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In the mid-1990s, when my pain began, I spied a note penned in my chart at a pain clinic that said, “refuses to accept the situation.” I thought, “Who wouldn’t?” The note seemed absurd. My pain was severe, debilitating, and virtually unrelenting. Accepting how I felt would have been terrifying and depressing. I craved hope and relief, not “acceptance.”
I have since learned that living well with chronic pain requires a level of acceptance. However, by acceptance, I do not mean resignation, giving up, or believing that nothing will change. Such negative sentiments are often communicated in comments like, “you have to live with this.” Yet even the meaning of this phrase depends on how you say it. If you emphasize “live,” the focus can be on how to live, as in a worthwhile life. Emphasizing “with” acknowledges the relationship; and, as in all relationships, chronic pain has ups and downs that can change with deliberate attention. Emphasizing “this” can refer to how things are this moment, rather than a projection into the future. Acceptance includes all of these.
The change-acceptance dialectic
Acceptance is the effective alternative to denying or fighting reality, wishing things were otherwise or fixating on how they “should” be. Pain in life is inevitable, but suffering and misery are not. These can result from the way we respond to pain. The more we fight against it, the more likely we are to experience negative emotions, such as anger, hopelessness, and despair, and the harder it becomes to identify changes that can help. Like those Chinese finger-trap toys, the more forcefully we tug to release our index fingers, the more tightly ensnared they become. Calming down and taking stock of the situation opens the means to escape.
As Marsha Linehan, founder of dialectical behavioral therapy (DBT) succinctly expressed: pain without acceptance = suffering. Linehan created the therapeutic approach of DBT to alleviate the intense emotional pain associated with borderline personality disorder. Its core assumption is that change and acceptance are intertwined. At first glance, this can be hard to fathom. We typically think of our efforts to change things as emerging out of non-acceptance. We either decide to accept things as they are or we seek to change: change or acceptance, not both.
Consider the process that led to the DBT’s creation. In the late 1970s, Dr. Linehan wanted to test the effectiveness of behavioral change strategies on a population with unequivocal suffering and gathered a clinical sample of women with recent suicide attempts and/or persistent thoughts about ending their life. She quickly learned that the implicit message in her behavioral change strategies pathologized the women she sought to help: “If I need to change, there must be something wrong with me.” Because many of the women were raised in environments that were abusive, neglectful, or otherwise unresponsive to their needs, this message was particularly invalidating.
In response, Linehan incorporated messages from Zen Buddhist traditions that emphasized acceptance. This approach focused on the women’s strength and current capabilities rather than their need to change. The women craved acceptance, but not at the risk of downplaying their hardship. Acceptance, alone, elicited the response: “Can’t you see I am in terrible pain?”
Dr. Linehan, and her colleagues at the University of Washington, eventually realized they would have to integrate approaches to change and acceptance in a way that somehow harmonized them. Their inspiration arrived in the concept of “dialectic,” meaning the synthesis of seemingly oppositional viewpoints to arrive at a new place.
Linehan and her colleagues built DBT on the premise that people have the capacity to hold conflicting ideas. In DBT, clients learn skills to practice self-acceptance and constructive change, and work together with their therapist to resolve perceived contradictions between these. Healing also comes from refuting false dichotomies in favor of a middle path. This includes acknowledging therapist and client as similarly fallible and accountable, and change as constant and inevitable.
As a psychotherapist who has been teaching weekly DBT skills classes since 2005, I have witnessed dramatic results. As someone living with chronic physical pain, these skills have also been invaluable in my own journey. My clients often say that DBT should be mandatory education.
All-or-nothing thinking
As a culture, we frequently rely on cognitive shortcuts, such as seeing a situation or person as “all good” or “all bad,” which relieves us from more in-depth consideration of nuances and complexity. Consider how rare it is in our bipartisan political system for members of one party to support the other’s proposals. So what happens? We can end up stuck, unable to move forward. People tend to be either “pro” or “con,” despite the vast area that exists in between.
This dichotomous all-or-nothing paradigm also pigeonholes individual responses into more extreme interpretations or reactions. Assuming an “all bad” vantage point intensifies negativity, which can color the entirety of an experience. When we label something as problematic, we become more likely to neglect contrary data. Assuming “all good” sets up unrealistic expectations that cannot be maintained. This is intensified in individuals with borderline personality disorder, who often fluctuate between idealized views and intense disappointment. The teachings of DBT are useful for improving life with chronic pain of all kinds. Consider the following:
The sick-well dialectic
The simplistic notion that people are either sick or well is inadequate when considering chronic pain. People living with ongoing pain must resist the urge to put their life on hold until their pain stops. Living well with chronic pain instead relies on the ability to consider the uncomfortable grey area (in-between sick and well). Rejecting the reality that pain, even severe pain, can be part of life prevents effective adaptation. Accepting one’s pain does not imply that it will never improve. However, waiting for the absence of pain interferes with the vital work of living. The pain dialectic is about figuring out what life can be at this moment.
Societal messages can interfere. Despite the prevalence of chronic pain, popular discourse often represents pain as something that can be subdued with medication or overcome through willpower. Greeting cards wish a “speedy recovery” or “Get better soon!” but lack narratives about ongoing pain. When the benchmarks for health and happiness are high, individuals may become more vulnerable to judging their own struggles as unacceptable, which adds to suffering. This can also be intensified by the invisible nature of pain. Individuals who suffer from maladies that are imperceptible to others may feel judged or pressure to fit into a sick/well dichotomy that adequately represents their experience. Responding to the mundane query of "How are you?" with "I hurt like hell and am doing the best I can" challenges convention.
Synthesizing the extremes
When pain is intense and/or frequent, it's particularly challenging to avoid extreme thinking. Yet, alarmist, negative self-talk can turn pain into suffering in a flash. Consider the following thoughts:
- I can’t stand this.
- The pain has to stop.
- I will resume my life when the pain’s gone.
- I am nothing if I can’t _____ [fill in meaningful activity/role].
These are understandable reactions to pain. However such statements of non-acceptance interfere with positive change. Consider the result of taking a leap of faith and synthesizes the extremes:
- I cannot stand this but I am standing this.
- The pain is what it is.
- I am living right now, even with this pain.
- I am many things. Pain is one part of my experience.
Acceptance of reality keeps people from retreating from life, despite difficulties. When it comes to pain, or any experience, all we ever have to survive is this very moment. Acceptance focuses on the present moment, for what it is, rather than forecasting a worst case scenario or engaging in other emotion-laden narrative. Worrying about a future moment only adds distress to this one. Through acceptance, people can commit to the process of coping as best as they can. It also reduces painful flare-ups and subsequent negative self-talk that come from denying the problem, which often leads to overdoing it.
Read on for some specific skills from DBT that help with chronic pains of all kinds:
