S3:Ep22 – Acceptance and Commitment Therapy
Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.
This episode is brought to you in part by our generous sponsor, Lilly.
Dr. Melissa Geraghty: Hi, I’m Dr. Melissa Geraghty, and I am very honored to be here today to present about acceptance and commitment therapy. I’d like to start by telling you a little bit about myself. I’m a licensed clinical health psychologist specializing in chronic pain, complex medical, and eating disorders. I’m an international workshop presenter, and I’m a person with chronic pain and physical disabilities.
I specifically have five different types of migraine disease, including a CSF-leak-related headache from a neurosurgery I had in October 2019, and I also have a rare disease of my spinal cord. I’ve been a migraine advocate for quite a while, and I’m really just proud to say that I am now a CHAMP board member. I co-presented the opening workshop at RetreatMigraine in 2019, I’ve attended Headache on the Hill in 2018 and 2019, and I also was part of the INvisible Project: Migraine Edition by the U.S. Pain Foundation in 2017.
Moving along to this first slide here about navigating the migraine experience, I think most of us, if not all of us, can relate to this — of wishing that our expectations were smooth sailing, but in reality, having migraine disease is quite messy. It’s quite all over the place, so trying new medications, trying to figure out triggers and such, and it can be quite complex. And what I love about acceptance and commitment therapy — abbreviated it’s ACT — what I love about ACT is that it really allows us to learn how to live with this migraine experience and have more compassion with ourselves. And we’ll definitely be talking more about what that looks like.
There are six core processes of action. Before I go through those, what I have found that it’s best to learn ACT through experiential activities. And so with the time I have allotted, I’m going to do my very best to give a brief overview of ACT and how it can help with migraine and chronic pain in general since we won’t be able to do many experiential activities together.
So the first six core process of ACT is self as context, and that is we are not our thoughts, feelings, sensations, or the images we see in our heads; rather, we are the observer of our thoughts, feelings, etc. Acceptance, which is the willingness to experience difficult thoughts and experiences. Cognitive defusion — observing your thoughts without being ruled by them. Committed action — taking action to pursue the important things in our life. Values, which is what is truly important to you in life. And contact with the present moment, which is focused on the here and now or, otherwise, mindfulness.
And so psychological flexibility is the overarching goal in ACT. What that is is it’s the ability to stay in contact with the present moment regardless of unpleasant thoughts, feelings, and bodily sensations while choosing one’s behaviors based on the situation and personal values. So psychological flexibility is not a state of happiness or ease. It is really the ability to be able to navigate life in a flexible way, especially when difficult feelings and thoughts arise.
This is what’s called the ACT hexaflex. It goes through the six core processes of ACT and how these six core processes allow us to work towards psychological flexibility. So if I were to read all these in order, it would say, “Given a distinction between you and the experiences you’re struggling with, are you willing to have these experiences fully and without defense as they are and not as they say they are and do what takes you in the direction of your chosen values at this time in this situation?”
And so if you go ahead and break that down, essentially what this is showing us is that there’s different ways that we can help ourselves out when we’re dealing with difficult thoughts and emotions so that we can really learn how to, again, give ourselves a little more compassion.
ACT is inherently judgmental free. Some therapies unintentionally make people feel bad about having negative thoughts, and then we feel worse when we can’t stop thinking these negative thoughts. What ACT does is it shows us that we can’t control all the thoughts that we’re having or the feelings we’re having, but we can absolutely choose our actions and behaviors. What ACT also does is it teaches us that our brains give us so many different types of thoughts and that all thoughts are OK even if we don’t like them. What’s really cool too is through ACT, we learn that we can choose which thoughts we have stock in.
So, for example, if I’m having the thought that my migraine disease makes me a burden to my family, it’s not a helpful thought. So I can really look at it and be like, “All right, this is not a helpful thought for me to be having.” And it can very easily go down the rabbit hole of — I can start thinking my migraine disease is a burden. And then now I’m thinking that, “Well, no one likes me. I’m not going to be invited to anything anyway because people are going to be tired of dealing with the girl with the migraine attacks,” and so on and so forth. And then all of a sudden, we can get into this psychological turmoil because where we’re really taking stock in the thought of “My migraine disease makes me a burden to my family.”
And what ACT does is when we notice that we’re having unhelpful thoughts like this, we can ask ourselves, “Well, what else can we do in this moment instead of going down that rabbit hole?” And this allows us to shift our focus about what we’re doing to something we care about. Instead of trying to make ourselves feel worse or trying to force ourselves to feel better or arguing with these thoughts, ACT shows us we don’t have to do any of that. We can have those thoughts, recognize we’re having those thoughts, and then ask ourselves, “OK, what can we do in this moment to help ourselves out, give us a little compassion in this moment that we’re struggling in?”
With ACT, it has a lot of acronyms, and here’s one. Accept — abandoned the fight with your chronic pain. We’re going to talk more about what that means. Choose — choose mindfully how to live instead of allowing for automatic or conditioned responses to live life for you. And take action — live your life.
And so more about the psychological suffering — we know that physical pain and psychological suffering are very much tied together. So it’s our perception of pain that has an impact on our psychological suffering. If we begin to look at our pain differently and try to lean into it instead of steer away from it, our quality of life can begin to improve. And you may be thinking, “Lean into my pain. What is she thinking?” But stay with me. I’m going to explain it further as we go on to the next slides.
So, many people with chronic pain alter their life in some way to accommodate their pain because it’s ingrained in us to want to control it. However, what many of you may have found that the more we try to control our pain, the more resistance we’ll be met with. What I mean by this is if a person in pain continues to miss out on opportunities to connect with others due to pain, such as visiting a friend, they may think that they are controlling their pain by avoiding all these activities. Yet the problem is the pain still remains, and that’s not going to change. Days, weeks, months later, the person is still going to have pain but now with the burden of a life that doesn’t feel fulfilling because they’re not engaging in things that they care about.
So people with migraine, we know very well that in order to live our values, it is a delicate balance of honoring our triggers while still trying to be active in our life. And, of course, this is easier said than done, but it’s definitely possible.
With migraine, a lot of the time, our experience is about waiting. It’s about waiting for symptoms of an attack to lessen, waiting for medications to kick in, waiting for doctor’s appointments, waiting for medications and tests, and waiting to feel good enough to meet with friends. But if we use this waiting mentality in terms of living our values, we would be waiting forever and wouldn’t do anything meaningful. What I mean by that is sometimes people get in the trap of saying, “When I feel less pain, I’ll be able to do X, Y, and Z.”
But we all have the ability to live our values the best we can given the circumstances. It is possible to live with chronic pain and lead a valued life. And our lives may not look as how we intended, but they can still be full of meaning. So, for example, if I’m in a bad migraine attack, am I able to text a friend instead of doing a Zoom meeting with them or in-person because that’s just not feasible right now? How can I still live my values when I’m having a pain flare? What does that look like?
There’s this interesting concept of clean pain versus dirty pain. And clean pain is the actual pain sensations we’re having such as stabbing back pains, swollen and achy feet, migraine, neuropathy. So that’s clean pain.
Dirty pain, on the other hand, is our reactions to the pain. Dirty pain is trying to control and fix what can’t be controlled and fixed. So, some more examples — dirty pain is the thing your mind tells you about your physical pain. It’s all the things that can run through our heads when we engage in activity that can put us in more pain. It’s also the avoidance behaviors that we engage in in attempts to keep ourself from feeling pain.
And we know with migraine that sometimes there’s no discernible rhyme or reason for a migraine attack, but still many of us still like to try to control it as if there is. And dirty pain is also our attempts to relieve ourself from pain when relief might not be possible. So you see it can get really messy. And as it says here, raw pain — which is also clean pain — so raw pain by itself is not nearly as punishing and wrathful as raw pain plus psychological suffering, and that dirty pain is definitely that psychological suffering we’re talking about because it’s all the baggage we have to our reactions to pain.
Also, in society, we’re taught to distract and fix constantly. And what we find is that might work in the short-term for pain, but it doesn’t work in the long term. When we try to ignore our pain through distraction, it often ends up getting louder and louder trying to get our attention. And we’re so good at trying to distract and fix things in our society.
So, for example, if my car breaks, I take it to a mechanic and I get it fixed. If my fridge breaks, I get it fixed. I find out what the problem is; I get it fixed. But when it comes to our pain, it’s not that easy to just do a quick fix or just try to avoid the pain, especially when it’s just full throbbing in us. It’s in our face. It’s hard to avoid it.
So, while initially paying attention to our pain can be a scary thought and we might initially notice that our pain intensifizes — can you tell I’m having some migraine brain right now? So I’m going to say that again. So, while initially paying attention to pain might be scary to us, it’s really vital to surviving the chronic-pain experience, and we’ll talk more about that as well.
So, yeah, avoidance of pain, be it physical or psychological, it really gives the pain power and that eventually catches up to us. The more we try to avoid our pain experience, again, like the last slide, the more it gets into our face.
And that’s the same with avoidance of discomfort. Who wants to lean into pain, right? That sounds like a very odd request. But what we’ve found through ACT is that resisting our pain experience contributes to our psychological suffering in forms such as depression, anxiety, which then can also create more physical pain and more psychological pain.
However, if we address the pain as it comes or as it heightens, if we notice it and be curious about our pain, our brains attend to it in the moment, and then we can go ahead and settle around our pain experience. Of course, the pain is still there, but then it no longer owns us, and we can provide ourselves with the much-needed self-compassion that we deserve in that moment.
And while it’s beyond the scope of this presentation, ACT teaches people the many ways of how we can go ahead and lean into our pain. And I am going to give one example later on, but just know that not everyone is going to like every type of coping skill. And so in therapy sessions, I provide my patients with multiple different types of coping skills and ways of looking for things so they can definitely customize their coping skills to what helps them.
And so, like I said earlier, “Make yourself available to the discomfort and pain — what is she saying? Why would anyone want to do it?” And so I created this little image of this guy sweeping some stuff in a rug. And it’s always a good idea at the time, of like, “I’m just going to ignore this pain, so I’m going to sweep it under the rug. I’m just going to ignore these thoughts that I’m a burden. I’m going to sweep it under the rug.”
But what inevitably happens is it ends up exploding in our face. So we end up feeling overwhelmed, frustrated, having anxiety, having increased pain, lots of thoughts of “Why me?” and depression, explosions, right? All this stuff kind of gets in our face because we’re trying to avoid dealing with all of that.
And so a good analogy of why that’s not helpful is this tug-of-war analogy. So imagine pain, like migraine, is over here, and then you’re over here. And you’re in this tug-of-war with your migraine pain — or migraine symptoms. I mean, insert whatever you’d like in there, right, because we know that migraine is not just pain. It has a whole cluster of frustrating symptoms, right?
So we can be in this tug-of-war with our pain where it can go something like this: “Fuck this pain. I can’t believe this is happening again. I’m going to miss my kid’s activity again due to migraine. My wife is going to think I’m lazy because I can’t do the dishes because I have a migraine attack.” And around and around we go. So you can see that you’re in this war, this tug-of-war with your pain and the frustration of it.
And remember, as we talk about this, we can’t help thinking these thoughts. But when we find ourselves in this tug-of-war, full-out battle with our pain, we can do something about it to help ourselves out so we don’t go down that rabbit hole of thinking all these thoughts and just kind of staying there.
So, again, we have migraine, and we have ourselves here, and we’re in the tug-of-war. And so what seems to be a quick fix at the time is what I like to call a Band-Aid fix. So that might include distraction, denial, overuse of medication, alcohol or drugs, avoidance, napping. And while distraction, denial, avoidance, and napping is not always inherently bad — and sometimes these things can help us, of course — what happens is if we just continue to go ahead and rely on these things all the time, we can find ourselves in a trap where our life starts to get smaller as we can be consumed with constantly trying to avoid migraine attacks.
And even though, intellectually, we understand that we could do everything perfectly and still have a migraine attack, we can really get in this trap of narrowing our lives, of trying to really avoid an attack that we don’t know if that avoidance is even helping or not, right? So sometimes when we’re in a full-out tug-of-war battle with our migraine, we’re so physically and emotionally exhausted that we just want these quick fixes. And, like I said, sometimes these things — other than the overuse of medication, alcohol, and drugs — sometimes these things can be beneficial. Maybe we need a nap. For some people with migraine, a nap can take their migraine pain away.
So, again, it’s not that this is a black and white. But if all we are doing is napping all day long, that, of course, can increase depression, increase anxiety, increase our social schedule from going maybe like this to this. So doing these Band-Aid fixes, while they might be helpful in the short term, can really hinder us in the long-term.
So what this looks like, if we try to get a visual in our minds of this tug-of-war that we’re having, is if we can notice that we’re having the tug-of-war and then go ahead and try to drop the rope. Trying to drop the rope means trying to drop that fight, the constant back and forth of where our pain brains can take us.
So it’s recognizing that this pain is what it is. How can I take care of myself in this moment? Should I ask for help? Should I text a friend? So instead of engaging with that “Why me? I can’t believe this is happening. Oh, my goodness, blah, blah, blah,” and fighting it, we’re dropping the rope and going, “OK, my pain’s here. What can I do right now to help myself out and give myself compassion?”
And that leads us to the point of acceptance. So “acceptance is the act by which you allow yourself to willingly engage in your pain.” And, really, acceptance is all about empowerment. It doesn’t mean you like your situation. It doesn’t mean that you’re going to stop trying or that you’ve stopped having hope for treatments that may help. It’s not that at all.
Acceptance really curbs the need to fight a constant psychological battle with yourself. It’s like dropping the rope in that last slide. And when you go ahead and accept your situation, you’re no longer stuck in the trap of waiting to have less pain or less anxiety or less depression to participate in your life. You can start living life now no matter your physical disabilities. And, of course, it may not look how you want it to look, but you can still find ways to engage in your values.
So it’s important to note that the willingness to work on acceptance can absolutely come and go. What I like to share is that sometimes my bratty self comes out, as I call it and says, “Fuck this migraine. I’m beyond coping. I’m not doing anything in the moment to help myself out.” And I pout and complain. And, yeah, I mean, I do this for a living, and of course I’m still going to fall in that trap sometimes when I’m in particularly bad pain flares, and that’s OK.
But also, when this happens, when that bratty beyond-coping-skills self comes out, my psychological suffering increases, and many times so does my pain. So this process isn’t going to look perfect, and there’s no way that you’re going to be able to have acceptance of your pain all the time. But it’s really important that we try to strive for it and really allow ourselves, again, some compassion. And I know I’ve said that many times in this presentation, but I think it’s really hard for a lot of people who have chronic illnesses to give ourselves that. So that’s why I keep repeating that throughout this presentation.
So understanding more about acceptance is there is a difference between acceptance and resignation, and I think that’s why a lot of people are turned off with the term acceptance because they think of this version of acceptance. So acceptance with resignation, that steals more hope than pain itself can do. But acceptance with resilience, which is the type of acceptance we’re talking about, really makes it possible for a person to reinvent him or herself.
And what this looks like is this example in Dr. Webster’s book. So Marsha says, “This is my life from now on. I’ve got to either deal with it or crack up.” And Dr. Webster goes on to say, “Marsha was resilient. She acknowledged that pain had become a permanent presence in her life and then set about trying to make the best of her new situation.” And there is indeed a freedom in self-acceptance and compassion. And that’s what I love about ACT is it does allow you to look at your pain a bit differently.
So what’s the point of all this? What happens when you work towards accepting your current situation, leaning into the pain, and practicing dropping the rope? You no longer are defined solely by your pain, and you can make room for other aspects of you, and this can look like this.
So pain and disability are a huge part of my identity, and it impacts every part of my life, and I also have many values that I care about and I focus on. I am disabled, and I have values and goals, so I think that’s worth saying again. It doesn’t have to be one or the other.
In the disabled community, especially over the past few years, there are movements that say, “Say the word,” so say the word disabled, not differently abled. Even the phrase “I am not my illness” has fallen under scrutiny. And while there are many aspects that make up me, I can’t just remove being disabled. I can’t just wake up one day and decide “I’m not disabled,” in my mind.
And I think it’s best to identify what fits you and with the knowledge that it’s okay to go ahead and change that identity. So for me personally, I strongly identify with being disabled, but it also doesn’t dismiss all the other facets of me. Again, it doesn’t have to be one or the other. I have a rare disease, I have multiple migraine diagnoses, but I’m also a Lord of the Rings fan, as you can see here, a doctor, a wife, amateur gardener. So I’m all these other things.
And, oftentimes, what happens is when we are starting to feel like we’re becoming more defined with our pain because it takes up so many facets of our life, some of these other things that we care about can go on the wayside. And what ACT does is it allows us to try to get in contact with some of those things that maybe we have put on the side because we’re focusing on being full-time pain patients — contacting insurance, going to doctor’s appointments, being in rooms with the shades closed. All these sort of things absolutely impact our life. And, again, ACT wants to acknowledge those things that impact your life and also gently allow you and encourage you to be able to fit in some things that you really care about too.
So there are many common reasons people give for avoiding self-care, and here’s some of them. We’re going to go through them. “I’ve tried these mindfulness therapy techniques before, and they don’t work. My pain is real.” “This can’t possibly make a difference — my pain is real, not in my head.” “I’m not the relaxing type.” “It won’t work.” “My family needs me, so I don’t have time for myself.” “I’m in too much pain.” “I’m too tired.” “I don’t have the energy.” “I don’t have the time.” “What will people think if they see me doing nothing? I do so little as it is.” “It’s selfish to take time for myself.” “I already have too many things to do.” “I have ADHD, so I can’t pay attention long enough.” “This is hippie new-age crap.”
So if you’ve thought any of these or all of these, you can thank your mind for these thoughts and then practice self-care anyway. And many times when I end up hearing these things, I talk to the person more about the context, because it turns out that there’s a lot of misinformation about certain coping skills. And, unfortunately, sometimes people have been taught incorrectly by counselors who weren’t trained in pain. And so that’s why I’ll have people say, “No, I’ve tried that mindfulness crap before, and it doesn’t work.”
And like with this example, mindfulness — mindfulness is not supposed to be unicorns and rainbows. The intent is not to take the pain away. The true goal of mindfulness is actually to learn how to attend to the present moment, which includes learning how to lean into our pain instead of run from it.
But a lot of times, when people hear the word mindfulness, they get very triggered and thinking that, “Well, that didn’t help me. I’m still thinking when I’m doing mindfulness,” or, “My pain is still there.” And it’s not about that. So that’s why I like definitely talking to my patients about the context of how they tried certain things or where they’ve heard certain things, because often we’ll find that it’s because they haven’t heard the proper explanation of it.
So now we’re going to go ahead and assign some homework for all of you. And this model here is my pug, King Leonidas. Cutie, right? So, mindfulness of physical pain — this is something that I created for my patients, and many of my patients will put it in their phones so it’s easily accessible or have a printout in a therapy binder or such. And this is an example of how we can lean into our pain.
So P is pursue the present moment. Breathe slowly and deeply. Notice the colors, objects, and noises around you. And what this does is often when we’re in specifically a severe pain episode, our mind can be just swimming with all things pain. And so having to take the time to actually look at colors, objects, and such might sound juvenile, but what it does is it physiologically kind of slows our brain down in order to ground ourselves. So it can really help ourselves out.
So A is allow yourself to lean into your pain. So make room for it; acknowledge its presence. Remember when we ignore or distract from our pain, we can only do this for so long before our pain heightens, right? This is just like the slide where I showed the guy sweeping everything under the rug, that we can only ignore it for so long before, poof, it goes up in our face.
I is interview your experience. Be inquisitive. Am I experiencing stabbing pain, lightning pain? Am I feeling sad or frustrated? So this is that part of leaning into our pain again.
And N, now act on your values. Values are the things we care most about in life, such as self-care, relationships, and creativity. In this moment, should you use a heating pad, color a mandala, talk with a loved one, pet your dog, cuddle up with a blanket or a movie?
So notice that the goal here isn’t to be like, “Oh, you’re going to do these things, and you’re going to get out of pain.” That’s not realistic. The goal here is to be like, “Oh, you’re going to do these things, and while the pain may still be there, you’re also going to do things to take care of yourself and to live your values so that you feel like you’re living a more enriched life.”
So I’m hoping that this mindfulness of physical pain will give you a little bit of insight of how you’re able to help yourself and still live your values while you’re in pain. And it’s not easy, but it’s definitely worth it. I really like this picture. “You are not weak because your illness. You did not fail treatments. The treatments failed you. Your illness is not your fault, you did not cause this.” And “You are not a failure. You are a warrior.”
So here are some references I have if you’re interested in learning more about ACT. There’s this great summary called “Embracing Your Demons” that I have right here. Also, some further reading, and if you’re interested in finding a psychologist that specializes in ACT for chronic pain, you can go ahead and access the Association for Contextual Behavioral Science website.
I actually have this picture on a shirt, and I wore it to one of the Headache on the Hill retreats. And it’s just very near and dear to my heart because I really look at us as being migraine warriors. If you’re interested in following me at all, here are some of my social media websites. I do tend to post a lot about chronic pain and mindfulness, depression, and eating disorders. So I’d love to be able to support you in that way.
And thank you so much for having me. I hope that this brief synopsis of ACT gave you some things to think about.
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*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.