"I just want my pain to go away" - Moving towards pain acceptance and life beyond pain.

That which we resist persists Carl Jung

Can Pain Acceptance and the concept of ‘And this too’ form a bridge between distressing pain to a life beyond pain?

“I just want my pain to go away”. If you are a person in pain, how often have you had this thought? Or if you’re a healthcare provider or other professional working with people in pain, how often do you hear these words? It seems like a simple, obvious desire or goal to want to rid ourselves of pain. Isn’t it reasonable to want to stop suffering? Well, of course, it is…. And in many cases, pain relief is achievable. But what if the goal itself becomes problematic and part of the suffering?

Let me tell you about a couple of people I’ve been working with recently. Mark has a 2-month history of upper thoracic pain. His scans are clear, but his pain is impacting work and he has a complex history of psychosocial distress. Jean has recent onset low back pain with minor S1 radiculopathy (sciatica and minor nerve root compression). For Mark and Jean, the very presence of pain (much more than its intensity or impact) is so distressing, they just desperately want the pain to go away. However, for both, their overall clinical presentation would suggest that pain may be a companion for quite some time (e.g., because of the nature and natural history of the problem in Jean’s case and the degree of psychosocial contributing factors in Mark’s). Unfortunately, the desperation for the pain to go away and the sheer stress that comes with this is likely leading to more pain and suffering and greater medicalization (e.g. more scans, medication and injections). It also seems to be stopping them from getting the full benefit of the kinds of pain care strategies that are more strongly indicated in their situations (e.g. exercise, doing enjoyable activities, stress-relieving strategies). ‘Down the rabbit hole they go’.

So, how does ‘pain acceptance’ fit in here? Accepting pain may seem a bit contradictory in pain care when the goal is to move beyond pain. But if we reflect on the definition of acceptance in pain care it may start to feel more relevant, Pain acceptance is the process of giving up the struggle with pain and learning to live life despite pain (1). It is considered to have some key components such as engagement in life activities regardless of pain, and ‘pain willingness’ which is the recognition that avoidance of pain or full control of pain may not be completely achievable and so we may develop an acceptance or willingness to experience some pain (2). We may recognize that pain may not change – for some people this is for the time-being or for others it may be a longer-term situation.

In our book Pain Science Yoga Life (3) we refer to the Buddhist influenced concept ‘And this too’ which reflects these aspects of acceptance. We can hold space for pain, pathology, illness etc. but also recognize that we, and our lives are much richer and include many more dimensions than pain and suffering. This offers a space for inclusion…… I have a lot of pain but I enjoy being outside so I will go for a walk or spend some time sitting by the sea, even with my pain … I include both…. And this too.

Focusing on Pain Acceptance versus Pain Relief- are they mutually exclusive?

Over the last few years, I’ve had a question in my head about when pain acceptance is appropriate and when, as a clinician, I should be focused on pain relief. This stemmed from a workshop I chaired at the Australian Pain Society Conference where Professors Peter O’Sullivan and Kevin Vowles were speaking about their research on pain care options. Peter was speaking about Cognitive Functional Therapy (CFT), a multidimensional pain care approach where a reduction in pain is a core goal. Kevin was discussing Acceptance and Commitment Therapy (ACT) where a reduction in pain isn’t a specific goal or a focus for treatment (if interested see end section on ACT and its research). Both of these approaches have evidence that they can improve aspects of pain for people with persistent pain (4-7). I asked Peter and Kevin whether they felt these two approaches were in conflict. Their answers ran along the lines of perhaps different options may suit different people at different stages of their care. I respect the neutral stance of the answer offered; however, it’s a question that has stayed with me… wanting further exploration – when is pain acceptance a good thing and when should we strive more actively for pain relief? And are they really mutually exclusive? I think in pain care, many only engage in pain acceptance when pain is really persistent. That was certainly my initial interpretation – acceptance was the reserve of chronic pain management programs when pain relief was no longer an option.

However, as I came to understand acceptance more fully, I began to see the value of pain acceptance in a broader way with potential for inclusion across pain care, even in straightforward clinical problems where we would expect pain to change and for people like Mark and Jean.

I see leaning in, being OK with experiencing some discomfort without getting overly distressed, stepping back from our automatic thoughts and reactions for long enough to see what’s helpful or not, engaging in meaningful values based- activities even in an adjusted or graded way, and ultimately creating space for change, as supportive of most evidence-based pain-care. So, to explain further, here are a few notes on what I’ve come to understand pain acceptance is and isn’t. Let’s start by tackling some common misunderstandings.

Pain Acceptance is not:

- about giving up or giving in

This is really important to recognize. Pain acceptance isn’t a case of accept your lot, admit defeat and continue to suffer. Often when I talk about pain acceptance with clients, there is an initial phase of resistance or an interpretation that acceptance means giving up. I’ve also witnessed acceptance come under considerable attack in professional circles. The arguments often lie around the focus that pain relief is an important part of pain care, so shouldn’t we try to relieve pain rather than ‘accept’ it i.e., give up? Accepting that the current situation isn’t wonderful but being willing to do our best, even with pain present, while at the same time staying calm, is far from giving up!

- about ignoring pain and pushing through regardless

Sometimes pain acceptance is misunderstood as ignoring pain. While pain acceptance does mean we are willing to experience some pain and engage with activities that are important or meaningful for us, we don’t have to push through regardless. We can take a gentler perspective where we gradually re-engage with activities we may have avoided. We can start by adjusting our activity or our expectations, then slowly and steadily pace up an activity. Pain acceptance often means accepting some limitations too. Pushing through regardless is usually linked with lack of acceptance as we strive ‘to beat this pain’.

- about suppressing our emotions or trivializing our painful experiences

Actually, when using pain acceptance as a mindfulness practice (more below), we are encouraged to acknowledge the pain we are experiencing and the emotions that may come with that. We may notice that we feel a lot of discomfort and that we feel angry, frustrated, sad, depressed, and more. We can notice these emotions and sense them but not get lost in them. We try to step back from our thoughts and feelings and notice them simply for what they are- thoughts and feelings.

Pain Acceptance is:

- a mindfulness practice

Mindfulness can be thought of as ‘moment -to-moment’ awareness (8-10). This means being present in the moment, as it is, without being caught in thought spirals about the past or dreams or projections about the future. We often think of mindfulness as meditation or other exercises, but they are just that- exercises. To be mindful, means ‘accepting’ the present moment as it is…. It is a lived experience - experiencing the highs and lows of life with evenness of mind and composure. We try not to become overly distressed by suffering or to avoid it at all costs. Rather we sit with whatever struggle we are working with, recognizing it for what it is and that it is truly part of life. By the same token we try to avoid continuously grasping for more pleasant or desirable experiences or situations. When we live mindfully and when we have pain, we would notice that pain is present, we feel it but try not to get caught in worrisome thoughts about it or spend all our time willing it to be gone. Nothing further is added to it. We recognise that the nature of life is to be full of ups and downs - periods of ill health, sadness, distress as well as happiness and invigorated living. And with a focus of And this too we are aware that as well as pain, there is much more within our lives at any one time.

- about evenness of mind

A key part of acceptance and of mindfulness is the sense that ‘I am OK’. Even if we have pain or are suffering in other ways, often, in the moment, we are still OK. Without ignoring pain, we can try to maintain a sense of calm and regulate our distress as we experience pain and suffering. Acknowledging the fullness of our lives also helps with this process… And this too…

- about giving up the struggle with pain

We recognize that pain may be a companion, perhaps at least for now, and instead of spending all our energy focused on changing pain, we start living again. Ironically, even though the focus isn’t on alleviating pain, pain relief can be a by-product (7). And certainly, lower disability, better quality of life and improvements in mood arise when we have greater pain acceptance (7, 11). Sometimes, we have to accept that in many cases, at least for now, we may not be able to change the situation (diagnosis, financial situation, relationship, place you live, work etc.). When we give up this struggle with something that may not change, we create space, time and energy for a new focus – our meaningful activities.

- about understanding that the nature of pain is to protect us, but that our nervous system may be overprotective

When our nervous system becomes overprotective it can start to predict we are in danger when we are not. We can then ease into the idea that pain doesn’t always mean harm. This is particularly the case for persistent pain where our nervous system can take on the shape of an over-protective mamma bear. Pain is a protective response that our brain / nervous system produces to safeguard us. Our traditional thinking means many of us interpret pain as reflecting tissue damage but pain, particularly persistent pain can reflect a state where our nervous system is predicting we might be in danger even with the slightest hint of trouble. These ‘cues for protection’ (12, 13) are many and varied and range from how we think about our body, pain, injury or pathology to how we move, how well we sleep or what our relationships are like etc. When we lean into our painful experiences and consider what might be triggering them from a wider perspective, we may come to understand ourselves more fully. How do we react to stress? Do we need to move more? Do we need to improve sleep or check in on our relationships? When we take a step back from our experience, this can open avenues for our care that might have some far-reaching benefits.

- about finding our values and taking positive action to live well

A core element of acceptance-based approaches like ACT (Acceptance and Commitment Therapy) is spending some time identifying what’s important to us – our values. Then committing to an action plan based on these values (1,2). If my values lie around spending time with my daughter, instead of avoiding going to the playground with her because of my back pain, I commit to 10 or 15 minutes once a week at the playground, then gradually increase that. If that’s not possible, I find other ways to spend quality time with my daughter. My focus becomes about how I can fulfill my value of spending time with my daughter instead of focusing on what I can’t do…. And this too

- about being kind to ourselves

Not kind in a ‘I need another cake’ way, but kind in a ‘what do I need to live a happier life’ way. This is all about spending more time doing the things we love, even in the presence of pain. And this can have far-reaching benefits. By spending time doing more of what we love with the people we love, we gain lots of positive effects- our mood is better, we spend more time being active or outdoors, we spend more time with people and are less isolated, we activate our natural pain-relieving system (e.g. endorphins) and ultimately help our pain and suffering. We might also learn our limits, respect them and honour ourselves a little more, rather than beat ourselves up or feel guilty about what we can’t do.

- about being able to step back from our automatic thoughts about our pain and recognize when our thoughts may be helpful and when they might not be so helpful

This is key to mindfulness. We start to notice (with kindness, not judgment) what our automatic thoughts or responses are (8, 14). We explore them with a little curiosity – are they helpful or not? Maybe the response was helpful at one time but not anymore. Maybe it has a root or source that we can acknowledge. We can thank ourselves, our brain and nervous system for trying to protect us but start to let go of what’s not needed anymore. This creates space for new responses, new ways of thinking about our bodies and our pain. A core part of this is about being flexible in our thinking – this is called psychological flexibility. We take a step back and check in on fixed beliefs and try to let them go if they are standing in our way of living a fuller life.

- about creating space

And here is the real gold. When we get to grips with all of the elements of pain acceptance, we truly create space for change. Change in how we think, how we move, what we feel, how we live our lives. And when we find ourselves living fuller lives, our nervous system, might, just might, turn down the dial on protection, and on pain and suffering.

Can pain acceptance and optimism for pain relief live together? I think so. And for people like Mark and Jean as they navigate their pain journey, perhaps including pain acceptance is a worthy piece of their pain care. It may help them ride the ups and downs of their current situation more comfortably, with less distress, and stop them tumbling down the rabbit hole of excessive or unwarranted investigations or treatments. If you'd like a 'patient' perspective, check this out.

Namaste,

Niamh

Post Script

Acceptance and Commitment Therapy: Evidence in Brief

Acceptance in pain-care is often housed with Acceptance and Commitment Therapy, or ACT for short. For those a little less familiar with the term, ACT is a form of cognitive behavioural therapy that focuses on accepting the current situation, identifying ones’ core values and putting in place strategies for getting back to valued-centred living (See Table 1 for more detail) (1,15). The origins of ACT lie in addiction therapy but it has been adapted for use in lots of challenging situations - persistent pain being one of these. In pain care, the focus is not on relieving pain per se, and often therapists ask clients to not focus on this for full engagement in the therapy. But do note, for people undertaking ACT there is considerable evidence of improvements in quality of life, and even pain relief is a common by-product (7). Interestingly, greater levels of acceptance is a key mediating factor for some of these changes (11, 16, 17).

Six key features to ACT (1, 15)

1. Acceptance: being able to sit with pain and not allowing it to dominate your life.

2. Cognitive defusion: differentiating ourselves and our actual experiences from our thoughts. This is a matter of being able to step back from our thoughts and not cling to them so tightly.

3. Flexible present-focused attention: tracking and being present in moment-to-moment experiences.

4. Self-as-context: being able to understand the “observing self.” There are two different aspects to the mind, the thinking self and the observing self. Most people think of the mind as being the thinking self, the part that comes up with thoughts, beliefs, memories, and so on. Many people aren’t aware of the observing self, the part of our mind able to step back and observe the thinking self and the rest of our being. This part of yourself is and always will be the same you (the true self or the witness), whereas our thinking self and physical self can, and will change over time.

5. Values: identifying our values, what’s important for us and how we live our lives.

6. Committed action: we commit to changing our actions, our behaviours and patterns based upon our values.

References

1. McCracken & Vowles, ACT and Mindfulness for Chronic Pain. American Psychologist Journal, 2014. 69(2): p. 178-87.

2. Vowles et al.The Chronic Pain Acceptance Questionnaire. Pain, 2008.140(2): p. 284-91.

3. Moloney & Hartman, Pain Science Yoga Life. 2020 Edinburgh, Scotland: Handspring Publishing Ltd.

4. Vibe Fersum et al. Cognitive functional therapy in patients with non-specific chronic low back pain. Eur J Pain. 2019;23(8):1416-24.

5. Vibe Fersum et al. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain. Eur J Pain. 2013;17(6):916-28.

6. O'Keeffe et al. Cognitive functional therapy compared with a group-based exercise and education intervention for chronic low back pain. BJSM. 2020;54(13):782-9.

7. Veehof et al. Acceptance- and Mindfulness-Based Interventions for the Treatment of Chronic Pain. Cognitive Behavioural Therapy, 2016. 45(1): p. 5-31.

8. Kabot- Zinn, J., Full Catastrophe Living. 2005, New York, NY, United States: Bantam Dell.

9. Rinpoche, T., Open Heart, Open Mind. 2012, New York, United States: Harmony Books.

10. Bishop et al. Mindfulness: A Proposed Operational Definition. Clinical Psychology, 2004. 11(3): p. 230-241.

11. Akerblom et al.The Mediating Role of Acceptance in Multidisciplinary Cognitive-Behavioral Therapy for Chronic Pain. Journal of Pain, 2015. 16(7): p. 606-15.

12. Butler & Moseley, Explain Pain. 2003, Adeliade: Noigroup Publications.

13. Moseley & Butler, The Explain Pain Handbook: Protectometer. 2015, Adelaide, South Australia: Noigroup Publications.

14. Brach, T., True Refuge. 2016, New York, United States: Bantam Books.

15. Feliu-Soler et al.Current Status of Acceptance and Commitment Therapy for Chronic Pain J Pain Research, 2018. 11: p. 2145-2159.

16. McCracken & Vowles, A Prospective Analysis of Acceptance of Pain and Values-Based Action in Patients with Chronic Pain. Health Psychology, 2008. 27(2): p. 215-20.

17. Kratz et al.Medicate or Meditate? Greater Pain Acceptance Is Related to Lower Pain Medication Use. Clin J Pain, 2018. 34(4): p. 357-365.