Coping: Ideas that Change Pain

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

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

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

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

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

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

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

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

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

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

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

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

Author: Murray J. McAllister, PsyD

Date of last modification: 10-30-2015

Therapeutic Neuroscience Education: A New ICP Website Content Page

As an educational and public policy think tank, the Institute for Chronic Pain (ICP) brings together thought leaders from around the world to provide information about chronic pain and its treatments. We make every effort to provide academic quality information in ways that are also approachable to patients and their families. We also aim to bring this information to healthcare providers, third-party payers, and public policy analysts. We envision a day when all stakeholders in the field of chronic pain management have a scientifically accurate understanding of the nature of chronic pain and how best to treat it – a day when healthcare providers deliver and patients demand treatments that science has shown to be effective.

The information that we provide on our site meets various important criteria. These criteria are the following:

  • The information is of academic quality while at the same time being approachable by patients and their families.
  • The information is empirically (i.e. scientifically) supported by high quality research and appropriately referenced.
  • The information is unbiased by financial support from the pharmaceutical and medical technology industry.
  • The information is unbiased by any need to maintain discipline-specific traditions or positions of authority (i.e., no need to maintain a specific discipline’s “turf”).
  • The information is provided within a forum that allows for open, respectful dialogue and social connectedness.

By providing information that meets these criteria, we aim to provide accurate and trustworthy information about chronic pain and its management from an organization that is trustworthy, transparent and community-based.

In doing so, we hope to raise our cultural understanding of the nature of chronic pain to a level that is as accurate as the current state of science allows.

Our educational and public policy mission also has significant ethical implications. Care for chronic pain patients (or for patients with any health condition, for that matter) should be as effective as possible. When multiple treatment options exist for a particular condition, we maintain that treatment decisions should be guided by science – by the question of what’s most effective, regardless of other possible concerns, such as the profit-motive or tradition-bound practices. Similarly, patients and their families should educate themselves about the nature of pain and what treatments have been scientifically shown to be effective. However, patients and their healthcare providers have historically lacked a trustworthy and easily accessible source for such information. At the ICP, we aim to fill this gap and provide accessible information about the nature of chronic pain and how best to treat it. With such information, both healthcare providers and patients can improve their decision-making by relying on a scientifically accurate understanding of pain and its treatments. In these ways, we aim to raise the quality of care for chronic pain. It’s the right thing to do and, if successful, we might just change how we manage chronic pain for the better.

As stated, in pursuing these efforts, the Institute for Chronic Pain brings together thought leaders from around the world to provide this scientifically accurate and trustworthy information. Today, we announce a new content page to our website on Therapeutic Neuroscience Education, authored by Adriaan Louw, PT, PhD, CSMT. Adriaan is a leader in Therapeutic Neuroscience Education (TNE). A physical therapist by training, he is a frequent lecturer, a researcher, and an author of a number of patient-friendly books, such as Why Do I Hurt?, among others. He is also the CEO of the International Spine and Pain Institute, an educational seminar organization for healthcare professionals.

His piece on TNE fully meets our criteria for inclusion on the ICP website. It is scientifically accurate and yet accessible by patients, their families, their healthcare providers, and the third-party payers who pay for their care. Indeed, teaching people about pain — providing them with scientifically accurate yet easily understandable information about pain — lies at the heart of therapeutic neuroscience education.

Therapeutic Neuroscience Education is a relatively new therapeutic intervention therapeutic neuroscience educationthat aims to change patients’ perception of pain by providing them with a more accurate understanding of the nature of pain. Akin to a cognitive behavioral intervention, it employs verbal-based lessons along with visual illustrations and diagrams with the goal of changing how patients make sense of their pain. In other words, it helps patients to understand their pain in a more scientifically accurate and less threatening way. Once this more accurate understanding is achieved, patients are typically more willing to engage in therapies that have been shown to be effective.

Typically associated with physical therapy, TNE is actually an intervention that most any healthcare provider might pursue given sufficient training. With such an expertise, chronic pain management providers of all kinds might provide TNE while engaging in their own discipline-specific interventions. Thus, it might be considered a cognitive-based meta-therapy that can be provided at the same time as other therapies.

We appreciate Adriaan’s expertise and contribution to the ICP. Please read his important piece on the ICP website and talk to your healthcare providers about whether TNE might help you to manage chronic pain more effectively.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-7-2014

Finding Hope in Acceptance

At first thought, it might seem crazy to accept that your pain is chronic. When I bring it up with patients, many of them tell me, not without some irritation in their voice, “I’ll never give up hope of finding someone who can fix me!” Indeed, it’s common to think that accepting the chronicity of your pain is the same thing as giving up hope that you’ll ever get better. So, why in the world would you ever want to accept that your pain is chronic?

Contrary to what you might think, accepting that your pain is chronic is the first step in actually getting better. It opens up a whole new way of getting better, a way that takes into account the realities of your pain condition. As such, it’s a new and more realistic way to have hope.

To understand the point more clearly, let’s briefly review two different models of healthcare – two different ways that we get better when having an illness or injury. These two models are what we might call the ‘acute medical model’ and the ‘rehabilitation model.’ The latter is sometimes called the ‘self-management model.’ (For a more thorough review of these models of healthcare, click on this post here.)

Acute Medical Model

The acute medical model of healthcare is what most of us think of when we go to see a healthcare provider. When sick or injured, we go to a provider who determines what’s wrong and provides a treatment that cures us. The healthcare provider is an expert who usually knows more about the condition and the treatments than we do. The treatments themselves are usually medications or procedures that act on us. We don’t typically get better by doing things ourselves. Rather, it’s the treatments that get us better and we rely on healthcare providers to provide us with those treatments. Lastly, getting better in the acute medical model is usually thought of as getting cured. We return to our usual state of health — how we were before we became ill or injured.

Hope of getting better within the acute medical model lies in finding the right healthcare provider who knows what’s wrong and knows how to cure you. In this model, hope lies external to you. You find it in the expertise and treatments of a healthcare provider.

Now there’s nothing wrong with the acute medical model. It’s all well and good when we have a condition for which there actually is a cure. Indeed, it’s likely the best thing to do. But, what do you do when you have a condition for which there is no cure?

Rehabilitation Model

The answer to the question, of course, isn’t to give up hope and do nothing. There’s actually a different way of getting better. It’s the rehabilitation model of care. It requires, however, redefining how to get better and even redefining what it means to get better.

In the rehabilitation model of care, the emphasis is on what you, the patient, do to get better — not on what the healthcare provider does to get you better. Specifically, the focus is on the patient acquiring the abilities to make healthy changes, which, when done over time, have a positive impact on the chronic health condition that you have. These changes fall into two categories: a) changes in health behaviors, or what’s often referred to as lifestyle change, and b) changes in coping, or what’s often referred to as stress management. The goal of learning and engaging in these health behaviors over time is two-fold: you reduce the symptoms of the condition and you reduce the impact that the chronic health condition has on you. In other words, you get so good at self-managing the condition that it no longer is as problematic as it once was. As a consequence, you can move on with the rest of your life, engaging in the meaningful activities of life – such as work, family activities, social and recreational activities.

Notice that the rehabilitation model doesn’t promise a cure. The reason is that the conditions for which the rehabilitation model is best suited are those conditions that are chronic. They have no cure. Nonetheless, the patient does get better in very real and meaningful ways.

Notice too that hope gets redefined. It allows for having hope even when there is no cure. Finding a cure is not the only way to get better. Therefore there’s still hope. It’s just a different way to have hope, a hope that realistically takes into account the chronic nature of the condition you have, but nonetheless points to how to how you still can get better.

The conditions for which the rehabilitation model is best suited are chronic conditions, where there is no cure, such as chronic pain syndromes, diabetes, heart disease, and spinal cord injuries, among others.

Finding Hope in Acceptance

Acceptance that your pain is chronic is the first step in pursuing the rehabilitation model of care. Rehabilitation is hard work. It also takes time. You don’t do it if you think that a cure is just around the corner. Once you recognize, though, that your chronic pain really is chronic, it becomes your life-saver – or life-retriever. You start to get your life back. You learn how to self-manage your pain and you practice it to the point that you move on with the rest of your life. Your life doesn’t have to be about chronic pain.

Patients can keep their life on hold when they insist on finding hope only in a cure. They seek out appointment after appointment, attempting to find the right specialist who will know what to do to make their pain go away. Oftentimes, they seek out surgeries or interventional procedures that seem as if they might be a cure, but aren’t. Each time they seek out a new specialist, there is hope. Each time, though, it gets dashed because there really is no cure for chronic pain. Chronic pain really is chronic.

The point, here, is not a criticism of such patients. What we are describing makes sense if you think of healthcare as only the acute medical model. If we think of healthcare providers as specialists who fix us when sick or injured, it makes all the sense in the world to look for the right one who can do the job – even if you have to try one after another. It’s a hard lesson to learn when realizing that it’s only sometimes that healthcare providers act like a mechanic. A lot of the time, we have no fixes. So, again, I’m not judging when I describe patients who fail to accept that their pain is chronic.  We can all understand how it happens. They are trying to find hope in a cure.

What if, though, at the end of the day, the hope is really a false hope? It can become a vicious cycle that leads to depression and oftentimes more pain. Hope is found with each new procedure, but each procedure fails to cure the pain and so hope is dashed. If hope is defined by finding a cure, and if there really is no cure, then you are left helpless – and hopeless.

Maybe it’s best to find a new way to have hope.

You find it by accepting that chronic pain really is chronic. You accept that you are not going to get better by finding a cure. Rather, you accept that you are going to get better by learning to self-manage it. You learn how to make healthy changes in your life that, when done over time, reduce your symptoms and reduce the impact that chronic pain has on your life. You get so good at managing chronic pain that it is no longer the preoccupying problem that it once was. Your life consists of the stuff of life and chronic pain comes along for the ride, but remains in the side car.

It’s okay if you don’t know how to do it yet. Most patients have to learn how to do it. Oftentimes, I remind patients that you’re not born with the knowledge of how to self-manage pain successfully. People have to learn it. And it’s okay if you don’t know how and have to learn it.

What matters, though, is that you learn how. It’s possible to learn how to self-manage pain and do it successfully. People learn how to do it everyday in chronic pain rehabilitation programs. And you can too.

You just have to first accept that your chronic pain is really chronic.

(For more information, please see: “What is chronic pain?” or “Why the healthcare system refuses to accept the chronicity of chronic pain.”)

 

Author: Murray J. McAllister, PsyD

Date of last modification: 8-26-2013

What is rehabilitation?

People often equate ‘rehabilitation’ with physical therapy. It’s something a patient does following an injury or a complicated surgery. Still others think of ‘rehab’ as a treatment for alcoholism or drug addiction. A few years ago, a British soul singer had a hit single with the song “Rehab.” The lyrics were about whether to check herself into substance dependence treatment or not. ‘Rehabilitation’ can also be a form of vocational counseling. Injured workers re-learn how to go back to work in what’s called ‘vocational rehabilitation.’ Yet another example is the treatment that patients often get after they suffer a heart attack. Patients in such situations participate in ‘cardiac rehab,’ in which they learn healthy lifestyle changes, such as exercise, smoking cessation, dietary changes, weight loss, and stress management. Similarly, a traditional form of chronic pain management is a treatment called ‘chronic pain rehabilitation.’ Chronic pain rehabilitation programs are an interdisciplinary treatment that involves learning healthy lifestyle changes that reduce pain over time and learning improved ways of coping with the pain that remains chronic.

Why are all these different types of therapies called ‘rehabilitation’? What do they have in common?

Rehabilitation model of care

These questions imply that we should step back a bit, away from the particulars of these different treatments, and understand that all these treatments share an underlying model of care. It’s called the ‘rehabilitation model of care.’ Let’s explain what it is and, in doing so, it will be helpful to differentiate it from another model of healthcare, the acute medical model.

The rehabilitation model of healthcare focuses on what the patient can do to get better. Patients learn healthy lifestyle changes and ways of coping that lead to improved health when done over time. ‘Self-management’ is the term that refers to these health-improving changes. The rehabilitation model of care is typically best suited for chronic conditions, conditions for which there are no cures. Rehabilitation helps patients to get better by reducing the impact that a chronic condition has on their lives. That is to say, by learning how to successfully self-manage a chronic condition, patients can keep the condition in check and move on with the rest of their lives.

The rehabilitation model of healthcare differs from the acute medical model of care. The latter is the model of care that underlies the delivery of many medications and surgical procedures. Its emphasis is on what the healthcare provider can do for the patient. Its goal is to alleviate symptoms and, ideally, bring about a cure. It tends to be best suited for acute conditions, such as injuries and infectious illness.

Both models of care have their time and place. It’s safe to assume that no one is going to attempt to self-manage an acute appendicitis or try to find the right specialist to cure alcoholism. Rather, we focus on acute care procedures when having appendicitis and other curable conditions; we focus on rehabilitation and self-management when having chronic conditions, such as alcohol dependence.

Chronic conditions

The lynch pin that determines the type of care to pursue is whether the condition is chronic or not. If the condition is chronic, then there are no cures for it. So, rehabilitation is the preferred treatment approach. Sometimes, there are medications that can help to manage a chronic condition. Some examples are insulin for diabetes, or high blood pressure and high cholesterol medications for heart disease, and antidepressants and anti-epileptics for chronic pain. Sometimes, too, certain surgical procedures can keep a person with heart disease alive, but ultimately it still does not cure the underlying disease. So, when having a chronic condition, most patients are referred to some type of rehabilitation care where the focus is on what patients can do to minimize the condition and minimize its impact on them.rehabilitation

The rehabilitation model of care is used with some of the most significant health problems of our day: diabetes, heart disease, chronic pain, among others. With diabetes, it tends to be called ‘diabetes education’ or ‘diabetic self-management.’ The focus is on accepting the chronicity of the condition, dietary changes, weight loss, exercise, and stress and mood management. With heart disease, the approach is called cardiac rehabilitation. The focus is on accepting the chronicity of the condition, dietary changes, weight loss, smoking cessation, exercise, stress and mood management. With regard to chronic pain, the rehabilitation model of care is used in chronic pain rehabilitation programs. The focus of such programs is on accepting the chronicity of pain, exercise, relaxation therapies, and cognitive behavioral strategies that reduce pain, insomnia, stress, anxiety, and depression. The goals for any of these types of programs are for the patient to successfully self-manage their chronic condition and be able to live well despite having it.

Key differences between the acute medical and the rehabilitation models of care

The following table highlights the key differences between the acute medical model and the rehabilitation model of care.

Acute Medical Model of Care                          Rehabilitation Model of Care

Ideal of care is to provide a cure or ‘quick fix’ Ideal of care is to assist patients in making healthy changes (accept, adapt, compensate, cope, ‘move on’) and live well despite having the condition
Goal is to return to premorbid functioning (how the patient was prior to onset of the condition) Goal is to get better than how ever the patient is today
Hope lies in what the healthcare provider can do for the patient Hope lies in the patient taking back control
Power lies in the expertise of the provider (relies on an ‘external locus of control’) Patient becomes empowered (relies on an ‘internal locus of control’)
The therapeutic relationship tends to be hierarchical; the provider is the expert, active agent; the patient is a passive recipient of care The therapeutic relationship is less hierarchical; provider is like a coach who educates and motivates the patient; the patient is like an athlete who practices and implements the changes
Progress is qualitative: cured yes/no Progress is incremental: by degrees
Can have spectacular results, but also iatrogenic results Progress is slow; rehabilitation is relatively benign
Has a point of diminishing returns (i.e., the more procedures patients get for the same condition, the less likely they tend to be beneficial) The longer you do it and the more you do it, the better you get
Well-suited for acute injuries and illnesses Well-suited for chronic conditions

 Author: Murray J. McAllister, PsyD

Date of last modification: 1/11/2013