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In the first treatment session, we revisit the goals of an ACT approach and distin- guish between (1) working to control pain no matter the cost, and (2) living a mean- ingful life even when pain is there. Our goal as clinicians is to empower families in doing the latter. From an ACT perspective, values represent a chosen life direction that cannot be achieved in a static or absolute sense as can concrete goals (although concrete goals can be set in the service of moving in a valued direction). We introduce values work early in the program to enhance client motivation and to establish a course for treatment. Values work is also critical in facilitating difficult exposure tasks that may or may not result in symptom reduction. As noted earlier, ACT differs from some behavioral approaches in that symptom reduction is not an end goal. Yet we do not ask our clients to face pain for pain’s sake. Instead clients are asked to make commitments that may involve facing pain when the costs of not doing so are high and in many ways

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life deadening. In this way, values work dignifies the patient’s engagement in painful exposure exercises that offer no promise of symptom reduction (e.g., Dahl et al., 2004; Robinson et al., 2004).

We begin to identify valued domains at the start of treatment; however, values clarification is an ongoing process that continues throughout the course of therapy (and life). At the start of treatment, the clinician might dialogue with the child about what a valued life would look like in a world full of possibilities and without limitations. We keep it simple with children, perhaps starting out with an empty blackboard and asking the child what he or she would like to do more of. Oftentimes patients provide “reasons” and “stories” for why a valued life is not possible (e.g., “my pain keeps me from doing fun things”; I need to get rid of my pain”; “I can never have a normal life because of my pain”).

We begin right away to use defusing language with the child (e.g., “so your mind is at it again, telling you ‘the good life’ isn’t possible”; “you’re having the thought that this is going to be really hard, if not impossible”). Rather than disagreeing or diving into content, the clinician might write down all of the reasons, stories, and rules that surface during the values-identification process and simply acknowledge that this is what our chattering minds do. We recommend staying connected with the child’s values and asking the child to suspend reality for a moment: “Okay, just for this exercise, let’s wipe pain off the table altogether. What would your life look like in a world with no pain? What would you choose to do in a world where you’re in charge and pain doesn’t stand in your way? What would you be doing, like with your hands and your feet?” The clini- cian might also introduce or revisit the pain monster at this point.

Therapist: Last time we met, I got the impression that life isn’t really the way you want it to be right now.

Child/Teen: No, it sucks. Everything hurts.

Therapist: I also got the feeling that you have tried a bunch of different things to make your pain go away, but this hasn’t worked all that well. You’re still in pain.

Child/Teen: Yeah. It doesn’t matter what I do. Acupuncture worked for a while but not anymore.

Therapist: It sounds like you’re stuck. You’ve tried everything and nothing has worked.

Child/Teen: Yeah.

Therapist: And it’s costing you big time. So much of your life has become about managing pain—not about living and doing those things you truly want to do.

Therapist: Of course. This sounds really yucky. Like a big pain monster standing between you and what you really care about. And that’s what I’d like to talk about today. I want to learn more about you and your values—what you really, really care about; what matters most in your life; you know, the important and cool stuff. I want to learn more about what you enjoy doing, the people you enjoy spending time with, and what you dream about doing now and in the future. How does that sound?

Child/Teen: Sounds okay, I guess. It’ll be kind of hard though. There are a lot of things that I can’t do right now—not because I don’t want to but because I can’t.

Therapist: I agree that this exercise is really hard at times. You might have thoughts like “I won’t be able to do this” and “I don’t want to talk about my values because I’ll just be disappointed afterward when I can’t do anything.” If your mind gives you thoughts like these, simply notice them. You might even say to yourself, “There’s another thought.” And you can let me know what your mind is saying—what thoughts you’re having and how you’re feeling inside. If and when discomfort comes up for you, we can think of it as a little pain monster sitting on your shoulder, chatting away. [The clinician might enlist the child’s/teen’s help in drawing the pain monster on the board.] Does your mind ever bully you, boss you around, or put you down like this?

Child/Teen: Sometimes, like when I study for an exam. I think, “What if I fail?” and “I’m not as smart as the other kids.” Is that what you mean?

Therapist: Yes, that’s it exactly. That’s your mind giving you a hard time. It’s like a little pain monster that follows you wherever you go. My mind does that too; sometimes it kicks my butt, telling me all kinds of wacky or hurtful things. So here’s my suggestion: When our minds start chattering away and giving us reasons why we can’t do this exercise or why we can’t have a good life, then we’ll simply notice what our minds are saying. And we’ll sit with the pain monster and listen without necessarily doing what it says. Instead we’ll continue writing out your values, even if the pain monster interrupts, says this will never work, or whatever. We’ll come up with things that you want to do, and we’ll talk about your dreams and what you long for, even if the pain monster says you will never get there. Are you willing to do this?

Child/Teen: Sure. I can try.

At the beginning of treatment, youth often describe their “values” in terms of con- crete goals. In this case, the clinician can help the child find the value by asking why various activities are meaningful—what makes it special to the child? During the initial

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values-identification process, children and adolescents may also state that they don’t know what their values are or that there isn’t anything they wish was different in their life. Almost always, such responses are instances of experiential avoidance. After all, it hurts to care deeply about something, especially when we’re fused with the belief that we can never have or achieve it. Thus the youth’s verbal reports may be functioning as avoidance of anxiety and sadness associated with caring (“valuing”) about something that is seemingly unattainable. In such cases, the child might be asked what he or she would choose to do if pain went away. The clinician might also ask the patient to recall an earlier time in life when things were different, a time when he or she remembers having goals and dreams. The child can describe meaningful moments in his or her life—what he or she was doing, whether anyone else was there, and what made this moment special. It may also be useful to initiate defusion and mindfulness work at this point to promote acceptance of painful experiences that might otherwise interfere with the values-clarification process.

In our work with pediatric pain patients, the purpose of values work extends beyond goal setting to initiate treatment. Valuing in ACT is itself an ongoing process of expo- sure to painful private experiences (such as thoughts, emotions, and memories) that inevitably arise when we honestly evaluate our lives (e.g., thoughts about past failures, fear of future rejection, perceived injustices, feelings of hopelessness, and sadness over a “wasted life”). By revisiting valued domains and barriers to living a meaningful life, patients are exposed to unpleasant thoughts and feelings as well as to challenges in their physical environment (which may also elicit aversive private events). Repeated exposure to these aversive experiences combined with defusion and mindfulness practice pro- motes willingness to enter fully into values work in and out of the therapy room.