A few months ago, I attended a seminar on Cognitive Behavioral Therapy. I did so because I’ve long been aware that this type of therapy comes highly recommended by many spine experts for those dealing with the psychosocial aspects (i.e. your emotions, attitudes, the roles you play at home and work, etc.) of chronic back pain. Cognitive behavior therapy has a great reputation for helping people who live with pain address distorted thinking patterns that get in the way of successful pain management.
Related: What Is Cognitive Behavior Therapy?
While I was at the workshop, I asked the instructor, Dr. Daniel J. Moran, Board Certified Behavior Analyst and founder of the MidAmerican Psychological Institute in Joliet, Illinois, about the specific ways in which cognitive behavior therapy is used for people with chronic neck or back pain. His answer surprised me.
Dr. Moran took the opportunity my question presented to him to introduce me to another type of therapy called ACT. ACT stands for Acceptance and Commitment Therapy. Moran says that ACT works from a different model than does traditional behavioral therapy methods (such include - but are not limited to - cognitive behavioral therapy).
A little lore is in order here. Dr. Moran informed me that when you are speaking about ACT, it is important to call it ACT, and not ACT therapy. (The “T” in ACT stands for therapy, so it is redundant to tack “therapy” on to the end.) Moran was adamant on this point, so I decided to respect it.
ACT uses a mindfulness based approach. The goal is to help you change unhealthy behavior by developing psychological flexibility, he says. He also says that ACT adds a spiritual component to psychotherapy, yet it is a method build on empirical science.
A 2011 study by Wicksell and associates, entitled “Mediators of change in Acceptance and Commitment Therapy for pediatric chronic pain,” which was published in Pain Journal concurs with Moran’s definition of ACTs. In their abstract, the researchers define its as “an extension of traditional cognitive behavior therapy aimed at improving functioning by increasing the ability to act effectively in the presence of pain and distress, that is, psychological flexibility”.
The basic tenet of ACT is that developing your psychological flexibility may help you increase the fullness with which you live your life.
If you think more psychological flexibility will be too much for your neck or back, think again.
ACT is helpful for chronic back pain management because it teaches you to approach the pain in a different way, says Dr. Melissa Rowland, PsyD. (Rowland is one of Dr. Moran's associates at the MidAmerican Psychological Institute.) Cognitive behavior therapy targets distorted thoughts and changes them. ACT helps you become aware of your thoughts, and to realize they don't have to be a barrier.”
In addition, the ACT framework provides tools for engaging in the areas of your life you determine to be the most meaningful to you.
What Is Psychological Flexibility?
Let’s start by defining psychological flexibility, and understanding the role it plays in managing chronic back pain. According to Dr. Moran, psychological flexibility is the ability to change posture(s). When ACT is used for pain management, this definition refers to perceptions - perceptions you hold of yourself, your symptoms and your ability to participate in your life.
“ACT helps people be in the present moment,” Dr. Moran informs me.
Becoming present in the face of your pain and other symptoms is an important step towards achieving psychological flexibility. Being present helps you recognize that attempting to avoid or get rid of the pain actually leads to more of it, along with increased difficulty dealing with life, Rowland comments. “For example, when you maintain a mindset that revolves around accommodating your pain, you may find yourself missing out on important events, missing sleep or taking pain medication that has side effects that impair functioning.”
"Psychological flexibility can change your perspective on pain,” she continues. “It may help you transition from relating to the pain as something that constantly nags you, and something that prevents you from engaging with your life and reaching your goals, to an experience that does not have to control everything that you do."
Clinical Differences between Cognitive Behavior Therapy and ACT
The difference between cognitive behavior therapy and ACT goes beyond the choices an individual makes regarding the best way to address aberrant thoughts. It has a clinical rationale, as well.
According to Joanne Dahl, Ph.D., ACT therapist and Associate Professor and senior lecturer of Psychology at University of Uppsala in Sweden, traditional behavior therapy (cognitive behavioral therapy is the most well known example) is built on the idea that behavior related to your pain and any associated stress is a sign that some kind of underlying disease or condition is at work.
In contrast, she says, ACT facilitates changing the associations and thought processes that are tied to unhealthy behavior. For the record, "unhealthy behavior" in this case, is behavior that likely increases your pain and decreases your quality of life.)
In other words, when you see an ACT therapist, the goal is not to decrease the symptoms of an assumed pathology; the goal is, instead, to increase your psychological flexibility.
Rowland agrees, saying that for people who deal with chronic pain, a course of conventional cognitive behavior therapy might aim at reducing or eliminating symptoms. But when you engage with an ACT counselor, she says, you get access to ACT’s toolset (my terminology). This toolset – comprised of what is known in the ACT world as the 6 Core Processes- is specifically designed to help you get past your reactions to pain as well as any the inconveniences that come with it. The idea here is to move forward, to engage with your life - pain, symptoms, and all.
“ACT results in the willingness to be more honest, and to stop buying into your symptoms,” Moran says.
Moran says another way to understand ACT is as a therapy that helps you avoid avoidance behavior. An example of avoidance behavior is if you were to cease all movement and exercise based on a fear that these activities would make your pain worse, or that you would re-injure yourself, or even embarrass yourself because you feel uncoordinated. This is technically called fear avoidance behavior. Fear avoidance can have a negative impact on the outcome of your treatment. Luckily, the 6 Core Processes of ACT provide a way to deal with fear avoidance behavior in the context of a pain management plan.
In case you're interested the 6 Core Processes are: Acceptance, cognitive fusion, being present, self as context, values and committed action.
An ACT therapist can help you use the 6 Core Processes to keep pain from interfering with what you want your life to be about, Rowland tells me. “Using ACT for chronic pain is about helping you to live alongside your pain, instead of allowing pain to take over your thoughts and experiences."
Pain doesn’t have to be front and center, just because it's there. As long as you are willing to both recognize and live with your pain and other symptoms, ACT may be just the ticket for dealing with the effects of a chronic neck or back condition. With effort, ACT may help you change your perceptions, and move the pain from the foreground of your life to the background.
Related: Chronic Pain and Depression
Plumb, J. ACBS Podcast. An Introductions to Values with Joanne Dahl. Association for Contextual Behavorial Science website.Oct. 2011. Accessed Aug 2012. http://contextualpsychology.org/podcast/08_an_introduction_to_values_with_joanne_dahl
Hayes, S. The Psychological Flexibility Model. Association for Contextual Behavorial Science website. Jan 2006. Accessed Aug 2012. http://contextualpsychology.org/the_six_core_processes_of_act">http://contextualpsychology.org/the_six_core_processes_of_act">http://contextualpsychology.org/the_six_core_processes_of_act
Moran, D. Phd. MidAmerican Psychological Institute. Interview and Seminar Notes. Cognitive Behavioral Therapy Techniques. Madison, WI. July 2012.
Melissa Rowland, Psy D. MidAmerican Psycological Institute, Joliet, IL. Email and phone interview. July 2012.
Rainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ. Fear-avoidance beliefs and pain avoidance in low back pain--translating research into clinical practice. Spine J. 2011 Sep;11(9):895-903. http://www.ncbi.nlm.nih.gov/pubmed/21907633