Many clients with chronic pain spend enormous amounts of time, energy and money trying to control or eradicate pain. The unfortunate clinical reality (for some) is that total pain relief is not always possible. When this is the case, a shift in approach to pain care is often necessary. Modern pain care emphasizes the resumption of daily activities despite—not dependent on the absence of— pain. This shift in clinical perspective requires an understanding of the psychological impact of chronic pain and a real-world integration of the knowledge into clinical practice. What strategies has your client tried to control or fix their chronic pain? 

“I try to not think about the pain”

“I rest when I have pain”

“I roll on a foam roller to alleviate the pain”

“I decrease my activity”

“I listen to relaxing music”

“I take CBD oil”

“I pop a pill”

When Controlling Pain Becomes the Problem

Avoiding pain is natural.

To some extent, everyone has engaged in behaviors to escape from the unpleasantness of pain. Common as it is, avoiding pain can actually make it worse. The behaviors and strategies clients use to avoid pain can lead them down a path of misuse, disability and even death (think opioids).

In Acceptance and Commitment Therapy (ACT) the persistent avoidance of painful and unpleasant events is known as experiential avoidance. These behaviors are common and are a naturalized way of responding. In order to avoid negative thoughts, memories, feelings, and physical sensations, people may attempt to replace them with positive thinking and distraction. When these attempts don’t work, thoughts and feelings surrounding the pain experience take control.

There are countless ways experiential avoidance shows up in a client’s behavior:

“I try to put it out of my mind”

“I’ll go to my__________, they’ll fix it!”

“I have a drink”

“I smoke pot”

“I ask for a second opinion, they must have missed something”

When attempts to control pain repeatedly fail, self-identification with pain often becomes a defining issue that interferes with a person’s ability to live a rich, full and active life.  

Opening Up and Willingly Moving Forward

Acceptance and Commitment Therapy (ACT) is a cognitive behavioral therapy that focuses on psychological flexibility. The general goal of ACT is to increase psychological flexibility– to make contact with the present moment as a conscious human being, and to persist in behaviors that serve valued ends. This is a process of embracing whatever is causing distress or suffering, and inspiring commitment to

actions that uphold personal values(1). Psychological flexibility can also be defined as:

• • Coming in full contact with painful and unpleasant internal experiences while consciously taking meaningful actions.

• • Contacting the present moment fully as a conscious human being, and based on what the situation, changing or persisting in behavior to serve your chosen values.

In everyday language, this means holding unpleasant internal experiences lightly and acting on longer-term values rather than short-term impulses, thoughts, and feelings. Psychological flexibility is what you want to nurture in your clients while modeling it in yourself as a pain professional.

Psychological flexibility is established through six core ACT processes.

When applied to the treatment of chronic pain, ACT seeks to dissociate the physical sensation of pain from emotional distress. The bedrock supporting ACT is the idea that discomfort can be lessened by pursuing a new path that emphasizes values; the things give our lives purpose and meaning – even in the presence of pain.

The concept of mindfulness, central to ACT, refers to the ability to engage with and experience the present moment, be it pleasant, unpleasant or neutral. This ‘mindful’ awareness leads to a willingness to notice and name unpleasant experiences as they are, allowing them to defuse so that they don’t dictate one’s actions.

Check out this podcast with Dr. Kevin Vowles, PhD on How To Avoid The Trap Of Negative Thinking Using ACT.

Swimming Ashore with Creative Hopelessness

A first step in targeting pain-related behaviors is helping the client notice which pain control behaviors are preventing them from moving forward. A good metaphor for the practitioner to think about is a dog chasing its own tail. Tail chasing is a common play behavior in puppies, but one in which the pursuit leads no closer to the destination. While some clients openly and willfully identify chosen behaviors that have not worked, many clients struggling with chronic pain may be reluctant to do so.

The purpose of creative hopelessness is to create a context where futile struggles can be abandoned while new solutions can be claimed.

Creative hopelessness is a technique in the ACT model to help clients realize the unworkability of the control agenda. In other words, it aims to undermine the control agenda by gently and compassionately exposing the costs of avoidance behaviors (2).

It does not imply that the patient is hopeless!

Creative hopelessness is not a feeling: it is a liberating action of letting go of an agenda that has not worked so that more productive and innovative actions can take place. (3)

Creative hopelessness is not always used in the ACT model for pain. It comes in handy when you suspect or know a client is clinging tightly to the “control agenda.” This is often observed in the rule-governed language clients use such as: “In order to exercise, the pain has to go away” or“I’ll go back to work once the pain is gone.”

Creative hopelessness will gradually chip away at the control agenda, making room for healthier behaviors that align with the client’s values.

ACT and Creative Hopelessness in Pain Care

The adverse consequences of pain on daily activity are the main reasons people seek the care of physical therapists and other pain professionals. As you engage your client in therapeutic exercise to restore mobility and activities of daily living, ACT can be a useful psychological technique to assist in pain care. It can help clients drop the rope in the tug-o-war with pain. In the podcast How To Live An ACTive Life Beyond Pain Combining ACT & PT, Jennifer Battles describes how to use ACT to increase adherence to physical therapy routines. Results of her work, available here, demonstrate that a brief ACT intervention can improve patients’ physical therapy treatment and home exercise adherence. These findings suggest that ACT may help to promote the behavioral changes necessary to successfully managing pain.

The following randomized controlled clinical trials provide evidence that ACT reduces the physical and emotional impact of chronic pain:

✓ Dahl et al. showed that workers at risk for long-term disability resulting from stress and pain symptoms were less likely to take sick leave after attending ACT sessions (4).

✓ Wetherell et al. reported that ACT and cognitive-behavioral therapy (CBT) provided similar improvements in pain interference, depression, and pain-related anxiety in chronic pain patients; patient satisfaction, however, was significantly higher with ACT (5).

✓ A systematic review and meta-analysis assessing results from acceptance-based interventions for the treatment of chronic pain concluded that ACT may be more suitable than CBT for patients with high levels of experiential avoidance and lower levels of meaning in life. (6)

✓ Another review on the same topic suggests that ACT is effective, particularly at enhancing physical function and decreasing distress, as compared to inactive treatment (7).

✓McCracken et al. studied 108 patients with chronic pain that went through 3-4 weeks of ACT treatment; an improvement of 34% in pain-related depression and anxiety, physical disability, medical visits, pain intensity, and pain medication was noted,  and 81% of these improvements continued 3 months later (8). Moreover, at the three-year follow-up, 64.8% of patients had reliably improved in at least one key domain: acceptance of pain and values-based action (9).

✓ For the first time, an ongoing clinical trial in Ireland will evaluate the effectiveness of a combined Exercise and ACT programme (ExACT), in comparison to supervised exercise for chronic pain (10).

5 Questions to Undermine Control Strategies

The following questions can be used to grease the wheels and facilitate creative hopelessness. This can be used with a variety of pain conditions. Creative hopelessness can be used by mental health professionals (psychologists, LCSW, counselors, coaches) as well as physical medicine professionals (PTs, OTs) to help clients open up and explore why they feel stuck.

1- What Have You Tried?

“What have you tried in order to control, get rid of or alleviate the pain?”

To help clients remember all the different things they’ve tried, therapists can use the acronym STOP, representing 4 broad categories of experiential avoidance:

• Substances: “Have you used any substances to avoid or get rid of the pain?”(foods, drinks, recreational drugs, supplements or herbal remedies, and over-the-counter or prescription medications)

• Thinking: “Have you tried to not think about the pain or change your thoughts about the pain?” (self-help books on positive thinking or work with a therapist to try to reframe thoughts, delete thoughts or change thoughts.)

• Opting out: “What important, meaningful or enjoyable life activities, events, challenges, or people do you avoid, escape, procrastinate, or withdraw from because of chronic pain?”  (work, relationships, recreation, school etc.)

• Pause:“What have you tried to press the pause button on your pain? (this often shows up in distraction techniques such as listening to music, meditation or reading. Healthy behaviors such as meditation can be used as an avoidance strategy).

2- How Has It Worked?

An important first step here is to validate your client’s response by acknowledging their efforts and identifying what has worked and what has not in their attempts to control chronic pain.

“Did you get relief from doing/taking _______?

How long did it last?”

In this step, it is important to distinguish form from function, namely what actually works to relieve pain and what has been a short-term “fix” or avoidance strategy. You will find that most clients have a long list of treatments that have failed or only alleviated pain temporarily…but none that have provided long-term relief.

3- What Has It Cost?

Compassionately, you then ask about the cost these short-term control strategies have had with regard to work, health, time, money, energy, relationships, and opportunities.

“Have these efforts, and the price you’ve paid, decreased or increased over time?”

“Are the costs worth the results you’ve gotten?”

It is common for clients to say that the short-term strategies have cost them lots of money, as well as contact with the things that are most important to them, such as work, family, friends, and recreation.

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4- What is that Like for You?

As the patient steps back and looks at these strategies through a new lens, your aim is to cultivate a self-compassionate reflection on how clinging to the control agenda has created more suffering in the long term. Again, you want to validate your patient’s efforts. Suggest that most of what they tried makes perfect sense; they’ve worked very hard, they are not lazy, and they’ve done what is only natural and what most people would do. Also help them notice that, although some of these things may have worked temporarily, these tactics ultimately did not provide consistent or long-term relief, and instead have led them away from the things they enjoy, cherish and value in life. It is normal for the client to experience sadness, fear, anger or frustration. A good way to buffer this and to help the patient cope is by asking them “What would you say to someone you love, if they had been caught in the same trap for so long, and they were feeling what you are feeling right now?”

5- Are You Open To Trying Something Different?

After helping your client realize there is little or no benefit in pursuing the same pain avoidance strategies, indicate that there is an opportunity to turn hopelessness into creative ground. You might say… “You have tried many times, and for so long, to resist and control your pain, yet the results are less than ideal; are you open to trying something different, that might work better, in terms of building a better life?”

If the answer is yes, you may begin to work on simple, non-confronting willingness exercises based on the various core processes of the ACT model that include cognitive defusion, mindfulness and clarifying values. 

Infusing Principles of ACT Into PT Practice

Physical therapists are in the unique position to impact change amidst the chronic pain epidemic that we are facing in America (11). Psychologically informed practice is a beautiful marriage between mind and body. It is a point on the imaginary line between the narrowly focused biomedical model and the cognitive-behavioral approaches developed for the treatment of mental illness (pain and psychopathology are not synonymous). Utilizing ACT principles, such as creative hopelessness, in physical therapy practice is a great way to boost patient adherence to treatment. It is also a way to bring your patients back in contact with activities they have abandoned in their struggle with pain. Moreover, techniques used in ACT can also help your patients cope with feelings of anxiousness or melancholy.

To learn more about ACT, download the free ACT Starter Kit by going to www.DrJoeTatta.com/75Download.

Inside, you will find a full explanation of the ACT model for pain, a few metaphors you can use in therapy, as well as some of the latest research confirming the effectiveness of ACT for chronic pain.

REFERENCES:

1- Hayes, S. C., Pistorello, J., & Levin, M. E. (2012). Acceptance and commitment therapy as a unified model of behavior change. The Counseling Psychologist, 40(7), 976-1002.

2- Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. F., & Strosahl, K. (1996). Experiential avoidance and behavioral disorders: A functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64, 1152–1168.

3-Hayes, S. C., & Strosahl, K. D. (Eds.). (2004). A practical guide to acceptance and commitment therapy. Springer Science & Business Media.

4- 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.

5- Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, 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.

6- 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.

7- Hann, K. E., & McCracken, L. M. (2014). A systematic review of randomized controlled trials of Acceptance and Commitment Therapy for adults with chronic pain: Outcome domains, design quality, and efficacy. Journal of Contextual Behavioral Science, 3(4), 217-227.

8 – Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: a study of effectiveness and treatment process. Journal of Consulting and Clinical Psychology, 76, 397-407.