Rikard Wicksell: "Pain should not be allowed to dominate your life"

Text: Cecilia Odlind, first published in Swedish in Medicinsk Vetenskap 4, 2015.

Human beings probably fear pain more than death. Psychologist and researcher Rikard Wicksell believes that this may be correct.

“Being in pain is incredibly tedious. It is something that everyone – literally everyone – has problems handling. But pain is also a vitally important signal that informs us when something is wrong and urges us to immediately solve the problem. In other words, it is designed to make us lose focus on everything else,” he says.

We can often alleviate acute pain through the use of temporary medication and by addressing the root cause. When the condition becomes long-term, pain can overshadow an entire life. This affects one in five Swedes, and 50 per cent of all sufferers experience inadequate pain relief. According to Rikard Wicksell, the healthcare services have long been unable to act adequately to help people effectively deal with this type of pain.

“Medical staff have focused on understanding and interacting with biological mechanisms and have ignored important knowledge that has developed within psychology,” he says.

Over the years, a number of studies have been published that show that the situation and the circumstances surrounding the individual sufferer heavily influences the experience of pain.

“If we do not know the root causes, we cannot change them. But perhaps we can change the context in which pain occurs. Perhaps we can move our focus from the experience of pain, which the patient cannot control, to pain behaviour, which we can affect, and thus decrease the impact pain has on life and everyday situations. That is what we had in mind when we started our activities,” he says.

For Rikard Wicksell, the problem with chronic pain became apparent to him when he was a teenager as his mother was struck by a rheumatic disease called psoriatic arthritis.

“I saw that she couldn't even cope with what she actually lived for – her family.”

An angry period followed, marked by sadness and frustration over not being able to help his mother. In hindsight, he can see that the feeling of helplessness sparked an intense thought process. Most probably, the idea that life could be improved even when pain could not be reduced started to form in his mind then and there.

The pieces fell into place after getting briefly side-tracked: he first qualified as an economist but has never worked in the profession. Instead, he applied to study psychology – and was hooked.

“During the course of the programme, I saw evidence of how important psychology was and of how little we know about it. I also found my motivation: the desire to help people who had ended up in difficult situations to find their way back to a meaningful existence,” says Rikard Wicksell.

The method that he has developed together with the doctor Gunnar L Olsson, specialist in pain relief, is based on ACT, Acceptance and Commitment therapy. It is a development within Cognitive Behavioural Therapy, and is primarily used to help people with chronic and non-treatable pain. ACT aims for patients to live active and meaningful lives, even in moments of strenuous pain. The therapy involves learning not to put excessive effort into trying to eliminate unpleasant experiences that are difficult or impossible to get rid of.

“Many people who have suffered chronic pain for a long time explain that they have become cautious and avoid many situations and important activities to minimize pain. Their lives have become increasingly restricted, but their level of pain remains, says Rikard Wicksell.

New patterns of behaviour, characterized by avoidance, can easily be formed over time, but are difficult to break. Therefore, ACT also involves specifically practicing how to break such old and dysfunctional behaviour patterns. This can mean daring to lift one's child, ride a bike, or work more hours, despite associating this with increased pain. Acceptance training means practicing identifying the impulse to act, and then choosing not to flee or avoid discomfort, even if this seems to be the most natural way of acting at the time.

Quality of life can dramatically increase.

“Were not talking about miracles here, but we have seen many examples of life quality dramatically increasing. The pain remains the same, but is no longer allowed to control the patient's life in the way it used to,” he says.

Rikard Wicksell's research has primarily focused on evaluating the effects of ACT, and a number of studies show that the methods work. In order to make ACT accessible to more people, such as patients who live far away from the hospital or have difficulties getting around, the research group is now developing an internet-based ACT treatment programme. Another important question is why the therapy works well for some individuals, and not so well for others.

“At present, we have no good way of predicting the effect of the treatment; increased knowledge would allow us to adapt the treatment to individuals' needs, and thus improve our results.”

In a newly started project, he will examine the importance of biological processes, together with Mats Lekander, professor of health psychology at the same department. Analysing brain activity and inflammatory biomarkers will hopefully provide a better understanding of what causes chronic unclear and debilitating pain, and the effects of behavioural change. A third project will examine the transition from acute to chronic pain: Why do some patients develop chronic pain and disability after surgery?

“If we could identify what influences this, we would have entirely new opportunities both to predict who is at risk of suffering such pain and to work preventively,” says Rikard Wicksell.

As patients who suffer with long-term pain require a great amount of resources, he believes that caring for these patients at an early stage could have a huge impact on healthcare services. But not only pain patients can be helped by ACT; rather, there are good reasons to investigate whether the therapy can help others suffering from intractable and disabling conditions such as epilepsy. Patients who have survived cancer but suffer from residual symptoms is another potential target group. In general, Rikard Wicksell believes that there should be an increase in behavioural medical perspectives in order to increase the quality and effects of healthcare. And more psychologists.

“There is a lack of competence and resources within the somatic care services when it comes to addressing problems such as anxiety, fatigue, and sleeping disorders, which we know are prevalent. As long as this deficiency exists, care will be substandard and incomplete,” he said.

Rikard Wicksell believes that having personal experiences of chronic pain within his family has increased his understanding of the patients.

“Existential questions, like what the patient wants out of their life, his or hers greatest sorrows and life goals, are important parts of the treatment in order to understand the problems and motivate a change. Knowledge of the damage pain can cause can make this easier,” he says.

Being both a clinician and a researcher is important to Rikard Wicksell.

“Everything happens at the hospital; this is where I have the ability to affect and change our activities to directly impact the patients. At the same time, I understand the importance of carrying out scientific evaluations before deciding on changes.

Due to his background in psychology, he knows that our minds can play tricks on us.

“Intuition does not always lead us down the right path and therefore, a critical examination approach is necessary. That is why I am also very careful with the scientific principles,” says Rikard Wicksell.

Although Rikard Wicksell cannot save everyone, he has already helped many patients with chronic pain to achieve a richer life, thanks to a new approach. He has also committed to spreading his ideas to the rest of society and in 2014 he released the popular science book “Att leva med smärta. ACT som livsstrategi” [Living with pain. ACT as a life strategy]. His mother has read parts of it.

“I hope I have inspired my mother to do more with her life than what she thought possible in her darkest moments. When I see her doing things which I know are difficult for her, it fills my heart with joy,” he says.