Welcome back to the Healing Pain Podcast with Dr. Ashlyne Mullen
In this episode, we are discussing how to use the body as a metaphor to overcome chronic pain and suffering by combining yoga with acceptance and commitment therapy. If you have been following along with this show, you have taken some of my courses or perhaps read my book, Radical Relief, you know that metaphor is essential in the treatment of chronic pain. Metaphors can and begin as very short, tiny little senses, such as motion is lotion. That’s a metaphor that David Butler created.
They can be longer, more drawn-out story-like metaphors that helped tell the story of what’s happening in the body and the mind of someone with pain and what they can do to overcome it. In acceptance and commitment therapy, we use longer story-like metaphors. For example, tug of war with a pain monster or struggling in quicksand. You will find those in my book. They are also common in almost every single ACT protocol that’s out there but as you become well-versed in ACT, you start to create your own metaphors.
For example, the protector within is a longer story-like metaphor that I created that you can find in my book, Radical Relief. From there, especially as a physical medicine professional, the natural extension is to not only talk through these metaphors but take the metaphor and combine them with movement. In essence, put the metaphor into motion. How can we use the body as the metaphor and as a way to tell the story about the metaphor?
One nice way to do this is to use yoga. Combining yoga with ACT makes sense because both yoga and ACT have deep roots in the traditions of mindfulness. When you combine ACT with yoga, it creates a nice holistic mind-body program that integrates psychology with yoga and supports behavior change, which is the one thing we are always after. We are after changing someone’s behavior so they can overcome chronic pain. As you begin to weave together the psychology of pain, yoga, behavior change, metaphor and movement, this enables your client to understand how to gain emotional balance, promote better mental health as well as physical health. They start to embody the perspective that healing requires both the body, as well as the mind when it comes to overcoming chronic pain.
My guest who discusses how to use the body as a metaphor is Dr. Ashlyne Mullen. She is a New York City-based psychologist who has extensive training in ACT, yoga, as well as health psychology. She specializes in treating those struggling with anxiety, chronic illness and pain, insomnia, grief, as well as a life transition. If you are new to either ACT or yoga, you will find this interesting. If you are a licensed health professional, who’s taken my ACT for chronic pain course, you will see how you can start to use what you learned in that course and apply it to the body. Let’s begin this episode and meet Dr. Ashlyne Mullen.
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Watch the episode here:
How To Use The Body As A Metaphor To Overcome Pain: Yoga-Based Acceptance And Commitment Therapy (ACT)
Ashlyne, welcome to the show. It’s great to have you on.
Joe, it’s great to be here.
I’m excited to talk to you about your work. I know you have one great paper that has been published. The name of that paper is called Curriculum-Based Yoga and Acceptance and Commitment Therapy Training Intervention for Undergraduate Students: Mixed-Method Investigation. It was published in the 2021 Journal of Contextual Behavioral Science if anyone wants to access it. I was interested in chatting with you because I know there has been some work done in the realm of comparing CBT to yoga. There has been some less with comparing ACT to yoga. I know that’s what the body of your research focuses on. A good place to start is, what gave you the idea for this study?
I have always been curious about how the mind and body intersect. I had a lot of experience in the ACT. My Master’s was very ACT-focused and I practice yoga to cope throughout grad school. I saw the connection between yoga and ACT there. As I was going throughout my Doctorate, I saw, in other ways, it was used in CBT and other therapies, how it can be targeted to help with different psychological issues. I thought, “Why not use it with ACT and try it out?” I was fortunate that they let me create and implement this yoga and ACT study for my dissertation.
They are both relatively new to a certain extent. As far as the research goes, there’s a huge body of research on CBT and general exercise for obviously both physical and mental health conditions. When you start to niche down into those areas like ACT as a newer form of CBT and yoga, as far as the mindful movement aspect of it, there’s less concerning the trial. Interestingly, you are taking things that are less well studied and saying, “Let’s combine these and study them, pick them apart.” Specifically, you study this about college students. Why college students? Maybe you can give us a little bit of context around what college students experience in the realm of distress.
College is a stressful time and a time of transition. A lot of things come up for them. There are a lot of things that they are juggling there, especially with my population, there’s school and work. Some people have families. It’s a difficult time. There are a lot of research showing high levels of Psychological or high Pathology in the college student population. I thought that this would be a great area to try out this protocol with ACT and you know that.
Within the university setting, there are counselors for people. Some colleges have significant counseling centers and other colleges have fewer services available. That’s important to think about.
I worked at a few different College Counseling Centers throughout my training. We were only allowed to see people for six sessions because there were such an influx of clients and a need, too, so we had to see them for successions and then refer out after that. It was like triage. There’s a need.
Your particular study embedded this ACT-yoga approach into the curriculum. They took it as a class like you take a normal university class.
We came to them. It was great to show, this is what mental health can look like. If you were open to it, maybe you can follow up with your College Counseling Center but it gave them a glimpse of that. It gave them a glimpse of psychological health and wellbeing.
You brought the services to them, in their environment, which is important. Often, the places we treat patients or provide services are more sterile clinical-like settings. It was in the university setting. Were there three different groups that you had in this study?
We had an ACT and yoga group, an ACT-only group, and then a control condition.
ACT combined with yoga and control, which is usually like an education session or something like that.
It wasn’t an education session. They just got the same measures. There was no treatment intervention.
Sometimes these are rather long, twice a week for six weeks. How much intervention did they each receive?
The workshop itself was only an hour and a half. There were measures given before the intervention. A week before and also consent like, “Is this something you are open to doing?” There was the hour and a half intervention, either yoga and ACT or ACT only. We did have an additional piece where we sent text messages that were prompts related to the workshop and that was over four weeks. Four weeks past the workshop, we administer measures again.
As far as the intervention, is it a 1.5-hour session for them?
Yes.
It’s relatively brief, which is interesting.
That’s something that if I were to do differently and had the option to, I would have multiple sessions. It would increase the dosage and be better. The downside is I can’t take up class time for interventions.
It is interesting to think about dose-response because in one way it’s like, “If we can implement this in an hour and a half and there are good outcomes, then maybe there’s a place for a brief intervention.” It’s also nice to know. However, when we up the dose and the frequency, the potential outcomes are greater. What did you expect to see from the intervention? What were the hopes and the big vision?
I was hoping that there would be a greater decrease in psychological and flexibility with the yoga group compared to the ACT Group and the control group. I was hoping that the additional piece of yoga would show greater psychological flexibility and reduce stress more so than the ACT group. That’s what I was hoping for.
What did the results show?
The results showed that after the yoga and ACT group, there was a heightened level of psychological inflexibility immediately after the workshop but then it went down following a four-week follow-up. That was very interesting. It’s something that we reflected on and what that means. What we found from other ACT studies or what research has shown, is that after an ACT intervention, there is a heightened level of psychological inflexibility because what am I doing in that workshop? I’m asking you to be open to the things that you may not want to be open to, things that we may avoid or the struggles. If I’m giving you a measure immediately afterward, you may be like, “I do have some struggles going on,” and report higher levels of psychological inflexibility.
In your study, you have that graph. There’s a spike. It’s like this upward trend of psychological inflexibility, and then it comes way down at the post-intervention.
What’s salient is that it’s so much higher than the ACT only because we tried to match the two interventions to be identical, except that the yoga had movement pieces included. That movement heightens your sense of what’s going on in your body. In the workshops we did, we had the students get up and move around. You are more in tune with what’s happening.
Can you explain a little bit to us what this looks like so most people can imagine what yoga looks like because we are familiar with yoga? For those who understand ACT, they realized, “There’s some training of the six psychological processes in there,” but what does it look when you combine that ACT and that yoga group?
What we try to do is find postures that reflected certain ACT processes. For example, acceptance, what we had them do is think of something that they are struggling with, try and hold it in goddess pose, which is like a squat. Notice what’s showing up for you as you hold it and sit with it as long as you can. To go to the star pose, which is completely out and going back and forth, what is it like to hold these struggles while in these different postures? We made it up. We were trying to think about what movement do we feel embodies acceptance. That was one example. Yoga also has a lot of mindfulness in it. The mindfulness piece that we used was three-part breathing or Dirga breathing, where you use the three chambers and controlling your breath. For the values, instead of using values, we use a mantra, finding your mantra. What’s something that you can tell yourself to give you comfort and to set an intention, which was committed action and intention towards that mantra.
Using movement and the body of the metaphor for certain aspects, that goddess and star pose, you are starting to say, “How do I use the body to explain acceptance to avoidance?” You can start to cultivate that psychological flexibility and inflexibility. It wasn’t a yoga class with ACT instruction on top of it. It was taking poses and discussing how it relates to those processes.
We also had an exercise where students got into the tree pose, which is the balancing pose. We had them get in a circle, try tree pose alone and notice what was showing up, and maybe the difficulty with that. Expanding their arms to their partner, using their partner as support, noticing the difference with that and how much we can all relate to this struggle together, and how much support you feel are balanced in a sense you feel when you have each other. That felt to me very powerful in the workshops.
You are a little bit surprised at the outcome that the ACT plus yoga group didn’t have significant differences, is that correct?
I was hoping that will be.
There have been other studies that looked at ACT and yoga. It’s interesting because yoga does have a mindfulness aspect to it. This is all very technical. I always wonder, how do we design these studies to tweeze out what’s happening in the study? Since yoga involves both exercise and mindfulness, how do we start to differentiate just mindfulness from ACT when we insert it into the program? There’s also an aspect of exercise instruction alone that can, in some way, promote health, both physically as well as psychologically. There are many different levels to that, which is all interesting.
It’s hard to measure and pick apart what this active treatment piece is.
A little technical, I was looking at the measures that you use in the study. Were there other measures? Now that you have completed the study, do you feel like, “Maybe we should use a different measure for this study,” or something that may have been more appropriate or sensitive for the aim of this particular study?
It would have been helpful to have a mindfulness measure alone and track that over time. That would have been interesting to do, something to add, maybe more qualitative measures, too. We did have some qualitative measures at the end because this was a feasibility study. I wanted to see, what your reaction was, did you like it or not like it? Would it help?
It was a mixed-method study. What were some of that qualitative input that came out of it? How did people respond to this ACT-yoga intervention?
For the most part, people said that it was very helpful, that they enjoyed it and felt like they dealt with stress better. I was surprised because there were 3 or 4 people who said they stopped smoking, which was great. We weren’t targeting smoking but it’s amazing. There were a few who said they are sleeping better. It was nice to see behavioral changes as well as feeling less stressed. A lot of people said, “More grounded or more mindful.” It was great to see that feedback.
You weren’t necessarily targeting those lifestyle behaviors change aspects but it came through. Why do you think that came through? Is it just in the values work? Maybe they had a more heightened awareness of the avoidance type of activities they engaged in when they were experiencing distress in school.
I’ve got a lot of feedback on the discussion of being on autopilot and how some of us are on autopilot all the time. What are you missing out on that? What does it like to be in the present moment? To slow things down. What’s happening now? That piece could be related to it and also the mindful eating, which was we walked through like, “What is it like to observe this chocolate, observe the wrapper?” What is it like to feel it? We encourage people to use that practice in other places. Maybe it showed up in smoking.
There’s a movement in the world of physical therapy and other specialties specifically around chronic pain of a more psychologically informed and based care. It’s combining psychological interventions with more physical interventions, which a lot of your work centers around. Do you notice that movement in the world of psychology specifically because obviously, you are working intensely with the mind? Is there a movement to start to weave in more movements, somatic changes and interventions, and are you using some of that in your daily practice?
There’s a movement for movement. When I was creating this, I was surprised by my books. There was yoga for emotional trauma, yoga for stress and yoga for anxiety. I have a lot of different yoga books. I am trying to move it or incorporate it into my practice. I often talk about, “Are you exercising?” Especially during this pandemic, are you getting up? Are you moving? Why don’t you take a break and walk around the block? We talk about doing different exercises. I have done some chair yoga in my private practice but I have considered having a class once we can go back in person and incorporating yoga into some type of group therapy.
I’m curious when you approach your mentors and things like that, were they a little bit like, “This is a little more in the physical space and less than the psychological space,” or were they very much like, “It’s interesting to look at the overlap of the two?”
All three are supportive of incorporating movement into therapy. Something to think about is when you are doing it and research. There are a lot of obstacles or barriers, especially with movement. What if someone gets hurt? What if someone can’t do that movement? What if there’s a disability? With yoga, you are finding modifications, you are meeting and the person with where they are at, that’s what we did in the class but we had to be mindful and aware of what practices we are introducing to this large study of people.
How would you like to see this work evolve?
I would love to have some type of group therapy where we incorporate movement. There’s something nice about the connected piece. It would be nice to have the same group of people once a month or something like that, or have a text message piece with different meditations each week, meet again once a month and have a class. That would be great. It also would develop a sense of community.
The group aspect is so important, especially with all of these chronic health conditions and pain, particularly lots of research around how groups can be extremely supportive. Facilitating groups is a rewarding experience for practitioners as well. It has been great speaking with you. Let us know how we can learn more about you and follow your work.
Thank you. I have a website, DrAMullen.com. You can go there and learn more about me.
Make sure to check out Ashlyne. Her website is pretty easy. It’s DrAMullen.com. At the end of every episode, I ask you to help us out, share this with your friends, family and colleagues on Facebook, LinkedIn, Twitter, Instagram or everyone talking about ACT, the influence of yoga and how those two converge and can be used for effective treatments for both physical and emotional distress. If you are on Instagram, make sure to tag me, take a screenshot of this episode, and then you can tag me. My handle is easy. It’s at, @DrJoeTatta and I will be sure to tag you back. I look forward to seeing you all here again next episode. Take care.
Important Links:
- Radical Relief
- Ashlyne Mullen
- Curriculum-Based Yoga and Acceptance and Commitment Therapy Training Intervention for Undergraduate Students: Mixed-Method Investigation – Journal
- @DrJoeTatta
About Ashlyne Mullen
Dr. Ashlyne Mullen is an NYC-based licensed clinical psychologist who works with adults and young adults in private practice.
She has extensive training in Acceptance and Commitment Therapy, yoga, and health psychology.
She specializes in those struggling with anxiety, chronic illness, chronic pain, insomnia, grief, and life transitions.
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