One of my beefs about cognitive therapy has to be the concept of ‘maladaptive’ or ‘erroneous’ beliefs. For many people experiencing pain, their beliefs are based on experience since developing persistent pain – so we could readily be called out if we suggest that their belief that ‘I always get a flare-up when I lift boxes off the floor’ was erroneous! It actually does happen, they do get pain every time they do this activity.
The problem with this thought is that it may be accurate, but it’s not helpful. And while the statement itself may be accurate, the underlying (and unstated) belief is something like ‘…and I shouldn’t have to experience pain’, or ‘…and I won’t cope with a flare-up’, or ‘…it’ll be horrible/awful/a disaster if I have a flare-up’.
So we’re not going to win if we reality-test the original statement, instead we need to help the person recognise the unstated rules, beliefs or attitudes that are being repeated, and help them work out more helpful ways of supporting action.
Eliciting the underlying statements can be tricky. Many people with pain haven’t actually explored their belief that they ‘shouldn’t’ have ongoing pain – I mean, who wants pain? And all our media and health professionals and medications and everything suggests that having pain is unnecessary and wrong! BUT people do have ongoing pain, not everyone can have their pain reduced, and pain is a fact of life (especially in developing countries).
Sooo, what can someone who isn’t a cognitive therapist say or do to help?
Some ways to elict automatic thoughts first:
It’s helpful to have a card with some of these prompts written down if you’re not used to asking this type of question…
Once you’ve helped the person access their automatic thoughts (remember they can also be images!), then it’s helpful to probe more to find out what is driving that thought. Some useful questions are:
- What would it mean if that were true?
- Why does that bother you?
- What does it say about you if that were true?
- What is the effect of thinking like this?
Then it can be helpful to gently challenge these beliefs – like ‘what does ‘not coping’ really mean?’, ‘why do you think you were singled out to have ongoing pain, if no-one is supposed to have it?’
Asking for evidence to support the underlying rules, attitudes and beliefs needs to be done empathically, but consistently. Some people will find it really hard to identify just what they do mean by their automatic thought, and may need some time to become aware that it’s their evaluation of the experience that is troublesome rather than the experience itself. And its always up to the person to make a choice about whether they want to reconsider their automatic thoughts or not – it’s just your role to help them identify the consequences of their choices.
If they want to avoid activities because ‘it hurts’ the consequences are known – it will gradually become more difficult to maintain activity, and they will be acting against some of their values.
If they want to continue to believe that they ‘shouldn’t experience pain’ – they may continue seeking treatments, only to find that they’re disappointed again and again, which can be demoralising.
As a therapist, it’s really helpful to check your own automatic thoughts when you start to do this work – perhaps you avoid challenging people because you believe ‘people should be happy after they’ve seen me’, or ‘I shouldn’t upset people’.
Perhaps you are worried that you may harm someone if you ask them to continue with an activity when they’re sore…
Perhaps you think people ‘shouldn’t’ be asked to persist with activities ‘because I wouldn’t want someone doing that to me’.
The effects of our own automatic thoughts and underlying beliefs shouldn’t be ignored, because thoughts are powerful drivers even when they’re not fully expressed!
Remember, in chronic pain, people don’t die of pain – they suffer from fear, demoralisation, lack of hope, feeling out of control and feeling pessimistic for the future. It’s our job to help them recognise that they can take control, and while pain is unpleasant (and it truly is!), it can be managed and life can be good.