Al isn’t very happy. He’s been told that his back pain, which he’s had for six months now, is not likely to go away. He’s been having treatments from physiotherapy, had a return to work programme developed by an occupational therapist, tried medications and injections but nothing has taken his pain away.
He’s slowly stopped seeing his mates, isn’t sleeping well, hasn’t been out fishing in months, and he’s even had trouble keeping from shouting at his boys.
Al doesn’t sound all that different from many of the men I’ve seen in pain management.
Some people call him “unmotivated” because he’s stopped thinking about goals for the future, and does his exercises in a half-hearted sort of way. He doesn’t always attend his appointments. It’s hard to know whether he’s actually doing his home exercise programme. A far cry from the “hard-working, reliable” man who runs his own business.
What’s going on? We could say he’s depressed, and maybe he is. But more importantly, why is he depressed? He doesn’t describe his pain as anything more than a 5/10 where 10 is the most extreme pain he can imagine.
We’ve all met an Al, I’m sure. Superficially he looks fine, but a throwaway comment nails it: “I’m just not myself any more, I want things to be normal”.
All of us have an idea of who we are. A self-concept is a set of representations about who we are, what we do, how we do it, and why we do it.
We all have several self-concepts – the “actual” self, the “ideal” self (who we would like to be), the “ought” self (the person others think we should be), the “feared” self (the person we really don’t want to be) and so on (Higgins, 1999; Markus & Nurius, 1986).
Our sense of self is based on a collection of memories, a pattern of behaviours that we’ve developed and continue to develop as we aim to be the person we want to be.
Our sense of self guides our choices and the way we do things.
Al is used to getting up early in the morning, usually about 6.00, so he can get out to the site he’s working on that day and begin work by about 7.30. Since he developed his back pain, Al’s had trouble getting out of bed before 8.00.
He’s always tired. He’s not sleeping. He’s the last one in the house to get up, and he can’t even get to the work site until 9.00 because his body is sore and he can’t seem to wake up.
He doesn’t like who he’s become. He feels lazy and useless.
I’m sure this is a common sentiment among pain patients. We are all disappointed, even angry, that we can’t do the things we used to do, planned to do, or hoped to do.
Achieving self-coherence by re-occupying self
One of the neglected aspects of pain management is how to help someone deal with the changes to his or her sense of self.
Life becomes chaotic when assumptions we make about the world no longer apply. The main concern of someone who is learning to deal with chronic pain is how to make life and self make sense again, to regain some coherence. When they successfully solve this problem, it’s like all the various aspects of “self” have been reassembled.
Yet what do we so often do when we doing pain management? We tell people like Al to “relax” and “pace” (Al learned as a child that you don’t stop until the job is done). We tell him he needs to move in certain ways (as a plumber?
What can we do?
I think we need to take some time to understand Al and what’s important to him. Not just the occupations (activities) but also the way he does them, and why he does them. How do they contribute to his sense of self?
Perhaps help him develop a new self that lets go of the old “normal” but includes some of the most important values expressed differently.
I call this flexibly persisting – as Antony Robbins says, “staying committed to your decisions, but staying flexible in your approach”.