My name is Melissa Canter, PsyD, and I am currently the Secretary of AAPP. I was tasked to complete AAPP’s second newsletter post on a pain-related topic and have been told not to include a current recipe, horoscope readings, or favorite dinner spot of the steering committee members. On a more serious note, I am proud and humbled to be a part of this organization, and proud of our mission: AAPP is a place to educate, network, advocate, and share information regarding the practice and study of pain management. We also strive to provide a place for pain providers to connect.

Those of us lucky enough to find our way into this field are, I believe, a part of a shift in the way society and medicine understand and treat individuals with chronic pain. There is more awareness regarding the challenges of treating chronic pain and the need to add pain psychology into the fold. I believe that most providers and patients would agree that chronic pain involves an interaction of biological, psychological, and social factors, and that a multidisciplinary team is critical for effective treatment. Pain psychology is a key component of that team. The need for behavioral-health approaches to treating chronic pain is now referenced in CDC guidelines as well as the US Department of Health: Pain Management Best Practices report, just to reference a few relevant guidelines. You can find this report in the reference section, below.

AAPP works hard to offer up-to-date, live and virtual educational talks, which strengthens our ability to do this important work. I hope this newsletter provides additional information, or, at the very least, provides the means to distract you from your busy day.

As a pain psychologist I use a variety of treatment approaches in my individual and group treatments (e.g., CBT, interpersonal psychotherapy, attachment theory, etc.). Sample treatment goals for psychosocial interventions include decreased catastrophic thinking, decreased fear-avoidance behaviors, decreased depression and anxiety, decreased disability beliefs, a shift from external to internal locus of control, and increased acceptance of chronic pain. Acceptance and Commitment Therapy (ACT) is one of the evidenced-based treatments for the disease of chronic pain. Many mental health professionals are familiar with ACT as it applies to depression and anxiety. This therapy has been studied in multiple psychiatric populations, but why is ACT helpful for the treatment of chronic pain? Other treatments, like CBT, don’t focus on acceptance but rather management and reduction of pain. ACT is not a symptoms reduction model, and accepting chronic pain is a hard pill to swallow. Many patients would literally rather swallow a hard pill or endure a painful procedure, if it meant lessening pain. These treatments can be done passively and with a bit of avoidance of the experience of pain itself, which is completely understandable. However, pain is part of the human journey. It will be near impossible to escape this journey without pain. With that being said, we can learn to move along the acceptance of pain continuum instead of resistance of pain.

ACT uses the following math equation to teach this concept:

Suffering = Pain x Resistance

This equation means that the more we resist pain, the more we tend to suffer. Resistance in the medical model manifests as frequent and multiple doctor visits, or unnecessary procedures and medications, all with the intention of trying to stop the pain. I’ve known patients to travel to different states to find a doctor who can “cure” pain, which leads to more disappointment and pain in the long run. As my AAPP colleague Dr. Chris Gilbert put it, people tend to “fight” pain with grim determination as if it’s an aggressive enemy that must be vanquished. Pushing and searching for a medical solution, as if that’s the only possibility of relief, is a major form of resistance. That said, it’s also totally understandable given that most pain sufferers have been taught that pain is biomedical and have never even heard of the biopsychosocial model.

It is my goal to help people reduce the suffering component of the equation by understanding its opposite form:

Wellbeing = Acceptance / Pain

“Acceptance” doesn’t necessarily mean “accepting and doing nothing about the pain.” In ACT, it means embracing the difficult task of acknowledging the reality of pain and medical diagnoses while pursuing valued life activities in the presence of pain. This requires a willingness to remain in contact with the active experience of life, including both good and bad experiences. For example, ability to appreciate the small things in life (e.g., daughter’s smile) which may have missed in the past.

The ACT approach to pain involves two fundamental concepts. First, we strive to accept any aspects of pain that we’ve not yet been able to change, including the difficult thoughts, feelings, and bodily sensations that come with pain. Second, acceptance allows us the freedom to commit to acting in ways that make us feel vital and energized. In other words, we can now put energy into the things that we care about instead of devoting energy toward resisting pain. This concept does not mean giving up hope of a better life; however, it does mean continuing to actively engage in meaningful activities while in pain rather than avoiding and withdrawing. Engagement in activities that are meaningful can lead to pain reduction and increased quality of life (what a great side effect)!

ACT incorporates a technique called cognitive de-fusion, which is un-fusing, or detaching, from thoughts. This concept enables us to create some space between who we are and what we think and emphasizes that we are not our thoughts. This involves a willingness to let go of attachment and over-identification with thoughts. When people are fused with thoughts, their identity becomes their beliefs. For example, “I’m medically ill; therefore, I am a sick person.” Fusion becomes problematic when thoughts are viewed as facts, and this serves to keep people stuck in patterns of thinking that lead to emotional suffering. Cognitive de-fusion is a tool that serves to disentangle people from thoughts that cause suffering. The first step is to recognize that we are the observers of our thoughts, and that we are not the thoughts themselves. This is also a common technique used in Mindfulness-Based Stress Reduction, another evidence-based treatment for chronic pain. Freedom from unnecessary emotional suffering begins with a willingness to look at thoughts differently and let go of attachment to thoughts, especially those which are negative. One common exercise is to passively observe thoughts as though they are clouds in the sky or leaves floating down a stream.

ACT is one of many therapeutic interventions that can be taught to people living with chronic pain. Ultimately, most of my patients come to me feeling stuck because of their pain, and their lives have been placed on hold. The central goal of ACT is therefore to teach people cognitive and behavioral flexibility – that is, to think and act differently in the face of pain and find new and better ways of living with it. My plan is to help people become less stuck by helping them better tolerate uncomfortable emotions and physical sensations, as well as move forward toward vitality. Overall, I’m humbled that patients let me be a part of their journey. Humility and curiosity are why I found my way to pain psychology and AAPP.

For those interested in learning more about ACT, here are a few references:

  • Living Beyond Your Pain by Joanne Dahl, Ph.D. and Tabias Lundgren, MS
  • The Mindfulness & Acceptance Workbook for Anxiety by John P. Forsyth, Ph.D. and Georg H. Eifert, Ph.D.
  • ACT Made Simple by Russ Harris, MD (second edition 2019)
  • US Department of Health: “Pain Management Best Practices” report (May 30, 2019; (Note: the behavioral health section begins on page 37.)