyond Your Pain
- Acceptance and Commitment Therapy and Relational Frame Theory in Relationships
- Steve Hayes – past episode
About JoAnne Dahl, PhD
JoAnne Dahl, PhD, is a professor of psychology at Uppsala University, Sweden. JoAnne is a clinical psychologist specializing in behavior medicine.
She is a co-author of The Art and Science of Valuing in Psychotherapy, Acceptance and Commitment Therapy for Chronic Pain, Living Beyond Your Pain, and ACT and RFT in Relationships.
The Healing Pain Podcast brings together top minds from the world of pain science and related fields to discuss the latest findings and share effective solutions for persistent pain.
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