Acceptance and Commitment Therapy (ACT), with its core principle of acceptance, has much to offer those who are suffering from a chronic health condition (see this article). One of the core skills used in ACT to help you step out of the negative spiral of dirty distress and shift your attention to meaningful activity is “Mindfulness”. In this article, I will explain how mindfulness is used with compassion to manage negative thoughts, feelings and emotions so that they do not stop you living a life you value.

Mindfulness
While mindfulness has been a part of the Buddhist tradition for over two and a half thousand years, it was only brought to the world of psychotherapy in 1979 by an American medical professor and author - Jon Kabat-Zinn. He integrated mindfulness into a treatment program (Mindfulness Based Stress Reduction) to successfully help people manage chronic intractable pain.

Kabat-Zinn defined mindfulness as “paying attention, on purpose, in the present moment and without judgment.” So, it is a form of meditation that cultivates focused attention on present moment experiences with full acceptance of whatever arises – including awareness of pain. The power of mindfulness is now being realised as more and more studies are finding evidence supporting the effectiveness of mindfulness to help people cope with anxiety, pain, depression, and chronic illness. Scientific research has also found that regular mindfulness practice can enhance immune functioning, decrease reactivity to stress and increase positive states of mind. 

Self-Compassion
One of the more powerful recent developments in therapy for me over the last decade has been Compassion Focused Therapy (CFT), developed by an English psychology professor – Paul Gilbert. Professor Gilbert has highlighted that we are often harshly critical of ourselves for things that are not in our control, in a world that is very challenging with a mind that is often chaotic and easily triggered into distress.

CFT aims to help you cultivate a compassionate resource within yourself to help you manage these realities. Although it has gathered momentum over the last decade, developing compassion for ourselves and others has its roots in the Buddhist teachings, as found in Loving Kindness meditations. Loving kindness practices are now being integrated into psychotherapy because of their power to transform suffering. 

Chronic Health Conditions and Grieving
When managing chronic health issues, it is helpful to be aware of the stages of grief outlined by psychiatrist Elizabeth Kübler-Ross. While she identified these stages in her work with people suffering from a terminal illness, they were later found to be just as relevant for those grieving for the loss of health in a chronic illness. You may have observed in yourself the Denial (“maybe they got it wrong, maybe it will go away”); Bargaining (“maybe I can fix it with this vitamin or that alternative approach”), Anger (“why do I have to have this ...it’s not fair”); Depression (I can’t do X, Y or Z anymore) and finally Acceptance (“It is what it is. I can make room for this, and live a full life around it”).

However, it is important to keep in mind that these stages are not just moved through sequentially and in this order – it is a back and forth movement and the feelings may arise at any time and in any order. Also, as grief is a very personal experience, not everyone experiences all the stages, and each stage can last for minutes to months to years, depending on the individual.

What makes grieving even more difficult is that your ailment may also be progressive, or have additional associated health conditions that may appear further down the track. Consequently, just when you think you have accommodated this illness, the goal posts are moved and there is more you have to find a way to live with. And there you are feeling angry or denying or bargaining again.

Use Self-compassion to Step Back from the Struggle
As mentioned in a previous article, when managing a chronic illness it is very common to find yourself struggling to “get rid of” it or to control it, which only makes matters worse. Knowing that grieving is a normal process of coming to terms with a chronic illness will help you to step back from it and notice the struggle, rather than stay in the struggle. Mindfulness can also assist you with disengaging from the struggle and having compassion for yourself in this process is vital.

This may be most relevant when you find yourself feeling angry and frustrated about your medical condition and your inability to control it. As I have said, anger is part of the normal grieving process in the face of losing health and managing limitations you are confronted with. However, as there are no suitable external targets for this anger, you may turn this anger inwards, feeling angry at yourself, or your body, for letting you down or creating this illness.  You may be criticising yourself for not being able to do more or cope better.

This is where Compassion Focused Therapy (CFT) can be invaluable. Instead of blaming yourself, CFT helps you to cultivate a “compassionate-self” by imagining what you would say to a dear friend if you wanted to be compassionate and caring towards them. Connecting to this compassionate-self can turn on the areas in your brain associated with self-soothing instead of self-criticism. The self-soothing system in your brain can be activated by speaking to yourself in a kind inner voice with caring words and using a loving facial expression with some gentle touching or patting of your face or body (our brains are intrinsically wired to be soothed by these actions). 

This compassionate-self would be like a caring buddy who can be with you 24/7 to support you at difficult times.  A part of you that is committed to your well being and has the wisdom to know and remind you that this is not your fault, and you are doing the best you can in a life that can be very challenging.  

Just imagine for a moment, what it would be like to go through life with a reliable, compassionate and caring companion by your side. That is exactly what CFT offers you. We are all told that you cannot be truly loved until you learn to love yourself. In the same way, I would say you cannot truly come to terms with a chronic illness until you learn to develop compassion – truly, deeply – for yourself. 

Appreciate what you can do
Another key to managing a chronic health condition is being mindful and appreciative of want you can do, rather than focusing on what you can’t do.  So, after kindly acknowledging the difficulties you are dealing with, this compassionate-self could also help you to shift your focus away from what you can’t do, to appreciating your body and the millions of things that you are still able to do. Bringing an attitude of gratitude to your daily life, and ‘counting your blessings’ in the midst of your limitations will help you through. 

This does not mean that you shut out your grief. You still need to allow some time to feel the loss and anger and shed some tears.  But then you will be more able to shift your focus and re-engage with the present and do something that you find meaningful or pleasurable.

I remember once being on a beautiful beach in the Whitsundays, but being unable to walk along it as I had an episode of plantar fasciitis (a painful foot condition). It was such a beautiful cloudless sunny afternoon that I did not want to miss out. So I got down on my knees and crawled along the beach and found the most beautiful tiny shells hidden amongst the washed up seaweed that I would never have seen otherwise. I was able to fully focus (mindfully) on the sand and shoreline, enjoying the colours, and textures, and really savoured this moment in time. I collected the shells in a bag which I keep in my office to remind me of being mindful of the small positive joys that may otherwise be overlooked in the midst of limitations and distress.

Mindfulness, Self-Compassion and Pain
Mindfulness can be used in one of two ways to manage pain or other unpleasant body sensations. Initially you may use it to assist with moving your attention away from the feeling onto more rewarding aspects of your present moment. Using your senses, you may shift your focus from the disagreeable sensations and worries, to more pleasant sensual experiences like tasty food, enthralling music, the smell of a flower, feeling a hug, stroking a pet, or looking at a beautiful sunset. You may also shift your attention to think about what you value and decide how you want to act in the present moment with the discomfort.

With more advanced practice in mindfulness and self-compassion, you will be able to observe your unpleasant sensations with curiosity and kindness. Subsequently, you will notice any thoughts, sensations and emotions as they arise, without trying to change them or condemn them. Rather, you will have the capacity to sit with them, describe them as they are in this present moment, and watch them come and go with compassion for yourself. Repeated practice will enable you to become more open to them and to give up the struggle and judgements that would make them worse.

To allow you to experience this with some guidance, I invite you to go to this website where you will find a range of free downloadable Loving Kindness meditations. One of my favourite meditations is the one by Mary Brantley (under Additional Guided Meditations) and is called Lovingkindness for the Body. This meditation is particularly soothing as it combines mindfulness with an attitude of gratitude and loving kindness. 

Changing your Brain
Psychologists have long known that what you pay attention to will change the way you experience your environment.  Recent studies have revealed that what you focus your attention on repeatedly over time can also ultimately make long lasting changes in brain pathways and structures. Just like building and maintaining muscle strength can be done with repeated weight lifting, repeated activation of certain brain pathways will create, strengthen and maintain them. Thus, regular self-compassion and mindfulness meditation will make changes in your brain. This will mean that what was initially a state of mindful awareness, acceptance and self-compassion, can become more of an enduring way of relating to yourself.

Again, it is similar to training with weights so that you can play a sport better. While you may not notice the benefits at the time (and it may even feel tedious), it is when you are out on the playing field later that you appreciate the time you have put into training to build up that strength.  Thus, I encourage you to put the time into a regular mindfulness and self-compassion practice (even if it is just a few minutes each day pausing to observe your breath and then wishing yourself well). If you put the time into developing this part of your brain, you will then have access to a resource that will allow you to maintain a degree of equanimity in the face of flare-ups and all the other challenges that come with chronic health conditions. 

Chronic health conditions bring many challenges such as pain or irritating sensations; fatigue; and restrictions on what you can do or eat. Which psychological therapies offer the most effective coping strategies for managing such challenges? My experience, (both personally and professionally) leads me to put Acceptance and Commitment Therapy (ACT) and Compassion Focused Therapy at the top of my list. In this article, I will discuss some core principles of ACT and how they can help with managing chronic illness and pain. ACT is a mindfulness–based behaviour therapy. In another article, I have talked more about the use of mindfulness and Compassion.

ACT (pronounced as the word “act”) was developed in the late 1980s by American psychologists Steve Hayes, Kelly Wilson and Kirk Strosal. They saw it as an evolution of the well-established school of Cognitive Behaviour Therapy. Since its development, research involving controlled randomized trials has supported the effectiveness of ACT in managing a range of conditions including depression, anxiety and chronic pain.

As the name implies, ACT involves both acceptance and commitment. ACT aims to assist you to acknowledge and accept what you cannot control (thoughts, feelings, body sensations … whatever life throws at you) so that you do not waste your energy struggling with and judging your illness and your reactions to it.  Instead, you commit to take effective action in areas you can control – like how you want to be in the domains of your life that you value (e.g. relationships, health, and personal growth).

When you have a chronic illness, the aim of ACT is to create a life that is rich and meaningful around pain, illness and negative emotional states and thoughts - rather than a life free of pain/ illness/anxiety/depression/stress etc. Trying to be free of these symptoms is simply an unhelpful pursuit as, by definition, a chronic condition is one you need to learn to live with. Paradoxically, despite what many believe, acceptance actually leads to symptom reduction as we remove the overlay of the disabling distress that comes from the ‘I want this illness gone’ mindset.

Acceptance
The principle of “acceptance” is the most valuable concept for you to embrace on your journey with chronic Ill health. The Buddhist teacher, Shinzen Young, developed this formula to explain suffering. He said Suffering = Resistance x Pain. This is where the notion of acceptance comes in, as acceptance is the opposite of resistance. So, the more you resist and struggle with your illness, the greater the suffering you experience.

In ACT, acceptance does not mean you like your illness or have no negative thoughts or feelings about it. It means:  

• you stop struggling to get rid of it or control it (which is not a battle you can win with a chronic condition) 
•  you stop judging it or criticising yourself for having it (which only compounds your negative feelings)  
• you stop analysing why you have a flare up now (when there are often no answers) 
  

Instead, you acknowledge and make room for feelings like physical pain, or sadness about limitations, so that you can be the person you want to be around these feelings. You do not let your pain and illness hold you back from life-enhancing and meaningful actions. And you don’t let them stop you from being the person you aspire to be. 

Clean and Dirty Distress.
ACT makes a distinction between “clean distress” and “dirty distress” when dealing with the emotional and physical pain associated with chronic illness. The essence of “clean distress” is that you are just experiencing the pure distress in the present moment (“I’m sad, this is unpleasant”; “I am in pain”) without muddying the waters by adding in further negative thoughts like:

•  judgements (“I should be able to cope better”; “I shouldn’t feel upset”), or
• assumptions (“This is my fault”; “Other people cope better than I do”)
• or predictions (“I’ll never be able to cope with this”).

 “Dirty distress” also refers to additional feelings about your feelings (e.g. irritated about being sad - “I shouldn’t feel sad – I should just get on with it”).  Thus, feeling irritated about your sadness over how you can no longer do that favoured activity or eat that favoured food is “dirty” distress. Judging yourself for being sad would also be “dirty” distress, while the sadness itself is “clean” distress. 

Just to be clear, it is not about being a “stoic” and soldiering on regardless. For example, ignoring pain could mean you do not pace yourself which could also take you down a path of more pain.  You do still need to make time and space to acknowledge the emotional distress that goes with the physical pain or chronic condition.

So how do you do this? Studies have shown that writing about or talking out loud (even if it is to yourself) about upsetting situations reduces emotional distress. On the other hand, just thinking about it increases negative feelings.  Keeping a journal will assist you with expressing your emotions, particularly if you want an alternative to talking to loved ones about it. (When pain and illness is chronic, friends and family do have their limits on how much they want to hear about it). 

Clarify Values
In ACT we also help people clarify their values so they can take actions towards creating the life they want. One ACT exercise to assist with this is to picture your funeral and imagine what people from different areas of your life (friends, family, work) will remember about you and how you lived your life. If what you imagine is not what you would like, this may guide you in making some changes now while you still have time.

Some other questions to ask yourself which may also help with values clarification are:

• What do I want my life to be about? 
• If my health was to get significantly worse in 12 months time, what would I regret not having done?
• What is most important to me? 
• Are my choices and actions in line with what I value?
• How do I want to be with friends/family/community/myself despite the challenges of this chronic health condition?
• In this moment, if I were being the person I want to be, how would I act right now? 
• If my health wasn’t such a problem for me, then I would _____________________.

Think about if there is anything you value that you have put on hold because you are making your life all about coping with your health condition. Actions and choices that take you away from the direction of what you value will lead to greater suffering. Actions and choices in the direction of what you value will lead to vitality. 

Applying ACT to Flare-ups
Coping with some health conditions may also mean coming to terms with the fact that they are chronic, waxing and waning ailments. Flare-ups happen, and finding a reason for a flare-up can drive you crazy. Often there is no pattern or obvious trigger to explain a flare-up. Therefore, no way of predicting it, and accordingly, no way of controlling it. This can be very frustrating.

Rather than trying to look back over what you did or did not do to cause this flare-up, or planning for every way you might avoid it in the future, it is better to acknowledge that you are having a flare-up because you have a condition that flares up. It is what it is.

So how do you want to be in the face of this flare-up? Kind and gentle with yourself in the present. Allowing yourself some space to feel the sadness, anger, frustrations etc, before engaging with how you want to be in this next part of your day. Making choices in areas that you do have control over. Choices that will be in the direction of managing this flare up and your health as best you can. This may involve:   

• meditating and/or medicating to assist with discomfort
•  pacing what you do if your are in pain 
• reminding yourself that flare-ups pass 
• shifting your attention away from “why?” to other things (sounds, people, and activities) in your present environment
• you may even choose to set aside some time to acknowledge (and even write about) your feelings now or later

Writing thoughts down (just as they are, without arguing with them) is a key strategy from ACT as it strengthens the “observing part of you” who can step out of negative spirals of thoughts and feelings. While you can’t control whether you have negative thoughts and feelings, you can choose what to do next. You can choose to believe the thoughts (like “I can’t do anything” or “I am a failure”) or you can see them as just thoughts which come and go and may or may not be true.

ACT emphasises that it is best to be guided by what your experience tells you is doable, rather than what your thoughts tell you that you “should” be able to do. Therefore, give yourself permission to take small steps in the direction of meaningful activities if you are unable to do as much as you would like. Even if they are small steps, they are still in the direction of what is important to you.

In a nutshell
To summarise, ACT is all about accepting what you can’t control, and committing to doing what you can in spite of the pain, fatigue, limitations and other challenges that come with chronic health conditions.  You do this in order to create a life you value.