Mindfulness, CBT and ACT for Chronic Pain
Always helpful, often necessary, but rarely sufficient
Posted December 8, 2014
I have procrastinated in writing this blog. It has taken me some time to come to a clear understanding of the role of mindfulness for people with chronic painful conditions. I have struggled to align my belief in the power and usefulness of mindfulness in general with the results from experience and research on the actual effects of mindfulness when applied to individuals with chronic pain.
The practice of mindfulness changed my life in the 1990s in many substantial ways. It opened up doors to a better understanding of myself and the world around me. When I became a teacher of mindfulness meditation in 1999, I was excited to be able to help others discover the value in sitting with an open, non-judging, and loving mind. Given that the application of these ancient concepts had been so meaningful and useful to me, I assumed others would find similar results. These assumptions proved to be correct. People who took my mindfulness classes uniformly found it to be helpful, on a scale from moderately useful in coping with the stresses of life, to utterly life changing.
Based upon some preliminary research studies and the anecdotal experiences of other mindfulness teachers, I also thought that people who were suffering from chronic painful conditions would be helped as well. However, for the most part, I have not found this to be the case. People who took my mindfulness classes to better cope with life stress, worry and anxiety typically found benefit, as did those who happened to have chronic pain. But we usually noted few changes in the actual severity of the pain itself. I rationalized this finding to my inexperience as a mindfulness teacher, which was certainly a possible explanation, although I worked diligently to be the best teacher that I could be. Or I just assumed that the people I was seeing with chronic pain were simply unable to approach the breadth and depth of mindfulness in order to change their lives.
In 2002, I started a new medical practice using a novel mind body approach for people with chronic pain. The impetus for this practice was the work of Dr. John Sarno. Back in the 1980’s, Dr. Sarno recognized that a substantial portion of individuals with chronic pain did not have structural disease processes. He found that many people could recover from chronic back pain and other associated conditions by understanding this simple truth and by changing their view of the source and meaning of their pain. This understanding was a major awakening for me, in a similar way to the awakening that I had when I began to practice mindfulness.
As I began working with patients, I found that it was relatively easy most of the time to identify the sources of pain (structural disease processes versus pain caused by neural pathways). I also discovered that many people recovered from neural pathway type pain using the approach outlined by Dr. Sarno. The approach outlined by Dr. Sarno did not incorporate mindfulness techniques. Yet, the results were often dramatic, i.e., chronic pain was actually eliminated or drastically reduced within a relatively short time in a majority of people who adopted this approach. This was clearly different from the situation in which chronic pain patients were helped to better cope with pain. I was quite surprised and amazed. As a doctor who had just learned this mind body approach, I was helping patients become pain free. How and why was this happening? And how should mindfulness be incorporated into this treatment model?
Over time, I worked to better understand these processes. I read as much as I could about chronic pain. I carefully reviewed available research on the various methods of pain treatment, including the studies using mindfulness. Here’s what I found.
Over the past two decades, there have been hundreds of studies published on mindfulness. A brief review was published in a recent edition of Scientific American. A much more extensive series of reviews can be found in The Wiley Blackwell Handbook on Mindfulness edited by Dr. Ellen Langer. We now know that mindfulness practice results in positive changes in one’s brain. This has been shown in people who are long-time daily meditators as well as in those who are just beginning their practice. These changes consist of alterations in brain wiring patterns and increases in volumes of certain brain regions. These changes are associated with increases in overall well-being and decreases in fear (amygdala function) reactivity. Studies of mindfulness in people with anxiety and depression demonstrate significant reductions in symptoms. There are even changes on chromosomes suggesting that markers of aging can be altered. Overall, this is very impressive and very encouraging.
However, research conducted in the area of chronic pain is not as positive. In 2007, Grossman and colleagues found mindfulness practice to be effective in a group of people diagnosed with fibromyalgia, in a quasi-randomized study. However, when these investigators conducted a more complete follow up evaluation in 2011, using a more rigorous randomization scheme, he found improvements in quality of life measures, but no improvements in pain severity.
These results were very similar to the studies using cognitive-behavior therapy (CBT) for chronic pain. This body of research shows that CBT has a similar pattern of effectiveness for chronic pain in general, and for fibromyalgia in particular, i.e., mild to moderate improvements in mood and quality of life, but very small changes in pain severity.
A few years ago, another psychological intervention for chronic pain became popular, acceptance and commitment therapy (ACT). ACT is a combination of CBT and mindfulness. Looking closely at the results of ACT reveals the same pattern. Once again, little effect on pain itself.
A study by Wetherell et. al. compared ACT to CBT and found that both interventions decreased pain interference (in other words, these methods helped people to function better with pain), yet neither decreased pain severity.
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Why does chronic pain not respond to these interventions? And why do most peoplewho use the approach that I learned from Dr. Sarno see significant reductions in actual pain? I pondered this for quite some time and I will summarize my thoughts here. For a more complete discussion, please see a chapter I wrote for Dr. Langer’s book of collected essays on mindfulness.
In order to understand the reasons for these research results in my opinion, it is necessary to think about chronic pain in a new way. I have blogged about the phenomenon of chronic pain on this website by examining pain itself, neuroplasticity and the role of the brain in creating or exacerbating pain.
As I have discovered, many if not most people with chronic pain do not have a structural cause for their pain. Their pain is real, very real, and it is caused by neural pathways that have been learned by their brain/body. As odd as this assertion may seem, I have learned that chronic pain (for most, but not all) is primarily a brain/neural pathway phenomenon. And therefore, most people with chronic pain can recover. While I recognize that most pain specialists will disagree with me about the roots of most chronic pain, I am part of a new organization that embodies this viewpoint. Moreover, this viewpoint is at the heart of understanding the differences in response rates between CBT, ACT and mindfulness and the approach that I now use.
CBT, ACT and mindfulness start with acceptance of the present moment. Even though these therapies are used for people with chronic pain and there is often a shared belief (on the part of the therapist and the client) that they can get better, there is also an underlying assumption that the pain is caused by a structural problem that is not curable. This, of course, has been reinforced by physicians who do not have an understanding that pain can be caused by neural pathways and therefore interpret pain as always caused by a structural problem. For example, patients are told that the abnormalities found on their MRIs are the cause of pain, even if those abnormalities are routinely seen in people who do not have pain. Therefore, patients get the message (either implicitly or explicitly) that they are not going to have resolution of their pain, i.e., that they will probably be in pain for the rest of their lives. They, hopefully, are going to be helped to manage it so that they can live a more functional life. However, the belief that pain will last forever can be deeply depressing. I had a patient tell me recently that the first thing he was told by his ACT therapist was that he would have to learn to accept his pain and learn to live with it.
This message of the permanence of chronic pain undermines recovery in several ways. First, it negates a central tenet of mindfulness practice; that of impermanence, the concept that everything changes and that everything is transient. People with chronic pain often have a very difficult time applying that critical concept to the pain. Their acceptance of pain now applies not only to this moment, but to all future moments as well. Second, it removes a sense of hope and optimism that can come from understanding that they can (and probably will) have dramatic reductions in pain. Believing that improvement is possible and attainable is a key factor in the healing power of the mind, which is sometimes referred to as the placebo effect. Pain caused by neural pathways (which comprises the majority, but certainly not all, of chronic pain conditions) can be cured in many people by applying these two concepts, by understanding that the pain is transient and caused not by a structural problem and by believing that it will go away by changing these neural pathways in the brain and body. It turns out that this is why so many people have recovered from pain using the approach laid out 40 years ago by Dr. Sarno. They didn’t need mindfulness, or CBT or ACT therapy; they needed to change their underlying concepts of what the pain represented.
This is a process that encourages people to overcome their pain, i.e., standing up to it, rather than fearing it. I met a woman who had had back pain for several years despite surgery and injections. She found it very difficult to stop fearing the pain, which has taken over her life and her pain persisted. Last week, she wrote this to me:
I was in quite a bit of pain but I was also super-determined to walk in the neighborhood. I said to my subconscious mind, "I am walking today despite the pain. You can make it easy for me or you can make it difficult. But I am doing it!" I walked about a half an hour and my pain lessened considerably. This was a huge breakthrough for me and I can now see that this program is working! I am astonished. I cannot believe it.
My experiences with hundreds of chronic pain patients over the last decade have clearly taught me that these concepts about the very nature of chronic pain are the most important first steps in recovery. However changing how one understands the pain and finding hope in the belief that the pain can be cured is not always sufficient. Many people do need more; they often need specific therapy.
What kind of therapy is beneficial? What are the specific components of therapy most applicable to people with chronic pain? I will address these issues in an accompanying blog post on this website. I can tell you that mindfulness, CBT, and ACT based interventions are definitely part of the equation, i.e., they are always helpful. In fact, mindfulness practice is often a necessary component of healing. However, it is now clear that without a change in the understanding of the true nature of chronic pain, mindfulness, CBT and ACT are rarely sufficient in and of themselves.
To your health,
Howard Schubiner, MD