Digging Deeper

When it comes to psychological therapies, it can seem like there is a lot of choice- with not much clarity – about what works for which condition and for which type of person. Also, all therapies have been shown to be roughly as effective as each other. This makes sense when you think about how different people are in their approaches to life and their problems; so too will different types of therapy will work for individuals and be favoured by different therapists, who are also individuals. The important question is, how do you know if ACT is for you? Hopefully by reading the following article will answer some of your questions about ACT and whether you will want to find out more. Or maybe you have previously tried a therapy that has not worked for you because you found yourself always saying “yes, but…”.

Acceptance and Commitment Therapy (ACT) is called a 3rd wave Behavioural Therapy, meaning that it comes from the same school of therapies as Cognitive Behavioural Therapy (CBT), known as ‘2nd wave’. These therapies developed from the original Behaviour Therapy, and they consider behavioural change to be fundamental in changing thoughts and emotions that are causing someone distress. CBT was developed in its current form in the 1960s, combining behavioural therapy and cognitive therapy, where the interaction between thoughts, feelings, behaviours and physical sensations was seen as being the driver for maintaining psychological distress.

Most of the evidence base supports CBT for chronic pain, as CBT lends itself easily to outcome studies and so most research happens with CBT. CBT recognises that someone’s thoughts (their interpretation) of a situation influences their feelings about that situation and eventually their behaviour within it. Naturally, their physical sensations (meaning primarily their physical sensations of anxiety, depression, craving, pain etc) and emotions affect their thoughts. Psychological difficulties are therefore seen as arising from vicious cycles that arise.

CBT views a person’s thoughts and feelings as contributing to their suffering with their pain, and helping to reduce the negative impact of pain on their lives. The following diagram shows how the thoughts, emotions, sensations and behaviours in response to pain feed into each other to make it all worse. For example, the pain causes a person to have negative thoughts about themselves, their abilities and their future. This leads to feelings of anxiety (e.g. about what the pain means) and sadness and frustration (e.g. at all the things they cannot do as a result of their pain). Worry about damage causes them to reduce activity levels, or frustration at reduced activity levels causes them to overdo activity leading to a crash. A flareup of pain causes a sense of hopelessness, and reinforces beliefs that the pain is in control and that whatever they try, the person cannot continue their life as they want with their pain. You can see how each part of a person’s thoughts, feelings, sensation and behaviour interlink and feed into one another:

CBT tries to identify thoughts and behaviours that contribute to someone’s distress. By challenging these thoughts and teaching coping skills to change behaviours, reducing pain behaviours and increasing healthy behaviours, people can improve their mood and set up more positive cycles of thinking and feeling. Challenging thoughts means identifying the common thinking errors that may be present, and learning to weigh up the evidence for a more “rational” response to a situation.

CBT uses education about pain mechanisms and coping skills training to improve a person’s sense that they can manage their pain. By learning about pain mechanisms and how to pace oneself people learn how to gradually increase their activity levels and improve fitness. Other coping strategies include distraction, relaxation and social skills training. People learn to challenge their own assumptions by trying “behavioural experiments” where by gradually increasing activity, they test whether it increases their pain or not.

By learning to recognise their negative thinking patterns and to use more helpful coping strategies, people learn to feel more able to manage their pain. Goals of CBT are to improve physical fitness, improve assertiveness, increase pain coping skills and teach people how to adapt activities to be possible with their pain.

Research shows that CBT is effective in helping people with a wide variety of psychological difficulties as well as with chronic pain. It has shown that people become more able to cope with their pain, to reduce the distress they feel in response to it and to increase their sense of how well they are able to cope. They have also proven increased activity levels which has a positive impact on their mood.

However, CBT has some shortcomings, particularly when it comes to chronic pain. Firstly, whilst thinking errors may be present, often negative thoughts about pain are perfectly reasonable. Trying to challenge these thoughts can mean we get caught up in arguments that go round and round. This can happen within the individual themselves, but also between the individual and therapist, which means that therapy can start to feel unhelpful. CBT tries to get someone to think their way out of the problem, and focuses on their being a problem that we need to get rid of. As we have seen with the article on control (see David Craig’s article on “Trying to control pain and the problems this brings”) when it comes to pain, control itself can be the problem!

ACT takes a completely different approach to chronic pain. It understands that pain hurts, but sees the struggle to avoid and control it brings the most suffering to a person’s life. Therefore, it does not focus on the pain itself and trying to reduce it, or even how to cope with it. Instead, ACT looks to build a person’s psychological flexibility to allow them to focus their energy and attention on what really matters to them. ACT looks at accepting the presence of distressing thoughts, feelings and physical sensations in order to allow the person to pursue life activities that matter to them, and that their pain and efforts to control it have taken the person away from. In the ACT approach, people reconnect with their own values, which becomes their own motivation for behaviour change.

Observing thoughts and feelings as they are, without trying to change them: this lines up with chronic pain. The pain sensations are not signals of ongoing damage, but will continue to be present, as will the sadness and frustration as a result of the presence of these symptoms. ACT asks you to stop fighting these facts, as these reactions are not errors of judgement but completely normal and understandable reactions to the pain. Focusing on the pain and trying to control / reduce / avoid it just leads to other problems and that vicious cycle. ACT teaches us to allow the presence of the pain signals and focussing on living a life that matters to someone.

ACT still sees thinking as an important contributor to distress, but it looks at the thinking process itself as the issue. Rather than getting caught up in arguments with the thoughts themselves, and indeed with the pain itself, ACT teaches people to learn to let these thoughts go and to refocus their attention on what they are able to change. Have you even noticed that the more you argue with your thoughts the more powerful they get? This is because the more attention we give something, the more it grows. ACT tries to refocus our attention on our values, what is important to us, and putting our energy more into this so that it is our enjoyment of life that is fed by attention and grows.

ACT teaches skills to strengthen a person’s psychological flexibility rather than to try to break down the problem. This means to learn how to bend around a problem to still allow you to move in the direction you want to go in. Perhaps with modifications considering the presence of the pain and the limitations that imposes. These skills can be divided into three categories.

With mindfulness skills helping people to pay attention to the present moment and to accept their sensations, thoughts and feelings for what they are (Read David Craig’s article “Mindfulness and Chronic Pain”). To learn acceptance to allow those to be ‘present’ whilst engaging in what matters. Learning what does really matter and goal setting and committing to activities that are in line with this, see article entitled, “If I’m not trying to control my pain, what am I suppose to do?”.

Why you should try this approach when previous therapies haven’t worked?

There are many more types of psychological therapy, which again will offer different approaches to peoples’ difficulties. Different therapies will focus on different aspects of the person, their relationship, their histories. Some will be more focussed on how a person relates to those around them as a result of how they related to their early attachment figures (usually parents). Others will look at exploring repeating patterns in reactions and how to identify those and change them. Others again look at a person’s social network and how their interrelationships can contribute to difficulties. We have chosen ACT for this program because it provides people with the space to explore their feelings as well as discover concrete coping skills to help them manage their practical difficulties as well as the emotional ones that are caused by chronic pain.

ACT does not focus on why you became stuck in the first place and what it was about your history that meant you became stuck. It is not that we as ACT therapists are not interested in that or think that you should not be, but more that in our experience, by the time someone is coming for ACT therapy, they have tried exploring their problems and the root of their problems only to find themselves more stuck in their problems! We concentrate more on learning how to look at your situation in a different way so we can focus on doing more of what is helpful to you, rather than focusing on what’s not helpful and trying to change that.

CBT may also use techniques such as acceptance, mindfulness, defusion and exposure, but they will be used alongside a variety of other techniques all linked to the hope that pain will reduce or be better managed as a result of their use. In ACT acceptance, mindfulness, defusion, and exposure are never linked to pain management, reduction, or coping per se. Instead, they are used to enhance a vital life.

In summary, the ACT model differs from traditional CBT in its focus on moving toward a vital life rather than on pain management.