Old beliefs die hard: case conceptualising coping with a flare-up

We know about neuroplasticity – how the brain so wonderfully remodels connections continuously.  We also know how hard changing habits can be.  The underlying premise of the cognitive behavioural approach to coping with chronic pain is that people can learn new ways of viewing their situation and develop new responses, and in doing so, start to live well again.  The process is not easy!

Before I go further, I want to reassure readers that the case presentation I’m going to discuss is a fiction – based on several real patients, but with details altered to protect identity.

One of the most difficult aspects of coping with chronic pain is that the pain doesn’t remain at a constant level.  It fluctuates in intensity, it can remain high for varying periods, it can drop seemingly without any reason, and dealing with life in the face of the unpredictability of this can be really challenging.  There are a lot of different terms for these exacerbations – I often read of ‘breakthrough’ pain, typically in conjunction with an article about medication, with the paper recommending ‘as needed’ medication to eliminate the pain.  I also often hear patients talk of  ‘reinjuring’ which can often lead to fear that there is some ongoing damage in tissues, and can be associated with avoiding the use of that body part.  I prefer to call them ‘flare-ups’, because they are in the main simply a flare-up from baseline levels of pain – and typically drop down again after some time.

It’s not surprising that many people look for the ’cause’ of the flare-up.  Sometimes this is relatively easy, maybe a sudden increase in activity level, maybe a stressful emotion, maybe a change in temperature or even forgetting to take a regular medication.  Many times, though, flare-ups arrive completely out of the blue (well, probably gradually increase rather than suddenly at very high levels), and there is little point in trying to find out ‘what caused it’ and a lot more about learning how to deal with the situation.

Jenny is a woman with chronic low back pain.  She’s changing from one type of medication to another, and in the middle of this has been faced with a new employer taking over the shop in which she works.  Jenny is just new to learning how to cope with chronic pain because until now she’s been able to have periodic injections that reduce her pain, but she’s recently been advised that these injections are not available to her because their effectiveness has been gradually becoming less and less.  She’s also been used to using ‘as needed’ medication when her pain is high, and while she’s quite familiar with and can effectively use breathing, positive self talk and activity management most of the time, during a flare-up she’s mainly used prn medications.

To help her begin to understand why she gets so distressed during flare-ups, when most of the time she manages her daily life reasonably well, I decided to use one of the ‘traditional’ cognitive behavioural case conceptualisation forms with her.  The version I’ve used comes from Judith Beck’s book ‘Cognitive therapy: Basics and Beyond’, but there are many version of this available on the internet. This is an abbreviated version.

Jenny has a very good relationship with her partner and two children. As a family they have good social connections in their local community, and have maintained supportive contact with their extended family. She has several close friends with whom she can talk and feels comfortable expressing her frustration about her pain. She has had generally good health, has never had a problem with mood or anxiety in the past, and has demonstrated resilience in the face of a past relationship breakup. She and her partner have their own home, her partner is in fulltime work, and her children have moved from living at home to attending university.
Jenny has had a past history of widespread pain. She’s had one previous relationship that lasted for 6 years, but they then separated with some distress. She is the middle child of three, and was the ‘responsible’ one and consequently felt somewhat ignored by her parents as she was growing up.
Rules to live by
Jenny identified that she is vulnerable to thinking that ‘if I work really hard, then things should work out’ – if things don’t work out, then she must have done something wrong. She’s also aware of thinking that ‘I must have control’, and ‘situations need to be controlled’ in order to keep calm. In relation to other people, she commonly believes ‘if it’s to be, it’s up to me’, and she is aware of her belief that ‘other people will let me down, so I’d better do it myself’.
Underlying core beliefs
“I’m helpless” and “I’m unlovable”
Coping strategies to counter these beliefs
Making sure every detail is controlled, working very hard to please people, not letting other people take on responsibility, thinkiing the worst in order to make sure plans are made to counter those possibilities.
Current triggering situation
Stopping the use of ‘as needed’ medications during a flare-up
Automatic thought about this
“If I can’t use medication, I’ll be helpless and pathetic and I’ll let people down”
Emotions elicited by this thought
Fear, sadness, distress
Physical responses
Heart racing, feeling nauseous, tensed muscles, perspiring, fast breathing
Behavioural responses
Wide awake in bed in the middle of the night, tearful and seeking comfort from her husband

What can Jenny do?

By reviewing her case conceptualisation, Jenny became aware of some of the wider triggers of her current distress – the immediate distress from feeling she had no way to control her pain during a flare-up because medications were no longer available was certainly part of the picture, but after looking at her form, she was also aware of how much energy she had put in to not asking for help, keeping her pain a secret, how hard she worked to meet her very high standards – and these standards had arisen partly because of her pattern of seeking to control situations around her to avoid feeling helpless and rejected.  She was also aware that some of her rules that if she ‘did everything right’ then her pain ‘should’ go didn’t apply in the case of her chronic pain.

Just by becoming aware of how she’d arrived at her current situation, Jenny’s sense of control returned a little.  Even if she couldn’t change much about her pain, she could understand why she felt so distressed when things were out of her control.  She also became aware that some of her old patterns of behaviour, like trying to avoid asking other people to help her was unhelpful in her current situation and she could afford to relax her standards and ease up by ‘making an exception’ to her rules for the present.

It’s ‘echo’s’ like these that can influence how people with chronic pain can manage their situation.  We humans are great at learning from past situations – just sometimes the past was a long time ago, and we may not have revisted ‘the rules’ that worked well then, but are unhelpful now.  By being aware that Jenny had developed some strong beliefs and behaviours that, to be honest, are generally positive (working hard and being reliable and trustworthy are good things) – but applied inflexibly they can create difficulties that make living well very hard.

I chose to work through this with Jenny – she’s someone who has readily adopted this new approach to living with her pain.  She’s now a bit more aware of some of her old beliefs, and I’m certain her brain is busily developing new connections to help her approach her situation in a different way.

For more information on this kind of approach, head to this page on GET.gg that has heaps of worksheets, and don’t forget my most popular page – some awesome CBT worksheets and resources that leads to some of the best websites I’ve found.  There are more sites listed elsewhere on my blog – just go to the search button above, and enter ‘CBT’ or ‘worksheets’ or ‘resources’ and you’ll find them.  Don’t forget that I blog most days during the working week, (time off for good behaviour over the weekend), and I love comments. You can also subscribe using the RSS feed link above.


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