Flexibility – of the psychological kind

More holiday reading to ponder… One of the fascinating developments in psychology over the past 50 years is the ongoing study into what constitutes psychological health. It’s been known by many names – ego-resilience, executive control and self-regulation – but the work on these areas hasn’t been pulled together into a coherent whole until recently. The authors of this paper suggest that this is partly because of the nature of defining this particular beast – what is health after all? Their argument, and one that I find rather appealing, is that a main feature of health is to be able to apply the right kind of response to the many different situations in which we find ourselves. In other words, flexibility.

Occupational therapists in particular will rejoice at the way in which psychological flexibility is defined in this paper, because it refers to “… a number of dynamic processes that unfold over time. This could be reflected by how a person: (1) adapts to fluctuating situational demands, (2) reconfigures mental resources, (3) shifts perspective, and (4) balances competing desires, needs, and life domains. Thus, rather than focusing on specific content (within a person), definitions of psychological flexibility have to incorporate repeated transactions between people and their environmental contexts.(emphasis mine).

Thinking about some of the people I’ve worked with (and reflecting on my own tendencies!), some of the problems that plague people arise from repeatedly trying to apply one set of coping strategies to a new or challenging situation.  When someone experiences a limitation in an area of function, our problem-solving minds typically want to ‘fix’ it – and while this can give us some great work-arounds it can also lead us up the garden path when those solutions don’t apply.

Let me illustrate: many of us grew up with the maxim ‘if a job is worth doing, it’s worth doing well’, or ‘don’t leave a job half-done’.  This is a great rule of thumb in most situations – it stops us from being half-hearted and it keeps us committed.  There is good reason for it being one of those things our parents and teachers drum into us.  BUT when it’s applied to managing chronic pain it can work against people – because it invites people to persist in completing activities in a ‘boom and bust’ pattern.

While most people can readily apply ‘exceptions’ to rules like ‘if a job is worth doing, it’s worth doing well’ so that if the person has a bout of influenza, or has just had an earthquake (for a very real example to us Cantabrians!), for people with chronic pain it can be hard to work out when to recalibrate expectations.  This is a very real example of the need to be flexible about expectations and behaviours.

While it’s easy to see the need to be flexible in terms of choices around temporary changes to health status or environmental demands, it’s much more difficult for many people to see the need to review choices in light of longer term changes to health status.  As a result, so many people I’ve worked with end up applying a rigid, global ‘rule’ to the way in which they live their lives, despite longstanding reductions in their functioning.  This leads to increased distress as their internal expectations don’t match what they can actually do – and a process of managing emotions while working to be more flexible with internal rules is a major part of the work of pain management.

It’s also one reason I don’t think it’s possible to work in pain management without a working knowledge of how to help people identify their thoughts and the effect of thoughts on emotions and behaviour.  After all, it’s relatively easy to ‘teach a skill’ like activity management – but a whole different ball game to help the person feel OK about applying activity management in his or her own context.

Kashdan and Rottenberg identify that there are several underlying building blocks of psychological flexibility.  These include: executive functioning – those parts of the brain involved with prioritising and integrating cognitive capabilities such as being able to shift attention away from what is less important to what is important; self-regulation – being able to tolerate distress and experience it but make choices about responding; being able to selectively apply task persistence or to choose to stop; identifying emotions and recognising their temporality.  As Kashdan and Rottenberg state: “Creating categories and labels is normal and it is only when it is automatic such that a person is unable to detach from particular thoughts and feelings, where they are viewed as objective representations of reality instead of temporary, products of the mind.” It’s that swift and automatic labelling that allows people to notice but not react, and is a skill we start to learn from childhood.

They go on to say “When a person is unable to accept frustration and unwanted negative experiences, attentional  capacity and decisionmaking capabilities are narrowed…Instead of flexibly responding to a situation in an active  manner, a person preoccupied with avoiding experiences is psychologically unavailable to adapt to the cues afforded by an existing situation.”

Finally, they identify “executive functioning also typically includes working memory and recall, information processing speed, and the ability to inhibit behavior.” Persisting memories can interfere with making accurate assessments of here and now, being able to rapidly recall information enables people to draw on appropriate knowledge for a specific situation and evaluate its usefulness, and being able to stop behaviour that is unhelpful is a really important aspect of developing an adaptive response to a new situation.

An ongoing job for any human is to “… maintain a delicate balance between investing effort into our current  surroundings and conserving mental energy for potentially significant future situations.” We typically simplify this by developing habits and routines (sound familiar Kielhofner fans?).  Part of psychological flexibility is being able to ensure these habits and routines support flexibility rather than remain fixed and not necessarily helpful.

I think the construct of psychological flexibility, and particularly acknowledging the ways in which executive functioning is such an important feature, is something clinicians working in chronic pain need to come to grips with.  If we can help people develop flexible and adaptive responses to the limitations of chronic pain, while recognising that chronic pain directly fatigues executive functioning, we’ll be going a long way towards helping people re-engage with what is valued and rewarding in their lives.  More learning for us clinicians, methinks!

Kashdan, T., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of health Clinical Psychology Review, 30 (7), 865-878 DOI: 10.1016/j.cpr.2010.03.001

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