Change in "Self-as-Context" ("Perspective-Taking") Occurs in Acceptance and Commitment Therapy for People With Chronic Pain

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Read Full Text: Change in “Self-as-Context” (“Perspective-Taking”) Occurs in Acceptance and Commitment Therapy for People With Chronic Pain and Is Associated With Improved Functioning (This is a paid article, but we still thought it was important to cover.)
Journal: Journal of Pain
Year Published: 2017
Ranked 64th on our 2017-2021 list of the 100 Most Influential OT Journal Articles
CEU Podcast: Acceptance and Commitment Therapy, Pain, & OT with Linda Crawford (CE Course)

I think all OT practitioners should understand the basic tenets of Acceptance and Commitment Therapy (ACT).

ACT weaves together multiple concepts that we’ve already explored in the Club. And, on a personal level, it provides helpful tools we can utilize as we navigate complex situations in our work.

But, ACT is not just personally helpful; the research we’re looking at today shows us why we need to be aware of it as therapy professionals. Namely: Research supports the use of ACT in addressing chronic pain.

This week’s article focuses on an interdisciplinary team—including OTs—who provided intensive pain management treatment built around ACT.

For me, this article really demystified our role in pain management teams. More than that, it raised big-picture questions about how we can get more involved in this important practice area. I can’t wait to discuss all of this with you!

Let’s dive in.

What is Acceptance and Commitment Therapy?

Acceptance and Commitment Therapy is widely considered a third wave of cognitive behavioral therapy. While prior therapies focused on changing unhelpful thought patterns, ACT encourages people to recognize and accept their thoughts—and then continue to take actions in pursuit of their goals.

Here’s my own example of the type of thinking ACT encourages: “Oh, interesting—I’m noticing that I’m afraid of pain. Now I am going to do my safe exercises, and pay attention to my body as I do them.”

This is much more productive than trying to suppress fear of pain—and waiting until the fear goes away before moving forward. (Because it may not!)

The goal of ACT and its core processes is “psychological flexibility.” This means being in the present moment with full awareness and openness

to our experience and taking action guided by our values.

In essence, ACT is a model of behavior change. (Which makes it super relevant to OTs).

ACT has 6 interrelated core processes:

1.) Acceptance

Let go of impractical resistance to unwanted thoughts and experiences.

2.) Cognitive Defusion

Separate yourself from your thoughts. Notice and acknowledge them, but realize you are not controlled by them. (Think: “I am noticing that I am afraid” versus “I am afraid”.)

3.) Being Present

Be aware and fully in contact with the present moment. (This is very similar to the concept of mindfulness for chronic pain, which we’ve already explored.)

4.) Self-as-Context

Realize you are not controlled by every unhelpful thought that passes through your brain. You can transcend your thoughts and observe them. From this view, we can see ourselves as a complex web of thoughts and influences—but within this context, we can still choose our actions. (The founder of ACT also refers to this as “a transcendent sense of self.”)

5.) Values

These are the qualities we want reflected in our actions.

6.) Committed Action

This is the culmination of the theory (and the part that feels so OT)! Once we’ve accepted that we have unhelpful thoughts and circumstances—and realized that we can transcend them—we can persist in actions guided by our goals.

What is the role of ACT in addressing chronic pain?

There is a growing base of research supporting the use of ACT in addressing chronic pain. (The evidence backing this approach has only continued to grow since the article covered here was published in 2017. See these brand-new papers on online-based ACT and ACT for pediatric chronic pain.)

In an effort to increase the effectiveness of ACT for chronic pain, researchers have sought to identify which elements are the most potent.

These specific elements of ACT for chronic pain have already been studied: 1.) acceptance, 2.) present focused awareness, 3.) cognitive defusion, 4.) values, and 5.) committed action.

That leaves one key missing piece: Self-as-context.

Which leads us to this study….

What was the intent of this paper?

The authors examined ACT for chronic pain, specifically asking:

  1. Did ACT have an effect on chronic pain and self-as-context, as expected?
  2. If so, was this effect positively correlated with positive treatment outcomes?

What were the methods?

Participants were adults attending a pain management center in London. 412 adults provided baseline data. 213 contributed to the follow-up data 9 months later.

The mean pain duration of particpants at baseline was 106 months (8.8 years). In decreasing order, the most prevalent primary pain sites were: back, lower limbs, upper limbs, pelvic region, head, and abdomen.

What did the treatment program entail?

Treatment was provided over 4 full days for 4 weeks. It was delivered in groups of 9–11 participants by a team of:

  • Psychologists
  • Occupational therapists
  • Physical therapists
  • Nurses
  • Physicians

Here was the specific role of the OTs (16 sessions, 18 hours total):

Instruction and practice of value-based, motivational methods as well as practical skills training. This included:

  • Discussion and exercises for value clarification and goal setting.
  • Sleep education, including use of a sleep diary and calculator of sleep efficiency.
  • Other functional abilities such as communication, activity management, and return-to-work skills.

What assessments did the team use?

Participants completed measures at the beginning of treatment, at the end of the 4 weeks, and 9 months later. These included:

See all pain assessments

What were the results?

Overall, there was marked improvement in scores across all measures at the end of treatment and at 9 months post-treatment.

At the end of treatment:

  • 42–68% of patients improved to a meaningful degree on each outcome measure
  • 7–9% worsened to a meaningful degree

At 9 months, the numbers remained similar:

  • 47–56% of patients improved to a meaningful degree on each outcome measure
  • 7–14% worsened to a meaningful degree

Additionally, self-as-context correlated with functional improvements. Namely:

  • Pain-related interference (assessed by the BPI)
  • Work and social adjustment (assessed by the WSAS)
  • Depression (assessed by the PHQ-9)

Conclusions and discussion

Chronic pain can bring a sense of deep personal loss, threat, and even disintegration.

Addressing these changes through intensive ACT treatment delivered by an interdisciplinary team led to measurable improvement in “self-as-context.”

These changes correlated with functional improvements and showed medium-term benefits.

This supports self-as-context as an important part of ACT and shows that continued research into this therapy for chronic pain treatment is merited.

Takeaways for OT practitioners

(Please note: These are my personal takeaways. They are not mentioned specifically in the article.)

1. Chronic pain management continues to be a major theme in OT-related research.

Our current list of 100 influential OT articles includes 14 examining OT’s role in pain management—making it the most-studied topic on our list.

But, despite exciting new research on OT’s role in pain management, very few of us here in the US get to focus on pain management in our practice—or even consider it one of our specialties.

For a mind-blowing take on why effective pain management strategies are not getting delivered to patients, please read our past article: Providing chronic pain management in the “Fifth Vital Sign” Era. (The short version of the story is that opioids have overtaken the pain management industry, despite their devastating effects on patients.)

Though they are few in number, there are OTs who focus on pain management, and I’m excited to welcome one of them—Linda Crawford—to the podcast next week to share about her business, Brave Therapy.

Here’s the full APA citation for this article:
Yu, L., Norton, S., & McCracken, L. M. (2017). Change in “Self-as-Context” (“Perspective-Taking”) Occurs in Acceptance and Commitment Therapy for People With Chronic Pain and Is Associated With Improved Functioning. The journal of pain, 18(6), 664–672.

Earn one hour of continuing education by listening to the podcast on this article!!

In this podcast episode, we dive even deeper into this topic, with OT (and Club member!), Linda Crawford. You may be eligible for continuing education credit for listening to this podcast. Please read our course page for more details!

What questions/thoughts does this article raise for you?

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What an interesting article, and pain management is a huge part of so many diagnoses… it sounds so intensive though, that I wonder if the people enjoyed it or would recommend it? while they saw improvements, I wonder what this would look in a randomized controlled trial-- did some just naturally get better? i also wonder how this could be adapted for people and therapists that don’t have that amount of time, or for kids.

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That’s such a good thought about how intensive it is. I do feel like in generally when we look at more intensive programs like this, they tend to have the best outcomes- but these certainly aren’t the conditions most of us work in.

I wonder if in general our approach to therapy should shift towards more intensive options, or if need to push to find effective treatments in the format that most OT is actually delivered. (I’m asking you this in particular, because we are slated to look at another tx option I think of as intensive: CIMT!)

On a personal note, I found just spending time with this article has been personally helpful in how I think about my own thoughts and emotions! I’ve even found myself weaving the concepts into conversation with friends!

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I have personally found Acceptance and Commitment Therapy (ACT) very helpful as a patient, while living with a chronic painful condition (rheumatoid arthritis - RA) for 2 decades. I also use an ACT informed framework in the online support groups I facilitate for people with RA and similar conditions.

Here’s what I love most about the “exercises for value clarification and goal setting:” so many patients end up crafting their entire life around “making the pain go away,” that they forget to connect to opportunities that exist even despite pain.

The ACT exercises help them confront that there are still opportunities to connect to what they value most in life, despite pain. It’s a really wonderful a-ha moment to witness!

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I’ve found the same thing with ACT - it truly changes how you look at life! You realize how often our default assumption is that we should “feel better” all the time. If a good friend tells you she’s suffering, your default instinct from how we’re socialized is to “make it better,” but what if instead we were taught to simply sit with someone in pain, to validate their emotions and to allow them to persist despite the pain, rather than forcing them to “feel good,” which ultimately is a losing proposition (it’s the “Happiness Trap” Dr Russ Harris discusses in his book by the same name).

As a parent I also find it un-burdening to focus on acceptance versus feeling better. My job as a parent can’t be to make my child feel better, but I can help them “feel” better, meaning I can help them connect to their feelings, give themselves self-compassion and become resilient in the face of discomfort. Super powerful stuff!

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@CherylCrow I am so inspired your story and always want to ask you so many questions. I’m going to limit myself to one :slight_smile: :

Was there a particular place you learned the values clarification and goal setting exercies from the ACT lens? There is so much to read about it- I’m curious what resources OTs would find most helpful?

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Here’s what I love most about the “exercises for value clarification and goal setting:” so many patients end up crafting their entire life around “making the pain go away,” that they forget to connect to opportunities that exist even despite pain.

This is so true. Some people with chronic pain are unable to get past their pain and get so preoccupied with making it go away that they lose sight of the big picture. Therapists working with them are frustrated because nothing can be done unless the pain is gone (which may not be possible). On the other hand, there are some patients that are in constant pain but have learned to manage it and work through it. Pain threshold and pain tolerance are very individual.
Interesting article, excited to hear the podcast next week.

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You can always ask me as many questions as you’d like, I’m an open book!

As a patient, my therapist led me through an interesting thought exercise where they basically pointed out that I do have a choice about whether to have my life ruled by my phobia (specifically claustrophobia including small spaces like airplanes). I REALLY value travel and it’s something that my husband and I have bonded over and enjoyed as a family with Charlie as well. However the flying part causes me extreme stress and I sometimes want to avoid it altogether, which is a common coping tool in anxiety disorders. But he basically led me through the consequences of taking my phobia to the extreme - let’s say I literally NEVER fly or go anywhere with a small space ever again. That would go against my own values of exploring the world, seeing new things and connecting with my partner and family (as well as professional goals - attending conferences, etc).

That really helped, to take my strategy to the logical conclusion and to see that it was untenable, but it still was a CHOICE - a lot of ACT practitioners talk about a “choice point,” where we can choose to take actions “towards” or “away” from our values. This choice point PDF is really helpful and could be applied in many OT clinical settings.

I think a good old fashioned “values sort activity” is a helpful tool in a variety of occupational therapy contexts, you can find a free one here: Value Sort — The Good Project

Another would be this 60 second video on the "passengers on the bus" metaphor - instead of thinking we have to “get rid of” uncomfortable thoughts and sensations before living a good life according to our values, what if we could take them along for the ride? I find that super helpful and those in my groups seem to respond well to it too!

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