A couple of days ago I mentioned the satisfaction I feel when a person I’ve been working with faces a setback and manages it successfully on their own for the first time.   Someone replied saying that we all face pain setbacks alone, so what did I mean really – and I thought today I’d quickly expand on what I did mean!

Chronic pain persists (goes without saying) but its pattern is to fluctuate from time to time and often without clear provocation – so it’s not very helpful to try and look at what ’caused’ the pain to change.  Yet this is so often what we as clinicians ask about, and more often what the person experiencing the pain tries to do.  Flare-ups happen irrespective of how hard we try to avoid them, so it’s useful IMHO to group flare-ups alongside other ‘set-backs’ and think of them instead as ‘things that make it hard to use my coping strategies’.  The reason being? Our focus in pain management isn’t the pain intensity, it’s about having effective coping strategies so we can sustain working towards our valued goals.

When we start thinking of living life irrespective of pain fluctuations, then it’s much easier to look at the vast range of factors that influence whether we successfully use coping strategies that help move us towards goals, or whether we revert to actions that take us away from achieving values.  We can start to see that living well with chronic pain is mainly about changing habits of a lifetime (which is why it’s so hard!).  This means some of the literature we can draw on to help us help our patients includes not only goal setting and action planning, cognitive behavioural therapy and self regulation, but also relapse and relapse prevention.  Marlatt and Gordon have written extensively about relapse prevention in alcohol and drug rehabilitation (here’s a brief overview of their model), and I’ve found it useful to use their model when I work with patients to review what lead to them reverting to ‘old habits’ in the face of challenging times.

Most of us know that when we start to change a habit, we don’t deliberately choose to slip up and go back to old ways.  Instead, the ‘old ways’ just seem to slither in and before we know it, we’re back doing just the thing we said we’d never do again.  The reality is that it’s a whole series of seemingly irrelevant decisions, or small events that lead up to the slip up where we forget to use the new behaviour.  Just think of your exercise plan, or your decision to never eat that much again, or even to study well before the exam!  We all do it – slide back into those old habits.

A high risk situation is one in which the chances of us reverting to old habits is much more likely – a bit like the difficulty a quitting smoker has when sitting with friends who are all smoking at a bar, or failing to go out for a walk on a day when we’re late back from work and the weather is chilly.

What happens if we go back to old habits?  Firstly, the new habit seems pretty difficult to do, it does require more effort and the old habit probably has some short term payoffs.  That first drag on a cigarette hits the cortex so quickly that the horrible smell, the cost of cigarettes, the effects on health and even the aging effects on skin are simply forgotten.  We have to remember that old habits probably have something about them that makes them ‘work’ – at least in the short term.  So it’s helpful to recognise both the good and not so good about the old ways, and plan to make the not so good a little more evident during high risk situations.

Secondly, if we were feeling a little shaky about the new habit, perhaps not quite trusting that it will work out in the long run, then revert to the old ways, the embryonic confidence we were developing in the new habits will be sorely tried.  It’s much harder to stay strong in a new habit when we’re still newbies at using it.  It’s helpful to practice the new habit with support, or avoid very challenging situations initially when learning a new way of coping.

Thirdly, if we have slipped up and used the old way of coping, the risk of the ‘what the hell effect’ is much higher.  The technical name for this is ‘rule violation effect’ and it basically means that if we’ve set up a new rule then break itjust a little, we’re much more likely to then completely break the rule than to return to the new habit.  Think of a bar of chocolate – one tiny piece is a slip up, then we might remember that we were going to ‘never eat chocolate again’ – having broken the rule, I know I’m likely to say to myself  ‘Oh what the hell, I’ve broken my diet today already, might as well eat the whole bar and start again tomorrow’.  Whoops.  Reframing broken rules into ‘slips’ or ‘lapses’ rather than ‘relapses’, recognising that slips do occur and congratulating yourself on recognising that you have noticed that you’ve slipped makes it much easier to feel good about returning to the original intention.

I’m sure you can see how difficult it is for people with chronic pain who may be faced with not just one habit to change, but many.  Not only do they need to work with their own thoughts and feelings about making these changes, many of the people around them – even health care providers! – can unwittingly place obstacles in the way of the person remaining focused on the new habits.

An example might help.

Allan is a guy who has a very painful hand after sustaining a crush injury and developing a CRPS.  After about three years of unhelpful surgeries and fairly high doses of various medications, he was referred for pain management and started to use things like activity regulation, cognitive reframing, coping statements, breathing and so on.  He even weaned himself of all medication and eventually returned to work, but over Christmas, took a break for about a month to have a summer holiday with his family.  When he returned after his vacation, he had about two weeks working where he had more jobs to do than he’d had for a long time.  Then work slowed down.  His pain increased and he said it was the most painful it had been since before he came to Pain Management.

His wife’s first instinct was that he’d done something to his hand and she went with him to the GP to ‘find out what’s going on’ and maybe have another scan ‘just in case you’ve broken something’.  His GP suggested he go back onto tramadol for a while, and would he like to have some physiotherapy.  Allan decided not to do any of this – he got out his folder of pain management strategies, reviewed his setback plan and started back on the things that he’s found work well.  But his confidence was shaken and so he called me to see if we could review his setback plan and check that he hadn’t forgotten anything.  We went through all the various factors that are, for Allan, high risk situations where he may fail to use his coping strategies – and there they all were.  Changes to routine, a long time where his pain had been quite low then a sudden increase in pain, family stress and social cues from his wife and GP, and he was beginning to feel a lot less confident in his skills – all of these are Allan’s high risk factors.

I’m pleased to say that I got a call from Allan a week ago – he’s back working full time again, didn’t have a scan, didn’t start taking medication again, is regularly playing squash and using his coping statements, and feeling in control.  His confidence has been boosted, and his mood has returned to normal.

That’s what I call ‘managing a setback successfully by yourself’.  Well worth an hour’s follow-up appointment, I think, and a whole lot less costly than having another (useless) scan, more (expensive) medications, stopping work (and feeling stressed because of financial woes), and being a patient (again).

For the visual amongst us – CB Worksheet

I’m a very visual person, I love to see what I’m doing, and I use visual imagery a lot in my language and my processing. Many of our clients are also visual – or they’re kinaesthetic – and they need to see and manipulate rather than listen and talk.

At some point while working with a person it can be helpful to diagram a situation so that you and the client can see what is going on – and the influences that may be having an effect on the situation. In some CBT language this is called ‘psychoeducation’ but I prefer to call it ‘mapping’. To me, the client and I are mapping what happens so we can both discover new ground.

It often starts when I’ve been asking about automatic thoughts – those quick images or phrases that fly through when we encounter a situation. They happen all the time and reflect underlying processes and judgements that influence our emotions and actions. Often they pass through without us being aware of them, but their influence is very strong. Sometimes untangling the thought, the emotion and the action can be difficult, so I start with the event and remain open to working out, with the client, what happened next.

I’ve attached a worksheet that you can use with a person, although I have to admit to mainly drawing in freeform on a whiteboard or handy pieces of paper! Whiteboards are great because if you make an error or want to revise something you can easily wipe it out, which can really make an impact on the person when they reflect on the effect of changing their automatic thought.


You can start with almost any situation – but for occupational therapists or physiotherapists, I find it can be a great tool to use when someone hasn’t followed through with home learning (their ‘mission’). You can pick a time when they didn’t do their exercise, for example, and work out what went through their mind, and find out any underlying beliefs – or external influences – that made it difficult for them to choose to do what they had agreed. For example in this situation – I’ve added in colour some of the therapeutic processes being used.

Therapist: “How did you go with your walking plan over the week?”

Client: “Uh, only got out once – I just had one of those weeks”

T:”How about we go through exactly what happened one of those days you meant to do it but didn’t?”

C:”OK, I suppose so”

T:”So what day can you remember most easily?”
Elicits readily remembered event

C:”Thursday morning, the weather was foul and the kids were playing up and my back was sore and I just didn’t feel up to it”

T: “Let’s start from the first time you thought about your walk. What went through your mind?”
Eliciting automatic thought or image

C: “I thought, Oh no, my back is just too sore and I’m going to be too tired today”

T: “Let’s put that down on the map. Then can you remember how you were feeling at the time?”
Moves to identify the emotion. For some people, this is very difficult and the therapist needs to work through behaviours and thoughts several times, or provide prompts for the type of emotion being experienced.

C: “Guilt! I knew I should be going, but I just didn’t feel up to it.”

T: “So you felt guilt then – any other feeling? What about when you though you would be too tired today?”
Simple reflection, but working through the superficial emotion to a deeper emotion more relevant to the thought the client had.

C: “I suppose I felt quite down then”

T: “So you felt quite down. What does that feel like in your body?”
Simple reflection. Links this with physical/behavioural changes in the body, drawing together the link between thoughts, emotions and pain.

C: “Heaviness in my chest, and my back feels so stiff and sore”

T: “What did you do then?”

C: “I carried on with the housework, but I went quite slowly and was grumpy all day. It was a bad day.”

T: “So, what else was going on that day?”

C: “The kids were being awful and shut in, and all I wanted was a bit of peace and quiet”

T: “Sounds like a real challenge to keep it together when all these things stack up – how did you manage before your back was sore?”
Slightly more complex reflection, elicits previous positive coping strategy. Therapist would draw on the map that the kids were influencing the situation too, also the client’s thought that ‘all she wanted was a bit of peace and quiet’

C: “I would have packed them up and headed out to the park to give them a breather, and myself a break.”

T: “Am I reading you right that getting out is a good thing when you’re feeling a bit stressed?”
Further reflection, this time extending it to include the concept of responses to stress – this could be explored further in another session. What are her typical responses to stress, what situations stress her, how does stress manifest itself in her body, how does pain and exercise influence stress. At this stage the therapist could simply record ‘stress’ on the map, with an arrow pointing to the event ‘going for a walk’

C: “Yup. My back just gets in the way so much”

T: “So it seems that on a horrible day, when the kids are acting up and you’re feeling a bit sore and down, you’d usually get out and about and take a break, but you thought on that day that you would be too tired to do that. Have I got it right?”
A longer reflection, which could almost be called ‘a bouquet’ – gathering together all the relevant pieces of information, summarising and asking whether the therapist has heard it correctly.

C: “Yes, that’s about it”

T: “On the one hand you felt too sore and tired to do anything much, but on the other hand you had a whole day when the kids were acting up AND you were sore and now you feel guilty for not exercising! Where does that leave you?”
Therapist starts to develop ambivalence about the situation, and ensures responsibility for working a way through this rests with the client.

C: “Stuck!”

T: “What are some of your options on a day like that?”
By asking the client for options, the therapist demonstrates faith in the clients own abilities, builds on the client’s strengths and preferences, while helping the client remain focused on achieving both of her valued activities – being a good parent who can keep her cool, and getting a bit fitter despite her pain.

At this point, the therapist is opening up the opportunity for the client to start problem solving ways to achieve both exercise goals and being a good parent.

I hope you’ve enjoyed this wee piece of how I might have worked through a situation where someone hasn’t followed through with home learning – it’s a very common situation, but allows us a chance to work through the factors that will probably influence lapses or relapses once the client leaves us.
More tomorrow!