Over recent decades, a reasonable amount of data has been generated which suggests that greater acceptance of chronic pain is associated with fewer pain-related difficulties, such as distress and disability, and better overall quality of life (for reviews, see: McCracken & Vowles, 2014; Scott & McCracken, 2015; Vowles & Thompson, 2011). Pragmatically, however, the idea that one might want to be more “accepting” of chronic pain runs contrary to common sense and may be confusing. It may also lead to people with pain simply being told to “accept it,” which generally fails to do much of anything useful. Part of the confusion surrounding acceptance may arise from the history behind behavioral approaches to health as they compare to modern approaches that often prioritize the 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. My hope for this blog is to provide clarity in relation to the potential areas for confusion regarding the proposed role and purpose of acceptance as it pertains to chronic pain.
An accurate understanding of acceptance in chronic pain requires some history. The study of acceptance can trace its roots back to the radical, or “thoroughgoing,” behaviorism of Skinner (Skinner, 1945, 1974; also see Moore, 2008 for an outstanding book-length exposition on radical behaviorism). Skinner’s work has two important facets as it relates to why greater acceptance of pain might be useful.
The first is that the radical behavioral tradition views strictly eliminative approaches, those which prioritize the elimination of behavior or symptoms, and are therefore based in aversive control (Follette, Linnerooth, & Ruckstuhl, 2001; Lovibond, 1970), as highly problematic. The problem with these approaches stems principally from the fact that aversive control leads to a narrowing of response options, which generally function as attempts to avoid or escape from the aversive experience, as well as an insensitivity to the relation between behavior and its consequences (Goldiamond, 1974; Hawkins, 1986). In chronic pain, for example, response options to pain can narrow such that the dominant mode of responding is one of pain avoidance – the person’s life is dominated by efforts to avoid or eliminate pain. The literature is replete with data suggesting that such inflexible avoidance brings with it broader negative consequences in the form of worsening and sustained disability and distress. The well-established fear avoidance model of pain (Leeuw et al., 2007; Lethem, Slade, Troup, & Bentley, 1983; Vlaeyen & Linton, 2000) represents a prime example focusing the deleterious impact of persistent avoidance on functioning. From the perspective of radical behaviorism, the problem here is not limited to avoidance and its associated problems, further problems are likely when avoidance behavior persists in spite of equally persistent failures to achieve its objective (i.e., pain reduction or elimination) over the longer term. Spending the day in bed to avoid pain simply doesn’t work for those who have chronic pain. 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. Persistent pain unwillingness, the antithesis of pain acceptance, may likewise reflect maladaptive behavior control efforts and indicate an insensitivity, or lack of responsiveness, to the equally persistent failing quality of the respondent behavior. Thus, excessive aversive control can lead to problems – avoidance attempts dominate as the goal is to avoid the aversive sensation of 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 based in Skinner’s radical behaviorism, that of Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 2012). As part of its stated success criteria for chronic pain, ACT does not require elimination, or even reduction, of pain – or other aversive experiences for that matter (see Vowles, 2015 for an introduction to a special issue on this topic) – 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 making use of 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 over an individual’s behavior, then perhaps treatments which are predominantly reliant on aversive control themselves, in this case treatments that focus only or primarily on pain reduction, may be ill-advised in a context of significant unwillingness to experience pain. Perhaps paradoxically, significant unwillingness may signal a need for increased willingness in the service of valued activities, not less pain, better pain “management”, or other similar interventions. 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 that are worth the experience of pain. In my clinical experience, people with pain can readily identify these areas, desperately want to return to them, and readily agree that these areas matter even when pain is present. Such patient sentiments can allow further conversations about whether treatment might usefully include valued areas 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.
If you would like to know more Kevin Vowles is giving a course at Neuroscience Research Australia, Sydney, Australia on the 19th – 20th of March. Places are filling fast so book now if you would like to attend. To register click here: Working with Acceptance, Mindfulness, and Values in Chronic Pain: A Skills Building Workshop
About Kevin Vowles
Over the course of his career, Kevin has worked almost exclusively in the area of chronic pain and has been a key figure in the development and adaptation of Acceptance and Commitment Therapy (ACT) for this complex condition. He has authored many of the key research publications in this area and his work is cited by the American Psychological Association’s Division of Clinical Psychology in their listing of ACT for chronic pain as an intervention with strong research support: the highest possible grading.
Kevin completed his PhD in clinical psychology at West Virginia University in 2004 and post-doctoral fellowship at the University of Virginia the following year. From 2005 to 2009, he was employed by the Centre for Pain Research at the University of Bath. Beginning in 2009, he accepted a position to provide psychology leadership in developing a novel interdisciplinary pain rehabilitation program with Keele University. After three years of trial funding, this program was deemed by the UK’s National Health Service to be highly effective in both clinical and financial terms and permanent funding was secured. This service was awarded with the National Care Integration Award in 2012. That same year, Kevin moved to the Department of Psychology at the University of New Mexico, where he is currently an Associate Professor, to continue his work in the development and evaluation of treatment methodologies for those experiencing chronic pain and illness. He has published over 65 articles in the area since 2002.
Follette, W. C., Linnerooth, P. J. N., & Ruckstuhl, L. E. (2001). Positive psychology: A clinical behavior analytic perspective. Journal of Humanistic Psychology, 41, 102–134.
Goldiamond, I. (1974). Toward a constructional approach to social problems: Ethical and constitutional issues raised by applied behavior analysis. Behaviorism, 2, 1–84.
Hawkins, R. P. (1986). Selection of target behaviors. In R. O. Nelson & S. C. Hayes (Eds.), Conceptual foundations of behavioral assessment (pp. 331–376). New York: Guilford Press.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The process and practice of mindful change (2nd ed.). New York: Guilford Press.
Leeuw, M., Goossens, M. E. J. B., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. S. (2007). The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. Journal of Behavioral Medicine, 30, 77–94.
Lethem, J., Slade, P. D., Troup, J. D., & Bentley, G. (1983). Outline of a Fear-Avoidance Model of exaggerated pain perception–I. Behaviour Research and Therapy, 21, 401–408.
Lovibond, S. H. (1970). Aversive control of behavior. Behavior Therapy, 1, 80–91.
McCracken, L. M., & Vowles, K. E. (2014). Acceptance and Commitment Therapy and mindfulness for chronic pain: Model, process, and progress. American Psychologist, 69, 178–187.
Moore, J. (2008). Conceptual foundations of radical behaviorism. Cornwall-on-Hudson, NY: Sloan.
Scott, W., & McCracken, L. M. (2015). Psychological flexibility, Acceptance and Commitment Therapy, and chronic pain. Current Opinion in Psychology.
Skinner, B. F. (1945). The operational analysis of psychological terms. Psychological Review, 52, 270–277. http://doi.org/10.1037/h0062535
Skinner, B. F. (1974). About behaviorism. New York: Random House.
Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85, 317–332.
Vowles, K. E. (2015). Editorial overview: Third wave behavior therapies. Current Opinion in Psychology, 2, v–viii. http://doi.org/10.1016/j.copsyc.2015.03.008
Vowles, K. E., & Thompson, M. (2011). Acceptance and Commitment Therapy for chronic pain. In L. M. McCracken (Ed.), Mindfulness and acceptance in behavioral medicine: Current theory and practice (pp. 31–60). Oakland, CA: New Harbinger Publications.