Treatment Plan: Do Nothing?

It’s cold and flu season again and we all do the best we can to stay well and avoid catching an all-too-contagious virus. We each have our own go-to plans of how to fight it: vitamin C, zinc or elderberry supplements, gargling with salt water, staying warm, rest and binge-watching Netflix shows. My grandmother swore by anise candy that she made from scratch, while my father prefers a hot toddy to remedy a cold. Washing hands is still the number one way to avoid illness — along with avoiding contact with your face, and keeping your immune system strong. Far too many of us have also taken antibiotics despite the fact that they do nothing for a virus and their overuse has now created resistant strains of bacteria for all humans (Ventola, 2015). You may be tempted to go to the doctor for antibiotics “just in case,” and then the antibiotics are falsely credited for your recovery since you always do eventually recover. Primary care physician and medical director at Chapa-De Indian Health, Dr. Mike Mulligan, says in reference to antibiotics, “If I do nothing I will be doing right by patients most of the time compared to if I prescribe something. If I prescribed antibiotics for everyone who wanted them, I would most often be doing wrong.”

Typically when we go to the doctor we expect someone to do something, yet overtreatment is far more common than under-treatment and the impact causes real harm. Dr. H. Gilbert Welch has investigated how and why this happens for many health problems including heart conditions, headaches, back pain, knee and hip joints, gastrointestinal disorders, and even cancer. In his book Less Medicine, More Health (2015), he examines how early detection hasn’t led to saved or improved lives, which defies logic at first glance. The over-prescription of medications alone is nothing short of epidemic, most glaringly seen with the overuse of opioid pain medications.

Chronic pain is that much more frustrating because of its long duration and frequently leaves people feeling Something More Should Be Done. It seems like Something Else Must Be Wrong if only the doctor could find it. Each specialty department shakes their heads and gives the “good news” of normal or inconclusive scans. Navigating health care systems is not easy to begin with chronic pain rehab programand there are still far too few comprehensive pain management programs that focus on functional rehabilitation. Once in a while the ragged pursuit of Something Else can lead to a more thorough workup or referral to a good treatment program. It depends where the Doing More is directed. Too often, the quest for the Something Else leads to tests and treatments that carry their own risks without relief; often frustrating and distracting to the patient and doctor, resulting in more pain, medical appointment exhaustion, and patients feeling demoralized and hopeless.

Chronic pain has few circumstances where invasive procedures are the best choice. Usually if surgery is warranted it becomes quite clear early on and a 2nd or 3rd opinion will render the same conclusion. The risk of more pain is high with surgery when done because “it might help,” even if the structure has been “fixed.” To a surgeon, fixed means correcting the abnormality. To you as a patient, fixed likely means less pain and improved function. The past 30 years has revealed that abnormal scans of the lumbar spine are common among pain-free individuals and normal scans are common among those who experience pain (Jensen, et al., 1994; Borenstein, et al, 2001). So if the abnormal is normal and abnormal findings do not predict pain, what do we do now?

Last week my daughter’s knee swelled up larger than a softball until she could no longer bend it. We had an x-ray and waited. And waited. The swollen mass grew bigger and her doctor reassured us that ice, elevation and anti-inflammatories were the best treatment. This was hard for me to believe and my mind raced: What caused it? There must be a reason! Why is it so large? Can’t we test the fluid? Can’t we do something to make it go away quickly? I felt like I was Doing Nothing and this felt terrible, but her doctor had ruled-out life and limb-threatening infection and it was the right call. Had I gone to the emergency room, the fluid may have been tapped, risking infection, leading to antibiotics, potential complications and unwanted effects, including more time in bed. An MRI may have revealed an abnormality that was unrelated, which could have led to Doing Too Much. My worst fears were not realized, but it was tempting to buy into the fear that Doing Nothing would lead to a bad result that could have been avoided if I had Done More. What felt like Doing Nothing really was doing something – something at home (elevation, ice, anti-inflammatories, and coping with fear and pain) and Nothing More at the hospital.

The Temptation

It is tempting to assume:
• If there is pain, something is wrong.
• If something is wrong, it can and should be found if we look hard enough.
• Once it is found, it can be fixed.
• If it is fixed, I will feel better.

These assumptions are myths that have been dispelled over time. Sometimes we hurt without any abnormal findings. Sometimes looking harder leads to more problems rather than fixes. Even if the source of pain is found, it may be best to avoid invasive treatments. And the fixing of found abnormalities helps — if you are a car (but even then be cautious of overtreatment!).

But isn’t the pursuit worth the risks? Welch’s data suggests not. One common example is a CT scan – the radiation may increase cancer risk and should be avoided whenever possible. But there also are lesser known risks he calls “incidentalomas” – those incidental findings that appear abnormal on a scan, but do not actually explain or contribute to the symptoms you are experiencing. These red herrings lead to many unnecessary procedures including what I call health-ectomies, or removal of healthy organs in the hopes that it will solve the problem. This is very common in abdominal pain, one of the leading causes of emergency room visits (CDC, 2011). In our highly medicalized society that relies on technology to save us, we can be misled to think that everything can and should be found on a scan or test. However, the search may only distract you from good self-care in the pursuit of an outside fix. Living in the information age leads us to think that more information is better, but more is not always better. “Better information is better,” Welch says (2015). We need useful information to move forward with clarity in medical decisions and health. “At least I would know” does not work if it distracts you from the truth. The truth may be that your disks are degenerating, but it is not typically the cause of your discomfort.

The Frustration

It’s frustrating to be told no, you don’t need that test, that the cause of your do nothingsuffering is unknown, or that there is no cure. “That’s all I can do,” are not words we like to hear. They rank up there with “Could it be depression?” Your doctor may or may not have explained to you why more tests are not recommended. Some people suspect it’s to save money, but most clinics have financial incentives to perform more tests, not fewer. You as the patient may feel more taken care of, more thoroughly examined, but it may not lead at all to better care. Sometimes it is best to Do Nothing, at least nothing at the doctor’s office.

The Fear of Missing Something

The Fear of Missing Something is real and powerful. Any doctor can tell you how terrible it feels when something has been missed. It haunts them for a lifetime. This is a fear of patient and doctor alike, although it is overtreatment that is the common daily occurrence. Most of us feel better Doing Something. Mistakes are made when we are guided by fear rather than facts. We depend on doctors to rule-out anything life-threatening. Afterwards, it can feel devastating when it’s suggested that you “learn to live with it.” But this is not because doctors don’t care enough to do more. Most health care providers really do care, and they care enough to do less. This is where their job ends and yours continues.

Chronic pain is often part of a feedback loop with the central nervous system that becomes sensitized even when the pain signal from body to brain carries no new or useful information about the condition of the body. Inflammation and degeneration are common pain-related issues best treated by lifestyle improvements. A spinal fusion may “fix” the current instability, but create more instability in surrounding areas. It may “fix” the problem, but also severely decrease range of motion. Medication almost always has unwanted effects. Injections have risk and the benefits must outweigh the risks for it to be a good choice for you. Physical therapy may hurt and you swore you would never go back, but finding a physical therapist who specializes in chronic pain is a key part of rehabilitation. Dr. Nobert Boos and colleagues (2000) found that the physical and psychological aspects of a person’s job predicted pain over a 5-year period better than MRI results. If the chronic stress of a tyrant boss or conflict-filled relationships are fueling inflammation in your body, you might consider treatment that targets these root causes of inflammation rather than pursuing a traditional medical fix targeting the wear and tear that’s found on MRI.

Often the body does best when it’s left to its own devices rather than modern medicine interfering at all. You may feel like More Should Be Done, but for chronic and stable conditions or the common cold and flu, wellness is best found at home, not at the doctor. Self-care is a full time job and the goal is to get so good at it, less effort is required over time.

References

Boos, N, Semmer, N, Elfering, A, et al. (2000). Natural history of individuals with asymptomatic disc abnormalities in MRI: Predictors of low back pain-related medical consultation and work incapacity. Spine, 25, 1484-1492.

Borenstein G., O’Mara, J. W., Boden S. D., Lauerman, W. C., Jacobson, A., Platenberg, C., Schellinger, D., & Wiesel S. W. (2001). The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic individuals: A 7-year follow-up study. Journal of Bone & Joint Surgery, 83, 320-34.

Centers for Disease Control (CDC). (2011). http://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2011_ed_web_tables.pdf

Jensen, M. C., Brant-Zawadzki, M. N., Obuchowski, N., Modic, M. D., Malkasian, N., & Ross, J. S. (1994). MRI imaging of the lumbar spine in people without back pain. New England Journal of Medicine, 331(2), 369-373.

Schwartz, A. L., Landon, B. E., Elshaug, A. G., Chernew, M. E., & McWilliams, M. (2014). Measuring low-value care in Medicare. JAMA Internal Medicine, 174(7), 1067–1076.

Ventola, C. L. (2015). The antibiotic resistance crisis. Part 1: Causes and threats. Pharmacy and Therapeutics, 40(4), 277–283.

Welch, H. G. (2015). Less medicine more health. Boston, Massachusetts. Beacon Press.

Date of last modification: 12-22-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

What Would You Do If You Had Less Pain? (Part 2)

 

  1. Spend More Time with Loved Ones
  2. Travel
  3. Be More Independent
  4. Enjoy Life More
  5. Be In a Better Mood

6. If you answered Spend More Time with Loved Ones, it is clear that family and friends are a top value for you. You may feel you aren’t doing your part in the relationship. Perhaps, you say, “I don’t want to slow them down” and so you miss out on fun events with them. Or are you used to being the caregiver in your family? Maybe you withdraw from other because you are uncomfortable asking for help.

Solution: Withdrawing from people you love doesn’t usually help with pain in the long run. However, taking self-care breaks or setting healthy boundaries with loved ones is a necessity for a good life even for those without chronic pain. It is tempting to put fun activities or strengthening relationships on hold until pain decreases, but this may result in more strained relationships and cause you more pain in the end. If taking care of others is important to you, pain might be a signal for you to find more balance between taking care of others and your own self-care. Don’t jump back in at full force, but show up when you can and participate in a way that works for you now. As for not slowing them down – they likely value you for who you are, not what you do. You might value yourself the same way and let them decide if they mind being slowed down.

7. If you chose Travel, it is likely you have an adventurous spirit, have traveled before and know the gifts of perspective, beauty, and excitement that travel can bring. Avoiding travel is a common mistake for those with chronic pain. If your condition is stable and chronic (not rapidly worsening, deteriorating, or waiting for surgery), you have likely been given permission by your doctor to travel, but it’s fear of pain that keeps you at home. You wonder what will happen if you have a terrible flare up on vacation and so decide to remain home.

Solution: What would happen if you had a flare-up on vacation? What is the worst thing that could happen? Be aware of how much fear is driving your decision to avoid travel. Pain can be awful and we want the comfort of home, but a flare is a flare. You may be out of your comfort zone experiencing a flare, but this is not something you can know for certain in advance. Our expectation is to feel our best on vacation. The reality is you might not, but don’t let this deter you from doing something you enjoy. You can bring pain with you anywhere — fortunately and unfortunately.

Challenge yourself to set up your trip for success. Thoughtful preparation will help. Be creative using supportive devices like canes, walkers, back supports, ice and heat packs to ease your ride. Work on conditioning yourself, eating right, sleeping well, and minimizing medications before you go. Creatively schedule the details of your trip to pace events such as sight-seeing, hiking, sitting, and build plenty of opportunities for rest and gentle movement into your itinerary. Take more time to go shorter distances. A slow, steady rate may take longer, but you may discover things otherwise missed on the journey.

8. If you said Live More Independently you may be grieving some of the personal losses that go with chronic pain. It is likely that you have been forced to give up some independence such as working, driving, or engaging in projects around your home. Adjustment to these losses certainly takes time and patience. It may be especially challenging if you are used to taking care of others and now you need help taking care of yourself.

Solution: Being truly self-sufficient is more of a myth than a way of life. Wanting to be alone too much may even be a sign of depression. Being interdependent, rather than independent, is how we survive as a group. It is very challenging to let go of control and let others help. Pushing yourself in an attempt to maintain complete independence can lead to misery. Eventually, it negatively impacts your well-being and the well-being of those around you. How do you feel when you help others? Likely, you enjoy it. What would it be like to afford them this same gift?

Chronic pain and limitations can be a catalyst toward recognizing the gifts that come with asking for help and relying on others. When you need help, use your energy to do what you can without fighting against yourself or others. Be realistic about what you can and cannot do and communicate clearly with those around you. All-or-nothing is not the best option. Try picking and choosing those activities you can still do safely on your own.

less pain9. If you chose that without pain you would Enjoy Life More, there seems to be no argument! Agreed, life would be more enjoyable without chronic pain and if that was possible, I would be selling the cure in bulk. But what will life be like for you if you wait to enjoy it only after pain goes away?

Solution: Any wish for suffering is unhealthy. However, pain is already here so we may as well recognize the gifts that can come with it. It can be a great teacher — not just a disciplinarian. It seems like everything would be better without pain, yet some people who have suffered greatly say that suffering was a gift that brought other beautiful things with it. Without the struggle, they would have missed out on the growth. This is not to say that you should start enjoying pain or be grateful for pain…that’s just crazy. Or is it?

Could we dare to be grateful for pain as we lean in to hear what it has to say? Might it have messages reminding us that we are human and to slow down, to prioritize our values, to take better care of ourselves, to lean into discomfort, to forgive, to share, to ask for help, to empathize, to be brave and stare it in the face, move through it rather than away from it — yes, even befriend it? This is the ultimate challenge in your relationship to pain. What would it be like to befriend yourself with pain? What would you lose if you stopped fighting pain?

10. If without pain you would Be In A Better Mood, you likely have insight into how pain and mood can impact each other. You may have noticed how irritable you become, or even that you can lash out at loved ones — and it justifiably bothers you. Pain can certainly take up so much space in our brains that we feel worn out, irritable, and as if one more thing will tip us over the edge. You may have thought, “If only pain would go away, I could be a nice person again!”

Solution: You may have already noticed that your mood is impacted by how your body feels, but did you know that your body also holds emotions in it and that your moods affect pain? Although the brain is the control center for your body and its sensations, emotions also reside in the body. Do you know where you feel frustration in your body? Where do you feel anger physically? What about impatience, fear, helplessness, loneliness, or sadness? Check your body when you are experiencing different emotions to see where you personally hold these feelings. Is it your shoulders, stomach, back, hands, jaw or forehead? Sooth your mood and pain at the same time. Try to move straight through discomfort and other strong emotions. Find small joys and comforts in the ordinary. Search for wellness by asking yourself, “What is right with my body today?” Be loving and patient with yourself and you may find that you are more patient with others as well.

Date of last modification: 10-20-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

What Would You Do If You Had Less Pain?

 

  1. Everything
  2. More of What I am Doing Already
  3. Clean My House
  4. Go Back to Work
  5. Exercise

1. If you chose Everything, you are among a noble, but misguided group of people who are thoroughly frustrated by being slowed down by pain. You have been dedicated to finding a fix for your condition and impatiently waiting to resume moving at the rapid pace you used to run through each day. You lament how much you used to do, continually comparing yourself to your pre-pain self.

Solution: Break down your Everything into tangible bite size pieces. What specifically would you choose to spend your time doing if you felt better? Pain can push us to prioritize what is truly important. Everything cannot be important anymore, so as much as you are tempted to fight it, begin to narrow your focus to what you really care about and allow this value to be at the forefront of each day. This will be a challenge if you are used to doing it all or thinking that you should be able to. Letting go of this old belief will make room for creatively reaching toward what you most value.

2. If you chose More of What I am Already Doing, this is an indication that you are already plugged into those activities that you value, but unsatisfied with the level you are currently participating in them. Your identity may be tightly entwined with your accomplishments.

Solution: Ask yourself, when will it be enough? When will I be satisfied with busy-880800_1920what I accomplish? Do I hold myself to a realistic and flexible standard? Pain does slow us down, but this is not always a negative thing. It can open us up to the beauty of seemingly small everyday things that often go unrecognized until we are brought to the moment. Discomfort can bring us to the moment, but it is up to us to find the beauty contained in that moment.

3. If you chose Clean My House, you may be among the many obsessively clean people or among the multitudes who are overwhelmed with too much stuff.

Solution: Your home may be messier than you prefer because you cannot scrub, stand, reach, or bend as easily as you used to. However, it may improve your daily quality of life to let go of some cleaning ideals and at the same time, simplify your environment. Having too much stuff to maintain makes it harder to navigate your home when you are hurting. Redirect your attention to those items that bring you the most joy – books, favorite heirlooms, artwork – and discard as much clutter as you can. This will free up space and energy for the relationships and activities that matter to you more than a clean house while at the same time tidying things up.

4. If you answered Get Back to Work, this is a good sign that you seek meaningful activities and find purpose in what you do. Many people have found that letting go of what they used to do is like losing part of their identity. On the other hand, dissatisfaction on the job is associated with more pain — so finding ways to enjoy work to some degree is important.

Solution: If you used to do work that would be harmful for you to return to, the harsh reality may be that you will have to reinvent yourself. List your current skills and other skills you may wish to acquire. The fear of failure can be strong, but do not underestimate yourself even with physical limitations. Many activities within a job can be modified, as there are hundreds of thousands of people living and working with chronic pain. At first, many people cannot imagine doing anything other than their previous vocation; however, those open to reinvention sometimes find even more fulfilling work than before.

5. If you said Exercise, you may be among the many people who have given up your favorite sport or exercise routine due to a painful condition. This is frustrating as a sedentary lifestyle can tumble into a myriad of other health problems. Dr. James Levine has said to the Los Angeles Times, “Sitting is more dangerous than smoking, kills more people than HIV and is more treacherous than parachuting. We are sitting ourselves to death.” Americans sit upwards of 13 hours per day between desk work and screen time at home. This does not include the 7-8 hours we spend in bed! But how do we exercise with chronic pain?

Solution: How much are you moving currently? Starting at your actual current aerobic exercisebaseline is the key to beginning a movement routine and gradually, gradually, increase in very small steps. This is the best way to reach your newly revamped realistic movement goals while avoiding major setbacks. You may not be able to do the gym workout you used to, but gentle movements are still movements and movement is essential for chronic pain and the prevention of many illnesses. Americans watch an average of 4 hours of television each day. What would it be like to add 4 minutes of easy movements to each of those 4 hours? That would be 16 minutes of movement in bite size chunks.

Exercise may not look how it used to. Many people with chronic pain find that pool therapy or stationary bikes work best for them. Others find the movements of qi gong or tai chi are easier than yoga or Pilates, and you still get the benefits of increased circulation, improved balance, better mood and deeper sleep. Build your tolerance slowly and then gradually increase the “dose.”

Date of last modification: 9-27-2016

Author: Jessica Del Pozo, Ph.D.

Dr. Del Pozo is the founder of PACE, a four-week chronic pain management program (www.paceforpain.org). PACE provides cognitive-behavioral therapies and mindfulness training for those with chronic pain as well as consulting and training services for healthcare providers. She is also the co-author of The Gut Solution (www.thegutsolution.com), a book for families with IBS utilizing SEEDS (Stress, Education, Exercise, Diet and Sleep), a biopsychosocial approach to IBS and RAP. Dr. Del Pozo is also on staff of a multi-disciplinary pain management program at Kaiser Permanente, where she helps many patients refocus their strengths to manage pain without opioid medications.

How to Get Better When Pain is Chronic

In the last post, we began to introduce a broad definition of coping, as one’s subjective experience, or reaction, to a problem. In this post, let’s expand on this definition and explain how coming to cope better with a problem is a process of coming to experience the problem in a different and better way.

Coping is how we subjectively experience a problem

In our society, when having a problem, we tend to focus on the problem itself, its characteristics and how they do or don’t lend themselves to resolving the problem. In so doing, we put our focus and energy towards fixing or getting rid of the problem. This way of thinking about the problem is all well and good. It likely lends itself to our society’s successes in developing technological solutions to many of the great problems that we have faced.

As an example of this tendency to focus on problems and fixing them, we need only to look to the problem of pain and how we tend to focus on it, and how we try to get rid of it or otherwise reduce it. Knees and hips can now be replaced and we have a large assortment of different medications that can reduce pain and sometimes get rid of it entirely.

However, instead of focusing primarily on the problems itself, we might also coping with painbring our attention to the unique characteristics of each individual with the problem and how they understand it, feel about it, perceive it, and how they behave in regards to it. In effect, we might focus on the characteristics of each person and how these characteristics influence the way individuals experience the problem.

For wherever there is an objective problem in the world, there are also perceiving subjects who have the problem.

We typically call the ways that people experience problems “coping.” It’s something that usually we only direct our attention to when we can’t come up with a solution, or fix, to a problem itself. Nonetheless, it comes in handy in such situations because it offers a way to still get better even if there is no fix to the problem. Namely, we get better at coping with the problem: we can become less distraught by the problem or less impaired by the problem.

In this regard, in returning to our pain example above, we might focus not so much on how to get rid of pain, but how to get better at coping with pain. This change in the approach to getting better may come in handy when pain is truly chronic and you’ve already tried every reasonable procedure and medication without any significant benefit. In such a situation, you focus not so much on how to reduce pain, but on how to increase coping.

In doing so, you can come to learn to tolerate pain that at present is intolerable. You might even get so good at coping that you do more than simply tolerate it – you might get so good at coping that the pain goes from something that is the central focus of your life to something that occurs in the background of your life. It becomes a problem, in other words, that’s not very problematic.

Moreover, you can do such thing without ever reducing pain itself. It can all occur by changing how you experience, or cope with, pain.

It may sound too good to be true.

How coping better makes problems less problematic

It’s important to recognize that people who cope well with a problem tend to experience the problem as less significant or severe than those who don’t cope well with the problem. In other words, when we aren’t coping well, we tend to perceive or judge the problem that we face as more problematic than those who cope well with it. For example, if you had taken a speech class and had actually given many speeches before in the past, you might find the prospect of giving a speech to a packed auditorium as less problematic as someone without your level of expertise and practice. You might find it quite tolerable, in fact possibly even not problematic at all – something in the category of “Well, it was no big deal.” However, another individual, who faces the challenge of giving the exact same speech to the exact same auditorium, might find it overwhelming, paralyzing or intolerable. This individual might judge the problem as one of the hardest things he has ever done in his life.

Objectively, it’s the exact same problem, but the two people subjectively experience it in very different ways. We might say, in such cases, that the differences lie in how well the individuals cope with the problem of giving a speech to a packed auditorium.

How well we cope depends, of course, on how significant the problem is. Big or complicated problems are more difficult to deal with than small or simple problems. Most people will find talking to a group of two or thee people easier than an auditorium of two or three hundred. Nonetheless, how well we cope with problems is also dependent on other things too.

Cope with PainNotably, it’s dependent on certain characteristics of the person who is coping with the problem. If one knows a lot about the problem and is actually an expert on the topic, then typically that person copes better than someone who doesn’t know as much about the problem. Or, if someone has experienced the problem before or expects the problem to occur, then that person often copes better than the individual who has never encountered the problem before or someone who is taken by surprise by the problem. Confidence plays a role here too. Someone who knows a lot about the problem and is well-versed or well-practiced with dealing with the problem tends to be more confident and that confidence aids in coping better. Someone who lacks such confidence tends to be more alarmed or even distraught, which makes for more difficulty in coping. In any of these cases, the subjective experiences of the problem are different for the different people, even if the problem was objectively the same problem.

We could go on indefinitely about the subjective characteristics of the coper, which play a role in how well the individual deals with a problem. We might make a list of subjective characteristics that determine, in part, how well one copes:

  • Degree of knowledge or expertise about the problem
  • How one conceptualizes the problem
  • Degree of accurate information that one has about the problem
  • How much one has practiced overcoming the problem
  • Other attitudes about the problem
  • Degree of confidence in facing the challenge
  • Degree of attention directed on the problem
  • How one feels about the problem
  • What one’s mood is at the time of encountering the problem (e.g., whether one is calm or irritable, depressed or anxious)
  • How much sleep one has had in the past few days prior to encountering the problem
  • How many other problems one is experiencing at the time of encountering a new problem
  • What one goes on to do about the problem (behaviorally)
  • Degree of loving support one has in facing the problem

There are literally countless aspects of the coper that determines, in part, how well one experiences, or copes with, a problem. Some of these characteristics lend themselves to better coping and some lend themselves to worse coping.

Getting better by getting better at coping

So, think about this simple fact: if you have a problem that can’t be entirely fixed, you could still get better by setting out in a concerted effort to get better at coping with it. You could, in effect, obtain training at having the problem and get so good at it that having the problem becomes less and less problematic. It could become, for example, something that occurs in the background of your day-to-day activities, but for the most part you’ve moved on and focus on the meaningful activities of your life. Indeed, there is simply no end to how good one can get in coping with a problem, even a problem that can’t be entirely fixed, like chronic pain.

Here is where true hope lies. Even when your pain is chronic, you can get so Needing Hopegood at coping with it that living with chronic pain is no longer a distressing or impairing problem. Alternatively, you can get so good at coping with it that it no longer requires opioids to manage it and so you can move on with the rest of your life.

Usually, this level of advanced coping requires a concerted effort of training, done over time, and typically with a team of healthcare providers who coach you and support you throughout the process. Traditionally, patients find such support and training in chronic pain rehabilitation clinics. Such clinics are a type of pain clinic that involve an interdisciplinary team of healthcare providers (consisting of at least pain psychologists, medical providers, and physical therapists, but oftentimes other kinds of providers as well) who work with patients over an extended period of time in the pursuit of not so much reducing pain, but improving the patient’s coping. Such clinics are not new, but have been around since at least the early 1970’s and as a result they have about four decades of published research proving their effectiveness (see, for example, these meta-analytic studies and literature reviews: Chou, et al., 2007; Flor, Frydrich, & Turk,1992; Gatchel & Okifuji, 2006; Neusch, et al., 2013; Turk, 2002).

When talk of the possibility of coping better feels like a criticism

Sometimes, when healthcare providers like me talk in these ways, it feels to patients with chronic pain like a judgment. It feels like blame. It feels like you’re being told there’s something wrong with you — that you aren’t coping well enough.

Oftentimes, when patients have people in their lives who judge them or stigmatize them for how they have been coping, they can come to hear their healthcare provider talking about the benefits of learning to cope better as a similar criticism.

In such cases, patients can come to refuse the recommendation to participate in chronic pain rehabilitation. The hopeful message that there is a traditional and scientifically proven treatment that helps patients to learn to cope better with pain can be met with quick and sometimes sharp rebuttals. Common examples are the following:

  • The provider must be insensitive.
  • The provider must not know what he or she is talking about (i.e. the provider is incompetent).
  • The provider doesn’t (or won’t) recognize that I’m coping as well as humanly possible given the amount of pain I have.
  • The provider must not have chronic pain or otherwise he or she would understand.
  • The provider must not believe me that I have real pain.
  • The provider is just out to make money and so wants me to go to yet another treatment from which he or she will profit.
  • The provider just wants me to get off opioid medications.

Obviously, talk of how to learn to cope better is a sensitive topic. It’s as if the same words can engender almost two opposite interpretations. The healthcare provider intends it to be a hopeful message – you can get better by undergoing extensive training over time and as a result come to cope better with a condition that is incurable. The patient, however, can hear it as an insensitive criticism of how the patient isn’t coping well right now.

Importance of trusting your healthcare provider

In such situations, what can make the difference is having a good, therapeutic relationship with your healthcare provider. If you know your provider and trust him or her, then you know that your provider isn’t just being mean or insensitive or ignorant of what’s it like to have pain or out to make money off you. Instead, you know that your provider has your best interest at heart.

Your thoughts

Have you ever had a healthcare provider talk to you about chronic pain rehabilitation or learning how to cope better with pain? What were your reactions? Have you ever attended a chronic pain rehabilitation program? Why or why not?

[Please note our comment publishing policies. All participants in the discussion will appreciate your cooperation with this policy.]

References

Chou, R., Amir, Q., Snow, V., Casey, D., Cross, T., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478-491.

Flor, H. & Frydrich, T., Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221-230.

Gatchel, R., J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.

Neusch, E., Hauser, W., Bernardy, K., Barth, J. & Juni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: Network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962

Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.

Author: Murray J. McAllister, PsyD

Date of last modification: September 11, 2016

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

Can you experience the same pain differently?

A major tenet of chronic pain rehabilitation is that the way you experience pain is not the only possible way to experience pain. In other words, the experience of pain differs across individuals and can even differ in the same individual across time. As such, it’s possible to have a different experience of pain than the experience that you have today, even if your pain remains on a chronic course.

This point isn’t necessarily controversial. Patients commonly make a similar point themselves. For instance, patients sometimes express that pain is a subjective experience that only they can feel.

The rub, though, lies in the consequences we draw from such a point. We can draw different consequences.

Patients often make the point about the subjective nature of pain as a means to defend against stigma. It’s a way to say that others shouldn’t judge if their experience of pain differs from the patient’s experience of pain. While it’s a good point that no one should ever stigmatize patients for how they experience pain, we might draw an altogether different inference from the point that pain is a subjective experience. This inference has nothing to do with the issue of stigma and it is often drawn by healthcare providers, particularly pain psychologists and others who work in chronic pain rehabilitation. This additional inference is that you can come to experience pain differently.

In other words, the subjective nature of pain is such that different people can have different experiences of pain and what this shows is that it is possible to experience pain differently than how you experience it today. You can learn, in other words, how to have pain in other ways. It’s a hopeful message. It’s the foundation for what pain psychologists do everyday – help people come to experience their pain differently, in ways that are better than how they presently experience it.

Coping with pain as changing how you experience pain

In effect, what’s happening is that, with the help of pain psychology and chronic pain rehabilitation, people come to cope better with pain. They literally experience their pain in new and different ways. They experience pain in ways that are better than they had experienced it previously.

They know, for instance, that their pain isn’t a sign of a fragile injury, which is experience painabout to get worse at any point in time. Subsequently, they are not alarmed by pain and do not understand it as some thing for which they must stay home and rest. Instead, they tend to see pain as akin to white noise, something that is there, but remains in the background of their attention. They remain grounded and focused on their activities, which they continue to do. They go to work and go to their children’s activities and go to the neighborhood potlucks. They do all these things with pain.

Now, that’s what coping really well with pain looks like.

When people cope well with pain, they literally experience it differently than someone who isn’t coping well – the individual, for instance, who is alarmed by pain, sees it as a function of a deteriorating disease that is inevitably going to get worse, and so subsequently believes the best course of action is to avoid the activities of daily life and instead stay home and rest, out of concern for not making their condition worse.

What would it be like to cope so well with pain that you literally experience it in the manner I previously described above – as something that remains present, but something that nonetheless doesn’t deserve a lot of day-to-day attention and emotional energy and so remains in the background of your daily activities like white noise?

There are countless lessons to learn that can be helpful when learning how to do it. The pain psychologists of a chronic pain rehabilitation clinic or program can help you to learn them. We have discussed a number of them in the posts of this blog (see, for example, posts on catastrophizing, all-or-nothing thinking, mind-reading, perfectionism, among others).

In our next post, we’ll review yet another important cognitive distortion that adversely affects how people experience pain. It occurs when people understand pain as something that always signals harm. It can happen, for instance, when people with back or neck pain understand their pain as solely the result of a fragile, degenerative condition of the spine. In large measure, this cognitive distortion is a consequence of how certain parts of the healthcare system understand back and neck pain as the symptom of degenerative disc disease. It’s therefore a complicated issue as it plays out in both patients and some healthcare providers.

It’s also, though, an important issue. Every rehabilitation provider tends to encourage patients to exercise, move and get back into life, within some reasonable limits. However, people don’t tend to do these things when they see their pain as signaling harm. Instead, what people tend to do when understanding their pain as indicative of a fragile injury is to become mildly alarmed, stay home and rest.

It’s therefore important to learn when pain is a sign of injury (for which you should become alarmed, stop what you are doing and seek care) and when pain is not a sign of injury (for which you try to stay grounded, redirect your attention elsewhere and remain engaged in the activities of your life). In other words, sometimes pain has a psychobiological function of signaling injury or illness and sometimes pain continues even though it has lost this function. It’s important to know the difference. In the former case, you take heed. In the latter case, you try to tune it out as white noise.

Will discuss more in the next post!

Date of last modification: 8-29-2016

Author: Murray J. McAllister, PsyD

About the author: Dr. McAllister is the executive director and founder of the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported. Additionally, the ICP provides scientifically accurate information on chronic pain that is approachable to patients and their families. Dr. McAllister is also the clinical director of pain services for Courage Kenny Rehabilitation Institute (CKRI), part of Allina Health, in Minneapolis, MN. Among other services, CKRI provides chronic pain rehabilitation services on a residential and outpatient basis.

Developing an Observational Self: How to Cope with Pain Series

From the time before Socrates in ancient Greece there stood a temple built upon a spring at a location the Greeks would have considered the center of the world. Inscribed on the walls of this holy temple was the simple phrase, “Know Thyself”.

This simple phrase inspired Socrates to a life of learning and teaching, and, from him, Plato learned to be a philosopher and later came to teach Aristotle. Subsequently, Western civilization, in large measure, began.

This maxim – “Know thyself” — and others similar to it were not uncommon in the ancient world. Indeed, a few thousand years previously, early Hindus and later Buddhists practiced a form of moment-to-moment self-knowledge, later coming to be called mindfulness.

The directive inherent to this maxim has two components. The first is to pay attention. In observational selfother words, slow down and observe what’s happening. In today’s language, we might express the maxim as something like, “Get out of your head and notice what’s going on around you.” When we carry out such a dictum, we become observant and reflective. We see or otherwise perceive things that we might not have heretofore noticed. We subsequently create opportunity to consider what it is we observe.

Good things happen when we do. We see good things and become appreciative. We stop and smell the roses because we were observant enough to even notice them as we walked by and as a result we are able to appreciate their visual and olfactory beauty. Whereas in one moment our kid might be bugging us because of her need for attention is interrupting our apparent need to make a phone call or put dinner on the table, in the next moment, once we get out of our head, we recognize just how funny or cute the kid is and we subsequently are overwhelmed by how much love we have for her.

So much of life goes unnoticed because we are simply and persistently reacting to whatever thoughts, feelings and needs that pop into our attention. Whatever pops into our heads tends to have a sense of immediacy to which we react impulsively, without thinking in the sense of thoughtful consideration. It’s just a never-ending chain reaction of stimulus and response, like billiard balls knocking into each other. Notice that when we live life as if we are a player in a video game that goes on in our head, simply and persistently reacting to whatever momentary thought, feeling, or need that pops into our head, so much of what goes on around us gets missed.

We don’t see how cute our kid is in that moment. We don’t notice that our spouse made coffee for us before leaving for work. We don’t smell the fresh air. We don’t taste our lunch. We don’t fully appreciate how funny it was when our coworker or neighbor made that comment yesterday.

Instead, we were busying ourselves with the immediacy of whatever popped into our head at the time.

Notice too all the things we could have done in those moments but didn’t do simply because it never occurred to us. When we react to whatever thought, feeling or need that pops into awareness at any given time, it’s as if the reaction that we have is the only possible thing to do at the time. We might even justify the reaction, if anyone ever were to ask us about what we did, by saying ‘Oh, I had to,’ as if the thing we did was the only possible thing that could have been done. However, it’s not really true, and this point brings us to the second good thing that happens when we get out of our heads and start to observe what in actuality is happening in any given moment.

Namely, we become liberated from being a passive recipient of what happens to us to an active decision-maker of a well-informed life. By observing what in actuality is happening in life, and by considering the various possible ways we might respond, we exercise choice. No longer is our life dominated by the apparent ‘must’ and ‘have to’ and ‘got to’, but rather we are free to choose. When we pay attention, we recognize that we do not have to simply endure things happening to us. We are not victims. We have the power to choose among a number of different options as long as we slow down enough to recognize and consider the options that are available to us.

The simple maxim – Know thyself”, then, is a truth that sets us free. It’s freedom from a determinism of automatic reactions to whatever life gives us. We no longer ‘have to’ do this, that, or the other thing, but are free to choose how we live our life. We no longer ‘can’t’ do anything but the reaction that we have automatically done countless times in the past and are now free to choose how we might respond and move forward. From moment to moment, we are free to choose how to respond even to the things in life that we do not choose – like bad things that happen to us. We still are free to choose how we react to them and the perspective by which we see them.

In sum, the second good thing that happens when we observe what’s happening is that we become intentional about what we do, how we react to things, and even how we perceive the things around us.

This ability to observe life and intentionally choose how to respond to the things that come up from moment to moment is the main goal of psychotherapy. Freud called this ability the development of an ‘observing ego’ and considered analysis a way to develop this ability. In more recent psychotherapies, we call it an ‘observational self’. It’s the ability, as described, to step out of any given moment, consider what’s happening, and intentionally choose how to react. Of course, in this day and age, we also call it ‘mindfulness’.

What does developing an observational self have to do with pain?

The development of the ability to step out of the moment and reflect on how to react to pain is the initial and most important thing to do in pain management. Everything else in pain management follows from this skill.

Pain has a sense of immediacy about it. It’s a sensation that is inherently emotionally alarming and to which we automatically react with avoidance behaviors – we stop what we’re doing, pull away and guard. This sensory, emotional and behavioral experience happens all at once, of course, and it happens automatically. We don’t typically choose any of it. The sensation just is alarming and we pull away and guard without ever intending to do so.

For example, if you were out hiking in the woods and, without looking, you stepped in a hole and twisted your ankle, you’d have pain. That is to say, you would have a sensation that was emotionally alarming and to which you would stop walking and guard your ankle in some manner. The whole experience would be almost instantaneous. It would also be automatic, in a sense. The alarming sensation and behavioral avoidance would occur without any intentional decision-making on your part.

However, if you had chronic pain, and you set out to pay attention to the pain that occurred with activities, you could learn to make the whole experience more intentional. You would do so in a multiple step process. You would first simply pay attention to the pain that occurs and not be taken by surprise by it. Chronic pain often has a degree of predictability that the pain of an acute injury doesn’t have. So, by paying attention, you could practice the skill of not being taken aback by the pain. Just as importantly, you could recall that you have chronic pain and that you’ve had it for some time and you know what it is. In most cases, chronic pain is the result of the nervous system having become highly reactive to the stimuli of activities that are normally not painful to do – like walking, sitting, standing up, laying. You could consider that, even though it is painful, these activities are safe to do– that you are not injuring yourself even though it is painful. In this manner, you start to control the sense of emotional alarm that you have with pain. You set out to intentionally remain emotionally grounded in the presence of pain. To this end, you also practice taking deep, diaphragmatic breaths to assist you in remaining calm. From this new-found perspective, you can also choose how to behaviorally react. You intentionally choose to engage in the activity and have the sensation while practicing remaining calm.

Suppose, for example, every time an individual with pain sits down she knows she’ll experience pain. More often than not, however, she doesn’t keep this fact in mind and she goes about her day, like most of us, simply reacting to whatever pops into her attention. She does this and then that, checking things off her to do list. Each time she sits down, she lets out a soft groan, grabs whatever is within reach in order to brace herself, and becomes, for an instant or two, emotionally and physically tense. The pain is severe and it takes her breath away.

She could, though, with some proper coaching from a psychologist at her pain clinic, set out to learn and practice the ability to step out of the moment and pay more attention to her actions. She could then practice slowing down the process of experiencing pain. In doing so, she pays attention to what she does and predicts the severe pain prior to sitting down. In this way, she isn’t taken by surprise each time. With knowing that it’ll hurt, she takes some deep diaphragmatic breaths as she works and reminds herself that even though it is painful she isn’t injuring herself every time she sits down. She intentionally recognizes that it is safe to sit down even though it hurts badly. In these ways, she practices remaining grounded while having pain. With her budding abilities to remain calm in the presence of pain, she intentionally sets out to control her pain avoidance behaviors. She makes the decision to stop letting out the groan because she’s predicted the pain and isn’t taken aback by it as she sits down. She intentionally stops her tendency to abruptly reach out for something to hold on to while she sits, reassuring herself that it is safe to sit down. She also tries to refrain from grabbing her back and instead sets out to remain as calm as she can be in the presence of her pain, even severe pain. She intentionally does all things, moreover, on a repetitive basis through the course of her day, day after day. She discusses her strategies with her psychologist each week, and her psychologist gives her pointers, which she tries at home. Over time and with practice, she gets better and better at it. By developing her abilities to pay attention, observe herself and engage in intentional decision-making, she comes to be able to control, in part, her experience of pain. She comes, in other words, to be able to control the alarming and behavioral aspects of pain and subsequently becomes able to remain grounded and productive in the course of her day, even though she continues to have severe pain.

This description is what good coping looks like. Good coping is not getting rid of pain, but getting so good at reacting to pain that it is no longer as problematic as it once was. It requires the development of an observational self from which you can have pain, remain aware of how you are reacting to it, and intentionally attempting to remain grounded and active while having pain.

From the river Ganges to the temple at Delphi and all the way through to the modern pain clinic, the dictum to know thyself travels through time because good things happen when we follow it. The ability to pay attention and engage in intentional decision-making when having pain is the initial and most important skill to develop in pain management.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-19-2016

Coping: Ideas that Change Pain

Coping-based healthcare is often misunderstood in society and, as a result, it is commonly neglected by healthcare providers and patients alike. Examples of such care are chronic pain rehabilitation for pain disorders, cardiac rehabilitation for heart disease, psychotherapy for mental health disorders, or diabetic education for diabetes. These therapies are often the last thing that healthcare providers recommend or the last thing people are willing to try, even though they are typically some of the most effective treatments for their respective conditions.

CopingThis misunderstanding and neglect is likely due to a number of reasons. Our healthcare system is set up for providers to focus on making patients well, not teaching them how to become well or get better at dealing with a health problem that won’t go away, such as chronic health conditions.

Another reason may be our shared desire for a quick fix. Understandably, when faced with a health problem, we often initially want something that will take it away, rather than coming to terms with the need to change our lifestyle in order to get healthier or become more effective at coping with the problem that we face.

Yet another reason is our societal misunderstanding of the role that genetics play in most of these chronic conditions. It’s not uncommon for people to report that their depression or back pain or heart disease or type II diabetes runs in their family, as if to say, there really isn’t much they can do about it. To be sure, at least some of these conditions, if not all of them, run in families, but a genetic predisposition is not destiny or fate. In all these conditions, the lifestyle choices we make in our lives also play a role and it’s healthy changes in how we live our lives that can make all the difference.

There’s also something about going to see a healthcare provider to learn how to be healthier that just doesn’t seem as real or effective as going to see a healthcare provider for a medication  or a high-tech test or an injection or a surgery. Coping-based care, in other words, seems so intangible. Acute medical care is something that you can touch, see, hear, even smell at times. You walk away with medications in your hand, a dull ache at the site of where you got the injection, or a hospital wristband. Such tangibles are missing when you see your rehabilitation provider or your psychotherapist or your diabetic educator. You walk away with nothing but ideas on how to make healthy changes in your life. In other words, what you walk away with is all in your head.

Speaking of which, yet another reason why coping-based therapies get short shrift in our healthcare system is stigma. We all might intellectually acknowledge that we could make healthier choices in our lives or deal better with the chronic conditions that we have, but hardly anyone ever wants to openly acknowledge it to others for fear of being blamed. In the face-to-face encounter of the examining room, healthcare providers too typically have a hard time bringing up the fact that, say, a particular patient could benefit from learning how to cope better with his or her problems. The act of bringing it up implies a judgment that the patient isn’t coping well and it’s a sensitive topic. People can become upset. Healthcare providers, despite all their training, are just people too and they become nervous in such situations, often too nervous, and so the whole topic never gets raised. It’s easier to focus on the tangibles – the medications, tests, injections, and surgeries. Even if the need for learning better coping strategies does get brought up, it’s not uncommon for patients to refuse it, asserting instead that they actually cope really well, despite evidence to the contrary. It can seem advantageous to deny that you are coping poorly when, in our society, coping poorly is a judgeable offense.

For any or all these reasons, coping-based therapies are commonly considered an after-thought, after the ‘real’ healthcare has been tried and failed. It’s too bad because these therapies can be highly effective.

In an ideal (i.e., stigma-free) world, these therapies would be able to stand on their own and be recognizable as the effective therapies that they are. However, we don’t live in such a world.

All of us need to do our part to promote these therapies so that people who need them gain the liberty to use them and become healthier and happier. That’s what’s really at stake here: because of stigma and ignorance and fear, we as a society don’t readily feel free to utilize treatments that can make us healthier and ultimately happier people, even when we experience health problems that can’t entirely be cured.

To this end, at the Institute for Chronic Pain, we make every effort to promote the legitimacy and effectiveness of coping-based rehabilitation treatments for pain. Using common, everyday language, we develop explanations of them that show how and why they can be helpful. We persistently discuss issues related to stigma, particularly how to respond to it so that people can overcome the sensitivity that comes along with openly acknowledging the need to learn how to cope better with the pain that remains chronic on a life-long basis. We then use social media as a means to proliferate these ideas and make them known on an international scale. In short, we promote ideas that change pain.

Our latest effort in this regard is a new content page on our home website. It’s on the nature of coping and how learning to cope better with pain is one of the most powerful interventions we have in the field of chronic pain management.

We hope that you find it helpful. If you do, please pass it on within your social network. Take the risk to acknowledge that there’s nothing wrong with learning how to cope better with a health problem that can’t entirely be cured. You might just help someone else find the help they need.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-30-2015

Overcoming Perfectionism

In the last post, we discussed the nature of perfectionism and the problems associated with it. Specifically, we reviewed how perfectionism is problematic and how perfectionism leads to poor coping with chronic pain. In this post, let’s review some basic ways to begin to overcome perfectionism.

Accepting the problematic nature of perfectionism

The most basic step to overcome perfectionism is to recognize and accept that perfectionism is a problem. Despite the kudos that perfectionists might receive for the excellent quality of work that they do, perfectionism comes at a price. The perfectionist, as we saw in the previous post, lives with low-level emotional distress:

  • Nervousness (i.e., can’t sit still)
  • A persistent lack of satisfaction (i.e., things are never quite good enough)
  • Time pressure (i.e., there’s always more to do)
  • A persistent sense of self-criticism (i.e., the perfectionist rarely feels good enough)

Technically, what we are talking about is anxiety and the compulsive need to always do something just a little bit better. The compulsive behavior quiets the anxiety, but only temporarily. It lasts only until you see something else that needs to be done, which usually occurs not long after completing the previous task.

Moreover, none of these characteristics make for effective coping with chronic pain. In fact, they lend themselves to poor coping:

  • Failure to pace one’s activities
  • All-or-nothing approaches to life activities, which lead to persistent exacerbations of pain
  • Anxiety and depression
  • Problems in relationships

So, the first step in the process of overcoming perfectionism is to recognize that it is a problem.

This recognition and acceptance is difficult for some perfectionists. The degree of difficulty depends on the degree to which the perfectionist has skill sets that psychologists refer to as insightfulness and ego strength. These skill sets are important to understand because they have to be developed in order to overcome perfectionism (or most any other unwanted personality trait).

The prerequisite skill sets for learning and self-growth

The capacity for insight involves the ability to reflect on one’s own thoughts, feelings, intentions, or actions. People with insight can step outside of themselves and observe themselves. In so doing, they consider how they have been thinking, feeling, and behaving. This skill set is also sometimes called an ‘observing ego’ or an ‘observational self.’ Whatever we call it, it’s the ability to take yourself as your own object of observation, reflecting on your inner workings and outward behaviors.

The skill set of insightfulness allows you to self-correct and learn from feedback. Suppose someone doesn’t see the error of his ways. Others might point it out, but the person doesn’t see it and so doesn’t take heed. Instead, she continues to think that what she thinks or feels or does is right or accurate or warranted (whatever the case may be). What would allow her to see the error of her ways? It usually doesn’t help to get mad and yell at her, right? What helps in such situations is to help her to be able to step outside of herself and reflect on her thoughts, feeling or actions. We might help her to see that her perspective is but one of many perspectives. Moreover, we would help her to start weighing her perspective against other perspectives, coming to reflect on which ones are more true or accurate or warranted.

In so doing, she comes to the insight that what she thought wasn’t true or what she did wasn’t warranted. In short, she comes to the realization that she was making a mistake, but didn’t know it at the time, but now she does. In other words, she developed insight.

From here, we can see that the skill set of insightfulness goes hand in hand with another skill that we discussed in the previous post: ego strength. If you recall, ego strength is the ability to accept and learn from the feedback of others. To tolerate feedback from others, you have to be able to see that your thoughts and feelings are but one perspective among many and to reflect on how the perspectives of others may have more or less merit than your own. You subsequently come to see that how you had been thinking or feeling may or may not have been right in some way and as a result you learn and grow.

No one learns in a vacuum. Most of the time, in order to learn, we need others to point it out to us, to teach us, to show us. We thus need to be open to the feedback that others can provide.

So, in short, what we have been talking about are the pre-requisite skills for learning and self-growth. They are the following two abilities:

  • To be insightful
  • To accept feedback from others

They allow us to understand that not everything we think or feel is right (i.e., insightfulness) and be open to viewpoints that might differ from our own (i.e., ego strength).

The spectrum of skills

Like any other skills in life, the skill sets of insightfulness and ego strength vary across people. We can see them as occurring along a spectrum from those who aren’t very good at them to those who are really good at them.

The good news is that these skills can be learned, just as any other set of skills can be learned. Sometimes, it takes time and sensitivity, but they can be learned. Typically, people learn such skills in psychotherapy because it allows for learning in a safe and trusting environment in which sensitive issues can be discussed without criticism or judgment.

So, no matter how good you currently are at these skill sets, you can always learn to do them better.

Relationship of insightfulness and ego strength to perfectionism

The skill sets of insightfulness and ego strength lend themselves to personal growth across all facets of life, including learning to overcome perfectionism. They allow the perfectionist to step outside himself and reflect on whether his drive to do better or to do more is really necessary. Without this capacity to self-reflect, the perfectionist simply takes his perfectionistic drive as obviously warranted and persistently engages in excessive activities, attempting to attain some unattainable, perfectionistic standard. With self-reflectiveness and openness to feedback from others, the perfectionist can catch himself in such thoughts and behaviors, consider whether they are warranted, and make an intentional decision to do something different.

Let’s take an example. Suppose a perfectionist with chronic pain wakes up one day with relatively little pain. He’s pleased by the good fortune of a good pain day and thinks, “Oh good, I’m going to get this filthy house clean (or my taxes done or clean the garage).” Prior to this day, he had been beating himself up for having allowed the house to get so messy, even though others in the family might think that the state of the house is pretty clean, or at least clean enough. Nonetheless, as a result of his relatively low level of pain today, our perfectionist comes to clean the entire house and makes it look perfect. In so doing, he relieves himself of the low level of guilt he had been carrying around for the previously perceived lack of cleanliness of his house. For these positive outcomes, he pays the price of exacerbating his pain and being laid up for the next few days.

Notice in our example that our friend never stops to consider whether his perceptions of the house as ‘filthy’ are accurate. He doesn’t reflect on whether making an already fairly clean house into a perfectly clean house is truly warranted. So too, he fails to consider the predictable consequences of his all-or-nothing approach to house cleaning – i.e., cleaning the entire house in one day.

I once worked with a man who had never considered the fact that most people don’t vacuum their carpets every day. When he finally came to believe me, the conclusion he came to was that most people must be slobs. In the course of the discussion, it didn’t ever occur to him that he was the outlier.

How do you intervene in the face of such perfectionism? Unfortunately, what often happens is that family and friends become frustrated and throw up their hands. Worse yet, some might even get angry and chastise our friend for doing too much and exacerbating his pain. Such reactions only serve to isolate the perfectionist as we saw in the previous post.

What happens, though, if we approached our friend with sensitivity to help him entertain the idea that his house is already clean enough. Remember, it was the perception of others in his family and, because we know our friend well, we know that his perceptions of what is clean or not are usually the outlier and that his family’s perceptions tend to be more accurate. So, in other words, what if we help him to see that his perfectionistic standards color his perceptions. In so doing, he comes to see that there are other legitimate ways to see things. From here, he might progress to the point of doing it on his own: that he can begin to weigh different perspectives against each other and subsequently come to see that he tends to be an outlier in how he sees the world. Still later, he might come to see that the standards of the majority are most often right – that good can truly be good enough. At this point in the process of overcoming perfectionism, he’s ready to practice this insight over and over again.

Practice

Learning any skill requires practice. Typically, you don’t try something once and then have it down pat for the rest of your life. No, to learn something and become proficient at it, you have to practice. So too it is with catching yourself in your perfectionistic tendencies and changing them.

You use the skill sets of insightfulness and ego strength to catch yourself. You literally practice being self-reflective and being open to feedback from others.

It’s actually a very difficult thing to do. Our thoughts, feelings, decisions, and subsequent behaviors fly by almost instantaneously without a moment’s notice. It’s this lack of noticing that makes everything that happens between the ears seem to fly by. We are, of course, the pilots of our own planes, but more often than not we are on autopilot. As such, we simply and automatically react to the events of life as they happen without ever making any intentional decisions to react in the ways we do. That is to say, we typically don’t pay attention to our thoughts and feelings and make an intentional choice as to how to respond to the events of our daily life. However, if we set out to practice remaining aware of our thoughts and feelings and reactions, we can subsequently become more intentional about our actions. It is here where you can begin to break the habits of acting out perfectionistic tendencies. However, this degree of self-awareness and intentionality is difficult for at least two reasons:

  • It’s difficult to remember to pay attention and maintain a degree of self-observation.
  • It’s difficult to gain intentional control over compulsive behaviors, such as acting on perfectionistic needs to do more or do something better.

Oftentimes, when setting out to make personal changes, it’s easy to forget to continue making the change almost as soon as you start. It might be a day or two or even a week before you realize that you haven’t been doing it and in fact had forgotten all about it.

There are a number of ways that you might try to remember to practice your self-awareness. You might, for instance, take some sticky notes and write the phrase ‘self-observation’ on them and then place them strategically around the house. You’ll run into them as you go about your daily life and they can serve as a reminder. You might also place a smooth stone in your front pocket and every time you accidentally touch it, it will serve to remind you to check in with yourself about what it is you are thinking, feeling and doing. If you are religious and have a prayer routine, you could add your intentions to practice self-awareness to your list of prayers. Maybe also you ask some trusted loved ones to help remind you to check in with yourself, especially if they see you engaging in perfectionistic thinking or behavior. When asking others for such help, it’s usually best to agree on some non-critical phrase that they will use when reminding you, such as, “I’m thinking it might be a good time to check in with yourself.” In any of these ways, you get reminders to practice self-observation.

Once you are practicing this kind of self-observation, you might notice that you can sometimes be aware of your perfectionistic tendencies, but be unable to stop yourself from acting on them. Old habits die hard, as the saying goes. This experience is a normal stage in the process of change. Try not to be critical with yourself. Keep trying to catch yourself in the moment and make an intentional decision as to what you are doing. You will get better at it with practice.

Remember that in the course of practicing any new skill there is a stage in which it is uncomfortable. When you first learn to play a musical instrument or a sport, there’s a time in which you aren’t very good at it and it’s sort of an unpleasant experience. Your jobs at that point are to simply tolerate this discomfort and continue to practice. With time and patience, you will get better and it is will become easier and more pleasant.

It helps to foster a sense of curiosity and humor with yourself. It oftentimes seems that those who make personal changes easiest are those who become pleased or excited when making connections between some insight they had and their own behavior. When catching themselves in some behavior that they want to change, they exclaim, “Oh there I go again!” but do so with a light-hearted curiosity or even some humor. In the right spirit, insightfulness can oftentimes be funny. It can also foster a certain sense of appreciation or fascination for how complicated we are as humans.

Conclusion

In summary, what you are practicing is the following:

  • Remaining observant of your thoughts, feelings, intentions (or lack thereof) and behaviors
  • Come to recognize that your perfectionism clouds your perceptions and that your perceptions can tend to be outliers when compared with those of others (i.e., you might tend to see something as not good enough when in fact most others would see that it is good enough)
  • Make an intentional decision to do something different than your usual attempts to make something better when it’s already good enough (i.e., you practice being satisfied)

The ultimate goal is to become satisfied when things are good enough. When you can do that, you’ll have a handle on your perfectionism.

Author: Murray J. McAllister, PsyD

Date of last modification: June 8, 2015

The Perfectionist and Chronic Pain: How to Cope with Pain Series

While clinical lore is that perfectionists are more prone to the development of chronic pain, it may just be that perfectionists are more likely to seek care for their chronic pain. Reason? Perfectionists with chronic pain are more prone to behavioral exacerbations of pain as well as anxiety and depression. Let’s see how.

Are you a perfectionist?

First, let’s define perfectionism. Perfectionism is a trait of an individual that involves two components:

  • Holding oneself to standards that are never quite attainable (or at least not for very long)
  • The compulsive need to nevertheless try to attain those excessively high standards.

So, the perfectionist is never quite satisfied with what he or she does and can’t seem to keep from trying to make what they do better in some way. If, on those infrequent occasions the perfectionist is satisfied, it usually lasts only until he or she sees some flaw in the original project and attempts to correct it or only until he or she moves on to the next thing on the ‘to do list.’

So what might a perfectionist look like in real life? Perfectionists tend to see how any given project might be done better. Others might congratulate them on a job well done, but the perfectionist tends to respond, either overtly or silently to themselves, ‘yes, but, this could have been done better, or if only we had more time, we could have…’ In such responses, you see the persistent lack of satisfaction with the quality of work, even when others think the quality is superior. In other words, perfectionists hold themselves to unattainably high standards, standards to which no one else would hold them accountable. These Perfectionismexcessively high standards are evident in the cleanliness and orderliness of their homes work environments. Everything has a place and is in its place. Sometimes, the unattainably high standards and the subsequent persistent lack of satisfaction come out in the quantity of work that perfectionists tend to think they should attain. They always have more to do on their ‘to do list.’ It’s hard for them to sit still, when they know that there is ‘so much more to do.’ In other words, it’s hard for them to stop their activity and simply enjoy a leisurely moment.

Notice the compulsive sense of urgency that operates with these unattainably high standards. It’s hard to just sit still and be leisurely or satisfied. Having cleaned the entire house before having guests, the perfectionist finds herself continuing to straighten up even after the guests have arrived. If the perfectionist does sit down to chat with the guests, his attention keeps returning to the one pillow across the room that’s out of place or the picture that’s hung slightly crooked on the wall. Sometimes, it’s persistent underlying tension that fuels this compulsivity – if you don’t act to fix the problem, you just get too antsy or nervous. Still other times, it’s excessive self-criticism that fuels the compulsivity – you beat yourself up in your head for having missed the one flaw and you keep at such self-criticism until you get up and fix it.

Notice that perfectionism isn’t a healthy or an adaptive way to be in the world. Despite the kudos that perfectionists tend to get from their employers or others, low-level negative emotional states tend to predominate the inner life of a perfectionist. They recurrently feel lack of satisfaction, tension, self-criticism, and time pressure (because there’s always more to do). As a result, relaxation, leisure, playfulness, spontaneity, care-free, and peacefulness are relatively uncommon experiences for the perfectionist.

Notice too that perfectionism and self-esteem are closely tied together. The perfectionist tends to mistake the quality and quantity of what they do with who they are or their worth. When what they do is never quite good enough, it’s easy to start thinking that they are never quite good enough. This dynamic further fuels the compulsivity to act to make things better: their self-esteem is riding on it. However, the compulsive actions to make the job or task at hand better is just a temporary fix. When the perfectionist puts the perfectionistic finishing touches on a job, any sense of satisfaction is short-lived, lasting only as long as it takes to move on to the next thing on the ‘to do list.’

Perfectionists are prone to all-or-nothing thinking and behavior. Because of their high standards, perfectionists tend to see only two options for engaging in any task or project: the right way or not at all. Any other way besides the right way leads to unresolved tension or self-criticism and so you might as well do it the right way right from the start. Otherwise, how can you sit still until the job is done, which means, of course, done right? It’s this kind of thinking that leads to compulsively excessive behaviors – staying up all night until the job is done or cleaning the entire house in one day or not sitting long enough to enjoy the company who came over to visit.

Over time, such all-or-nothing thinking and behavior also leads the perfectionist to be the only one who ever does anything around the house or on the team at work. Maybe initially, all the others in the family or at work pitched in. To the perfectionist, though, the quality or quantity of their work wasn’t quite good enough. So, the perfectionist felt the need to ‘finish the job’. That is to say, the perfectionist compulsively acts on his or her excessively high standards, which are of course higher than the good-is-good-enough standards of most people. At some point, the others start to catch on and think to themselves, ‘Why bother to help? She [i.e., the perfectionist] is just going to take over at some point and do it anyway.’ They may even come to resent the perfectionist for thinking that what they do is never quite good enough. If this process happens for a long enough period of time, then the perfectionist ends up with all the jobs, for the perfectionist is the only one who knows how to ‘do it right’ (at least to the eyes of the perfectionist).

Like any other personality trait, people can have varying levels of awareness or insight into their perfectionism. On one end of the spectrum of self-awareness, some perfectionists have a lot of insight into their perfectionism and can catch themselves when they get too uptight about some minor flaw. They might even be able to laugh about it when others bring it to their attention. These people, we say in the healthcare field, have ego strength – the ability to tolerate feedback about themselves and learn from it. The prognosis for these kinds of perfectionists is good. On the other end of the spectrum of awareness, some perfectionists lack insight into their perfectionism and keep compulsively trying to catch up to their inner standards without ever stopping to reflect on whether their standards are realistically attainable or not. Failing to engage in such self-reflection, they might actually see others as lazy or lacking attention to detail. They might carry around an underlying resentment that they have to do everything because ‘no one seems to do anything around here.’ In reality, though, the others aren’t lazy or inattentive, but rather squarely within the norm for quality and quantity of work. These kinds of perfectionists can therefore lose sight of the abnormal nature of their unattainably high standards and so come to see others, who hold themselves to normal – good-is-good-enough – standards, as abnormal. Such perfectionists thus can have little awareness of their own perfectionism and can in fact get defensive or irritated when it is brought to their attention. As such, these kinds of perfectionists lack ego strength – the ability to tolerate feedback about themselves and learn from it. The prognosis for these individuals is guarded.

Now, one can be a perfectionist without ever having chronic pain and one can have chronic pain without ever being a perfectionist. However, when perfectionists develop chronic pain, it’s an unfortunate combination. It lends itself to coping poorly with chronic pain. As such, they likely come to chronic pain rehabilitation in disproportionate numbers.

Perfectionism leads to behavioral exacerbations of pain

Perfectionists with chronic pain get stuck between a rock and a hard place. They experience compulsive needs to stay busy and ‘get the job done right,’ but if they do, they exacerbate their pain. If, however, they keep themselves from acting on their compulsive needs, they subsequently experience high levels of tension and/or self-criticism for failing to ‘get the job done right.’ So, they are caught between either high levels of pain or high levels of tension and self-criticism. As a result of this dilemma, perfectionists commonly go with the former: they give in to their perfectionistic needs and compulsively become excessively productive, thereby exacerbating their pain.

This all-or-nothing dilemma of perfectionism can make pacing almost intolerable. Chronic pain rehabilitation programs encourage patients to learn to pace their activities, as a way of finding the middle ground between the ‘all’ and the ‘nothing’ options. To perfectionists, though, pacing means that they have to get used to a life of not being good enough. In reality, what they might do when pacing themselves is good enough, but, to perfectionists, good enough isn’t good enough – it has to be perfect. Thus, to the perfectionist, pacing activities doesn’t seem a viable pain management option.

Perfectionism leads to chronic resting and activity avoidance

The only other option in this dilemma is to come to the conclusion that because of the pain you can’t do anything. Let’s see how this works. Suppose the perfectionist initially keeps attempting to maintain the perfectionistic standards and subsequently repetitively exacerbates his pain through the compulsive over-activity and productivity. At some point, he comes to find this state of affairs intolerable. His chronic pain rehabilitation providers have been recommending and encouraging pacing, but pacing leads to too much tension and self-criticism – living a life of recurrently failing to meet his expectations for himself. So, holding firm to his all-or-nothing perfectionism, he comes to the conclusion that if he can’t get the job done right, he can’t really do it at all. Pacing is a bogus option: there really are only two options – do it right or not at all.

As a result, perfectionists often become convinced that they can’t do anything because they can no longer do it exactly the way they used to do it.

The long-term behavioral consequence of this belief system is chronic inactivity. It leads to resting, staying home, and activity avoidance. These passive coping strategies, however, lead to de-conditioning, social isolation, a general decline of health, a worsening of pain, and increasing disability.

Now, perfectionists tend to buck at the term ‘avoidance’ above because avoidance implies choice – that they are tending to avoid activities when in fact they could do otherwise. Perfectionists thus assert that they aren’t avoiding anything, but rather they can’t do anything.

This belief in their inability to engage in their old activities is predicated, however, on having only two options for engaging in their old activities: either the ‘right way or not at all.’ If they could learn to tolerate pacing their activities, which would entail learning to tolerate being ‘good enough,’ they would find that there are all sorts of ways to engage in their old activities of life. They’d find that it just isn’t true that they categorically can’t do what they used to do. Indeed, they may just learn in their chronic pain rehabilitation program that there are all sorts of different ways to engage in the old activities of life.

Using opioids to maintain unhealthy perfectionism

Sometimes, perfectionists come to solve their all-or-nothing dilemma by relying on high doses of opioid pain medications. They maintain engaging in the ‘all’ option of the all-or-nothing dilemma by taking high doses of opioids to mitigate for the pain it elicits. In other words, they continue engaging in excessive levels of activities and productivity, which exacerbates their pain, but they compensate for it by taking high doses of medications.

This solution isn’t healthy or effective over the long-term. Most non-perfectionists would agree that using opioids to medicate behaviorally exacerbated pain is not the best use of these medications. It would be healthier and more effective to overcome the perfectionism and learn to pace. By doing so, one could get by on less medication or perhaps not even on any medication. From this perspective, we might see that the use of opioids in this way is not only a means to medicate pain but also medicate a psychological problem. Opioids are not an effective therapy for perfectionism.

From this perspective, we might also see that the continued use of opioids to treat behaviorally exacerbated pain puts the perfectionist at high risk for psychological dependence, increased tolerance, and/or addiction to opioids.

Perfectionism and anxiety

Perfectionism involves some degree of underlying anxiety. The perfectionist can’t sit still because if he did he’d become too tense or nervous or antsy. The excessive activity and productivity are thus solutions to the nervousness. It is for this reason that we consider such behavior to be compulsive. Compulsive behaviors are the behavioral antidote to anxiety – they get rid of the anxiety, but only temporarily.

We discussed above the role of ego strength when it comes to perfectionism. Those perfectionists with a high level of ego strength, who have insight into their perfectionism, can typically readily acknowledge the anxiety that underlies perfectionism. Those who struggle to maintain such insight, however, typically deny the connection. Instead, they remain convinced that maintaining perfectionistic standards is the right way to go about life.

To overcome perfectionism, one has to come to see the problematic nature of perfectionism. Once having insight into it, you subsequently have to begin the process of refraining from engaging in compulsive productivity. To do that, however, you also have to acquire ways to resolve the anxiety that remains when refraining from engaging in compulsive over-activity.

Perfectionism and depression

Depression can also become a consequence of perfectionism, especially when perfectionists never gain insight into the unhealthy nature of their perfectionism. Here’s how it works. Suppose a perfectionist remains steadfast to her unattainably high standards despite having chronic pain. She comes to see herself as persistently failing when chronic pain prevents her from attaining the standards. Persistent failure experiences lead to persistent self-criticism, which in turn can lead the perfectionist to see herself as a failure. Now, she sees chronic pain as the sole source of this recurrent sense of failure because, as we said above, she doesn’t see that her perfectionism is part of the problem. She subsequently attributes the source of her failure to chronic pain, something she has no ability to fix. As a result, she becomes hopeless. Hopelessness combined with a persistent self-critical sense of oneself as a failure equals depression.

Perfectionism as an obstacle to coping with pain well

In each of these ways, perfectionism lends itself to coping poorly with chronic pain. Of Perfectionistcourse, we are not blaming the perfectionist with these observations. Rather, the purpose is to see that perfectionism is an unhealthy personality trait that creates obstacles to coping with chronic pain well. It’s also something that can change with a concerted effort over time. Perfectionists with chronic pain learn to make such changes in chronic pain rehabilitation programs. By overcoming perfectionism, you can come to cope better with pain and as a result chronic pain becomes less problematic.

Living well with chronic pain is possible, but you have to learn how. For perfectionists, living well with chronic pain involves, at least in part, learning how to overcome perfectionism. In our next post, we’ll review common ways in which chronic pain rehabilitation programs coach patients how to overcome perfectionism.

(For more information on perfectionism in general, please see the information at Dr. Paul Hewitt’s Perfectionism and Psychopathology Lab or Dr. Gordon Flett’s video on perfectionism and health.)

Author: Murray J. McAllister, PsyD

Date of last modification: 5-3-2015

Mind Reading: How to Cope with Pain Series

No, this post isn’t about telepathy. It’s about a common problem faced by people with chronic pain and how to overcome it.

Mind reading defined

The phrase “mind reading” is a piece of technical jargon used in cognitive behavioral therapy and chronic pain rehabilitation programs. It refers to a particular type of thinking in which a person thinks that other people are judging him or her even though the other people might not ever say anything. As such, mind reading is a type of thinking that involves an assumption – an assumption that you know what others are thinking.

Mind reading involves two essential components. First, it is an assumption in which you think you know what others are thinking. Second, you assume that what others are thinking are negative judgments about you.

Mind reading typically occurs without much awareness on the part of the person who is doing it. When engaged in mind reading, you don’t intentionally set out to do it. Rather, it happens almost automatically. Before you even know it, you’re doing it, thinking that others are judging you and coming to feel judged and reacting accordingly. It’s for this reason that psychologists consider mind reading as a type of automatic negative thought. (We have previously discussed a different type of automatic negative thought in our blog post on catastrophizations.)

Typically, mind reading doesn’t accurately represent what others are really thinking. When engaged in mind reading, we tend to think we know what others are thinking of us, but this ‘knowing’ is more often than not an unwarranted assumption. Usually, we really can’t say with any degree of certainty that the assumption is accurate. Indeed, if we step back and think about it, as we are doing right now, it might be more accurate to say that most people don’t spend a lot of time judging us as they go about their own life activities. In reality, most people are too involved in their own business to notice us with any more than a casual glance in our direction. Despite this fact, when mind reading, the assumption that others are negatively judging us feels so accurate. We feel so certain that they are judging us. As such, we simply react as if it is really happening when in all likelihood it isn’t. Psychologists oftentimes call mind reading a type of cognitive distortion. In other words, mind reading is a type of thinking (i.e., cognition) that distorts reality, leading us to believe things and react to others in ways that aren’t accurate to what’s really going on in the thoughts of others.

Mind reading leads to emotional and behavioral reactions that are indicative of being judged by others, even though, typically, in reality, the other people aren’t really judging us. We might feel anxious or ashamed or angry or defensive. We might start fretting about why people are so judgmental or what we might say if they say something first. We might also change our plans in response to these perceived judgments of others. You might, for instance, hurry through the grocery store because you just ‘know’ that everyone is judging you by the way they look at you. Maybe, you leave the family reunion early because you just ‘know’ that Aunt So-and-So is snickering behind your back. Such thoughts and their subsequent feelings and behaviors typically occur automatically, in the background of your awareness, and it all goes on unquestioningly, without you ever checking it out against reality.

Every one of us engages in mind reading. Some people only do it on occasion and as such it doesn’t cause a whole lot of problems. Some people, though, engage in it more often. For them, it can become problematic.

It’s stressful to feel as if you are the object of judgment. It wears on your ability to cope with the problems of life. It saps your enthusiasm for the activities of life. It can also lead to anxiety of different kinds as well as depression. (We bring this fact up not to judge, but simply to acknowledge it and provide an explanation.)

So, while everyone does it, we can see mind reading as a type of thinking that occurs along a spectrum from those who do it less often to those who do it more often.

Mind reading and living with chronic pain

Mind reading can occur in all walks of life including in those who live with chronic pain. No doubt, at least some readers have already started to apply this notion of mind reading to themselves and have begun to identify examples of it from their own lives.

Countless patients over the years have expressed to me their ambivalence over the use of a disability parking permit. They report feeling conspicuous when they park in a disability marked spot, thinking that they need to justify their use of the spot to every passerby. I have had a few patients acknowledge that they really don’t need their cane, in terms of the potential of falling, but carry one anyway because it signals to others that their slow gait is justified. Countless patients have reported that they hardly ever go to parties anymore because they know that everyone judges them if they acknowledge that they aren’t working and are disabled.

Notice the assumptions that are happening in these examples. In each, the people think they know that others are judging them for having chronic pain or being disabled by pain and have subsequently changed their behavior as result. It’s like there is a persistent low-grade fear that pervades their daily experience – a subtle worry of what others think and what they might say, given a chance. Notice, too, that such subtle worry or fretting so often goes on automatically and unquestioningly, without a lot of awareness, at least until it gets named.

The persistent, low-grade nature of mind reading can take a toll. Such worry and fretting take energy. It’s one more drain of energy among all the other drains that can occur when living with chronic pain (such as insomnia, sedating medications, and the pain itself). It can come to justify social isolation and lack of activity outside the home. Mind reading can also lead to anxiety and depression and can even trigger panic if you are already prone to such problems.

In all, when it comes to living with chronic pain, mind reading makes coping with pain more difficult.

Common reactions to learning about mind reading

The notion of mind reading is commonly introduced and discussed in cognitive behavioral therapy and in the coping skills training courses that occur in a chronic pain rehabilitation program. Usually, once introduced, patients know exactly what we are talking about and can quickly come up with examples from their own lives. As discussed earlier, everyone does it, including those with chronic pain.

However, some people become troubled by the discussion and express one of two common objections.

One objection is that the notion of mind reading seems like a judgment itself. In other words, it seems like a criticism and that what we are saying is that people worry too much about what other people are thinking.

The intention, here, is not to criticize, but simply to acknowledge a problem that we all share to one extent or another. We don’t want to be in a position in which we maintain a pretense that we never worry or fret about what other people think of us. We all do it. There need be no shame in acknowledging it and nor should it be a criticism to talk about how we each do it. Moreover, it is a mark of strength to acknowledge one’s own problems, learn about them, and to learn about how to overcome them. Our discussion today is simply an opportunity to learn about a common problem and how to overcome it.

The other objection is that sometimes other people really do judge or criticize us. You may have someone in your life right now who does it. Perhaps it is a spouse or other family member or your supervisor at work. Maybe they tend to doubt the legitimacy of your pain or your sense of disability and have expressed, “Aw, come on now, it can’t be that bad!” Such judgments hurt and can make a lasting impression. You fret about it now, having conversations in your head with this person about what you could or should have said. These kinds of judgments from someone close to you and the resulting fretting can easily lead to persistent, low-grade worry that maybe everyone judges you similarly. This worry then can further lead to changing your behavior in public or with family in anticipation of what these other people might say. Notice how easy it is to start mind reading.

So, yes, the objection is a point well taken. Other people can in fact be judgmental.

And yet, is this fact the exception or the rule? Might we not agree that most people, most of the time, are simply too preoccupied by their own thoughts and worries to notice us, let alone think about us for long enough to actually judge us? I think most of us would agree that people don’t judge us as much as we tend to think they do.

It is this tendency that we are discussing – the tendency to mind read. So, while it is true that sometimes people really do judge us, maybe we can also spend too much time and energy worrying and fretting about what others think of us because in reality most people aren’t judging us.

So, what can we do about it?

Overcoming mind reading

The first step in overcoming the tendency to mind read is to simply learn about it, as we are right now. The second step is to learn to identify it in yourself. The third step is to get good at challenging it, once identified, by talking yourself through it in the moment.

As described above, usually the notion of mind reading gets introduced in cognitive behavioral therapy or in the group coping skills training within a chronic pain rehabilitation program. The discussion involves the use of examples, sometimes made up examples, but other times examples from the actual lives of patients. By using examples, the component parts of mind reading are identified and clarified. The use of this post is intended to provide a somewhat similar experience for the reader.

The next step is for you, the reader, to consider the role of mind reading in your life. Reflect on when you might do it and identify some examples from your own life. Perhaps, discuss them with your health psychologist or while you participate in your chronic pain rehabilitation program.

What you are doing while reflecting on examples from your daily life is getting better at identifying instances of mind reading. It’s important to develop this skill of identifying instances of mind reading in your life. As you get good at it, you can then use it to identify instances of mind reading in the moment. It’s the skill of becoming more aware of what it is that you are thinking and recognizing in the moment that you are engaged in mind reading – worrying about what others are thinking of you and changing your behavior accordingly.

The skill of being able to identify or recognize that you are mind reading is an example of a more broad skill that psychologists call developing an ‘observational self’ (what was once called an ‘observing ego’). An observational self is the ability to step out of any given moment and reflect on what we are thinking and feeling and doing. In short, it is our ability to think about our thinking. It is our observational self that allows us to be able to step out of the moment and recognize that we are mind reading – “Oh, there I go again, I’m mind reading right now.”

Without an ability to step out of the moment and recognize that we are mind reading, we go on in life engaged in mind reading without awareness, allowing it to guide our behavior and sap our energy and abilities to cope with pain. So, this skill of being able to identify and recognize our thinking is important.

But, what do we do once we recognize in the moment that we are mind reading?

You use your understanding to provide reassurance that your mind reading is unwarranted and as such you can be more self-confident in your daily activities. This further skill takes practice.

Say, for example, you go to the grocery store and park in a disability spot because you have a disability permit. You are not in a wheelchair, though, and so as you get out of your vehicle you start to worry about what others are thinking of you. Initially, you are automatically convinced that they are thinking, ‘Hey, what’s wrong with you? You don’t look disabled! You shouldn’t be parking there!’ You start to feel nervous and look down as you walk into the store, not wanting to make eye contact with anyone. But then you recall our discussion and this notion of mind reading. You use your understanding of it to identify that you are doing it right now! You think to yourself, “Oh, there I go again!”

As a result of this recognition, you talk yourself through it. You recall that mind reading relies on an unwarranted assumption – that just because some people are judgmental doesn’t mean that everyone is judgmental. You subsequently reassure yourself that in all likelihood the people passing you by right now are not judging you. Instead, they are likely lost in their own thoughts, hardly noticing you. You can then say to yourself, “I can be confident right now” and you lift your head up walk into the store.

Now, of course, at first you are not going to be very good at it. You might fail to recognize that you are mind reading and only come to think about it long after the fact. At other times, you might recognize it, but be unable to stop it or provide any meaningful reassurance to yourself. For instance, you might try to reassure yourself, but the words seem flat and empty. In other words, the nervousness of worrying what others are thinking might continue to get the best of you.

With practice, however, you will get better at it. Over time, you come to believe your reassuring self-talk more and more. Maybe you also start predicting that you will start mind reading before you even do it and begin providing reassurance preemptively. At some point, with practice, you begin to notice a budding sense of self-confidence. You find that you are a little lighter in your step and have a little more energy when you are out in public or when you are spending time with family.

As you practice, it’s important to recognize that you will never get to the point where you won’t ever mind read again. No matter how good you get at recognizing your mind reading and providing yourself with reassurance, you will never gain one hundred percent control over your thoughts and be able to stop mind reading forever.

A more realistic goal is to get to a point, with practice, where you engage in mind reading less and less often and that, when you do mind read, you catch it early in the process and successfully provide yourself with reassurance. When you can do all that, you will be more self-confident and better able to cope with pain.

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-8-2014