the NeuRA blog

Greater acceptance of chronic pain is associated with fewer pain-related difficulties, such as distress and disability, and better quality of life. Pragmatically, however, the idea that one might want to be more “accepting” of chronic pain runs contrary to common sense.

To help clarify this confusion the McAuley Group, which researches low back pain at NeuRA, is proud to be hosting a workshop led by Assoc Professor Kevin Vowles to help clinicians facilitate acceptance and valued activities in chronic pain sufferers.

In this blog Kevin, an expert clinical psychologist from the University of New Mexico, hopes to whet appetites by clarifying the role and purpose of acceptance as it pertains to chronic pain. For more information on the workshop, to be held at NeuRA 19-20 March, visit here.

Assoc Prof Kevin Vowles

The confusion surrounding acceptance may arise from modern approaches to health that prioritise reduction or elimination of undesirable personal experiences such as pain. Part of the confusion likely also comes from the paradoxical nature of acceptance in relation to these undesirable experiences. Acceptance by itself is unnatural. Thus, “accepting it” is probably not the whole story – it is necessary to also identify the purpose of acceptance.

Firstly, approaches which prioritize the elimination of behavior or symptoms, and are therefore based in aversive control, may be highly problematic. Aversive control leads to a narrowing of response options, which function as attempts to avoid or escape the aversive experience, as well as insensitivity to the relation between behavior and its consequences. In chronic pain, the dominant mode of responding may become one of pain avoidance – the person’s life is dominated by efforts to avoid or eliminate pain. Such inflexible avoidance brings with it broader negative consequences in the form of worsening and sustained disability and distress.

Further problems are likely when avoidance behavior persists in spite of equally persistent failures to achieve pain reduction. Spending the day in bed to avoid pain simply doesn’t work. The pain returns. Pushing through the “pain barrier” doesn’t work – because beyond that barrier is more pain. In other words, pain persists in spite of persistent behavior to avoid it. Thus, excessive aversive control can lead to problems – avoidance attempts dominate as the goal is to avoid pain, these avoidance attempts fail as pain continues, and life becomes smaller and more limited for the person in pain.

Aversive control can be contrasted with appetitive control. It may be most helpful to define this latter term in relation to an example treatment approach: Acceptance and Commitment Therapy (ACT). ACT does not require elimination or reduction of pain for treatment success. It isn’t that ACT practitioners don’t want people to feel better, it’s that it isn’t a prerequisite for treatment success. ACT focuses neither on the elimination of experiences or symptoms, nor on aversive control. Instead, it aims to build behavioral repertoires that effectively achieve positive goals over the long term. The intended purpose is an increase in consistent and reliable engagement in valued activities with pain, both when it is low, but also when it isn’t. This non pain-contingent process relies on one of appetitive control over behavior, behavior that is directed towards the pursuit of what is desired.

These two aspects of control, aversive and appetitive, have particular relevance with regard to the goals of treatment. If a lack of acceptance is indeed a reflection of wide-spread aversive control, treatments that focus only, or primarily, on pain reduction may be ill-advised in a context of unwillingness to experience pain.

Perhaps paradoxically, significant unwillingness may signal a need for increased willingness in the service of valued activities, not less pain. In essence, what may be needed is appetitive control – the pursuit of activities that have importance, meaning, and value even with ongoing pain. Thus, the issue is not to just “accept it”, but to determine if there are areas in life worth the experience of pain. In my clinical experience, people with pain can readily identify these areas, desperately want to return to them, and agree that these areas matter even when pain is present. Such patient sentiments can allow further conversations about whether treatment might usefully include valued activities and progress towards them as a marker of treatment success.

To summarize, from one perspective, the purpose of treatment is to allow patients to engage in activities that allow for a quality of life sufficient for their needs. It is within this purpose that acceptance of pain can be relevant – sometimes greater acceptance of, and consequently less time and energy spent struggling and avoiding, pain may free up behavior to allow for the pursuit of what is valued.

Kevin E Vowles, University of New Mexico