Fresh
data on ACT and RFT seem to be surfacing almost continuously these days. In
this edition of our newsletter, we are especially intrigued by a forthcoming article
on the use of ACT with children experiencing chronic pain.
One
of the distinctions that we often make as ACT therapists with our clients is
that between pain and suffering. While pain is regarded as the direct result of
difficulties in our lives, whether it is a physical ailment or natural response
to life challenges, suffering is the indirect result of being a verbal human
being who compares, evaluates, and struggles with our pain. Much of ACT
treatment involves teaching clients to cultivate a different relationship with
their suffering. A new study by Rikard Wiksell, working with adolescents with
physical ailments, suggests that ACT can be a useful treatment for changing
one’s relationship to chronic pain as well. Dr. Wiksell compared ACT treatment
with a multidisciplinary treatment approach that included an antidepressant,
and found that children receiving ACT had better outcomes not only in their
psychological functioning, but their physical functioning as well. In fact,
these better outcomes were still significantly better than the
multidisciplinary treatment at a 7 month follow-up. Although these children had
physical problems, their physical and psychological suffering decreased via the
exposure-based processes in ACT. Arguably, acceptance, defusion, and commitment
to valued activities increased the quality of these kids’ lives.
A
growing body of literature suggests that chronic pain is a substantial problem
among children, and that these children are at risk for continuing problems
into adulthood. Most of the research has addressed means of reducing pain and
distress, and CBT is an established treatment for this condition, although the
body of supportive data is relatively small. ACT views experiential avoidance
as the key measure in human functioning, rather than the presence or absence of
pain. This pain can be psychological or physical. More specifically, the ACT
model suggests that efforts to control, minimize, and avoid unwanted thoughts,
emotions, and sensations leads to excessive time focusing on pain and less time
building upon the quality in one’s life. ACT treatment builds competency in
accepting one’s experience while engaging in valued activities as the
alternative to this control agenda.
Wisksell
and his colleagues provided ACT treatment to 16 children coping with chronic
pain and compared outcomes to 16 children with chronic pain who received a
multidimensional treatment package at a children’s hospital. This
multidimensional treatment included amitriptyline, an antidepressant. Children
were assessed pre-treatment, and the conclusion of treatment, and approximately
3.5 and 7 months after treatment. The assessment package included various
measures of daily physical functioning, pain intensity, and beliefs about
impairment due to pain, and psychological well-being. Treatment was provided
individually on a weekly basis. ACT treatment lasted roughly 4 months while the
multidimensional treatment lasted somewhat longer.
The
results showed improvements in all measures for both treatments, and most
revealed large effect sizes. Furthermore, the ACT condition consistently
produced significantly better outcomes than the multidimensional treatment. On
a more qualitative note, the authors point out that the ACT treatment was of
shorter duration and may have cost substantially less than the alternative.
Given that this treatment reduced reports of pain and increased reports of
quality of life, these data strongly suggest that ACT is a viable and promising
treatment for chronic pain among children.
Clinical implications
Many
of us may have clients struggling with health problems on top of the
psychological struggles that they present in therapy. Chronic physical pain and
health problems can be exacerbated by experiential avoidance and fusion, just
as can psychological pain. If you are interested in applying ACT in the realm
of chronic pain, there are a number of ACT books and workbooks that cover these
topics. Here are three:
Citation: Wicksell, R. K.,
Melin, L., Lekander, M., & Olsson, G. L. (in press). Evaluating the
effectiveness of exposure and acceptance strategies to improve functioning and
quality of life in longstanding pediatric pain – A randomized controlled trial.
Pain.
Self as context is the concept that we are not the content of our experience -- we are not our thoughts, our feelings, our experienced sensations, the things we see, or the images that pass through our heads. Through exercises and metaphors, we can contact a transcendant sense of self that is more like the context,
perspective, or arena where life happens. In ACT, this self as context is contrasted with self as content, or the stories and thoughts that we have about ourselves, our identity, and our history.
In fusion with self as content, we lose the distinction between ourselves as the experiencer of life and the thoughts and stories that we tell about our lives. We would never get ourselves confused with the chair we sitting on or something that we are looking at, but when it comes to noticing that we are distinct from our own thoughts, it becomes much harder to take the observer position and to see the distance between our selves and our thoughts.
In ACT, people are trained to be more aware of this sense of self through a variety of exercises, several of which are relatively lengthy. However, these exercises can be quite brief. This is discussed to some extent in the book Learning ACT .
Today I stumbled upon an idea for an exericse that could create an experience of self as context. It came from an exercise by Eckhardt Tolle (not really a big fan of him, but I liked this exercise) that I modified to be more consistet with an ACT perspective and more focused on self as context specifically.
Here's the exercise (as I modified from the original):
Stop and silently listen to what you are saying to yourself, to the voice in your head. Once you are listening closely, ask yourself the following two questions:
Am I the thoughts that are going through my head?
Or, am I the one who is aware of these thoughts that are going through my head?
In this exercise, our job with these questions is not to answer them, but rather to sit with the question and wait, aware, and see what shows up. This is not about creating more thoughts, but creating a new awareness where we are aware of the distinction between ourselves and our thoughts. The point of the exercise is not to create belief in a new sense of
self, but to develop the ability to step back from thoughts, to observe
them with less entanglement.
If I were doing this in session with a client, I would probably debrief the exercise after I did it with them. Or I might give it as something to practice several times over the week between sessions and have them journal a bit about reactions to the exercise after they did it. Or I might record the exercise on my mobile phone using Drop.io and send a copy of the MP3 to a client to use in practice.
Perhaps you might try out the exercise yourself, right now and let me know what you think of it.
The Hexaflex Dimensional Approach to Diagnosis and the ACT ADVISOR Psychological Flexibility Measure are both relatively new iterations of the Hexaflex that have exciting applications for ACT clinicians. Let's take a look at them...
