Yesterday a couple of colleagues were talking about balance in life, and making it plain that they think people who spend a lot of time and energy on their work are sad. Their opinion? Work is the means to pay for your ‘real’ life, to spend more on working means less on what is really important to them. And musing on this, as I do, I thought about values and what we bring in to pain management and how this influences our practice. It also started me thinking about the goals and values of the people we see with chronic pain and disability.
One way of looking at the distress and disability associated with chronic pain might be to think of it as a result of conflict between what can be done (resources) and both values (what is important) and goals (how I want to express my values). An ongoing problem with life itself is the limited resource we have to do what we want! The whole of life is really about this balancing act. And I suspect that one of the major sources of distress for people with chronic pain is that they carry on using the same strategies to express values but with limited resources to achieve it.
I’m not the only one to think of it this way – several authors have talked about the concept of ‘psychological flexibility’ (McCracken & Vowles, 2007). Psychological flexibility involves several processes such as acceptance, mindfulness, values, and cognitive defusion. This is a bit of jargon from ACT (Acceptance & Commitment Therapy) and basically means being able to allow oneself to experience all that life brings, while at the same time choosing to act according to what is important and valuable to you – and being prepared to alter the way in which this is achieved, depending on the situation.
So one way of looking at people with disability from their chronic pain is that they are stuck. Stuck using old and unhelpful ways to achieve what is important to them.
ACT and several other similar mindfulness therapies makes a point about control. Basically, we can’t control much in life except our actions. If we try to control our thoughts, our emotions, other people’s reactions, and events in the environment we’re doomed to use a ton of energy and probably not succeed. We can control our actions, and we can choose to act according to our values. BUT we can’t predict the outcome of our actions because so many other variables influence this.
CBT teaches attention to automatic thoughts, processing their helpfulness and replacing or substituting unhelpful thoughts with ones that are in line with what the person wants. ACT can be similar in that one focus for therapy is to recognise that our thoughts are not US. We can stand back from our thoughts, be aware of them, but at the same time remain able to act according to other important values. One problem I have with CBT is that when my own resources are low (I’m really tired, maybe I’m a bit depressed) the energy it takes to process and evaluate my automatic thoughts can be really hard to find. It takes a lot less energy to simply allow the thoughts to be there but not act on them and remain focused on achieving things that are important to me.
One of the problems with pain management IMHO is that patients (and therapists) often want to ‘control’ the pain, and regain control of life again. But chronic pain is so seldom completely under ‘control’, it’s characterised by fluctuations, and we risk focusing on trying to prevent pain from fluctuating by talking about ‘controlling’ pain. Actually what we are trying to achieve in pain management is living according to what is important (valued) and being flexible enough to find ways to achieve this despite pain. Pain itself can become irrelevant, a bit like being too hot or too cold, or being in a noisy or smelly environment.
I am clearly a very sad person, because one of my passions is learning about pain and pain management. It’s also my work. I love spending time reading about pain management, I obviously blog about it, I talk about it, I use the skills personally every day, and I get to work with people who have chronic pain. I’ve learned I can’t control my own pain, but it can be irrelevant ‘noise’ that doesn’t need to distress me. What’s important to me, and what I value, is being able to keep on learning, keep on sharing what I’ve learned, and to live a life that is balanced – for me!
What this means is that there are times when I choose to act according to what is important to me, despite my own thoughts (which might be automatic, and wanting affirmation from people that I’m OK and not ‘sad’), and despite my own energy levels. To be able to choose whether I persist with some things and drop others, knowing that I’m living out my important values gives me that freedom that we call ‘being in control of my own life’.
It looks, from the literature, that being flexible, being able to accept what is without judging, to hold onto specific goals lightly and to act in line with our values makes an enormous difference to wellbeing. I hope that in pain management we can help people live well, maybe ACT is another way to do so.
I’ll leave you with this saying from my shopping list jotter:
‘The world is full of people who will go their whole lives and not actually live one day. She did not intend to be one of them.’
Yes, that’s me!
MCCRACKEN, L., & VOWLES, K. (2007). Psychological Flexibility and Traditional Pain Management Strategies in Relation to Patient Functioning With Chronic Pain: An Examination of a Revised Instrument The Journal of Pain, 8 (9), 700-707 DOI: 10.1016/j.jpain.2007.04.008
GUTIERREZ, O., LUCIANO, C., RODRIGUEZ, M., & FINK, B. (2004). Comparison between an acceptance-based and a cognitive-control-based protocol for coping with pain* Behavior Therapy, 35 (4), 767-783 DOI: 10.1016/S0005-7894(04)80019-4