ABCs of ACT: Applying Acceptance & Commitment Therapy to Chronic Pain Syndrome

In 1994, the International Association for the Study of Pain pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage,” and this has become the accepted of pain. As a psychologist, my attention to this has always been drawn to the phrases “emotional experience” and “potential tissue damage,” as these speak to the underlying cognitive perceptions that magnify actual physical pain.

Many people living with chronic pain have suffered spiritually and emotionally, which can increase pain catastrophizing and magnification. They have a chronic pain syndrome, which is a biopsychosocial phenomenon that impacts up to 25 percent of all individuals experiencing chronic pain.

Chronic pain syndromes typically do not respond to standard pain management treatments, in part because those treatments focus on physical symptomatology while neglecting underlying cognitive and emotional issues that sustain pain and suffering. In 1999, Eccelston and Crombez defined chronic pain as an “inescapable fact of life: Pain will emerge over other demands for attention. … Chronic pain can usefully be defined as chronic interruption by pain.” This interruption is to quality of life. How then do we as clinicians help our patients find their paths again?

Grateful in spite of pain

Helping individuals cultivate gratefulness to change their relationship to physical pain from one of emotional suffering to acceptance has been the heart of my work.

My work with chronic pain patients has been, for me, a constant lesson in the power of gratefulness. Helping individuals cultivate gratefulness to change their relationship to physical pain from one of emotional suffering to acceptance has been the heart of my work. At times, in truth, it has not been easy. Why, I am often asked, should a person with years of debilitating pain find anything to be grateful for? And how can gratitude be an effective tool for pain relief?

Not all ducks are white

Long ago in Medieval Europe, so the story goes, all ducks were white. Or so everyone believed.  White ducks filled the rivers and the ponds. They paddled on lakes and migrated overhead. Naturally, people assumed that if you saw a thousand white ducks, all ducks were white.  This is what we call an example of inductive reasoning.

For most of us, whether we are suffering from depression, stress, addiction, or pain, it may seem that all our ducks are white; that is, our current problems seem like they will never end and happiness or personal fulfillment will always be out of reach. We sink deeper into a kind of demoralized despair, isolating ourselves from our friends and family, maybe even turning to drugs to numb the awful thoughts and feelings we can’t escape.

Acceptance and Commitment Therapy for Chronic Pain

We had just sat down to begin a group on cognitive restructuring as a tool for pain management when a chronic back pain patient of mine–let’s call him Stu–shot up a hand to catch my attention. Bubbling with excitement, he announced to the group that he had just had a “black duck” moment. “I was outside at the footbridge staring down into the water at the trout. I felt a breeze, looked up at a huge puffy cloud crossing the sun, and all of a sudden I realized that I was completely at peace, completely relaxed. And at that moment, I didn’t have any pain.”

The group received this news with applause and I felt a certain satisfaction knowing that the intervention I call “finding your black ducks” had begun to take root within Stu. There was no question his pain would come back–he was a chronic pain sufferer after all–but he had come to recognize that he could never again tell himself, as many people with chronic pain do, that he was in constant pain 24/7.

Transforming Fear

Fear is an emotion aroused by the perceived threat to one’s safety and well-being, and it is one of the greatest obstacles to recovery from chemical dependence. For those still in the contemplation stage of change, fear might surface not just with respect to anxiety surrounding the physical pain of withdrawal but as the dread of judgment, punishment or rejection by others. Individuals driven by the fear of losing control (e.g., being powerless) believe they must avoid such natural human feelings as anger, grief or loneliness.

As G. Allan Marlatt, PhD has pointed out in his work on mindfulness-based relapse prevention (MBRP), addiction is a learned response built on both positive and negative reinforcements. While the (initial) pleasure in getting high or intoxicated acts as a positive reinforcement, sustained use is maintained through aversion to fear as the user seeks release from the pain, anxiety or depression associated with the crash or withdrawal from a substance.

A Mindful Recovery

It is 1 p.m., and just as I have done every Tuesday for the past eight months, I press the magnetic strip of my ID badge against the black plastic sensor outside the locked double doors of the Detox East Unit at Tarzana Treatment Centers. The locks click, and before the alarm sounds, I push open a door and find myself facing a long, ragged line of detox patients. Most are strangers to me, having arrived here within the past week. They look tired or restless as they eye me curiously.

“Are you taking us to the canteen?” one of them asks hopefully. “Nope,” I reply. “I lead the stress management group.” This is met with some grumbling, but one patient who has been here for a month on a methadone detox shakes her head and smiles. “So are we doing a tangerine meditation this week?”