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Acceptance & Commitment Therapy for Persistent Pain

February 17, 2016

Anybody who has been in significant, lasting physical pain will attest to the fact that the pain becomes a primary focus point around which everything else revolves. From an evolutionary psychology perspective, this makes complete sense - human beings evolved to respond to pain sensations by moving away from the source of the pain. You touch a hot stove; you move your hand away from the stove.

With chronic pain, however, the same mechanism used for acute pain (i.e. the removal of the source) is ineffective, as the source of the pain comes from within the body. Many people who live with chronic pain fall into depression and lethargy, spending most of their time and energy trying to get rid of pain that simply will not go away. Spending all of their resources on this ultimately unbeatable goal, they have little time and energy left over for things that would increase their quality of life - things like parenting, love, pursuing passions, community involvement, friendships, exercise and work.

Here, there is an underlying belief: “I will not be happy or be able to live my life the way I want to until I have gotten rid of my pain.”

This belief is echoed in today’s medical 

culture – modern medical treatment for chronic pain (i.e. muscle relaxants, pain killers, and even antidepressants) seek to reduce pain sensations in the body, though they are generally ineffective when it comes to chronic pain. In fact, in 2000, van Tulder et al. published a study, run by the Swedish government, that found that the

treatment that would give the most benefits to chronic pain patients was nothing at all. These medicines target the pain symptoms and so temporarily relieve them, but they often have side effects that limit the patient’s ability to engage in vital life activities. When the medication wears off, the patient ends up exactly where they left off, with nothing better to show for it, reaching for another pill.

It is no wonder that many people who end up on these types of medicines for the treatment of chronic pain end up with substance abuse problems, often accompanied by depression.


Acceptance and Commitment Therapy (ACT), a mindfulness focused, modern form of cognitive behavioural therapy, posits that pain (physical, emotional, or otherwise) is an inevitable part of human life. Everybody will experience pain at some point in his or her life. Yet, the modern Western world has come to the conclusion that it is not acceptable to feel pain.  It is only in the past several decades that the medical community has had such an extreme focus on pain control and reduction. Dahl and Lundgren explain, “when pain was unavoidable, we tolerated it. When pain became avoidable, it become intolerable. What we have created with our pain killers and pain management strategies is an intolerance and increased sensitivity to pain” (Dahl and Lundgren, 2000).

So, we know that pain is unavoidable, especially within the context of chronic pain (by definition, pain that persists or recurs for a long period of time). In fact, this pain is a natural part of the body healing itself from the trauma that caused it. What ACT sees as avoidable, and completely within our control, is a second layer of struggling that we add to our pain when we struggle with its existence.

 

 While pain hurts, it is the struggle with the pain that causes us to suffer. In ACT, we refer to the pain as clean discomfort – a normal, unavoidable aspect of life as a human being, and we refer to suffering as dirty discomfort – the discomfort that we add on top of the pain we already experience through the stories we tell ourselves about it, and the negative thoughts and feelings about the pain on which we focus our attention. When we continue to strive to control and reduce pain that cannot be controlled or reduced, these efforts become maladaptive. To put it simply, we only have so much time and energy to use as resources for our lives. Time and energy spent trying to change something that is ultimately unchangeable is time and energy that could have been spent engaging in vital activities that add to our sense of meaning, purpose and well-being.

ACT teaches chronic pain patients to observe those thoughts, feelings and body sensations as they are with a sense of openness and curiosity. From this mental space, which ACT refers to as “the observer perspective”, chronic pain patients begin to see that we are so much more than our pain, our thoughts, our stories, our beliefs, and our feelings about the pain. They begin to tap into a sense of self that transcends those experiences, and from this place, the content of thoughts are taken less seriously. This is extremely useful when clients have underlying limiting beliefs such as, “I will not live a whole and satisfied life until my pain goes away.” They become able to have these thoughts without buying into them, and start to exercise their ability to choose to engage in vital activities instead.

Acceptance of pain is also linked to lower self-rated pain intensity, less depression and anxiety, better work status and greater physical and social ability (McCracken, 2004). Clients learn to accept the pain that is there - not because it is something that they want to be there, but because by stopping the obsession with getting rid of the pain, they open up doors to other engagements in their life that they care deeply about.

The more that we attempt to avoid pain, physical or otherwise, the more controlled and limited our lives become. ACT teaches people with chronic pain to focus their attention on that which they can control, which has positive outcomes for life satisfaction, well being, purpose, achievement as well as overall pain reduction.

 

 

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