Pain, Acceptance, and Psychological Flexibility

Pain is real, and it is more than a physical signal

Pain is a real experience. The International Association for the Study of Pain defines pain as both a sensory and emotional experience and emphasizes that it is influenced, to varying degrees, by biological, psychological, and social factors. This does not mean that pain is imaginary or “all in your head.” Rather, pain is produced and regulated by a nervous system that is affected by injury and illness, but also by attention, emotion, stress, sleep, learning, expectations, behaviour, and the environment (Raja et al., 2020).

When pain persists, treatment often needs to address more than the physical source of pain alone. Psychological treatments for chronic pain do not necessarily eliminate pain. Their most consistent benefits are often reductions in pain interference, disability, anxiety, depression, and the degree to which pain controls everyday life. Acceptance and Commitment Therapy, or ACT, is one psychological treatment with substantial research support for chronic pain (Hughes et al., 2017; Lai et al., 2023; Martinez-Calderon et al., 2024).

Pain and suffering

It can be useful to distinguish between pain itself and some of the additional suffering that develops around pain.

Pain may include aching, burning, pressure, stabbing, throbbing, fatigue, or other unpleasant sensations. When pain persists, another layer can develop around it: fear of the pain, anger that it is happening, constant monitoring of the body, frightening predictions about the future, muscle bracing, withdrawal from meaningful activities, or the feeling that life cannot resume until the pain disappears.

This second layer is sometimes described in acceptance-based therapies as struggling with, or resisting, pain.

This distinction should not be taken too literally. Emotional distress is itself part of the experience of pain, and not all suffering can simply be removed by changing one’s attitude. The useful question is more practical:

Is fighting this experience helping me right now, or is the struggle with it adding another source of distress or limiting my life?

The problem of experiential avoidance

Human beings naturally try to avoid unpleasant experiences. Usually this is adaptive. If something is dangerous, moving away from it is sensible.

Problems can arise when avoidance becomes the main way of responding to experiences that cannot reliably be eliminated. Psychologists call this experiential avoidance, meaning repeated attempts to escape, suppress, control, or avoid uncomfortable sensations, thoughts, memories, or emotions, even when those efforts begin to interfere with life.

With persistent pain, this can gradually look like:

  • avoiding movement because pain might increase;
  • repeatedly checking whether pain is better or worse;
  • cancelling activities whenever pain appears;
  • spending large amounts of time trying to control or eliminate sensations;
  • waiting to feel better before seeing people, exercising, travelling, working, or pursuing interests;
  • becoming increasingly frightened by normal fluctuations in symptoms;
  • struggling internally with thoughts such as “I cannot stand this” or “this has to stop before I can do anything.”

Avoidance is not inherently wrong, and some pain does require protection or medical intervention. The question is whether a particular strategy is protecting your health or progressively shrinking your life.

Research on chronic pain consistently finds that greater psychological flexibility and greater pain acceptance are associated with better functioning. A 2025 meta-analysis involving more than 6,000 people found a moderate association between greater pain acceptance and lower pain-related disability. ACT trials also find that increases in psychological flexibility can help account statistically for improvements in treatment outcomes (Lin et al., 2018; White et al., 2025).

What does acceptance mean?

Acceptance does not mean liking pain, approving of it, giving up, or deciding that nothing can be done.

It also does not mean ignoring symptoms that need medical attention.

In ACT, acceptance means becoming more willing to experience sensations, thoughts, and feelings that are already present when fighting them is not useful, while continuing to take actions that matter to you.

You can seek medical treatment and practise acceptance. You can hope that pain improves and stop requiring it to disappear before you participate in your life.

The goal is flexibility rather than resignation.

A four-step practice for unpleasant sensations

One way to practise acceptance is to work directly with the experience of resistance. The following is a practical application of acceptance-based principles. The overall process of acceptance is well supported in the chronic-pain literature, although this exact four-step exercise should be understood as a clinical exercise rather than a separately validated treatment protocol.

1. Notice it

Bring your attention gently to what is happening.

Instead of immediately evaluating the sensation, see whether you can describe it:

  • Where is it?
  • Is it pressure, aching, heat, tightness, pulsing, tingling, or something else?
  • Is it constant or changing?
  • Does it have clear boundaries?
  • What happens from moment to moment?

You are observing the experience rather than immediately trying to change it.

2. Feel the resistance to it

Now notice what your mind and body are doing around the pain.

You might notice:

  • muscles tightening;
  • holding your breath;
  • pulling away internally from the sensation;
  • fear or anger;
  • an urge to make the sensation stop immediately;
  • thoughts such as “no,” “I hate this,” “I cannot tolerate this,” or “something terrible is happening.”

The resistance is not a mistake. It is an understandable protective response.

3. Relax the resistance to the pain

See whether you can soften the struggle without demanding that the pain itself change.

You might:

  • unclench your jaw;
  • lower your shoulders;
  • loosen your hands;
  • allow yourself to breathe normally;
  • imagine creating a little more space around the sensation;
  • silently say, “This is here right now” or “I can allow this moment to be as it is.”

You are relaxing the resistance, not necessarily relaxing or eliminating the pain.

4. See what happens

Observe what follows without requiring a particular result.

The pain may decrease, increase, move, or remain exactly the same. The more important question is whether your relationship to the experience changes.

Ask:

  • Is there slightly less struggle?
  • Can I breathe more freely?
  • Can I widen my attention beyond the painful area?
  • Is there something useful or meaningful I can do while this sensation is present?

The exercise has not failed if the pain remains.

Other ways to practise acceptance

Acceptance is a skill that can be practised in many different ways:

  • Allow the sensation to be present for a short period, perhaps 20 or 30 seconds, without trying to alter it.
  • Notice the difference between the sensation and your evaluation of it. “There is pressure in my back” is different from “This is unbearable.”
  • Soften around the pain. Notice unnecessary bracing in the jaw, shoulders, abdomen, hands, or breath.
  • Practise willingness in small doses. You do not need to become willing to have pain forever. Start with willingness to experience this particular moment.
  • Expand attention. Notice the pain and also your feet on the floor, sounds in the room, your breathing, the view from the window, or another part of the body that does not hurt.
  • Allow emotions associated with pain. Fear, sadness, anger, disappointment, and frustration can also be approached with acceptance rather than suppression.
  • Notice urges without automatically following them. An urge to lie down, cancel plans, check symptoms, or seek reassurance can be noticed before deciding what action actually makes sense.
  • Ask what controlling pain is costing you. Sometimes an enormous amount of energy is being invested in a problem that is only partly controllable.
  • Experiment rather than demand. Try allowing the sensation for one minute and observe what happens.
  • Practise acceptance when symptoms are moderate. It is usually easier to learn the skill outside the most difficult moments.
  • Let acceptance and active treatment coexist. Taking medication, receiving physiotherapy, exercising, resting, or seeking medical treatment is entirely compatible with acceptance when these actions are useful rather than driven solely by an urgent need to escape every unpleasant sensation.

Six skills for becoming more psychologically flexible

ACT describes six overlapping processes that support psychological flexibility, the ability to respond to difficult internal experiences while continuing to behave in ways that serve your life. Research in chronic-pain populations has found significant associations between functioning and all six processes, although the evidence for individual processes is not equally strong. Acceptance and overall psychological flexibility currently have the strongest treatment-process evidence; evidence for some of the other individual components is more correlational (Ding & Zheng, 2022).

1. Acceptance: make room for what is already here

Try asking:

  • “What am I experiencing right now?”
  • “Can I allow this sensation to be here for the next 30 seconds?”
  • “What happens if I stop trying to solve this experience for a moment?”
  • “Can I soften around this rather than brace against it?”

Acceptance is especially useful when continued attempts to control an experience are no longer working.

2. Cognitive defusion: step back from what the mind is saying

Pain often generates powerful thoughts:

“I cannot cope with this.”

“This will ruin everything.”

“I cannot do anything when I feel like this.”

The aim of defusion is not to prove these thoughts wrong. It is to experience them as thoughts rather than commands or facts.

Try:

  • “I am having the thought that I cannot cope with this.”
  • “My mind is telling me the ‘I cannot do anything while I hurt’ story again.”
  • Silently label what is happening: “predicting,” “catastrophizing,” “remembering,” or “worrying.”
  • Ask: “Regardless of whether this thought is true, what happens if I let it determine what I do next?”
  • Thank your mind for trying to protect you, then decide what action actually fits the situation.

The purpose is not positive thinking. It is creating enough distance from a thought to choose your behaviour.

3. Present-moment awareness: come back to what is happening now

Persistent pain can pull attention toward the past or future: “Why did this happen?” “What if it gets worse?” “How long will I be able to live like this?”

Practise returning attention to the present:

  • notice five things you can see;
  • feel your feet against the floor;
  • follow three natural breaths;
  • listen carefully to sounds around you;
  • describe the immediate physical sensation rather than predicting what it means;
  • notice when your mind has moved into a feared future and gently return to what is happening now.

The goal is not to concentrate so intensely that pain disappears. It is to regain some choice over where your attention goes.

4. Self-as-context: you are more than the pain

When pain becomes chronic, it can begin to dominate identity: “I am a person in pain,” “my body is broken,” or “pain is my whole life.”

ACT encourages noticing that you are the person having these experiences, rather than being identical to the experiences themselves.

Try shifting:

  • from “I am anxious” to “I notice anxiety”;
  • from “I am in unbearable pain” to “I am noticing pain and the thought that it is unbearable”;
  • from “my life is pain” to “pain is one significant part of what I am experiencing right now.”

You can also notice that sensations, thoughts, emotions, and memories continually change while the perspective from which you observe them remains available.

5. Values: remember what you want your life to stand for

Pain naturally makes symptom reduction a major goal. But a life organized entirely around reducing pain can gradually lose contact with everything else that matters.

Ask:

  • What has pain pulled me away from?
  • What relationships matter to me?
  • What kind of friend, partner, parent, colleague, or community member do I want to be?
  • What do I value about learning, creativity, nature, work, movement, spirituality, humour, intimacy, or contribution?
  • If pain were not making all the decisions, what would I want to move toward?

Values are directions rather than achievements. “Being a caring friend” is a value. Calling a friend this afternoon is one action that expresses it.

Improvements in values-based action have been associated with improvements in functioning in chronic-pain treatment studies (Vowles & McCracken, 2008).

6. Committed action: gradually do what matters

Once you identify something important, translate it into behaviour.

Examples might include:

  • walk outside for five minutes;
  • prepare one meal;
  • telephone a friend;
  • sit in the garden;
  • return to a hobby for ten minutes;
  • attend part of a social activity rather than cancelling completely;
  • complete an appropriately graded exercise recommended by a health professional;
  • take one small step toward returning to work or another meaningful role.

The aim is not to push through pain regardless of consequences. Committed action should be flexible and medically appropriate. It means gradually rebuilding a life around what matters rather than allowing pain alone to determine every decision.

A useful question is:

“Given that this is what my body and mind are experiencing today, what is one workable action I can take in the direction of the life I want?”

Measure progress differently

If the only measure of success is “How much pain did I have today?”, meaningful improvement can easily be missed.

Also consider:

  • How much did pain interfere with my day?
  • What did I participate in?
  • Did I do something important despite discomfort?
  • How much time did I spend monitoring or fighting pain?
  • How quickly did I recover after a difficult period?
  • Am I becoming less afraid of normal fluctuations in symptoms?
  • Is my world becoming larger or smaller?
  • Am I increasingly able to choose my behaviour rather than having pain choose it for me?

ACT studies suggest that improvements in functioning, psychological flexibility, pain acceptance, mood, and quality of life may occur even when reductions in pain intensity are relatively modest (Hughes et al., 2017; Lai et al., 2023; Martinez-Calderon et al., 2024).

A final caution

Acceptance should never be used to dismiss symptoms or to suggest that people should simply tolerate medically concerning pain. New, unexplained, rapidly changing, or severe symptoms should be appropriately medically assessed. For persistent pain, psychological strategies are generally best understood as one part of comprehensive care, alongside appropriate medical treatment, rehabilitation, movement, sleep, and other interventions relevant to the particular condition.

Learn more

Pain BC: Self-Management
A Canadian resource with education, self-management programs, tools, and support for people living with persistent pain.
Pain BC self-management resources

Pain BC: Find Help
Includes free educational resources, pain-management tools, support programs, and LivePlanBe+, an interactive self-management resource.
Pain BC Find Help

International Association for the Study of Pain: Chronic Pain
Reliable information about chronic pain and contemporary approaches to understanding and managing it.
IASP chronic pain information

Association for Contextual Behavioral Science: ACT for the Public
An introduction to Acceptance and Commitment Therapy and additional resources for learning about psychological flexibility.
ACT for the Public

Dahl, J., & Lundgren, T. (2006). Living Beyond Your Pain: Using Acceptance and Commitment Therapy to Ease Chronic Pain. New Harbinger.
A patient-oriented ACT workbook specifically designed for people living with persistent pain.

Caudill, M. A. (2016). Managing Pain Before It Manages You (4th ed.). Guilford Press.
A broader cognitive-behavioural pain-management workbook covering pain education, relaxation, activity, communication, problem solving, and self-management.

References

Ding, D., & Zheng, M. (2022). Associations between six core processes of psychological flexibility and functioning for chronic pain patients: A three-level meta-analysis. Frontiers in Psychiatry, 13, 893150. https://doi.org/10.3389/fpsyt.2022.893150

Hughes, L. S., Clark, J., Colclough, J. A., Dale, E., & McMillan, D. (2017). Acceptance and Commitment Therapy (ACT) for chronic pain: A systematic review and meta-analyses. The Clinical Journal of Pain, 33(6), 552–568. https://doi.org/10.1097/AJP.0000000000000425

Lai, L., Liu, Y., McCracken, L. M., Li, Y., & Ren, Z. (2023). The efficacy of acceptance and commitment therapy for chronic pain: A three-level meta-analysis and a trial sequential analysis of randomized controlled trials. Behaviour Research and Therapy, 165, 104308. https://doi.org/10.1016/j.brat.2023.104308

Lin, J., Klatt, L.-I., McCracken, L. M., & Baumeister, H. (2018). Psychological flexibility mediates the effect of an online-based acceptance and commitment therapy for chronic pain: An investigation of change processes. Pain, 159(4), 663–672. https://doi.org/10.1097/j.pain.0000000000001134

Martinez-Calderon, J., García-Muñoz, C., Rufo-Barbero, C., Matias-Soto, J., & Cano-García, F. J. (2024). Acceptance and Commitment Therapy for chronic pain: An overview of systematic reviews with meta-analysis of randomized clinical trials. The Journal of Pain, 25(3), 595–617. https://doi.org/10.1016/j.jpain.2023.09.013

McCracken, L. M., & Gutiérrez-Martínez, O. (2011). Processes of change in psychological flexibility in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy. Behaviour Research and Therapy, 49(4), 267–274. https://doi.org/10.1016/j.brat.2011.02.004

National Institute for Health and Care Excellence. (2021). Chronic pain (primary and secondary) in over 16s: Assessment of all chronic pain and management of chronic primary pain (NICE Guideline NG193).

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Vowles, K. E., & McCracken, L. M. (2008). Acceptance and values-based action in chronic pain: A study of treatment effectiveness and process. Journal of Consulting and Clinical Psychology, 76(3), 397–407. https://doi.org/10.1037/0022-006X.76.3.397

Wetherell, J. L., Afari, N., Rutledge, T., Sorrell, J. T., Stoddard, J. A., Petkus, A. J., Solomon, B. C., Lehman, D. H., Liu, L., Lang, A. J., & Atkinson, J. H. (2011). A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain. Pain, 152(9), 2098–2107. https://doi.org/10.1016/j.pain.2011.05.016

White, K. M., Zale, E. L., Lape, E. C., & Ditre, J. W. (2025). The association between chronic pain acceptance and pain-related disability: A meta-analysis. Journal of Clinical Psychology in Medical Settings, 32(3), 448–459. https://doi.org/10.1007/s10880-024-10061-1