Does Your Pain Clinic Teach Coping?

As we’ve discussed in an earlier post, not all pain clinics are alike. To be sure, all pain clinics provide therapies aimed at reducing pain. Some, however, don’t stop there. They set out to systematically coach patients to cope better with pain that remains chronic.

Types of Pain Clinics

Despite the fact that they all operate under the name ‘pain clinic’, there are at least four different types of clinics.

Interventional pain clinics:  Interventional pain clinics tend to focus on minimally invasive procedures, or ‘interventions’, coping with painwhich aim to reduce pain. To be fair, most interventional pain providers would assert that they also aim to improve functioning, which means increasing a patient’s ability to engage in the activities of life, such as being able to engage in household chores or returning to work. However, interventional pain clinics primarily aim to increase functioning by attempting to reduce pain, under the assumption that people will be able to do more when their pain is reduced (i.e., in an inverse relationship that as pain reduces functioning increases).

Examples of minimally invasive procedures that one might obtain at an interventional pain clinic are epidural steroid injections, nerve blocks, radiofrequency neuroablations, spinal cord stimulator implants and intrathecal drug delivery device implants.

Notice that nowhere within this list is there specific time and resources set aside to teach patients how to cope better with pain that remains despite the use of the afore-mentioned procedures. While certainly individual clinics and/or providers might vary, most interventional pain clinics concentrate on providing procedures, not providing groups or classes or even one-to-one time to coach people on how to live well with pain that remains refractory to procedures.

The observation is not a complaint. It’s just not what they do, just as bankers typically don’t provide legal advice, even though in some areas of the respective fields there is some overlap.

Long-term opioid management clinics:  Long-term opioid management clinics tend to provide access to the long-term use of narcotic pain medications. The aim of this type of clinic is to reduce pain and secondarily increase functioning. Akin to the interventional pain management aims, the assumption is that when pain is reduced, patients with pain will be able to do more and thereby their functioning increases.

Long-term opioid management clinics typically provide access to opioid, or narcotic, medications on an indefinite basis. Usually, patients see the healthcare providers on some regular interval to obtain a prescription of medications that lasts only until their next appointment. Oftentimes, this interval of time is monthly, though sometimes it’s shorter or longer in duration. Typically, the two main reasons such care comes to an end is when patients abuse the medications, in which case the patient is potentially referred to a substance dependence treatment program, or when patients become too tolerant to the medications and the medications are therefore no longer effective, in which case the patients are referred to another type of pain clinic.

Often, in long-term opioid management clinics, there might be a little bit more emphasis on coping with pain than in interventional pain clinics. So, providers might encourage exercise, staying active, the use of diaphragmatic breathing, or the use of more traditionally passive coping strategies, such as ice, heat, home traction units, or TENS units.

However, the primary focus of long-term opioid management clinics typically remains on providing access to opioid medications. Of course, there might be some exceptions, but for the most part the care in such clinics aim to reduce pain through the use of opioids and the elementary basics of coping that they teach are intended to complement opioids, not substitute for their use.

Orthopedic and surgery clinics:  Orthopedic and surgery clinics provide invasive procedures aimed to reduce pain. Surgery clinics make the same assumption about functioning as the previous two clinics do — that the primary purpose of the procedures is pain reduction and secondarily to increase function. How this assumption typically plays out in surgery clinics is that patients commonly remain off work prior to and immediately after obtaining a surgical procedure and, once a procedure reduces pain, patients go back to work.

Examples of procedures that surgery clinics perform are arthroscopic surgeries of various joints, joint replacement surgeries, and spine surgeries, such as laminectomies, discectomies, and fusions.

Chronic pain rehabilitation clinics:  Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care that aim to reduce pain, but primarily increase function. In this way, chronic pain rehabilitation clinics are different. Chronic pain rehabilitation clinics point to clinical and scientific evidence that pain is one of many factors that determine a patient’s functioning – one’s ability to remain engaged in the activities of life, such as work. What clinical experience and science tells us, in other words, is that how one responds to adversity, such as pain, is as important as how significant the adversity is – especially in terms of how one goes on to live with the adversity.

The importance of this observation cannot be underestimated. It elevates the importance of increasing coping to the same degree of importance that reducing pain has. So, to take an example, if we want to help people with chronic pain return to work, then we can approach this problem in two different ways: 1) we can focus on reducing pain, under the above-noted assumption that when pain is reduced people can subsequently return to work; or 2) we can teach people with chronic pain to respond more effectively to the pain so that they know how to cope with pain so well that the pain is no longer as problematic, or disabling, as it once was and subsequently they learn how to return to work even with pain.

Chronic pain rehabilitation clinics provide interdisciplinary rehabilitation care, which means it’s care that focuses on what the patient can do to reduce pain and live better despite having pain. Patients learn to engage in various lifestyle changes, which, when done over time, reduce pain. More importantly, because chronic pain is typically chronic and cannot be entirely cured, patients also learn how to change the ways they react to pain so that they can still do things in life, such as return to work and engage in other daily activities of life, even though they continue to have pain. In other words, chronic pain rehabilitation clinics provide systematic education on how to remain functional in life despite having pain.

In this way, chronic pain rehabilitation clinics teach coping in a way that no other pain clinic does. In fact, they tend to emphasize coping over pain reduction because they base their approach on acceptance of the fact that chronic pain is really chronic. There tends to be no misleading anyone, as typically, chronic pain can only be reduced so much in whatever clinic one seeks care. Rather than repetitively trying to cure an incurable, or chronic, condition, chronic pain rehabilitation aims to increase patients’ abilities to cope with pain and help them to get so good at dealing with it that pain is no longer the showstopper that it once was. Patients come to learn, in other words, to accept pain, remain grounded in the presence of pain, and make an intentional choice to go to work and remain at work (or some other similar activity of life) despite having pain. With practice and expert coaching from the staff of the chronic pain rehabilitation clinic, pain becomes no longer the central focus of life, but rather is something that is just a side issue, with work, family and other activities being the most central aspects of life.

Coping with pain

Sometimes, patients with chronic pain won’t believe that such progress is possible. They might be sensitive to the possibility that one could have chronic pain and remain at work, and so tend to assert that it is impossible. They might also fear the sting of stigma if they acknowledge that they might be able to learn a thing or two about how to cope better with pain. Instead, they might assert that they already know how to cope with pain and that they cope better than anyone else could, who might find themselves in a similar situation.

In these ways, some people can have difficulty with openly acknowledging that they don’t cope as well as they’d like or could.

However, the possibility of getting better through learning to cope better doesn’t have to be perceived in this way. Most people would say that there is nothing wrong with you if you don’t know how to read very well, or don’t know how to change a tire on your car, or don’t know how to speak a foreign language, or don’t know how to play basketball very well. It’s okay to not know how to do certain things really well.

In fact, most people think learning new things is good. It’s admirable to learn something really well. In learning, the person who learns has to acknowledge and be okay with the fact that they don’t know everything already. In most situations of learning, no one ever has a problem with this aspect of learning.

If you are okay with learning how to cope with pain really well, then chronic pain rehabilitation clinics might well be very helpful to you. Everyday, people with moderate to severe chronic pain learn how to cope so well with pain that they become much more functional in life. They go back to work. They attend family functions again. They do household chores and do fun things again with friends and family. In other words, they get back into life. Of course, in order to learn how, you’d have to be okay with being in a student role. But, again, most of the time, we think that learning is a good and admirable thing to do. The same can be true of learning how to cope better with pain.

Author: Murray J. McAllister, PsyD

Date of last modification: 3-23-2016

Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that is maintaining your pain on a chronic course. Let’s unpack this important statement.

It’s no accident that healthcare providers commonly refer to chronic pain syndromes as ‘complex chronic pain’ or ‘complicated chronic pain.’ It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central SensitizationCentral sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive — so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, in most typical situations, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-14-2016

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

“But, I have real pain”: When Ethics Collides with Ontology

No doubt, the words of this title have been uttered countless times by countless people with chronic pain. In my work in chronic pain rehabilitation, someone tends to say it to me most everyday. It often comes when discussing the effectiveness of chronic pain rehabilitation, which focuses on coaching people how to self-manage pain. A patient, say, gets referred to our chronic pain rehabilitation program, but the patient believes that it would be better to seek care elsewhere, such as with a spine surgeon, or an interventional pain clinic where spinal injections get performed, or at a clinic that provides long-term prescriptions of opioid pain medications. In such cases, I might make the recommendation that, as long as one is willing to learn how, self-management is an effective treatment option, even in many cases the most effective option. Nonetheless, the patient responds, “But, I have real pain.” The phrase, “I have real pain,” in these instances tends to justify the use of procedural-based medical care, which becomes opposed to seeking self-management based care, as if real pain could never be self-managed and so requires medical or surgical procedures or narcotic pain medications.

Still other times, the phrase “But, I have real pain” gets expressed when I talk to patients about the role of the nervous system in the cause of chronic pain. In chronic pain rehabilitation, we routinely discuss this role of the nervous system because it provides a scientifically accurate rationale for why self-management is effective: the self-management strategies that patients learn in chronic pain rehabilitation reduce pain and increase coping by targeting the nervous system and making it less and less reactive over time. So, we subsequently review with patients why it’s important to therapeutically target their nervous systems: it’s because pain is the product of a two-way communication between the nerves in the painful area and the spinal cord and brain. It’s not uncommon for patients to react to such discussion by retorting, “But I have real pain.” This response expresses disagreement with the overall conversation and alludes to a different way that they understand the nature of their pain. People often go on at this point to explicitly state their understanding of, say, back pain by emphasizing an orthopedic model of pain – something, like, “My surgeon said it was because my discs are degenerating.”

It’s not just patients who say it too. Providers commonly use the phrase as well. Most often, I suppose, providers say a variation of it to patients as a form of reassurance. “I know you have real pain” is a frequently necessary form of reassurance, letting patients know that they are believed. Countless times in case conferences, too, where the overall plan of care is discussed among a team of different providers, the phrase gets used, particularly when a case is discussed in which the orthopedic basis of pain can’t be found. An all-too-common example might be a patient who presents with chronic low back pain, but the MRI of the lumbar spine shows nothing that might reasonably be the cause of pain. In such cases, providers often profess, “I know he [i.e., the patient] has real pain, but the scans are normal…”

meaning of painWhat, though, does this phrase really mean? When we use the phrase ourselves or when we hear it, we tend to respond in the course of the conversation as if nothing out of the ordinary was just said. That is to say, we understand the phrase and subsequently move on without ever giving it a moment’s notice. But, if we were ever stopped and asked to explain what in fact we mean by the phrase, it gets a little difficult to actually put it into words.

What does it mean?

We might first notice that in the phrase, “But I have real pain,” the use of the word “real” would seem to be drawing a contrast. Specifically, at first blush, it seems to be contrasting the present “real pain” with pain that is… what… not real? Therein lies the problem. What might we ever mean by “unreal pain”? It’s a phrase we never use, not at least at any time I have ever heard or come across, and even if we did it would seem unclear as to what we might mean.

Pain is an experience that we either have or don’t have. Sometimes, we have a little pain and sometimes we have a lot of pain, but in either case, it is something we either have or don’t have. In what circumstances might we ever have a pain that is unreal, which doesn’t mean we have actual pain, but means something other than having no pain? It’s as if “unreal pain” lies somewhere within a never-never land between either having pain and not having pain.

So, on the face of it, it doesn’t seem to make sense to emphasize that one’s pain is “real” if the contrast that we draw by using it doesn’t make any sense. In other words, to contrast “real pain” with something that doesn’t make sense, something that’s really a nothing, is to say that we don’t really need to use the adjective “real” in the first place.

We might thus conclude, all pain is pain and call it a day.

Not the end of the story

Perhaps our analysis thus far is mistaken. Specifically, we may have mistakenly assumed that words have meaning only when they refer to something. In our analysis, we recognized that the adjective “real” in the phrase “real pain” appears to contrast with something, but we can’t find anything that the contrast “unreal pain” refers to. So, we came to the conclusion that the adjective “real” adds no value. Real pain is just pain, we concluded, so we might as well drop the adjective.

This tack would likely make us all uncomfortable for it really does seem like we are Real Painmeaning something important when we say, “I have real pain.” So, to keep looking for what we might mean by the phrase, we might recall Wittgenstein’s famous dictum that the meaning of words lie in their common everyday use (1953). He recognized that language doesn’t have universal referents in all times and places, but rather language can be and is more idiosyncratic than that. Words have particular uses in particular times and places. Language, of course, doesn’t run amok because people are similar enough and live in similar enough ways that we more or less can understand each other, despite the particularities of word uses. So, the meaning of words lie in their use and, sometimes, this use refers to things, but sometimes words have meaning in other ways. Perhaps, the phrase “real pain” is meaningful in one of these other ways.

I think we hit upon this use earlier in the introduction to this essay. The phrase “real pain” doesn’t refer to some special type of pain as much as it’s used to provide reassurance that others believe that one in fact has pain.

No one wants to be called or even considered a faker. There are times when others, such as family members or healthcare providers or employers or defense attorneys might consider whether the person who reports having pain is really faking that they have pain. In such circumstances, patients might assert, “But I have real pain” or still others might come to their defense by asserting that the patients have “real pain.”

Thankfully, such situations are not daily affairs for most people with chronic pain or for most providers in pain clinics. However, the phrase gets used much more commonly, even, as I suggested in the introduction, almost daily. So, there must be other uses – other ways of gaining reassurance by the phrase, “real pain,” even when no one is accusing anyone of faking.

Maybe, the use of the adjective provides a sense of legitimacy to one’s pain. In this way, perhaps it really is drawing a contrast between types of pain: pain that society tends to see as legitimate and pain that society doesn’t. What people defend against, then, when they use the phrase, “But I have real pain,” is stigma.

When stigma raises its ugly head

Patients and providers alike can tend to use the phrase “real pain” when emphasizing the legitimacy of one’s pain and any problems in functioning associated with it. “Real pain” is thus the contrast to the “it’s-all-in-your-head” type of pain. If you have trouble coping or are disabled from “real pain,” you get a pass. People tend to understand and allow you to stay home from work or allow you to be down about it and have a good cry. If, however, you have trouble coping or are disabled from the “it’s-all-in-your-head” type of pain, well, there’s no free pass for you. It’s time to ‘buck up and deal’ instead. No one excuses it when you stay home from work or sees your depressed tears.

Like “real pain,” though, the “it’s-all-in-your-head” type of pain is a bit slippery when attempting to define it. We all know what it means when we say it or hear it, or at least we think we do. Nonetheless, it’s hard to actually put it into words.

We tend to associate the “it’s-all-in-your-head” type of pain with stress-related pain. In chronic pain rehabilitation, we routinely review the importance of stress management when it comes to self-managing pain, but it’s not uncommon for patients to dismiss the relevance of the topic with the assertion, “But I have real pain.” Indeed, at times, we might be tempted to think they are on to something. For, at first blush, pain caused by stress and tension doesn’t seem as real as pain that occurs in relation to clearly identifiable tissue damage. Thus, our initial reaction is that the pain we feel when stepping on a nail seems somehow more real than the gut ache of the child who’s nervous about starting school tomorrow or the headache we might have after a bad day at work. From this light, real pain is pain caused by tissue damage, something that has nothing to do with stress. Stress is involved in the other type of pain, that not-as-real pain, which we refer to as the “it’s-all-in-your-head” type of pain.

An impasse?

But we might then think about what we just said for a minute. In so doing, it might slowly dawn on us that we’ve had a tension headache before, as have most people who have ever been alive on earth. Those tension headaches seem pretty real – that is, pretty painful. The telltale signs of a tension headache are descriptions like “pounding” and “vice-like.” Those descriptions even sound painful… truly painful… or might we say like real pain.

And of course it is. Anyone who has ever had a tension headache knows that it is really painful. You have a long and difficult day and as a result your head is pounding. You reach for the ibuprofen and lay down on the couch or just go to bed outright. You can’t really argue that a tension headache isn’t “real pain.”

Even in cases where pain is associated with identifiable tissue damage, stress makes it worse. When you stub your toe in the course of a lengthy argument with your spouse, the very “real pain” you have hurts worse than when you stub your toe during a really fun party or when watching an exciting football game. It doesn’t take a rocket scientist to tell you that stress makes the “real pain” of chronic conditions worse too. All it takes is the average person with rheumatoid arthritis. Here we have a condition that causes “real pain” and which is associated with clearly defined tissue damage and stress still makes that “real pain” more painful.

pain is painSo, now what do we do? We thought we were on to something. We thought we had found the meaning of the phrase “real pain.” We thought it’s that kind of pain which is associated with tissue damage and which differs from the stress-related “it’s-all-in-your-head” type of pain, but we now see that stress-related pain produces just as real pain as “real pain.”

We thus seem stuck. It seems so obvious that we know what it means when we use the phrase “real pain,” but it seems like we can’t define it. Can we, then, say that we know what it means?

Maybe, we have just come full circle (pun intended) to the tautology that all pain is pain.

References

Wittgenstein, L. (1953). Philosophical Investigations. New York: MacMillan.

 

Author: Murray J. McAllister, PsyD

Date of last modification: 9-20-2015

Self-Management

Often in discussions of chronic pain and its treatments, self-management gets neglected as a viable option. It gets forgotten about. Or perhaps it just never comes to mind when patients or providers talk about the ways to successfully manage pain. Instead, stakeholders in the field tend to focus on the use of medications or interventional procedures or surgeries.

Commentaries on the use of opioid medications often exhibit this lack of consideration of self-management as a viable option. For example, it’s common for stakeholders in the field to hold the use of opioids as self-evidently necessary to successfully manage chronic pain. The notion that self-management is a viable option is never even considered. Indeed, the underlying and unspoken assumption is that it is impossible to manage pain well without the use of these medications. (See, for instance, these thought leaders failing to mention self-management as an option in the face of the various crises that beset the practice of opioid management for chronic pain, here and here).

It’s an odd state of affairs for a major specialty within healthcare to persistently fail to consider, let alone promote, self-management as a viable option. Other specialty areas within healthcare don’t fail to consider the role of self-care. Think of how the fields of diabetes care or cardiology or mental health encourage and promote self-management. Such fields go to great lengths to motivate and teach patients to take ownership and responsibility for their health condition, lose weight, start and maintain an exercise program, quit smoking, eat right, manage stress, assertively resolve conflicts or other problems, and so forth.

The field of chronic pain management instead seems to subtly or not so subtly emphasize the need for patients to rely on healthcare providers to manage pain for them. How often do you hear the assertion that patients will suffer without the pain management that the healthcare system provides? With such assertions, we inadvertently proliferate a belief that it is impossible to self-manage pain well. As such, it hardly ever comes up as a viable option among the many different treatments for managing chronic pain.

Why is that?

 

Author: Murray J. McAllister, PsyD

Date of last modification: August 7, 2015

Do We Tend to Misunderstand the Nature of Pain?

We live in an interesting time within the field of pain management. We literally have two competing ways of understanding the nature of pain – what it is and how it works and what to do about it. One way of understanding pain is more commonly held than the other, but the other is more scientifically accurate. We are thus faced with the prospect that much of society and even many healthcare providers misunderstand the nature of pain.

It’s a provocative prospect, to be sure.

Competing models of pain

Most people, including many healthcare providers, associate pain with tissue damage, a Cartesian Model of Painphrase we might use to refer to some form of abnormality of bodily tissue. We might come up with any number of examples — a cut finger, a burn, or a broken bone, but, of course, there are countless ways we might suffer bodily harm. Generically, we might call such conditions “tissue damage” and we tend to associate it as the cause of pain. Indeed, we tend to think that some form of tissue damage must occur in order for there to be pain. So, if there’s pain, there must be some form of tissue damage that’s causing it.

This way of understanding pain is commonly used in many areas within the field of pain management. Suppose a person develops low back pain and seeks evaluation with a healthcare provider. It’s likely that both the patient and provider will assume that the cause of the back pain is some form of tissue damage in the area of the low back: a muscle strain, a ligament tear, nerve root compression, a disc bulge or herniation, or so forth. Testing, in the form of scans or diagnostic injections, might be pursued in order to identify the tissue damage, which is sometimes further referred to as the “pain generator.” Any number of treatments is subsequently pursued based on the view that some form of tissue damage must be causing the low back pain. Often unspoken, this way of understanding pain thus justifies what healthcare providers go on to do about the pain – various forms of physical therapy, chiropractic care, epidural steroid injections, nerve blocks, and spinal surgeries, all of which are commonly pursued as ways to heal the damaged tissue that must be causing the pain.

In the field of pain management, we refer to this way of understanding the nature of pain as the “Cartesian model.” Rene Descartes, a 17th century philosopher and mathematician, was likely not the first person to ever think of pain as occurring in this way, but he was the first to systematically write about it and publish it (Descartes, 1633/2003). This view has had great influence on subsequent generations, so much so, that most people today and many healthcare providers still unquestionably assume it to be true: if there’s pain, there must be some form of tissue damage causing it; so, we have to find the tissue damage and fix it or heal it; once successful in this endeavor, the pain should go away.

The problem with this way of thinking about pain is that, despite how common sense it seems, the empirical evidence doesn’t support it, especially when we use it to understand problems such as back pain.

  • Current established guidelines recommend against routine use of MRI or CT scans for low back pain because doing so doesn’t make people better and in some cases makes them worse; in other words, a search for putative tissue damage in the spine doesn’t help when attempting to find ways to have less pain (Cf. Chou, et al., 2011; Flynn, Smith, & Chou, 2011; Koes, et l., 2010).
  • The potential identifiable forms of tissue damage that might cause back pain in actuality don’t correlate with back pain; if potential forms of tissue damage, such as degenerative conditions of the spine, caused back pain, then we’d expect them to highly correlate with back pain, but they don’t (or at best they are only weakly correlated with back pain) (see, for example, Carragee, et al., 2005; Bogduk, 2012; Videman, et al., 2003).
  • Despite varying attempts to prove it over the years, there’s been no demonstrable evidence showing that interventional and spinal surgical procedures are any more than nominally effective (Atlas, et al., 2005; Gibson & Waddell, 2007; Leclaire, et al., 2001; Mirza & Deyo, 2007; Pinto, et al., 2012; van Tulder, et al., 2006; Weinstein, et al., 2006; Weinstein, et al., 2008).
  • Few in the field of pain management would argue that back pain isn’t overteated; that is to say, society has seen exponential growth rates in the use of interventional and spinal surgical procedures, but people aren’t getting better – they don’t return to work faster; they don’t reduce their use of opioids; and rates of disability for back pain are increasing, not reducing (Deyo, et al., 2009; Martin, et al., 2009; cf. Nguyen, et al., 2011).

Maybe we need to completely re-think how we think of back pain. Our attempts to provide interventional and surgical therapies to putative “pain generators,” or tissue damage, in the spine assumes that because there is pain in the back there must be tissue damage in the back that causes it. However, the widespread and persistent failure of these approaches should suggest that there must be another cause for back pain, something that doesn’t rely on tissue damage to cause it.

And don’t we know already that this must be the case? How else do we make sense of people with back pain who don’t exhibit some form of tissue damage that might reasonably account for their pain? Patients with back pain commonly present without objective findings on MRI or CT scans. Just as commonly, patients with back pain present with findings on their sans, but the findings aren’t of a type or in a location that might reasonably cause their pain. It’s a common, everyday occurrence. Put together, these two types of back pain patients are likely to be more numerous that the percentage of back pain patients with objective findings that are concordant with their pain.

What often happens in the large percentage of cases in which scans fail to explain the pain is that the legitimacy of the pain is questioned. The basis for such doubt is the Cartesian understanding that pain must have some form of corresponding tissue damage; since there is none in these kinds of cases, their pain is doubted.

Moreover, if the field more fully understood and appreciated the ramifications of the fact that degenerative changes of the spine fail to substantially correlate with pain, we’d have to acknowledge as a field that degenerative changes of the spine as seen on scans simply cannot be the cause of our patients pain as often as we tell them it is – even in cases in which the scans show findings that are of the right type or in the right location to infer a causal role. (Similarly, just as a suspect in a murder case was in fact at the scene of the crime doesn’t mean that he is the murderer.) As such, in a large percentage, if not the majority, of people with back pain, we simply cannot say that the putative tissue damage as seen on scans is the cause of their pain.

How can this be?

This Cartesian view might not be radically inaccurate, but it’s likely only accurate in certain circumstances. If I suffer an injury, and so cause some form of tissue damage, such as stepping on a nail, I’ll feel pain. So, in some cases, pain is associated with tissue damage. However, we would commit a logical fallacy (viz., affirming the consequent) to subsequently conclude that all pain must therefore be caused by tissue damage.

We actually have in the field of pain management a competing view of the nature of pain, how it works, and what to do about it. It’s referred to as the “neuromatrix of pain” (Melzack, 1989; Melzack, 1990; Melzack, 1999; Melzack & Loeser, 1978). It explains pain as a function of the central and peripheral nervous system. The nervous system, particularly the brain, is what produces pain. Sometimes, the nervous system produces pain in response to tissue damage, but it can produce pain in response to many other forms of stimuli as well.

In this way, the Cartesian model of pain can be subsumed within the more encompassing neuromatrix of painneuromatrix model of pain. We might see the Cartesian model of pain as akin to Newtonian physics – Newtonian physics isn’t exactly wrong, but it’s only right in certain circumstances and as such it can be subsumed within the larger general relativity theory of physics. Similarly, tissue damage might cause pain, but not all pain is caused by tissue damage.

In the neuromatrix of pain model, we have a scientifically supported understanding of pain that can explain how people have, say, low back pain whether or not they have any identifiable tissue damage in the spine. Consider, for the moment, the wide-ranging and important ramifications of a scientifically accurate model of pain that explains all pain and not just pain for which we can identify a corresponding form of tissue damage:

  • Patients would no longer feel the legitimacy of their pain is at stake when, in the majority of cases, no identifiable tissue damage can be found and providers would no longer be at a loss to understand how or why such patients have pain.
  • Patients and providers would no longer need to pursue an exhaustive search for putative tissue damage through the use of scans, diagnostic injections, and other assessments when initial findings upon evaluation yield none.
  • We could subsequently explain to patients in a convincing way why scans aren’t routinely necessary or helpful when it comes to non-specific back pain (i.e., now it simply doesn’t make sense to most patients and some providers because the assumption is that there must be tissue damage otherwise there wouldn’t be pain and so why withhold the use of the technology that might be able to find it?)
  • Rates of interventional and surgical procedures could be significantly reduced because we’d no longer be so certain that putative tissue damage must be the “pain generators” of back pain.
  • It provides an understandable explanation as to why interdisciplinary chronic pain rehabilitation is persistently shown to be the most effective form of chronic pain management, despite it doing nothing to resolve potential tissue damage that we tend to associate with the cause of pain.

Thus, the wide-scale adoption of the neuromatrix of pain model by patients, their healthcare providers, and society, more generally, would have far-reaching positive effects. In short, we would stop misunderstanding the nature of pain and what we should do about it.

The ICP Mission: Ideas that are Changing Pain

The Institute for Chronic Pain identifies the need to bring our societal understanding of pain into line with the findings of basic pain science of the last fifty years. In so doing, we aim to bring about the afore-mentioned important and necessary changes to the field of chronic pain management. We also understand that to do so it is not sufficient to focus solely on changing provider practice patterns. That is to say, we also need to change how the public at large understands the nature of pain. The guidelines for use of scans in low back pain is a case in point that attests to this fact: if patients don’t understand the basic rationale as to why scans are typically unhelpful in acute low back pain, then they’ll continue to expect that the field provides them. No amount of concerted effort on changing provider practice patterns will achieve a change in patient expectations. Instead, we need to explain why a search for putative tissue damage is unhelpful – it’s because in most circumstances back pain isn’t caused by overt tissue damage to the spine and mistakenly believing that it is leads to ineffective overtreatment.

The Institute for Chronic Pain steps into this need for providing understandable, yet scientifically accurate, explanations for the nature of pain and how to best, or most effectively, treat it. We use the internet and social media to proliferate these ideas. Our goal is the widespread adoption of these scientifically accurate ideas about pain, which in turn will change how we treat pain for the better.

To this end, the Institute for Chronic Pain has launched a new webpage on the neuromatrix of pain. Please take look at it and pass it on through your social networks. The more people proliferate these ideas, the more our field of pain management changes for the better.

References

Atlas, S. J., Keller, R. B., Wu, Y. A., Deyo, R. A., & Singer, D. E. (2005). Long-term outcomes of surgical and non-surgical management of sciatica secondary to a lumbar disc herniation: 10 year results from the Maine Lumbar Spine Study. Spine, 30(8), 927-935.

Bogduk, N. (2012). Degenerative joint disease of the spine. Radiology Clinics of North America, 50(4), 613-628.

Carragee, E. J., Alamin, T. F., Miller, J. L., & Carragee, J. M. (2005). Discographic, MRI and psychosocial determinants of low back pain disability and remission: A prospective study in subjects with benign persistent back pain. Spine Journal, 5(1), 24-35.

Chou, R., Qaseem, A., Owens, D. A., & Shekelle, P. (2011). Diagnostic imaging for low back pain: Advice for high-value health care from the American College of Physicians. Annals of Internal Medicine, 154(3), 181-189.

DesCartes, R. (1633/2003). Treatise of Man. Amherst, NY: Prometheus.

Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. I. (2009). Overtreating chronic back pain: Time to back off? Journal of the American Board of Family Medicine, 22(1), 62-68.

Flynn, T. W., Smith, B., & Chou, R. (2011). Appropriate use of imaging for low back pain: A reminder that unnecessary imaging may do as much harm as good. Journal of Orthopedic & Sports Physical Therapy, 41(11), 838-846.

Gibson J. N., & Waddell, G. (Updated January 6, 2007). Surgical intervention for lumbar disc prolapse. In Cochrane Database of Systematic Reviews, 2007 (2). Retrieved July 4, 2015, from The Cochrane Library, Wiley Interscience.

Koes, B. W., van Tulder, M., Lin, C.-W., Macedo, L. G., McAuley, J., & Maher, C. (2010). An updated overview of clinical guidelines for the management of non-specific back pain in primary care. European Spine Journal, 19(12), 2075-2094.

Leclaire, R., Fortin, L., Lambert. R., Bergeron, Y. M., & Rosignol, M. (2001). Radiofrequency facet joint denervation in the treatment of low back pain: A placebo-controlled clinical trial to assess efficacy. Spine, 26, 1411-1416.

Martin, B. I., Turner, J. A., Mirza, S. K., Lee, M. J., Comstock, B. A., & Deyo, R. A. (2009). Trends in health care expenditures, utilization, health status among US adults with spine problems, 1997-2006. Spine, 34(19), 2077-2084.

Melzack, R. (1999). From the gate to the neuromatrixPain, S6, S121-S126.

Melzack, R. (1990). Phantom limbs and the concept of a neuromatrixTrends in Neurosciences, 13(3), 88-92.

Melzack, R. (1989). Phantom limbs, the self, and the brain (The D. O. Hebb Memorial Lecture)Canadian Psychologist, 30, 1-16.

Melzack, R. & Loeser, J. D. (1978). Phantom body parts in paraplegics: Evidence for a central ‘pattern generating mechanism’ for pain. Pain, 4, 195-210.

Mirza, S. K., & Deyo, R. A. (2007). Systematic review of randomized trials comparing lumbar fusion surgery to nonoperative care for treatment of chronic back pain. Spine, 32, 816-823.

Nguyen, T. H., Randolph, D. C., Talmage, J., Succop, T., & Travis, R. (2011). Long-term outcomes of lumbar fusion among worker’s compensation subjects: A historical survey. Spine 36(4), 320-331.

Pinto, R. Z. Maher, C. G., Ferreira, M. L., Hancock, M., Oliveira, V. C., McLachlan, A. J., Koes, B. W., & Ferreira, P. H. (2012). Epidural steroid injections in the management of sciatica: A systematic review and meta-analysis. Annals of Internal Medicine, 157(12), 865-877.

van Tulder, M. W., Koes, B., Seitsalo, S., & Malmivaara, A. (2006). Outcomes of invasive treatment strategies in low back pain and sciatica: An evidence based review. European Spine Journal, 15, S82-S89.

Videman, T., Battie, M., Gibbons, L. E., Maravilla, K., Manninen, H., & Kaprio, J. (2003). Associations between back pain history and lumbar MRI findings. Spine, 28(6), 582-588.

Weinstein, J. N., Tosteson, T. D., Lurie, J. D., et al. (2006). Surgical vs. nonoperative treatment for lumbar disk herniation: The spine patient outcomes research trial (SPORT). Journal of the American Medical Association, 296(20), 2441-2450.

Weinstein, J. N., Lurie, J. D., Tosteson, T. D., et al. (2008). Surgical vs. nonoperative treatment for lumbar disc herniation: Four-year results for the spine patient outcomes research trial (SPORT)Spine, 33, 2789-2800.

Author: Murray J. McAllister, PsyD

Date of last modification: 7-4-2015

The ICP Supports the Make Your Day Harder Campaign

Recent data in the Lancet show that as societies become increasingly industrialized around the world, rates of low back pain, migraine, depression, obesity and type 2 diabetes increase (among other conditions). It’s an interesting commentary on the social determinants of health.

Why the increase?

modernityIt’s not that as societies industrialize they become awash in contagious viruses or bacteria that make people have these conditions. In fact, as societies industrialize, rates of infectious illness tend to drop and death rates overall drop. And, at any rate, viral and bacterial infections don’t cause the above conditions.

It’s also not that as societies industrialize the people who make up these societies develop genetic mutations that lead to the increasing rates of conditions such as low back pain, migraines, depression, obesity and type 2 diabetes. No, our genetic constitution doesn’t change that fast – at least not over the 50 to 100 years it takes for societies to industrialize.

So, what produces this rise in such conditions? General consensus is that it’s the psychosocial changes that come with industrialization: particularly, the increasingly sedentary lifestyle; the increasing consumption of cheap, processed foods (and the corresponding decrease in consuming traditional, whole food diets); and increases in chronic, non-life threatening, stress.

Sometimes, people get upset when healthcare providers talk like this. But, let’s explain.

The biopsychosocial nature of chronic health conditions

The afore-mentioned conditions are considered biopsychosocial in nature. That is to say, they are caused by a combination of multiple factors, some of which are biological, some of which are psychological, and some of which are social in nature. So, across the population as a whole, and even within any one individual, there are various combinations of these three factors that go into causing conditions, such as low back pain, migraine, depression, obesity, and type 2 diabetes, among others.

Now, with the advent of industrialization, it’s not the biological factors in the mix that seem to be increasing, but rather the psychological and social factors. It’s the increases of certain behavioral lifestyles and stressors, which seem to be accounting for the increases in these conditions. Meanwhile, the biological factors seem to be remaining largely constant.

So, what do we do about it? We educate ourselves. We practice tolerating what we learn and reflecting on it. We then slowly and incrementally begin to incorporate these lessons into our life by taking ownership of our health and begin to make small healthy changes in how we live. Slowly and incrementally, we continue and add to these changes. Over time, we become healthier and come to feel better, physically and emotionally.

The Make Your Day Harder Campaign

To this end, the folks at Dr. Mike Evan’s Health Lab developed an ingenious idea. They call it the Make Your Day Harder campaign. It’s provocative title challenges us to reflect on ways to make small changes in our daily life and get off our seats more. And then do it.

The idea, as Dr. Mike says, isn’t to take on a grand exercise routine. Rather, it is the idea to make small intentional decisions to use technology less. So, for example, walk upstairs to get your daughter from her room rather than texting her from the kitchen that it’s time for dinner; get up and turn the volume down on your stereo rather than using the remote control; walk over to your neighbor’s house to actually talk to him about borrowing some tool you need rather than calling him on your cell phone; use a rake rather than a leaf blower; take the stairs rather than an elevator; intentionally don’t take the closest parking space; and so on.

Now, of course, doing any one of these things once or twice won’t do much for you. However, if you cultivated an attitude of willingness to do them in which you were open to opportunities as they arose through the course of your day, these slow, incremental changes over time would help.

You might slowly become more physically fit. You might come to have a little more energy. You might not gain weight or as much weight over time. You might find that your life slows down a little bit and as a result you feel just a little less hectic and a little less stressed.

As Doc Mike points out in his 4 minute video, the goal, as funny as it might sound at first, is to live just a little bit more like how our parents or grandparents or even great-grandparents lived – for they had less chronic health problems and in some respects were healthier than we are today.

To be sure, these previous generations might have had higher death rates from infectious illness or injuries, but assuming they escaped these fates, they were leaner, more fit, and less chronically ill; which is to say, they were in some ways healthier. Now, as we said, in our current industrialized societies, the death rates from infectious illnesses and injuries have been considerably reduced. However, we suffer now from considerably more chronic health problems. So, maybe, we should get off our seats more and do things the old fashioned way: let’s use our bodies more and our technologies less.

So, Make Your Day Harder. Please pass it on through your social media.

Author: Murray J. McAllister, PsyD

Date of last modification: June 12, 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

A Healthcare Educational System

Coping gets short shrift in our healthcare system. We don’t spend a lot of time or money on it. Instead, we devote the vast majority of our healthcare resources to various procedures and medications that attempt to cure conditions, or at the very least attempt to get rid of the symptoms that on-going health conditions cause. We hardly spend any time or money on what patients themselves can do to keep the conditions from disrupting their lives.

At the Institute for Chronic Pain, we believe this lack of attention to coping is a mistake. It’s a mistake because it leads to poorer health and greater costs. Let’s explain how a significant lack of attention to coping leads to these unfortunate outcomes and then review what we might do about it.

A healthcare delivery system

For the most part, we have a healthcare delivery system. I mean this statement quite literally. The predominant way in which we provide healthcare in our society is that when something ails us we seek a healthcare expert who provides or delivers to us a procedure or therapy or medication that makes us well. The standard name for this type of healthcare is the ‘acute medical model’ of care. In such care, health is brought about by the healthcare provider. The provider has a certain expertise in what ails us. As patients, we lack this expertise and so rely on the provider to use his or her expertise in order to do something therapeutic to us. As such, healthcare providers do things to us to make us well, as long as we do what they recommend. Patients don’t have much role in the acute medical model, besides being compliant and patient with the recommended therapies and procedures and medications. The real power lies in the provider who provides healthcare. In this way, we come to healthcare providers in a state of ill-health and health gets delivered to us. As stated, we have a healthcare delivery system.

The acute medical model is all well and good, especially if we have cures for what ails us, or at least the ability to keep us alive in a medical emergency. When having an acute appendicitis or a heart attack, it usually pays to be compliant with the emergency room provider’s recommendations. In such situations, we become the passive recipient of the intellectual and technical expertise of a healthcare team that delivers us from a state of poor health and danger to a state of relative better health and safety. We can think of any number of acute health conditions for which this model of care is well suited and can produce dramatic, life-changing, indeed life-saving, results.

Perhaps it’s because the acute medical model can produce such results that it has become the predominant model of providing healthcare in our society. Whatever the reason, it has become the paradigm by which we conceptualize healthcare. By it’s terms, we understand the roles of providers and patients – those who provide healthcare and those who receive it. We use it to understand what we are supposed to do when being unwell – we rely on our healthcare providers to make us well. We use it to understand the healthcare system itself – we have a healthcare delivery system.

The practical consequences of the predominance of this way of understanding healthcare are numerous. Because the procedures, therapies, and medications of the acute medical model are valued in our society, they are typically reimbursed well. They are also reimbursed readily – they tend to have few obstacles to payments. As such, it’s largely how hospitals and clinics make money to pay salaries and other expenses and to make a profit. It’s largely how healthcare providers earn their living. It’s how the pharmaceutical and medical technology industries pay employee salaries and create value for shareholders. It’s also largely what patients want. Who doesn’t want a cure?

The predominance of the acute medical model can also lead to some unfortunate consequences, particularly when it comes to the role of the patient. As patients, we tend to believe that the acute medical model can deliver on its promise of making us well more often than it can in actuality. We might acknowledge that it can’t cure us of everything, but surely, we tend to think, it can keep us well enough. As such, the focus on healthcare in our society tends to remain on what healthcare providers and their technical expertise can do for us. Power and responsibility remain with the healthcare providers, even in cases where their power to make us well is not so great. This subtle form of dependency on the healthcare system to deliver wellness can therefore become increasingly problematic: it’s fine in the cases of acute appendicitis or acute heart attack, but not so fine in conditions where there is no cure.

Chronic health conditions are the bane of our society, generally, and of our healthcare delivery system, specifically. Conditions such as chronic pain, heart disease, type II diabetes, obesity, asthma, and others have become ubiquitous in our society. Whereas our grandparents, we might say, lived in an age of infectious illness (think influenza at the beginning of the twentieth century or polio in the early to mid-twentieth century), we live now in an age of chronic illness. Such chronic health conditions are what now burden us. Despite the magnitude of this problem, the healthcare delivery system isn’t particularly well-suited for this challenge even though, as a society, both as patients and healthcare providers, we tend to look to it for the solutions. It has no cures, to be sure. However, it can’t even keep us all that well. At best, it maintains the status quo of the current less-than-healthy state of the patient. Management and stability of pain, blood pressure, cholesterol, and blood sugars become the goal. Patients, in this model, are to remain compliant with the medication and other therapy regimens in order to keep their numbers within some acceptable range of poor health. Notice how patients remain subtly dependent on the delivery of healthcare in this system and yet the healthcare that is delivered is not so great.

Because of these factors, chronic conditions are also the main financial drain on our healthcare system. Chronic health conditions constitute 86% of the cost of our healthcare delivery system and are the leading cause of disability (CDC, 2015). Acute medical emergencies notwithstanding, for this devotion of healthcare dollars, our system of delivering healthcare fosters a subtle form of dependency in exchange for chronic, mediocre states of health and outright disability. Obviously, we don’t get a lot of bang for our buck.

The role of the patient in coping with health problems

So, what’s missing in this picture? It’s the lack of emphasis on what patients can do for themselves in responding to their own chronic health conditions. In the predominance of the acute medical model of delivering care, both patients and providers forget that patients themselves have a role to play in their health. We call it coping.

We might define coping as our cognitive, emotional and behavioral responses to a problem, such as a health condition. In acute health conditions, the typical coping response is the following: cognitively, we don’t know what’s going on and we need answers in the form of a diagnosis and treatment plan; emotionally, we’re concerned, if not alarmed and frightened; this emotional alarm is helpful because it motivates us to act and seek the help of those who do know what to do; and so, behaviorally, we seek healthcare providers who have the requisite expertise to do something to make us well again. This is what good coping looks like in acute medical model healthcare. If, however, as we do in our society, we continue to apply this model of healthcare to chronic conditions we don’t fair so well: cognitively, as patients, we remain lacking the requisite expertise to adequately respond to our condition; emotionally, we remain concerned, if not alarmed, by our on-going state of health and so remain motivated to continue seeking help from those who are supposed to deliver us out of our state of poor health; behaviorally, then, we continue to seek acute medical care – its procedures, therapies, and medications, which simply maintain the status quo. Lack of knowledge or expertise, emotionally alarmed, and dependent – these are not the characteristics of good coping, at least not in the context of chronic health conditions.

What’s lacking when we allow the acute medical model to predominate in our healthcare system is the capacity to:

  1. Cognitively, teach patients what they have, how it develops and why it continues on a chronic course; how to tolerate an understanding of the patient’s own role in these causal factors; and how they can respond to it.
  2. Emotionally, empower them so that they remain both confident in their own expertise of how to self-manage the condition and motivated to do so over the long-term.
  3. Behaviorally,  coach patients on how to make meaningful, productive and sustained changes in their lifestyle so as to improve their state of health and well-being.

The acute medical model simply fails to provide these kinds of help, as it’s not designed to provide it.

Nonetheless, outside the acute medical model, in what’s called the ‘rehabilitation model of care,’ we have healthcare providers who assume this role of using their expertise to teach, empower, and motivate patients to cope well with chronic health conditions. They are health psychologists and other rehabilitation providers. You find them in chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and, increasingly, cutting-edge interdisciplinary primary care clinics where you can see both a primary care physician and a primary care health psychologist.

Notice that the number of such providers and programs pale in comparison to the procedures, therapies, and medications of the acute medical model. As a society and as a healthcare delivery system, we continue to value external, technological procedures and pills over internal coping and lifestyle change, even though the latter is oftentimes more effective. Healthcare providers continue to refer patients to acute medical model care despite the option to refer them to rehabilitation, or coping-based, care. Patients continue to seek the former more than the latter. Insurance companies too continue to reimburse procedural- and pharmaceutical-based care at exponentially higher rates than education and counseling-based care.

It seems our priorities are out of whack when it comes to the greatest health needs of our society. In the case of chronic care, we don’t need more acute medical care, but more educational-based care.

A healthcare educational system

So, what if in addition to a healthcare delivery system we also had a healthcare educational system? What would it look like? Beginning with primary care, it would involve clinics that have not only primary care medical providers, but also primary care health psychologists. So, for example, type II diabetes patients would obtain medication management and nutritional counseling, as they do now, but also meet with a health psychologist to focus on the following:

  • Tolerating and accepting greater degrees of ownership and responsibility for their diabetes and overall health
  • Understanding the role that patients play in the development and maintenance of the condition
  • How to make incremental lifestyle changes to improve their diabetes and overall health
  • How to sustain these changes over time

In the limited number of primary care clinics that operate in this manner, the focus of such care is not to deliver well-being to patients, but to educate them, empower them, and motivate them to improve their well-being themselves. As a result, patients no longer remain in the afore-mentioned subtle dependency on the expertise of their healthcare providers. Through a healthcare educational system, patients become experts themselves.

Health psychologists, thus, operate under the principle that knowledge is often insufficient
for sustained meaningful change. In our current acute medical model, the education and counseling that medical providers engage in typically ends with the provision of information: information, such as that smoking is bad for you; that you should lose weight; that you should exercise more; that you should learn to manage your stress; and so on. However, who doesn’t know these things? Simply knowing these things isn’t typically enough to successfully quit smoking, lose weight, start exercising or manage stress. Information is therefore insufficient for successful lifestyle change.

As such, we typically need someone to sit down and go over how to apply this information in ways that lead to long-term successful lifestyle change. However, no one, in our current healthcare delivery system, sits down with patients and actually goes over how to cognitively tolerate and accept such information or how to understand the individual’s role in achieving these goals; no one sits down with them and shows how to become empowered, confident and motivated to pursue and maintain these health goals; no one sits down and clarifies how to actually make incremental behavior changes that can successfully meet these lifestyle goals; no one develops a trusting relationship over time in which these often sensitive discussions can be had, as a coach has with the athlete that he or she trains; and no one can meet with patients on a periodic basis over time, with extended appointment times that last anywhere from fifteen minutes to an hour. No expert healthcare provider performs this role, except for the health psychologist.

What would it be like to have a trusting relationship with someone in your primary care clinic in which you can have up to an hour appointment, without the sense of being rushed, to discuss sensitive issues about how your health affects your life, but also how your life affects your health, to learn and grow, and to become a healthier and happier person, despite having some chronic condition? You’d become an expert at coping with your chronic condition and as such you’d know how to manage it so well that it would no longer disrupt your life in any significant way: what occupies your time, attention and energy would be your job, family and other life pursuits – not your chronic pain, diabetes, or heart disease.

Outside the primary care office, a healthcare educational system would also have specialty clinics. They would be interdisciplinary in nature, such as chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and the like. Patients would seek care in these clinics in order to obtain advanced education and training in the self-management of their respective conditions. The function of these programs is typically two-fold. First, their intensity allows patients to take the next step in developing their expertise, which is to actually start reducing their dependency on the healthcare delivery system. By participating in these programs, patients get so good at self-managing their condition that they are able to reduce the amount of medications they take. Coping, in the form of healthy cognitive, emotional and lifestyle behavior changes, comes to be able to substitute for some of the medications that patients have heretofore relied on to manage their condition for them. Second, the intensity of these programs allow patients to learn and regain the confidence that they can return to some type of meaningful work.

Of course, a healthcare educational system wouldn’t replace a healthcare delivery system. There is a time and place for acute medical model care. Medical emergencies occur and the acute medical model is best suited to respond to such cases. Even in the acute phases of what might turn out to be a chronic condition, there can be a role for the acute medical model. So, for example, patients can often benefit from acute medical model pain or cardiac management in the early phases of these conditions, even when the conditions subsequently later become chronic.

However, the vision we are entertaining involves a re-setting of priorities or emphasis when it comes to the roles of both the healthcare delivery system and a healthcare educational system. Patients and healthcare providers wouldn’t continue to repetitively seek acute medical model procedures and therapies long after a condition has clearly become chronic. Rather, everyone involved would see the point of switching the emphasis away from vainly attempting to deliver well-being to patients and towards educating, empowering and motivating patients to successfully improve their own well-being. In so doing, as a society, we would have to modify the value we place on the acute medical model, seeing that it has high levels of value in only certain contexts, and we would have to increase the value we place on rehabilitation-based care.

An important and essential part of this re-evaluation of our healthcare system would be the role of the reimbursement arm of our system – health and disability insurance companies and government institutions. They too would have to modify the value they place on each of the respective types of healthcare. Currently, reimbursement rates for acute medical model procedures and therapies are exponentially higher than rehabilitation, or coping-based, therapies. This system of valuation cannot but influence what type of care gets provided. To be sure, it’s one of the reasons that the acute medical model predominates in our healthcare system.

What if, though, the reimbursement rates for medical providers were the same whether they provided education and counseling or a procedure? What if the health psychologist’s cognitive behavioral therapy was reimbursed at the same rate as medical providers’ education and counseling, or medical providers’ procedures? What if nutritional counseling and physical therapy were reimbursed commensurate to these other therapies as well? If the reimbursement rates of all these therapies were at least within the same ballpark, even if they weren’t exactly identical, we would have a very different healthcare system. Healthcare providers would stop being incentivized to provide acute medical care to conditions that are clearly chronic and they’d be incentivized to take the time to sit down with their patients and have the lengthy, oftentimes sensitive, discussions about how to cope with a long-term health problem.

Specialty care would significantly change too. In the vision we are entertaining, the value that we place on acute medical care would be commensurate with the value of coping-based care. Reimbursement rates for interventional procedures and surgeries would no longer be astronomically higher than interdisciplinary rehabilitation programs. To acknowledge that there may be a time and place for such former procedures, suppose that reimbursement rates declined only as they were repeated over time for the same condition. So, patients and providers might pursue interventions and surgeries, especially in the acute phases of a condition, but their value would decline as they get repeated long after it is clear that the condition is chronic. The reimbursement rates of interdisciplinary rehabilitation care would then start to become commensurate with acute care, especially when it comes to care for chronic conditions. In so doing, we’d stop incentivizing healthcare providers to deliver acute care to chronic conditions. The result would be that as a healthcare system we’d come to start valuing the right treatment for the right condition at the right time. We’d all obtain better care at a lower cost.

Whether you’re a patient, a provider or a representative of an insurance company, maybe it’s time to start demanding a healthcare educational system that focuses on coping-based care.

References

Center for Disease Control. (February 3, 2015). Chronic disease prevention and promotion. Retrieved from http://www.cdc.gov/chronicdisease/.

Author: Murray J. McAllister, Psy.D.

Date of last modification: April 12, 2015