Readers may be wondering why I’ve come over all happy clappy and jolly joy germ – well, I realised I’d been writing a lot about experimental and theoretical factors found to influence vulnerability to chronic pain, but I had been writing less about ways to help people cope more effectively with chronic pain.
I do have a soft spot for positive psychology because, as we can see in most of the major journals, psychological studies have primarily been interested in what goes wrong, why people may struggle to cope with their pain, and other aspects of vulnerability. Yet more people than not live well with their chronic pain, and rarely seek help for their pain – maybe we can learn something from how these people cope, and in doing so, help people who do need treatment develop some of those skills. This is the topic of my PhD – Living well with chronic pain.
Building on yesterday’s post about ways to increase positive emotions (I talked about savouring – recalling past positive experiences; being ‘in the moment’ in present positive experiences; anticipating future positive experiences) I want to briefly discuss why on earth positive experiences might be useful. Apart from just feeling good in the moment!
The ‘broaden and build’ theory provides a framework for understanding the utility of positive experiences – especially the value of having positive emotions during tough times. In this theory, developed by Fredrickson (2001), both positive and negative emotions have useful functional effects. From an evolutionary viewpoint, there has to be some sort of adaptive value in having emotions and in the broaden and build theory it is posited that negative emotions help with generating “action tendencies that focus and narrow thoughts and actions (to prepare the body for fight or flight)” (and I guess we’re all pretty familiar with this response, especially in Christchurch after the quake!), while positive emotions “broaden ones thoughts and actions, and by consequence build important personal resources.”
In other words, negative emotions help us reduce the number of action options so we can active and use them quickly, while positive emotions help us generate ‘out of the box’ options, those creative, flexible, innovative ideas that can solve a problem – you know those overnight ‘aha!’ moments when the solutions just fall into place.
The empirical support for these two opposing but complementary emotion-elicited strategies is pretty good – we are familiar with the idea that by relaxing and thinking of good times, peaceful moments and happy events, autonomic arousal generated by ‘stress’ is reduced. When there is no pressure to perform, people are often able to experiment and make mistakes and by doing so, arrive at unusual and exciting new possibilities – put a time pressure on and the options are narrowed and people revert to ‘tried and true’ behavioural repertoires.
Psychological resilience, or ‘bounce-back’ is possibly more common than not, according to Tugade and Fredrickson. They suggest that under short-term traumatic events (perhaps the death of a loved one, or, closer to home, an earthquake with disruption to homes, services and businesses) it’s normal to temporarily experience negative emotions – but the general life trajectory continues in similar directions as before the event. And for the majority of people in Christchurch, for example, despite the disruption we’ve experienced, life goes on. For a smaller number – life is disrupted much more seriously. Yet – in a couple of years, while the events of the last few months will be remembered, for more people than not, life plans and direction will be going along reasonably smoothly.
Of course this situation is different when the event is not short term, as in chronic pain.
The point that Tugade and Fredrickson make is that if resilience is commonplace, maybe it is also something individuals can learn, at least to a greater or lesser extent.
Back to the theory and how it might apply in chronic pain. Some people seem more able to bounce back than others – and one factor in this resilience, according to Tugade and Fredrickson, is that people who are high in general or trait resilience, might be more able to draw on positive emotions than people lower in this trait. For example, some people find it easy to use humour to cope with stressful times; some use relaxation – allowing time to interpret and assess problems before acting; some use exploration – looking at possibilities and options before taking action; and others use gratitude or hope – looking for the ‘silver lining’ or being thankful for ‘small mercies’ as my Grandmother would have said.
There is a relationship between the ability to access positive emotions through these strategies and physiological responses. Research cited in the paper by Tugade and Fredrickson found that “although both low and high resilient individuals experienced equal levels of cardiovascular arousal and subjective negative experience in response to a stressor, high trait resilient individuals exhibited faster cardiovascular recovery from negative emotional arousal. Additionally, ‘‘bouncing back’’ to cardiovascular baseline levels was partially mediated by resilient people’s experiences of positive emotion in the midst of distress (Tugade and Fredrickson, 2004).”
What does this mean for people with chronic pain?
Well it is well known that people with chronic pain can have difficulty down-regulating autonomic arousal. Things like heart rate and respiration rate, skin conductance and EMG can be readily increased – but people with chronic pain, even when they’re only recalling a time when their pain was high, find it reasonably difficult to reduce these readings. There are a range of programmes for biofeedback that can help people recognise their own body responses and just by giving visual feedback, can help people develop skills to down-regulate. Clinicians could enhance this process by helping people to remember happy times, or plan future positive events, or even simply be mindful of what is happening right now, as strategies to help people become more able to reduce their level of arousal.
What might this mean?
Well, resilient people seem to be able to recognise their own levels of arousal quite quickly – and then recruit resources to manage these situations quickly. Tugade and Fredrickson consider that one strategy resilient people use is ” effectively harnessing positive emotions to their advantage when coping, and they do so with a seeming intuitive sensibility.” They go on to suggest that by experiencing positive emotions, the short term effect is to broaden the range of behavioural options, making it more likely that they will find a solution to a difficult situation. They suggest that over time, and with repeated experiences of positive emotions, this broadened mindset might become habitual. Success breeding success.
So, quite apart from the need to help people in distress from their pain to generate short-term, ‘do-able’ goals to increase self efficacy, it seems that by being able to succeed and feeling good about doing so, people can develop skills over time that support resilience. Sort of like banking a range of coping resources based on creative and positive options that can be adapted to suit changing circumstances.
What can we do to help?
Step one is to recognise that resilience could be something we learn. Yes, some people have more innate resilience than others, but they also use skills that, over time, become more and more flexible and responsive. To help generate this resilience, helping people become more aware of good things that generate positive experiences seems an important step.
This might include things like scheduling pleasant events, writing down three things that have been positive each day, sitting for some peaceful time to simply appreciate something from nature, setting small goals – and achieving them, noticing unhelpful thinking and letting go of these thoughts in order to focus on what is important and valuable in the here and now.
I can see an enormous potential in helping people with chronic pain use these positive strategies – and who knows, it might even help us as clinicians?!
Tugade, M., & Fredrickson, B. (2006). Regulation of Positive Emotions: Emotion Regulation Strategies that Promote Resilience Journal of Happiness Studies, 8 (3), 311-333 DOI: 10.1007/s10902-006-9015-4