Pain management is like a 3-legged stool—
- medications, and
- psychological education and counseling.
Without all 3 legs, the stool will fall.
After several years of clinical practice (it’s been 16 years now), I began to construct a schema to help organize where to start—where I should start in my continuing education and where I should start with my patients when they presented for therapy.
The 3rd method is explored in this article, which suggests five mental/emotional skills we can learn to help manage our own pain as active patients.
The first leg of the stool is made up of interventional treatments, or “passive patient” approaches. These include surgeries, injections, manipulations, and other similar treatments. For these, all the patient has to do basically is show up and be still. I refer to it as “the auto repair school of medicine.”
The second leg of the stool is made up of pharmaceutical approaches. These treatments call for action on the part of the prescriber and the patient
Many pain practices start and end with these 2 general approaches, and offer nothing else. However, just as a stool would fall over with only 2 legs, pain treatment is truly successful only when the third leg of the stool is offered.
The third leg of the stool is made up of “active patient” approaches—skills and changes that patients make to help them cope with their condition. In the treatment of heart disease and diabetes, these are often referred to as “lifestyle changes,” and providers know that they are essential to bring a chronic condition under control.
While interventional and pharmaceutical interventions are important, the third leg of the stool is critical to successfully coping with pain.
Thus, what I developed was a conceptualization of the 5 basic or general skills that every patient with chronic pain should work to master to have the most success in dealing with their pain condition: understanding, accepting, calming, balancing, and coping.
The First Skill: Understanding
often the first order of business is to educate the patient about his or her condition and offer a plan of care he or she will accept.
As a psychologist, I often receive comments similar to “I don’t need a psychologist; my pain is real and it is NOT in my head.”
Having patients understand the pain gates concept (an overview is usually sufficient) helps them see the value of psychological interventions in treating chronic pain.
Psychologists and other providers often also address such issues as fear avoidance of pain, how in chronic pain “hurt does not mean harm,” and how a downward cycle of dysfunction and immobilization often is overlaid on chronic pain conditions.
Patients need to understand that with chronic pain “hurt does not mean harm.” The pain sensation is basically a false or over-amplified sensation and does not reflect new or more tissue damage. One important step for pain patients then is to realize that it is okay to move and to feel some pain.
While this may be true of Fibromyalgia and neuropathic pain, the pain of EDS is often a case of chronically acute pain from unstable body parts. When a joint is out of place, it is most definitely harmful to keep,using it and ignore the pain, just as it would be in the case of a dislocated joint.
The Second Skill: Accepting
How the patient thinks about his or her pain is critical to successful outcomes. “Catastrophizing”—the behavior of patients telling themselves that their pain is the worst imaginable, that relief is impossible, and that this is the worst situation of their lives—has been shown to be an important predictor of negative pain treatment outcomes.4 An important skill for the patient is be able to accept his or her situation and decrease their emotional struggle with the situation.
Acceptance and having appropriate attitudes and expectations about chronic pain are central to cognitive-behavioral therapy (CBT), which is the most commonly used psychological therapy for pain patients and has been shown to be effective in treating chronic pain conditions
On a simple level, I tell many patients that the basic issue is changing from thinking “woe is me” or “why me” to “what now.” When a patient begins to focus on what he or she can still do and what role in life he or she will have from now on, then this reflects increased acceptance
Avoiding “shoulds” is important (and is central to CBT).
Working with the patient to help them have appropriate and realistic expectations is important to any pain treatment.
The Third Skill: Calming
Pain is meant to stimulate the body into action and to avoid danger. This is the well-known “fight or flight” response. The natural reaction of patients with pain is to be in a state of physiological arousal. The problem is that, because the pain is ongoing, the body can be damaged by this ongoing stress. Therefore, an essential skill for any pain patient is to learn how to calm the body down
In our practice, my colleagues and I differentiate 2 aspects of calming. We first talk about calming down the body’s stress reaction—decreasing stress.
After teaching the importance of decreasing stress, we go on to discuss triggering the body’s calming (or relaxation) response. We talk about the difference between decreasing stress (decreasing adrenaline) versus triggering the body’s calming response (stimulating endorphins). This sets the stage for further education about relaxation techniques and how all relaxation techniques trigger this endorphin response.
This skill is a collection of various techniques and skills that revolve around creating a balanced and sustainable lifestyle. Patients with pain who describe themselves as being successful in managing their pain all report that they have developed a pattern of living that works for them, but they also report being adaptable to episodes of pain.
One specific skill within this category is “activity pacing.” This involves learning not to overdo activities. Patients who are coping well describe how they have learned to do a little bit at a time and not overdo it, while also staying fairly busy.
Another element of a balanced lifestyle includes good sleep hygiene and getting enough rest.
The Fifth Skill: Coping
The fifth and final skill is coping—that is, having tips, techniques, and plans to use when the pain becomes more severe. Surprisingly, sometimes this area is overlooked in professional psychology, but coping is a very important skill and often one of the first ones pain patients begin to develop. Often pain patients have limited skills in this area, so when pain increases the only coping skill they can think of is to take a pain pill. This can lead to all kinds of other problems and has been described as “chemical coping.”7 Pain patients need more coping techniques.
we published data from a pilot study last year in which we found that having patients attend a single 2-hour group session that went over these 5 skills was associated with a reduction in pain catastrophizing at 3-month follow-up.8 It appears to us that even a brief introduction to these 5 skills can have a positive and enduring impact.