How People Cope with Pain Really Well: 2

In the last post, we started a discussion about how people cope with chronic pain really well. Specifically, we looked at five attributes and skills that people do when coping well with chronic pain. The point of the discussion was that it is a way to learn how to cope better. Coping with chronic pain is a set of skills like any other set of skills and you learn how to cope with pain just like you learn other skills – like learning how to knit or play the piano or play tennis.

If you wanted to learn how to play the piano really well, you would do a number of things (such as take piano lessons), but one of the most important things is that you would study those who are better than you. You would play their recordings and listen and watch how they do it. You would then try to do what they do. The same can be true with learning how to better cope with pain. With this idea in mind, we looked at five attributes and skills that people do when they cope with pain really well.

These five things were the following:

• Being open to change and learning from others
• Accepting that chronic pain is chronic
• Focusing on self-management
• Engaging in a mild, low-impact aerobic exercise on a regular basis
• Understanding the relationship between pain and stress, and managing stress well

These are things that people do when coping really well with chronic pain.

Lets look at five more attributes and skills that make for good coping. As we do, remember one more thing from the last post. It was the discussion about how there is no shame in acknowledging that you can learn to cope with pain better. All skills, including the skills of coping, can be seen as on a spectrum for which there is no point at which you are as good as you ever will get. Rather, if you take any skill imaginable, you can always get better at doing it no matter how good you are at it. Any guitar player can get better with learning and practice – even rock and roll superstars. Any tennis player can get better too – even the pros. Similarly, anyone with chronic pain can learn to cope better -- no matter how good you are at it. So, there is no shame in acknowledging that you can learn a thing or two. You are in the same boat as everyone else. So, let’s look at five more ways to cope better with chronic pain.

1) People who cope really well don’t react to their chronic pain as if it is acute pain.

If you accidentally stepped into a hole and broke your ankle, the pain of the broken ankle would be considered acute pain. The normal reaction to such an injury would be to become alarmed, seek help, stop using the ankle, stay at home, and rest. With the pain of acute injuries, such as a broken ankle, this set of reactions would not only be normal but largely helpful. Generally, a broken ankle gets put into a brace or cast and we are told to stay off it. By doing these things, we allow the bone fracture to heal. Subsequently, the pain goes away. As such, this set of reactions to acute pain is a good thing.

However, what’s good for acute pain is not good for chronic pain. The normal sense of alarm that goes along with being in pain becomes problematic when occurring on a chronic basis. It can become any number of negative emotions, such as fear, anxiety, irritability, and even depression. The normal reaction of resting becomes problematic too when done on a chronic basis. While resting can help an acute injury, it can make chronic pain worse. Your body is made to move and if you don’t use it for too long you get stiff, achy, and sore. It's not just you. It's true for everyone of us. We also get out of shape and gain weight when we are inactive for too long. Becoming de-conditioned in these ways can make pain worse too. Staying home and resting for too long also leads to what healthcare providers call “fear-avoidance.” Fear-avoidance is the cycle of avoiding activities out of concern that the activities will increase pain. Any number of normal activities of daily life can increase pain and so it can become easy to stop doing them out of anticipation that they will cause pain. When done in response to acute pain, it might be helpful. When done on a chronic basis, it’s one of the ways pain can become disabling. Moreover, staying home and not doing your normal daily activities for too long can lead to becoming chronically bored or aimless or depressed. In all these ways, responding to chronic pain as if it is acute pain becomes problematic.

People who cope with pain really well make the transition in their understanding that their pain is no longer acute pain but chronic pain. They know what their chronic pain is and are no longer alarmed by it. They understand that chronic pain is a nervous system condition and not a long-lasting orthopedic injury. They understand that engaging in normal activities won’t make the nervous system condition worse, as it might if it was an acute orthopedic injury, like a bone fracture. Consequently, they no longer become alarmed that they will make the underlying condition worse when they do normal activities of life.

Now, of course, their pain might be worse when they do things, even if it doesn’t make the underlying nervous system condition worse. However, they recognize that not doing things makes their pain worse too. Staying home and resting doesn’t serve a useful purpose when done on a long-term basis. So, people who cope with pain well respond to their pain by saying, “I got to get up and do something!” or “I’ve got to get out of the house or else I’ll go stir-crazy!” That is to say, they react to their chronic pain in ways that are almost opposite to how you normally react to acute pain.

People who cope with pain well have gotten back into the normal activities of their lives despite the pain because the pay off is that it leads to improved coping. They are no longer bored or aimless or depressed. They are getting things done, checking things off their lists, and even having fun on occasion. Because they are doing these things, they feel productive. They feel like they are going somewhere and have a direction again to their life. Their self-esteem is on the rise. In all these ways, they are now coping better and their improved abilities to cope buffer the increased pain they may have from doing these activities.

2) People who cope with pain well pace their activities.

Having gotten back into the normal activities of life, people who cope with pain well are reasonable about how much they do. They do some things, but not everything. They break up a large activity or their entire ‘to do’ list into manageable size chunks. Referring to the story about the tortoise and hare, they might joke that their motto is “slow and steady wins the race.” That is to say, they have overcome any tendencies to engage in what psychologists call “all-or-nothing” approaches to life.

Additionally, they are reasonable about what they do, and not just how much they do. They might not expect to be able to water ski or dirt bike race. Nonetheless, they make it a point to still do a lot of fun things.

3) People who cope well with pain overcome any perfectionist or workaholic tendencies they may have had.

Perfectionists and workaholics get a lot of kudos in our society. They get a lot done and what they do they do very well. Employers love them and reward them for it. So, if you are a perfectionist or workaholic, it may have gotten you far before the onset of chronic pain. However, now that you have chronic pain, perfectionism and workaholism are problematic.

Perfectionism and workaholism are problematic in many ways. First, perfectionists and workaholics engage in “all-or-nothing” thinking and as such tend to struggle with pacing themselves. If they have a good day in terms of their pain level, they clean, not just the kitchen, but the entire house. As they do, they might say to themselves, ‘If you are going to do it, do it right or not at all.’ However, their strict adherence to perfectionistic standards leads to exacerbating their pain through over-activity. Second, their ‘do it right or not at all’ attitude lends itself to the ‘not at all’ side of the equation because they have chronic pain and the pain makes it difficult to ‘do it right.’ Not doing things leads to all the problems described above – getting out of shape, weight gain, aimlessness, and more pain. Third, once they have stopped doing things, they are prone to self-criticism. Their perfectionistic standards are hard taskmasters. When they don't live up to their standards, they get down on themselves. No one is harder on him- or herself than the perfectionist or workaholic. Such persistent self-criticism can lead to poor self-worth and depression. Fourth, perfectionism and workaholism tend to make people inflexible and poor adapters. We reviewed in our last post that one attribute of a good coper is someone who is flexible and can adapt. The ‘all-or-nothing’ thinking of the perfectionist or workaholic makes it hard to adapt and be flexible. They have difficulty finding the middle ground between their 'either-or' thinking. In all these ways, perfectionism and workaholism do not lend themselves to coping well with pain.

People who cope with pain well tend to have worked through their perfectionist and workaholic tendencies. With persistent effort and time, they have broken themselves of the habit of holding themselves accountable to perfectionistic standards. They have come to see that even before the onset of their chronic pain they never really did achieve those standards. Whatever they did, they could always find some fault or room for improvement. There was always something more on the list to do. It never really was a very good recipe for happiness. By overcoming perfectionism, they came to see that what they thought was happiness was really just temporary satisfaction. The feeling associated with a job well done lasted only as long as it took to move on to the next thing on the ‘to do’ list. And there was always more to do on the ‘to do’ list. So, people who cope with pain well have worked through these issues and no longer hold themselves to perfectionistic and workaholic standards.

4) People who cope with pain well maintain a regularly structured day.

Everyone has a routine. We typically go to bed and get up at more or less the same time each day. We typically eat our first meal in the morning, our second meal in the early afternoon, and our third meal in the late afternoon or early evening. We typically shower or bathe shortly after awakening or shortly before bed. Our typical daily chores and activities also follow a routine. We all do better when, more or less, we follow a routine.

Sometimes, of course, it’s fun to break up the routine. When we are on vacation, we enjoy the break in the routine. Right after retirement or obtaining disability, it is nice to have a break in our usual routines and many people have some fun with it.

However, if the break in the usual routine never returns to the normal routine or is never supplanted by a new routine, a couple of problematic things happen that reduce our abilities to function well in life. First, we become aimless. After awhile, we don’t know what to do with ourselves if we don’t have a focus for the day. Without a focus for our concentration and efforts, our attention tends to focus in on the problems of life. For those with chronic pain, our attention gets focused on pain and all the stressful problems associated with living a life in chronic pain. Second, we tend to start napping. Now, an occasional nap is fine, but when it starts happening everyday, it become problematic. It disrupts our nightly bedtime routines. It’s hard to fall asleep because of the nap earlier in the day. Once we start falling asleep later in the evening, we tend to start sleeping in longer and longer in the morning. In turn, this shift pushes the naptime later into the afternoon, which subsequently pushes bedtime later and later. As a result, a shift occurs in your sleep-wake cycle, sleeping more and more into the day and awake more and more at night. Chronic disruption in your sleep-wake cycle is a common cause of social isolation, aimlessness, persistent fatigue, and depression.

I often tell patients that we all need a reason to get up in the morning. We need to have some idea of what we are going to do with ourselves throughout the day. When, on a chronic basis, we don’t have any plans or routine to guide us through the day, then every moment requires a decision – “What am I going to do?” The question can become surprisingly hard to answer! It’s like when you were a kid during the last few weeks of summer vacation and you and the neighborhood kids have done everything you wanted to do; you sit around the house or backyard, staring at each other, asking, “What do you want to do? Oh, I don’t care, what do you want to do?” Back and forth it goes and boredom and aimlessness are the result. Routines serve the function of allowing us not to think so hard. We just know what we are supposed to do from one thing to the next. They keep our minds focused on getting things done, rather than becoming aimless or, worse yet, becoming focused in on all the problems of life while awake in the middle of the night when every one else is sleeping. That’s not what good coping looks like.

5) People who cope with pain well engage in a daily relaxation exercise.

Like mild aerobic exercise, a regular relaxation exercise is an essential component of successful self-management. People who cope with pain really well engage in both on a regular basis.

People commonly misunderstand the role of relaxation in pain management. They tend to think of it as something you do when experiencing a lot of pain in order to get through it. When they try it, it doesn’t work real well and so give up.

While a relaxation exercise can be done in the midst of a pain flare (think, for example, the deep breathing women learn for childbirth), relaxation for this purpose is a very difficult skill to achieve and it takes a lot of practice – more than most people are initially willing to do.

The most important reason a relaxation exercise is an effective treatment for chronic pain is that it is an intervention that targets the nervous system and reduces its reactivity over time. It’s more of a prevention type treatment than something you do in the midst of a pain flare.

Chronic pain is the result of the nervous system being stuck in a persistent state of reactivity that makes nerves highly sensitive to pain. As you know, any normal movement can be painful. Mild pressure like massage or even touch in the painful area of the body can feel painful. Of course, normal movements and massage and touch shouldn’t be painful, but they are because the nerves and the rest of the nervous system are stuck in a persistent state of reactivity, making the nerves in the painful area sensitive. It’s called central sensitization.

A daily relaxation exercise is one of many treatments for this condition. A relaxation exercise targets the nervous and relaxes it for a short period of time. After awhile, the nervous system returns to its high level of reactivity. If you do it again everyday, however, the nervous system begins to return to lower and lower levels of reactivity. As a result, you have less and less pain over time.

You are also more grounded and less stressed. As a result, you also tend to cope better.

A daily relaxation exercise is a two-fer: less pain over time and improved coping over time.

There are literally countless ways to get better at coping with pain. In this post, we reviewed five of them. We reviewed a different five ways in the last post. I intend to periodically review more ways to cope with pain on this blog.

Author: Murray J. McAllister, PsyD

Date of last modification: September 27, 2013