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

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

Fear-Avoidance of Pain

There’s a divide between chronic pain experts and their patients that rarely gets crossed. The divide centers on the issue of fear-avoidance. On one side of the divide, among chronic pain experts, fear-avoidance is one of the most well established facts about chronic pain and chronic pain-related disability. Over more than a decade, researchers and clinicians have extensively studied fear-avoidance and almost every month another study on it gets published in the professional journals. As such, it’s a well established fact among chronic pain experts. On the other side of the divide, it’s rare to find a chronic pain patient who has ever heard of it.

It’s a strange state of affairs that goes on between chronic pain providers and their patients. We know something important about chronic pain and chronic pain-related disability and our patients don’t know it. And yet, it goes unsaid. You’d think that everyone involved would want it shared. But, still, it doesn’t.

While I’ve never seen a study that could shed light on why the divide occurs, I have some thoughts about it. There are actually two reasons, but they go hand in hand.

First, we don’t share what we know about fear-avoidance because we aren’t very good at teaching patients (and maybe even the public) about what chronic pain is. Patients (and the public) commonly consider the sensation of pain as solely and only a physical sensation. As such, it’s thought that psychological aspects have very little to do with the sensation of pain itself. At most, the psychological aspects of pain are thought of as consequences of pain – that the distressed thoughts and moods, like fear, and the behaviors that go along with them are really just reactions to the physical sensation of pain. As chronic pain experts, though, we know that it isn’t true. While it requires and involves a physical sensation, to be sure, the experience of pain also inherently involves unpleasant and distressing thoughts, feelings, and behaviors. Any explanation of fear-avoidance requires this understanding of chronic pain – that it is more than simply and only a physical sensation. However, it is hard to communicate this notion. It’s difficult to teach patients to expand their understanding of chronic pain and incorporate its inherent cognitive, emotional, and behavioral components. Moreover, besides being hard to communicate, it has to be communicated well – with compassion and sensitivity — in order for most patients to succeed in understanding the true nature of chronic pain. This point leads us to the second reason for the great divide between chronic pain experts and their patients.

Second, to be frank, there can be a little pushback from patients when it comes to explaining that chronic pain is more than simply a physical sensation and that it in fact involves psychological as well as medical aspects. Frank discussion of the inherent psychological aspects of chronic pain can tend to get inhibited because it opens up the possibility of critical judgment and stigma by others. It’s safer to insist that chronic pain and its related difficulties are solely and only physical because in our society it is acceptable if you struggle with a medical condition. It’s not acceptable to acknowledge that you’re psychologically struggling. Consequently, and understandably, patients can resist coming to understand how chronic pain is inherently both a medical and a psychological condition – what healthcare providers call a biopsychosocial condition.

This resistance reinforces any unwillingness of healthcare providers to bring up the notion of fear-avoidance because it assumes a foundational understanding that chronic pain is both a medical and a psychological condition. To convey the latter, though, as indicated, it’s hard work. To succeed in doing so, it requires a high level of skill on the part of healthcare providers – a degree of interpersonal compassion and sensitivity. It also involves a level of interpersonal skill on the part of the patient – the ability to develop a safe, trusting relationship in which the patient can be assured that no critical judgment will occur.

Fear-avoidance is therefore a sensitive issue, which challenges the skills of both chronic pain experts and patients, if we are to ever bring it up. We have to admit that providers have a hard time talking about it and patients tend to have a hard time hearing about it. So, we avoid the topic. It’s a bit ironic: we avoid discussions of fear-avoidance. The great divide in knowledge and understanding subsequently continues.

If you’re game to talk about it, though, I’m game. Let’s give it a try.

There’s significant benefit if we can pull this off. As chronic pain experts, we know that fear-avoidance is one of the most important factors that lead to chronic pain-related disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999; Leeuw, et al., 2007; Vlaeyen & Linton, 2012). If you can learn about it, and acknowledge it when it occurs, then you can begin to challenge it and change it. It’s not an exaggeration to say that overcoming fear-avoidance is essential if you want to self-manage pain successfully. It’s really that important. So, let’s talk about it. Ready?

Fear-avoidance defined

Pain is a naturally unpleasant and distressing experience. We don’t laugh or jump up and down for joy when in pain. Rather, we cry and become alarmed. Pain captures our attention and our thoughts become concerned about it. We think about what’s causing it and how to get rid of it. Emotionally, we are alarmed and distressed. These cognitive and emotional aspects to the experience motivate us to get help, stop the pain, and avoid it again in the future.

These ways of experiencing pain and reacting to it are not chosen or the result of intentional decisions. When in pain, we don’t intentionally decide to perceive it as unpleasant or distressing, and subsequently begin to cry and emotionally become alarmed. Moreover, we don’t typically choose how we are going to think about pain and how we might make sense of it. Rather, pain just is inherently emotionally distressing and alarming. As such, even though we can tend to think of it as solely a physical sensation, we cannot wholly divorce the sensation of pain from how we perceive it, cognitively and emotionally. The cognitive and emotional distress is just part and parcel of the experience of the sensation. The whole experience also involves behaviors that are indicative of being in pain – the grimacing, verbal expressions, guarding, and the like. None of these behaviors are typically thought of as chosen behaviors. Subsequently, we might say that all these cognitive, emotional, and behavioral aspects to the experience of pain are automatic or reflexive.

Let’s take an example. Consider what happens when you burn your hand on the stove. Behaviorally, you reflexively pull your hand away and guard it. Tears might come to your eyes and you might exclaim all sorts of utterances. Cognitively, your thoughts are focused on the pain and what to do about it. Emotionally, you are upset and alarmed. Your emotional distress motivates you to act. It also motivates you to be careful next time. Later, you’ll apt to be apprehensive and take steps to avoid getting burned again.

Experts in chronic pain management call this constellation of cognitive, emotional, and behavioral components to the experience of pain, “fear-avoidance.”

Fear-avoidance is all well and good in an acute injury. It’s an adaptive and helpful response. It helps us to get better and avoid future injury.

What’s good for an acute injury, however, is not always good for chronic pain. Persistent fear-avoidance in chronic pain leads to persistent emotional distress and impairments in activities. In other words, chronic fear-avoidance is one of the most important factors that lead people with chronic pain to become disabled.

If, like the alarming nature of acute pain, chronic pain remains alarming indefinitely, then the natural reaction to pain is to always try to stop it or get rid of it. Since, though, the pain is chronic, there’s not much the typical chronic pain patient can do to stop it. Of course, there are medications and various kinds of therapies, but at best these approaches only reduce pain. It can then seem like the only thing that’s left to do is to stop doing activities that make pain worse.

If work makes your pain worse, and you struggle to tolerate it, coming home distraught by the pain night after night, then it can seem reasonable to conclude that maybe you shouldn’t go to work anymore. If the pain of sitting in the bleachers at your child’s sporting event or musical performance was too excruciating the last time you went, then you might find yourself making the tough decision to stay home tonight instead. Over time, you can come to anticipate when pain is going to become too overwhelming and consequently avoid those activities too. You end up declining invitations to the extended family reunion, the weekend trip that includes the long car ride, the outing to the amusement park, or other similar activities. All these examples are examples of fear-avoidance of pain and its associated activities.

Notice that inherent in all these examples is that pain is something that’s concerning and distressing, which then leads to not doing the activities that bring on pain. For after all, if, when doing some activity, the pain wasn’t alarming, then we’d say the pain was tolerable and we’d keep doing the activity. The pain would still be there, of course, but we’d do the activity without any concern or sense of alarm about it. In the examples above, though, the pain involved in the activities is distressing and alarming and so the activities are stopped. In the short hand of pain experts, these examples involve fear-avoidance of pain and the activities associated with pain.

What it all comes down to is that, when it comes to chronic pain-related disability, the cognitive, emotional, and behavioral aspects of the experience of pain are the most important components, not the actual physical sensation. It’s the sense of alarm that is the tipping point and stops people from doing things. Of course, the sensation plays a role, but without the sense of alarm – the cognitive and emotional ways of perceiving the sensation – the sensation itself would be tolerable and there’d be no need to avoid or otherwise stop the activity.

Now, here is where patients can start to get a little uncomfortable.

Common patient reactions to the notion of fear-avoidance

When first hearing about fear-avoidance, a common reaction among patients is something like the following: “It’s not my emotional or behavioral reactions to pain that disable me, it’s the physical pain!” The sentiment involves a concern for being judged and also being a little put off. Both sentiments are understandable.

At the end of the day, though, is it accurate and is it necessary? Would the patient be better off by coming to understand the truth about fear-avoidance and then learning how to overcome it? Let’s take a close look at these issue.

As suggested above, the point of the resistance to fear-avoidance is really two-fold, but they go hand in hand. First, it is an assertion about what pain is – that pain is a physical sensation that is wholly different from any cognitive, emotional, and behavioral factors related to pain. Second, it is an assertion that if psychological aspects of the experience of pain are acknowledged, then they open up chronic pain patients to the potential shame of stigma and the critical judgments of others. The two assertions work hand in hand because insistence on the notion that pain is solely and only a physical sensation puts it into the medical category of conditions and it is typically socially acceptable to be disabled from medical problems. But, if we acknowledge that there are psychological aspects to the pain experience, then we run the risk of putting it into the psychological category of conditions, and it just isn’t acceptable to be disabled by psychological problems.

As we said, it’s a sensitive issue.

Any response to this common patient reaction requires, not only an expert understanding of what chronic pain is, but also a deep level of compassion and sensitivity in order to convey this understanding to patients, making it okay enough for them to acknowledge and learn from.

Let’s try to show how it might just be true that the psychological aspects of the experience of pain are more important than the physical sensation, especially when it comes to chronic pain-related disability.

Consider, for the moment, two patients with chronic low back pain, Mr. Smith and Ms. Jones. Let’s further suppose that they each have the same exact degenerative changes in their lumbar spine, as evidenced by recent scans. Over the last month, each of their pain has been worsening.

Mr. Smith has been told and therefore believes that the degenerative changes in his spine are inevitably progressive. He conceptualizes his condition as that his ‘discs are degenerating.’ He believes (and may have been told) that given the degenerative nature of his condition he will likely end up in a wheelchair someday. During the last month, his pain has been worsening and he takes it as evidence of his inevitably degenerating condition. This perception of his pain is alarming. Out of this resultant fear, he responds with rest and inactivity. From his perspective, it makes all the sense in the world to rest and remain inactive. Given his understanding of his pain as the result of a fragile orthopedic condition that is inevitably getting worse, he reasons that he needs to not engage in activities as a means to prevent, or at least slow down, the degenerative process in his spine. Just as you wouldn’t walk on a broken leg, rest and not doing too much seems like the best approach for his condition. He rates his pain as intolerable.

Ms. Jones has been told that she has degenerative changes in her spine, but she has also been told it is normal for a person of her age. It was explained to her that the term ‘degenerative disc disease’ is actually a misnomer and that we now know it really isn’t degenerative or a disease. We know, for instance, that most of the time degenerative changes of the spine get better, not worse, and even in those situations where they don’t get better, they almost always stay the same. It was explained to her that chronic pain is actually a complex condition and that her pain is only partly attributable to her stable degenerative changes in spine. The overall state of her nervous system, in terms of central sensitization, and external stressors, can also play a role in maintaining her chronic pain.

Ms. Jones has taken these lessons to heart and is confident that she knows what her pain is and that it is chronic and stable. She has so fully accepted it that it no longer alarms her. She knows that reasonable activities are not going to make her stable degenerative changes worse. She’s identified for herself that if she stays home when having a bad pain day she has nothing to do but focus in on how much pain she has. As a result, her response to pain is to get up and go do something. Of course, she’s reasonable about it and she paces herself when needed. Nonetheless, she sees staying active and productive as ways to cope with pain. Because she knows her degenerative condition is stable, she reasons that the increase in pain over the last month isn’t due to a worsening of her spinal condition and subsequently looks to other reasons for the pain increase. She recognizes that the increase in pain corresponds, for instance, to the last few months of poor sleep and, sometimes, outright insomnia. She knows that her poor sleep is itself due to the stress of some recent family issues — one of her children is going through a difficult divorce and her grandson, from another one of her children, was recently diagnosed with autism. She recognizes that her increased pain is due to the stress of these family issues and the resulting insomnia. So, she sets out to take better care of herself and manage her stress better. She notes that her pain has increased but it still remains tolerable.

Mr. Smith and Ms. Jones have the same degenerative condition and, we assume, the same physical sensation. However, how they make sense of it is very different. How they feel about it is very different. How they behaviorally cope with it is very different. Mr. Smith experiences pain through the lens of it being indicative of a threatening condition that’s inevitably going to bring about severe impairments. Ms. Jones sees her pain as indicative of a benign and stable condition. She also recognizes that she has some control over how much pain she has by managing the state of her nervous system and how much stress she has. Mr. Smith sees his pain as largely out of his control. Mr. Smith’s moods are mostly fear-based. Ms. Jones is mostly confident. Mr. Smith engages in passive coping strategies of rest and inactivity. Ms. Jones engages in active coping strategies of remaining active, productive, and often getting out of the house. Mr. Smith experiences his pain as intolerable. Ms. Jones still rates her pain as tolerable, even though it has increased over the last month.

Mr. Smith, we might say, is fear-avoidant. Ms. Jones is not.

While hypothetical, the case examples show how it is possible that the psychological components to the experience of pain can make all the difference. The physical sensation, we assume, remains constant across both individuals. However, the beliefs about the sensation, the quality of the attention given to it, the mood states that occur during the sensation, and the behavioral responses to it, all have a reciprocal affect on the quality and intensity of the overall experience of pain.

In one instance, these psychological components make the pain intolerable and impairing. In the other instance, the psychological components make the pain tolerable and she refrains from becoming disabled.

A vast array of experimental and clinical research supports our hypothetical cases. Of course, a review of the biopsychosocial nature of chronic pain is beyond the scope of this blog post. I’d refer the reader, though, to any of the numerous reviews of the matter (e.g., Bushnell, Ceko, & Low, 2013; Linton, 2000). You’ll find that beliefs, particularly beliefs of the threatening nature of pain, can influence the self-rated unpleasantness and intensity of pain (Gracely, et al., 2004). It’s well established that people rate their pain as worse when they believe it’s somehow threatening to them, than if they believe it’s benign, even when the painful stimuli is held constant across both groups. You’ll find that it is well established that pain is worse when your attention is focused on it than when your attention is distracted (Bantick, et al., 2002; Eccleston & Crombez, 1999). It’s well established that people with negative mood states will have higher pain ratings than people with more positive mood states, again, even when the painful stimuli is held constant (Tang, et al., 2008; Villemure & Bushnell, 2009; Wiech & Tracey, 2009; Wiech, Ploner, & Tracey, 2008). It’s also well established that people who engage in passive coping strategies, such as rest and inactivity, tend to have higher rates of pain and disability than those who don’t (Jensen, Turner, Romano, & Karoly, 1991; Samwel, Evers, Crul, & Kraaimaat, 2006).

In all, there’s just no getting around the fact that the nature of chronic pain is such that it has both physical and psychological aspects inherent to it. The notion that pain is solely a physical sensation that can be wholly divorced from cognitions, emotions, and behaviors is just not true. In fact, like in the case of fear-avoidance, the psychological components can make all the difference in what makes pain tolerable or not.

As chronic pain experts, we need to find a way to routinely educate patients and the public about the true biopsychosocial nature of chronic pain. We also need to be able to do it well – with compassion and sensitivity. We need to understand why patients might tend to resist what we take as established truth. It’s because of stigma. It’s because in this day and age it is still not socially acceptable to see chronic pain as a psychological condition, even if it is only in part psychological. We need to be able to develop trusting relationships where the truth can be told and discussed, and patients remain accepted and respected.

Patients too need to practice having the ego strength to acknowledge this truth and do so without shame. You don’t have to buy relief from stigma by insisting on something that’s not true – the belief that chronic pain is solely and only a physical sensation that is separable from any psychological factors. The challenge is to practice remaining confident that you are doing nothing that’s worthy of criticism. We might rightfully judge and criticize someone who lies, cheats, or steals. But, we don’t judge or criticize those who struggle to cope with any of life’s psychological problems, chronic pain included.

Indeed, if we all could overcome stigma, then healthcare providers could openly talk about the well established psychological aspects of chronic pain, such as fear-avoidance, and our patients could openly hear it. Together, we could make significant progress in helping people to learn to live well despite having chronic pain. In so doing, we could bridge the divide that has prevented us from acknowledging what we all know is true.

References

Bantick, S. J., Wise, R. G., Ploghaus, A., Clare, S., Smith, S. M., & Tracey, I. (2002). Imaging how attention modulates pain in humans using functional MRI. Brain, 125(2), 310-319.

Bushnell, M. C., Ceko, & Low, L. A. (2013). Cognitive and emotional control of pain and its disruption in chronic pain. Nature Reviews Neuroscience, 14(7), 502-511.

Crombez, G., Vlaeyen, J. W., Heuts, P. H., & Lysens, R. (1999). Pain-related fear is more disabling than pain itself: Evidence on the role pain-related fear in chronic back pain disability. Pain, 80(1), 329-339.

Eccleston, C. & Crombez, G. (1999). Pain demands attention: A cognitive-affective model of the interruptive function of pain. Psychological Bulletin, 125(3), 356-366.

Gracely, R. H., Geisser, M. E., Giesecke, T., Grant, M. A., Petzke, F., Williams, D. A., & Clauw, D. J. (2004). Pain catastrophizing and neural responses to pain among persons with fibromyalgia. Brain, 127(4), 835-843.

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of he literature. Pain, 47(3), 249-283.

Leeuw, M. Goossens, M. E., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. (2007). Fear-avoidance model of chronic musculoskeletal pain: Current state of scientific evidence. Journal of Behavioral Medicine, 30(1), 77-94.

Linton, S. J. (2000). A review of psychological risk factors in back and neck pain. Spine, 25(9), 1125-1156.

Samwel, H. J., Evers, A. W., Crul, B. J., & Kraaimaat, F. W. (2006). The role of helplessness, fear of pain, and passive pain-coping in chronic pain patients. Clinical Journal of Pain, 22(3), 245-251.

Tang, N. K., Salkovskis, P. M., Hodges, A., Wright, K. J., Hanna, M., & Hester, J. (2008). Effects of mood on pain responses and pain tolerance: An experimental study in chronic back pain patients. Pain, 138(2), 392-401.

Vlaeyen, J. W. & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153(6), 1144-1147.

Villemure, C. & Bushnell, M. C. (2009). Mood influences supraspinal pain processing separately from attention. Journal of Neuroscience, 29(3), 705-715.

Wiech, K., & Tracey, I. (2009). The influence of negative emotions on pain: Behavioral effects and neural mechanisms. NeuroImage, 47(3), 987-994.

Wiech, K., Ploner, M. & Tracey, I. (2008). Neurocognitive aspects of pain perception. Trends in Cognitive Sciences, 12(8), 306-313.

Author: Murray J. McAllister, PsyD

Date of last modification: 9-9-2013

3 Healthy Ways to Overcome Stigma

If you have chronic pain, you also have to deal with social stigma. Stigma is the disapproval of others for how you are coping with pain. Friends, loved ones, employers, and even healthcare providers can judge you in any number of ways. They might disapprove when you rest or nap, or if you don’t work, or if you take narcotic pain medications. Such critical judgments from others are stigma.

Of course, it doesn’t happen all the time. Nonetheless, it likely happens enough of the time for you to be aware of it or at least its possibility when interacting with others.

Stigma puts people on the defensive. No one likes to be judged. It can lead to shame and anger. In the last post, we reviewed two ways people with chronic pain find themselves defending against stigma. They were:

  • emphasizing the medical aspects of chronic pain and, as such, emphasizing that you have no control over it
  • insisting that you are coping as well as possible given the condition that you have

While understandable, these ways of responding to stigma ultimately back fire in the end.

Let’s look at some ways to overcome stigma that are healthy and effective. Unfortunately, there are no step-by-step instructions for how to do it. It’s actually hard to describe how people do it. The ability to do it, though, involves at least three factors: coming to terms with the moral luck of your chronic pain; developing ego strength; and understanding that no matter how well you are coping with chronic pain, you can always get better at it.

All three of these factors, however, fall under the category of ‘easier said than done.’

The good news is that it is possible. It is possible to deal with social stigma in healthy and effective ways. Most people have to learn how to do it. It can be hard to learn. It takes a lot of practice. And, like most things that take practice, it takes time. Typically, people learn healthy ways to respond to stigma in one of two different types of therapy: in a chronic pain rehabilitation program or in psychotherapy with a health psychologist.

Let’s take each of these three factors and discuss them one at a time.

Coming to terms with the moral luck of your condition

A common response to stigma among those with chronic pain is to deny responsibility for the pain. Say, for example, that your spouse criticizes you for resting too much and not doing enough around the house. A natural reaction is to remind your spouse that you have a medical condition and there’s nothing you can do about it. You didn’t choose it. It happened to you. It’s out of your control. You are simply doing, you might assert, what everyone else does when having a medical condition: you stay at home and rest.

Your argument is that your spouse shouldn’t judge you because you didn’t choose it and it is out of your control. In effect, you are reminding your spouse of an assumption of moral reasoning that we all hold: we cannot be held responsible for something we didn’t choose or have control over. So, what you are basically arguing is that you can’t be held responsible (i.e., judged) for your pain because you didn’t choose it and you are essentially powerless to change the fact that you have it – i.e. you can’t be responsible for something you don’t have control over.

As we saw in the last post, this position has some problematic consequences. If you have no responsibility, it’s because you have no control over the situation and if you have no control, then you are powerless to do anything about it. You stop the disapproval of your spouse (or anyone else) at the cost of maintaining a viewpoint that you have no control and are therefore powerless to pain. It’s a bad way to understand your situation because it leaves you convinced that you are helpless.

It’s a dilemma: how can you overcome being stigmatized without asserting that you are powerless to your pain and therefore not responsible for its management?

It’s an important question because people who cope with chronic pain well see themselves as responsible for managing their pain, and their overall health, for that matter. They take ownership of their health and self-manage their pain. That is to say, they engage in healthy lifestyle changes and ways of coping that make their chronic pain tolerable enough so that they can move on with the rest of their life, engaging in productive and meaningful activities. That’s what good coping looks like.

It’s the chronic pain version of what we all know we should do when attempting to lead a healthy life – assume responsibility for our health and make healthy lifestyle choices, including healthy ways of coping with whatever life throws at us.

While it’s easier said than done, we all know it. We all know that we should assume responsibility for our health and well-being.

But how do you do it when being stigmatized? How do you overcome stigma while at the same time maintaining responsibility for your health and well-being?

Ancient and modern moral philosophers have studied this dilemma and they can offer some insights that I think are helpful for those with chronic pain. The insights involve the notion of moral luck. It’s the notion that much of what happens to us is beyond our choosing, but nonetheless we are still responsible for dealing with it as we go on with life. For instance, we do not choose the family we are born into and we do not choose much of our childhoods, but nonetheless these events have significant influence on us, an influence that reaches far into adulthood. Indeed, our childhood shapes us in countless ways and its influence extends throughout our lives. Were you born into a poor family or a wealthy one? Were your family relationships healthy or dysfunctional? Did you have one parent in your life or two? Did your parents divorce? Were they ever married? Were there any deaths in your family or did everyone remain healthy? So much of childhood is beyond our choosing and in effect is a matter of luck. It’s a matter of luck whether good things happen to us or bad things happen to us. In many ways, these unchosen events shape how we turn out as adults. Despite our lack of choice in all these childhood influences, we are nonetheless responsible for what we go on to do in adulthood. We are all subject to moral luck.

So, how does all this relate to chronic pain and dealing with stigma? You can use the notion of moral luck to understand your condition. It is true that you didn’t choose to have chronic pain, but nonetheless you are still responsible for how you are going to manage it, now that you have it. This way of understanding your condition is helpful in dealing with stigma. You are not to blame for your chronic pain. The stigma is not true! But, nonetheless, you are still responsible for how you manage your pain. And thank goodness too! For if you are not responsible for it, who would be? You don’t want to see yourself as having no control over your pain and health. For one thing, it is not factually accurate. For another thing, if it were true, it would leave you powerless, which in turn leaves you helpless and ultimately hopeless! So, accept the fact that you can self-manage your chronic pain. You just have to learn how. By understanding your condition with the use of the notion of moral luck, you can know that you are not to blame for your chronic pain, but you also know that you can learn to have some modest, yet meaningful, control over your pain.

The notion of moral luck allows you to side-step the social stigma of chronic pain. At the same time, it makes way for learning how to successfully self-manage pain.

Developing ego strength

When you acknowledge that you are responsible for managing your pain, you open yourself up to the possibility of judgment from others. In this post and the last, we discussed how common it is for people to become defensive when judged or stigmatized. Understandably, they become sensitive and angry. In their anger, they deny their ability to control the pain and therefore deny their responsibility for its management. At other times, they defensively assert that they are coping as well as humanly possible, which is another way to respond to stigmatizing statements that they aren’t coping well enough. These reactions are common.

What if, in either of these situations, you maintained your cool when someone questioned how you are coping with pain? What would that look like? Let’s imagine two different scenarios and review what it would be like if you interacted with the other person while remaining grounded.

In the first scenario, suppose someone critically judges you by accusing you of not coping well enough with your pain. You control your sensitivity and defensive anger, and in response assertively state that you do not appreciate the criticism. You ask the person to stop making such judgments. You do not lose it. You don’t cry or let your anger get out of control. Rather, you maintain your cool. Maybe, you acknowledge that everyone can always get better at dealing with problems, like chronic pain, and it may be true that you could learn to cope better, but the judgmental criticism is not helpful. In doing so, you simply state your peace and walk away.

In the second scenario, a healthcare provider begins to talk to you about participating in a chronic pain rehabilitation program. In describing the program, she states that it would help you to learn how to cope better with your chronic pain. Your immediate reaction is to become a little sensitive and think that she is judging you for not coping well enough. For after all, you’ve had a lot of people stigmatize you over the years and your immediate reaction is that your healthcare provider is doing it too. Before you say anything, though, you contain your immediate reaction and think to yourself, ‘No, she’s not judging me… She just trying to be helpful.’ You then ask about her recommendation and you talk about it without feeling offended. In the course of the conversation, you acknowledge that it would be helpful to learn some new ways to cope with pain and to get better at it. By doing so, you get a little vulnerable with your healthcare provider, but, at the same time, you remain strong, as it were, in your vulnerability. You know that it is okay to get help and you remind yourself before rejecting her recommendation that getting help is why you are seeing your healthcare provider in the first place. You remind yourself that everyone needs help, sometimes, and that it’s a mark of strength to acknowledge that you need help and could benefit from learning how to cope better with pain.

In both these scenarios, you demonstrate that you possess ego strength. Ego strength is a term that captures what in everyday language we might call ‘character strength’ or ‘maturity.’ It’s the ability to acknowledge that you don’t know everything and that you can benefit from learning from others. In short, it’s the ability to be in the student role. You can tolerate getting feedback about yourself without becoming ashamed or defensively angry. You take it in and learn from it.

People demonstrate ego strength when they acknowledge that they were wrong about something when apologizing. Workers demonstrate ego strength when they tolerate feedback from their supervisor when discussing how they could do their job better or during their annual reviews. Patients demonstrate ego strength when they acknowledge that they could do better while talking with their healthcare providers about making healthy lifestyle choices.

Now, of course, such discussions are a two-way street. The other person, whether a friend or work supervisor or a healthcare provider, can be more or less respectful and tactful when talking with you about ways to improve what you do. When the other person is good at communicating such information, it is easier to hear. But, you also have a role in such conversations. It’s the role of tolerating such discussions, and acknowledging that you don’t know everything there is to know about the topic, and can learn and improve.

Developing ego strength is also a way of overcoming stigma. When you know that you have room to grow and change, and are truly okay with it, it doesn’t bother you as much when others point it out. When they do it respectfully, your confidence in yourself allows you to be vulnerable and acknowledge that they are right – that you can stand to benefit from working on getting better at coping with pain. When they don’t do it respectfully, your confidence in yourself allows you to tell them that the way they’re talking to you is not helpful – even if it might be accurate in some way. Ego strength allows you to have the confidence that overcomes stigma.

Traditionally, psychotherapy is the place where people develop ego strength. You do so in a trusting relationship with a healthcare provider who helps you to accept feedback about yourself, learn from it, and grow. When it comes to chronic pain patients, such psychotherapy is done with a health psychologist. Developing ego strength also occurs in chronic pain rehabilitation programs, because they have traditionally been a psychology-driven therapy.

You can always get better at coping

In the course of developing ego strength, it becomes clear that the ability to cope with problems, like chronic pain, occurs along a spectrum. There is no endpoint in the ability to cope. No matter how well you are coping, you can always get better at it. This way of understanding coping allows you to overcome stigma.

We have seen how it is easy to respond to stigmatizing accusations that you are not coping well enough by asserting that you are coping as well as possible given the nature of your condition. Now, of course, the stigmatizing accusation is judgmental, disrespectful, and hurtful. So, it is understandable that you respond in some way. But, is this type of response factually accurate?

Patients commonly tell me that they have an incredibly high pain tolerance or that they don’t want to hear about ways to cope better with pain because they are coping as well humanly possible. These kinds of statements cut off the possibility of stigma, but they also cut off all discussion of the possibility of learning how to cope better too. And are they really factually accurate? Have such persons really reached an endpoint in their ability to tolerate and cope with pain? While their reactions to stigma are understandable, I think it is more factually accurate to see that, no matter how well people tolerate and cope with pain, they can always get better at it. There is always room for improvement.

Moreover, there is no shame in acknowledging in acknowledging where you are at on the coping spectrum. We are all in same boat, as it were. Wherever we are on the spectrum of coping, we can all get better at coping with adversity!

As such, it is most helpful to understand the ability to cope as something that occurs along a spectrum of coping, where there is no ideal endpoint. Wherever you are on the spectrum of coping, you can always get better at it.

The ability to cope with problems is like any skill. People don’t reach an endpoint in their ability to play a musical instrument or play a sport. A musician or athlete can always improve, no matter how good they get. The same is true with the ability to cope with adversity. The more you learn and the more you practice, the better you get at it.

So, what do you do when people disrespectfully accuse you of not coping well enough? Well, let’s review. With the help of your healthcare providers, you have worked through the moral luck of your situation. Over time, you have become confident that you are not to blame for your chronic pain, but you have also accepted ownership of your health and well-being. As such, you have been working with your healthcare providers in learning how to self-manage chronic pain. You have developed the strength to be in the student role with your healthcare providers. You have accepted their feedback and insights about you, and have learned from them, and have grown. You now have the confidence to know that it’s okay to be still learning. You know that you have come to cope better and better, but in reality there is always more to learn. You are now hopeful in ways that you haven’t been in a long, long time: you know that your future is one of continuously getting better and better at self-managing pain, as long as you keep learning and practicing. So, with all this hard work behind you, and with your new-found strength and confidence, you tell the people who disrespectfully judged you something like the following: you say that, while it may be true that we can all get better at coping, it is not right to judge and that they should stop being so judgmental. You then walk away without shame or anger, but with the confidence that you are on the right track.

Author: Murray J. McAllister, PsyD

Date of last modification: April 15, 2013