I’m spending a few days looking at practical ways for working with group CBT for chronic pain.  It’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  I’ve looked at how groups can impart a sense of optimism and at how they help people with a sense of  inclusion (sense of commonality), and group-based learning.  Today it’s time to look at emotional processing and group cohesion.

I’m sure I’m not alone in feeling slightly awkward in some social settings.  I really hate meeting a group of people who already know each other (I’m the odd one out), or in a bar where I can’t hear well, or at times when I’m feeling less than sparkling (maybe worrying about what people might think…).  I know I’m not alone in feeling that when I’m with people I don’t know well, I am not exactly open to pouring out my woes and being emotional. It can take quite a while to feel comfortable about expressing feelings in a group setting - but at the same time there is something comforting in knowing that if I’m feeling wobbly there are probably a few other people also feeling the same way, so we may all reach for the tissues at the same time!

Processing emotional content in a group setting can be both an amazing experience and at the same time an opportunity to feel really weird.  It all depends on how the facilitator or therapist responds.  Through exposing emotional content, we have greater access to automatic thoughts, assumptions, beliefs and behaviours that are often otherwise well hidden underneath our protective cognitions.  It’s at times when we feel more emotionally vulnerable that we have access to underlying ‘rules of living’ that we may otherwise be completely oblivious to.

What should a facilitator take notice of?

- times when a participant appears disengaged, perhaps doodling, or closing the eyes, maybe rocking on the chair or fiddling with a pen.

What could a facilitator do? To illustrate one way of drawing out the emotional response and opening up an opportunity to talk about what is happening here and now, the therapist could say:

Therapist: ‘before we go on, I just want to check in with the group.  Tony I can see you’re looking a bit distracted, what’s going on for you right now?’

Tony: ‘Oh nothing’

Therapist: ‘Oh.  How does what we were talking about fit for you?’

Tony: ‘Well, I’m just thinking why do I have to be here? I mean, I don’t think my pain is really chronic, and I know I can have another injection if only I talk to the doctor again, so do I really have to do all this psychological stuff anyway?’

Therapist: ‘Does anyone else feel like it’s going to be a really difficult process to learn self management, and maybe there is an easier way other than looking at thoughts and emotions and things?’

Andrea: ‘Well, yeah.  I mean, some of the doctors have said that I can just increase my medications and then maybe my pain will go down and I’ll be doing more, but I just can’t handle the side effects any more.  Those side effects can be worse than having the pain, I think.’

Therapist: ‘Does anyone else feel like it might be easier to just carry on with a medical approach and not look at other things?’

Tessa: ‘I tried that for years, but in the end I still have my pain and my emotions go  up and down every time someone suggests another medication – but I’m still here because I am so fed up with that rollercoaster, and I want to take control again.’

Therapist: ‘ Tony, what is it like for you to hear that other people feel in two minds about doing this self management approach, and there are some appealing things about using medications, but also some not-so-good effects?’

Tony: ‘Well I guess it makes me feel more normal, after all I’ve been on that emotional rollercoaster for a long time, and I really hate the side effects from medications too.  And the doctor said that he wasn’t very keen to give me any more injections.’

This approach can feel risky if you’re not used to facilitating – it’s allowing people the space to feel ambivalent and to process that anxiety but also to recognise that others in the group have also had similar experiences and offer either the same insight (I’ve been here before…) or a new insight (She’s handling it by being open-minded) that can reassure the person.  Provided that the facilitator can trust the group that there will be someone else who has moved through this same thought and emotion before, and go with the flow (roll with resistance), it’s possible to allow people to air their worries or emotions and still be able to move towards the goal of sharing and normalising many of the experiences the group shares.

Group cohesion is that sense that the group are ‘bonded’. There has been much written about the stages of development within a group – the ‘forming, norming, storming etc’  stages amongst others.  What happens is that over time a group may move to the point where it’s OK to disagree with each other, to challenge each other and to risk being ‘real’ with each other.  This can happen quite quickly, but I find that groups often get to the ‘I feel comfortable with this group’ stage (ie they all ‘get along’) but may get stuck and don’t move to the ‘it’s OK to be honest and real and disagree with each other’ stage.  It’s only when groups move to this deeper level of cohesion, IMHO, that they start to ‘work’ each other.

The therapist or facilitator can encourage this deeper relationship and here are several strategies that can also help:

1. Choosing a group that has similar characteristics – eg stage of change or readiness to adopt self management, maybe diagnosis or pain site, perhaps compensation status or job status
2. Ensuring confidentiality and creating the group norms
3. Ensuring a climate of acceptance, empathy and promoting sharing of information
4. Connecting two or more participants experiences
5. Responding to group process as it happens

More about this last one tomorrow. Group process is all about the things I’ve raised over the last couple of days – disclosure, optimism, inclusion, group learning, shifting from self to others, and managing both emotional processing and group cohesion.

I’ll review these tomorrow and add in some specific strategies that can be helpful to elicit each one.

`Yesterday I started to look at why pain management using a CBT approach can work well in groups.  As I mentioned, it’s the most researched form of CBT-based pain management, and offers some very helpful features for people with chronic pain.  Yesterday I looked at how a group approach can offer participants a sense of optimism.  Today I’m looking at inclusion (sense of commonality), and group-based learning.

One of the most striking features of having an invisible health problem is that many people can be walking around in our communities with their pain without anyone being any the wiser.  The sense of isolation experienced by some of the participants in the pain management programme I work on is astonishing.  It’s as if they are living in a bubble that makes interacting with other people profoundly difficult.  Being in a group setting with other people experiencing similar problems offers some really important things:

1. a sense of belonging, to recognise that chronic pain is experienced by other people who struggle with the same issues
2. a sense of normalising – recognising that some of the experiences are not strange or a sign of some unique failing on the person’s part, but are simply part of having chronic pain
3. the opportunity to learn from others who may have faced and coped well with very similar situations and arrived at helpful solutions
4. shifting the focus off the individual and offering them the opportunity to help others.  This can be an empowering situation for individuals who can otherwise feel helpless and hopeless.

The way the therapist facilitates group members to develop the sense of safety needed to share experiences, and confidence to offer opinions (especially opinions and doubts that contradict the ‘proper’ way to manage) is crucial to the success of the experience.

I begin the group programme with a brief outline of the purpose, housekeeping, and then very briefly ask particpants to share a little about themselves.  At the very beginning of a three-week programme it’s unnecessary, I think, to start with ‘icebreakers’ and I find many people simply hate them! So it’s a very simple ‘tell me a little about yourself and why you’ve come to the programme’.  Later on in the day I use the whiteboard to brainstorm all the possible topics that people might want to have the programme cover – I use a very open approach to do this, allowing the more vocal participants to start this process off.  Once a few topics are on the board, I’ll then start to prompt ‘people who haven’t had a chance to speak’, and I also allow some periods of silence because some participants need that time to process thoughts into words.

It’s once topics are on the board I notice that participants begin to warm up to each other and start to share the ‘back story’ of why some of the topics they’ve suggested are important.  Allowing this to happen without too much direction helps set the scene for people to see that the group includes people ‘just like me’, and I find the less vocal people start to show nonverbal participation.  Sometimes at this point it can be helpful to break off into pairs to share one another’s journey to coming to the programme – having to speak to only one person can help to make speaking and feeling included easier.

At this point the therapist can facilitate slightly deeper sharing – saying something like this:

Therapist: ‘Now that we’ve spent some time hearing about what’s brought people to the programme, and what they want to learn, we can see that although each person is unique, there are some similarities that you all share.  What do people think or feel about what they’ve heard?’

Tom: ‘At last there are other people who know that I’m in pain when I say I’m in pain!’

Alison: ‘It’s really strange because I’m usually the only one in pain and feeling like I really need to stand up or jiggle, and here are a whole group of people doing the same!’

Group laughs then silence

Therapist: ‘What about for others?’

Tony: ‘I thought everyone would be ACC whiners, but you’re not.  Is anyone else on ACC here?’

Andrea: ‘Yes I am, and I’m worried that ACC is going to kick me off compensation straight after the programme, and they’ve made me come here and I can’t work like this.’

Therapist: ‘It’s really great that you’ve talked about this Andrea, because a lot of people do worry about what is going to happen after the programme.  About half of this group are on ACC compensation, and we’ll talk about how to work with your case manager and what to plan for after the programme in several sessions.  It’s also a really important point you’ve raised about ACC making you come along.  Does anyone else feel like they’ve been made to come to the programme by someone else?’

Alison: ‘Well, I thought so at first because my case manager suggested I come to Pain Management, but when you did the screening you explained that I could decide whether the programme was for me or not, so I’m feeling OK about it now.’

Therapist: ‘Thanks for saying that Alison.  You’re right, coming to the programme is absolutely your choice, and it’s important you decide to be part of it yourself, and not for anyone else.  Not a partner, or a child, a doctor or even ACC can make you come along.  If you’re here because you think someone else made you attend, I can reassure you that if you decide at the end of today that this is not the right thing for you, we will communicate this with your case manager and there will be no penalty.’

This is an important ‘doubt’ that many people can have when asked to attend a pain management programme, as many people with chronic pain have some sort of relationship with a compensation agency.  We have a policy that people must be ‘ready’ to attend a programme for themselves, because we’ve found that although it’s possible to include people who feel coerced to attend and the group process can work with this, it makes progress very difficult.  Self management is that – self management.  It’s a choice, and people do need to be ready to pursue it.

Even after selecting people carefully for inclusion, participants can continue to feel worried about the consequences of completing a programme, and this is an issue to discuss openly.  We start doing this by a process called ‘fears in a box’, where after about three days, participants are offered the opportunity to write down their concerns or doubts about the programme, and place these thoughts in a box.  The team members review the written questions and at the end of that day, directly discuss these issues with the group.  Many group members say they feel relieved because they thought they were ‘the only ones’ to have the doubts, but typically it’s something many of them feel.  Offering participants a chance to anonymously air their worries helps the whole group feel more comfortable sharing their unique worries, allowing the therapist/facilitator to work through the issues to resolve them.

This week I’m looking a working effectively with groups for pain management using a CBT approach.  Someone said recently ‘why should six clinicians be tied up for three weeks with only six patients? there are other people who need pain management too’ - and over the past ten years I’ve seen numerous attempts to move from the group approach to individualised therapy, so some time reviewing why groups are a useful way to help people develop pain management skills might not be amiss!

Using a group approach was typical for pain management in the earlier days, say around the mid-1980’s and earlier.   It’s a convenient way to bring the specialised skills of an interdisciplinary team to people with pain, and especially within the setting often used in the beginning of CBT for chronic pain, which was an in-patient or residential setting.

Now things have changed with an increase in individual programmes, but still the majority of research is carried out on the outcomes of people attending group programmes (eg Edelman, Bell & Kidman, 1999; Thorn & Kuhajda, 2004 – this is a list that could go on!).

Why use a group?

Groups provide two main aspects that individualised therapy doesn’t, and these aspects are especially important for people with chronic pain.  The first is the opportunity for the group to broaden the range of possible concerns and issues that can be discussed. Instead of drawing only on the issues that one individual chooses to raise, group members will bring many different situations, both similar to and different from, the ones that another group member may raise.  This means many more opportunities for a person to learn how to apply cognitive behavioural strategies across different settings.  Participants in a group setting often express how alone they have felt in coping with their pain problem and how helpful it is to find a group of people who have similar concerns.

The second is the opportunity for group members to develop and demonstrate using CBT with each other. Group members become, over time, much more able to challenge each other very strongly over issues common to them all, than a group facilitator.  The multiple perspectives that individuals bring to viewing situations is very helpful when learning to challenge an assumption or belief, and the group setting provides a safer setting for developing the skills to challenge themselves.

Several other aspects support a group approach - operant conditioning occurs as group norms begin to shape behaviour.  The group can begin to initiate ‘well’ behaviour, and support each other with this.  (yes, it can go the other way – we’ll discuss this too!).  Effective communication, a skill many people with chronic pain have not developed, especially with respect to communicating about their pain, is used during a programme.   Observing others succeed or not, and the effective analysis of ‘what went well, what would you do differently’ is another aspect that is strengthened in a group setting, particularly as alternative options for ‘doing it differently’ can be suggested.

What is the difference between CBT in a group setting and CBT through a group?

I’m sure we’ve all spent time in groups where the discussion is rather stilted, directed to the ‘leader’ or facilitator, and members rarely, if ever, talk to each other. ( I can think of several staff meetings like this!)  If a CBT approach is to work well in a group, it’s not just about a facilitator using CBT with each individual in turn – that’s just CBT in a group setting.  To me it’s not nearly as effective as working through the group process using a CBT approach.  The differences appear subtle when I’m writing them, but never FEEL subtle when a group is actively processing!

It’s the way the facilitator encourages group participants to start the CBT process with each other that makes or breaks the group as an active component of a CBT approach.  I’m going to firstly discuss the group process within a CBT framework, and draw on Bieling, McCabe & Antony (2006) to do so.  Today’s theme is ‘Optimism’.

 Optimism.  Believing that treatment will help, and feeling positive towards the outcome is an aspect of group process that is strongly influenced by the group and the facilitator.  Facilitators can help group members encourage each other through modelling how they can do this.

Therapist: ‘Let’s see how you’ve planned to use activity regulation over the weekend, and let the group know what you think might get in the way of it’

Tony: ‘I’m going to work in my garden, but I’ve decided to use my phone to ring an alarm after 30 minutes so I stop before I overdo it.  Then I’ll go and stretch and get a drink of water before I get back into it.’

Therapist: ‘What’s going to be the biggest challenge to doing this on Saturday.’

Tony: ‘Probably my wife coming out to see how far I’ve got, and I’ll feel guilty that I haven’t done it all.’

Therapist: ‘Anyone else in the group have a similar worry?’

Andrea: ‘Yes, that’s me.  I’m sure that my husband will come out and take over whatever I’m doing and then I’ll feel I have to go on.  What I’ve decided to do is one part of the house that he never cleans – the toilet!’

Therapist: ‘That’s one way around it!  Justine, what do you think Tony could do?’

Justine: ‘I decided last week to tell my partner and my kids that this is my project and I want to do it myself.  I did feel worried about this but I picked up that I was listening to a ’should’ statement, and so I asked myself where it was written that I ‘had’ to get it all finished and that everyone else ‘had’ to be happy with it!’

Therapist: ‘And what happened?’

Justine: ‘The family left me alone until I went in for a coffee break, and then they said I’d done more than they expected!  So Tony could do the same thing, and maybe remind himself that doing something is better than doing nothing at all’

Therapist: ‘What do others in the group think about this suggestion?’ 

Silence

Therapist: ‘Justine, do you think you can say this directly to Tony?’

Justine: ‘Tony, do you think you can remind yourself that you’re doing more than you usually do, and breaking it up like this means you’ll be able to carry on longer in the day?’

Tony: ‘Yes, and I remember you, Graham, were saying the same thing about feeling guilty.  What do you think about this?’

Graham: ‘I do feel guilty when my family have to take over for me, but I liked what Justine had to say about doing something and it being more than nothing.  I could remind myself about this when I start worrying about what my family are going to say.’

Several things helped in this exchange – the therapist drew on the group’s common experiences, asked for specific responses (and more than one), then helped that person direct the comments to a group member rather than to the facilitator.

More on this tomorrow!  Remember you can subscribe using the RSS feed link above, or you can bookmark and come on back tomorrow! Comments and feedback welcome, just remember that comments are visible to all.  To contact me more privately, use the ‘About’ page and send me a message direct.

Bieling, McCabe & Antony, (2006). Cognitive behavioural therapy in groups. The Guilford Press: New York.

Edelman, Sarah; Bell, David R; Kidman, Antony D (1999). Group CBT Versus Supportive Therapy With Patients Who Have Primary Breast Cancer, Journal of Cognitive Psychotherapy.

THORN Beverly E; KUHAJDA Melissa C, (2006). Group cognitive therapy for chronic pain, Journal of clinical psychology , 62(11), 1355-1366.

Yes, I’ve been good this week, and I have given myself TWO WHOLE DAYS off work!
To reward yourself, take the following with a glass of water, and lie down.

Can you tell I have a teenager?

It’s true you know.

I’m a visual kind of girl, I need to see a diagram to help me conceptualise how the things I’ve been writing about recently all fit together. I’ve been looking at the various aspects of self regulation, emotions and executive functions and how this affects and is affected by stressors, of which chronic pain is certainly one.

Drawing again from Williams, Suchy and Rau, i’m going to try to describe how I think their model of executive functioning might influence the way I look at stress regulation in people with chronic pain.

This diagram is sort of upside down to me, but anyway, this is how I interpret it.
Initially we all have a genetic inheritance, or the genotype we were born with. This influences the way our neurotransmitter systems, brain circuitry, physiology and executive functioning work – but can be influenced developmentally by factors present either before birth, or during our formative years as children. The factors that can influence how our underlying systems work include attachments to others, trauma or abuse, opportunities for learning, stressors of many kinds and drugs.
These neurophysiological functions underpin our ‘personality’. As we know, different personality traits affect how we seek out and respond to stressors in the environment, including how much risk taking and novelty we enjoy, how much we react to the environment, how well we recover, and how we restore our functioning to homeostatis.

I see that in this diagram it looks like stress exposure, reactivity, recovery and restoration are linked in a unidirectional way – but I do wonder about this. At the same time, it does seem clear that each of these aspects of how we respond to stressors in turn affects that ‘black box’ of neurophysiological functioning. And the final outcome of these responses is seen in terms of physical and mental health outcomes.

I can see from this model how an acute trauma like a fracture, will be a stressor and directly affect the stress regulation factors – and at the same time will influence the neurophysiological circuitry. So in a vulnerable person, perhaps someone who has inherited less ability to regulate stressors or who has been unable to develop the potential of their genetic inheritance, the stress of an acute trauma could compromise their ability to self regulate, and in turn have much more trouble managing their acute pain – leading to a much greater potential for longterm disability.

What does this mean for clinicians?
As we learn more about how things like heart rate variability and other forms of self regulation can be trained and actually change how genes are expressed, I think we will have more of a basis for using biofeedback at an earlier stage and perhaps even as a preventive measure.

Appraisals, or how we view stressors, are directly addressed as part of CBT and ACT. Maybe again as a preventive measure, we can help kids develop skills in being aware of their own thought patterns and how to tolerate, or ’sit with’ emotions that are usually considered unpleasant. From some of the research discussed in Willaims, Suchy and Rau, it seems that both too little stress and too much stress are not good for wellbeing – but a certain amount is helpful and can be one way to develop resilience. Helping our patients learn to tolerate negative emotions and thoughts through mindfulness has been shown to influence prefrontal cortex activation.

Fitness affects executive functioning through several pathways, so the inclusion of exercise or activity in chronic pain management has an evidence base (even if there is no evidence that any specific exercise is better than another – yay! I can justify gardening and bellydance much more happily than vacuum cleaning or going for a run!).

I hope to have tweaked your interest in both self regulation and executive functioning over the past little while, it’s been interesting to read about these areas – and to ponder about how I can use them in my practice. Let me know if you’d like to know anything more – leave a comment, or you can email me via the ‘About’ page. Don’t forget that you can subscribe using the RSS feed link at the top of the page, or you can bookmark and just visit. I write most days – and tomorrow is Friday Funnies (I can hear the groans from here!).

Williams, P., Suchy, Y., & Rau, H. (2009). Individual Differences in Executive Functioning: Implications for Stress Regulation Annals of Behavioral Medicine, 37 (2), 126-140 DOI: 10.1007/s12160-009-9100-0

It’s visceral. Stress – hits you in the guts. Some of us cope well, some of us don’t – some of our stress lingers, sometimes it’s just the little things, those ‘daily hassles’ that end up tripping the switch. And I don’t think anyone would disagree that chronic pain is an enormous stressor. Regulating that stress level, or managing it effectively, has to be the main challenge in learning to live alongside chronic pain. Today’s post discusses executive functions (the parts of the brain that carry out self regulation) and stress.

Executive function is ‘… a multifaceted construct comprising a number of basic neurocognitive processes, including working memory, cognitive flexibility, response selection, inhibition, initiation, set formation, and set maintenance.’ Williams, Suchy and Rau state that ‘these processes allow us to generate goals and plans, modify our behavior in response to changes in the environment, and follow through and execute necessary actions in order to successfully achieve the intended goals.’ These functions are different from many CNS functions in that they require ‘attention’ or ‘volition’ to initiate and maintain them, whereas many other functions such as those that maintain homeostatis are pretty well automatic.

‘The areas of the brain thought to be primarily responsible for executive functions are the dorsolateral, superomedial, orbitofrontal, and ventromedial prefrontal cortices, anterior cingulate gyrus, the basal ganglia and diencephalic structures, the cerebellum, deep white matter tracks, and some aspects of the parietal lobes – and these are linked to each other and to other structures to ensure most cognitive processes including sensory perception, memory and language are linked.  As a result of these connections, EF serves as the interface between previously acquired knowledge and newly arising information in the environment.’ (Williams, Suchy and Rau, 2009) Can you see why I used a quote? I don’t trust myself to paraphrase!! These structures also link strongly to those automatic/homeostatic areas of the brain, so can influence emotional processing, autonomic control, and appetitive functions.

Even amongst people who don’t have chronic pain (or for that matter, low mood, or a brain injury), we vary in the ways in which we deal with stress. Williams, Suchy and Rau suggest that ‘even slight declines in EF can lead to a breakdown in stress regulation that affects both mental and physical health’ and that ‘aspects of EF are heritable.’ Certain executive functions such as switching attention, inhibiting a response or updating ‘working’ memory have been shown to be inherited.

I won’t go into detail about how this is studied, because it is quite complex and involves drawing conclusions from the results of both trauma or brain injury-induced deficits and the types of pathology found when people have been exposed to significant stress.  It’s also proven to be a very difficult area to study, especially in people with only slight deficits or ‘individual variations’ in the way they respond to stress.  Most neuropsychological tests are fairly blunt instruments and don’t show subtle problems, like those that occur when we’re stressed!

Some interesting findings, however, showing that traits like conscientiousness (also called ‘constraint’) have a positive association with better stress management and better health, while neuroticism (associated with the Behavioural Inhibition System – sensitising us to avoid harm, making us more tuned to negative cues) is associated with greater stress and poorer health.   Extraversion, or the tendency to want interactions with others and to become energised by them can be associated with additional risk taking, but also with positive affect which has a positive effect on health.  Openness to experience is a trait where people are basically inquisitive (that’s me to a T!) is associated with better adaptation to chronic illness, and the last one is agreeableness, or getting along with others and to cooperate, and it is associated with better health and lower stress.

What does this mean for chronic pain and executive functions or self regulation?

Perhaps some of the vulnerability to having trouble coping with longterm pain arises from genetic tendencies in the way our executive functions operate.  Remember that chronic pain is a stressor, and that chronic pain problems can arise during periods of increased exposure to stress.  This suggests that the effect of chronic pain on executive functions, or the ability to self regulate might influence how efficiently we can cope.  It also suggests that if our self regulation skills are vulnerable, then under stress we may find it much more difficult to manage.

From my last post, it also seems that we can develop self regulation, provided we have sufficient resource in terms of energy and social support (and someone to help establish appropriate goals).  Some people may find it more challenging not because they have less inclination to cope, but simply because they have certain tendencies that are inherited to make this aspect of coping much more difficult.

If as clinicians we can identify those people who need more support, and especially if we can identify some of the ‘components’ of executive functioning such as sensitivity to activating the Behavioural Inhibition System, maybe we can help prevent some of the chronic disability arising from having chronic pain, even if we can’t prevent the pain from being present. After all, it’s not the pain itself that is problematic – it’s the disability or functional limitations arising from the pain that create problems.

Williams, P., Suchy, Y., & Rau, H. (2009). Individual Differences in Executive Functioning: Implications for Stress Regulation Annals of Behavioral Medicine, 37 (2), 126-140 DOI: 10.1007/s12160-009-9100-0

I’m in two minds about attempting to regulate emotions. From ACT, and in particular, mindfulness, I’m learning that trying to control emotions and thoughts is darned near impossible – and unhelpful. From the research on the effect of pain on emotions and subsequently on self regulation, goals and coping, it seems that pain strongly influences emotion and that negative emotions in particular, influence the range of coping strategies and goals we choose – and success or failure in turn generates further emotion, and so on.

As Hamilton, Karoly and Kitzman say ‘the primary function of pain is to disrupt other ongoing activities and to direct attention toward the cause of injury or the extent of tissue damage’ – of course, in chronic pain, there may no longer be any injury or tissue damage, and instead we are left with the experience of disruption to activities without a purpose. Pain by definition involves negative emotions, which we have seen over these posts recently, can activate ‘harm-avoidance’ strategies. Over time, pain can reduce the attention given to, and pleasure obtained from, activities that are usually enjoyable, and can reduce how well we process normally positive information.

So, pain detracts from normally enjoyable activities and reduces the benefits we usually get from achieving goals, probably makes us less likely to choose goals that are driven by curiosity or positive benefits and instead increases the chance we’ll choose ‘harm avoidant’ goals, and when things go wrong, pain makes it much more difficult for us to look creatively at ways to cope.

Self regulation is influenced therefore by emotions – but at the same time, self regulation can influence emotions. Pain management goals in one study were not only influenced by negative emotions but also by the level of social support people had. Maybe routinely including family and social networks into pain management goal setting with people with pain would be helpful. I’m noticing that over the past 20 years, the number of people who attend assessments and pain management programmes with partners or family members has dropped considerably. It’s almost as if the person with pain is the only one who ‘has’ to cope. A couple of posts ago I discussed the need to ensure that people have adequate coping resources before setting self regulation goals, because these resources become depleted (and there is no doubt self managing pain is hard work!).

Yesterday I mentioned ‘emotional complexity’, or the ability to tolerate opposing moods. Hamilton, Karoly and Kitzman think that this ability is something that is acquired rather than a trait, and suggest that CBT and ACT may, because they help people understand the relationships between thoughts and emotions, help people develop the ability to regulate emotions. Of course, ACT suggests that rather than trying to control either thoughts or emotions, we simply acknowledge them and they will pass.

By maintaining focus on values, or what is really important, ACT suggests that we’re able to tolerate the fluctuations in emotions and thoughts and remain engaged with things that we value. ACT theory suggests that by allowing the moods or thoughts to flow, the natural ebb and flow of emotions continues rather than building up to an intolerable level, or being judged negatively.

This is a different approach to self regulation from CBT where CBT suggests that by logic we can reassess our thinking patterns and replace them with more helpful ones, and in turn these will influence emotions. I think CBT has its place, but more and more I’m finding that at least part of the time I’m encouraging people to ’sit with’ negative emotions and thoughts in order to reduce the threat value or judgements about them, and help people recognise that they will survive and can continue to do what is important even if at times they feel different feelings, including negative ones.

A good deal of pain management works on helping people cope with the stress associated with having pain. The authors suggest that it might be just as important to consider working towards approach-oriented goals, that is, doing things that have positive reward, such as social goals, because these both support self regulation, as well as generate positive emotion. ‘Therapists must emphasise to paitents that it is important to maintain focus on other goals, even during painful flare-ups…both patients and therapists [can] become focused on distress management and lose sight of goals related to an enhanced sense of wellbeing.’

The way I interpret this is that it’s just as important to help people identify social activities, leisure activities and have fun and grow as it is to persist with getting better sleep, return to work, or use relaxation to cope with a flare-up. I’ve been including scheduled pleasant events every day with patients for quite a while now – and it can be unbelievably difficult! Some people have never ‘had fun’, never had time to be sociable, never thought of relaxing or having a hobby or being creative.

I remember with one patient, we instituted a whole ‘Pyjama Day’ where she could take the phone off the hook, watch DVD’s, paint her nails, have a soak in the bath and read trashy novels! Initially it was really difficult for her to do this without feeling guilty, but later on she enjoyed it and started to look foward to it, and then started to plan self development ‘creative’ things she could do on that day. Yes, painting or photography or baking or learning a foreign language can be part of pain management!

This won’t be the last post on self regulation, coping, emotions, goals and chronic pain. It seems to neatly tie in with the focus of living a good life despite having pain, and especially of living according to values. I think self regulation is one of those ‘occupational performance components’ that might be overlooked by some occupational therapists who focus on occupational performance, or function, but might not consider the underlying skills and resources that need to be present for someone to function well. Occupational therapists have as a core philosophy that ‘doing is being’, and by doing functional activities, people become well. It looks like that assumption has some support from the literature, now it’s time to look at how to help people ‘do’.

Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

Can chronic pain be a force that shapes how we go about responding to challenges within our environments?

Does chronic pain influence how we feel emotionally about daily activities that contribute to overall goals, and perhaps negatively bias the way we think about the process of setting and achieving goals?

I’ve already concluded that having pain doesn’t mean people can’t do what they want to do, but it certainly makes it harder and less enjoyable.  Today’s post will briefly look at two theories that link emotion, cognition and pain.  Once again, I’m drawing from a paper written by Hamilton, Karoly & Kitzman (2004).

These authors refer to two theories – the first being a two-factor model developed by Carver and colleagues in which it is proposed that people have two emotional regulation systems.

1. A behavioural activation system (BAS) associated with positive feelings when the ‘appetitive’ systems is satisfied.  The appetitive system refers to a system that encourages us to approach and remain engaged with something for reward.
2. A behavioural inhibition system (BIS) that associates negative emotions with goals that are involved with avoiding harm.

Carver’s model proposes that emotions develop during the course of evaluating process towards a goal – if the going is good, we feel good and carry on.  If the going is not so good, we feel less positive and may disengage from that goal.  This emotional response influences whether we persevere or simply give up depending on our tolerance to not receiving immediate gratification.  So it makes me wonder whether helping kids to learn to persist with something until they do it correctly is actually a fundamental learning experience that is needed so they can learn ’stickability’ when the going is tough.

Hamilton, Karoly and Kitzman suggest that when we think about the effect of this model of emotion on self regulation, individual adjustments to the limitations of chronic pain might reflect how sensitive each individual is to either positive feedback or negative feedback.

This might influence how we give feedback to people who are pursuing a goal – some may need just that bit more encouragement and help to overlook the times they don’t succeed, while others might need to be encouraged to see the consequences if they don’t make progress (especially in the case of losing access to help from a compensation organisation).

The Hamilton, Karoly and Kitzman paper goes on to explore the evidence supporting Carver’s model and how this might influence individual differences that we see in people adjusting to the demands of chronic pain - perhaps some people are resilient because they can draw upon small steps towards a goal that others might overlook because they are less sensitive in the BAS.  Perhaps some are strongly sensitive to the BIS and as a result are more energised by avoiding the negative emotions associated with remaining ’stuck’ when coping with chronic pain. They also suggest that maybe chronic pain itself influences BAS and reduces its sensitivity (ie chronic pain reduces how ‘rewarding’ achievement feels), and/or increases the BIS sensitivity (ie makes it all the more important to avoid risky situations).  As they put it ‘pain-related negative affect could have a pervasive impact on the evaluation of goal-related progress and resulting affect…whereas periodic pain flare-ups may have a state-dependent effect on BAS/BIS sensitivity.’

The second model is one I have come across in my readings – Dynamic Model of Affect (Reich, Zautra & Davis, 2003).  In this model, Zautra and colleagues suggest that how well we adjust to chronic pain depends on individual differences in the structure of our emotional response, as well as the limitations we have in information processing. This model puts forward the idea that the relationship between feeling good and feeling more negative depends less on stable personality ‘traits’ than on the relationship between general mood and what is happening in the here-and-now.  Once again, research is cited by Hamilton and colleagues to demonstrate that when stress is low, both positive and negative moods vary independently – we can feel both happy and irritable and this can fluctuate just because it does!  During times of high stress, however, how good we feel is limited by the underlying level of negative emotion we’re experiencing.

When considering both models, Hamilton, Karoly and Kitzman suggest that Carver’s model refers to responses to individual events, whereas DMA refers to mood states that might occur over a period of time and across more than one dimension.  They also suggest that the DMA gives a better description of what occurs during increased stress, when it describes that cognitive and affective processing becomes more focused on avoiding threat than on seeking reward, while during low stress, both outcomes have equivalent influence.

The final aspect of emotion and chronic pain as it related to self-regulation, and in particular, setting and achieving goals, is that some people seem to cope quite well during periods of pain flare-up, and do so positively.  Zautra and colleagues call the ability to both experience negative emotional drive AND positive emotional drive ‘emotional complexity’. In terms of goals, an ‘emotionally complex’ person might be able to continue to react to positive events and ‘use that energy to fuel additional goal directed efforts’.

Attitudes towards experiencing emotions might influence the ability to be ‘emotionally complex’. If we’ve been taught that ‘feelings are bad’ and should be stifled, or that understanding and being clear about emotions is helpful, will influence how well we are able to identify the different emotions we experience, and how well we can tolerate having them.  Being aware that we can experience different emotions – and cope with them – has been shown to help people keep focused on goals even during periods of high stress, high pain and limited progress.

What might these two models mean for pain management?

As therapists we might need to ‘take the emotional temperature’ of the people we are working with.  If we are working with someone who is highly sensitive to being ‘driven‘ by avoiding negative emotions, we need to be aware of this during pain flare-ups – it might be even  more important to show people that they can persist during these times than to give them lots of encouragement to try new intrinsically rewarding activities.  Recording progress might help.  Encouraging recognition of even small progress during flare-ups is clearly important.

…but wait, there’s more! Tomorrow: regulating emotions and coping.

Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76

Husband 1.0
Tech Support
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Subject: Service guide for husbands
Dear Tech Support:
Last year I upgraded from Boyfriend 5.0 to Husband 1.0 and noticed that the new program began making unexpected changes to the accounting modules, limiting access to flower and jewelry applications that had operated flawlessly under Boyfriend 5.0.
In addition, Husband 1.0 uninstalled many other valuable programs, such as Romance 9.9 but installed undesirable programs such as NFL 5.0 and NBA 3.0. Conversation 8.0 no longer runs and House Cleaning 2.6 simply crashes the system. I’ve tried running Nagging 5.3 to fix these problems, but to no avail.
Desperate
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Dear Desperate:
Keep in mind, Boyfriend 5.0 is an entertainment package, while Husband 1.0 is an operating system. Try to enter the command: C:\>I THOUGHT YOU LOVED ME and install Tears 6.2. Husband 1.0 should then automatically run the applications: Guilty 3.0 and Flowers 7.0. But remember, overuse can cause Husband 1.0 to default to GrumpySilence 2.5, Happyhour 7.0 or Beer 6.1. Beer 6.1 is a very bad program that will create “snoring loudly” wave files.
DO NOT install MotherInLaw 1.0 or reinstall another Boyfriend program. These are not supported applications and will crash Husband 1.0.
In summary, Husband 1.0 is a great program, but it does have limited memory and cannot learn new applications quickly. Consider buying additional software to improve performance. I personally recommend HotFood 3.0 and Lingerie 5.3.