Welcome back to the Healing Pain Podcast with Sarah Wilson

We are talking about how to integrate Acceptance and Commitment Therapy alongside your existing physiotherapy or physical therapy practice. This episode is for physical therapists or physiotherapists, but it’s also for you if you’re an occupational therapist, a nurse, a doctor, a licensed massage therapist. Maybe even a mental health provider like a psychologist or social worker or a licensed professional counselor who is interested in learning how to shift their practice and seed their treatment with principles of Acceptance and Commitment Therapy. My guest is physiotherapist, Sarah Wilson. She qualified as a physiotherapist in 2001 following rotational post. She chose to specialize in pain management in 2006 and started to implement and learn about Acceptance and Commitment Therapy shortly thereafter.

Sarah has worked in both primary and secondary pain care before moving to the Bath Centre for Pain Services, which is a UK national center providing residential pain management programs for both groups as well as individuals. The Bath Centre provides care across the lifespan and uses an interdisciplinary Acceptance and Commitment Therapy approach. Sarah’s current research interests include psychologically informed physiotherapy. You’ll learn all about Acceptance and Commitment Therapy and how it can complement and improve a physiotherapist pain practice, what some challenges are for physiotherapists as they begin to implement ACT into their practice. Finally, some of the differences between Acceptance and Commitment Therapy and Pain Science Education.

If you’re a physical therapist or a physiotherapist or another licensed health professional and you’re interested in learning more about ACT and how you can implement it into your practice, make sure to register for the waitlist for the ACT For Chronic Pain course at the Integrative Pain Science Institute. You can simply do that by going to IntegrativePainScienceInstitute.com. Go to the Courses tab, scroll down and you’ll find the ACT for Chronic Pain Course Waitlist. I’m excited to share this with you. Sarah has over a decade worth of experience implementing ACT into physiotherapist practice. Without further ado, let’s meet physiotherapist, Sarah Wilson.

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Implementing Acceptance And Commitment Therapy (ACT) Into Physiotherapist Practice With Sarah Wilson

Sarah, welcome. It’s great to have you here.

I’m excited to be here.

I’m excited to talk to you about a lot of the work you’ve done in the world of physiotherapy and how you’ve implemented ACT or what’s called Acceptance and Commitment Therapy into your practice. I know ACT spans a lot of different disciplines. It comes from the realm of psychotherapy, but a lot of physical therapists, occupational therapists, social workers, counselors, even coaches and other people have a story to latch onto the work and are interested in it. When did you first encounter ACT in your career as a physiotherapist?

The first time I encountered ACT was many years ago. I happened to sign up for a two-day study day with Lance McCracken who worked at Bath Centre for Pain Services where I now work. I went along to this two-day workshop not knowing at the time what ACT was or what I was about to walk into. At that point, I’d been starting to specialize in chronic pain. I had an interest and starting to feel my way through that. I started my Master’s in Pain Management. I went on this two-day study day not to reinstate it, but life changed a little bit. Back then, we were hearing about CBT as physios.

This was pretty early on in pain management in the UK for physio. I connected to what I heard and had been very much working with chronic pain patients and going, “I must be a rubbish physio because these people aren’t getting better. Maybe I need to stop being a physio because I’m bad at it. These people with chronic pain, their pain is not changing.” That study day gave me like, “Maybe this is something that could be useful for my patients.” I went away and I wrote about it. I started playing around with some of the ideas and the things we’ve done. I started stalking the team in Bath and was like, “This is interesting stuff.” I uprooted my life to move to North Yorkshire to a team where they were bringing in some ACT stuff in pain. I played around with it some more and did some training. A couple of years later, I got a job at Bath Centre for Pain Services, where a lot of physio were at the time and they’d been using it for a while. From there it’s history.

To give people a little bit of context about you, you’re a physiotherapist in the UK. When you mentioned the Bath Centre, can you describe what that’s like? Where you’re working is what would we would term here in the US as inpatient or outpatient. How does your life look like on a daily basis?

We’re classed as a residential service in the UK. We try to see ourselves not as a hospital-based service, although we are based in a hospital. We’re a pain rehab service. We treat people across the lifespan. We treat children and adolescents. We work with young adult, transitional age groups and adults. We try and see people rather than by their age, but by their stage of development. We’re interested in how people’s lives are going. Have they reached the level of independence we’d hope to see in someone of that age group? How’s life going for them? People come to us either as a one-to-one admission, so they work with a team on their own for either 1 or 2 weeks generally. The children will be with a parent and we work with the dyad. For adults that come on their own or maybe with a significant other or they come for a 3 or 4-week residential program. They were there pretty much 8:45 until 4:30 every day with a mix across all of our services of physio, OT, psychology. We’re very much a psychology-led service. We have ACT as our coordinating model across the whole team. We all blend acting with what we do at an individual level on the programs.

You went on this continue education weekend workshop about ACT. Before that, were you exposed to more traditional CBT and knew what that was and had started to use some of that?

Certainly, over in the UK, Louis Gifford, I’m hoping you’ve come across all of his stuff. He was a bit of a pain legend in the UK. I’d been engaging with what he’d been writing with people like Zara Hansen, who was one of the first physios to qualify in CBT. We’re starting to play with blending some of those ideas in and starting to think about a shift into self-management and how we helped people to do things with pain or to think about some strategies. Back then, we’re more strategy-based care. We’re thinking about teaching people skills-based pacing, communication skills and relaxation, pieces from CBT, pieces from here and there, but nothing coordinated or defined model.

Like many people, when they’re introduced to ACT, it has the clouds part and the light starts to shine through a little bit. Can you talk to us about why it may have been like that for you when you started to look at ACT through the lens of physiotherapy?

It’s weird because to me, the beauty of ACT often as professionals is it touches something in us. It freed me up because all of a sudden it took the pressure off from the top to fix the person because they didn’t need fixing. It allowed me to be a bit more creative to think about who the person was in front of me. It lets go of my, “I’ve got to fix them so they can get back to their life. I’ve got to do something.” Also for me, I recognized how it related to my own life and how I could use that stuff for me. It bolted in.

If you look in the world of physiotherapy, probably the most popular form of Cognitive Behavioral Therapy, even though people don’t necessarily call it Cognitive Behavioral Therapy, is Explained Pain or Pain Neuroscience Education. Those are theories and processes on how someone’s thoughts and beliefs affect their physical function or affect their function. ACT is that, Explained Pain is that, traditional CBT is that. Those approaches are a little bit more geared towards symptom reduction, where ACT is not necessarily about pain and/or symptom reduction. Can you talk a little bit about how long or how you started to approach that as a physiotherapist? If you’re a physiotherapist, you probably be trained before maybe five years ago. There’s been a heavy biomedical model around symptom reduction for us as professionals.

I came to this years ago and that’s when the world was very different. I want that guide. I’ve heard about this cool thing and all of these physios just went, “What are you talking about? There’s all this good stuff.” Early on, I used to use a lot more pain education as a treatment or a way into treatment. Having worked at Bath for years now, I still see a role for pain education. It’s helpful for people to understand this because it is scary for people. Something’s happening to them. They can’t explain it and they start to doubt themselves. They start to doubt what’s going on. I’m not processing. It’s validating. What I come to question is the long-term workability of the behavioral change that can engender. For some people that is exactly what they need.

They take education and they’re brilliant. That’s freed me up. They go off and they live their life and that’s brilliant. I spent a long time working at the other end of pain management. I see a lot of people who they can tell me almost as much as I know about pain science. They’ve done their research and yet that behavior is closed down. Life isn’t going brilliantly and they’re struggling. I feel like catching for some people. Collecting knowledge and collecting understanding becomes their way of trying to control their experience and that become problematic. We have to be careful not to say education, good education, but think more about what’s the function about behavior.

Is it helpful and helping them get to where they want to go? It’s brilliant. Let’s help them with that. If what we’re seeing is if something happens in my body, I’m scared. I’ll go and ask a professional, they give me a good explanation. I’ll go away for a bit. I’ll manage until the next sensation and then I have to keep going on this loop. There’s a point at which I worry that we’re no longer supporting self-management. We’re not empowering our patients. What we’re doing is making them reliant on us in order to get that change. That’s where for a time perhaps my formulations become more sensitive to aspects of that.

You’re still using bits and pieces of pain education on a regular basis.

If you think I’m working on a national service, people go, “We’re going to their primary care service.” They’re sent there to the secondary care. They will come to us possibly via other mental health services or specialist. By the time people get to us, there’s very little that I’m going to know that no other physios have ever met them before. That’s the other thing for me, it’s remembering this isn’t about I’ve got physio knowledge. Because I worked in a specialist center, I’m going to do the education better. There are some competent people that these patients have met. Unfortunately, they haven’t had the talk of treatment that they’re going to respond to. My job is to do something that is different.

Bolstering or supporting or even at times turbocharging approach as a physiotherapist and even your approach with some pain science is the ACT that you start to weave into your practice. What’s the biggest change that ACT has brought to your practice? I know we can touch on that from the perspective of you as a professional and then the perspective of working with patients. Let’s talk about the perspective of you and the patient first, that dynamic.

If I’m completely honest, probably the moment that had the most impact on me was doing the workshop with Ken Wilson years ago and sitting down and listening. That is the thing that I come back to when I’m working with people and training people. What you need is there in front of you. That is for me the biggest change that sometimes I need to share. I need to stop working so hard and allow the patient to help me to get up and to see how they see things and why they’re struggling. That’s probably the biggest transition. My practice has gone from I’m the expert, I’ve got all the answers, I’m going to fix you to crunching. Sometimes I have no idea how we’re going to do this. What if we have a look at this together and see if we can figure something out?

Has that stance alleviated some of your own stress and pressure at work as a physio?

It doesn’t go away. I still internally feel a massive pressure ignite. You work in a national center. You feel a big pressure into getting to get people better. That’s how we get a funding. There’s a weight of expectation that comes with that, but ACT has allowed me to not have to react to them in the same way. I can see the times when that’s been helpful for the person in front of me. Remember it’s not about me, it’s about what I’m there to do for them.

Talk to me about the challenges of a physiotherapist. Physiotherapists are storing more and more to learn about ACT and they’re hearing about mindfulness and other mindfulness and cognitive-based approaches. Like you, they’ve tried pain science or pain education. They liked it but they noticed that it may not work so great for certain people or for certain populations of people. They’re looking at ACT but they’re saying, “I’m not sure. I don’t know if I can do this. I don’t know if I want to use it. I don’t know how this fits.” What are the challenges for physios implementing this into practice?

Historically, a lot of the training has been very mental health focused. As a physio, you’re suddenly going back to before a lot of things guys were getting involved in this. There was a real challenge making that accessible to myself and being able to pull out from that work and that training that I need to deserve as a pain physio. That’s one side of the challenge. Also, there’s so much help out there as well. There are so many people who write blogs and tweets. They’re saying that they’re using things and it’s hard to actualize what they’re talking about, who is using terms correctly. Particularly in physio communities, I hear this word acceptance being banded around. When I hear patients telling me that their physio has told them to accept that pain. It’s finding a way for people to find their way in and to find a way to understand what the model is. Not just look at one piece of model because it’s easy to use psychological flexibility and to talk about these experiences.

Also accessing things like supervision as well, particularly for people who aren’t working within a dedicated team. Maybe they’ve got psychologist. Maybe they’ve got experienced clinicians who can help them with that. Start trying to figure it out because there’s among them. It helps to take a bit of a leap of faith and you have to decide that you’re going to give it a go. That could feel risky in particular as a physio because all of your colleagues are fixing people around you. Maybe you are telling them that they are and that can make you vulnerable. That set a stage that often we talk within our unit, within the clinicians that come through and train that then has come among them and that can be terrifying.

All of a sudden, all of these things I feel safe to and already feel confident, that make me feel like a competent professional. I’m starting to let go of them. I’m not sure what I’m going to do to replace it. That’s a vulnerable place and it’s a scary place. Having an access to support and talk to people and get some feedback is important. Otherwise, it can be a bit of an awkward experience to you and the patient. Many don’t learn and shape in the way that it would be.

I like what you said about letting go of certain things. Because what I’ve seen among physios, with any psychologically informed practice, they start to reflect upon their own experience and their own beliefs about what works, what doesn’t work, what I should be using, what I shouldn’t be using. As they start to let things go, they’re excited to let things go and have something new to commit. At the same time, they’re like, “If I let that go, who am I then? Am I now a physiotherapist? Am I now a psychologist? What am I then?” There’s this whole process of looking at yourself like, “What’s happening now? How do I go forward with this?

I remember the many times. I initially found myself sitting along the sixth floor going, “That helped me.” Nobody understands what ACT is when you are physio. I don’t want to mess with projects. Physio has got something to offer these people. I also see the value of this and I can’t make it work and how I put this together. It’s those conversations that helped me to start to find my way through it and to figure out what it was. I was lucky that I had peers around me who had gone through this process. That is helpful. If you’re doing it on your own, it can feel like, “What does work?” I’d figure out some things that maybe aren’t so helpful.

With all my programs, I have Facebook groups where people can communicate and chat on Facebook and then I give them live calls where we can meet for 90 minutes and role play, ask questions, go through case studies. What you’re saying is so important that people need that mentorship and that guidance as they’re learning new skills. When we talk about that scope of practice area, that delicate seesaw, where do you separate the scope of practice between how you’re using ACT versus a psychologist? Let’s talk about that first. I think there have to be a separation like that.

The way I look at it is I’m incredibly lucky to work in an interdisciplinary team. I get to work in a much broader scope than if I was working on my own because I’m formulating with other people in the team. The exposure I get to how other people are working over the years has created a way that I can do pieces of work, that if I was seeing someone in primary care practice or secondary care even, I wouldn’t be going there. I wouldn’t be exploring some of those things. I wouldn’t be working with some of those things in quite the same way because of my professional boundaries. I am incredibly lucky that I get to play with that to explore what it can do. Also, I run teaching for people who work in other settings and it’s remembering what’s appropriate for them to be doing. How can we look at something that we can contain, understand, got a shared language about, but also that fits within people’s skills and help them also to understand their own skills? That’s the key piece to me.

Professionally, we have to be honest with ourselves and that we have to have an awareness of our own scope of capability and practice. A lot of the interesting work has to come if this grows in the way that it has been. It’s going to be about how we look at things like competence, how we look at people’s ability to deliver things without moving into either unsafe practice that’s otherwise relax about delivering underpowered intervention. The risk is some people will say, “I’ve done this and it doesn’t work.” Using ACT becomes very difficult because they’ve had this experience that it doesn’t work. They’re caught in that. One area of this is competence, skills and its ability to practice. Also, it’s understanding what the impact of doing underpowered or calling it ACT but it’s something else could be in terms of that person’s ability to engage in the future.

That’s based on someone’s competence in using ACT. Also, at times with psychological informed practice, things can become so watered down that they are no longer what they were intended to be.

People can become hooked on one piece. People also go with much-favored processes. We can all have our favorites, but we do need to touch in with what else is going on and to think about the whole piece as well. Consider in particular, there’s a lot of overlap. We need to be able to move flexibly ourselves within that.

You mentioned processes. There are six core processes in ACT that fold into psychological flexibility, which is the entire theory. Do you try to target each process over the course of let’s say seven sessions? Do you have your own framework that you’ve developed as a physio as you work to evaluate and treat your patients?

Yes. In programs, there is this flow.

What comes first? You’re in an interdisciplinary team. Some programs will put values first. Some protocols will put values in the middle.

Creative hopelessness is where we would generally stop. Both are very stuck with patients and they need some help to look at why they’re here, what is working in their life, how can we start there to make some contact with that. We’ve played around with different orders and I have to say, we don’t have that settled up. There is no program manual. Often, values are what comes in early because we want people to have some sense of why they’re there, what they’re working for. We don’t want to one work each much less defined because we went with what’s there. One of the interesting things that happens the more experienced you become as a commission is that you start to move between the process more fluidly within your session.

It doesn’t have to be a one session, then an extended session, then a diffusion session. You’re tapping into the interaction between you and the patient using that. We’re never done with the processes and we’re never done with the values. It’s always trying to retap. Often on the program where you’ve got psychology strong and physio and IT, it’s like delivered a passenger session so they doing passenger on the bus. I was doing some yoga and bringing passengers in. The absolute beauty of being a physio is that we can stop playing with movement whilst then tapping back into that work that’s been done with psychologists. We can start to pull them out as it happens when people are faced with something that is probably going to be painful or is going to bring up the fear of pain increasing. That is the piece that I love with my job because I get to go play with it.

We’re putting the mind and the body back together. We’re one of the few professions that can do that. One, we have the time to do it. Two, we have the knowledge. Three, we can do it effectively from an evidence-based.

It’s always interesting how the different professions can sometimes see different behaviors. Someone can be doing well, contacting stuff in the present, thinking about changes but when the reality of doing something, when they feel whacked and tired. Someone is looking at something physically with them. You can see something different. Sometimes we see people do amazing things with movement and yet the psychologist can be going, “This is a load of rubbish. I don’t want to do this.” It can give people different ways to access that as well. That’s important.

Do you think ACT applies to every sub-specialty in physiotherapy? We have pain physiotherapist, sports physiotherapists, pediatrics, adolescents, geriatrics. We’re a very big, broad profession. Along with that, do you think it can be applied and work well with acute pain as well as chronic pain?

The evidence is starting to think about this differently. It’s important. Maybe we can help people get less stuck. This is an area that is hopefully going to grow. Because if we can take people who have an acute pain problem or even things like post counsel pain where maybe it doesn’t feel like in priority but they’re wrestling with something difficult. Often, people get pain after chemotherapy or after surgery. We can start to help people have a way to manage that. Maybe they don’t get some stuff down the line. I work with the some of the most complex patients in the UK. We have people coming from Europe, USA. I hope one day that I’m out of a job because we can create all the stuff that people are getting quite so stuck. That would be the journey.

Can you share a success story of a patient who you’ve worked with anytime within many years where you used ACT in some active form principles and how it helped turbo boost that session or that course of treatment?

The one that sticks on my mind are the people where I’ve seen massive change. I’ve worked with people who’ve been bed-bound for two years, oftentimes in their 20s and 30s. To work with some of them for a series of weeks and is bed-bound, then for them to come back to their follow-up on a train, on their own, two hours. These are the ones that are spectacular. I also worked with a lot with kids who are out of school and who are struggling with the physical pain that they experience. Also, it’s very hard for other kids to understand that a child is suffering emotionally and physically, particularly with chronic pain, that their condition is unbearable. They judge them and they think it might not be true and there can be blame and all sorts of things. Seeing a child and seeing they don’t have to come out of school and that they can make the choice to go back into school, maybe back into PE, and you think that’s an important developmental thing for them. Also, there’s this little physio part of me that’s like, “Their body needs them to do this.”

If they go through maturity and they have to work their heart and lungs and they have to build their physical capacity. It feels like those are the ones where you get a window of opportunity. Watching that happen is always exciting. ACT allows you to see the breadth of their suffering and to apply things. I was working with some young people in a yoga session and they’re all sitting there going, “I don’t want to do it. I’m tired.” Yet, when you look at where this tired child shows up at school and struggling. We can work in yoga, working physically and doing something without getting tired. We can then translate that into other areas. That’s the absolute beauty for me. You can be creative with it.

I’m glad you brought up pediatrics and PT and ACT because oftentimes orthopedic, pain specialists, physical therapists are connecting and learning about ACT. We haven’t seen it too much spill over into those other areas. PT is a great place for it because kids are creative and ACT is a creative process as well.

You can have real fun with other forms with acting out passengers. There’s fun stuff that you can do. In a funny way, if you can get them a little bit looser and you can help them to see almost in a way they get to jump their peers because they get this light level life experience. They’ve dealt with something hard and they learned that life lesson. They go into the world and a little bit better prepared.

It’s been great talking with you, Sarah. I know you’ve worked ACT into your physiotherapy practice for decades now almost, which is great. In some ways, people in the UK are a little bit more advanced than we are here in the US because you have got a good healthcare system that helps professionals meld this into their practice a little bit faster than here in the US. We’ll catch up to you, I promise. If people want to learn more about you and all the things that you’re up to, how can they reach out to you?

My Twitter handle is @Wilson_Sarah23. People can link up with me on Twitter. We do have a website for Bath Centre for Pain Services. You can have a look at what we do as a unit. We are lucky to have a dedicated unit and to be able to do clinical work, research and all of that together.

I want to thank Sarah Wilson for being here. She’s a great physiotherapist who’s implementing ACT into her physical therapy practice. You can check out the Bath Centre online at their website to learn more about their pain services. You can tweet directly to Sarah. Her Twitter handle is @Wilson_Sarah23. Make sure you tweet out to her and thank her for all the great information that she shared. Make sure you take this and share it with your friends and family on Facebook, Twitter, LinkedIn, in a Facebook group, wherever you have people, friends, tribe of people who are interested in pain, physiotherapy, ACT, all the great things that we talk about here. I’ll see you next time.

Important Links:

• Sarah Wilson – LinkedIn
• ACT for Chronic Pain Course Waitlist
• @Wilson_Sarah23 – Twitter
• Bath Centre for Pain Services
• https://integrativepainscienceinstitute.com/act-for-chronic-pain-waitlist/

About Sarah Wilson

Sarah qualified as a physiotherapist in 2001. Following rotational posts she specialised in pain management in 2006 having developed a clinical interest in this area and started to learn about Acceptance and Commitment Therapy. Sarah worked in primary and secondary care pain management settings before moving to the Bath Centre for Pain Services (BCPS), a UK national centre providing residential pain management programmes on a group and individual basis in 2008. The BCPS provides care across the life span and uses an interdisciplinary Acceptance and Commitment Therapy approach. Sarah has a research interest in the implementation of psychologically informed physiotherapy and also works as a lecturer at Brunel University where she has been involved in developing an M-level module in pain management for the Advanced Clinical Practice programme.