Question 1

Does "willingness to experience pain in the service of values" mean that a person should act as though their pain isn't even there?  Do they seize the day even if they suffer a flare up? Many pain management programs teach pacing, stress reduction - are these things irrelevant or forms of avoidance?

Lance McCracken · Accepted Answer

Any act of willingness, any engagement in what one want to do, and how one wants to do it, any act of this type that includes pain, should be a choice.  Ideally it would be done or not done based on what a person wants and what their experience has shown them they are likely to get out of it in the current situation.  Willingness by definition includes pain, consciously allowed, consciously given a place to be. Willingness includes "like it is there" and "like it is not there." It is embraced as present but not given another other role in regulating what is done.

"Seize the day" can be done in different ways.  "Seize" sounds a little aggressive or impulsive. Embrace each moment in the day might be a little better.  Pacing or stress reduction can be avoidance or helpful engagement depending on situation and results gained. These are terms that can be enacted in many different ways and for different purposes. There is also good stress and bad stress, so to speak.

Question 2

I have patients who have many, very challenging symptoms, and they are absolutely incredulous at the idea that they can engage in values-focused action in any meaningful way.  They feel invalidated and incredulous about the idea.  What do you do with this situation?

Lance McCracken · Accepted Answer

Show understanding for how unbelievable or impossible this looks and actually sit with that for a while with them.
Start somewhere else, not with values focused action as such.
Ask, ..... and what are you doing right here, right now? [essentially noticing that the act of speaking with you is a kind of values-based act]
At some point, after suitable listening and understanding, proceed with defusion and perspective taking and see if it can be observed that the mind is trying hard to figure this out and protect you, and of course the mind will do this, this is what minds are for.  And, what do you want to do?

Question 3

Does ACT dovetail with Johann Vlaeyen's exposure-based treatments for addressing fear of pain?  How so?

Lance McCracken · Accepted Answer

There are differences and similarities between Johan's exposure treatment and ACT, both procedurally and in terms of processes of change.  Johan's approach typically aims for cognitive and emotional change, reduced fearful thoughts and fear, and then avoidance via this change in experience.  ACT aims more primarily for avoidance reduction, not by reducing fearful thoughts and fear but by altering the avoidance promoting properties of the painful situation.  So, I see these as distinct in method and process, however, you can do either one and apply it to the problem of fear-avoidance-hypervigialnce-deconditioning-depression.  I would not blend them. I would stick with one or the other.

Question 4

What does ACT offer that 'traditional CBT pain management groups (relaxation training, cognitive restructuring, pacing, etc) doesn't?  How do these approaches compare when they are examined?  Is ACT superior?  If so, how?

Lance McCracken · Accepted Answer

ACT offers an alternative model of therapeutic change and some different methods or methods applied somewhat differently.  Relaxation, cognitive restructuring, and pacing are not usual methods in ACT, although it is perfectly ok to use them if the situation calls for it. ACT instead would apply methods of acceptance, cognitive defusion, and committed/values-based action. There is a lot of overlap between traditional CBT and ACT, and differences are partly differences of emphasis. Underling these differences of emphasis are differences in theory and philosophy.  ACT is neither superior nor inferior to traditional CBT based on current data.  I always say that the better model will be the one that leads on to better treatment, better developments in the future.  It is not superiority today.

Question 5

I have found that some professionals equate ACT / acceptance of pain with telling patients to ignore pain or to not bother trying coping strategies to manage pain - how do you address this misconception?

Lance McCracken · Accepted Answer

Yes, this is a misunderstanding, but perhaps an understandable misunderstanding.  How you will address this misconception best will probably depend on the context.  Simplest words: acceptance is not ignoring, it is allowing.  Acceptance does not mean "don't bother coping" - it is more like a special kind of coping that is focused more on life than on pain.

Perhaps a slightly radical way to address this misunderstanding is to ask the professional if they are finding that it helps or is successful to say these things.

Question 6

What defines chronic pain?

Lance McCracken · Accepted Answer

Generally what defines it is that it carries on when it should have otherwise subsided.  I think that is the heart of it.  And, people will often say, loosely that this period of time associated with this "should have otherwise subsided" is 3 to 6 months depending on the tissue involved.

If you are otherwise interested in what specifically defines the "pain" part of chronic pain, there is now a new "official" definition:   https://www.iasp-pain.org/PublicationsNews/NewsDetail.aspx?ItemNumber=10475&navItemNumber=643

Question 7

A client I am working with learned a Zen technique to handle pain where she gradually took her awareness from her body to her immediate space to the larger space, then community, and so on moving further outward. In ACT is the idea to do something similar i.e. to create more space for the pain?

Lance McCracken · Accepted Answer

This kind of expanding awareness is a classic ACT-type of acceptance exercise.  yes, fits well.  You can also see this as a shift of the context around pain, seems like a good approach to me!

Question 8

What is the evolutionary purpose of chronic pain?

Lance McCracken · Accepted Answer

Hmm....  What is the evolutionary purpose of cancer, diabetes, heart disease, stroke, asthma?  True short term pain is understandable and serves purposes to protect and support healing.  I don't see any evolutionary advantage to chronic pain.  It may be a kind of unfortunate side effect of short term pain: having a pain system is useful and advantageous, and to have a body is very useful!  If you have a body and a pain system and the body gets banged around and exposed to illness and disease, or whatever, sometimes you get chronic pain.  No reproductive advantage and no clear group advantage as far as I can see but add on to these other good things, as I say a side effect.  I also don't see a way that evolution should have or could have weeded it out, at least not a clear way.

Question 9

Are doctors indifferent towards people's pain?

Lance McCracken · Accepted Answer

Which doctors?  All people have the capacity to be relatively more or less sensitive, connected, affected, or unware, and indifferent, doctors included.  Some people might say that doctors need to have some "professional distance" some perspective or neutrality, they might need to stay remote from the suffering to a degree.  I might say that doctors need different awareness, sensitivity, and concern or feeling depending on the situation.  Miscarriages, loss of a loved one during an operation, a trauma case in the ER, end of life palliative care, brain surgery, mental health problems: people in different circumstances will be best served by doctors who interact with them with different qualities in that moment. At the same time doctors are people, and like all people, a natural inclination is to turn away or to shut down in the face of pain and suffering. It takes learning and practice to care, feel, and face other peoples' pain.

Question 10

Does ACT for chronic pain differ from ACT for other mental health issues like anxiety?

Lance McCracken · Accepted Answer

Not really. ACT for chronic pain will vary depending on the person receiving the treatment, ideally. So will ACT for mental health problems like anxiety. In the end there can be as much difference between people within the chronic pain population as there is between chronic pain and anxiety.  The principles and methods and exercises will pull from the same set.

Having said that, for a therapist, if till helpful for a therapist to be knowledgeable about the condition being treated and that will make a difference.

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