ACT for Chronic Pain

Chronic pain affects millions of people worldwide, and if you are one of those people, you know that medication only addresses part of the problem. Indeed, you may find that the way pain affects your moods, thoughts, and feelings also has an impact on your life and overall sense of well-being. What other solutions might be available? Could acceptance be the answer?

Emotional response to pain

Chronic pain can be so debilitating that you might sometimes find yourself trapped in a negative cycle of anxiety and fear. If this cycle becomes ingrained, you might start dealing with pain in ways that actually exacerbate it — pain-controlling thinking and pain-avoiding thinking.

Psychological responses like this are known as “rigidities,” which can benefit from increased fluidity/flexibility. This can be achieved through counseling or self-help exercises. Reducing rigidity can result in positive effects, such as diminishing anxiety and low mood, improving functional status, and even easing reliance on medication. Increased psychological flexibility is also an all-round asset in life. It can help you react and adapt to new or increasingly severe adversities in more positive, healthy ways. Being flexible with your emotional responses can help you live “in the moment” and derive more enjoyment from life despite the pain you may be experiencing.

If you can relate to psychological rigidity or, indeed, have any negative emotional responses to your pain, Acceptance and Commitment Therapy (ACT) could play a role in helping you cope with pain and the impact it is exerting on your life.

What is ACT?

ACT has risen to prominence in the last decade as a tool to help people with various ailments, including chronic pain, adjust to their condition. It encourages people to honestly evaluate how their condition affects their thought patterns. They are also coached to do the same for what they value in their lives (or what can make their condition more bearable). This helps them to react to pain in different, more constructive ways.

ACT also involves the “demotion” of pain and negative pain-associated mental effects to a more appropriate, less overwhelming position in your life. Dr. Victoria Parlane, health psychologist and ACT practitioner, says, “In my experience of working with people with persistent/chronic pain, they are often caught up in a fight with their pain, and it is the fight, rather than the pain, that is restricting their lives in a very unhelpful way. My clients often say they feel that their life is ‘on hold.’ For example, they say, ‘When the pain goes away, I will be able to do this or that.’”

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Pain-controlling and pain-avoiding thoughts

Controlling

– This pain is impossible to deal with; I’ll have to increase my medication.
– I need to spend more time and energy on finding a way to make the pain stop.
– This pain is unbelievably bad; I’ll have to go back to the doctor again.
– If I was stronger, I would be able to make the pain go away.

Avoiding

– It’s perfectly OK for me to have a few extra drinks or snacks today to help me with the pain.
– If I don’t think about the pain, it will go away on its own.
– The pain is so bad, I’ll call in sick to work and try to sleep it off.
– I’m justified in spending all day watching TV to distract myself from the pain.
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How could ACT help you?

ACT could help in the following six areas:

– acceptance: the acknowledgement that thoughts and actions that avoid or try to control pain or its onset are not the most effective or healthiest ways of managing it;

– committed action: the determination to do or achieve things important to you while simultaneously experiencing pain;

– cognitive de-fusion: the “de-coupling” of strong negative thoughts or feelings from pain (e.g., “Pain is bad, but I don’t have to link thoughts and feelings arising from other bad things to it.”);

– flexible present-focused attention: the ability to be mindful of your immediate environment, thoughts, and feelings while something else (e.g., pain) is also present;

– self-as-context: a sense of perspective about your life and the role of pain in it; and

– values-based action: identifying activities that matter to you and that you are willing to prioritize above the pain-avoiding or pain-controlling thoughts and behaviors you may have adopted.

It is important to note that acceptance isn’t about giving in to the pain or merely learning to put a smile on your face while getting on with your day-to-day tasks. Acceptance is acknowledging the truth of your pain so that you can listen to it and work with it, rather than against it. It is letting go of the idea that you can control everything.

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Evidence for ACT

– Actively trying to control pain while performing physical exercises, such as stretching and bending, is associated with poor performance. People who notice the pain without reacting and instead focus on functioning perform better.

– ACT as part of a multidisciplinary pain-management program resulted in significant improvements in one or more major outcomes — debility, pain, anxiety or depression — for just over 46 percent of attendees.

– Reduced psychological rigidity has been linked to significant reductions in the number of medications required, functional decline, and consultations with health-care professionals.

– A recent in-depth review of 11 studies involving ACT for chronic pain found that it was associated with significant improvements in pain acceptance and reductions in psychological rigidity, anxiety, depression, and functional impairment compared to no treatment or conventional treatment.

– On the other hand, one study found that ACT did not affect pain severity or quality of life, and any positive effects tended to decrease as time passed. This suggests that ACT is most effective if its techniques are practiced regularly and often. In essence, you need to keep up with your ACT training to avoid rigidity returning to your psychological responses, just as you would warm up and stretch before exercising to keep your joints and limbs flexible. It also carries the message that ACT may have no direct effect on pain severity, but it can help reduce the psychological toll it takes on your life.
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How can I try ACT?

A psychologist or therapist can provide ACT in a group or one-on-one setting. However, you can also try it out yourself. “ACT-based interventions are active in nature,” explains Parlane. “In my experience, it is about how open and accepting the client is to flexibility, learning new skills and being open to what shows up with exposure exercises, which are tasks that bring the client into immediate awareness of pain-associated thoughts, feelings, sensations and behavioral urges that otherwise they would usually avoid.” According to Parlane, engaging in this work can overwhelm some people as they begin reducing “control” strategies such as avoidance and distraction or suppressing thoughts and feelings. “However, as clients begin to increase psychological flexibility through exposure and testing out behaviors such as daily chores, physical activity, traveling and engaging in social activities, they can often regain some control of their life,” she reassures.ACT Techniques

While ACT is often administered as part of a pain-management program, Parlane believes it can be effective as a standalone therapy. “Learning ACT processes for my own private struggles and management of pain many years ago helped significantly,” she shares. “A combination of health professionals and medication did not necessarily achieve the desired outcome of helping me feel equipped to function well.”

Opening up to pain

Essentially, ACT promotes the acceptance of pain, increased mindfulness, and commitment of the self to more positive, constructive actions in life. In turn, the method helps reduce negative emotions and thoughts in response to pain. Activities such as meditation and mindfulness can help increase pain acceptance, which is often referred to as “opening up” to pain.

Identifying your values

Individuals participating in ACT are also encouraged to focus on behaviors and aspects of life that they personally value. This activity can improve your ability to persist with an enjoyable or important activity or occupation while simultaneously experiencing pain. According to Parlane, “In my opinion, the ACT model is workable, with less focus on reduction and control of symptoms, but instead with an emphasis on the acceptance of pain and distress to promote values, which often reduces avoidance and, consequently, influences pain-related disability. Basically, it enables people to learn ways to step away from the battle of fighting with the pain by learning acceptance processes to enable them to focus on a valued life.” In other words, doing what matters becomes more important than waiting until the pain diminishes or goes away.

Finding an ACT practitioner

If you want to start an organized ACT program, research psychotherapists, counselors, or doctors who offer the therapy in your area. Alternatively, you can ask your physician about ACT during your next appointment. If ACT is not available in your area, you can access a course online or even download ACT apps onto your smartphone (see some of the best apps below).

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The best ACT apps

ACT Companion

– ACT Coach
iTunes
Android

– What’s Up?
iTunes
Android
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Commit to accept

If you take anything away from this article, I hope it is the knowledge that the best way to deal with pain is to accept and approach it, rather than fight and avoid it. This equips you to cope with the pain in a constructive way and to prioritize your values for a better quality of life. You may have to live with chronic pain, but the power to manage it in a positive, effective, and healthy manner lies with you.

Nicola Davies, PhD, is a health psychologist. She has developed training modules for pain specialists on the use of ACT for chronic pain.

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