Question 1

How does working towards values help with chronic pain?

Lance McCracken · Accepted Answer

Nice short and relevent question!  Answer: When chronic pain is present there are many feelings, thoughts, sensations, and related events in the world that begin to influence what you do.  This is essentially automatic. Pain, anxiety, confusion, and rather predominantly attempts to avoid, fix, problem-solve, understand, or stop the pain take over. Pain and all the experiences that come with it can easily dominate, take priority. Life become avoidance and problem solving. And often this does not work particularly well, and it become quite sad and boring.  Values clarification and planned and executed values-based action is a way to reorganize life around what you want to do and how you want to do it. If you can set aside the struggle with pain, you can then do other things. Values provide the guidance for what that is and how.  Then, chronic pain may still be present but it is not in charge any more, unless you put it in charge again.

Question 2

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.

Question 3

What are the mechanisms by which ACT creates change for chronic pain?

Lance McCracken · Accepted Answer

The theoretically proposed mechanism by which ACT creates change is via psychological flexibility (PF), and the available evidence shows that this indeed seems to be how it happens. There is both correlational evidence from uncontrolled trials and evidence from mediation analyses based on randomized controlled clinical trials that show this to be the case.  It is not every component of psychological flexibility that has the same amount and quality of evidence, but certainly there is convincing evidence that acceptance seems to play an important role. However, just about every facet by now has at least some suggestive evidence even if only correlational.  So that means cognitive defusion, present moment focus, self-as-perspective, values, and committed action also seem to play a role.

When I say each of these things I mean them to relate to outcomes such as disability reduction, improved daily activity, and emotional functioning. There may be a more complex way in which PF actually alters the experience of pain itself, but that perhaps for another day.

Question 4

How does present moment awareness help with chronic pain if the pain is part of the present moment?

Lance McCracken · Accepted Answer

In an actual present moment that has pain in it, it is just a moment of pain, AND there are many other things one can focus on, if you actively choose your focus in the now.  You can broaden or narrow the focus. You can focus on the pain or something else, or something else.  In this sensory focus mode the mind is given a vacation. Focus in the present moment is a attention management behavior pattern that YOU can do and explicitly not something that you will apply your thinking, judging, interpreting, and comparing mind to doing.  Notice that if you notice the present moment with your senses, sight, hearing, touch, smell, while you are connected to the sensations there, this is all it is. It is when the mind gets involved that a moment of pain is not a moment of pain anymore, it is now a moment of pain that is "horrible," "exhausting," "terrifying," that may "never end," and easily overwhelms.  Actually seeing that moments of pain appear in a context of many other events, and inside of you, in the same moment, can keep them from seeming bigger and dominating over you.

Question 5

How does acceptance of pain improve the experience of it?

Lance McCracken · Accepted Answer

Acceptance can be defined different ways. One way is to say it is a process of actively doing what one wants to do, with pain present, and without doing attempts to resist or control the pain.  How this is likely to improve the experience of pain is that pain is contacted just as it is without resistance, particularity without the futility, frustration, and failure experience of resistance when resistance is ineffective.

Acceptance also "improves" the experience of pain because is puts it in a context of just one of the things being experienced. If you are going to have pain in any case, what you would rather have pain and enjoyable time with family or friends, or just pain? I would call the former an improvement over the latter. The other trick here is that if we give pain the chance, outside of a context of engagement and refraining from resistance, it is not just pain, it is probably pain and some form of misery. The engagement piece of acceptance, or we could say that values and committed action parts of ACT, fill the space with something meaningful and "improve the experience" of pain, as one way to look at it.

Question 6

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 7

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 8

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 9

18 y/o male from an intact family who developed migrainous headache over two years ago, that has become intractable: how do I help him deal w/ serious concerns about his future: "will I have pain for the rest of my life?" etc.  thanks.

Lance McCracken · Accepted Answer

There is lots of context here I will not know, such as medical and personal history.  I also will not know what has already been established or agreed as the focus of your time with him.  With this very limited information my first reaction is to validate the want to know, to say "I can entirely understand this question, ...  of course when we hurt or suffer, we want to know what will happen...."

Another point could be to find what he wants to achieve, particularly within a frame of what you can he can actually do together.  Knowing the future can look like the means to achieve one's goals, but it is not a very reliable means to do that, and mainly that is mainly because it is impossible to do.  The point here is that this question is connected to  some purposes.  What are those purposes and what is another way, an actually doable way, to achieve those.

Question 10

Are there any head to head studies comparing ACT to CBT efficacy for chronic pain?

Lance McCracken · Accepted Answer

There is at least one.  Head to head may not be the most informative way to learn and improve treatment.  I'll try to attach.  The study was published in the journal PAIN in 2011 by Wetherell et al.

Question 11

Do you think a person's mental health plays a role in moving pain from an acute to a chronic disposition? Or is it more common for chronic pain to be the precursor for psychological distress?

Lance McCracken · Accepted Answer

The transition from acute to chronic pain seems to be a complex and highly individualized process.  There are essentially many routes from A to B and there are many things we do not know about these routes.  Likewise, "mental health" is complex. What is "mental health?"  It is a kind of summary abstract concept.  Let's put it this way, our body, our behavior, our thoughts, and feelings are constantly interacting with each other, and impacting on each other, and in interacting turn with all of the elements of the world around us. Acute pain appears in this context and begins to participate in this large dynamic network of interacting events.  For example, pain appears.  Pain leads to Fear, sadness, guilt, embarrassment and these may lead to avoidance and withdrawal (and vice versa), which in turn will impact on the way the body feels and operates, which in turn impact on one's thoughts and feelings, and so on.  "Mental health" is what we call some of these elements.  I think you can see though that the "action" happens, so to speak, probably the production of chronic from acute pain, at a level of behavior and experienced events.

Question 12

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 13

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 14

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 15

How do you help individuals who struggle to understand 'willingness' or defusion?  Is there a way to simplify/clarify what these involve/look like?

Lance McCracken · Accepted Answer

I can certainly understand the approach that aims to help people understand these concepts, including willingness and defusion.  At the same time I don't think this is a necessary step in developing behavior patterns that include qualities of willingness and defusion.  In a sens "getting it" in the mind is not the same as, nor is it a prerequisite to, getting it in one's behavior.  In a sense willingness is essentially an act of making contact with events that could otherwise coordinate avoidance but to do so without avoidance, to "lean it" where an inclination is present to lean away.  The  mind cannot do this and does not need to understand this.  Of course the mind also will not want to step aside from trying to take over this task.  I realize that this might sound unusual.  ACT the main treatment vehicle that includes willingess and defusion these days is all about stepping outside of mental cognitive process, getting in touch with how the world is organized, and doing what one wants to do in that space.  Seeking understanding is entirely understandable, but not necessary. In fact it can be an impediment.  The need for understanding, ironically, actually feeds fusion and avoidance. Taking a step without necessarily understanding is can be an act of willingness.

Question 16

How do you help individuals who are very, very convinced that they cannot live a meaningful life if pain is present?

Lance McCracken · Accepted Answer

(1) empathise and understand, (2) find out more about what "live a meaningful life" means to them, (3) look at the ways they have tried to do this so far, (4) find out if that is working and what is being learned from the experience, (5) ask if they would be willing to do something different to build that meaningful life, (6) is yes, begin seeing if new ways work better than the old ways.  This situation described in the question is classic psychological inflexibility. So, that process to help here would be to build psychological flexibility, as skills to learn and apply, not as a way to be convinced of something different.

Question 17

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 18

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 19

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.

ACT for Chronic Pain