ACT: Is it anything to get excited about?

Physiotherapists tend to have a bit of a reputation for jumping onto bandwagons. In writing this blog I am committing hypocrisy by admitting I am a strong proponent of Acceptance and Commitment Therapy (ACT).

Yes, it’s true I can be accused of jumping onto a bandwagon. If I look up the meaning of bandwagon here’s what shows up:

The etymological meaning – (1899) “attaching oneself to anything that looks likely to succeed”

The modern dictionary – ‘used in reference to an activity, cause, etc. that is currently fashionable or popular and attracting increasing support’

So the more people that adopt a particular trend, the more likely it becomes that other people will also hop on the same bandwagon.

Why do we jump on bandwagons?

There a number of reasons:

1. The need for inclusion, we do it because we don’t want to be left out irrespective of our values or beliefs.
2. Physiotherapy’s endless entanglement with its own existential crisis.
3. They can give us purpose and meaning.
4. A desire to be right.
5. Align our beliefs and behaviours with a group. Social psychology refers to this as herd mentality or ‘groupthink’.

So, Is ACT anything to get excited about?

I can’t say I’ve met any proponent of ACT that gets hugely excited about it. I personally, do lean on it fairly heavily and that’s not because ACT has become a bandwagon.

The evidence base has shown, if we specifically look at biomedical processes of disease treatment/management, there is little in the way of success in long term outcomes for persistent pain (Vowles & Thompson, 2011). It could be argued that pain in some cannot reliably or clinically be treated with mainstream medical care without potential harm and perpetuation of pain states. In addition, the ongoing pursuit of pain reduction or elimination reinforces a message that pain must be reduced in order to improve function. Furthermore, the research base suggests that ongoing and increasing biomedical escalation can lead to an increase in worry and hypervigilance (Eccleston & Crombez, 2007) and that frequent fighting for pain control is a reliable predictor of worse pain, greater disability, higher depression and distress, more pain related fear and avoidance and more healthcare use (McCracken, Eccleston, & Bell, 2005; McCracken, Vowles, & Gauntlett-Gilbert, 2007; Vowles & McCracken, 2010; Vowles, McCracken, Sowden, & Ashworth, 2014).

The ACT argument is that meaningful function can be restored in spite of a perpetuating pain state. ACT does not target pain reduction or elimination as per mainstream medical care. Instead, ACT examines ways of reducing suffering that is commonly associated with persistent pain. Unfortunately, right now, there is no “cure” for pain. This idea or notion of a “cure” for pain creates a whole other phenomenological and philosophical argument, which is beyond the content of this blog.

A wee side note…

Physiotherapy is in the midst of embracing the CBT approach of cognitive restructuring, a process by which clients evaluate, challenge and construct alternative thoughts with supporting evidence (Hayes, 2019; Thorn, 2017).

The physiotherapy profession is embracing more psychologically informed practices, which is great, but I find I am conflicted with the need to justify psychologically informed practice within physiotherapy. To me this is purely about justifying our existence as a profession as we start to drift into psychological practices. There is a significant evidence base supporting psychological approaches within chronic pain that, if working as part of an MDT/IDT, informs and supports all members as we should work collaboratively with each other and with the person living with pain. Perhaps an area of upskilling on my part….

Furthermore, a problem I have with evidence based practice is that we tend to lean quite heavily upon it to support our reasoning or put another way to support our biases. An unfortunate flaw in our ability to think critically.  

Back to Cognitive Restructuring and ACT…

As Hayes (2019) highlights in his book the premise behind restructuring thoughts was to address flawed habits of thinking, yet the challenges of trying to change thoughts is essentially underpinned by a biomedical approach. Essentially “fixing” flawed thinking. In contrast, Thorn (2017) identifies that the power of cognitive restructuring lies not in changing thoughts but changing the relationship to our thoughts. Isn’t that the premise behind ACT? More upskilling on my part…

So whilst ACT is aligned with other psychological approaches such as CBT, it’s important to identify how it compares with CBT and even exercise.

Given that ACT is still a very young approach and CBT is mature and has an extensive research base, ACT stacks up rather well. A recent systematic review and meta-analysis from Hughes, Clark, Colclough, Dale, & Mcmillan, (2017) identified ‘In the one study to compare ACT with CBT, few differences were identified, though on a small number of measures small effects favoured CBT over ACT’ and that ‘the evidence base for the effectiveness of ACT relative to other active treatments remains limited due to a lack of RCTs comparing ACT to more substantial active comparators for chronic pain, such as multi- component CBT.’ So there just aren’t the studies as yet comparing ACT and CBT. Personally, I find it a tad harsh when someone criticizes a method that shows significant promise alongside mainstream psychological therapies such as CBT or exercise.

Why am I such an advocate?

I’ve written about how Physiotherapists and Occupational Therapists are perfectly aligned to deliver ACT based approaches.  Embedded within ACT is the philosophical basis of ‘functional contextualism.’ Functional contextualism is a pragmatic point of view, the act of doing, something that aligns with PT and OT philosophy given what we do is based within movement and activity.

Functional contextualism is about finding useful ways to help people learn what works to increase valued living in diverse situations and life circumstances. So, what this means is that people try to find things that work for them in the context of their lives. It’s not about right or wrong, such as in the face of pain i.e. “I shouldn’t do this because I will do more damage because that’s what the pain is telling me”, ACT is simply and pragmatically ‘making room’ to enhance valued living.

I think the reason why I am such an advocate is because of how versatile ACT is in the way it wants to “work with” rather than “do to” a person living with pain. ACT is honest, non-judgemental nor didactic, nor is it paternalistic or dogmatic. It intends to support people by finding workable ways of living with the challenges of adversity that life throws at us rather than always trying to fix. Is that not something that we could all benefit from??

I want to leave you with a quote from the founders of ACT. I believe all individuals that adopt ACT as an approach accept that it could so easily become a bandwagon, but they recognise that ultimately things will change and that they intend to act with flexibility as the research base continues to expand and likely comes under scrutiny.

“Given enough time, scientific theories are found to be wanting.  So far, that is without exception, and we have no reason to believe that psychological flexibility as a model or ACT as a method, as they are now understood, will ultimately escape the ash bin of history. The point is not to create a theoretical or clinical monument to immortality. The point is to create progress in our scientific understanding of human behaviour across multiple domains” (Hayes, Strosahl, & Wilson, 2016, p. 355)

Thanks for having a read

TNP

References

Eccleston, C., & Crombez, G. (2007). Worry and chronic pain : A misdirected problem solving model. Pain, 132(3), 233–236. https://doi.org/10.1016/j.pain.2007.09.014

Hayes, S. C. (2019). A Liberated Mind: How to Pivot Towards What Matters Most. New York: Avery.

Hayes, S. C., Strosahl, K., & Wilson, K. G. (2016). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change (Second Edi). Guilford Publications.

Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & Mcmillan, D. (2017). Acceptance and Commitment Therapy (ACT) for chronic pain: A systematic review and meta-analyses. The Clinical Journal of Pain, 33(6), 552–568. https://doi.org/10.1097/AJP.0000000000000425

McCracken, L. M., Eccleston, C., & Bell, L. (2005). Clinical assessment of behavioral coping responses: Preliminary results from a brief inventory. European Journal of Pain. https://doi.org/10.1016/j.ejpain.2004.04.005

McCracken, L. M., Vowles, K. E., & Gauntlett-Gilbert, J. (2007). A prospective investigation of acceptance and control-oriented coping with chronic pain. Journal of Behavioral Medicine. https://doi.org/10.1007/s10865-007-9104-9

Thorn, B. E. (2017). Cognitive Therapy for Chronic Pain (2nd Editio). New York: The Guilford Press.

Vowles, K. E., & McCracken, L. M. (2010). Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes. Behaviour Research and Therapy. https://doi.org/10.1016/j.brat.2009.09.011

Vowles, K. E., McCracken, L. M., Sowden, G., & Ashworth, J. (2014). Psychological flexibility in coping with chronic pain: Further examination of the brief pain coping inventory-2. Clinical Journal of Pain. https://doi.org/10.1097/AJP.0b013e31829ea187

Vowles, K. E., & Thompson, M. (2011). Acceptance and Commitment Therapy for Chronic Pain. In L. M. McCracken (Ed.), Mindfulness and Acceptance in Behavioural Medicine: Current Theory & Practice. Oakland, CA: New Harbinger Publications.