Essential Skills for Living with Pain
I could actually head this post with the title ‘Essential Skills for Living’ and leave out the pain part, because as I reflect on the events over the past week, and the aftermath as residents of Christchurch start to demolish then rebuild their homes and businesses, these same skills apply.

How do people live well despite adversity? Our lives are not straightforward and both major events and daily hassles are encountered and influence thoughts, emotions and behaviour. It’s normal to have a range of emotions, abnormal to be ‘happy, happy, joy, joy’ all the time (despite the adverts!).

It has been postulated that the ability to regulate emotions is a sign of adulthood, and that being unable to regulate emotions is a contributor to much emotional ill-health. Emotion regulation is about being able to monitor, judge, and work with emotional responses in order to achieve goals. We can’t simply give up because it’s hard to learn to do something. We need to manage disappointment and develop grit and determination. Berking, Wupperman et al (2008) summarise the skills thought to be important for life – the ability to:

  1. consciously process emotions and be aware of them
  2. identify and label emotions
  3. interpret emotion-related bodily sensations
  4. understand what emotions prompt us to do
  5. support oneself when emotionally distressed
  6. actively modify negative emotions in order to feel better
  7. be resilient to or tolerate negative emotions
  8. accept emotions
  9. confront emotionally distressing situations in order to achieve important goals

Whew! That’s a bit of a list! These same authors carried out a study to establish those skills that are associated with good mental health, and to look at those that are enhanced during treatment to influence a good outcome.  What they found was that three skills in particular were associated with good mental health – the ability to modify negative emotions; the ability to be resilient to negative emotions; and acceptance of emotions.

In other words, being able to do things to lift spirits or reduce frustration, to know that negative emotions won’t last forever and won’t overwhelm, and being able to accept that emotions are present without judging them are all skills that, in particular, help people cope with adversity.

The question now is – how can these findings be transferred into what clinicians working in pain management can offer the people we see every day?

Most of us working in chronic pain management know that we can influence other people through what we say and do.  We can help the people we work with by recognising that therapy is not easy – and that it’s OK to experience disappointment, frustration, sadness and grief. We can model this by ‘making space’ for people to express these emotions during sessions without quickly moving along, making a joke, or otherwise trying to alleviate the feeling.  What we can say are things like ‘it’s OK to take some time to feel what you’re feeling’; ‘let’s just give you a moment to be with what you’re feeling right now’.

In ACT, this is called ‘being present’ – and the people we work with may themselves rush past a moment of negative emotion.  They may do this by changing the subject, turning away or making a quick quip.  We can help people experience their emotions by gently stopping them for a moment and asking them to ‘just notice what is happening’.

When we do this, we’re modelling that it’s OK to experience emotions, that it’s not going to de-rail the session, that we’re not afraid of emotions and that we’ll be there.  We’re not trying to comfort or challenge that emotional content, but instead we’re allowing it to be.

Flink, Nicholas, Boersma and Linton (2009) describe another approach – what they call ‘interoceptive exposure’.  Participants in this study were asked to “calmly focus their attention on their pain sensations, whether sitting or performing activities associated with more bothersome pain (e.g. standing, walking). They were told to expect some increase in pain initially but to keep their attention calmly focused on the pain, allowing themselves to feel it, as much as possible without thinking about it or trying to change it or block it, until it was less bothersome.”

This is a specific attentional control skill that asks the person to experience their pain, probably initially increasing their anxiety about doing so, but then, by being calm and allowing it to be present, allowing that anxiety to reduce.  It is a form of mindfulness.

I intend to look, over the next few days, at some of the other strategies that we can use during pain management to help people develop skills of emotion-regulation.  I think they’re skills everyone could learn and use – what are your thoughts?

Don’t forget that I blog most days during the week, that you can subscribe using the RSS feedlink above, or via email, and that I love comments and observations!  You can also follow me on Twitter and Facebook.  If you’re an occupational therapist and would like to look at my ‘OT Only’ section, just drop me a line via the ‘About’ page.

BERKING, M., WUPPERMAN, P., REICHARDT, A., PEJIC, T., DIPPEL, A., & ZNOJ, H. (2008). Emotion-regulation skills as a treatment target in psychotherapy☆ Behaviour Research and Therapy DOI: 10.1016/j.brat.2008.08.005

Flink, I., Nicholas, M., Boersma, K., & Linton, S. (2009). Reducing the threat value of chronic pain: A preliminary replicated single-case study of interoceptive exposure versus distraction in six individuals with chronic back pain Behaviour Research and Therapy, 47 (8), 721-728 DOI: 10.1016/j.brat.2009.05.003



  1. I totally concur with your perspectives concerning emotional awareness, regulation, etc. Ironically, the same conditions apply to relapse prevention for usuing-abusing substances. Alan Marlott , Ph.D has written much on this subject of avoiding intense emotional experiences as a way to induce relapses. I believe mindfulness-body scan- without judgement is a critical method to help patients acknowledge then adapt to their conditions. Amazingly, many patients will say if they can stay with their emotions at each moment in time, they may disappear OR that deeper emotions may be generated such as grieving (the loss of the way they want to be, the way they were vs the way they are at the present time. )

    1. And funnily enough we were just talking about Marlatt’s model of relapse prevention today – with a nod to the need to identify emotional content being one of several things that can trigger lapsing. While some people do recognise that by staying with their emotions they lessen, or may become deeper (and open the door to new areas of growth), I’ve found it’s also worth acknowledging to people that they may not experience any change in emotion, or indeed anything at all! And that it’s quite OK for this to happen. It’s that ability to simply be with whatever arises during mindful attention that is quite the hardest thing to achieve!

  2. Very nice Bronnie.
    Thank you. More food for thought.

    Good luck to you and your fellow Christchurch dwellers in rebuilding your homes.
    I am sure your situation will allow you much opportunity to consider your blog.

    I, too, as a therapist and as one putting my body back together again can apply and consider your thoughts above.
    I have done some techniques like you lay out, but have not been so calculated. You bring me back to thoughtfulness.

    If you indulge my sharing:
    I remember one case where the client was experiencing severe distracting pain as we practiced walking during a biofeedback session. Her particular pain had been present over about 20 odd years since the birth of her last child. Her frustration, despair and anger grew as the usual stretching techniques and posture correction offered little help which did not last to relieve the pain nor to lower the EMG. Finally, she vented, out of character, strongly dumping her emotions with me. It took me a moment to catch myself and remind myself not to take it personally but to allow her. I was in no danger. I stood quietly holding her gaze. When she finished ‘exploding’ she apologized, uncomfortable with her ‘lack of control and decorum’. The EMG showed her tension dropped immediately after only the emotional outburst. Together we completed the walking session with no further rise in the EMG which would indicating we should intervene. I pointed all of this out to her and suggested she find it useful to express herself appropriately and effectively, even if it was only to vent to friends, but also addressing directly situations that she felt needed to be addressed. I had the opportunity to see her about a year later. She reported that she successfully applied these techniques and was much more in control of that specific pain which seemed tied to expression and emotion.

    A remarkable and dramatic experience for me and for her.
    BTW this happened in a multi-disciplinary pain center where the patient received psychology, PT, OT, voc. counseling etc in an 4 week intensive program. This experience came together during an OT/biofeedback session late in her program. I believe it was so strong because it was during her last week when she was expecting to go and to be independent. The session made her expect to fail. The experience was shared with the team, especially with psychology.

    I look forward to thinking about your blog while I go through my coming days. Thank you.

    1. It’s my pleasure – and thank you so much for describing your experience with your client. Something occupational therapists can help with is generating situations in which people encounter difficulties – and in doing so, we can model that it’s OK to feel emotions and choose to experience them without either a meltdown or ignoring them. Experiential learning can be powerful stuff!
      Thanks for your comment about the Dandelion – I have a soft spot for them!

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