‘What do I do when I’ve had enough’: The Effect of Emotions on Self-regulation & Chronic Pain

As soon as read the first paragraph of the paper I’ve used as the basis for this post, I knew I was onto something that resonated with my original occupational therapy values. It says this:

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.

  1. The groups were ‘self-sufficient’ – this group endorsed goals such as ‘getting on with my life’ and gave low priority to social validation;
  2. ‘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;
  3. 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

The art of chronic pain

Pain is invisible – and people with pain often find it difficult to express exactly what their pain is like in words… BUT art can express so much that words can’t and the art of chronic pain can be found in all sorts of places.

Today I was given a pamphlet from a nonprofit organisation called PAIN Exhibit in the US.  The organiser and creator of this group is Mark Collen, who has experienced chronic pain for over ten years.  If you go to the website PainExhibit.com, you’ll find some incredibly powerful images created by people who have chronic pain.  Some of the images are hard to look at, they’re so evocative.

Mark has published a brief pamphlet about chronic pain, and the website also has some information about chronic pain, but the main purpose of the site is to use art to communicate.  It is hoped that by communicating, people will find it easier to listen and learn more and eventually reduce ignorance and lack of treatment.

If you’ve a mind to look at more painful images – Flickr has some incredibly powerful images (not just photographs) of pain.  Again, some are very hard to look at, but clearly demonstrate the emotional impact that pain has.

Art has been used for expressing the impact of pain – collage can be used to by patients to express the impact of pain on parts of their lives and also to explore future options.  It’s also a great activity in which people can use their activity regulation, posture, distraction and other strategies while at the same time being involved in an expressive activity (there speaks an OT from years gone by!).

I couldn’t resist this illustration – by Jason Smith, from Endeavours Magazine, University of North Carolina, Chapel Hill.

Practical techniques of mindfulness

I’ve been looking around at quite a few different ways to learn and practice mindfulness. There are heaps and I realise that I’m just dipping my toe in water that has been flowing for many hundreds of years really.

If the essence of mindfulness is to be fully present, then most of us have probably achieved this at various times in our lives – that sense of ‘flow’ or the moments when body, mind, spirit and any other bits of the human self integrate without recalling the past, without predicting the future. To deliberately re-create this, especially during more challenging times, is what I want to consider today.

I mentioned a day or so ago that for some people, explaining the how and why is much less successful than plunging right in. I think I am biased in terms of preferring to understand the ‘why’ before I do things… Perhaps something that is distinctive in this therapy is the experiential elements – it really is important as a therapist to know how and to practice mindfulness, so that it’s a lot easier to explain and guide another person into it. Now I’m not the only person who has said this: Dr Chris Walsh writes about this in his paper on Practical Techniques in a section called Why mindfulness instructors need their own practice. He says ‘To teach an experiential skill (to coach) requires some mastery of that skill…experiential information is often conveyed non-verbally. This can be done skilfully if the instructor carries the information at an experiential level, within the body…This makes it easier to learn by modelling, just as a rock climbing student might do with an instructor.’

So…what can we do to learn?

My first steps for myself were to learn to be mindful of my breathing. It’s an ancient zen practice to meditate breathing – to achieve complete focus only on the breathing of ten breaths. Try it now – to completely focus only on breathing in, breathing out – without distraction, without mind chatter including labelling or naming sensations, without the thoughts taking off…

Now the mindfulness part of this is to notice the thoughts wandering and gently allow them to float away while returning the attention to your breath again.

Being a very visual person, I use imagery for myself a lot – so images like the thoughts are wrapped up in a bubble, floating in the air…. or thoughts are simply blowing away from me…. or are falling onto floating leaves in a stream… or drifting down like leaves from a tree….or feathers…

Most of my images are from nature, but other images I’ve experienced using include sitting in a train, allowing the thoughts to be falling far behind as I move onward…being in a boat, watching the thoughts floating away on the wake….thoughts being part of a machine, being taken in and being processed, coming out the other side on a conveyor belt and moving far away…

I usually spend a few minutes actively ‘managing’ my thoughts using imagery, then my focus on it’s own returns to my breath.

To guide my focus on my breath, I notice my breath in my body. The cool air coming in my nose, and down my throat, becoming warmer as it moves deeper into my body – the warmer air coming out of my nose and moving the tiny hairs of my nostrils. The movement in my body as the air fills my lungs, tightening pressure on my belly against my clothing as my lungs are filled, relaxing as I breathe out. Awareness that my breath out is often longer than my breathe in, that my breathing is ‘coming from’ my belly button…

And usually I become aware that I am naming these experiences, and allow my mind to name them then return to just feeling them rather than naming them. Being gentle rather than critical, taking my time so my mind and body have no coercion or force or requirement to do anything – rather, just allowing it to occur and noticing it as it happens.

A words I associate with this practice is ‘curiousity’ or ‘inquiry’ or even ‘exploring’, but not in an active sense, just in a floating sense.

A killer for mindfulness is to expect a certain emotion, feeling or result. That’s like expecting it to be something that it hasn’t yet achieved. My preparedness to receive what happens is the key to using this process. Sometimes I do feel incredible peace and connection, other times I feel detached, or as if I’m a spectator. Still other times I leave feeling energised or ready for action, while at other times I feel ready to fall asleep. What will be, will be and what happens, happens… That is at the heart of the practice, to just allow space for something or nothing to occur, and just be.

Sometimes while sitting with an experience during this breathing practice I can feel emotions welling up (and I have seen this with other people I have coached). Again, this is something that can just be allowed to happen then subside – emotions never stay forever, unless we are trying to edit them or restrict them or focus in on them. Allowing the emotion (fear, sadness, anger, loneliness) to rise then fall so we go with it, and accept it as part of our experience, makes it less powerful and it passes on.

Distraction in the learning stages of meditating is very common. Again, I’ve used imagery for myself, other times I have just said to myself before I start that I will hear noises or feel sensations and that they are there but will just help me appreciate the moment. So I allow them to be heard, then gently return to the breath. Sometimes just being aware of the space between each sound or sensation, or distinguishing between different sensations on different parts of my body can allow them to be felt then my mind returns to my breathing.

I have used prepared scripts, pre-recorded onto CD or MP3 player, and sometimes used music (mainly ambient sounds from nature or bells). This is great initially I think, but over time it can become the focus and be a sort of prop that interferes with the process of being fully present. So perhaps it’s something to use in the beginning, but later can be used occasionally to keep the experience fresh. The mindfulness can be brought into every day activity like brushing your teeth, or getting into the car and putting the keys in the ignition, or even while washing dishes and doing laundry.
For some good examples, Chris Walsh has made some great suggestions, with references to refer to.

I particularly like Chris’s description of ‘Urge Surfing’. This is a method to reduce the ‘feeding’ of an urge by either trying to resist it, or attending to it and actually doing it. Essentially it follows exactly the same format as I’ve described above for emotions and sensations, by sitting with the impulse or urge, allowing it to build by gentle acknowledging it as a thought, then perhaps defining it, or perhaps letting our attention return to our breath and noticing any changes to the urge or sensation throughout the cycle of the breath. Chris recommends five cycles of breathing – I think it doesn’t matter how long it takes! I can see application of this in exposure therapy, and I know I have used it myself without realising that was what I was doing! You know when you really want to scratch an insect bite? And can’t? And you can allow that feeling to pass… and it does…

Finally, this is a great site with a wonderful paper by Ruth Baer summarising the conceptual and empirical features of mindfulness training. Enjoy.

And for some koan to consider as you meditate? Try these… they are ancient.