“We have so committed ourselves in different ways that we have hardly any time for self-reflection, to observe, to study.” —Jiddu Krishnamurti
Psychological flexibility (PF), a core principle of Acceptance and Commitment Therapy, is defined by a non-judgmental disposition to acknowledge and accept the circumstances of life, both good and bad, and commit to behavior that sustains and enhances what is meaningful and valuable to us.
One of ACT’s six core processes is self as context.
Self as context is the classic observer stance. To notice who is noticing in the various domains of experience (1).
The ability to observe thoughts, feelings, and emotions that we have about ourselves.
The experience of chronic pain can undermine this ability.
Persistent pain often becomes a ‘guiding theme’ that displaces joy, erodes self-confidence, and puts a strain on relationships.
ACT believes that while pain hurts, it is the struggle with pain that causes suffering.
A re-examination of the “thinking self” versus the “observing self” is part of ACT’s strategy to reduce pain, suffering and to live better.
Three Dimensions of the Conceptualized Self
The PF model conceptualizes the “self” along three dimensions (2):
Self-identification with the content of one’s psychological experiences, namely all the beliefs, thoughts, feelings, and images of oneself (“I am this, think I am”). This process is also known as cognitive fusion.
The awareness of ongoing experiences related to the self.
De-identification with one’s psychological experiences (“I think this about me, but the true me transcends my thoughts”). Also referred to as contextual self or “the observer self.”
Listen to this podcast HOW TO AVOID THE TRAP OF NEGATIVE THINKING USING ACT WITH DR KEVIN VOWLES, PhD
Over-attachment to self-as-content may lead to avoidance.
In contrast, self-as-context, facilitated by the awareness of ongoing experiences (self-as-process), can promote commitment to more effective and engaged patterns of behavior which are in line with life goals and values.
Dr. Lance McCracken and colleagues put forward a nice distinction between the two terms:
“Metaphorically speaking self as context is like a perspective one can take on one’s thoughts and feelings, a perspective that includes a distinction between self and these experiences, a sense of self as “container” of one’s thoughts and feelings, or like a “place” where one’s thoughts and feelings occur” (5).
Is Assessing Self-As Context Problematic?
Within the same work, McCracken and coworkers developed the Self Experiences Questionnaire (SEQ) to examine the role of self in chronic pain. The SEQ includes 15 items rated on a scale from 0, ‘‘never true,’’ to 6 ‘‘always true’; examples include:
- Although I can get caught up with my own thoughts, emotions, and sensations, I can also separate myself from them.
- I am able to step back from my emotions and observe them from a separate point of view.
- I can observe experiences in my body and mind as events that come and go.
The SEQ was applied in a 2017 study by Lin Yu, S. Norton, and L. McCracken that appeared in the Journal of Pain (6). It examines whether self-as-context changes over time after an interdisciplinary ACT-based pain treatment program and how this change correlates with several measures of well-being in patients with chronic pain.
The study included 412 adults (281 women and 131 men) that received an interdisciplinary ACT-based pain treatment program in the UK. Median pain duration was 106.0 (range, 4–744) months, and the most common primary pain sites were:
- Back (n = 363, 88.1%)
- Lower limbs (n = 325, 78.9%)
- Neck (n = 263, 63.8%)
- Upper shoulder or upper limbs (n = 252, 61.2%)
- Pelvic region (n = 207, 50.2%)
- Head, face, or mouth (n = 153, 37.1%)
- Abdominal region (n = 136, 33.0%)
- Chest (n = 105, 25.5%)
- Anal or genital region (n = 68, 16.5%)
Among participants, 50.5% (n = 208) were out of work because of pain; 14.1% (n = 58) were retired; 14.3% (n = 59) were working full-time, and 9.5% (n = 39) worked part-time because of pain.
Assessments took place before treatment (baseline), upon completion of treatment (post-treatment), and at 9-month follow-up, and consisted of self-reported measures of:
- Treatment processes:
- Pain Intensity: Average pain intensity over the past week on a standard scale from 0 (no pain) to 10 (extremely intense pain)
- Pain acceptance: Assessed using the Chronic Pain Acceptance Questionnaire (CPAQ), a 20-item measure of the interrelated activity engagement and willingness or openness components of pain acceptance. A shorter version of the CPAQ (the CPAQ-8) was used in the study
- Self as Context: Assessed using the Self Experiences Questionnaire (SEQ) (5)
- Treatment outcomes:
- Pain-related interference: Assessed by the Brief Pain Inventory (BPI), a 7-item questionnaire that rates pain interference on general activity, mood, walking ability, normal work, relations with other people, sleep, and enjoyment of life
- Work and social adjustment: Assessed using the Work and Social Adjustment Scale (WSAS), a 5- item self-report measure that measures the impairment of functioning in terms of work, home management, social leisure, private leisure, and personal or family relationships
- Depression: Assessed using the Patient Health Questionnaire (PHQ-9), a 10-item self-report scale for assessing the severity of depressive symptoms
The treatment program was delivered over 4 full days per week for 4 weeks, in a group format (9 to 11 participants per group) by a team of psychologists, occupational and physical therapists, nurses, and physicians. It included physical exercise, skills training, and education designed to explicitly enhance the key processes of PF.
Below is a brief overview of each discipline’s contribution:
|Psychology||22||Exposure-based and experiential exercises, metaphor, mindfulness practice, and motivational methods|
|Physical Therapy||24||Physical exercises designed to increase aspects of psychological flexibility*|
|Occupational therapy||16||Teaching and practice of value-based, motivational methods, and practical (function-related) skills training|
|Primary physician||3||Lecturing on pain mechanisms, diagnoses, and treatments|
|Nursing||9||Lecturing and counseling on pain, medication, and health|
|Friends and family visit||1||A single session with friends/family|
* Physical therapists helped patients to approach or feel physical sensations that represent a natural part of functional movements, to reverse goal-interfering avoidance of physical movement, to practice awareness of the experiences that appear when they do that, and to clearly see relations between physical movements, physical exercise, and goals and values. A small amount of teaching on movement and pain was also included.
To learn more about ACT for chronic pain, and how it could be implemented in Physical Therapy practice, check out this blog: USING ACT TO INFORM PHYSICAL THERAPIST PRACTICE
Results. Most patients showed significant improvement in every measured outcome from baseline to post-treatment and maintenance of improvement at 9-month follow-up. Results also showed that:
- Pain acceptance (a process that reflects openness in the Psychological Flexibility model) increased among all participants
- Pain ratings decreased from baseline to post-treatment, and the reduction remained at follow-up
- Clinically meaningful improvement* on each measure of outcome: BPI (pain-related interference), WSAS (functional impairment), and PHQ-9 (depressive symptoms), was noted in 42.0% to 67.5% of participants at post-treatment, and in 46.5% to 56.3% of participants at follow up.
- Clinically meaningful worsening* of BPI, WSAS, and PHQ-9 was seen in 6.6% to 9.4% of patients at post-treatment, and in 7.0% to 14.1% of patients at follow-up.
- Patients that worsened their symptoms also showed a reduction in measures of pain acceptance and self-as-context at both post-treatment and follow-up.
* Defined by improvement/worsening greater than one-half of a standard deviation -a measure of data dispersion around the pooled mean score- from baseline.
Moving Beyond The Self to Less Pain
Despite substantial improvement in all pain-related measures, the study showed that the overall improvement in self-as-context was relatively small, and decreased slightly at follow-up. This is not completely unexpected, because self-reflection (taking perspective) is arguably one of the most difficult psychological processes to engage on and maintain over time (7). There is also a lot of variability in people’s disposition to open up and be willing to undermine the noxious entanglement with one’s thoughts and feelings (cognitive fusion) that often accompanies chronic pain (8, 9, 10).
The authors point out that self-as-context training in the program may have been insufficiently addressed, and speculate that some aspects of ACT, including self-as-context, may be best delivered on an individual basis, rather than the studies group format.
Nevertheless, the results of the study align well with previous reports showing that moving from self-as-content to self-as-context improves emotional and physical function in patients with chronic pain and alleviates symptoms of depression (11, 12). The study adds further to the mounting evidence on the effectiveness of ACT to treat chronic pain (13).
Distancing from ourselves to examine the thoughts and emotions that revolve around chronic pain is difficult, but ultimately rewarding. The Indian philosopher Jiddu Krishnamurti talked lengthily about this struggle:
“Because our minds are always interfering, limiting, encroaching upon its functioning; and therefore it is important to understand first the mind and its ways; otherwise we shall be caught in illusions, caught in words and sensations that have very little significance. And as, for most people, ideas merely act as a refuge, as an escape, ideas which have become beliefs, naturally they prevent complete living, complete action, right thinking.”
To learn more about ACT for Pain and training for practitioners click here!
1- Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour research and therapy, 44(1), 1-25.
2- Yu, L., Norton, S., Harrison, A., & McCracken, L. M. (2015). In search of the person in pain: A systematic review of conceptualization, assessment methods, and evidence for self and identity in chronic pain. Journal of Contextual Behavioral Science, 4(4), 246-262.
3- Toye, F., Seers, K., Allcock, N., Briggs, M., Carr, E., Andrews, J., & Barker, K. (2013). A meta-ethnography of patients’ experience of chronic non-malignant musculoskeletal pain. Health Services and Delivery Research, No. 1.12
4- 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.
5- Yu, L., McCracken, L. M., & Norton, S. (2016). The Self Experiences Questionnaire (SEQ): Preliminary analyses for a measure of self in people with chronic pain. Journal of Contextual Behavioral Science, 5(3), 127-133.
6- Yu, L., Norton, S., & McCracken, L. M. (2017). Change in “self-as-context” (“perspective-taking”) occurs in acceptance and commitment therapy for people with chronic pain and is associated with improved functioning. The Journal of Pain, 18(6), 664-672.
7- EE- Byrne, A. (2011). Knowing that I am thinking. Self-knowledge, 105-124.
8 – Tang, N. K., Goodchild, C. E., Hester, J., & Salkovskis, P. M. (2010). Mental defeat is linked to interference, distress and disability in chronic pain. Pain, 149(3), 547-554.
9- Morley, S., Davies, C., & Barton, S. (2005). Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance. Pain, 115(1-2), 84-94.
10- Hazeldine-Baker, C. E., Salkovskis, P. M., Osborn, M., & Gauntlett-Gilbert, J. (2018). Understanding the link between feelings of mental defeat, self-efficacy and the experience of chronic pain. British Journal of Pain, 12(2), 87-94.
11- McCracken, L. M., Gutiérrez-Martínez, O., & Smyth, C. (2013). “Decentering” reflects psychological flexibility in people with chronic pain and correlates with their quality of functioning. Health Psychology, 32(7), 820.
12- Yu, M. (2017). The Effects of Mindfulness on Self-Rumination, Self-Reflection, and Depressive Symptoms: A Research Proposal. Behavioural Sciences Undergraduate Journal, 3(1), 1-7.
13- Feliu-Soler, A., Montesinos, F., Gutiérrez-Martínez, O., Scott, W., McCracken, L. M., & Luciano, J. V. (2018). Current status of acceptance and commitment therapy for chronic pain: a narrative review. Journal of pain research, 11, 2145.