The Pain Acceptance Model

The Chronic Pain Acceptance Questionnaire (CPAQ). Rikard K. Wicksell, Gunnar L. Olsson, Lennart Melin, further validation including a confirmatory factor analysis and a comparison with the Tampa Scale of Kinesiophobia, European Journal of Pain, Volume 13, Issue 7, 2009

• fear of pain has been shown to play a central role in the development of disability among chronic pain patients
• acceptance of, or willingness to experience, pain and distress has appeared as an important factor in determining peoples’ ability to restore functioning in the presence of chronic pain
• laboratory studies have indicated the usefulness of applying acceptance strategies when coping with experimentally induced pain
• studies have suggested the importance of acceptance strategies when emphasizing a shift in focus from symptom reduction to valued living to facilitate increased functioning in the presence of chronic pain and distress

 
On the Chronic Pain Acceptance Questionnaire (CPAQ), there are 11 questions regarding Activities Engagement and 9 regarding Pain Willingness.  The combined scores purport to score one’s “acceptance”, or their better functioning and higher satisfaction.
However, the Acceptance questions contain problematic assumptions about pain.  For instance,

​Question 2, “I would gladly sacrifice important things in my life to control this pain better, “ requires the answer “Never True” for a high Function/high Satisfaction score.  But there are many important things in my life that I have had to sacrifice due to my chronic pain that would absolutely make my life worse should I engage in them.  In fact, as part of a well-tempered pain management strategy, I have to carefully monitor my activity levels so that I don’t have to sacrifice important things in my life like socializing with friends or doing things I enjoy.

Question 11, “My thoughts and feelings about pain must change before I can take important steps in my life,” is odd because it assumes there are thoughts that need to change.  If I answer “Never True”, I score as very low, and high function/high satisfaction if “Always True.”  So, do my thoughts and feelings always need to change then?  What does this mean?  Given the basis for the questionnaire, I’m assuming the correct attitude is that “my pain is what it is and that I can continue to engage in important activities to the best of my ability (according to my pain management plan) despite it,” e.g. accepting it and continuing to function. 
 
If the goal of Acceptance in management of Chronic Pain, according to the Hexaflex model of ACT, is to accept the pain objectively through defusion, so as to better allow oneself to manage their pain within reasonable schedule of mental and physical activities, then it is in alignment with pro-social values of egalitarianism with regard to individual burden. 
 
However, if the goal is to increase one’s ability to tolerate increased pain levels brought on by participation in a heavier schedule of physical and mental activities, then two ethical issues arise. 1) The individual is now experiencing higher levels of pain, discomfort, and stress, placing them at greater risk for failure to manage their pain.  2) The social burden is shifting from society onto the individual at the expense of their well-being, with the proposition that they will be “trained” to take on the extra burden of tolerating it.
 
Subjectivity and pain is real, and I don’t want to diminish the value in use of technologies that allow individuals to better cope with the emotional and cognitive effects of suffering with chronic pain.  In my 35+ years of chronic pain, my greatest struggle has been in the untangling of the painful stimuli within my body and my mental and emotional response to it.  Some days the pain seems bad and yet I feel like I can do more, while other days the pain doesn’t seem as bad, and yet it somehow bothers me more and I have less “energy” to engage.  On a daily – sometimes hourly – basis, I am faced with the question of “should I push through it?”  The answer to this question cannot always be “yes”.  And yet, as those of us with chronic pain will attest, when it is “no,” there is always at least some small part of us that feels guilty, that we are letting someone down, letting ourselves down.
 
The results of the Acceptance model should never be that we are made to feel we are letting anyone down.  But if there is a value-judgement embedded within it that requires us to effectively deny our pain, to expand our capacity beyond what is reasonable given our limitations, then it is an ugly use of technology, designed not to improve the life of the individual but to ease the social burden on society for supporting them should their require additional assistance (e.g. unemployment, etc.).

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