Can you experience the same pain differently?

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

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

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

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

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

Coping with pain as changing how you experience pain

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

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

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

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

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

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

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

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

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

Will discuss more in the next post!

Date of last modification: 8-29-2016

Author: Murray J. McAllister, PsyD

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

All or Nothing Thinking: How to Cope with Pain Series

All or nothing thinking is one of the most common, problematic ways of coping with pain. It’s right up there with catastrophizing, fear-avoidance, and refusing to accept the chronicity of pain. All of these problems prevent people from coping with pain well and being able to live a full life despite having chronic pain. Since we have reviewed the other problematic ways of coping with pain in previous posts, let’s discuss all or nothing thinking today.

All or nothing thinking defined

All or nothing thinking is a type of thinking that leads to perceiving a situation as having only two ways to look at it. We come upon a situation and conceive of it as leaving us with only an either-or choice: it has to be either this way or that way.

Sometimes, these two options are conceived as both bad in some way. The common, everyday phrase for this kind of all or nothing thinking is being “stuck between a rock and a hard place.” There’s no middle ground – at least in our initial way of thinking about the situation. So, when engaged in all or nothing thinking, we think about some situation and conceive of it as having only two responses and oftentimes we see these options as both bad.

Some examples of this kind of all or nothing thinking are the following:

  • A patient complains that she doesn’t want to take opioid medications for pain anymore because they cause sedation, constipation, and she doesn’t like how her friends and family look down upon her for having to take them; but she thinks that the only alternative is to not take the medications and subsequently live in intolerable pain and suffering.
  • A patient believes that since he can’t work anymore he must be a loser.

Notice that in these examples the people engage in all or nothing thinking because they seem to be able to only consider two possibilities, and both of them are bad. In the way they are approaching these problems, there seems to be no middle ground. As far as they are concerned, it’s an either-or situation and both options are bad.

Sometimes we engage in all or nothing thinking in yet a different way. While we conceive of a situation as having only two options, we see these options as not both bad, but rather as either all good or all bad. Again, there’s seems to be no middle ground. We have either two potential ways to respond – either the best way or the worst way.

Some examples of this kind of all or nothing thinking are the following:

  • A patient tends to believe that he has to clean the entire garage if he were to clean it or he might as well not even bother with it at all.
  • A patient believes that, unless there is a cure for her chronic low back pain, she has to remain on disability.
  • A patient says to her provider, “My life used to be perfect. Now, it can’t get any worse.”

Notice that in these examples the people conceive of their situation as having only two possible ways to look at it. It never occurs to them that there might be some middle ground. For them and the way they see it, there are really only two options – either one that’s all good (or would be all good if it could be obtained) or one that’s all bad (i.e., the one they are living with).

All or nothing thinking is a cognitive distortion

Psychologists characterize all or nothing thinking as a type of cognitive distortion. Cognitive distortions are habitual ways of thinking about things or perceiving things that fail to accurately reflect reality. We have discussed cognitive distortions before in posts related to catastrophizing and mind reading. These types of habitual ways of thinking are also cognitive distortions.

Cognitive distortions, such as all or nothing thinking, tend to occur automatically, without much awareness of the person who is doing it. Typically, we don’t intentionally make a choice to view things in such black or white ways. Rather, they occur reflexively or habitually. We sometimes call cognitive distortions ‘automatic negative thoughts’ to capture the characteristic of them as going on without much intention or awareness on our part.

Another important characteristic of cognitive distortions is that they tend to influence what we believe about any given situation. Without much awareness that we are engaging in all or nothing thinking, we tend to believe that the way we are perceiving a situation is in fact the way the situation is. In other words, when engaged in all or nothing thinking, we mistake the either-or way of perceiving the situation as reality itself. We thus tend to think that in reality we really do have only two limited options. So, therefore we feel stuck in a no-win situation.

It can be hard to get outside of the all or nothing thinking and see the situation from a different perspective. Sometimes, of course, if someone comes along and helps us to see that there is some other way of looking at the problem, we come to see it too and we are subsequently grateful. We might exclaim, “Oh! I never thought of it that way!” This kind of help liberates us, if you will, from the no-win either-or way that we were conceiving of the problem and we can then cope better with the problem. Other times, though, we might not see any other way of looking at the problem, even if others are trying to help us see it differently. In fact, we might respond to their assistance with thoughts that they are just minimizing or invalidating the severity of the situation. Still other times we might think that they just don’t get it – they have never lived through what we are living through and so we think that they are unable to understand. In such cases, it can be hard to get outside of our either-or way of conceptualizing the problem and see that perhaps we have more than just two limited options.

All or nothing thinking leads to poor coping with problems

All or nothing thinking doesn’t lead to coping well with pain. It’s easy to start seeing the reality of life with chronic pain in binary ways that leave people stuck and exhausted and possibly hopeless and lonely:

  • “I have to be on opioid medications or face intolerable pain and suffering.”
  • “I have to clean the entire house or not at all.”
  • “I have to be cured or remain on disability for the rest of my life.”
  • “You either have chronic pain and so ‘get it’ or you don’t have chronic pain and so can’t understand where I am coming from.”
  • “I’m on disability and so I must be a loser.”
  • “My provider didn’t cure me… so she must be incompetent.”
  • “My previous provider wanted to talk to me about learning ways to cope better, but he doesn’t get it. I’m coping extremely well under the circumstances. It’s just that the pain is so bad. He’s supposed to fix that – not talk to me about how I could cope better with it.”
  • “Before chronic pain, my life was perfect.”

Notice that these common sentiments admit of no middle ground. They are ways of seeing life with chronic pain in stark, either-or ways. All of them are no-win situations. They either leave people with two bad options or one good option and one bad option, but the good option is typically unobtainable. Either way, when engaged in such ways of thinking, they leave people stuck.

As such, all or nothing thinking leaves people feeling pretty lousy about themselves or their lives in general. Put yourself into such ways of thinking, entertain what it would be like for a moment, and you can see how easy it would be to begin to feel stuck in life, becoming anxious, angry, alienated, dejected, hopeless, or depressed.

From here, we can see how all or nothing thinking doesn’t lead to coping with pain very well.

Please note that we are not criticizing or judging anyone for not coping well when engaging in all or nothing thinking. No one is perfect and no one copes perfectly with life’s adversities, including chronic pain. We are simply trying to describe one of the ways in which we sometimes don’t do it very well. By describing it, without criticism, we can learn from our common mistakes and subsequently learn how to approach the problem of living with chronic pain differently and more effectively.

A student wouldn’t learn very much if her teachers only told her that she was doing things well, even when she wasn’t. No, at some point, her teachers have to provide her with feedback about the things she is not doing well. Now, of course, they do it without judgment or criticism, but rather warmth, respect, and a high regard for her well-being.

It is in this spirit that we discuss problematic ways of coping such as all or nothing thinking.

Overcoming all or nothing thinking

To overcome all or nothing thinking and subsequently come to better cope with pain, people need to develop two internal skills. One skill is being able to maintain what we call an ‘observational self.’ The second skill is what we call ‘ego strength.’ These skills are closely related to each other, but let’s review them one at a time.

What we mean by an observational self is the capacity to step outside ourselves and think about how we are reacting at any given moment. In common everyday language and situations, we refer to our observational self when we say things like ‘Think before you speak!’ or ‘Listen to yourself!’ or ‘Think about what you are doing.’ In each of these situations, the speaker is asking the other person to reflect on what he or she is saying or doing. When we take ourselves as our own object of consideration, and think about how we are reacting, we are engaging in our observational self. In other words, as human beings, we have the capacity to think about thinking! We can consider and reflect on, not only our thinking, but our ways of conceptualizing a problem or how we are reacting to it or how we are feeling about it and what it is that we want to do about it.

We can use our observational self to think about whether we are engaging in all or nothing thinking. It helps, of course, to do what we have been doing today, which is to learn about all or nothing thinking. We can subsequently use our newly learned understanding of all or nothing thinking to begin identifying it in the moment. In doing so, we use our observational self skills. We step outside the given moment and observe how we are perceiving a situation. In doing so, we can come to recognize that we have been engaging in all or nothing thinking. We identify it and name it to ourselves. “Oh, there I go again. I am engaging in all or nothing thinking.” Notice that this ability assumes that we are able to step outside of ourselves and begin to reflect on what it is we are thinking. In other words, we use our capacity to engage in our observational self.

Once identified, we can begin to challenge the accuracy of the all or nothing thinking. Inherent in our understanding of all or nothing thinking is that this kind of thinking distorts our understanding of the reality of the situation. The reality is not really what we think it is. By understanding this aspect of all or nothing thinking, we come to see that perhaps we have more than two, limited options. Maybe we remind ourselves that there must be more than two ways of looking at the problems that confront us – even if we don’t see it right a way. By challenging the accuracy of how we have been conceptualizing a problem, we come to see that perhaps we are not as stuck as we thought we were.

More often than not, in these situations, it is helpful to have someone you trust help you to see the problem differently. We often say, in everyday life, ‘Two heads are better than one’ because another person can have a different perspective from the one that we have. In this way, another person can help us to get outside of ourselves and access our observational self. Subsequently, we can then come to see that how we are thinking about a problem is not the only way to think about it. In other words, we can identify that we have been engaging in all or nothing thinking. We then come to understand that we have more options than simply two bad options. It’s at this point that we often look at our trusted companion and say, “Oh! I never would have looked at it that way, but that’s a great idea!” It’s the proverbial light bulb moment.

Now, it requires ego strength to allow ourselves to see the point of view of another. It’s our capacity to tolerate feedback from another and learn from them. We call it ‘ego strength,’ because it is a sense confidence that we are still a good person even if we didn’t think of it first or have to learn from another. We might say that it is an inherent sense of security that we are still okay even if we don’t know everything and sometimes have to rely on others for help.

We likely all know people with a low level of ego strength and people with a high level of ego strength. People without a lot of ego strength tend to have difficulty admitting it when they don’t know something. They have trouble tolerating feedback from others and get defensive or irritable. They tend to think it is weak to ask for help. They tend to deny that they are struggling to cope with a problem, because doing so would mean for them that they are weak. People with a high level of ego strength can acknowledge when they don’t know something. They can admit that they are not doing something well and can ask for help. And they do these things without feeling ashamed. They remain confident in some manner that they are still a good person, even if they need help coping with a problem.

We need at least a certain level of ego strength to allow others to help us. It takes a certain degree of internal strength or confidence to acknowledge that we need help and to listen to the feedback of others. The pay off here, though, is that the feedback of others can help us to step outside of ourselves and see our problems from a different point of view. We sometimes need a different perspective and we can only get it from another person. There’s no shame in that! It’s called learning and learning is good!

So, in overcoming all or nothing thinking, we need to rely on our capacities for our observational self and our ego strength. We need to step outside of our all or nothing thinking and recognize it as not accurate to the reality of the situation. Oftentimes, in such situations, we require feedback from another person who sees the problem differently. We need to allow this different perspective in, and acknowledge that we can learn from it. We need to acknowledge that we are not coping perfectly and can learn a thing or two from others. However, we can only acknowledge that we aren’t coping well if we know that it is not weak or shameful to do so. We need to be able to maintain some degree of confidence that we are still a good person even if we aren’t coping well at the present moment. In other words, we need to have at least a certain level of ego strength.

Coping with pain well

It’s possible to cope with pain well. It’s possible to live well despite having chronic pain. Now, it takes a lot of work and the majority of this work lies in learning how.

The work involves developing your ego strength and capacities for engaging your observational self. With such skills, you begin to catch yourself in all or nothing thinking. You challenge whether it accurately represents the options that you have. You also allow trusted others to help you to see problems differently, allowing you to see that you have more options than you thought you had. It can be quite liberating to see that you have options when you initially thought that you were stuck.

Of course, to have these kinds of insights more frequently, it takes practice. All or nothing thinking tends to be automatic or habitual. It is often hard to see that you are doing it. You have to catch yourself in all or nothing thinking, reflect on it, and come to see that you have more than two, limited options. With practice, however, you get better and better at it. In other words, with practice, you come to cope with pain better and better. At some point, you come to be able to live well even if you do have chronic pain.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-13-2014

Mind Reading: How to Cope with Pain Series

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

Mind reading defined

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

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

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

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

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

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

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

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

Mind reading and living with chronic pain

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

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

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

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

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

Common reactions to learning about mind reading

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

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

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

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

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

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

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

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

So, what can we do about it?

Overcoming mind reading

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-8-2014

Catastrophizing and Chronic Pain

It’s not uncommon to exclaim, at the beginning of a pain flare, “I’m not going to be able to stand it!” Another might express, “Now, I’m not going to be able to do anything today!” Yet, another takes it as a given that the increased pain is an indicator that the underlying health problem is getting worse. From this assumption, it’s easy to start thinking about how the future holds nothing but increasing disability, wheelchairs, and suffering.

These sentiments are examples of catastrophizing.

What is catastrophizing?

Catastrophizing is what we do when we see something through the lens of it being the worst-case scenario. We believe and feel that something is worse than it actually is.

We all do it. Everyone catastrophizes at least occasionally. Some of us do it a lot. Most of us are somewhere in between. The point, though, is that we all do it.

The most common example of catastrophizing is simple worrying. When we worry, we don’t ponder good things happening to us. We don’t even tend to think about minimally bad things happening to us, such as inconveniences or hassles. We don’t tend to waste a lot of time worrying about those things. Rather, it’s the really bad stuff that we tend to worry about. It’s the worst-case scenarios that hold our attention and get us worked up.

Now, the thing about catastrophizing is that we tend to overestimate the likelihood that the worst-case scenarios will occur. Of course, worst-case scenarios are possible. Sometimes, they do in fact occur. If, however, we step back and take a real objective look at them, we might compare how often they occur with the countless number of times when they don’t occur. The comparison is stark. Worst-case scenarios are possible, but they are not likely. They tend to be once or twice in a lifetime events. When catastrophizing, though, we see the worst-case scenario as all-but-inevitable or, worse yet, already happening. There’s an assumption of certainty about it. That is to say, this sense of certainty comes about by overestimating the likelihood of the worst-case scenario.

Like anyone else, people with chronic pain can catastrophize. Take the common sentiments expressed in the above examples. When experiencing a pain flare, common automatic reactions are that you aren’t going to be able to stand it or that now you’ll never get anything done or that you think the increased pain is indicative of an inevitable worsening of the underlying health condition that initially started the pain. There is a sense of certainty that goes along with these automatic reactions. You just “know” that you won’t ever be able to stand it, or that you’ll never be able to get anything done, or that increasing disability is inevitable. However, if you can step out of the moment, and hold on your judgment of such certainty, you might begin to reflect on how true, really, these sentiments are.

What makes you so sure that you’ll ‘never be able to stand it’? How do you ‘know’ that this pain flare is going to be the whopper of all whoppers? Maybe it would be best to hold judgment, and see if it will be as bad as you anticipate. It might just turn out to be a run-of-the-mill flare. In fact, it is much more likely that it will be an average pain flare than the one that you’ll ‘never be able to stand.’

How warranted is your certainty that you’ll ‘never be able get anything done’? How likely is that scenario to occur? With a little creativity, there is almost always going to be something that you can do, even while experiencing a pain flare. Maybe you could sit and pay bills. Maybe you could call someone who you have been meaning to call but haven’t gotten around to it. Maybe you are at work and you decide to use the afternoon to catch up on reports and emails. You sit for a while at the computer and then you stand for a while at the computer, putting a few books under the keyboard, so you can still work at the computer. You also might take breaks to walk the hallway or stretch or both. Now, it won’t be the most productive day you’ll ever have, but, with pacing and a little adaptability, it’s much more likely that you’ll be able to do something productive.

What about the certainty that your pain flare is a sign of your inevitable decline? How true is that worst-case scenario? Of course, it is possible, but it’s not very likely. The nature of chronic pain is that pain waxes and wanes – pain flares come and pain flares go. What’s the likelihood that this pain flare is the one that won’t ever go away and from which you’ll start the decline into becoming wheelchair-bound? Isn’t it much more likely that this pain flare, like the others that come before it, will come and go?

While always possible, worst-case scenarios are low probability events. When we catastrophize, though, we overestimate the likelihood that the worst-case scenario will occur and become certain that it will happen or is already happening. We lose perspective on the problem and become certain that it is worse than it actually is.

Catastrophizing influences our perceptions

The sense of certainty that goes along with catastrophizing colors our perceptions, making what we experience worse than it actually is. This fact is what leads psychologists to categorize catastrophizing as a form of cognitive distortion. Catastrophizing distorts what it is we perceive.

It’s not very mysterious. Rather, it’s super common. We can think of any number of examples. Suppose your boss makes a critical remark about you and later looks at you strange after you say something in a meeting. You associate these events with some problems you have been having at work and before you know it you are taking the boss’ remark and the look as confirmation that any day now you are going to be let go. If you don’t step out of the moment, and gain some perspective on how you are perceiving these events, your experience is that you simply and unquestionably are in the process of getting fired and it can’t get much worse. To take another example, suppose you are arguing with your spouse and he or she walks out of the room hurt and angry. Your first thought is that your last hurtful remark put your spouse over the edge and that he or she is now leaving you. Your immediate reaction is one of ‘Don’t leave me!’ For the moment, your thoughts are going a million miles an hour and you have all the accompanying feelings of fear, anger, and abandonment. If you don’t step out of the moment, get grounded, and reflect on what’s going on, your experience is that your marriage is unquestionably ending and it can’t get much worse. In both these cases, we see that catastrophizing distorts our experience of what is really happening.

Catastrophizing tends to happen when we are ungrounded, vulnerable, anxious, or upset already and then something bad happens. In such cases, it’s hard to see the problem clearly. We are too ungrounded or anxious or upset. As such, the overall experience of the problem is that it is worse than it actually is. Conversely, when a problem occurs during a time that we are grounded, focused, supported, and confident, we deal much better with it because, in part, we see the problem more accurately.

The two parts that make up experience

This last notion leads to an exceptionally important, yet often overlooked, fact about human experience. We tend to think that whatever it is that we experience is solely due to what is happening to us. That is to say, we often simply assume that the quality and intensity of our experiences are only due to the qualities and severity of the external things that occur to us. It’s as if we forget that there’s a perceiving subject, who has these experiences.

Now, of course, what we experience is determined in part by external events – what they are, whether they are bad or good, and how bad or good they are. But, our experience is also determined in part by where we are at when these events occur.

When we are grounded and present, we might notice the beautiful sunset and fully appreciate it. The sunset subsequently might have a big impact on us. If, however, we are lost in our thoughts, or fretting because we are stuck in rush hour traffic, we might hardly even notice the beautiful sunset, let alone appreciate it, and subsequently it has little to no impact on us. It’s the same external event, but two very different experiences and the experience is determined by how we are at the time of the external event.

Human experience is made up from two parts: 1) the things that happen to us and 2) how we are when things happen to us. When we are grounded, supported, confident and well-rested, we tend to experience the same event differently than when we are anxious, upset, vulnerable, lonely, abandoned, or overly tired and fatigued.

Catastrophizing is one of the ways that we color our perceptions of events when we come to the event feeling anxious, upset, vulnerable, left alone, or fatigued.

Catastrophizing is all-too-human

Sometimes, people are reluctant to acknowledge that they catastrophize. You can sometimes feel judged when people tell you that you’re making a mountain out of a molehill. You might automatically want to respond with assertions that the problem really is that bad — it really is catastrophic — and then feel invalidated when they don’t believe you.

It’s important to remember, though, that we all do it. It’s part of our all-too-human condition. Human beings are not perfect. We are not omnipotently objective observers of the things that happen to us. We have all sorts of beliefs, attitudes, and feelings that bias and distort our perceptions. And, yes, we also catastrophize. All of us sometimes perceive things as worse than they really are. Some people do it rarely while other people do it a lot. Most of us are somewhere in between, catastrophizing more than rarely and less than all the time.

A good healthcare provider tends to remind us of things that we already know, but tend to forget in our day-to-day routines. One of these reminders is that it is a mark of health to be able to admit our imperfections. The first step towards getting better with regard to a problem is always to admit that you have the problem. In the case of catastrophizing, it’s a mark of health when we can acknowledge that we catastrophize, especially at the time when we are actually doing it. Indeed, an important health skill is the ability to step out of any given moment, reflect on what’s going on, and come to see the problem more clearly. By gaining perspective on the problem, we reduce the distress that’s associated with the problem and the problem comes to no longer have such a big impact on our lives. The problem comes to be less problematic as we initially experienced it to be.

This process is one of the many ways that people come to cope better with problems in life, including chronic pain. That is to say, we come to cope better with a problem when we get better at catching ourselves catastrophizing it, acknowledge that we are doing it, and reality-checking it. We thereby come to see the problem more clearly and subsequently we cope with it better– the problem becomes less distressing and less impairing.

Author: Murray J. McAllister, PsyD

Date of last modification: 11-24-2013