Acceptance and Commitment Therapy (ACT) and persistent pain

What is Acceptance and Commitment Therapy (ACT)?

ACT is a therapeutic approach developed by Stephen Hayes and colleagues (Hayes, Strosal & Wilson, 1999), and is part of the ‘third wave’ approaches of Cognitive Behaviour Therapy (CBT).  In a nutshell, ACT is about living a valued life even in the presence of difficult thoughts, feelings and emotions.  It is summed up nicely in the hexaflex outlined below – but boils down to

  • Open up (to difficult thoughts, feelings and sensations – rather than avoid them)
  • Be here now (cultivate a sense of here and now awareness – not caught up in the past or the future) – can I notice the moment to moment changes in my painful body and painful thoughts and feelings?
  • Do what matters (lead a values led life)

At the very core of all of this is enhancing ‘psychological flexibility’.  I have read that Stephen Hayes would not use the word ‘Acceptance’ if he was to develop ACT now, because of the difficult connotations of that word, but more on that later.  Excitingly, it was included in the recently updated NICE guidance for chronic pain for the first time (April 2021) – a confirmation of its usefulness with people with persistent pain.

The ACT Hexaflex

Why is ACT helpful for people with pain or other difficult health conditions?

At the start of my career I spent a few years working as a clinical psychologist in a palliative care service.  I was finding CBT, something I had been well schooled in throughout my doctoral training, a little lacking.  How do you help people face the end of life whilst encouraging them to restructure ‘maladaptive thoughts’?  They were dying, lots of painful thoughts and feelings were showing up.  I discovered ACT, which sat so much better with people with long term health conditions.  The goal of ACT is not to get rid of pain, loss or overwhelming emotion. (This can sometimes be an unpopular moment in the therapeutic conversation). However, there is good news; you will learn how to change your relationship with pain.  Often, this starts with a little ‘creative hopelessness’ – often people have tried All. Sorts. To. Get. Rid. Of. Pain.  Once we explore how sometimes the medications, surgeries, injections, avoidance and self criticism have not got rid of the pain, – ‘a place where new possibilities for changing your life arise’ (Dahl and Lundgren, 2006).

It’s not the pain itself, but the response to pain which becomes painful

Not only can pain that has persisted for a long time be painful, but then our response to that pain can become painful too.  What do people lose as a consequence of pain?  Relationships, jobs and things that are meaningful?  Opportunities?  A future you had hoped for without pain?  A young woman I am currently working with summed this up tearfully recently.  ‘It started as a physical struggle, now it is a mental battle.  The pain isn’t even that bad today, but I am broken inside’. 

Acceptance?  Of pain?  What the hell?

One of the aims of ACT is to reduce ‘experiential avoidance’ – something we all do to a degree – to feel unwilling to remain in contact with a painful event.  Acceptance is a difficult word when it comes to pain.  Why would you accept it?  Doesn’t that mean giving up, giving in or resigning yourself to a life of misery?  On the contrary.  To open up, engage with it and stop fighting with it can feel empowering and freeing.  It’s a little counterintuitive – like lying in quicksand – if we were stuck in quicksand, we would be inclined to fight, struggle and get further stuck in the quicksand.  Top tip – lie down in the quicksand.  It prevents the fight – struggle – stuck cycle!  Pain does not need to equal suffering…’what we resist, persists’.

How do you ‘do’ ACT?

One of the many wonderful things about ACT is it is incredibly experiential.  When we do something different, try these things out maybe alongside our clinician, we are more likely to remember and act on them than just talking about doing them.  There are lots of metaphors used in ACT, one of my favourites is the Passenger on the Bus (see here for a recent post of mine on LinkedIn – we made a video a few years ago of ‘graduates’ of a pain management programme – every single person mentioned the bus).  Can we open up to the experience of pain?  Allow it to be there, for now?  We cannot change the weather, but we can learn skills to handle the storm.  This is incredibly empowering for people who have been drowning in a sea of pain.

Can we really think about who we are and how we want to show up in this life?  How do I want to be as a friend, partner, parent, employee, member of a community, etc?  What is truly important to me?  Then can we take committed action, to act in line with these values, despite the pain?

ACT can also be pretty fun – trying out new skills with playfulness and creativity.  Have you ever tried singing, rapping or saying a painful thought in a silly voice?  This is one of the many ways of ‘unhooking’ from those painful thoughts, feelings and sensations, which we get snagged in.

How does it pair with pain science?

We know that modern pain neuroscience is showing promising signs for persistent pain, that we can be hopeful that pain can change for some people.  However, it is not a quick fix, and supported self management, and reducing our feelings of danger and threat are paramount.  ACT is a perfect companion to this research. I was fortunate enough to attend intermediate and advanced training with the fantastic Russ Harris in 2015. All of the clinicians at Retraining Pain are ACT trained, and use this model centrally in their practice.  It is important we use this model skilfully – it is not about minimising, dismissing or making fun of people’s difficult experiences.  To read more about how psychologists can help people with pain, and how a multidisciplinary team can help, see our earlier blog posts here and here

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