Anyone who works in pain management knows that sense of profound satisfaction when someone says ‘My pain is no different, but I feel differently about it’. It’s a sign that something has shifted for the person, that they’ve started to move towards accepting it, taking charge of life again instead of waiting for, hoping for something to take it all away.
After working for about 12 weeks with one man, yesterday was the last session. We reviewed his formulation together – looking not so much at how his pain arose (it’s neuropathic post-surgical pain), but the influences on his experience of his pain. We looked at the problems he was having with his pain – poor sleep, feeling unwell and nauseous when it spiked, trouble concentrating and managing work, feeling low in his mood and worried that his work performance was suffering, and his low activity level. Together we’d developed this picture of what was happening, and together we’d worked out some options for coping with it.
My main approach initially was to work on sleep – because for this man, sleep was a major problem.
He’d have trouble going off to sleep, get to sleep after a couple of hours, only to wake up an hour later with a spike of pain. Then he’d have trouble getting back off to sleep, and eventually fall asleep only to wake an hour before he really wanted to, feeling exhausted.
So we talked about the natural sleep cycle and the things that can disturb sleep. We talked about how his mind was busy when he went to bed (and what was on his mind at that time), and how his body became tense and uncomfortable when he woke with his pain – which set off another bout of worrying. We talked about how hopeless and helpless he felt when he went off to bed and when he woke so early in the morning to face another day of ‘fighting with this pain’ as he put it.
We talked about ways to calm a busy mind – the 15 minute ‘appointment with worry’ technique. Making an appointment for 7.15pm to worry furiously (writing down every worry for the entire 15 minutes which is harder than it sounds!), and then telling himself not to worry every time he started to throughout the day – because he had this appointment!
We discussed sleep hygiene, and how this might help him use bed for sleeping not worrying or watching TV or eating.
We worked on helping him reduce his physiological arousal by developing self regulation skills. It turned out that this became one of his most helpful strategies – diaphragmatic breathing, Jacobsen relaxation, and imagery. He practiced this with biofeedback (Wild Divine was one of his favourite programmes).
His sleep pattern started to return to a more normal pattern, with less time before he went to sleep, and waking only briefly through the night.
We looked together at his thought patterns – what was going through his mind about his pain? We talked a lot about unhelpful thinking patterns like crystal ball gazing, emotional reasoning, ‘shoulds’ and other rules, and magnification and minimisation. We looked at the effect of having these thought patterns, and worked through them to find out if they were accurate, or whether there were other ways of looking at the situation.
Finally, we spent a long time discussing acceptance. Not losing hope, not giving up, but not fighting, not being angry with the pain. Making space for it to be there, because it would be there anyway. Allowing it room to breathe and then settle back down – because it always does settle down after a while.
This man kept a pain diary throughout – not something I asked for! But interesting to see that his pain intensity didn’t change, neither did the frequency of severe spikes of pain. What did change was his record of ‘botheredness’ – how much he was bothered by his pain. If you like, this was his judgement about the pain. This reduced over time as he began to describe his pain as like a naughty child having a hissy fit – give it time to settle down, and it does. Pay attention to it – and it’ll act up, ignore it, and it’ll try harder to get your attention.
It’s great to have a chance to reflect with a person on what they’ve discovered about themselves, and how they can enjoy a full life even if it’s different from their previous one. It’s such a good feeling and why I love working in this field.
Have a great day!