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Temporomandibular Joint Disorder https://www.instituteforchronicpain.org Mon, 30 Jan 2023 17:27:47 +0000 Joomla! - Open Source Content Management en-gb The Perfectionist and Chronic Pain: How to Cope with Pain Series https://www.instituteforchronicpain.org/blog/item/158-61the-perfectionist-and-chronic-pain-how-to-cope-with-pain-series https://www.instituteforchronicpain.org/blog/item/158-61the-perfectionist-and-chronic-pain-how-to-cope-with-pain-series 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 excessively 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

Perfectionism Roadblock Sign 300x254In each of these ways, perfectionism lends itself to coping poorly with chronic pain. Of course, 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.)

Date of last modification: 5-3-2015

Author: Murray J. McAllister, PsyD 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sun, 03 May 2015 12:32:48 +0000
A Healthcare Educational System https://www.instituteforchronicpain.org/blog/item/157-60a-healthcare-educational-system https://www.instituteforchronicpain.org/blog/item/157-60a-healthcare-educational-system

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

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

A healthcare delivery system

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

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

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

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

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

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

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

The role of the patient in coping with health problems

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

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

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

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

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

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

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

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

A healthcare educational system

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

Date of publication: April 12, 2015

Date of last modification: September 21, 2021

About the author: Dr. Murray J. McAllister is the founder and publisher at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Its mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Healthcare System Sun, 12 Apr 2015 15:44:55 +0000
The Biopsychosocial Nature of Pain https://www.instituteforchronicpain.org/blog/item/156-59the-biopsychosocial-nature-of-pain https://www.instituteforchronicpain.org/blog/item/156-59the-biopsychosocial-nature-of-pain

Contexts matter. The same joke might go over in very different ways, depending on whether it’s told by a comedian in front of an audience at a comedy club or told by an applicant in the middle of a job interview. An action done over and over again might be considered in one context an admirable example of perseverance in the face of adversity, whereas in another context it might be considered an exercise in futility.

Contexts matter in health too. The onset of a health condition might have two very different trajectories based on the contexts in which its onset occurs. Take, for example, a flu infection. It might be a nuisance for someone who is otherwise healthy, whereas the same infection might be disastrous for an elderly person or for a person whose immune system has been compromised due to undergoing chemotherapy. The overall presentation of flu in these cases is different because of the context. They each share a common precipitating cause – the influenza virus, but their illness is manifested differently due to the contexts that they don’t share.

In this light, we have to acknowledge the importance of context as a cause of health problems. In the common influenza examples described above, the context plays just as an important causal role as the influenza virus itself. Indeed, it’s the context that determines whether the flu will be either a nuisance or life threatening. In other words, the particularities of the person who has the health condition – the host, if you will -- have a causal influence on the overall ways that the condition presents.

Moreover, it’s hard to imagine a health condition that occurs in isolation of the person who has it. As such, we must acknowledge that health conditions almost always have multiple causes – the precipitating event and how it interacts with the particularities of the person who has it and experiences it.

The common reductionistic view of health conditions

In our society, we tend to forget this simple fact about health. We tend to equate a health condition with a single precipitating cause and explain the differences across people who have the same condition by asserting differences in the severity of the precipitating cause. So, in the influenza example above, we tend to explain differences in severity of illness by asserting that one person’s influenza infection (i.e., the precipitating cause) must be due to a more virulent strain than another person’s flu infection.

As a society, we take this stance all the time in chronic pain management. We assume that people with high levels of pain and disability always must have had more severe precipitating injuries than those who have less pain and disability. Of course, sometimes it is true. Someone who breaks her neck in a motor vehicle accident may result in a high level of pain and disability.

Reductionism leads to stigma

Yet, not everyone with pain, perhaps not even a majority, fit neatly into this simple equation that differences in pain and disability are always explainable by differences in the precipitating event or cause.

It’s not uncommon for people to have excruciating pain and severe disability from moderate injuries, such as a fall from a ladder or stairs, or mild injuries such as a muscle strain from lifting something or simply bending over to pick something light off the floor. It’s even common for people to have severe pain and impairment without a precipitating injury or illness at all.

These people don’t fit into our common assumption that severity of pain and disability must always correspond with severity of precipitating injury or illness. Unfortunately, what happens to these people is that they get stigmatized. Others invalidate them by doubting the legitimacy of their pain and disability. “All you did was to bend over and pick up your hammer off the ground,” they might say, “How can you have so much pain that you can’t work?”

But what if there is a rational explanation for their pain and disability?

Chronic pain is multifactorial

We need to recognize that pain is more complicated than we tend to think it is. There is always more than one factor that initially causes pain and always more than one factor that maintains pain on a chronic course. A good place to start to recognize these facts are in the context in which precipitating causes occur.

In healthcare, we tend to categorize the contexts in which health conditions occur in three ways. They are biological, psychological and social contexts.

The 'bio-' in the biopsychosocial

The biological contexts are the health of the person in terms of his or her bodily systems – the nervous system, the endocrine or immune systems, for instance. In the cases above, we described two people with the same precipitating event, an influenza infection, and saw how in one person the flu was a minor illness and in another it became a life-threatening illness because of differences in their immune systems. Whether healthy or compromised, the immune systems of each have an influence on the overall presentation of the illness. Indeed, in the case of the person with the compromised immune system, it is equal in importance to the precipitating cause of the influenza infection itself: it’s what makes the infection life threatening.

Similarly, the health of a person plays a role in the onset and chronic maintenance of pain. We know, for instance, that certain conditionsImage by Britta Preusse courtesy of Unsplash make the onset of pain more likely or the transition from acute pain to chronic pain more likely. Obesity is an example. Those who are obese are more likely to develop low back pain (Shiri, et al., 2009), hip and knee pain (Andersen, et al., 2003). Oftentimes, the cause of their low back, hip or knee pain gets attributed to osteoarthritis, but osteoarthritis isn’t necessarily a discrete illness. It’s typically considered overall wear and tear that comes with age, or in the case of those who are obese, the extra weight that those joints must bear. Thus, obesity can be a cause of a new episode of pain.

The overall health of the nervous system also plays a role in the development of chronic pain. We know that people who have been subjected to prolonged stress are more likely to develop a new episode of pain and develop chronic pain once pain occurs. Examples are people who have experienced trauma or who are depressed or anxious or experiencing other life stressors (Croft, et al., 1995; Linton & Bergbom, 2011; McBeth, et al., 2007; Pincus, et al., 2002; Raphael & Widom, 2011). It’s not because they are any more accident-prone or illness-prone. Injury or illness, we might say, is an equal opportunity event. Rather, it’s that nervous systems under prolonged stress tend to have lower thresholds for stimuli to provoke pain and tend to become increasingly sensitive once a new episode of pain occurs.

Obviously, there are countless facets about the overall health of people that can play causal roles in either the development of pain or in the transition from acute to chronic pain. These biological factors provide a context in which a precipitating event, such as a painful injury or illness, occurs and they influence how the pain of the precipitating event is manifested.

The 'psycho'- in the biopsychosocial

The psychological contexts are the psychological conditions and stressors that impact the nervous system, as well as health beliefs and behaviors that might impact the experience of pain and how people react to pain once becoming injured or ill. As suggested above, those who have struggled with trauma, anxiety or depression are at greater risk for developing pain and especially transitioning from acute to chronic pain once having an acute injury or illness. In other words, the state of the nervous system at the time of the acute injury or illness, especially when it’s under prolonged stress, can have a causal role in the development of subsequent chronic pain. In this way, we can rightly say that anxiety and depression can be one of the many multifactorial causes of chronic pain.

Indeed, in people who subsequently develop chronic pain, it’s actually quite common to have experienced trauma, anxiety and/or depression prior to the acute onset of pain (Knaster, et al., 2012; Magni, et al., 1994) and these emotional disorders interact synergistically with biological causes of pain to heighten the overall experience of pain (Domnick, Blyth, & Nicholas, 2012). These factors can tip the scale, as it were, to transition acute pain into chronic pain, following a precipitating painful injury or illness.

Other psychological factors, besides emotions, can exercise a causal role in the development of pain and chronic pain. Beliefs about pain and prior learning about pain can influence how pain is experienced and what we go on to do about it once having it (Arnstein, et al., 1999; Edwards, et al., 2011; Linton, Buer, Vlaeyen, & Hellsing, 2000; Nahit, et al., 2003). Some beliefs about pain and what we are supposed to do about it are helpful. They can reduce the intensity of pain or promote healing or recovery in the case of acute pain. They can also promote coping well with pain and remaining active in the case of chronic pain. Some beliefs, however, are not so helpful and can lead people to inadvertently experience more pain or do things that don’t promote recovery or good coping. Examples are catastrophizing, fear-avoidance beliefs, and engaging in illness behaviors (e.g., persistent resting and activity avoidance).

There are countless more psychological factors that can influence how pain and disability are manifested. Nonetheless, the point here is to recognize that the context in which pain occurs has an influence. It has a causal role – even if it’s not the initial or precipitating cause – in how we experience pain and what we go on to do about it once becoming injured or ill.

The ‘social’ in the biopsychosocial

The social contexts are those social conditions and stressors that can impact the nervous system or otherwise affect the trajectory of people’s health. These aspects widen the context further, beyond the biological and psychological make-up of the individual. They involve the make-up of the individual’s surroundings in terms of their relationships and social resources. We know that these factors too have a causal influence on health, pain included.

To illustrate the point, let’s take an all-too-common example that occurs within our field of chronic pain management. Suppose you see a woman who has chronic daily headache. Outside your clinic, she’s been treated for many years with medications and interventional pain procedures. She tells you that she’s been told she has cervicogenic headache, which means that her headache is thought to be due to structural problems in the cervical spine (i.e., neck). On MRI, she does in fact have modest degenerative changes, but these findings are common in people of her age. As such, we might consider this way of understanding her pain as a biomedical conceptualization. You, however, are a provider who understands chronic pain from a biopsychosocial conceptualization and so you ask, in your initial evaluation, about her psychological health as well as about her relationships, home life, financial stressors, and about where she lives in the community. At first, she’s a little taken aback. No one, she tells you, has asked about such things, at least not in the depth that you go into. She also doesn’t understand, she says, what all of this has to do with her pain. With budding trust, however, she begins to tell you that she has been involved in a domestically violent relationship for many years.

Might it not be reasonable to suppose that the persistent stress of physical, emotional and sexual violence plays a causal role in her headache pain? How could it not? Such prolonged stress would have to adversely affect her nervous system and thereby exacerbate her chronic pain. Even if, as has happened to her, we adequately treated any ‘cervicogenic’ aspects of her pain, wouldn’t it be insufficient to adequately manage her pain? We have to address the social causes of her pain condition as well.

Domestically abusive relationships are not the only type of persistently stressful relationship that can affect the trajectory of chronic pain. Care-taking relationships are also chronically stressful: care-taking an elderly parent with dementia, care-taking a spouse with cancer or a spouse disabled by a stroke, care-taking a child with special needs. Chronic marital conflict, short of domestic abuse, might be another. The absence of relationships can also be a chronic stressor in the form of loneliness that can influence the development of pain (Jaremka, et al., 2013).

These chronic social stressors affect the nervous system, likely making it more sensitive to stimuli, and thereby exacerbating pain, as well as sapping the ability of such people to cope with the pain that they experience. As such, social stressors have a causal influence on pain, even if they are not the initial precipitating cause.

We also know that poverty and living in dangerous neighborhoods can affect overall health as well the onset of pain and its chronicity (Gooseby, 2013; Ulirsch, et al., 2014). These social-based stressors adversely affect the nervous system and thereby adversely affect pain levels as well.

We know too that lack of access to adequate healthcare affects the trajectory of pain once having an acute injury or illness. Lack of insurance or being underinsured can often lead to emergency room based care or other stop-gap measures that are poorly suited for chronic conditions. Lack of availability of effective chronic pain management, even for those with adequate insurance coverage, can also play a role (Prunuske, et al., 2014). For example, the most effective form of chronic pain management, interdisciplinary chronic pain rehabilitation programs, is not widely available in the United States (Schatman, 2012). As such, many people with chronic pain simply do not have ready access to them and so must rely on less effective means to manage their pain. These social factors thus influence the pain levels of an individual’s condition.

Conclusion

Like all health conditions, pain is multifactorial. Meaning, multiple factors go into causing pain and maintaining it on a chronic basis. In our society and healthcare system, we tend towards understanding pain in reductionistic terms – understanding pain as solely the result of the event that precipitated it – an injury or illness. This reductionistic understanding leads to the belief that severity of pain and disability is solely the result of the precipitating event. So, if pain and disability are severe, there must have been a severe injury or illness. Most people’s pain or chronic pain, though, simply don’t fit neatly into this reductionistic model. They can have high levels of pain and disability in the absence of severe injuries or illnesses. As a result, they often get stigmatized: others doubt the legitimacy of their pain and disability. However, there is a rational explanation for these people’s pain and disability. Their pain, as with all people’s pain, is not solely caused by the precipitating event that started it all. Pain is multifactorial: there are multiple causal influences to pain in terms of the overall contexts in which injuries and illnesses occur. The biological, psychological, and social health of these contexts play a part in the onset and chronic maintenance of pain. These causes provide a rational, accurate and legitimate explanation for how pain and chronic pain become manifested in individuals.

(For more advanced study of the biopsychosocial nature of chronic pain, please see Gatchel, et al., (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624. doi: 10/1037/0033-2909.133.4.581)

References

Andersen, R. E., Crespo, C. J., Bartlett, S. J., Barthon, J. M., & Fontaine, K. R. (2003). Relationship between body weight gain and significant knee, hip and back pain in older Americans. Obesity Research, 11(10), 1159-1162.

Arnstein, P., Caudill, M., Mandle, C. L., Norris, A., & Beasley, R. (1999). Self-efficacy as a mediator of the relationship between pain intensity, disability and depression in chronic pain patients. Pain, 80(3), 483-491.

Croft, P. R., Papageorgiou, A. C., Ferry, S., Thomas, E., Jayson, M. I., & Silman, A. J. (1995). Psychologic distress and low back pain: Evidence from a prospective study in the general population. Spine, 20(24), 2731-2737.

Domnick, C. H., Blyth, F. M., & Nicholas, M. K. (2012). Unpacking the burden: Understanding the relationships between chronic pain and comorbidity in the general population. Pain, 153, 293-304.

Edwards, R. R., Cahalan, C., Mensing, G., Smith, M., & Haythornwaite, J. A. (2011). Pain, catastrophizing, and depression in rheumatic diseases. Nature Reviews Rheumatology, 7, 216-224. doi: 10.1038/nrrheum.2011.2

Gooseby, B. J. (2013). Early life course pathways of adult depression and chronic pain. Journal of Heath and Social Behavior, 54(1), 75-91.

Jaremka, L. M., Fagundes, C. P., Glaser, R., Bennett, J. M., Malarkey, W. B., & Kiecolt-Glaser, J. K. (2013). Loneliness predicts pain, depression, and fatigue: Understanding the role of immune dysregulation. Psychoneuroimmunology, 38(8), 1310-1317.

Knaster, P., Karlsson, H., Estlander, A., & Kalso, E. (2012). Psychiatric disorders as assessed with SCID in chronic pain: The anxiety disorders precede the onset of pain. General Hospital Psychiatry, 34(1), 46-52.

Linton, S. J & Bergbom, S. (2011). Understanding the link between depression and pain. Scandinavian Journal of Pain, 2(2), 47-54.

Linton, S. J., Buer, N., Vlaeyen, J., & Hellsing, A. (2000). Are fear-avoidance beliefs related to inception of an episode of back pain? A prospective study. Psychology & Health, 14(6), 1051-1059.

Magni, C., Moreschi, C., Rigatti-Luchini, S., & Merskey, H. (1994). Prospective study on the relationship between depressive symptoms and chronic musculoskeletal pain. Pain, 56(3), 289-297.

McBeth, J., Silman, A. J., Gupta, A., Chiu, Y. H., Morriss, R., Dickens, C., King, Y., & Macfarlane, G. J. (2007). Moderation of psychosocial risk factors through dysfunction of the hypothalamic-pituitary-adrenal stress axis in the onset of chronic widespread musculoskeletal pain: Findings of a population-based prospective cohort study. Arthritis & Rheumatism, 56, 360-371.

Nahit, E. S., Hunt, I. M., Lunt, M., Dunn, G., Silman, A. J., & Macfarlane, G. J. (2003). Effects of psychosocial and individual psychological factors on the onset of musculoskeletal pain: Common and site-specific effects. Annals of Rheumatic Disease, 62, 755-760.

Pincus, T., Burton, A. K., Vogel, S. , & Field, A. P. (2002). A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 27(5), E109-E120.

Prunuske, J. P., St. Hill, C. A., Hager, K. D., Lemieux, A. M., Swanoski, M. T., Anderson, G. T., & Lutfiyya, M. N. (2014). Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: A population-based study using 2010 NAMCS data. BMC, 14, 563.

Raphael, K. G. & Widom, C. S. (2011). Post-traumatic stress disorder moderates the relation between childhood victimization and pain 30 years later. Pain, 152(1), 163-169. Doi: 10.1016/j.pain.2010.10.014

Schatman, M. E. (2012). Interdisciplinary chronic pain management: International perspectives. IASP Pain Clinical Update, 20(7).

Shiri, R., Karppinen, J., Leino-Arjas, P., Soloviev, S., & Viikari-Juntura, E. (2009). The association between obesity and low back pain: A meta-analysis. American Journal of Epidemiology, 171(2), 135-154. doi: 10-1093/aje/kwp356

Ulirsch, J.C., Weaver, M. A., Bortsov, A. V… & Mclean, S. A. (2014). No man is an island: Living in a disadvantaged neighborhood influences chronic pain development after motor vehicle collision. Pain, 155(10), 2116-2123. Doi: 10.1016/j.pain.2014.07.025

Date of publication: 3-1-2015

Date of last modification: 3-21-2021

Author: Murray J. McAllister, PsyD, LP 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Biopsychosocial Sun, 01 Mar 2015 19:03:24 +0000
Why We Do What We Do https://www.instituteforchronicpain.org/blog/item/155-58why-we-do-what-we-do https://www.instituteforchronicpain.org/blog/item/155-58why-we-do-what-we-do

The Institute for Chronic Pain has a new content page on our website entitled: Why Healthcare Providers Deliver Ineffective Care. As is our custom, we announce such additions to the website on our blog and provide a little introduction to it. The content on this new page of the website is particularly important to me because providing content like it is one of the reasons why I founded the Institute. It’s not too far of a stretch to say that it’s why we do what we do. By way of introduction, then, I’d like to explain.

I founded the Institute for Chronic Pain for a number of reasons, but one of them continues to this day. Indeed, I am reminded of it most everyday.

The reason is others and mine persistent frustration over what seems like an almost endless delivery of ineffective healthcare within the field of chronic pain management. At the time of the Institute’s formation, in late 2012, the previous decade had seen an exponential increase in the delivery of procedures and therapies for chronic pain, most notably, spinal injections, spinal surgeries, and the long-term use of opioids. The use of these procedures and therapies had far surpassed the field’s traditional and empirically-supported treatment – the interdisciplinary chronic pain rehabilitation program, which had been the mainstay of treatment for twenty or thirty years by the end of the last century. For all those previous years, patients had benefited from such programs and with each decade the field had published more studies and meta-analyses demonstrating their effectiveness. In the mid-1990’s to the early 2000’s, the field began to change and change rapidly. The use of spinal injections, spinal surgeries, and opioid medications became prolific, far exceeding the use of interdisciplinary chronic pain rehabilitation programs. As a result, interdisciplinary chronic pain rehabilitation programs began to close their doors in great numbers for lack of patients.

One might consider such a sea change within the field of chronic pain management a natural progression of the field: due to scientific advances and discoveries, one set of therapies came to predominate over an older form of therapy. However, it wouldn’t be accurate.

The older form of therapy, interdisciplinary chronic pain rehabilitation programs, remained (and still remains today) the more empirically-supported treatment. In other words, such programs remain the more effective treatment and yet, as a field, we routinely deliver care that is not as effective as we could deliver – we routinely provide spinal injections, surgeries and opioid medications to patients with chronic pain, and tend to forego recommending the more effective option of interdisciplinary chronic pain rehabilitation programs. While recognition of this problem is growing and gaining momentum, this state of affairs continues to this day.

Typical responses by the healthcare system: empirical-based healthcare

Many in the field, who recognize this problem, attempt to resolve it by focusing on changing the practice patterns of providers – encouraging them to recommend less orthopedic-related care, such as spinal injections, spinal surgeries, and opioid medications, and instead recommend more nervous system-related care, such as interdisciplinary chronic pain rehabilitation.

Specifically, leaders in the field attempt to educate and persuade healthcare providers to make recommendations based on what the available scientific research tells us is most effective. This ideal for guiding the practice of healthcare is called ‘empirically-based healthcare.’ The word ‘empirical’ in this context means scientific and phrases such as ‘empirically-based’ or ‘empirically-supported’ when used in the context of treatments means that the scientific evidence supports the effectiveness of the given treatment.

This goal to have the scientific evidence for or against treatments guide our recommendations is important. It should lead the field to make more recommendations for those treatments that science tells us are effective and lead us to make less recommendations for treatments that have been shown to be less effective. Indeed, who wouldn’t argue that we should be focusing our care and resources on treatments that are the most effective?

Health insurance companies and professional provider organizations

Typically, health insurance companies or different types of provider organizations lead the drive to change provider practice patterns within the field of chronic pain management. Insurance companies periodically institute policy changes that encourage the use of empirically-supported treatments and various professional organizations develop guidelines for what constitutes appropriate care for different chronic pain conditions. In my geographical area, for instance, local insurance companies have twice attempted to mandate that patients receive non-surgical second opinions, such as psychological evaluations for rehabilitation care, before obtaining spine surgery. I personally have also served on two different guideline development committees for the management of back pain.

While admirable, these attempts never succeed in producing a significant change in the practice patterns of healthcare providers. They fight a steep uphill battle. Many of the forces for maintaining the status quo of providing ineffective healthcare on a widespread basis remain powerful and complicated. They are difficult to resolve. We discuss many of these problems in the new content page of our website.

Despite these problems, the actions of insurance companies and professional organizations are necessary. For after all, providers are an important part of the healthcare equation. They are the ones who make the recommendations and deliver the care. It’s obviously important therefore that they become convinced to recommend care that science has shown to be most effective.

While necessary, a sole focus on changing provider practice patterns is not sufficient to bring about widespread change in the field. Such a focus leaves out the role of patients who, in large measure, have a say in the care they receive. Any change to the field of chronic pain management must also focus on changing societal beliefs about chronic pain and how to best treat it.

The role of the Institute for Chronic Pain

To meet this need, we developed the Institute for Chronic Pain. While insurance companies and professional organizations play a necessary role in attempting to change the ‘supply’ side of care (i.e., what tends to get recommended by healthcare providers), the Institute for Chronic Pain focuses on changing the ‘demand’ side of care (i.e., what patients and their families expect and want when seeking chronic pain management).

Why is the latter important?

Through much of my career I have worked within interdisciplinary chronic pain rehabilitation programs. I have evaluated countless patients for such programs and a common experience upon evaluation and subsequent recommendation of the treatment is that patients refuse it.

Now there often are many reasons why people can’t or won’t pursue such a recommendation, but a common one is that the recommendation to participate in an interdisciplinary chronic pain rehabilitation program simply doesn’t make sense to them. It’s understandable given our societal belief systems about the nature of chronic pain. Many in our society understand chronic pain as something that is the result of a long-lasting orthopedic injury and as such they think that the most effective approach is to pursue orthopedic-related interventions, such as injections or surgery, that treat the spine or other joint that is the site of pain. As a result, given these societal beliefs, patients can come to refuse to participate in an interdisciplinary chronic pain rehabilitation program, in favor of seeking less effective orthopedic-related care – spinal injections, spinal surgery, and use of opioid pain medications.

To this problem, we have been actively attempting to produce content that explains how chronic pain is typically a nervous system-related condition, not an orthopedic condition, and so therefore should be mostly treated through interdisciplinary chronic pain rehabilitation. We have reviewed how the field is in the process of a paradigm shift, a change in how experts in the field understands the nature of chronic pain and what the field considers to be the most effective treatments for it. We have reviewed the contrasting ways of understanding chronic pain and have reviewed how basic science indicates that chronic pain is the result of a nervous system condition called central sensitization. We have reviewed and clarified the relationships between chronic pain and a number of the most common complicating conditions, such as anxiety, depression, trauma, insomnia, fear-avoidance, and catastrophizing; in so doing, we have explained that these conditions commonly complicate the course of chronic pain because they too are nervous system-related conditions. We have reviewed how interdisciplinary chronic pain rehabilitation focuses on reducing central sensitization and thereby such programs reduce the typical cause of pain and suffering. On our social media sites, such as Facebook, Twitter, and Linkedin, among others, we post (on an almost daily basis) news reports on published studies of the relationship between chronic pain and the nervous system, particularly the brain. In all, the Institute for Chronic Pain devotes much of its resources to changing our societal beliefs about the nature of chronic pain and how best to treat it. Our aim is to bring our common societal understandings into line with the consistent findings of the basic and applied science of pain.

In short, as our mission states, we aim to change the culture of how chronic pain is managed.

In response to these efforts to change our societal understanding of the nature of chronic pain, there remains a common reaction to which we, as the Institute for Chronic Pain, have not yet responded, at least not until now. Within the public at large, but also within the clinic when reviewing the above information with individual patients, there remains doubt that orthopedic-related care, such as spinal injections, surgeries and use of opioids, are less effective than interdisciplinary chronic pain rehabilitation. The doubt continues due to the following reason: people don’t believe it simply because orthopedic-related therapies are so much more commonly performed than interdisciplinary chronic pain rehabilitation therapies. If what we say is true – that science tells us that orthopedic-related therapies are less effective, then it would mean that the field of chronic pain management has gotten it absurdly wrong. But this conclusion, for many, seems too hard to believe. In other words, the difference between how many in the field actually practice and how science informs us that we should practice seems too incongruous to be believable.

Understandably, then, the question thus remains: ‘How could the healthcare system have gotten it so wrong? These therapies (spinal injections, spine surgeries, opioid medications) just simply have to be the most effective treatments or healthcare providers wouldn’t recommend them as often as they do.’

To this question, we put together and published the new webpage, entitled: Why Healthcare Providers Deliver Ineffective Care.

Author: Murray J. McAllister, PsyD

Date of last modification: 1-20-2015

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Chronic Pain Rehabilitation Programs Wed, 21 Jan 2015 06:39:35 +0000
Ending the Stigma of Pain: A New ICP Webpage https://www.instituteforchronicpain.org/blog/item/154-57ending-the-stigma-of-pain-a-new-icp-webpage https://www.instituteforchronicpain.org/blog/item/154-57ending-the-stigma-of-pain-a-new-icp-webpage

The stigma of chronic pain is personally hurtful. It is a negative judgment of you that others make. Specifically, stigma occurs when others judge you simply for being who you are – someone with chronic pain. You are looked down upon because of it. As such, stigma is more than hurtful. It’s shaming.

As we have seen from previous posts, stigma can also prevent those with chronic pain from getting the help that is most effective – chronic pain rehabilitation programs that focus on helping patients to successfully self-manage pain and live well despite having pain. Understandably, people with chronic pain don’t want to be blamed for their condition and so it is common to defend against the shame and blame of stigma by holding onto the belief that there is nothing they can do about their pain. The implication is that if there is nothing that they can do about it, they can’t rightfully be blamed for it. As a consequence, stigma can come to prevent people with chronic pain from acknowledging that it is possible to self-manage pain successfully – that there is something they can do about it. So, they come to be reluctant to participate in a treatment that teaches them how to do it.

Ending stigma thus has paramount importance. All stakeholders in the field have to take it on and foster change in how those with chronic pain are seen by society. We all need to find ways to overcome the negative judgment that society places on those with chronic pain.

To this end, the Institute for Chronic Pain (ICP) site has a new webpage on how to end the stigma of chronic pain. Using lessons from the past, we discuss ways to approach stigma and resolve it on both a personal level and, perhaps, even on a societal level.

Please visit our latest webpage: How to End the Stigma of Pain.

Author: Murray J. McAllister, PsyD

Date of last modification: 12-29-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stigma Mon, 29 Dec 2014 15:10:20 +0000
Follow Us Now on Twitter https://www.instituteforchronicpain.org/blog/item/153-56follow-us-now-on-twitter https://www.instituteforchronicpain.org/blog/item/153-56follow-us-now-on-twitter

You can now follow the Institute for Chronic Pain on Twitter! Check us out at:

On all our social media sites, we add content daily on news, blogs, and sites that are related to chronic pain.

As always, you can still follow us on FacebookPinterest and Linkedin.

Following us on one of our social media sites is one of the best ways to support the work of the Institute. We appreciate your support!

Author: Murray J. McAllister, PsyD

Date of last modification: 12-7-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) News & Recent Events Sun, 07 Dec 2014 08:16:08 +0000
Stress, Inflammation and Chronic Pain https://www.instituteforchronicpain.org/blog/item/152-55stress-inflammation-and-chronic-pain https://www.instituteforchronicpain.org/blog/item/152-55stress-inflammation-and-chronic-pain

People with chronic pain know that they tend to have a pain flare when they are under stress. They are, however, sometimes sensitive to acknowledge it aloud for fear that others might think that their pain is all in the head. Nonetheless, the fact that stress makes pain worse is entirely normal and common. It is a natural product of how we are made.

In fact, stress has a much more significant role in the production of pain than simply making it worse. The development of pain itself, from acute injuries or illness to the long-term maintenance of chronic pain, incorporates what we call the stress response. In other words, were it not for our stress response, we would not have pain as we know it. To review the remarkable and significant role that the stress response has in pain, we would require much greater time and space than this blog post allows. [For a good review within the professional literature, please see Chapman, Tuckett, & Song (2008)].

Instead, in this post, let’s look at one way stress exacerbates pain and leads to what we typically call a ‘pain flare.’ We’ll focus our attention on a particular aspect of the stress response, which leads to increased pain: inflammation. Specifically, let’s review how stress triggers our normal and natural stress response, which subsequently produces inflammation that, in turn, makes pain worse.

The immune system

The immune system is our natural defense system. It works in conjunction with our nervous system and our endocrine (or hormone) system. Traditionally, we have always divided these systems up as if they are three separate systems, but we now know that they do not operate independently of each other. So, whenever we discuss the functioning of one system, as we are today discussing the immune system, we have to keep in mind that structures in the brain, the rest of the nervous system, neurotransmitters, and hormones are almost always also at play when the immune system functions as it does.

So what does the immune system do? Traditionally, we have understood the immune system to have a defensive role in response to injury or infection. When injury or infection occurs, the immune system produces inflammation. Inflammation is a catchall term used to describe a number of different types of chemical messengers and cells that fight off the infection or prepare for healing. For instance, it’s what makes us well when we are sick by fighting off viral or bacterial infections.

Many years of basic science in psychology and biology have allowed us to now know that inflammation also plays a role in changes in mood and behavior, both of which can also allow for fighting off infection or responding to injury with damage control (Sternberg, 2001). In more general terms, these psychological responses are also responses to danger. Indeed, we now think of the immune system, in conjunction with the nervous system and the endocrine system, as part of a three way response to danger, or what we call the stress response.

Stress response

The stress response is our natural cognitive, emotional, motivational, bodily, behavioral and social response to a danger, or what we might more generically call a ‘stressor.’ Take for example, thousands of years ago, we would have been likely living on the savannas of Africa and we would have faced various threats, such as the possibility of being attacked by lions.

In response to the stressor of a lion attack and its resultant injuries, we naturally and automatically react, without conscious awareness or intention, with our built-in stress response. A quick review of the multifaceted – or biopsychosocial – aspects of this stress response are the following:

  • Cognitive responses: Heightened focus on the danger, rapid learning about the danger and subsequent acute memory of the stressor, among others
  • Emotional responses: Heightened alarm, anger and/or fear, increased sense of social belonging, among others
  • Motivational response: Heightened drive to react, increased energy
  • Bodily responses: Among others, increased muscle tension, heart rate, blood pressure; increased glucose in bloodstream; increased immune response
  • Behavioral and social responses: fight-or-flight, and tend-and-befriend (i.e., some combination of taking on the danger or getting away from it and/or joining together, coming to the rescue, and protecting or caring for one another and wanting to be cared for) (Taylor, et al., 2000)

In later posts, we’ll discuss in more detail the various aspects of the stress response, but this quick overview is important for two reasons.

First, and foremost, we see clearly the larger context in which the immune system functions. Its defensive function is part of a greater whole and the whole is the protective, or defensive, function of the stress response. From here, we can also see how the stress response is a whole contingent of automatic responses, from the microscopic to the macroscopic, that occurs when we are threatened by danger. In other words, it is the stress that the human organism undergoes when threatened.

Second, we see that in our society we tend to categorize these microscopic to macroscopic responses under particular headings, such as those that are biological, those that are psychological, and those that are social. We subsequently tend to think that these categories represent actually different things and then begin to wonder how they are connected. However, these categories do not represent distinct kinds of things. They are heuristic categories that reflect different aspects of the same kind of thing, the human organism, or person. In this way, we no longer wonder how “the mind” is connected to “the body,” as if they are two separate kinds of things. No, the cognitive, emotional, motivational and social aspects of the stress response occur within the same kind of thing as the biological and behavioral aspects of the stress response do. That is to say, they occur within a person, not some separate entities called “a mind” or “a body.” As such, in science and healthcare, we typically no longer refer to this mental/physical or mind/body distinction, but rather refer to these aspects of a person with the term ‘biopsychosocial.’

Inflammation

So, the stress response involves many natural, automatic responses and one of them is the immune system kicking into high gear to produce inflammation (Kiecolt-Glaser, et al., 2002). This response clearly makes sense. If we go back to the example of a lion attack, we will have a greater chance of surviving if our immune system is functioning in high gear as it fights off any infections from the scratches or bites that we might get.

This peak performance is the product of the immune system working in conjunction with the sympathetic nervous system and the endocrine (or hormone) system. Specifically, different structures in the brain, associated with the fight-or-flight response, send messages via a highway of nerves to the pituitary and adrenal glands, which then produce hormones such as cortisol and adrenaline (also known as epinephrine). These are often called ‘stress hormones’ and they are responsible for getting us ramped up. For instance, cortisol prevents insulin (another hormone that’s produced in the pancreas) from working well and so glucose (i.e., sugar) increases in the bloodstream, giving us increased energy. Initially, these hormones also start the immune response in the form of white blood cells and what are called cytokines. We call this immune system response ‘inflammation.’

Inflammation is what occurs when, upon injury, the injured area becomes red, swollen, and sensitive to the touch. The redness and swelling is our immune system at work, the white blood cells and cytokines engaging in their protective function, engaged in damage control. The sensitivity comes because the immune response irritates the nerves in the area. At this stage, this irritation is good because it serves a protective function. If the injured area is sensitive to the touch, it is going to prevent us from using it or poking it too much or otherwise re-injuring it. Subsequently, we are motivated to protect or guard the area. We’ll come back to this point.

At this time, there are also cytokines in the brain too intermingling with its hormones and neurotransmitters. If the injury or infection is severe enough or widespread enough, this mix of chemicals in our nervous system, including the brain, further lead to a run down feeling, which we call ‘malaise.’ It’s the ‘blah’ feeling we have when sick: run down, achy, fatigued, and unmotivated to do anything but lay around and rest. We are also motivated at this stage to need others, associate with them, and depend on them for help. In other words, we feel upset, perhaps even a bit abandoned, when others ignore us when we are sick or injured. We’ll come back to this point too.

After some time, these processes unfold and the threat passes (for example, microscopically, the infection and injuries from the lion attack have been successfully warded off and subsequently healed, just as we might have banded together, at a macroscopic level, to fight off the actual attack in the first place). Subsequently, cortisol tells the brain to start turning off the stress response.

The whole process is remarkable, even amazing. At all the multifaceted levels, from the microscopic to the macroscopic, we are made to survive. The stress response is an almost beautiful, elegant way to optimize our chances of survival when threatened by danger.

We still respond to threats, or stress, with the stress response

Admittedly, lions don’t attack us much anymore. With some few exceptions (such as the occasional natural disaster or bad car accident, or the activities of soldiers and first responders), our life and limbs don’t get threatened very often in our present day and age. We still, however, face threats.

The threats that we most commonly face nowadays are psychological and social in nature. They are the death of a spouse or child or other family member or friend. They are the loss of a job and subsequent loss of income. They are the bankruptcies and home foreclosures. They are the overly critical bosses or the fights with a sister or brother or when best friends move away. They are a son or daughter joining the armed forces and going off to war. They are the occasions when a family member comes down with a serious illness, say, cancer. They are the times when we have to live with a chronic illness, such as chronic pain. These kinds of stressors are not threats to life or limb, on the order of a lion attack or combat, but nonetheless they are threats. They are threats to our livelihood and well-being.

As such, we are hard-wired to respond to such stressors with the stress response.

Moreover, we also have the ability to anticipate the above-noted psychological and social threats. That is to say, the kinds of threats listed above are not the only kinds of threats that we commonly face. We also face the threat of anticipating the potential for those kinds of stressors.

We call it anxiety. It is the worrying or ruminating or fretting about the possibility that we face any of those threats listed above – the loss of a job, the loss of an income, the home foreclosure, the overly critical boss, the well-being of our loved ones, the loss of our health, the living with pain and all the problems that occur as result.

Human beings have an amazing capacity to worry about everything that could go wrong. In a sense, it’s a form of the stress response, preparing us for danger. However, anxiety or worry is what happens when our stress response has become stuck in the ‘on’ position. When anxious, in other words, we continue to prepare for danger or threat even when there is no actual threat, just the possibility of one.

Either way – whether we are actually living through a stressor or worrying about the possibility of a stressor, we still automatically, and without much conscious intention, still respond to such threats with the stress response.

Stress and inflammation make pain worse

If you have a chronic pain condition, you know that stress makes it worse. From here, we can see why. When experiencing a stressful event like those listed above or when worrying about the possibility of such a stressful event, you automatically, and without conscious intention, react with the stress response. Your immune system, in conjunction with your nervous system and endocrine system, puts out inflammation in response to the real or perceived threat. This inflammation causes irritation to your nerves, including the nerves in the area of your chronic pain. As a result, the nerves become more sensitive, just as they are supposed to do when the immune system is engaged in the stress response. With the nerves more sensitive due to the increased inflammation, they subsequently require less stimuli to cause pain and you experience increased pain with your normal activities.

For instance, suppose that you have chronic low back pain and usually it doesn’t hurt to get out of a chair. However, when under stress, the stress response leads to higher levels of inflammation, which make the nerves in your low back more sensitive. As a result, the stimuli involved in the act of getting out of a chair makes your low back painful when ordinarily you can get out of a chair without pain at all. What you experience in such instances is the all-too-common exacerbation of pain due to stress.

Notice that your immune system is doing exactly what it is made to do when under threat. While problematic, it is normal and common.

It can become increasingly problematic when the stressor remains unresolved and subsequently goes on for some time. The threat is on-going and so the stress response continues unabated. The level of inflammation becomes higher and higher. The nervous system as a whole becomes more sensitized. As a result, widespread inflammation can lead to both increasing pain and more widespread pain, in the form of body aches.

Moreover, as we saw above, widespread inflammation can lead to malaise, an overall 'blah' feeling. You become fatigued and unmotivated to do anything but rest. In addition to higher levels of pain or possibly even more widespread pain, you are now not feeling well. You feel like you have the flu, but without the flu.

At the same time, your needs for others increase. It is the result of the tend-and-befriend aspect of the stress response. These needs are the needs for others to provide comfort and care. You don’t want to be left alone and, if you are, it’s like adding insult to injury.

Now, some people might not want to admit that such emotional and social needs arise when not feeling well. For after all, we have a sense from society that we are supposed to remain strong and independent. If we don’t, we have a good likelihood that we'll face stigma.

It’s important to recognize, however, that such emotional and social needs are built right into us when the stress response kicks in and, particularly, when it goes on for some time. It’s important to understand that you are not just being weak. The stress response is doing exactly what it is supposed to do in response to a threat against your well-being.

It’s okay to acknowledge it. It is a common and natural consequence to stressors, or threats.

What you can do about chronic pain

With that said, however, it’s also important that you recognize that you are not helpless to it.

Chronic pain rehabilitation programs are a traditional form of chronic pain management that focuses on reducing the stress response in the presence of pain. Through multiple therapeutic modalities, they focus on reducing the reactivity of the nervous system and teaching you how to maintain this reduced reactivity of the nervous system, which, in turn, leads to less inflammation and less pain, greater energy and motivation, and greater abilities to independently do what you want to do. The Institute for Chronic Pain has a number of resources that provide information on chronic pain rehabilitation.

A brief list follows:

References

Chapman, C. R., Tuckett, R. P., & Song, C. W. (2008). Pain and stress in a systems perspective: Reciprocal neural, endocrine and immune interactions. Journal of Pain, 9, 122-145.

Kiecolt-Glaser, J. K., McGuire, L., Robles, T. R., & Glaser, R. (2002). Emotions, morbidity, and mortality: New perspectives from psychoneuroimmunology. Annual Review of Psychology, 53, 83-107.

Sternberg, E. M. (2001). The balance within: Science connecting health and emotions. New York: W. W. Freeman.

Taylor, S. E., Klein, L. C., Lewis, B. P., Gruenewald, T. L., Gurung, R. A., & Updegraff, J. A. (2000). Biobehavioral response to females: Tend-and-befriend, not fight-or-flight. Psychological Bulletin, 107(3), 411-429.

Author: Murray J. McAllister, PsyD

Date of last modification: 5-10-2017

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Inflammation Mon, 24 Nov 2014 08:06:51 +0000
Why the Stigma of Chronic Pain Remains https://www.instituteforchronicpain.org/blog/item/149-52why-the-stigma-of-chronic-pain-remains https://www.instituteforchronicpain.org/blog/item/149-52why-the-stigma-of-chronic-pain-remains

Attempts to challenge the stigma of chronic pain often fail. Despite arguments from providers and patients alike, stigma remains a persistent problem. 

Attempts to challenge stigma typically defend those with chronic pain by denying that chronic pain has anything psychological about it. Of course, there are various ways to assert this argument, but the most common is apt to be some version of the ‘It’s not in my (or their) head.’ As such, the initial premise of the argument is the denial that there is any relationship between chronic pain and any potential psychological aspects of it. The next premise tends to assert that chronic pain is instead a medical condition. The conclusion is that we shouldn’t stigmatize those with chronic pain just as we don’t stigmatize anyone else with a bona fide medical condition.

More succinctly, society tends to see the psychological aspects of chronic pain as worthy of judgment and so we, as a field, tend to attempt to get rid of the stigma of chronic pain by trying to get rid of the psychological aspects of chronic pain.

How often do you hear patients and providers alike asserting that the patient has ‘real pain,’ which is immediately followed by the denial of 'it is not in my (or his or her) head’? In effect, the argument assumes that real pain has no psychosocial aspects to it at all. With this premise, the argument attempts to refute stigma.

At best, this argument and ones similar to it only temporarily quiet the stigma that our society places on those who are living with chronic pain.

The reason, I think, is that the premise that chronic pain can be void of anything psychological is false. As much as we might deny it, chronic pain is in part a psychological condition. Most people know it too, which is why the stigma of chronic pain keeps coming back.

The experience of pain is the product of the severity of any condition that might underlie the pain, the sensitivity of the nervous system, and how well the person with pain is coping. Coping is inherently a psychological issue. The sensitivity of the nervous system is also a psychological issue.

A denial of these realities only works for so long. Reality has a way of reappearing.

Try as we might, then, we can’t get rid of the psychological aspects of chronic pain. Chronic pain just is one of those health conditions that walks on both sides of the fence: it is inherently a condition that has both medical and psychological aspects.

What thus becomes clear is that the essence of the problem of stigma when it comes to chronic pain is that as a society we tend to stigmatize all things psychological and so by association chronic pain becomes stigmatized too.

So, what do we do if we want to get rid of the stigma for those living with chronic pain? Maybe we stop doing it in a roundabout way and hit it head-on. That is to say, let’s stop trying to get rid of stigma by trying to rid chronic pain of its psychological aspects. Rather, let’s try to get rid of stigma by challenging this association between stigma and all things psychological.

Why is having a condition that’s in part psychological in nature so bad? Why do we assume that it is worthy of criticism or judgment? Like many things in life, it can be hard to cope with chronic pain. Why must someone who is struggling to cope with chronic pain be shunned?

Compassion seems a much more appropriate response.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-26-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Stigma Sun, 26 Oct 2014 19:26:31 +0000
All or Nothing Thinking: How to Cope with Pain Series https://www.instituteforchronicpain.org/blog/item/148-51all-or-nothing-thinking-how-to-cope-with-pain-series https://www.instituteforchronicpain.org/blog/item/148-51all-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

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) All or Nothing Thinking Mon, 13 Oct 2014 20:30:41 +0000
A Webpage Worth the Read https://www.instituteforchronicpain.org/blog/item/147-50a-webpage-worth-the-read https://www.instituteforchronicpain.org/blog/item/147-50a-webpage-worth-the-read

Those of you who are connected to one of our social media sites know that we tend to post daily on the latest news and research in the field of chronic pain management. We recently came across a description of cognitive behavioral therapy for chronic pain on the web, which we initially thought we’d send out on one of our daily posts. After finding myself reading it for a second time, however, I thought that it was too good to simply send out on social media without more comment than the usual line or two of introduction that we tend to provide.

The webpage is Dr. Christopher Pither’s piece ‘Cognitive Behavioural Approaches to Chronic Pain.’ It’s part of the Wellcome Trust’s website on pain that originally accompanied an exhibition at the Science Museum in London, entitled ‘Pain: Passion, Compassion and Sensibility.’ The website overall is also well worth reviewing, containing webpages on an eclectic range of topics, including scientific research on pain, therapies for pain, the history of how we have conceptualized and treated pain in the past, and cultural issues surrounding pain. All of it is thought provoking as well as useful information to know.

As indicated, Dr. Pither’s article itself is entitled ‘Cognitive Behavioural Approaches to Chronic Pain.’ It is simply the best and most concise description of cognitive behavioral therapy for chronic pain that I have so far come across on the web.

He opens the piece with a compassionate, yet scientifically accurate, description of how chronic pain develops. He reviews the many and complex variables involved. I especially appreciate how he sticks to what the scientific data tell us while at the same time remaining empathic and non-stigmatizing. The importance of this approach to his writing lies in the scientific data: while painful acute injuries and illnesses occur to all of us, likely at a roughly equal rate across all people, what predicts the transition from acute pain to chronic pain are psychosocial factors. To put it another way, those who are at most risk of developing chronic pain once an acute accident or illness occurs are those whose central nervous systems have been previously up-regulated for psychosocial reasons. Now, of course, these consistent scientific findings do not mean that people with chronic pain are to be blamed for their condition. It is simply to assert a common truth that we all know, if we consider it for a bit, which is that the overall context in which an acute injury or illness occurs matters. If an upper respiratory infection occurs in a person whose immune system is already compromised, then that upper respiratory infection will likely take a much different course than if the same infection occurred in someone whose immune system is not already compromised. Similarly, if an acute painful injury or illness occurs in someone whose nervous system is already up-regulated, then the pain is likely to take a different course then if it occurred in someone whose nervous system is not up-regulated. Namely, the pain has a higher likelihood of continuing past the normal healing process of the original acute injury or illness, thus becoming chronic pain. Dr. Pither acknowledges such a scientific based understanding of the development of chronic pain, but does so with compassion and empathy. For after all, that is what people with chronic pain deserve.

All the stakeholders in the field of chronic pain management needs more of this kind of discussion. Whether we are provider, patient, family member, or policy analyst, we have yet to figure out a way to consistently be able to talk about the real psychosocial aspects of chronic pain without raising the specter of stigma. Indeed, all too often, we try to get rid of stigma by denying all the inherent psychosocial aspects of chronic pain. We do so, though, at our own peril. When we deny a major aspect of a health problem in order to resolve a social problem, like stigma, we are bound to have poor outcomes in the management of that health condition. Imagine the cardiovascular field attempting to successfully manage heart disease if its psychosocial components were off limits to discuss and in fact were denied as unrelated. Whether as patient or provider, the management of heart disease would fail if we couldn't discuss the role of smoking, lack of exercise, obesity, poor nutrition, depression, and stress. Similarly, in chronic pain management, we are bound to have poor outcomes if we cannot discuss the role of the psychosocial aspects of chronic pain. But, of course, we need to be able to have this discussion without stigmatizing the patient. Typically, in our field, we don't do a good enough job of walking this fine line. Dr. Pither, however, seems to be able to do it. We should learn from his example.

Dr. Pither also astutely describes the common trajectory of care that patients go through on their way to ending up in a cognitive behavioral based chronic pain rehabilitation program. Because chronic pain is truly a ‘biopsychosocial condition’ that doesn't fit well into the acute medical model of care, providers tend to refer patients back and forth between the medical side of the healthcare system to the mental health side of the healthcare system with neither being able to help very much. All too often this back and forth care goes on too long. Eventually, as Dr. Pither notes, someone refers patients with chronic pain to a cognitive behavioral based chronic pain rehabilitation program where they begin to get the care that most accurately addresses the true biopsychosocial condition that they have.

While rightly claiming that cognitive behavioral based chronic pain rehabilitation programs are the most effective therapy for chronic pain, Dr. Pither’s writing exhibits the scientific values of humility and constraint (i.e., good science tends to provide conservative interpretations of the data, never making greater claims than what the data reveal). I appreciate such humility and constraint. I think that all too often in healthcare, and in the field of chronic pain management in particular, providers tend to promise more than they can deliver. Don’t get me wrong. I don’t think that the multitudes of well-trained professionals in the field are equivalent to the snake oil salespeople of yester year, intentionally making pitches that they know aren’t true. No, what I am saying is that I think there is a pervasive lack of understanding among the stakeholders in the field of what science tells us are the most effective ways to manage chronic pain. Without such knowledge, providers and the public tend to believe that everything we do -- any chronic pain treatment that is commonly provided – is effective. Unintentionally, then, providers of various treatments for pain can tend to go beyond the data and promise substantial pain reduction, if not a cure, when discussing with patients what can reasonably be expected. The sentiment in Dr. Pither’s piece does no such thing. He rightly acknowledges that cognitive behavioral based chronic pain rehabilitation is the most effective treatment, but states, with humility and constraint, that what constitutes the greatest effectiveness in the field of chronic pain management is helping patients to live well despite having chronic pain. We simply do not have cures for chronic pain. Nonetheless, there is hope. People with chronic pain can live well. They just have to learn how and they learn how to do it in cognitive behavioral based chronic pain rehabilitation programs.

Charles Pither, MBBS, FRCA, is a physician and consultant in pain medicine. He practices at RealHealth, London, England.

Please read his piece entitled, ‘Cognitive Behavioural Approaches to Chronic Pain.’ You can find the link to the webpage.

Incidentally, if you aren’t already connected to us through social media, please check them out and connect with us. It is one of the most important ways you can support the work of the Institute for Chronic Pain. Being socially connected can also provide you with daily information, news and research that are useful, accurate, and up-to-date. To do so, just click on one of the following links and hit the follow or like button: Facebook, Linkedin, Google+, or Pinterest. Thank you for supporting the ICP.

Author: Murray J. McAllister, PsyD

Date of last modification: 10-4-2014

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Cognitive Behavioral Therapy Sat, 04 Oct 2014 14:26:46 +0000