Acceptance and Commitment Therapy (ACT) in the Treatment of Pain

As a clinical counsellor, I am dedicated to individualized treatment, and I draw from and integrate different evidence-based approaches based on the client’s needs, preferences, and goals. One of the modalities I incorporate into my work is Acceptance and Commitment Therapy (ACT). I wanted to share a bit about this empirical approach and how it can be applied to individuals with persistent pain.

ACT’s six interconnected and overlapping pillars are Acceptance, Cognitive Defusion, Contact with the Present Moment, Self-as-Context, Values, and Committed Action. ACT aims to enhance psychological flexibility and resilience, and treatment can be summarized as “get present, open up, and do what matters”.

Acceptance

Applied therapeutically, acceptance means fully embracing thoughts, emotions, and experiences without trying to avoid, suppress, or change them—especially when they are painful or uncomfortable. 

This does not mean resignation or passivity but rather an active choice to allow thoughts and feelings to be present without unnecessary struggle. I like the analogy of trying to keep a beach ball pushed underwater; it takes effort to keep the ball (thoughts & feelings) submerged. This effort is exhausting and usually results in the ball flying into the air (overwhelm, outburst, intense reactivity), whereas if we practice letting the beachball float (allow thoughts & feelings), we learn to create space to be with and accept all our experiences, even the challenging ones. 

Acceptance includes a mindset of being willing to open up to emotions, thoughts, and sensations (including pain) without trying to escape them, which counteracts avoidance. In sessions, I help clients practice acceptance by mindfully noticing their inner experiences without judgment and creating space between themselves and their challenging thoughts, beliefs, memories, or emotions. Acceptance can be both empowering and liberating, allowing us to focus on what truly matters. Therefore, with ACT, the goal is not to eliminate pain, but to learn to live with vitality despite the pain or discomfort one is experiencing. Using this approach, individuals learn that pain is not an enemy that needs to be controlled or fought against and that they can achieve a meaningful and healthy existence even when pain persists.

Measurement:

The Chronic Pain Acceptance Questionnaire (CPAQ) is a 7-point scale used to measure the acceptance of pain based on answering 20 statements regarding activity engagement and pain willingness. Evidence suggests that the willingness to accept pain can reduce unsuccessful attempts to avoid or control pain and thus focus on engaging in valued activities, pursuing meaningful goals, better functioning, and higher satisfaction. 

Action Step: 

Where in your life can you practice acceptance this week? 

Cognitive Defusion

In ACT, it is understood that most suffering is caused by being “hooked” by our cognitions (our thoughts), which dominate our overt and covert behaviour (i.e. our actions and attention). In other words, we become “fused” with our thoughts, beliefs, urges, and feeling states and allow them to yank us around, preventing us from living in alignment with our values. It is common for individuals to internalize thoughts as literal truths about themselves. 

The antidote to this is defusion, or creating distance, whereby people learn to respond more flexibly to their thoughts and feelings. Defusion incorporates curiosity and openness; we learn to examine our thoughts and feelings more flexibly. Defusion helps us learn to stop fighting, avoiding, obeying, and believing our thoughts and instead start to notice that thoughts are just words or mental events rather than absolute truths. Thus, unhelpful thoughts become less overwhelming and more manageable. During a session, I help clients notice, question, and create space for limiting thoughts such as, “I am too weak to recover” or “I can’t be happy if I have this pain”. 

What Thoughts are Hooking You?

To determine what thoughts are hooking clients dealing with persistent pain, I would ask, “If I could listen in on your mind, what would I hear it saying about the pain you are experiencing?” Next, I would explore how unhelpful thoughts are linked to behaviours by asking, “When these thoughts push you around, what happens next? What do you start or stop doing?”. The answers will help identify where a client is fused with thoughts and what they are avoiding due to believing them.

Clinical Example – Labelling Thoughts

Let’s use the example of a client with the pervasive thought, “I can’t be happy if I have this pain.”

First, write the thought down, say it aloud, and explore the feelings that come up.

Next, under that write, “I’m having the thought that I can’t be happy if I have this pain.” Then, say this aloud and notice what arises.

Lastly, write down, “I notice I am having the thought that I can’t be happy if I have this pain.” Again, say this out loud, and notice what arises.

With this cognitive defusion exercise (there are many!), individuals learn that they are not their thoughts, that there is a way to create a bit more space between themselves and their thoughts, and that thoughts aren’t facts! For many clients, it can make a big difference in how they begin to relate to their thoughts; they become less hooked with their thoughts, and they have less grip on them. Individuals learn to question their thoughts with more curiosity and less judgment.

**The aim of defusion is not to dismiss or get rid of unwanted thoughts and feeling states, but to learn a new way to relate to them**

Measurement:

The Psychological Inflexibility in Pain Scale (PIPS) assesses cognitive defusion and psychological inflexibility in people with persistent pain. It measures two main components: avoidance of pain and fusion with pain thoughts. Higher scores indicate higher levels of psychological inflexibility. 

Action Step: 

What is an unpleasant or limiting thought, emotion, sensation, or memory that dictates your behaviour?  Can you begin to create space between yourself and this thought?

Happy Defusing!

Contact with the Present Moment and Self-As-Context

How can ACT be used for those easily distracted, disengaged, disconnected from thoughts and feelings, stuck in the past, or preoccupied with the future? The antidote to inflexible attention is contact with the present moment, or being present.

Contact with the present moment is understood as flexibly paying attention to our experience in the here and now, including what is happening in our outer and inner worlds. The aim is to enhance awareness and fully engage in what we are doing, increasing satisfaction and fulfillment in our lives. Fostering flexible attention is essential for self-awareness, adds richness to our lived experience, and involves paying attention with lots of openness and curiosity. If you are thinking this sounds like mindfulness, you are right! With clients, I refer to contact with the present moment as mindfulness, being present, present-moment awareness, or focusing – same thing ☺

In counselling, I help clients tend to their present moment by asking questions such as, “Do you notice what is happening in your body right now?” or “Where is the feeling most intense?” For some clients, this is where I would introduce meditation in a session.

Three present-moment skills are engaging, savouring, and focusing. Engaging skills aim to help clients fully engage with activities and connect deeply to whatever they are involved with. Examples include giving someone your full attention and paying full attention when you fold the laundry or brush your teeth. Savouring skills teach clients to enjoy and appreciate anything pleasurable. For example, slow down and savour your coffee or a warm shower. Focusing skills help clients concentrate entirely on the task at hand, including flexible attention. Sometimes, we need a narrow focus (if there is worry or rumination), and sometimes, a broad focus. For example, working with clients experiencing pain, it is imperative to validate and acknowledge the pain and encourage a broader focus by having the client engage with their senses (what can you see, hear, touch). 

The next ACT pillar is self-as-context, which can be referred to as the noticing self, observing self, or witnessing self; the part of us that does all the noticing. It’s the stable place inside you that can make space for difficult thoughts and feelings. 

Teaching clients to “notice the noticer” helps enhance defusion, acceptance, and contact with the present moment and supports the development of flexible perspective-taking.

To introduce this concept, I like using the sky and weather metaphor. The noticing self is the clear, open, unchanging, spacious sky that can withstand any type of weather no matter how bad it gets, with the weather representing difficult thoughts, feelings, or physical sensations (such as pain). The sky is the safe space within that can observe any hurricane or thunderstorm (and the weather always changes!). No matter how bad it gets, the weather cannot hurt the sky, and the sky always has room for it. 

Clinical Example – Notice you are Noticing 

For a client experiencing pain, I might use the noticing exercise experientially within meditation or conversationally, using phrases like, “There is pain, and there is the part of you noticing pain,” “As you notice the pain, be aware that you are noticing,” and “If you can notice the pain, you cannot be the pain, and there is so much more to you than the pain.”

Measurement:

One assessment tool that can be used to measure present moment awareness is The Mindful Attention Awareness Scale (MAAS). MAAS is a 15-item scale, with higher scores representing higher levels of mindfulness.

Action Step: 

Commit to incorporating present-moment skills throughout your day. Take five mindful breaths, drive without distraction, gaze into the eyes of a loved one or a pet. This is about more BEing and less DOing. 

Values and Committed Action

We have reached the final two pillars of ACT, values and committed action, and it makes sense to address these processes together.

One of the main goals of ACT is to help individuals commit to pursuing what they value most in life despite painful thoughts, emotions, or sensations. Actions that align with one’s values bring meaning to one’s life.

Therefore, for clients who experience pain, our early work will include helping them identify their values. This can empower individuals to focus their priorities away from the pain and toward doing more of what is meaningful in their lives. I liken values to your north star or inner compass, which helps to create an action plan and set meaningful and measurable goals. Many clients discover that once they are clear on their values and what truly matters, they are clearer about their daily choices. For values identification, I typically use Brené Brown’s list of values as it offers the most options and is an engaging activity that most clients enjoy ☺

Next, I will collaborate with clients on the specific committed actions they are willing to make in alignment with their values, which includes planning for roadblocks or barriers that may arise, and using the other ACT processes, such as cognitive defusion, present-moment awareness, and the noticing self, to help them succeed.

Measurement:

The Committed Action Questionnaire (CAQ-8) can be used to assess whether one’s committed actions align with one’s goals and values. Higher scores indicate greater commitment. 

Action Step: 

Spend some time this week identifying your top five values. What do these values mean to you? What is one action you can commit to that is aligned with each value?

ACT is a versatile, transdiagnostic model based on acceptance, mindfulness, commitment and behavior change strategies aimed to increase psychological flexibility. Research supports using ACT for individuals with pain and for using ACT within an integrative pain management program supporting biopsychosocial care.