Chronic pain is often defined as any pain lasting more than 3 months, and may arise from an initial injury, an on-going illness, or no clear cause. The change and suffering wrought from chronic pain could fundamentally interfere with our sense of who we are. Chronic pain sufferers often struggle with their sense of self, feeling “this is no longer me”.

Psychological approaches have been applied and deemed effective in improving psychological and daily functioning for people with chronic pain. A recent advancement in this path is the development and application of Acceptance and Commitment Therapy (ACT). The underlying framework of ACT is a small set of psychological processes, called Psychological Flexibility (PF).

PF is often summarized as  “open, aware, and active:”(1) willingness to experience unwanted feelings and thoughts, (2) awareness of events in the present, and (3) actions guided by goals and values. For example, instead of lying in bed to avoid pain and fears, a chronic pain sufferer acting with high PF may choose to go for a gentle walk with their partner in the presence of their pain and fears, directly experience all of the feelings of the walk, and perform it with a sense of purpose, because spending quality time with their loved ones is what they regard as important.  ACT is designed to improve functioning through fostering PF. In ACT, thoughts and feelings are not a problem, unless they dominate our behaviours and limit our choices at the expense of our goals. Therefore ACT does not predominantly attempt to change the content of thoughts and feelings, but to reduce the influence of thoughts and feelings on behaviour. Non-verbal experiential exercises and metaphors are commonly used in ACT. There is accumulating evidence in support of the effectiveness of ACT in chronic pain among many other conditions. A recent review summarised evidence from 10 randomized control trials. In the trials reviewed participants were randomly assigned to ACT treatment or control group, and PF processes and treatment outcomes were compared between the two groups. The data suggested that participants in ACT group showed significantly higher level of PF, as well as better physical functioning, higher level of life satisfaction, and lower levels of pain, disease impact, depression, anxiety, and distress.

ACT has a particular focus on sense of self. ACT views the self in two senses: a sense of self-as-content and a sense of self-as-observer. Simply put, self-as-content is “who I think I am”, our self evaluations, and the content of our thoughts and feelings related to our selves, our qualities, roles etc. Self-as-observer is a transcendent sense of self that is free of these contents as defining elements. Metaphorically speaking, this is like stepping back from your thoughts and feelings and taking a perspective, to observe these, or being above your thoughts and feelings. It is like you are the stage where your thoughts and feelings occur, or the container that contains your thoughts and feelings. In ACT self-based therapeutic techniques are used to facilitate an experience of this transcendent sense of self.

Our minds are never tired of judging us and telling us who we are. And we are so used to experiencing what our minds say as an accurate reflection of the situation we are in and following it. But do we have to? How would it be if we carry these judgments as blemishes, wrinkles, and dimples on our bodies, and keep walking in the direction that takes us to where we want to get to?

Lin Yu and Lance M. McCracken
Health Psychology Section, Psychology Department, King’s College London, Guy’s Campus, London, UK

Publication

Model and Processes of Acceptance and Commitment Therapy (ACT) for Chronic Pain Including a Closer Look at the Self.
Yu L, McCracken LM.
Curr Pain Headache Rep. 2016 Feb

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