This blog post is based on an article in the August/September 2012 issue of Pain Practitioner.
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.
With the recent publication by the Institute of Medicine that as many as 100 million Americans experience chronic pain at any one time, the pressure to provide relief has escalated to unprecedented levels (1). Opiate prescriptions have skyrocketed since 1999, and we are now just beginning to see the unintended consequences: according to the Centers for Disease Control and Prevention (CDC), “Enough prescription painkillers were prescribed in 2010 to medicate every American adult around-the-clock for a month.” (2). Spine surgeries have increased fifteenfold over this same time period, yet emerging research shows that not only does the success of repeated surgeries diminish to discouragingly low levels—5% by the fourth surgery in one study—but that injured workers who forgo back surgery actually return to work at higher numbers, more quickly, and with fewer problems from opioid dependence or addiction than those who opt for surgery (3,4,5).
The difficulty with chronic pain is that, too often, it develops into a chronic pain syndrome that requires the kind of intensive interdisciplinary treatment that goes beyond the scope of most pain management practices. Psychogenic and emotional pain need to be addressed in order to help resolve the constellation of symptoms that magnify the perception of physical pain. While a busy pain management practice may not be equipped to deliver, in an integrative fashion, treatments for depression, anxiety, physical deconditioning, social isolation, weight fluctuation, sleep disturbance, the effects of litigation or unemployment, and sexual dysfunction—to name some of the key symptoms of a chronic pain syndrome—a multidisciplinary residential program brings all its efforts to bear on just those elements.
Past approaches to multidisciplinary treatment for chronic pain, especially those emerging in the later half of the 20th century, utilized psychosocial models described in the research of Turk, Gatchel, and others. In these models, cognitive-behavioral therapy (CBT) led the interdisciplinary charge with cost-efficient and positive treatment outcomes (6,7). Apart from medication management and physical therapy, counselors and psychotherapists adhered to a group therapy model to work on “top-down” methods of diminishing pain through such interventions as cognitive restructuring, problem-solving, and psychoeducation.
Slowly, over time, a mindfulness-based model for treating chronic pain, as created and popularized by Jon Kabat-Zinn, Saki Santorelli, and their colleagues at the University of Massachusetts Medical Center, has begun to filter into the wider world of chemical dependence and pain management (8). Even as the benefits of this metacognitive approach for depression, stress, and relapse prevention have become increasingly accepted through robust research, mindfulness as a means of diminishing psychogenic pain drivers has continued to be viewed as complementary to CBT (9).
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) represents an even more fully integrated approach to the top-down treatment of chronic pain syndrome. In broad terms, ACT (pronounced act) integrates cognitive-behavioral therapy with metacognitive approaches to help individuals a) unattach from rigid patterns of thought; b) accept and embrace the reality of their situations; c) explore what it is that may give their lives greater value; and d) commit through action or behavioral changes to those treasured values.
Developed over several decades by Steven Hayes, PhD, ACT has its foundations in relational frame theory (RFT), applied behavioral analysis (ABA), and the philosophy of functional contextualism (10). Essentially, ACT regards no thought or feeling as inherently maladaptive or dysfunctional—a philosophy that sets it apart from mechanistic models of the mind—but views the context in which thought functions as the key to understanding how to transform one’s relationship to “negative” hedonic states or cognitions (11). Dr. Hayes and others have provided years of research to support the use of ACT for substance dependence, mood dysregulation, and chronic pain (12,13).
In the ACT model, individuals engage in the cognitive process of examining how they become fused to certain rigid and maladaptive thoughts that inhibit psychological flexibility and close off a wider range of choices. The process of cognitive defusion opens them up both to a greater acceptance of what is and the possibilities that arise from the act of letting go of a too-limited perspective. By way of example, I was working with a 22-year-old woman with a history of chronic pain stretching back, by her report, to age five. She came into a session one day complaining that “the hospital was not giving me enough pain medications.” This thought was fused with another: “Pain medication is the only thing that makes me feel better.” No matter how I tried to reason with her about self-efficacy in pain management, she kept returning to this theme of external cure-seeking.
Finally, I utilized a typical ACT intervention: I wrote her initial thought down on one side of a sheet of paper and her second thought on the other side. I asked her to hold the sheet up to her face. I then had her turn the paper over and hold the other “thought” up. I asked her what she could see with either thought in front of her. Of course, with the paper up, regardless of the thought, her view was blocked. I asked her to put the paper down on her lap. Now she could see beyond those thoughts and we could open up a deeper conversation about how, in seeking a “cure” for her pain outside of herself, she was neglecting self-management skills that would increase her own sense of personal agency. She hadn’t pushed the fused thoughts away—they were, after all, there on her lap for her to glance at any time she wanted—but she had found a way to gain a wider perspective and become more response-able.
Cognitive defusion is only one aspect of ACT; the guiding principles of mindfulness—paying attention to the present with non-judgmental self-acceptance—help individuals cultivate experiential acceptance rather than experiential avoidance, which leads to greater depression, anxiety, and social isolation. With respect to behavioral interventions, the key element of ACT is the clarifying of values and understanding what is important to us to live lives of meaning and purpose. The same young woman, when asked what she valued, told me she wanted to be a mother and have children. I explained to her that those were goals; what was it she valued about being a mother? She responded that she wanted to be a good mother. We explored the qualities of “good” for her and she was able to identify that it was important to her to be a “loving, kind, nurturing” person. Now we had arrived upon what she valued in herself. She might never achieve her goal of being a mother but she could always make the choice to lead her life in a loving, kind, and nurturing fashion.
So what are black ducks, how does one find them, and how does this ACT intervention integrate cognitive and metacognitive approaches to pain treatment? Derived from my clinical work with chronic pain patients, the concept of finding one’s black ducks is grounded in Hempel’s Raven Paradox, which seeks to demonstrate the limitations of inductive reasoning (14,15). Clients are told a story of how in Medieval Europe everyone believed, based on observation, that all ducks were white. Discovery of a single black duck, however, created a paradigm shift in this false system of belief. For chronic pain patients, a black duck may be a moment of spontaneous laughter in which all thoughts of pain are forgotten. This unique outcome offers up the recognition that by engaging fully in a present-centered activity, experience is accepted, thoughts are restructured, and suffering gives way to a life of greater meaning and purpose. Patients are encouraged to become “farmers” of black ducks and to nourish their ugly ducklings so that they may grow into beautiful swans (e.g., they begin to commit to valued actions). Those moments in which they have coped successfully with pain (or cravings and urges) serve, ultimately, as internalized reminders that nothing is permanent and that black-and-white thinking can be replaced by greater psychological and emotional flexibility.
Seeking the black ducks in our lives is but one of many ACT metaphors that illustrate the concepts of non-judgmental self-acceptance, presence, cognitive restructuring, un-attachment from suffering, and greater self-efficacy through generating creative and flexible responses to new stressors. In this sense, ACT belongs in the pain-management tool bag as a unifying bridge between cognitive and metacognitive approaches to treatment; it provides the pain practitioner with a solid evidence-based therapy that addresses not just the chronic pain but the whole person.
- Institute of Medicine Report from the Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. Washington (DC): The National Academies Press; 2011. http://books.nap.edu/openbook.php?record_id=13172&page=1. Accessed July 9, 2012.
- Centers for Disease Control and Prevention, Vital Signs. Prescription Painkillers Overdoses in the U.S. [online]. November, 2011 http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html. Accessed July 29, 2012.
- Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA. 2010;303(13):1259-1265.
- Ragab A, Deshazo RD. Management of back pain in patients with previous back surgery. Am J Med. 2008;121(4):272-278.
- Nguyen TH, Randolph DC, Talmage J, Succop P, Travis R. Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects: A Historical Cohort Study. Spine. 2011;36(4):320-331.
- Turk D. Clinical effectiveness and cost effectiveness of treatments for patients with chronic pain. Clini J Pain. 2002;18(6):355-65.
- Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain, J Pain. 2006;7(11):779-793.
- Kabat-Zinn J. Full Catastrophe Living. NY: Delta Press; 1991.
- Tan G, Craine MH, Bair MJ, et al. Efficacy of selected complementary and alternative medicine interventions for chronic pain. J Rehabil Res Dev. 2007;44(2),195-222.
- Hayes SC, Barnes-Homes D, Roche B. Eds. Relational frame theory: A post-Skinnerian account of human language and cognition. New York: Kluwer Academic/Plenum Publishers; 2001.
- Harris R. ACT made simple. Oakland, CA: New Harbinger Publications; 2009.
- Wilson KG, Byrd MR. Acceptance and commitment therapy for substance abuse and dependence, in Hayes SC, &Strosahl KD, Eds. A Practical Guide to Acceptance and Commitment Therapy, pp.153-184. New York: Springer Press; 2004
- Vowles KE, McCracken LM. Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. J Consult Clin Psychol. 2008;76(3), 397-407.
- Singer JA, Singer BF, Berry M.. A Meaning-Based Intervention for Addiction: Using Narrative Therapy and Mindfulness to Treat Alcohol Abuse, in Routledge, C. and Hicks, J. Eds. The experience of meaning in life: Classical perspectives, emerging themes, and controversies. New York: Springer Press. In press.
- Hempel, C. G. Aspects of Scientific Explanation, New York, NY: Free Press; 1965.