The primary goal of chronic pain treatment is to reduce disability. It is often assumed that the way to effectively reduce disability is to first significantly reduce pain, and through pain reduction a person can return to life.
Newer and alternative approaches are being used by physical therapists and other rehabilitation professionals, such as Acceptance and Commitment Therapy (ACT), which proposes that pain reduction is not necessary for reduced disability. Instead, disability reduction occurs when one’s response to pain changes and the unsuccessful struggles for pain control decrease. A change in perspective occurs and the person is able to re engage with the people and activities that are meaningful to them.
As a physical therapist, when you begin to use Acceptance and Commitment Therapy for the treatment of chronic pain and as a way form of psychologically informed practice, you will notice how important metaphors are in the treatment room.
Metaphors are a useful way to reconnect people to their values, help them defuse from language and cognition and create new patterns of committed action. Best of all, adding new metaphors to your practitioner toolbox will enhance communication as well as the therapeutic relationship. Metaphors also allow the listener to generate his or her own conclusions about the situation being presented. In the context of treatment, the practitioner not longer has to provide a detailed explanation, explain how pain works or the rehabilitation process. The client will extract their own meaning from the metaphor and change behaviour accordingly.
As a physical therapist, I’m fond of metaphors that are fun and involve playfulness, movement and action. The Circus ACT is a metaphor that illustrates the futility of control. Developing a few evidence-based strategies to control pain can be beneficial in the beginning of treatment. But when pain control becomes the focus of someone’s life it can prevent them from engaging with the people they love and the activities that are meaningful and bring them joy.
The Circus Act Metaphor
Trying to control your painful thoughts and sensations is like being part of a circus act—one with jugglers in one ring and flexible acrobats in the other. Just about anyone can juggle one ball. Lots of people can even juggle two balls. But what happens when you get to three, four or five balls? All of your energy, effort, and attention is focused on one place… and nowhere else. It becomes difficult to keep up this juggling act. Eventually, all of the balls come crashing down on you. Something that started out simple and harmless is impossible to keep up. Now the acrobats, on the other hand, they just focus on one thing, becoming more flexible. Day by day, they stretch, move and bend. Sometimes they are a bit sore but they know it is in service of a better performance and taking care of their body.
This is what controlling pain and our internal experiences can be like.
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We have the perception that we’re doing a good job of keeping all the unpleasant stuff in check, and maybe to some degree, you are. But it takes a lot of effort which means our attention isn’t on other important areas of your life. Eventually, all the balls come crashing down, and not only do we still have those unpleasant experiences to deal with but a big mess of balls that we have to clean up. Sometimes, when the balls come crashing down they may even harm you.
The reason I like the Circus Act metaphor is that people with pain are on a mission to find a “cure” that exists outside themselves. They collect treatments such as meditation, special exercise, manual therapy techniques, diet, supplements, multiple prescription drugs, electrical stimulation machines, CBD oil…the list can become very very long.
Some of these are valuable health-promoting behaviors, but the constant struggle of collecting all of these interventions and then squeezing them into your life… that control agenda can backfire.
When I was new to ACT, an important a-ha moment for me was that you have this idea that you have to get rid of ALL of the control stuff. That’s not the case! Experiential avoidance is anything you’re doing to change and control your internal experiences. There are examples of experiential avoidance or control that they might count toward the definition. But experiential avoidance is only “bad” if it has a negative cost of living a valued life.
You can even “act” out the Circus Act metaphor with your patient in the clinic by using simple props. I encourage you to take a playful approach with all the metaphors you encounter in the course. Give them all a try and don’t become too fused to any one metaphor. Soon you will be creating your own metaphorical stories.
Grab some tennis balls and try the Circus Act metaphor with your patient.
Let me know how it goes!
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