‘Living with chronic pain is a balancing act. People with chronic pain are required to make daily decisions about how best to cope with illness-related demands while managing other role-related obligations. Although some people become overwhelmed by the demands of illness and daily life, many, if not most, remain focused and well-adjusted, and do not require the services of a mental health professional. … Why do some redouble their coping efforts following a health set back, whereas others become demoralised?’
I concur with the idea that ‘most remain focused and well-adjusted’ – and that it’s the daily decisions, the little things that need to be prioritised and undertaken each day that require motivation and energy to keep doing when you have chronic pain. Karoly and colleagues have written several papers on the ‘organising’ role of goals especially in chronic pain, and this paper by Nancy Hamilton extends the model proposed by Karoly to include the ‘energising’ influence of emotion.
How does this fit with self regulation?
Well, to achieve goals within life, we require the ability to control our thoughts, feelings, actions and physiology. We particularly need to do this when goals are not met immediately or are frustrated. It’s a skill that incorporates multiple neural pathways, builds upon traits we are probably born with, but is able to be developed (otherwise we’d all have a paddy if we couldn’t have a piece of chocolate NOW!). It seems that the importance we place on a goal, along with our confidence that we can achieve it, strongly influences how willing we are to attempt or persist with it.
Where emotions fit within this model is, according to Karoly, in terms of the level of arousal as well as in terms of the type of goals selected. Humans are generally goal-directed rather than simply reacting to situations. In other words, what we do and the goals we choose are related to what we think is important, and what we think is important is developed from interaction with our social environment (family and community), and all of this is influenced strongly by the emotions we feel. Emotions generate ‘energy’ and focus, and enable us to recruit resources to work towards goals that we’ve chosen.
We all know that people with chronic pain vary tremendously in terms of how they go about adjusting to the experience of chronic pain. The differences are not only in terms of ‘success’ – or not – but also in terms of the processes and strategies people employ. Karoly’s model identifies 14 factors that influence goal-related self-regulation, and each of these introduce variation in how people adjust or self regulate. Not all of these factors are directly influenced by emotions, but several most certainly are.
The first area to consider when looking at emotions and goals, is the role of emotion on the actual goal content – what the person wants to achieve. Goal choice is underpinned by values, or what the person thinks is important – but deciding whether to approach or avoid certain activities is often motivated by emotions. Consider, for example, people who are fearful of experiencing pain who seek all manner of ways to avoid engaging in activities that ‘might’ increase their pain.
One client, for example, was highly fearful of bending to the floor from standing to put shoes and socks on so for three years she sat on the floor to do this. She also avoided standing to shave her legs, wash between her toes, and to put her knickers and tights on!
In contrast, positive emotions such as joy and happiness influence us to pursue goals that increase the chance for obtaining rewards and have long-term pay-offs such as social activities or creative pursuits.
Pain is, as I’ve said before, by definition a negative experience. The link between experiencing pain and feeling sad, guilty, frustrated, irritated, hopeless or anxious (just to name a few!) is incredibly strong – and dysregulation of affect is often a feature of chronic pain. People do cry more often, feel irritable, get grumpy with others and become depressed.
In this paper, Hamilton and colleagues suggests that pain and negative emotion ‘tend to activate similar goal-related trajectories.’ What they mean by this is that both pain and fear, for example activate increased awareness of threat, more focus on the self, preparedness to avoid harm, and according to Affleck, quoted in this paper, ‘pain often activates the negative emotion systems, perhaps as a redundant alarm.’
Emotions also vary with the types of goal content chosen – from a study by Hamilton, Karoly & Zautra (2004), people with fibromyalgia were able to be divided into three groups on the basis of affective and disease-specific outcomes.
- The groups were ‘self-sufficient’ – this group endorsed goals such as ‘getting on with my life’ and gave low priority to social validation;
- ‘treatment seeking’ people formed a second group characterised by goals to find a treatment provider who can ‘cure’ and gave low priority to social validation;
- while the third group gave priority to social validation goals rather than finding effective treatment for their symptoms.
The three groups varied systematically in terms of negative affect – people in the last group also reported the highest levels of pain and negative emotions. People who said they were ‘getting on with it’ reported lower levels of pain and negative emotion. It’s not clear whether this is a causal relationship because of the correlational design of this study, so it will be necessary to watch and wait to see whether pain and negative affect tend to bias the goals that are selected and how they’re valued, or whether the goals chosen actually determine the emotional outcome.
Where does this leave us?
Well, it suggests that adjusting goals – both the type of goal and the difficulty of the goal – might be an incredibly important aspect of self regulation to focus on when we see people with pain. Nothing new there. But it might also influence and be influenced by the emotions the person is experiencing. If we’re considering the role of failing to achieve goals, we’re likely to find that this experience of failure will have a dual effect on pain and emotion. We may need to set goals that are very achievable, especially in the early stages of engaging in pain management. We might need to reconsider the effect of, for example, failed attempts to return to work.
Conversely, achieving a goal, particularly a social or interpersonal goal, has an influence on mood – irrespective of pain and fatigue. From this we could consider the role of group activities, particularly exercise or discussion groups, that engage people in positive ways and gradually increase the demands. Success breeds success.
Recently I’ve used a ‘Plan to do’ and ‘Did do’ diary where people plan their day’s activities, then record what they actually did. This provides immediate feedback on progress – and successfully achieving what was planned, no matter how low the level of activity, provides a sense of accomplishment and becomes reinforcing.
More on this tomorrow!
Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76