Pain Acceptance rather than Catastrophising influences work goal pursuit & achievement

We all know that having pain can act as a disincentive to doing things. What’s less clear is how, when a person is in chronic pain, life can continue. After all, life doesn’t stop just because pain is a daily companion. I’ve been interested in how people maintain living well despite their pain, because I think if we can work this out, some of the ongoing distress and despair experienced by people living with pain might be alleviated (while we wait for cures to appear).

The problem with studying daily life is that it’s complicated. What happened yesterday can influence what we do today. How well we sleep can make a difference to pain and fatigue. Over time, these changes influences can blur and for people living with pain it begins to be difficult to work out which came first: the pain, or the life disruption. Sophisticated mathematical procedures can now be used to model the effects of variations in individual’s experiences on factors that are important to an overall group. For example, if we track pain, fatigue and goals in a group of people, we can see that each person’s responses vary around their own personal “normal”. If we then add some additional factors, let’s say pain acceptance, or catastrophising, and look to see firstly how each individual’s “normal” varies with their own acceptance or catastrophising, then look at how overall grouped norms vary with these factors while controlling for the violation of usual assumptions in this kind of statistical analysis (like independence of each sample, for example), we can begin to examine the ways that pain, or goal pursuit vary depending on acceptance or catastrophising across time.

In the study I’m looking at today, this kind of multilevel modelling was used to examine the variability between pain intensity and positive and negative feelings and pain interference with goal pursuit and progress, as well as looking to see whether pain acceptance or catastrophising mediated the same outcomes.

variationsThe researchers found that pain intensity interfered with goal progress, but it didn’t do this directly. Instead, it did this via the individual’s perception of how much pain interfered with goal pursuit. In other words, when a person thinks that pain gets in the way of them doing things, this happens when they experience higher pain intensity that makes them feel that it’s hard to keep going with goals. Even if people feel OK in themselves, pain intensity makes it feel like it’s much harder to keep going.

But, what’s really interesting about this study is that pain acceptance exerts an independent influence on the strength of this relationship, far more than pain catastrophising (or thinking the worst). What this means is that even if pain intensity gets in the way of wanting to do things, people who accept their pain as part of themselves are more able to keep going.

The authors of this study point out that “not all individuals experience pain’s interference with goal pursuit to the same extent because interference is likely to depend on pain attitudes” (Mun, Karoly & Okun, 2015), and accepting pain seems to be one of the important factors that allow people to keep going. Catastrophising, as measured in this study, didn’t feature as a moderator, which is quite unusual, and the authors suggest that perhaps their using “trait” catastrophising instead of “state” catastrophising might have fuzzed this relationship, and that both forms of catastrophising should be measured in future.

An important point when interpreting this study: acceptance does not mean “OMG I’m just going to ignore my pain” or “OMG I’m just going to distract myself”. Instead, acceptance means reducing unhelpful brooding on pain, or trying to control pain (which just doesn’t really work, does it). Acceptance also means “I’m going to get on with what makes me feel like me” even if my pain goes up because I do. The authors suggest that acceptance might reduce pain’s disruptive influence on cognitive processes, meaning there’s more brain space to focus on moving towards important goals.

In addition to the cool finding that acceptance influences how much pain interferes with moving towards important goals, this study also found that being positive, or feeling good also reduced pain interference. Now this is really cool because I’ve been arguing that having fun is one of the first things that people living with chronic pain lose. And it’s rarely, if ever, included in pain management or rehabilitation approaches. Maybe it’s time to recognise that people doing important and fun things that they value might actually be a motivating approach that could instill confidence and “stickability” when developing rehabilitation programmes.

Mun CJ, Karoly P, & Okun MA (2015). Effects of daily pain intensity, positive affect, and individual differences in pain acceptance on work goal interference and progress. Pain, 156 (11), 2276-85 PMID: 26469319

Pain management: CBT or a CBT perspective?

There is a bit of a misconception about CBT for chronic pain management. Some people think that it consists only of cognitive behavioural therapy as it is used for depression or other mental health problems. And this often means people think mainly of cognitive therapy as conducted by clinical psychologists – meaning that clinicians from other professions can lack confidence to be involved.

I thought today I’d outline the views of one of the ‘founding fathers’ of the cognitive behavioural perspective for chronic pain, Dennis Turk. In a paper by Turk and colleagues Kimberley Swanson from University of Washington School of Medicine, Department of Anesthesiology, Seattle, and Eldon Tunk, Emeritus Professor in the Department of Psychiatry and Behavioural Neurosciences, McMaster University, Ontario, the psychological models used to conceptualize chronic pain—psychodynamic, behavioural (respondent and operant), and cognitive-behavioural are described. They also briefly review treatments based on these models.

One of the main points of this editorial paper is, in their words, ‘to differentiate the cognitive-behavioural perspective from cognitive and behavioural techniques and suggest that the perspective on the role of patients’ beliefs, attitudes, and expectations in the maintenance and exacerbation of symptoms are more important than the specific techniques.’ (more…)

Count your blessings and focus on the positive

I just had to record this reflection on my last session with a wonderful client who has been struggling with chronic pain, anxiety and not feeling at all confident that she can take action.
I’ve been following a different tack with her from usual, and instead of working hard on modifying thoughts and beliefs, I’ve been using a ‘meta-cognitive’ approach where we’ve been ‘noticing’ her thoughts and feelings – and taking actions in line with her valued goals anyway.

Alongside this awareness of thoughts and emotions without acting on them (or avoiding them), we’ve been working on using mindfulness and full appreciation of the NOW, and identifying the positive in each day.

What I’ve noticed is how much lighter and easier the sessions have been – how much we laugh and how much more positive the talk is. She’s also doing much more and ‘analysing’ much less. In doing more she’s gaining joy and happiness from living in alignment with what’s really important to her (even if I don’t always agree with what she thinks is important!). What I mean by this last comment is that she believes it’s important to help people feel happy by doing things for them, which sometimes contradicts some of her other values which are about enjoying peace, having time out to think, and being independent.

Some useful tools have been the ‘importance’ and ‘confidence’ rulers from the Motivational Interviewing approach, the ‘wise self’ or ‘mini me’ looking from above at thoughts, feelings/sensations and actions, mindfulness meditations, and goal setting and problem solving. The work is much more about taking action, becoming aware of values and actions that are in line with values, noticing the good in a day and planning to make it happen, and allowing thoughts and feelings to simply float by.

The thought struck me that people who we think are brave because they climb really big mountains only become brave by climbing really big mountains. Bravery isn’t about the emotion attached to it, it’s about doing despite the emotion (in fact, bravery is almost entirely about feeling afraid, but doing it anyway!). To become confident and increase self esteem, we need to do things that we are not confident about, so that by achieving we increase our self esteem.

How to cope with pain Pain-Blog Carnival

If you haven’t popped across to How to Cope with Pain Blog – now’s the time!
The very best of a range of excellent pain-related blogs is showcased on this month’s Carnival, sure to be something there for everyone!
My post from December 18  is included in this Carnival.  Enjoy!
How to Cope with Pain is now offering a monthly Pain-Blog Carnival during the last week of every month, to include each month’s best posts. December’s carnival is now posted. New bloggers are always welcome to contribute.

Positive psychology – Polyanna or Promising?

holly-cherubl.jpgI was hoping to post on positive psychology and chronic pain, but have failed to find any specific references using these two headings – I then had a brain-wave and without waiting for someone reading this to locate something for me… I remembered the body of research in contextual cognitive behavioural therapy – mainly by Lance McCracken.
So this post is dedicated to CCBT, positive psychology and the season of good cheer!

Anyway, the reason for wanting to post on this aspect of psychology is that I have a hunch that resilience (my PhD topic!) and aspects of positive psychology might just be relevant for people learning to live with chronic pain.

So, what is positive psychology?
It is the ‘scientific study of the strengths and virtues that enable individuals and communities to thrive’ (Positive Psychology Centre )
It’s derived from the early humanist psychologists such as Carl Rogers, Abraham Maslow and others, and further developed by Martin Seligman, Albert Bandura and others, with the focus being on strengths, and those features of human life that promote wellbeing, resourcefulness and the ability to develop.

For a great list of resources and links relevant to positive psychology, go here: and go here for links to various questionnaires that may be useful.

Anyway, to come back to my hunches… psychological flexibility is a feature of positive psychology, and involves processes of acceptance, mindfulness, values, and cognitive defusion (for a longer explanation of these see McCracken, L. M., & Vowles, K. E. (2007)).

Positive values such as the following seem to enable people to live well despite life events around them:

  • finding good things about each event that happens in our lives,
  • having compassion for ourselves and others,
  • being creative and finding opportunities for development

When people don’t demonstrate cognitive flexibility, they can remain fixed in resentment and anger, attend to only a few things (and judge the experience negatively), and believe that what they think is so, rather than a thought that alters depending on context. What this means in pain management is that people fixate on their pain and the negative judgement of that pain and how it interferes with their activities, remaining angry and fixed in the ways that they approach life.

Using what we can learn from positive psychology, we may be able to help people in this position draw on their strengths by assessing coping strategies in terms of strengths rather than us as professionals dwelling on their vulnerabilities and problems.

For example, we may look at the values that they are using when declaring that ‘I can’t do pacing’ – does this reflect their desire to achieve and their ability to persevere despite pain? Instead of a negative feature, can we help them identify their strength with task persistence or achievement, and develop the ability to apply this value flexibly and in contexts in which this is helpful?

McCracken and others have spent a good deal of time exploring the concept of acceptance, finding strong positive relationships between acceptance and function, acceptance and positive affect, and acceptance and reduced use of avoidance (see below for references). I’m looking forward to the time when we can read of others researching this area – perhaps from the Positive Psychology Centre or similar.

In the meantime, we can learn from this research ways to encourage the people we work with to sit ‘with’ their pain, becoming aware of pain but not judging it negatively (or positively), help them to look for positives (remember the post about counting your blessings?

And in this season of good cheer, perhaps we can interpret the ways people cope with their pain in positive ways – what is adaptive about their strategies? How can they be used to help them achieve their goals in life? What features of what they currently do can be drawn upon to help them succeed?

Finally, can we as treatment providers look on the bright side too? Can we give ourselves credit for continuing to work in this complex and challenging area, often with limited idea of just how effective we are? And perhaps, by being ‘Pollyanna’ for a while, we might catch sight of the promise, possibilities and potential in our clients and ourselves – and have a Brilliant New Year!

If you’ve enjoyed this post, and others – subscribe above using the RSS feed, and leave a comment!

BTW For a great place to review positive psychology from a personal perspective, go to Authentic Happiness and spend some time mooching about the information and resources held there…

McCracken, L., & Samuel, V. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain, 130(1), 119 – 125.

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., Eccleston, C., & Bell, L. (2005). Clinical assessment of behavioral coping responses: Preliminary results from a brief inventory. European Journal of Pain, 9(1), 69-78.

McCracken, L. M., & Vowles, K. E. (2007). Psychological flexibility and traditional pain management strategies in relation to patient functioning with chronic pain: An examination of a revised instrument. The Journal of Pain Vol 8(9) Sep 2007, 700-707.

McCracken, L. M., & Yang, S.-Y. (2006). The role of values in a contextual cognitive-behavioral approach to chronic pain. Pain, 123(1-2), 137-145.