Pain, Interrupted: Empower Your OT Practice with ACT & CBT
By: Sonia Gavrilova, 2nd year UofT MScPT student ∙ Estimated reading time: 8 minutes

Picture this

A new client walks into your clinic, defeat etched across their face. They share their story of ongoing pain that has plagued them for years. They have tried everything, from various medications, and therapies, to behavioral techniques, but still feel like the pain haunts them. Primarily, they share that the pain has stopped them from participating in the activities they love so much and that they just haven’t been the same since. 

Sound a little too familiar? 

We thought so, since so many of us have been there.  

Chronic pain is one of the most prominent and complex challenges that rehabilitation practitioners face in their clinical practices. Once pain persists for longer than 3 months, it is defined as being chronic. 

Thanks to advancements in pain science, we now understand that pain doesn’t just interfere with a person’s life physically—it can weave itself into every corner of their emotional and psychological world. This creates barriers that make treatment frustrating for both clients and therapists. Setbacks are common, and building rapport can be challenging when clients feel misunderstood or hopeless.

Addressing chronic pain in occupational therapy

Occupational therapists (OTs) play a key role in the treatment of chronic pain, considering that they support individuals in returning to their everyday activities and responsibilities. But how can OTs and other professionals navigate the rollercoaster that is chronic pain, especially when there is seemingly no end in sight? 

That is where Acceptance and Commitment Therapy (ACT) comes in. ACT is a transformative approach to chronic pain that shifts the focus from eliminating the pain in its entirety, to supporting clients in living meaningful and fulfilling lives despite it. 

Curious to learn how Acceptance Commitment Therapy could transform your practice? Bronnie Lennox Thomspon’s course, ACT and Occupational Therapy for Pain Rehabilitation, breaks down how you can integrate these powerful strategies into your practice. 

Take a look at Bronnie
Lennox Thompson's course

What is ACT and Why Does It Matter in OT?

The ACTual Deal. Let's break down acceptance and commitment therapy and the biopsychosocial model for chronic pain

I’m so sorry about the pun, but I had to!

In her course, Bronnie Lennox Thompson introduces Acceptance Commitment Therapy as a type of therapy that centers on taking action in the face of pain and that is guided by an awareness and openness to an individual’s experiences. One of the ideas at the foundation of ACT is psychological flexibility, which is an individual’s ability to take mindful, aware, and value-based action, despite the presence of challenging circumstances. Rather than combatting pain and consistently fighting against it, ACT takes on a more grounded approach that allows individuals to live effectively and continue to prioritize valuable activities, without denying the presence of pain. 

Grounded in pain science, Acceptance and Commitment Therapy is a behavioral therapy, meaning that it is focused on experiential learning, as opposed to talk therapy. The idea is to do doing, and reflect on how doing felt afterward. Through this doing, individuals can develop stronger relationships with their bodies, and build a sense of self to return to in daily activities. 

Furthermore, ACT is an effortless example of the biopsychosocial model (pictured below) at work, which highlights that pain isn’t just a physical issue - it’s influenced by emotions, thoughts, and social interactions. First coined by George Engel in 1977, this model is especially relevant to chronic pain, as it captures how pain is a psychophysiological behavior pattern that cannot be categorized as strictly biological, psychological, or social. Of course, another added benefit is that the biopsychosocial model just happens to be at the root of OT practice!

Curious to explore the biopsychosocial model and its relevance to your practice even further? Enroll in THE Biopsychosocial Bundle today!

Let’s get into it: The Choice Point Model for OT practice 

A key concept in Acceptance Commitment Therapy is the idea of workability. Spoiler alert: "Workability" isn’t just something we made up—it’s a real (and very important) ACT term. OTs are pragmatists and contextualists, meaning that a person’s life context is of particular importance when considering how to move them toward what they value most. Thus, workability looks at how meaningful action can actually work in a person’s given environment, since our behavior does not exist in a vacuum, but in relation to the people, places, and things around us.  

The Choice Point model illustrates how ACT integrates the concepts of a biopsychosocial approach and workability, as it conceptualizes how different decisions throughout our day-to-day move us away from or toward the activities that we find meaningful.

Choice Point mentions how certain “hooks” can quite literally hook you backward and away from your goals, while “helpers” do the opposite and “unhook” you, thereby moving you toward living a meaningful and vibrant life. 

Some examples of hooks include: 

• Thoughts and feelings in the moment (we are not our thoughts or emotions!
• Other people’s reactions to our behavior 
• Not stopping and considering before acting (autopilot mode) 

Some examples of helpers include: 

• Cues that can remind us of “towards” behaviors 
• Thinking as “future me” 
• Recalling our values and asking if our actions are aligned with them 

OTs can integrate the Choice Point model into their practice by supporting clients in recognizing their “hooks” and developing skills to increase their “helpers” to ultimately progress toward living a life that is closer aligned with their values and goals. 

Want more practical tips for using the Choice Point model? 

Enroll in the course today!

The triple threat: The 3 ACT pillars every OT should know

Now, remember when we briefly touched on psychological flexibility? Does “mindful and value-based action” ring a bell? 

Psychological flexibility spans three pillars initially introduced by Strosahl and Robinson, and they are openness, awareness, and engagement. 

When clients with chronic pain experience any challenges with these pillars, ACT can be a powerful intervention for OTs to implement. Each of these pillars is rooted in the biopsychosocial model, and aligns with OT’s goal of promoting increased function and meaning in daily activities.

Let’s dive into each pillar a bit deeper: 

Openness: This pillar focuses on acceptance; accepting what cannot be changed, accepting the presence of distressing feelings, and accepting that pain is present. However, this acceptance also fosters the ability to then let go and distance oneself from negative thoughts.

Awareness: This one is all about presence. Have you ever experienced moments, hours, and even days when you’re so in your head that life passes by in a blur? This is especially true for individuals who are experiencing pain. The awareness pillar focuses on finding the present moment and consistently returning to it.

Engagement: Commitment and action. This pillar is all about do, do, do. Engagement involves defining values, stating them, committing to them, and seeing them through every day. 

Looking for specific examples on integrating ACT into your practice? 

Take this course

ACT vs. CBT: The ultimate showdown in pain management

Cognitive behavioral therapy as an additional behavioral approach in OT

Cognitive behavioral therapy (CBT) is like that old friend that you can call anytime you need a favor. Reliable, present in the pain science literature, and commonly integrated into practice, CBT is primarily focussed on changing and rewiring harmful thought patterns to positively influence behavior and emotions. In a pain science course with Embodia, practicing osteopath, author, and pain management expert, Allison Sim describes how CBT is all about analyzing thoughts under a microscope - if we can alter these thoughts, we can inspire powerful and lasting change in the resulting behavior. 

Allison Sim explains that, according to the evidence, CBT as a sole intervention for chronic pain can lead to reductions in stress and catastrophizing, but minimal change in actual pain levels. She also mentions a small-to-moderate effect size in behavioral flexibility and willingness, meaning that clients are willing to be flexible and adaptable with their thoughts after CBT. 

Flexibility vs. fixing: How ACT and CBT address pain differently

So, how do Cognitive Behavioral Therapy and Acceptance and Commitment Therapy each tackle pain? Well, one can say that CBT does outright “tackle” the pain, while ACT gives it a warm hug. 

It can therefore be said that ACT and CBT are both players on the same team; they just play different positions. Both approaches can also be integrated into a multimodal approach to help clients build a flexible, durable, and sustainable mindset around pain, which will ultimately lead to greater function and improved quality of life! 

Your ACT and CBT clinical toolkit 

Get in, we’re going shopping (for those handy clinical skills, that is)!

Mean Girls references aside, let’s dive into some practical techniques you can implement into your practice today!

Mix it up: Why a multimodal approach is the MVP for chronic pain management

Here are some strategies that draw from both Cognitive Behavioral Therapy and Acceptance Commitment Therapy principles, taken from the pain science experts, Bronnie Lennox Thompson and Allison Sim themselves! This is just an example of how you can integrate these strategies into your everyday practice. When reading through these, see if you can detect different elements of CBT or ACT!

1. First and foremost, listen to the client’s whole story. It is important to really hear the client when they are sharing with you. The best way to build rapport is to really set time aside in your initial assessment to hold space for what the client has lost. This also allows you to see what a client’s thought patterns are around their pain. 

2. Use all that knowledge you have about pain to mythbust some of the negative beliefs and perceptions clients might have around pain. You never know what lingering thoughts can be replaced by more positive or reassuring, evidence-based beliefs. Check out this blog to learn more about how to help your clients debunk some common myths about their pain!

3. Create behavioral experiments and encourage clients to try novel ways of completing activities. They can perform these activities with you present so they can assess how they feel out loud and in the moment, and perhaps reframe their perspectives of specific activities!

4. Encourage and guide clients through rebuilding the stories they tell themselves about who they are and the roles they play. As they navigate chronic pain, they might need to redefine what it means to be a “good mother” or a “good employee.”
   
   

Ready to transform your pain management practice? 

Well, that’s it, folks! 

As we discussed, Acceptance and Commitment Therapy and Cognitive Behavioral Therapy can be integrated into a multimodal approach to support clients living with chronic pain in living enriching and meaningful lives. 

ACT offers a groundbreaking perspective of accepting the presence of pain and focusing on living a fulfilling life anyway. Some of the models of ACT that we looked at include the Choice Point model and the three pillars of psychological flexibility, all of which relate directly to the biopsychosocial model. 

On the other hand, CBT includes acknowledging and rescripting negative thought patterns at the root of our behaviors. Both CBT and ACT are fantastic, evidence-based approaches to navigating the complexities and challenges of pain!

Ready to take the leap? 

Level up your game by enrolling in the course today and unlocking a treasure trove of practical strategies for managing chronic pain and transforming the lives of your clients! 

Now, let's set the scene: 

A new client walks into your clinic, frustration and fatigue clouding their face. They’ve battled pain for years, and they’re coming to you for the answers they need.

But this time, you’re not just listening. After reading this blog, taking the course, and exploring our biopsychosocial course bundle, you are armed with fresh tools, a renewed sense of confidence, and a new perspective on pain management. You have everything you need to help your client reclaim their life - and that’s the game-changer. 

So go forth, be brave, and step boldly into your next session, armed with knowledge, empowered by new skills, and ready to make a difference. 

Links to explore:

Courses

THE Biopsychosocial Bundle 
“Clinicians Get Creative” with Bronnie Lennox Thompson
Motivational Interviewing, CBT, and ACT for Treating Pain - Course with Allison Sim

Blogs

This super fun blog on central sensitization and biopsychosocial assessments
Debunking 3 Myths About Back Pain
Yoga and Science in Pain Care - Just Listen - Exploring the Lived Experiences of Pain
Yoga and Science in Pain Care - Compassionate Pain Care: Where Science & Humanity Merge

References and links

1. Bernardy K, Klose P, Busch AJ, Choy EH, Häuser W. Cognitive behavioural therapies for fibromyalgia. Cochrane Database of Systematic Reviews. 2013(9). doi: ​​10.1002/14651858.CD009796.pub2

2. Broderick JE, Keefe FJ, Schneider S, Junghaenel DU, Bruckenthal P, Schwartz JE, Kaell AT, Caldwell DS, McKee D, Gould E. Cognitive behavioral therapy for chronic pain is effective, but for whom?. Pain. 2016 Sep 1;157(9):2115-23. doi: 10.1097/j.pain.0000000000000626

3. Canadian Association of Occupational Therapists. Chronic pain: The role of occupational therapy [Internet]. Ottawa: Canadian Association of Occupational Therapists; 2011 [cited 2024 Oct 18]. Available from: https://caot.ca/document/8201/Chronic%20Pain%20EN.pdf

4. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychol Bull. 2007;133(4):581-624. doi: 10.1037/0033-2909.133.4.581

5. Miaskowski C, Blyth F, Nicosia F, Haan M, Keefe F, Smith A, Ritchie C. A biopsychosocial model of chronic pain for older adults. Pain Med. 2020 Sep 1;21(9):1793-1805. doi: 10.1093/pm/pnz329

6. Strosahl KD, Robinson PJ, Gustavsson T. Brief interventions for radical change: Principles and practice of Focused Acceptance and Commitment Therapy (FACT) [Internet]. New Harbinger Publications; 2012 [cited 2024 Oct 18]. Available from: https://www.scribd.com/document/392955840/Kirk-D-Strosahl-Patricia-J-Robinson-Thomas-Gustavsson-Brief-Interventions-for-Radical-Change-Principles-and-Practice-of-Focused-Acceptance-and-Com

7. Thompson BL, Ramanauskas C. Articulating Occupational Therapy's Unique Contribution to Pain Management. New Zealand Journal of Occupational Therapy. 2024 Apr 1;71(1).

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Date published: 29 October 2024
Last updated: 29 October 2024