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Effectiveness of back treatments https://www.instituteforchronicpain.org Tue, 31 Jan 2023 09:39:53 +0000 Joomla! - Open Source Content Management en-gb Reducing Pain Talk: Coping with Pain Series https://www.instituteforchronicpain.org/blog/item/211-reducing-pain-talk-coping-with-pain-series https://www.instituteforchronicpain.org/blog/item/211-reducing-pain-talk-coping-with-pain-series

A common complaint among people with chronic pain is that their pain has come to occupy too much of everyone’s time, attention or energy. In other words, it can sometimes feel like their pain is the only thing anyone ever talks to them about – that they’ve become almost synonymous with their pain.

We call it pain talk. Pain talk is the persistent verbal focus of everyone’s attention on the pain of someone with persistent pain.

Most, but not every person* with persistent pain has experienced pain talk. They quickly and inevitably add that they appreciate, of course, the attention of their friends and loved ones, but it comes to get old.

Might the same be true of you?

Friends and family can develop over the years a tendency to make you and your chronic pain, its treatments, and your overall well-beingImage by Priscilla du Preez courtesy of Unsplash the topic of conversation. For after all, it tends to be the socially appropriate thing to do. When people are sick or injured or otherwise unwell in some way, we are all supposed to ask about it, express condolences and offer help. Indeed, most people want to express their concern in these ways.

This normal behavior is all well and good. Most of us appreciate some attention when not feeling well or injured or what not. People bring over dinners and help out around the house. Maybe they bring your kids to piano lessons or sports practices for a few weeks following a surgery. Everyone, on both the receiving and giving ends, tend to appreciate these gestures.

It’s also common that after a while these kinds of overt offers of assistance tend to fall away. Life goes on for other people and it’s hard to keep up with such overt helping behaviors. However, the well-being of the sick or injured person tends to remain in the object of everyone’s attention when others do in fact come around. In other words, despite overt helping behaviors falling by the wayside, most people continue to talk to you about your well-being. Again, it’s thing that we are supposed to do.

While initially nice and helpful, when this state of affairs continues on a chronic basis, it can become increasingly problematic. There comes a point for many people where it’s preferable that you are no longer the focus of everyone’s attention. The attention, in the form of you being the object of everyone’s conversation, can become problematic in a few different ways.

It causes inner conflict for you

Suppose that your spouse when she comes home from work tends to ask, expectantly, “How’d you do today?” which implies that she’s hoping you’ll be better. You tell the truth, which you can see in her demeanor is disappointing, and so you feel bad for disappointing her that your pain is still as bad as it ever was. Suppose your four-year-old daughter comments that she wishes you could pick her up, but knows you can’t because it hurts your back. Out of the mouth of a babe, she means no ill will. It’s just an innocent yet accurate comment and yet you end up feeling terrible. Or perhaps, you see your cousin for the first time in a number of months and the first thing she asks about is the surgery that she had heard you had. You know she just had a baby and you want to be there for her, yet she’s trying to be there for you. The brief interaction immediately puts you on edge.

What lies at the heart of these interactions is what, in psychology, we call feeling conflicted. You end up feeling guilty or awkward or ashamed or irritable that you’re yet again the topic of conversation. At the same time, however, it’s not that you can get upset with them. They are expressing a sincere regard for your well-being! It would be socially inappropriate for you to express your displeasure with their attempts to care about you. It’s a no-win situation. You feel conflicted.

This recurrent sense of feeling conflicted is stressful. It wears on you and reduces your abilities to cope with pain. Stress, of course, also makes pain worse.

As a result, pain talk that was initially helpful and nice can become increasingly problematic once it continues on a chronic basis.

People tend to give you unsolicited advice

Suppose your neighbor sees you across the yard and asks, “How’s your back?” and then goes on to ask whether you’ve ever tried chiropractic. He continues for a few minutes on how much it helped so-and-so. Or suppose your friend at church or synagogue or mosque sees you and comes over to tell you about laser surgery that he saw advertised on TV last night. Your cousin insists that you absolutely must try some salve that he absolutely swears by.

You’ve heard it all before, but what do you say? Of course, you’ve considered those therapies or maybe you’ve even tried them. Nonetheless, you nod your head and politely let them finish their thought, but the whole experience makes you irritable.

People trigger bad emotional reactions

Sometimes, people trigger an emotional reaction that you’d rather not have. In fact, as an active coper, you try to stay out of either the victim perspective or the perspective of perceived injustice. Nonetheless, other people’s attitudes can put you into a bad emotional place. Suppose your brother-in-law exclaims, “If they can put a man on the moon, why can’t they fix your back?” Or suppose a friend comments on how unfair it is that nothing legally happened to the person who caused the motor vehicle accident that started your chronic pain. Or perhaps it was your sister who, getting mad that your disability claim was denied, expresses, “It’s so unfair that you can’t get disability – you paid into it for years!”

Such comments, while understandable and perhaps wholly accurate, put you in a bad emotional place. They stoke the resentment that occurs deep inside you. They tap you into the long-held anger and powerlessness and lack of control that you can sometimes feel. You try not to go there too often, because you find yourself too depressed when you do, but it is difficult to hear such comments without going there.

It’s not anyone’s fault

Please notice that in observing these complicated interactions no one is blaming anyone or criticizing those who talk too much about your pain. It’s not anyone’s fault. Pain talk is normal and natural, while at the same time it isn’t helpful.

So, what do you do about it?

One long-standing recommendation in chronic pain rehabilitation is for patients to have a discussion with their friends and loved ones and ask them to stop talking about pain. The discussion might go something like the following:

“I’d like to talk to you about something that is important to me. It’s the fact that we talk about my pain a lot – how I’m doing, whether it’s a good pain day or a bad pain day, and how my therapies are going. I know that you ask about all these things because you care about me. I appreciate your caring – I want you to know that. However, I’m also trying to cope better with pain and to do that I need to focus on my pain less. I need to get involved in other things that also matter and preoccupy my time and energy with these things, not my persistent pain. So, one thing I’ve learned recently is that I should ask everyone in my life to stop talking or asking about my pain. This will free us up to talk about all the other things that matter in life. It will also serve to keep me focused on these things, and less on my pain. If we all agree, I’ll make you a deal in that I will update you on my pain if there is any significant change for the better or for the worse. But as long as my chronic pain remains chronic, let’s try to stay off the subject. OK?”

Reducing pain talk leads to improved coping

Pain has a natural capacity to command our attention. When it’s a bad pain day, it’s hard to focus on anything else. This relationship between pain and attention is reciprocal or self-reinforcing: the more pain we experience the more we focus on it, but the more we focus on it the more pain we experience.

It is possible to counteract this natural tendency for focusing on pain. It involves a learning process over time and it takes repetitive practice, but it is possible. It’s a process of recognizing in the moment that your attention is focused on pain and making an intentional effort to change the focus of attention to something else – something that it is stimulating or interesting or pleasurable or meaningful in some way.

This process of repetitively recognizing and changing your focus of attention is helped along when others stop talking about your pain. Your interactions with them become focused on other things in life that are stimulating, interesting, pleasurable or meaningful.

When other things in life that matter start to compete for our attention, we can come to experience less pain. Pain gets relegated, as it were, to the background of our everyday lives. It’s a little bit like white noise. When a box fan gets turned on, it seems loud and it competes for our attention. But as we get involved in other activities, the stimulation remains, but we stop paying so much attention to it. We start to hear it less. We’ve all had the same experience with pain. When we get involved in other things that compete for our attention, we come to experience the pain less.

When we talk about pain less, life is less stressful. We don’t have to put up with feeling conflicted – knowing that others care about us but wishing they’d stop talking about pain so much. We also have a greater likelihood of staying out of bad emotional places, like experiencing the resentment that’s common when you have a chronic pain condition that you didn’t deserve or ask for.

Reducing pain talk also reminds you and everyone else that you are more than just your pain. You have endeavors and aspirations, activities about which you are passionate, and relationships that are meaningful. Reducing pain talk takes these issues off the back burner and puts them front and center. They can again come to define your identity.

Of course, when you see your healthcare providers, go ahead and talk about your pain. But in the course of your everyday life, it is best to repetitively practice staying off the subject. It's what people do when they cope well with pain.


*Such concerns are not always true of all people with chronic pain. Some people report basically the opposite experience. In their case, no one in their life asks about their pain anymore. They tend to feel alone and can understandably wish for someone to ask about their well-being once in a while. This state of affairs is also problematic. It deserves a discussion of its own and so we’ll save it for another post in the Coping with Pain Series. So, for now, let’s focus this post on how to cope when your pain occupies too much of everyone time, attention and energy.

Date of publication: October 21, 2017

Date of last modification: October 21, 2017

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

 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sat, 21 Oct 2017 14:07:52 +0000
Reducing Pain Behaviors: Coping with Pain Series https://www.instituteforchronicpain.org/blog/item/210-reducing-pain-behaviors-coping-with-pain-series https://www.instituteforchronicpain.org/blog/item/210-reducing-pain-behaviors-coping-with-pain-series

One of the more long-standing recommendations of chronic pain rehabilitation is to reduce pain behaviors. It’s one of the ways that people with persistent pain can learn to cope better with pain. Let’s review how to do it.

Introduction

Pain can be, of course, a naturally distressing and impairing experience. When in pain, we tend to be alarmed and react with grimacing, guarding, resting, or stopping any activities associated with pain. In these ways, we can see how pain involves distress and impairment.

Indeed, we might go as far as the International Association for the Study of Pain (IASP) in acknowledging that such emotional and behavioralImage by Milada Vigerova courtesy of Unsplash aspects of pain are part and parcel of the very experience of pain itself. Often quoted, the IASP defines pain as an “unpleasant sensory and emotional experience… associated with actual or potential tissue damage” (IASP, 2012). In other words, pain is a sensation, of course, but it isn’t any old sensation. It’s a distressing sensation. Tickles and itches are also sensations, but tickles make us giggle and itches are aggravating, at least until we feel the relief that comes from scratching. Sensations thus have an emotional aspect, which in part is what differentiates them from one another. Pain’s emotional aspect is distress or alarm. Pain is an inherently alarming sensation in which we automatically exhibit grimacing, groaning, bracing, or guarding behaviors that lead to stopping activities and resting. These latter emotional-behavioral expressions of pain are referred to as pain behaviors.

Unchosen nature of pain behaviors

The sensory, emotional and behavioral aspects of pain are typically not chosen. We do not have a certain sensation and, upon reflection, choose to become alarmed and express it by groaning or grimacing and protecting the painful area. No, the distress and associated behaviors occur along with a certain sensation and are part and parcel of the experience of pain. They occur reflexively or automatically, without intentionality or choice.

We might put the point in terms of an equation:

Pain = sensation + emotional alarm + reflexive behavioral avoidance

The essential variables of the equation occur in most any experience of pain. Let’s take an example. Suppose we are hiking through a forest and I accidentally step into a hole in the trail and break my ankle. Without reflection or intentional choice, I begin to have a sensation in my ankle, become alarmed, grimace, call out, and reflexively engage in protective or guarding behaviors. It all happens in an instant and automatically.

All of these variables are what we call “pain”.

Bringing pain behaviors under voluntary control

Pain behaviors are typically reflexive and not the result of intentional decision-making because we lack awareness of when we will feel pain. Pain, in other words, takes us by surprise. Without ever thinking about it, we grimace, garb at the painful part of the body, and exclaim “ouch!” or some other expletive.

In the broken ankle example above, I have no reason to anticipate the pain of the broken ankle. Rather, I simply and unwittingly step in the hole and the injury occurs. With the pain of the broken ankle, I grimace, brace, favor my ankle, and exclaim a painful utterance.

In cases of chronic pain, an important difference typically occurs. It’s the fact that chronic pain is persistent or repetitively present under certain circumstances. This persistent or repetitive nature lends itself to being aware enough to anticipate pain.

Suppose I have chronic low back pain. It’s a persistent dull ache that is always present. Whenever I get up from a chair or sit down on a chair, though, I additionally experience a sharp stabbing pain. It occurs most every time I sit down or get up and it has done so for years. Suppose further that because of the pain I also tend to grimace and hold my back stiffly, and whenever I sit down I tend to brace myself and let out an audible sigh.

The persistent and repetitive nature of chronic pain offers an opportunity that doesn’t occur in cases of acute pain, such as when I unwittingly step into a hole and break my ankle. The opportunity is that the persistent and repetitive nature of chronic pain allows for bringing a degree of awareness to the pain and even to anticipate it. With this degree of awareness, it becomes possible to develop greater intentionality with regard to pain behaviors. That is to say, one might begin to practice bringing pain behaviors under greater voluntary control.

In the example of chronic low back pain with repetitive stabbing pain upon sitting down or getting up from a chair, I could set out to bring my awareness to it and make an effort to control my grimacing, bracing and exclamations whenever I sit down or get up from sitting.

Of course, it would take some practice. There’s no pain behavior switch that can be turned off like a light switch. Rather, it would take repetitive practice to bring awareness to the pain and to anticipate it, such as when sitting down, and make an effort to control its behavioral expression. With practice, one could gain greater and greater voluntary control over pain behaviors and even the sense of alarm that goes along with the sensation.

The process of practicing thus involves bringing awareness to pain and its behavioral expression, anticipating pain, and the practice of choosing a different set of behaviors than the reflexive and automatic behaviors associated with pain. It could also involve reassuring self-talk that you know what your pain is, that you have it no matter what you do or don’t do, and, as such, the pain of chronic pain isn’t always signaling harm. Your chronic pain, you remind yourself, is like a broken fire alarm that keeps sounding the alarm whether there’s smoke or not. So, when you sit down and experience the sharp stabbing pain, the pain you experience isn’t necessarily signaling that the sitting motion is injuring you. The dull ache that you feel at all times of the day whatever you do or don’t do isn’t signaling that you are continuously injuring your back. Rather, the pain you experience is chronic pain and you experience it whether you are injuring yourself or not. The purpose of this reassuring self-talk is to begin turning down the sense of alarm that accompanies the sensation of pain. The goal would be to remain emotionally grounded in the presence of pain. With your increased awareness of pain, you might, for instance, take a deep breath to calm yourself and clear your head before sitting down and experiencing the sharp stabbing sensation. The improved emotional control over pain lends itself to improved control of the behavioral expressions of pain.

Imagine a day when you still experience the same level of pain that you do today, but you are no longer alarmed by it, and you confidently engage in life activities without any degree of vigilance to pain or fearful bracing and guarding. No one would ever know that you have the pain that you do. When, on some occasion, you tell them about the severe pain that you do in fact experience, they’d believe you and say something like, “Wow, you cope so well with it.”

Coping well with pain involves controlling pain behaviors

After all, what is coping well with pain? Coping isn’t getting rid of the pain, but rather putting up with pain. It’s tolerating pain. Now, everyone tolerates pain. It’s not ever a question of whether you or anyone else tolerates pain or not. Rather, coping involves a question of degrees. How well does one cope? Coping, as I like to say, occurs along a spectrum from low levels of coping to high levels of coping.

If we understand that coping or pain tolerance occurs along a spectrum, then we can recognize that no matter where you are on the coping spectrum you can always get better at it. Reducing the emotional distress and behavioral avoidance of pain is a way to get better at coping with pain.

Suppose we worked with a woman who experienced recurrent migraine headache. She had migraines most every day and she preferred to lie in bed with the shades drawn and the lights off when experiencing a migraine. Over the years, she found herself engaging in these behaviors more and more. She came to a chronic pain rehabilitation program because she wanted more out of life. She also needed to keep her job. When she forced herself to remain at work, she tended to rub her temples and the back of her neck on a persistent basis. She tended to have a grimace on her face and also sighed frequently.

When we initially brought up the recommendation to begin practicing controlling her emotional alarm and pain behaviors, she was offended. She thought we were judging her and asked rhetorically ‘what else am I supposed to do?’ We acknowledged, just as we did above, that such alarm and behavioral avoidance of pain is normal and natural. The point is that no one is judging her because engaging in these behaviors is normal.

We pointed out, though, she was coming to the program to learn how to cope better with pain and that if she’d trust us and practice what we were teaching her, she would in fact learn to cope better with pain.

So, she began to practice bringing her awareness to the pain and how she was coping with it. She recognized that, even though it was painful to remain erect and out of bed, it was safe for her to do. She acknowledged, in other words, it wasn’t injuring her or harming her to remain at work even though her head pounded. With such awareness, she further considered that she could make a value cost-benefit decision in which she weighed the value of pain reduction by remaining home in bed in the dark versus remaining at work, secure in her job, and involved in meaningful activities that brought value to her life.

She subsequently began, over time, to choose the latter. She made a concerted effort to remain grounded in the presence of her pain and redirect her attention to work or other valued-life activities. She would catch herself sighing and rubbing her temples and remind herself to stop and get involved in the activities she was pursuing.

We gently and respectfully pointed out such behaviors to her to help her in becoming more aware of them. She trusted us that we weren’t just picking on her, but helping her to cope more effectively with pain.

She came to conclude that if she were home on a Friday night watching a movie and wanted to rub her temples, it would be okay; but she wanted to be able to have the wherewithal to keep herself from engaging in such behaviors if, for examples, she were at a work meeting with colleagues or in a job interview. In the latter situations, it would be better for her to be able to cope with pain without engaging in such behaviors.

With effort, practice and openness to feedback, she came to be able to remain at work, engaged in the activities of work, even though she had a migraine. People stopped worrying about her at work and she stopped worrying that her job was in jeopardy. She felt self-confident in the presence of pain. She felt productive and proud of herself. Her career path was again heading in the right direction.

Even though she continued to have migraines, they were nowhere near as distressing and impairing as they once were. In other words, She had learned to cope really well with her pain.

Conclusion

Reducing pain behaviors is a long-standing recommendation in chronic pain rehabilitation because it is a way to learn to cope better with pain. It takes coaching from providers who you trust and who are gentle and respectful in their feedback. It takes time and effort. It also takes repetitive practice. However, it is also possible. It’s possible to learn to cope better with pain and reducing pain behaviors is a way to do it.

References

International Association for the Study of Pain (IASP). 2012. IASP taxonomy. Retrieved from: https://www.iasp-pain.org/Taxonomy

Date of publication: October 9, 2017

Date of last modification: October 9, 2017

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

 

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Mon, 09 Oct 2017 15:19:13 +0000
Developing an Observational Self: How to Cope with Pain Series https://www.instituteforchronicpain.org/blog/item/168-71developing-an-observational-self-how-to-cope-with-pain-series https://www.instituteforchronicpain.org/blog/item/168-71developing-an-observational-self-how-to-cope-with-pain-series Developing an Observational Self: How to Cope with Pain Series

From the time before Socrates in ancient Greece there stood a temple built upon a spring at a location the Greeks would have considered the center of the world. They called the temple, "Delphi". Inscribed on the walls of this holy temple was the simple phrase, “Know Thyself”.

This simple phrase inspired Socrates to a life of learning and teaching, and, from him, Plato learned to be a philosopher and later came to teach Aristotle. Subsequently, Western civilization, in large measure, began.

This maxim – “Know thyself” -- and others similar to it were not uncommon in the ancient world. Indeed, a few thousand years previously, early Hindus and later Buddhists practiced a form of moment-to-moment self-knowledge, later coming to be called mindfulness.

The directive inherent to this maxim has two components. The first is to pay attention. In other words, slow down and observe what’s happening. In today’s language, we might express the maxim as something like, “Get out of your head and notice what’s going on around you.” When we carry out such a dictum, we become observant and perceive things that we might not have previously noticed. 

Good things happen when we do. We see good things and become appreciative. We stop and smell the roses because we were observant enough to even notice them as we walked by and as a result we are able to appreciate their visual and olfactory beauty. Whereas in one moment our kid might be bugging us because her need for attention is interrupting our apparent need to make a phone call or put dinner on the table, in the next moment, once we get out of our head, we recognize just how funny or cute the kid is and we subsequently are overwhelmed by how much love her.

So much of life goes unnoticed because we are simply and persistently reacting to whatever thoughts, feelings and needs that pop into our attention. Whatever pops into our heads tends to have a sense of immediacy to which we react impulsively, without thinking in the sense of thoughtful consideration. It’s just a never-ending chain reaction of stimulus and response, like billiard balls knocking into each other. Notice that when we live life as if we are a player in a video game that goes on in our head, simply and persistently reacting to whatever momentary thought, feeling, or need that pops into our head, so much of what goes on around us gets missed. We don’t see how cute our kid is in that moment. We don’t notice that our spouse made coffee for us before leaving for work.

We don’t smell the fresh air. We don’t taste our lunch. We don’t fully appreciate how funny it was when our coworker or neighbor made that comment yesterday.

Instead, we were busying ourselves with the immediacy of whatever popped into our head at the time.

Notice too all the things we could have done in those moments but didn’t do simply because it never occurred to us. When we react to whatever thought, feeling or need that pops into awareness at any given time, it’s as if the reaction that we have is the only possible thing to do at the time. We might even justify the reaction, if anyone ever were to ask us about what we did, by saying ‘Oh, I had to,’ as if the thing we did was the only possible thing that could have been done. However, it’s not really true, and this point brings us to the second good thing that happens when we get out of our heads and start to observe what in actuality is happening in any given moment.

Namely, we become liberated from being a passive recipient of what happens to us to an active decision-maker of a well-informed life. By observing what in actuality is happening in life, and by considering the various possible ways we might respond, we exercise choice. No longer is our life dominated by the apparent must and have to and got to, but rather we are free to choose. When we pay attention, we recognize that we do not have to simply endure things happening to us. We are not victims. We have the power to choose among a number of different options as long as we slow down enough to recognize and consider the options that are available to us.

The simple maxim – "Know thyself”, then, is a truth that sets us free. It’s freedom from a determinism of automatic reactions to whatever lifeCourtesy of Unsplash gives us. We no longer ‘have to’ do this, that, or the other thing, but are free to choose how we live our life. We no longer ‘can’t’ do anything but the reaction that we have automatically done countless times in the past and are now free to choose how we might respond and move forward. From moment to moment, we are free to choose how to respond even to the things in life that we do not choose – like bad things that happen to us. We still are free to choose how we react to them and the perspective by which we see them.

In sum, the second good thing that happens when we observe what’s happening is that we become intentional about what we do, how we react to things, and even how we perceive the things around us.

This ability to observe life and intentionally choose how to respond to the things that come up from moment to moment is the main goal of psychotherapy. Freud called this ability the development of an observing ego and considered analysis a way to develop this ability. In more recent psychotherapies, we call it an observational self. It’s the ability, as described, to step out of any given moment, consider what’s happening, and intentionally choose how to react. Of course, in this day and age, we also call it mindfulness.

What does developing an observational self have to do with pain?

The development of the ability to step out of the moment and reflect on how to react to pain is the initial and most important thing to do in pain management. Everything else in pain management follows from this skill.

Pain has a sense of immediacy about it. It’s a sensation that is inherently emotionally alarming and to which we automatically react with avoidance behaviors – we stop what we’re doing, pull away and guard. This sensory, emotional and behavioral experience happens all at once, of course, and it happens automatically. We don’t typically choose any of it. The sensation just is alarming and we pull away and guard without ever intending to do so.

For example, if you were out hiking in the woods and, without looking, you stepped in a hole and twisted your ankle, you’d have pain. That is to say, you would have a sensation that was emotionally alarming and to which you would stop walking and guard your ankle in some manner. The whole experience would be almost instantaneous. It would also be automatic. The alarming sensation and behavioral avoidance would occur without any intentional decision-making on your part.

However, if you had chronic pain, and you set out to pay attention to the pain that occurred with activities, you could learn to make the whole experience more intentional. You would do so in a multiple step process. You would first simply pay attention to the pain that occurs and not be taken by surprise by it. Chronic pain often has a degree of predictability that the pain of an acute injury doesn’t have. So, by paying attention, you could practice the skill of not being taken aback by the pain. Just as importantly, you could recall that you have chronic pain and that you’ve had it for some time and you know what it is. In most cases, chronic pain is the result of the nervous system having become highly reactive to the stimuli of activities that are normally not painful to do – like walking, sitting, standing up, laying. You could consider that, even though it is painful, these activities are safe to do– that you are not injuring yourself even though it is painful. In this manner, you start to control the sense of emotional alarm that you have with pain. You set out to intentionally remain emotionally grounded in the presence of pain. To this end, you also practice taking deep, diaphragmatic breaths to assist you in remaining calm. From this new-found perspective, you can also choose how to behaviorally react. You intentionally choose to engage in the activity and have the sensation while practicing remaining calm.

Suppose, for example, every time an individual with pain sits down she knows she’ll experience pain. More often than not, however, she doesn’t keep this fact in mind and she goes about her day, like most of us, simply reacting to whatever pops into her attention. She does this and that, checking things off her to do list. Each time she sits down, she lets out a soft groan, grabs whatever is within reach in order to brace herself, and becomes, for an instant or two, emotionally and physically tense. The pain is severe and it takes her breath away.

She could, though, with some proper coaching from a psychologist at her pain clinic, set out to learn and practice the ability to step out of the moment and pay more attention to her actions. She could then practice slowing down the process of experiencing pain. In doing so, she pays attention to what she does and predicts the severe pain prior to sitting down. In this way, she isn’t taken by surprise each time. With knowing that it’ll hurt, she takes some deep diaphragmatic breaths as she works and reminds herself that even though it is painful she isn’t injuring herself every time she sits down. She intentionally recognizes that it is safe to sit down even though it hurts badly. In these ways, she practices remaining grounded while having pain. With her budding abilities to remain calm in the presence of pain, she intentionally sets out to control her pain-avoidance behaviors. She makes the decision to stop letting out the groan because she’s predicted the pain and isn’t taken aback by it as she sits down. She intentionally stops her tendency to abruptly reach out for something to hold on to while she sits, reassuring herself that it is safe to sit down. She also tries to refrain from grabbing her back and instead sets out to remain as calm as she can be in the presence of her pain, even severe pain. She intentionally does all things, moreover, on a repetitive basis through the course of her day, day after day. She discusses her strategies with her psychologist each week, and her psychologist gives her pointers, which she tries at home. Over time and with practice, she gets better and better at it. By developing her abilities to pay attention, observe herself and engage in intentional decision-making, she comes to be able to control, in part, her experience of pain. She comes, in other words, to be able to control the alarming and behavioral aspects of pain and subsequently becomes able to remain grounded and productive in the course of her day, even though she continues to have severe pain. In other words, she has developed the skill of mindfulness as it relates to pain management.

This description is what good coping looks like. Good coping is not getting rid of pain, but getting so good at reacting to pain that it is no longer as problematic as it once was. It requires the development of an observational self from which you can have pain, remain aware of how you are reacting to it, and intentionally attempting to remain grounded and active while having pain.

It's called mindfulness and it's an essential skill for managing pain really well. 

From the river Ganges to the temple at Delphi and all the way to the modern pain clinic, the dictum to know thyself travels through time because good things happen when we follow it. The ability to pay attention and engage in intentional decision-making when having pain is the initial and most important skill to develop in pain management.

Date of publication: 6-19-2016

Date of last modification: 8-28-2022

Author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and publisher of the Institute for Chronic Pain.

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Sun, 19 Jun 2016 20:29:03 +0000
Coping with Pain: How People Who Cope Really Well Do It https://www.instituteforchronicpain.org/blog/item/112-15coping-with-pain-how-people-who-cope-really-well-do-it https://www.instituteforchronicpain.org/blog/item/112-15coping-with-pain-how-people-who-cope-really-well-do-it

If you wanted to learn how to knit well, you might take a class at your community craft store. You might also get a how-to book out of the library or watch a few YouTube videos. But as you did all these things, you would also pay attention to those who already knit well and watch how they do it. You would then try to do what they do.

The same thing would be true if you wanted to learn how to play a musical instrument well or play a sport well or fish well. Say, for example, you wanted to learn how to become a better guitar player. You would probably take lessons from a teacher. You might read how-to books and watch videos on the internet. But you would also listen to how really good guitar players play. And you would try to play like them.

Why shouldn’t the same thing be true with coping with pain?

If you wanted to learn to cope with pain better than you do at present, then you likely would do a few different things. You might find teachers to teach you how (usually, when it comes to chronic pain, such teachers are called chronic pain rehabilitation providers and are found in chronic pain rehabilitation programs). You might read about how to do it (such as in blogs and self-help books). You might also watch videos on the internet (such as this one here).

Also, though, you might try to learn from those who cope with chronic pain really well. Just like learning any other skill, it is helpful to learn from those who do it well. You learn what they do and then try to do it yourself. Of course, like any skill, it takes practice and sometimes it takes a lot of practice.

Looking at coping from this perspective takes the mystery out of it. Coping with pain involves skills like any other skills. In this way, it is just like knitting, playing tennis, fishing, or playing the guitar. These activities are all a set of skills and similarly coping with pain is a set of skills. Like any other set of skills, the more you learn about how to cope and the more you practice, the better you get at it.

Skills, like coping with pain, might be thought of as occurring along a spectrum in which there is no endpoint. There is no point at which you are as good as you possibly ever will get. No matter how good you are at a particular skill, you can always get better with learning and practice. Whether you are a novice tennis player, a pretty good tennis player, or a professional, you can still get better at playing tennis. You can always hone your skills and get better with practice. The same is true with playing a musical instrument. Whether a beginner or a virtuoso, the musician can always get better with learning and practice. The same is true with coping with chronic pain. No matter where you are on the spectrum of coping with pain, you can always get better at it.

Looking at coping in this way takes the judgment out of it. You don’t have to feel bad if there is more for you to learn about how to cope with chronic pain. Everyone, no matter who you are, can learn how to cope with pain better. In reality, it’s true of coping with whatever problem you face. There is simply no endpoint at which someone knows all there is to know about how to cope with the problems they have. Let’s, then, look at what people do when they cope really well with chronic pain. Research psychologists spend a lot of time studying how people cope with adversity of any kind. Clinical and health psychologists spend a lot of time teaching patients how to overcome adversity. Based on this research and clinical experience, we might review a number of skills and attributes of people who cope well. The point here is that it is a learning process. Just like the guitar player who studies superstar guitar players by listening to them and trying to do what they do, let’s review the skills and attributes of people who cope really well with chronic pain. By doing so, you learn from them and can practice doing what they do.

As we do, try not to feel bad about yourself if you don’t do exactly what they do. Remember the point about the spectrum of coping with pain: coping is a set of skills and no matter how well (or not-so-well) you cope with chronic pain, you can always get better at it. It’s true for everyone. So, don’t feel bad if you can learn a thing or two. Everyone is in the same boat as you are. (In fact, rather than feeling bad about it, celebrate it! Isn’t it great that you can learn to cope better with pain!)

There are almost countless ways to get better at coping with chronic pain. In this post, we will review five of them. We will then review five more in the following post. The intention is for these posts to be a series that reoccurs on a periodic basis.

Skills and attributes of those who cope with chronic pain really well

1) They are open to change and learning from others.

People who cope with pain really well are open to change. They recognize that things will have to be different now that they have chronic pain. In this way, they are flexible and adaptable. They do not insist on returning to exactly how they were the day before they were injured or became ill. They recognize and accept that doing so would be impossible. Rather, they are open to new ways of living. They adapt their work positions or even seek out new employment positions that work well with their chronic pain condition. They find new social and recreational activities. If it hurts too much to stay in the bowling league, they join a cribbage league instead. They also find new ways to stay involved in their religious or civic organizations. Because they are open to change, they might still work or still have fun with their friends and family and are still engaged in their community, despite the chronic pain.

People who cope well with chronic pain are also open to learning from others. They don’t get offended or defensive or nervous when talking about how they might come to learn better ways to cope. Rather, they acknowledge that they don’t know everything there is to know about coping with pain. They also recognize that there is no shame in learning new ways. Like we did with the discussion above on the spectrum of coping, they understand that they can learn a thing or two and don’t feel bad about it.

2) People who cope really well with chronic pain accept that their pain is chronic.

Initially, it might seem counter-intuitive to accept that your pain is chronic. Understandably, many patients want to maintain hope by trying to find the right specialist who can cure them of their chronic pain. At some point, though, it’s helpful for most patients to recognize that medical management has its limits. Why? Because when your pain is truly chronic, it means that it is not curable. Chronic health conditions are conditions for which we have no cures and for which the patient will have to live with. Insistence on finding a cure long after it is reasonable to recognize that your pain as chronic becomes itself a problem. It can reduce your ability to cope because it leads to a vicious cycle of false hope in a cure that never comes followed by failed treatment and then disappointment. Hope and disappointment is a common theme as patients talk about what they have tried when attempting to cure their pain – the various medications, injections, and surgeries they have tried. If this cycle continues for too long, patients come to feel hopeless and depressed.

So, at some point, it is helpful to accept the chronicity of chronic pain. People who cope really well with chronic pain do it. They don’t spend time trying to fix what is ultimately an unfixable problem. They recognize it would be a losing battle and that it would lead to becoming hopeless and depressed.

3) Instead, people who cope really well with chronic pain focus on what they can do to manage their pain.

They seek out things that they can do to manage pain rather than looking to other people or other things to manage their pain for them. They don’t see ‘pain management’ as something that their healthcare providers do or that their medications do. Rather, they see that the lion share of it is their ability and responsibility.

They have a routine of ways to self-manage their daily level of pain. When they have a typical pain flare, they ask themselves what’s going on in their lives that might be contributing to it and then set about to resolve it. In short, they consider themselves to be primarily responsible for their health in general, not their healthcare providers.

This point is true of all people who cope well with any chronic health condition. The person who copes well with heart disease is typically one who doesn’t primarily rely on healthcare providers to manage the disease for them. Rather, one who manages heart disease well is one who quits smoking, engages in regular exercise, changes their diet, loses weight, and manages stress. Of course, they might see healthcare providers too. However, it is a matter of emphasis.

People who manage chronic health conditions well are those who primarily see their health as their responsibility and so rely on their healthcare providers less, rather more.

This emphasis on what the patient can do is called empowerment. People who cope with pain really well feel empowered and confident in self-managing their chronic pain. They know what their pain is. They are not alarmed by it. They know what to do about it. And they do it.

4) People who cope with pain really well exercise on a regular basis.

Typically, they engage in a low-impact, mild aerobic exercise at least three to four times per week. Examples are walking in a pool, walking outside or on a treadmill, riding a stationary exercise bicycle, or using a stationary arm bike. All these exercises involve a low degree of impact to the body. However, they all are aerobic, or cardiovascular, exercises. That is, they get your heart rate up.

The importance of a mild aerobic exercise is its effect on the nervous system. Following an aerobic exercise in which you get your heart rate up for a period of time, the nervous system relaxes. You feel grounded. You have a sense of well-being. It’s why people exercise to manage stress. Runners call it ‘a runner’s high.’ However, you don’t have to run in order get it. The exercises listed above will do just fine.

Why is this important and why is it helpful? It’s because chronic pain is a nervous system condition. Whatever the initial cause of your pain, if you have chronic pain, then you have a nervous system that is stuck in a persistent state of reactivity, making the nerves super-sensitive. Any little movement sets the nerves off firing pain signals to the brain. People who successfully self-manage chronic pain maintain their nervous system reactivity in the lowest possible state. One of the many ways to do this is to engage in a regular, low-impact aerobic exercise.

Following each time you engage in an aerobic exercise, your nervous system relaxes for a period of time. Of course, since you have chronic pain, it returns to a higher level of reactivity after awhile. However, if you do it again and again, on a regular basis over time, your nervous system returns to lower and lower levels of heightened reactivity. In effect, you are down-regulating the reactivity of your nervous system. As such, you have less pain and more ability to cope.

Also, regular aerobic exercise improves your mood. Again, many people exercise solely for its stress-relieving properties. When we engage in an aerobic exercise, we feel good, not only physically, but emotionally too. When you exercise on a repetitive basis, your mood gets better and better. Consequently, when your mood improves, you cope better with the chronic pain that remains.

For both of these reasons, people who cope with pain really well almost always engage in a low-impact, mild aerobic exercise on a regular basis.

(Let me make two quick notes before moving on. First, you should always check with your healthcare provider before starting an exercise routine for the first time. Chances are, they will be quite supportive of the idea. However, some people might have medical conditions that can complicate matters and for which you need specific instructions for your specific condition(s). Second, many healthcare providers continue to treat chronic pain as if it is the result of a long-lasting acute injury. They subsequently recommend stretching and core strengthening exercises. These might be helpful, especially if you are out of shape and would find walking, for instance, too difficult. However, their effectiveness for chronic pain is limited. They are best seen as a way to get you into enough shape that you could then transition to a low-impact, mild aerobic exercise. They are like a bridging exercise to get you to your goal exercise.  In and of themselves, you probably don’t want to expect a lot of improvement in pain or coping from them. Improvement comes when you are able to engage in a mild aerobic exercise over time. )

5) People who cope really well with chronic pain understand the relationship between pain and stress.

They understand that they have to keep their nervous system in check. They understand that whatever affects the nervous system also affects pain levels. Moreover, they understand that stress affects the nervous system. They subsequently use this knowledge to help them cope with pain: one of the chief ways to manage chronic pain well is to manage stress well.

People who cope with pain really well see life’s problems in terms of their stressful impact and how these stressful problems make their pain worse. They see such problems and automatically assume that the stress of them affects their pain levels. Any of life’s problem can be stressful, of course, but some examples are you and your spouse not getting along, your kid getting into trouble, a period of insomnia, getting behind on bills, or the loss of a loved one. People who are coping with pain really well take it for granted that these kinds of problems make their pain worse.

This knowledge allows them to cope with pain well in two different ways. First, they understand that their pain levels are in some ways a barometer of what else is going on in their life. They always have, of course, some baseline level of pain from the pain condition they have. However, what makes their pain wax and wane beyond the normal level of pain is how much stress they are experiencing. If their pain is through the roof one day, they ask themselves what else is going on. They subsequently identify the stressful problem and set about working on it. By resolving the problem, they reduce their pain back down to their normal level of chronic pain. In this way, managing stress is a way of managing pain. Second, by knowing the relationship between pain and stress, they don’t become alarmed when experiencing a pain flare. They don’t, for instance, think that their underlying health problem is worsening or they don’t think it is necessarily cause for seeking repeat diagnostic testing. They know what it is and can identify where it is coming from. They know that it is a stress-induced pain flare. Then, they set about trying to resolve the stressful problem and reducing the reactivity of their nervous system.

In these ways, they remain grounded, empowered, and in control. These are attributes of those who are coping with pain really well.

For more information, please see the next post in the coping with pain series.

Author: Murray J. McAllister, Psy.D.

Date of last modification: April 21, 2014

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

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joemcallister4@gmail.com (Murray J. McAllister, PsyD) Coping Mon, 03 Jun 2013 06:42:35 +0000