Manage Your Pain: Practical and Positive Ways of Adapting to Chronic Pain - Michael K. Nicholas, Allan Molloy, Lee Beeston, Lois Tonkin (2012)

Chapter 9. Recognising And Overcoming Obstacles To Change

In this programme you will be trying to find ways of overcoming the problems caused by chronic pain. If persisting pain is interfering with your ability to achieve your goals or even to maintain your normal lifestyle then you need to find ways around it. Your goals may include such things as: giving-up pain killers and sleeping tablets, driving the car for more than a short distance, going back to work, doing more household chores, cooking a meal for friends or family, or just being able to play with your children or grandchildren.

As each person with chronic pain will face different problems, it is important that you should first work out the problems you want to deal with and the goals you want to achieve. [The chapters on Overcoming The Effects Of Chronic Pain On Activities and Setting Goals will deal with this in more detail].

Of course, achieving these goals will not be that easy (if it were, you would have achieved them already). You will face many obstacles. This section will deal with some of the problems you might face in trying to achieve your goals despite persisting pain.

1) Changing the way you’ve been living.

Some of these changes may be quite small, like doing some stretching exercises first thing in the morning. But other changes may be much larger, like attending an adult education class or even returning to work.

While you may be very keen to make these changes and achieve your goals, you may still find it quite difficult to break out of old ways or habits. Of course, if you’re not quite sure if you do want to make these changes, it will be harder still. You may also say that “if only the pain would go away, then I’d get going”. This is completely reasonable. But if your doctors have not been able to cure the cause of your pain, then waiting for it to happen before you get going could mean a long wait. The outcome is also uncertain - there is no guarantee that waiting 6-months or even a year would be enough. But that would be another year gone from your life. On the other hand, if you said something like “well, I won’t give up hope of a cure, but in the meantime I’ll see what I can do for myself” at least you’d avoid losing that time for nothing.

It would seem a good idea, then, for you to give some thought to why you want to make these changes and to how they might affect the way you’ve been living. What might you lose? What might you gain?

Another way of thinking about it might be to write down a list of the advantages and disadvantages of staying the way you have been and then a list the advantages and disadvantages of the changes that achieving your goals might bring.

Sorting out these issues may not be easy but it is very important that you do so and that you are as honest and realistic as possible with yourself. You may find it helpful to discuss this with your doctor or a clinical psychologist.

Your list of advantages and disadvantages of changing versus not changing could look something like this:

A. Keeping things as they are

or B. Changing

Try making up your own lists then sit back and think about what they show you.

2) Fear of pain; fear of doing more damage.

Even when you’re sure about the changes you want to make and why, you might worry that doing exercises or increasing your activity level could lead to more pain or even further injury to yourself.

How could you overcome these fears?

Information and reassurance? If you think information and reassurance would help, ask your doctor about your worries and read the sections of this book that might deal with your particular concerns (such as Chapter 3, What is Going on Inside Your Body When You Have Chronic Pain and Chapter 7, Overcoming the Effects of Chronic Pain on Activities). Sometimes you might find it helps just being able to talk through your fears and worries with someone else - even if they can’t tell you anything you don’t know already.

Do it - Once you feel reassured that you are not going to harm yourself, it can be very helpful to try and do the activity you are fearful of. Usually, it is best to start by doing a little at a time and then gradually do it more often. For example, if it was an exercise you were fearful of, you could start by doing it only once or twice (or whatever you felt you could do). Then, every second or third day or so you could do a little more of the exercise, until after a few weeks you could do it as often as you liked. By taking this gradual approach you will probably find that your confidence builds up as you progress (especially when you find that whatever you were fearful of didn’t happen or wasn’t as bad as you expected). Of course, as your confidence builds, your fears will be gradually overcome.

Use your relaxation technique - The relaxation and desensitising techniques you will learn during the programme can also help in overcoming fears, especially if you remember to practise them whenever you feel yourself starting to worry. [Read Chapters 11: Challenging Ways Of Thinking About Pain, 12: Using Relaxation, and 13: Attentional Techniques].

3) Time and motivation

You might find you don’t seem to be getting anywhere when you make the first steps towards your new goals. For example, when you reduce your pain killers just a little you may not notice any real improvement in how you feel. Similarly, if your goal is to walk for 1 hour but you have to start with only 5 minutes you may find it quite frustrating to walk only a short distance before you reach your goal for the day and have to stop.

Even though your goals are important to you, they may take some time to achieve. You might think that it’s just not worth all the time and effort, especially if the extra activities are causing you more pain.

How could you deal with these sorts of problems?

Your goals give you some incentive, but they may be too far away to have any effect to begin with. It may be like setting out to become a rocket scientist or accountant in a top firm - first you have to get into university. Then you have to complete a university degree or two in the right subjects. Then if your grades are good enough you might get a job in the area you want. On the other hand, it may take two or three job changes to get the one you want. No one ever gets to their ultimate goals in life in one jump. So we all need ways to keep going while we’re getting there. How could you do this?

Will power? It’s often not clear what is meant by this, but we may see it in famous sports people when they look very determined. Even so, how long do they have to keep it up? Usually, it’s only for an hour or less. Perhaps a few days in some sports. In your case, however, you may have to keep working at your goals for months not days or hours. By itself, being determined is unlikely to last long enough to help you achieve your goals. Even top sport people know that. After all, they often have to train for months or years to get to the top. Will power may give you a start or help you at difficult times, but it’s not going to be enough to keep you going. Other measures will also be needed.

List reasons for trying - One way could be to recall your list of the reasons why you are trying to achieve your goals (for example, how much you will enjoy being able to do more, how it will make things easier for you and your family, how much you don’t like the side-effects of your tablets, etc.). You could remind yourself of these reasons each time you found your motivation dropping.

Break your goals down into achievable bits - If your ultimate goal is to walk for an hour, that might take a while to achieve. But you could break it down into, say 5-minute stages. So you could start with 5-minutes as the first goal. When you can manage that you would go for 10 minutes, then 15 and so on. In this way you could identify long-term goals and short-term goals. It’s the same as the old idea of learning to walk before you run.

Record your progress - You can also keep a written record of your progress, like a diary or a graph. This can act as a reminder of your achievements and help you to see that while it may not feel like it, you are getting there gradually. The diagram below provides an example of this.

Sitting tolerance (how long I can sit still before getting up or changing position).

Give yourself a reward or reinforcer - You could also encourage yourself by giving yourself some sort of a reward each time you achieve your goals for the day. Such a reward need only be something small. For example, you could just give yourself a ‘pat on the back’ or a small treat - reminding yourself as you do it that you have earned it because of your own efforts. Of course, keeping a record of your progress may also be seen as a type of reward for your efforts - due to the sense of achievement you get from it.

Some people find it difficult to think of giving themselves a reward. If so, it may help to call it a reinforcer instead. This is a term psychologists use as its meaning is more neutral than ‘reward’. In the rest of this book we will use the word ‘reinforcer’ instead of ‘reward’.

Rather than use just one reinforcer all the time, we would recommend that you build up a list of several different ones - and vary their use. In this way you can avoid getting used to one and finding it boring. But remember, only use reinforcers that mean something to you. For example, one lady described how she liked to get up in the morning and sit at the kitchen table with a cup of tea and read the morning paper. But in order to reinforce her exerciseroutine she decided to only have her tea and read her newspaper once she had done her morning exercises. In this way she managed to keep up her exercise programme long after her initial will power would have worn off.

Even saying “I did it” or “well done, that’s something I’ve achieved” is better then saying nothing or ignoring your achievements. It is even worse to criticise your achievements because they are not what you expected of yourself or what you used to be able to do - remember, you probably didn’t have pain then.

Get your family or friends to help - You might also get your family and friends to help by reinforcing you with praise and encouragement whenever you achieve your goals (or better still, when they see you trying). In fact, it is more helpful if your family and friends praise you for what you have achieved, even if it’s not perfect, rather than focus on what you haven’t achieved.

In general, it may also help if your family and friends let you try to do some things first rather than do them for you - even though they might be able to do them quicker or better at present. Of course, you should discuss these issues with them first so they will understand and know how best they can help. Encouraging them to read this book is also likely to help them understand the programme.

4. Conflicting advice

If you have seen a number of doctors and other health care professionals about your pain, it is likely you will have had conflicting advice, leaving you feeling confused. Some may have told you to rest or “take it easy”, while others may have advised you to “keep active”. Some may have said “no tablets”, while others may have said “take as many as you need”. Some may have said you need surgery, while others may have said “don’t even think about surgery”. Whose advice do you follow?

There is no easy answer to this question. At times, they may all be right. But not usually at the same time. Deciding which advice to follow may be easier if you can understand why you have persisting pain. Reading the section in the book on medical aspects of persisting pain could help here. At least that will tell you about the sorts of reasons that can cause pain to persist and the treatment options with a reasonable amount of scientific evidence to support them.

It is also very important that you discuss the likely causes of your pain with your doctor. As mentioned earlier, even if he or she cannot cure your pain, your doctor should be able to reassure you that there is nothing seriously (life threatening or crippling) wrong with you. Your doctor can also arrange for any suitable tests or investigations to be carried out. Your doctor will also be able to discuss any treatment options with you. But if you are not happy with his or her advice, or find it conflicting with other advice, then you should consider getting a second opinion from another doctor. You can ask your doctor to suggest someone as he or she should not mind, and may even be pleased to have another opinion too. Your doctor could also refer you to a multidisciplinary pain clinic where specialists in pain management can provide a comprehensive assessment and advise you and your doctor on appropriate treatmentoptions.

Your doctor should also be able to tell you about the possible outcomes of any treatment and any risks you may face with those treatments. An important rule in medicine is to do no harm. So, at least you could start with treatments that won’t cause you any harm. Doctors call these “conservative treatments”. Most physiotherapy treatments may be called “conservative”. That doesn’t mean they will help everyone with persisting pain, but they shouldn’t make it worse.

At the end of the day, you will have to make a choice as to which advice you will follow. Whichever course you decide to take, you should try to be as informed as possible about the treatments offered, what they will do and what the possible drawbacks are. You should also check your progress yourself on a regular basis - are you any better or not? Is the treatment helping you to achieve your goals? If not, it may be that that treatment is not really helping you and you should see your doctor about stopping it.

You should approach the methods described in this book in the same way.

To conclude

By now you should have some ideas about why you would like to make some changes to the ways you manage your pain. If you’re still not sure, then it could help to discuss it with your doctor or physiotherapist. If that is not enough, then you could ask to be referred to a suitable clinical psychologist or psychiatrist, or to a hospital pain clinic. A suitable clinical psychologist or psychiatrist is usually one who is familiar with the problems that people in persisting pain have and the treatment options available. Even if they can’t offer you much help directly, they should be able to help you talk over your concerns. This should help you to clarify what you’d like to do next.