Attention Please! Attention management for chronic pain
A debate that’s been going on for some time is the role of ‘distraction’ in pain management.
So many of the people I see have told me they ‘just ignore’ the pain, or ‘I try to distract myself’, or similar, that there isn’t much doubt to me that people habitually use attention management as a coping strategy – yet the research findings have been quite mixed, especially with respect to ‘distraction’ and ‘ignoring’ pain.

Pain is naturally an attention-grabber. That’s one of the main purposes of acute pain, IMHO, to attract attention and direct the person to DO something in response. Of course in chronic pain, there is little to DO, so the person needs to redirect attention away from pain and back into the task at hand.

As I posted late last year, this process of redirecting attention detracts from the cognitive reservoir, so there is more effort needed to carry out tasks, it is more fatiguing, and it requires effective self regulation which also becomes depleted over time. (As an aside, I wonder whether one of the features of resilient people is that they have more effective self regulation skills, so they achieve more despite chronic pain – just a thought!).

The results from attention management are mixed, but despite this, many if not most CBT programmes include something on attention management such as attention diversion, imagery, and more recently, mindfulness.  The theory behind these interventions is derived from several models: Fear-avoidance model suggests that by avoiding activities, the negative thoughts about the pain become dominant and the individual becomes hypervigilant.  An information processing model suggests that there is only a certain amount of ‘brain space’ available to actively process information (a little like a torch shining into a dark room illuminates only what is within the beam of light), so whatever is salient, novel, intense and so on will ‘grab’ the attention, leaving the rest of what is going on to be ‘in the dark’ so to speak.

Mindfulness brings another style to attention management.  In mindfulness, the possibility that sensations can be recognised as simply that: sensations without emotive labelling (‘that is prickly’ rather than ‘I hate that prickly feeling’); leaves the individual able to engage with the sensations (ie feel them) but not buy into the emotional burden of judging those feelings.

A well-written but not empirically-tested manual for attention management was used in this study by Elomaa, Williams and Kalso (2009), to specifically look at the effects of attention management provided in a structured way, and within the context of a group programme.  The authors indicate that there were no other cognitive coping strategies provided as part of this programme, and that the facilitator followed the manual and allowed group discussion using CBT principles to help develop the skills.   The participants did, however, receive treatments aimed at reducing pain during the programme.

As usual, a battery of questionnaires was given to participants and these included the Pain Anxiety Symptoms Scale, the Fear Avoidance Behaviour Questionnaire, the Pain Vigilance and Awareness Questionnaire, and a Depression Scale.  Measures were taken at five time points (initial assessment, pre-treatment, post-treatment, 3- and 6-month follow-up). Information about pain location, duration of pain and work status was collected at every time point.

The treatment consisted of modules, which share a common CBT structure, from orientation, assessment, and reformulation/re-conceptualisation of the main issue to skills teaching, rehearsal, generalization and homework exercises.  If you’re interested, I’ve given the link to the manual above, and this paper also outlines the content of each of the six sessions provided.

57 participants were recruited to the programme, 41 started treatment, and five either  didn’t complete all the sessions, or didn’t complete the questionnaires.  Reasons for not participating were due to work issues, or ‘physical health’ (the details of physical health problems aren’t discussed).   27 of the 31 participants included in the analyses were women, most were married or in a relationship, half were not working or retired, and mean pain severity during the programme was 7.0 (SD = 1.5), 21 were concurrently receiving medical treatment for their pain.

Over the study period, pain intensity dropped, interference from pain dropped, and anxiety measures for experiencing pain also dropped.  There was no change in mood scores.  In the follow-up period (to 6 months postprogramme), pain intensity and pain interference continued to drop (although not as much as in the first time period); pain-related anxiety and fear-avoidance beliefs also dropped, but vigilance to pain didn’t continue to drop.  An interesting finding was that the people who attended the six month follow-up had lower FABQ scores and better self-rated working ability than those who only attended the three month follow-up.  Interference from pain was also lower in this group.

A further aspect of this study is that the use of techniques after the programme was also examined.  This is important, because some studies have shown that people typically don’t use any of the coping strategies 12 months after completing a pain management programme (see my post about this here).

Cutting to the chase for clinicians: What can we make of this?

The first thing is that there are some limitations to this study, apart from sample size – people were also receiving medical pain reduction treatment which could influence pain intensity (well, it’s meant to!!), and may also influence distress, catastrophising and function.  The measures used were all self-report, and most of the respondents were women who were not particularly depressed, although their pain intensity was quite similar to the people attending Burwood Pain Management Centre.

A couple of interesting things for me: it’s good to know there is a manual that can be used to deliver a systematic set of attention management strategies. This is one way at least to ensure that people who receive pain management have some consistent content (although there is no obligation for anyone anywhere to include this!).  Would that more programmes had some standardised components, although I’m one of the first to roar if I HAD to deliver a standard programme!  Despite this, it’s a start to learning more about the individual content of pain management that might be effective, rather than seeing it as one big black box.

Another interesting thing is that these psychologists consistently recognised the need to integrate the coping strategies into daily life. What a groundbreaking thing!  Perhaps that could be something that people delivering exercise programmes could consider too?!  Or instead, suggest that an occupational therapist be involved in delivering and helping people generalise and personalise their skill repertoire.  Just a thought.

Elomaa, M., de C. Williams, A., & Kalso, E. (2009). Attention management as a treatment for chronic pain European Journal of Pain, 13 (10), 1062-1067 DOI: 10.1016/j.ejpain.2008.12.002

McCracken LM, Dhingra L. A short version of the Pain Anxiety Symptoms Scale
(PASS-20) preliminary development and validity. Pain Res Manage

Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs
Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low-back
pain and disability. Pain 1993;52:157–68.

McCracken LM. Attention to pain in persons with chronic pain: a behavioral
approach. Behav Ther 1997;28:271–84.



  1. Looks like a great resource, Bron, thanks for the link!

    You have clearly written this blog simply to provoke me 😉

    1. I think distraction is to attention management what ‘being careful’ is to pacing. Namely a poor or selective interpretation of a useful strategy. Trying to ‘take your mind off’ your pain, or ‘blocking it out’ appears futile and can lead to a subsequent increase in pain. So as a short term strategy it has a place, but not always practical with a chronic condition. Mindfulness seems to be quite distinct – being aware of the sensations but reframing them or functioning despite them makes more sense to me.
    2. Nice dig at the physio’s. As a cheap psychologist myself (physio) I would counter that it’s not the profession but the individual that needs challenging. There are as many OT’s reinforcing pain contingent behaviour (toilet raise anyone?) as physio’s trying to cure chronic conditions.
    How about the initial referral to health professional? Something that specificies a clinician with experience in chronic pain, rather than a particular profession. i suspect that is a far bigger indicator of appropriate intervention than the undergraduate course they attended.

    Keep up the good work – I’ll have to start thinking and reflecting on my practise soon!



    1. So unfair P, I’d never do something just to provoke anyone in particular – on the other hand, opening up discussion is most definitely dear to my heart!
      I agree: the simplistic ‘distraction’ term is as woolly as an OT weaving, while ‘pacing’ is as good as a hot pack for a physio…so it’s up to us to start getting clear on what we mean by each term. I like the definitions and treatment protocols as detailed in this manual, and I do wish I could think of a way to study ‘pacing’ in a similar way! But I fear ‘pacing’ is more tainted than even ‘distraction’, in that almost everyone knows something about pacing even if they never actually use it themselves – it’s talked about in so many ways, even alcohol intake!
      Oh and yes I do agree, it’s less about the original professional training and more about the knowledge-base that’s up-to-date and relevant to be ‘safe’ to practice!

  2. Speaking as a chronic pain sufferer from birth until the age of 40, I have to say that having distractions were the key to some of my survival. In fact when I am counseling folks about those suffering with CP, one of the worst questions that someone can ask is “How are you feeling?” When you are using all of your resources to deny your pain, you do not want to have to reflect on it by acknowledging it.
    As an artist, I can truly say that when I am doing serious work in the studio I am not even aware of my pain. it returns only when I take my focus off my painting. So there has to be some mental anesthesia that can be affected by taking your mind off the pain.

    1. Hi Mary
      Thanks for taking the time to comment! I think the argument over ‘distraction’ is when people try to ‘ignore’ their pain – and that’s almost impossible, because as soon as I say ‘don’t think of your pain’ – you know what you’re thinking about! Distraction involves being immersed in something that is intrinsically interesting or more salient, more involving, more attention-grabbing than the pain. I know what it’s like to use this approach myself – writing, drawing, dancing, and it’s very effective – but not quite as effective when pain is very intense. Deliberately avoiding experiencing pain (or unpleasant thoughts and judgements about pain) is difficult to do, that’s why mindfulness has been introduced, and I’ve written quite a bit about that – and will do so more in the future.
      Thanks for sharing, and I hope you come back soon!

  3. Wow, as usual, your post is resplendent with thought-provoking material! I could do my own post on here (LOL!) in response to yours, but I’ll only comment on a few things.

    1) To be resilient one needs to have good self-management skills. I call it good “bounce-back-ability”. Chronic stress and pain can lessen the bounce factor.

    2) When I was awaiting my first hip replacement, I was substitute teaching. It was not easy by any stretch of the imagination. However, I found that the students kept my attention diverted from that excruciating pain. Distraction did work for those hours that I was in the classroom.

    Having said that, I’d get home and be done for the day and the evening! Getting a good rest was difficult, since the pain would then kick into high gear.

    I like what Mary said re. “mental anesthesia”…she was engaging in her art and that fed her soul, which rejuvenates us and allows us to continue on in the face of hardships. The proverbial breath of fresh air!

    3) Finally, one size does not fit all. I was blessed to be treated by a physiotherapist who understood this in respect to ice or heat. I knew when one would do the job vs. the other. She advocated listening to and respecting the wisdom of the body.

    There are general guidelines to be followed, but there are always exceptions to the rule.

    1. I’m always happy when someone takes the time to comment! Brilliant stuff!
      Resilience is what I’m studying as part of my PhD – what do people do to ‘bounce back’ and cope well even when the going is tough? And yes, the research supports your idea that pain and stress reduce how readily you can bounce back – but still some people manage it! My theory is that if these skills are learned, and used frequently and flexibly before chronic pain develops, they can then be turned on when needed with less effort than for people who haven’t had these skills before their pain. It doesn’t mean they can’t develop the skills, but it might be quite a challenge.
      Attention management works, no doubt about that – it’s just that if we just try to ‘ignore’ the pain, it doesn’t go away at all, in fact it gets much worse. And some studies show that while we might be able to actively distract for a while, once we stop distracting, the pain is more pronounced. I’m not sure of the exact mechanism, but it’s something I’ll look into.

      And yes, I couldn’t agree more – one size doesn’t fit all. That’s why health professionals need to learn to think and reason before they act, and then view their interventions as an experiment – let’s see if it works. If it doesn’t work, it’s not the patient’s ‘fault’, it’s simply that the hypothesis being tested wasn’t supported by the evidence. That means the therapist and the person with pain need to re-think the underlying rationale for the intervention: is it relevant in this case?

      Looking forward to more discussion – thanks!

  4. Oooo, how I would love to have this conversation in person! How about I pop on down there? 🙂 (If only it were so easy!)

    Are you on Skype, by any chance?

    I’m definitely not about ignoring the pain. I agree with you, pain is there to tell us to slow down, to alter or to fix. It is our amber or red light system.

    However, in order to get moments of respite, we do need to do something to feed our souls.

    You may find this interesting. For years I kept a journal chronicling all my health concerns – aches, pains, etc. I have since stopped doing that and now look for and record signs of wellness. There’s a marked difference!

    I’ll leave it at that for now.

    1. Come on over – only a hop, skip and a jump to here!!!
      Yes I am on Skype (well I have a skype address) but I haven’t learned how to use it yet…
      I completely agree that we need to have things to feed our souls – that’s exactly the point about mindfulness and ACT (Acceptance and Commitment Therapy) – it’s about allowing yourself to be WITH the pain instead of working hard to ignore it or focusing on it (like you’ve found with no longer writing about your pain!), and at the same time going out and doing what is of value to YOU. What enriches your life somehow removes the ‘sting’ from pain, although we might need to think about why we are doing it. The trick is to do things with a valued purpose in mind – so although I loathe vacuuming, I value having a serene and tranquil house, so vacuuming is done with that in mind instead of ‘Oh how much I hate cleaning!’

      Feeding your soul, IMHO, is about doing what you believe is of value and being IN the moment instead of behind or in front of it.

      I hope you enjoy Friday Funnies – it’s almost time!

  5. Now where is that Star Trek transponder when you need it? LOL!

    I had a client who used her dish-washing as a time to balance her nervous system – rather than “Oh, gee, dishes AGAIN!”, she worked from a place of restoration…similar to you and your vacuuming.

    Your patients/clients are?/will be? fortunate to work with someone such as yourself!

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