Jennifer L. DelVentura, PhD ABPP
Jennifer L. Steiner, PhD ABPP
“I just want my life back, I want to feel like me again”. This is a common refrain in our work as pain psychologists. Too often individuals with chronic pain feel as though their lives have fundamentally changed from ones defined by activity and engagement in a meaningful life to ones full of limitations, isolation, and feelings of loss. Many feel unable to move forward in their lives without elimination of the pain and find themselves stuck in an endless search for a cure, spending enormous amounts of energy, money, and time searching for the next best treatment or the “right” doctor. For these patients, life becomes about escaping the pain and no longer about living. But escape from pain is short-lived, and often comes at a price–from medications that offer temporary relief while also reducing functioning due to drowsiness, to self-medication with alcohol, drugs, or food which offer short bursts of pleasure or distraction, but serve to worsen pain, depression, and isolation over time. Of course, patients want the pain to be eliminated, but often what is most distressing about a life with pain is the loss of the sense of self, meaning, and purpose.
Indeed, research has demonstrated that individuals with chronic pain experience a change in self-concept after the onset of chronic pain (Harris, Morley, & Barton, 2003; Hellstrom, 2001; Leventhal, Idler, & Leventhal, 1999). For example, patients may feel that they are no longer the person they were prior to pain and may go through a period of mourning the loss or death of the “past self”. Others go through feelings of loss for the future “possible self,” “what could have been,” and plans that they envisioned for themselves that they fear will never come to fruition due to their pain condition. Some individuals may fluctuate between both of these experiences. It is perhaps not surprising then that depression is highly comorbid with chronic pain, and for some individuals much (though not all) of this can be attributed to the changes in quality of life and sense of self observed with pain.
Acceptance of Pain
Traditional treatment approaches often focus on symptom reduction and “fixing” the problem of pain, leaving patients feeling frustrated, discouraged, and depressed when the pain is not sufficiently alleviated. But what if the pain did not have to be “fixed” in order to improve functioning and quality of life?
Acceptance of chronic pain and illness has been a growing area of interest over the past 20+ years and has been defined as “acknowledging that one has pain, giving up unproductive attempts to control pain, acting as if pain does not necessarily imply disability, and being able to commit one’s efforts toward living a satisfying life” (McCracken, 1998, p. 22). It does not mean that one “gives in” to the pain and succumbs to an unsatisfactory life; but rather, that one makes a conscious decision to fully live with the chronic pain or illness while still being aware that the condition may not improve. One of the foundational theoretical underpinnings of acceptance-based approaches is that it is actually the lack of engagement in meaningful life experiences and activities, not the pain itself, that leads to suffering. Through acceptance it is believed that individuals change their relationship with their pain and how pain impacts their quality of life. Indeed, greater pain acceptance has been shown to be associated with better mental health outcomes physical functioning, quality of life, etc. (McCracken, 1998; Viane et al, 2003).
Acceptance and Commitment Therapy (ACT, pronounced like the verb “act”) for pain is an evidence-based psychological intervention aimed at increasing pain acceptance. ACT helps patients to realize that many of the things they do to try to control pain (e.g., avoidance or self-medication) may actually cause further damage to health, emotional state, and quality of life in the long-run. For example, many of the patients with whom I [JLS] work have said that they spend most of the day resting or “waiting for the pain to subside” before they will do anything (play with children, get dressed, complete small chores around the house, etc.). As a result, patients often end up waiting all day, and sometimes weeks, before anything gets done. In ACT, the therapist helps the patient realize that waiting for pain to go away is futile and unproductive as the pain is always present (indeed, it is “chronic”!). This is done in part through helping the patient explore what matters to them (personal values) and helping them find a way to pursue those actions even in the presence of pain. Through a combination of ACT techniques that include collaborative evaluation of the utility of pain reduction and avoidance strategies, exploration of personal values, values-based goal setting, and mindfulness, patients regain a sense of control over their lives so that they are dictating their actions rather than allowing pain to control all of their life choices. This makes for happier patients and more successful encounters for providers. The key is helping patients see that they don’t have to completely give up on what matters to them, but to flexibly find ways to pursue their dreams even if it looks differently than what they originally had in mind.
Take for example a patient I [JLS] worked with who was a former college athlete and had lifelong dreams of teaching his sons to play soccer. However, chronic lower back issues had made it impossible for him to play with them. Together we devised a way for him to engage in teaching his sons the game, even if he could not physically participate. He now helps coach his sons’ soccer team, watches game tapes with them, and attends all of their games. His pain is still present and he has continued to experience some physical limitations; however, he has said that he is less focused on his pain. As a result of being able to do more with his children, he reported decreases in depression and increased quality of life.
ACT for chronic pain is considered to have strong empirical support based on guidelines outlined by the American Psychological Association (APA). Meta-analytic work examining ACT for Chronic pain has demonstrated that ACT is associated with positive effects on depression, disability, and quality of life, as well as modest effects on anxiety and pain interference (Veehof, Oskam, Schreurs, & Bohlmeijir, 2011; Veehof, Trompetter, Bohlmeijir, & Schreurs, 2016). These studies suggest that effects from ACT are comparable to effects from CBT, though some studies that have directly compared the two common interventions have found greater patient satisfaction associated with ACT (Wetherell, 2011). Unlike cognitive behavioral therapy (CBT; long known as the “gold standard” of psychological treatments for chronic pain), which often places emphasis on symptom reduction and changing maladaptive thoughts about pain, ACT emphasizes increasing quality of life through values-based behavior and letting go of attempts to control or avoid the pain that have ultimately proven to be unproductive. ACT (compared with TAU) is also associated with reduced absence from work and utilization of medical resources due to pain with some of these changes maintained at follow-up (Dahl et al, 2004).
A note about what ACT is NOT.
There is a common misconception that ACT for chronic pain is akin to telling patients to “suck it up and do it anyway”. That is not what we are suggesting. Rather, from an ACT perspective to improve patient quality of life we must find a way to help the individual pursue values in different ways and stop waiting for pain to go away, as that day may never come. Similarly, ACT does not propose that patients give up any and all pain management strategies, but to consider the effectiveness or workability of these strategies and give up the ones that interfere with values or quality of life.
FINDING AN ACT THERAPIST
Finding a therapist trained in ACT is not always easy. We encourage referring providers to be aware that not all pain psychologists are trained in ACT, and not all ACT therapists have experience with chronic pain. A good place to start is the Provider Directory through SPS and outreaching these psychologists directly to ask about their expertise or recommendations for other providers in your area. Most states also have State Psychological Associations with member directories that often list providers’ areas of expertise as well.
You can also search for providers in your area through the Association for Contextual Behavior Science (ACBS) website at this link:*
https://contextualscience.org/civicrm/profile?gid=17&reset=1&force=1
Most of us may agree helping patients with chronic pain can be challenging, and we may not always be able to “cure” or even reduce the pain. However, through interventions like ACT and focus on finding new ways to pursue a meaningful life, we may be able to reduce suffering. Isn’t that really the point?
*Please be aware that providers listed on this website are self-identified as ACT providers, and expertise in chronic pain is not guaranteed.
References
Dahl, J., Wilson, K. G., & Nilsson, A. (2004). Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: A preliminary randomized trial. Behavior therapy, 35(4), 785-801.
Harris, S., Morley, S., & Barton, S. B. (2003). Role loss and emotional adjustment in chronic pain. Pain, 105(1-2), 363-370.
Hellström, C. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology and Health, 16(1), 111-124.
Leventhal, H., Idler, E. L., & Leventhal, E. A. (1999). The impact of chronic illness on the self system. Rutgers series on self and social identity, 2, 185-208.
McCracken, L. M. (1998). Learning to live with the pain: acceptance of pain predicts adjustment in persons with chronic pain. Pain, 74(1), 21-27.
Veehof, M. M., Oskam, M. J., Schreurs, K. M., & Bohlmeijer, E. T. (2011). Acceptance-based interventions for the treatment of chronic pain: a systematic review and meta-analysis. PAIN, 152(3), 533-542.
Veehof, M. M., Trompetter, H. R., Bohlmeijer, E. T., & Schreurs, K. M. G. (2016). Acceptance-and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive behaviour therapy, 45(1), 5-31.
Viane, I., Crombez, G., Eccleston, C., Poppe, C., Devulder, J., Van Houdenhove, B., & De Corte, W. (2003). Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal. Pain, 106(1-2), 65-72.
Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., Solomon, A.J., Lehman, D.H., Liu, L., Lamg, A.J., & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098-2107.