Welcome back to the Healing Pain Podcast with Joe Tatta, PT, DPT, CNS
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Using Acceptance and Commitment Therapy (ACT) To Build Resilience In People With Pain With Joe Tatta, PT, DPT, CNS
Living with and overcoming any type of chronic health condition can require substantial physical as well as psychological resilience. Over time, this has a tendency to deplete one’s emotional reserves. Struggling with pain and the eternal quest for pain control can leave most people feeling exhausted and depressed. When this continues month after month and year after year, it can feel like the very life force is being drained from your body. A key part of our job as professionals who treat people with pain is to facilitate and rebuild this sense of resilience. Resilience is defined as one’s ability to adapt and function well, despite significant psychological, as well as physical stress or distress.
This quality is associated with a shift toward healthier behaviors and more vital living. Resilience factors have gained increased attention in the field of chronic disease management as key mechanisms in the relationship between symptoms and disability, using interventions that cultivate mindfulness, involving acceptance, values-based living, the ability to distance from one’s thoughts and emotions, a non-judgment of present moment experiences and the ability to contact a new sense of self have all emerged from the evolution of traditional cognitive behavioral therapy.
Acceptance and Commitment Therapy, also said as one word, ACT, is one method you can use to cultivate resilience and promote health behavior change. This is achieved through the training of one core psychological process called psychological flexibility. In this episode, you’ll know from practitioners from around the globe who are using ACT in research and practice to help people overcome persistent pain. We begin with the originator of ACT, Dr. Steven Hayes.
ACT methods help people engage in needed exposure when they see that there is something there but after all, at some level, as you begin to expand your life out, you’re going to expose yourself to new situations. If you’ve been engaging in very defensive behavior physically with regard to your pain and you may have a provider saying, “That predicts long-term problems.” Those kinds of physical avoidance patterns or offensive bodily things can exacerbate an injury making it more difficult to do the physical things that might help you be more flexible and effective physically.
If you’re going to change your life, you’re going to hit some of those places where you’re afraid. Am I going to feel it again? Am I going to injure it again? In ACT, it’ll give you some of those skills to help you enter into needed exposure in a way that’s emotionally and cognitively. The other thing is it’ll give you a values-based reason to do it at all, which helps you persist and walkthrough. Another one is this broader, more open attentional process can help us square this circle, which is, on the one hand, you may be being asked to walk into exposure.
On the other hand, you’re being asked to still respond to your body and not push yourself beyond a safe limit. That’s very tricky when you’re dealing with something physical like chronic pain. The experience of being able to be more open, read your body in a little more way, read this present moment, can be supported by the practices that allow us to get into this more mindful. I have to go back to the mode of mind. We do have data that people are more likely to persist if it’s values-based and accepting and they’re more likely to try in the first place. They’re more able to stay within self-limits.
Up next is psychologist, Robyn Walser.
Whatever is happening for the individual, I want to do exposure work or willingness work in such a way that they are more interested in some ways in the bodily experience of it than what’s happening in their head. I’m going to look at that too, but I want to get them fully present to all of the experiences that they’re having in their body, becoming aware of them, changing the perspective on it so they can see it as an experience that they are having. Watching its rise and fall, noticing its intensity, quality and how it shifts as they continue to observe it.
Essentially, we’re creating new learning here is that they learned that these experiences are not dangerous, that they’re safe, even if those experiences arise. They can be with and hold these experiences without the need to avoid and move away from things that they care about in their lives. We do look at thoughts a little bit. We’re seeing them for what they are. Thoughts. We’re having people take perspective on thinking, seeing the mind as a learning critter that doesn’t unlearn. We can’t unlearn. It just learns. It adds to learning.
What I’m hoping that folks will be able to see is that they can observe the ongoing process of thinking. They don’t have to get all entangled in what their mind is saying about them as a result of the trauma. If I’m working with someone with chronic pain, your mind is going to say things like, “I can’t do it. This is impossible. How can I go on like this?” Pulling people away as with trauma from what they care about, what matters to them and meaning in life, diffusing from disentangling people from their minds in ways that help them to step forward in meaningful values-based engagement in the service of vitality, rather than in the service of happiness.
Some people might think that’s an odd thing to say. You don’t want people to be happy? I do, but we don’t walk around happy. Happiness isn’t a permanent state. It shows that if you are trying to suppress pain, you’re trying to eliminate and get rid of emotional pain that we’re not very good at targeting that single emotion and saying, “I want that one to go away so I can have all the others.” If you try to push one down, you push them all down. If you’re not willing to have emotional pain, you’re also not going to have joy. You’ve cut joy off as well. If you open yourself up to experiencing, you’re available in the moment for pain or joy, whichever one is there.
Psychologist, Ashlyne Mullen.
We tried to find postures that reflected certain ACT processes, for example, acceptance. What we had them do is think of something that they’re struggling with, try and hold it in goddess pose, a squat. Notice what’s showing up for you as you hold it and sit with it as long as you can. Go to a 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 like, “What movement do we feel embodies acceptance?” That was one example.
Yoga 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 mantra. Finding your mantra, what’s something that you can tell yourself to give you comfort and setting an intention, which was committed action and intention towards that mantra.
Physiotherapist, Mary Grant.
Living well with pain is a difficult concept, isn’t it for all of us? It doesn’t sound right living well the same. It’s a tough one. The first step is to acknowledge the patient’s journey to date, what they’ve tried already to get rid of pain and how this has worked or maybe not worked for them. What I love about ACT is using measures like storytelling to try and maybe help the patient to see that maybe there are other ways around this, that maybe it’s okay to drop trying to control the pain or get rid of the pain agenda because that can be hard for people if that’s what they want to do. You have to go carefully with that with people.
The next thing, once you’ve bought that suggestion out there that may be controlling the pain is not maybe the most beneficial way to go, maybe they’re ready to try something new. That’s where clarifying what values are for them as humans, like what and who they care about most in their lives. That’s the next big pain that can have them go on the path towards going back to what they want to do or be is different.
Psychologist, Lilian Dindo.
It’s not disease-focused or disorder-focused. It’s strength-focused. We’re trying to build on their strengths and to help them develop resilience. The term psychological flexibility is too jargony for the community, but resilience is a term people get. In a way, psychological flexibility is resilience. We help people develop greater resilience by connecting to the life that would honor the things that they’ve been through. How do you live a life that honors the people you’ve lost along the way? What do you think a fallen soldier would want? How do you think they would want you to live your life?
Do you think they would want you to withdraw? What would it look like to turn a page so that you’re not rereading the same chapter of your book? You’re opening up a new book and we give you the skills to do that. We help you recognize what are some of the challenges and behaviors that feel good in the moment but lead to long-term negative impacts. I don’t think I’ve gotten good at describing it very briefly but they get the acceptance piece. Our brain doesn’t work by subtraction. I don’t ask my veterans to try to change their memories or experiences. I try to help them build on those experiences.
Up next is Physical therapist, Mary Doyle.
I found a change for me to go from that instructor mode, “I’m the one that knows stuff. Let me enlighten you. If you know this stuff you’re going to get better.” Sometimes it would work and be okay. They would be absorbing it. A lot of times they wouldn’t. “Let me tell you about it again. Let me tell you a different way. Let me use this instead.” They still wouldn’t get it because I’m still on the other side, telling them what to do or how they should be thinking. That’s where ACT helps. It’s allowing them to get that confidence up that they can help themselves.
That’s so hard because they walk into the clinic and they expect you to fix them. They expect to be better walking out, but they have a super mistrust of the whole medical system of anything coming from the Department of Corrections. If you’re not saying exactly why you’re here, they’re not going to listen and then they’re not going to do the things that they need to do to get better. They have to be able to think of it themselves. I have to be able to guide them so that they can get there.
It’s Physiotherapist, Davide Lanfranco.
Full suppression is about anything but allowing the full to be there. Distracting yourself, watching the movies, putting the music corner, trying to think positively that belongs to these very toxic messages that are delivered by the society. Think positive, positive thoughts, positive vibes, put their way out of everything that is scary negative and that is not nice and replace it and change it with positive stuff. These toxic messages lead us to the understanding that negative thoughts, scary thoughts, anxious thoughts are wrong and must be pushed away.
When you push them away, you get their equal effect. They’ll come back even stronger. Research has shown us that suppressed thoughts are characterized by the increased return of the suppressed content. You may be familiar with the polar bear experiment I’ve done. I don’t remember in which year, in which we showed people a polar bear and then they told them to try to not think about the polar bear and it was impossible. When we tell our patients and it’s something I hear very often from my colleagues, they say to their patients, “Try to be positive things will be all right. Don’t think too much about it. Don’t stress too much. Thank you.”
If she or he could have done it, she or he would have done it already. You don’t need to tell the person to think positive or don’t stress about it or don’t worry. Acceptance Commitment Therapy and cognitive diffusion teaches us how to do this from another perspective and how to take a step a step back. Cognitive diffusion is something powerful.
People where the eye level of cognitive fusion don’t even recognize they’re having thoughts in the first instance. They think that is the truth. I have a bad back. That is the truth. It’s not even a thought that is passing through my mind. They think that is the truth. Before going and using fancy techniques and nice techniques of the Acceptance Commitment Therapy, the first step with this patient is helping them be more aware of their cognition.
Psychologist, Lance McCracken.
For any individual that we see, we’re going to have outcomes of interest. In pain management, we have some conventional ones like pain interference, disability, depression or pain intensity. That one we’ll have is a range of variables that we know are correlated with those because I’m sure if you manipulate that correlated variable, it’ll impact your outcome of interest. These links are very individual. They’re based on a person’s learning history and their situation. If you add a couple of other features to the individual and they may be bidirectional, the relationships between these process-type variables and outcomes go in both directions.
They’re dynamic, they change during treatment. They may go back and forth to strength or they may strengthen in their impact or lessen their impact. They’re multivariate, bidirectional, dynamic and individual. They are something catastrophizing, for example, something about avoidance by the same token. Something about behavioral engagement or behavioral activation. There is going to be an intentional process domain we probably need to nail down, something about awareness and attention.
We don’t have that many more. ACT is based on psychological flexibility, 6-facet or 3-dimension open and engaged model. People are interested in psychological flexibility and ACT, we’ll see evidence for these facets, but not everyone would agree with that. You have to begin to ask questions about, “What’s enough evidence to call something an evidence-based process?” That’s a little bit all over the place. There are probably some that look pretty strong, most people would agree. We’re still populating this space of evidence-based processes.
It’s over to Physiotherapist, Tom Young.
Some of what we do more traditionally, there is something seductively complex about it. All the independent regional models. “I’m going to watch you walk. You’ve got shoulder pain. Your ankle’s pronating ten degrees.” Accepting that maybe that A) It doesn’t have the best evidence to begin with, and B) Letting go of that sense of, “Maybe I’m not quite as clever as I think I am.” That’s a challenge. You acknowledge your sense of intellectual vanity and letting go of that a little bit can be a challenge and answering what you expect a patient needs. Maybe you encourage a patient to do something, and in the session, they buy it and they’re like, “This is so important to me. This is awesome.”
They have a big pain flare. You can swoop back in and try to save the day and say, “Here is what we’re going to do. We’re going to control this and back off.” That rubs people off agency. Part of that is trying to model a boldness about pain and, “You have pain, but what else came up for you? Was that some excitement when you did that thing? Was that some joy at the moment? What else was there a room for at that moment?” I’ve done the less of a win-loss there is as a frame for me. That’s what frames. Trying to fix chronic pain is like banging your head against a wall.
I talk a lot about patients letting go of that fight. As a practitioner, I also have to do that. If I’m still secretly like, “All of this is to make you have a less painful experience,” I keep on feeling lost and that’s not a battle I’m winning. To truly let go of that control for myself and be willing to model a boldness about pain is quite liberating and always bring it back to, “That happened. What else? What’s important to you?”
If you’re a practitioner and you’re interested in learning more about mindfulness and acceptance-based approaches for chronic pain, as well as other chronic lifestyle-related conditions, make sure to check out our resources over at the Integrative Pain Science Institute.