Apart from pacing, there can be few coping strategies that people dislike more than task persistence.
What is task persistence and why do people dislike it?
Task persistence is about maintaining activity despite fluctuations of pain intensity – allowing pain to increase without stopping. Isn’t that pacing, you say? Well, perhaps part of pacing … In a recent paper by McCracken and Samuel (2007), pacing was positively related to activity avoidance and disability.
‘People who accepted their pain and participated in high activity in conjunction with little avoidance demonstrated distinctly better physical and emotional functioning than other groups.’
As I’ve mentioned before, pacing can become confused in the minds of people with pain and become instead ‘avoiding activity that increases my pain’. While pacing can be useful for people who may be over active, it is less than helpful for people who readily avoid.
So, how can someone keep going with an activity when their pain increases? Apart from using efficient movements, planning to ensure appropriate rest breaks are taken and so on, some cognitive strategies are very useful.
Distraction using engaging imagery or activities can be useful. Distraction by actively trying to suppress thinking about pain has the paradoxical effect of increasing the frequency of intrusive thought, so it’s more helpful to have something really interesting, something that the person is intrigued by, or something that requires concentration to use in this situation. Some examples:
- stimulating conversation
- imagining a scene or object in visual, auditory, olfactory and textural detail
- singing a song or reciting poetry or readings
The important thing about distraction to help maintain activity is that it shouldn’t interfere with the completion of the task.
Coping statements are statements that reassure or encourage coping – things like ‘only five more minutes’, ‘only 10 more times’, ‘I can make it’, ‘I’ll be fine’, ‘I can keep going’ can be used as self encouragement to maintain engagement in the task. At times this may be combined with thought stopping, a deep ‘out’ breath and previously rehearsed statements. When presenting this to the person, it can help to say that it’s like having an internal coach!
It may also be useful to work through automatic thoughts that may arise when trying to carry out task persistence – becoming aware of these automatic thoughts may help identify the content, underlying attitudes, beliefs, rules or assumptions, and provide an opportunity for the person to challenge their beliefs about pain, particularly catastrophic beliefs. When doing this, identifying suitable replacement statements is an essential component.
Planning ‘chunks’ or scheduled stops or changes of activity help to maintain task persistence because it assures the person that the activity will end – provided the person continues to the end.
Setting a target and recording achievement has been established for years in sports training. Setting and recording the frequency of a behaviour has been used in behavioural therapy and the act of recording itself can change the behaviour. In task persistence, setting a target and recording achievement can be a powerful way to help the person maintain frequency or time undertaken. It can become a self-competitive strategy, with pain intensity NOT being recorded. Recording can be physical charting or verbal reporting to another person.
Encouragement from others when we achieve is a strategy that we don’t always specifically employ. In task persistence it can be a real boost, and one that we can gradually reduce over time as part of a gradually reducing level of intermittent reinforcement, especially in the middle phases of a programme to increase activity level.
Why do people not like using task persistence?
It specifically asks people to learn to accept the presence of pain. Although many of us believe that we help people manage their pain, we can inadvertently help people avoid approaching painful activities, and in doing so reinforce pain as a threat, and to be feared. McCracken and colleagues have studied acceptance and positive coping with pain and their findings strongly suggest that until people accept their pain as being ‘OK’, or ‘an experience’ rather than a feared experience, disability continues.
I’ll post more on this topic later – until then, a couple of readings for you to refer to:
McCracken, L. M. (2007). A Contextual Analysis of Attention to Chronic Pain: What the Patient Does With Their Pain Might Be More Important Than Their Awareness or Vigilance Alone. Journal of Pain, 8(3), 230-236.
McCracken, L. M., & Samuel, V. M. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain Vol 130(1-2) Jul 2007, 119-125.
McCracken, L. M., & Yang, S.-Y. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain Vol 123(1-2) Jul 2006, 137-145.
And – a really good website on Acceptance and Commitment Therapy.
This is an awesome repository of knowledge on ACT, including specific areas referring to pain management.
A book well worth considering, developed for people with pain but great for therapists, is Living beyond your pain: Using Acceptance and Commitment Therapy to ease chronic pain by Dahl and Lundgren.
Date last modified: 1 March 2008
Originally, I was going to criticize your “Why do I write this Blog” entry, when you spoke of “pacing” as a means of avoidance. That was until I found this entry!
I have often used the term “pacing” as a means to describe what I am doing when I take a break from an activity, and initially felt that your reference inferred my “pacing” definition was improper. Silly me, I just use the wrong terminology, and now know the proper term for this! I am a 40 year old Disabled Veteran, living with chronic pain has been my lifestyle for near 12 years. I started a Blog thinking I could help. A place where those who suffer, like I could render emotional support, advice, and a bended ear when we are just too tired of involving our loved ones with our story of grief. So, from me to you, thank you for your efforts to bring intellect into the medium, I will link your Blog with mine, if you approve!!!
as being a way people avoid
Hi RLD619 – thanks so much for taking the time to comment! Yes I think the word ‘pacing’ is probably a bit over-used, and I know not everyone agrees with my definition but I do think it clarifies the term and helps people understand that avoiding fluctuations in pain leads to gradual reduction of activity.
You’re very welcome to add my blog to your blogroll – yes people who experience persistent pain do need to be able to feel acknowledged and encouraged, it’s an incredibly debilitating and lonely disorder to try and live with on your own.
Hi, am an occupational therapy student from Malaysia. I am doing my orthopedic placement at the moment and am working a lot with CTD clients besides experiencing persistent pain myself due to a mild spinal cord injury. I found your post very interesting, but what I find in most cases of CTD clients is that what brought them to the hospital in the first place is that they did not respect the pain (and probably used task persistence as a coping strategy – recently a friend in a petroleum company told me about his colleagues all suffering CTD en masse to the point where some of them even had their hands clawing yet they did not seek treatment until it was very very serious. I am not sure if task persistence is a safe strategy to use. Perhaps you could provide some examples of when task persistence is appropriate?
You make a good point – some people who experience chronic pain are ‘over-doers’ while others are ‘under-doers’, and still others swing between both extremes.
Using task persistence is appropriate when you are helping a person develop tolerance to activity. It needs to be carefully managed so that the baseline level of activity is only just into the discomfort zone but not too far, and then increases in activity are gradual (10% increases every week seems to be the typical way to increase).
I’ve written more recently about people who over-do, but there is less information/research on these individuals than those who under-do.
the article is good