by Charity Paijmans,
www.stressproofed.co.uk, email admin@stressproofed.co.uk Tel: 0121 288 3440.
A biomedical model dominated our concepts of illness for around 300 years (and would still seem to in popular imagination). This approach views the human body as mechanical, ie it is controlled by physical forces - and reduces explanations of pain to a simple link between the damage to the body and the amount of pain experienced: the more damage, the more pain. The biopsychosocial model of pain, introduced by Engel in 1977, was the first to highlight the importance of experiential factors. (Thorn, 2004)
The gate control theory of pain, first introduced by Melzack and Wall in 1962 and further developed in the eighties, proposed that the brain plays a dynamic role in pain perception. Their original hypothesis was that a gating mechanism in the spinal chord widens or narrows as a result of signals descending from the brain, therefore relatively more or fewer pain signals reach the brain. Melzack and Wall also posited that psychological factors influence the degree to which the gating mechanism opens, ultimately contributing to how the brain responds to painful stimulation.
From 1990 Melzack expanded the gate control theory. He proposed a ‘neuromatrix’ model which extends the gate control mechanism from the spine to include a ‘widespread network of neural loops’ (Thorn, 2004) including such structures as the thalamus, limbic system and cortex. This newer model also argues that the processing of pain by the brain is of genetic predisposition which is modified by experience.
Acute and chronic pain signals eventually move along different pathways in this neural network. Acute pain signals move along fast pathways while chronic pain signals move along slow pathways. Deardoff (2003) writes ‘slow pain tends to be perceived as dull, aching, burning and cramping. Initially the slow pain messages travel along the same
pathways as the fast pain signals through the spinal chord. Once they reach the brain, however, the slow pain messages take a pathway to the hypothalamus and limbic system. The hypothalamus is responsible for the release of certain stress hormones in the body, while the limbic system is responsible for processing emotions. This is one reason why chronic (back) pain is often associated with stress, depression and anxiety. The slow pain signals are actually passing through brain areas that control these experiences and emotions.’
He continues: ‘The brain also controls pain messages by attaching meaning to the personal and social context in which the pain is experienced. This occurs in the cortex…soldiers who are wounded in combat may display much less pain than similarly wounded civilians involved in accidents. The meaning attached to the situation seems to be the important difference.’
The importance of meaning in how situations are perceived can also be seen in substance misuse work. Many American soldiers fighting in Vietnam became addicted to heroin. On their return to civilian life a significant proportion of these ‘addicts’ were easily able to stop using the drug without any adverse reactions. (Gossop, 1982)
While the meaning given to a situation is clearly important it is equally important not to make it the only part of the equation. It is important to emphasise the responsibility that individuals can take in managing and thus – hopefully – reducing their pain perception, but not without acknowledging that chronic pain is a real experience.
As shown above there is a clear role for addressing stress management with chronic pain patients. The following part of the assignment will focus on the relevance of Stress Management Training to working with clients with chronic pain.
Stress is defined by the HSA (Health & Safety Executive) as “the adverse reaction people have to excessive pressure or other types of demand placed on them”. Raymond and Wilson’s definition acknowledges that this adverse reaction can be emotional and/or physical and that it can be real or perceived which correlates with our understanding of the fight or flight response being activated by perceived threat: “a mental &/or physical response, by an individual, to an inappropriate level of pressure, whether real or perceived”.
Chronic pain is usually defined as pain that has lasted for at least three months (sometimes, six), where tests show that the initial injury is healed or that all results are negative.
Stress management training is an eight session ‘course that addresses cognitive, physiological and behavioural aspects of the stress (fight or flight) response. (The Stress Consultancy 2001).
It is important that all three aspects are addressed when dealing with chronic pain patients. Historically, the physiological component has received the most attention (Tucker, 2005). Yet behaviour and thinking / feeling can change significantly in response to chronic pain. Such conditions usually involve a complete restructuring of life as the patient has previously known it, due to the feeling / belief that one is unable to maintain a previous ‘normal’ level of activity. This can be complicated by having to deal with – or feeling unable to deal with – emotional reactions to such changes and to the onset of the disease / condition. The total effect is that the fullness of life experienced by the patient can be significantly compromised.
Physiology
It is my belief that gaining a good knowledge of whatever problem one is dealing with makes it easier to manage. In relation to chronic pain this would involve having an understanding of how chemical reactions in the body may affect our muscles / thoughts. This is covered comprehensively in the Stress Management Training programme.
Cognitive
In the introduction to ‘Cognitive Therapy for Chronic Pain’ (Thorn, 2004) Dennis C Tuck writes:
“Our thoughts, usually automatic and often not immediately conscious, have a profound effect on both our short-term and long-term adjustment to pain. Cognitive therapy focuses specifically on the cognitive processes and the assumptions and beliefs that underlie this process.”
Relaxation
In relation to dealing with stress and other chronic conditions, such as chronic pain, ‘relaxation’ doesn’t simply mean doing things that you enjoy, which don’t involve much physicality or relate to work. One can still watch television, have a ‘relaxing’ bath or do some knitting yet not be able to switch off racing thoughts or soften muscles. Relaxation involves allowing the mind to slow down and become less active, essentially giving your brain a break. It also involves reducing the tension in one’s muscles, which contributes to a feeling of calm and bodily comfort (Cole et al, 2005). Stressful situations can cause both bodily and mental tension which, for clients who already have a painful condition, can contribute to a greater intensity of pain being experienced. Cannone & Hefferon (2006) explain this in the following way “…many people who do not know how to control stress let it build up as tension often times in their muscles. This muscles tension places constant stress and strain on the muscles and can contribute to muscle imbalances” and by extension, chronic pain. (my italics)
The questionnaires in session one serve several purposes – initially they allow the trainer to gain a broad understanding of the issues in the client’s life which have contributed to their stress levels. Secondly they serve as a tool for establishing a relationship between trainer and client without the client having to jump straight in and confront the thorny issue of just why they are so stressed – which, at this stage, they are unlikely to fully understand themselves.
Session one establishes the expectations of the training (ie that it is participatory) straight away by giving clients something to take away in the form of knowledge about the fight or flight reaction. This can immediately be put to good use. For clients with painful / chronic conditions knowledge of the fight & flight reaction - and how muscle tension affects their condition - can help inform their choices about relaxation. Such knowledge and the ability to make an informed choice can generate a renewed, and potentially life improving, sense of control, if they are prepared to use their new knowledge to interrupt and then change their reactions.
The learning provided in each session, the relaxation cds and the self monitoring forms are important components of the stress management training and it is particularly important that it starts from the beginning of the intervention. In my experience of working in the mental health field, clients are more likely to stay the course if they feel that they can take something useful from the first session.
Session 2 generates a much more focused picture of how the client’s life is currently affected by stress. This helps the client to clarify the issues for themselves (form S2.a) and to really start thinking about what they want to change and how they will know when such change is happening (S2.b). My coaching / mental health work has taught me that eliciting a very clear awareness of issues contributing to current problems and how life will look when the right changes are being made is both important and empowering for clients. This is particularly important for clients dealing with chronic pain as having a sense of control over their life can be a significant factor in how pain is managed.
Eleven years of working in the mental–health field has ingrained in me that having a good knowledge of any condition we are dealing with can make management of said condition relatively easier. In relation to stress, increased knowledge of what elements contribute to stress, and then being able to connect these to ourselves, particularly in terms of how well we do or don’t manage them, can enable one to discard some stuff and realise that we need to work on other areas. Form S2.c is a useful tool to help clients with this process. If clients struggle to come up with a ‘list of ten things that they can do that they enjoy’ I tell them that it can be a work in progress and that they can add to it as they identify new things that they have enjoyed. Having a wide range of enjoyable / meaningful activities at their disposal is important to people with chronic pain as their subjective pain levels may influence what they can do at any given time and being able to lose oneself in an enjoyable activity can have a positive impact on how pain is experienced.
Obviously it needs to be emphasised to clients that the benefits of the training are commensurate to the effort put in – which in my experience is not something that people often want to hear (I’m hoping that this will be different in private practice). Whilst doing background reading for this assignment and thinking about my current client group (drinkers), it occurred to me how important it is to break this idea down for clients: in order to benefit from the training they need to commit to putting time aside to practice the skills being taught. This ‘time’ is time that they are investing in themselves – although this concept my need addressing! It is also important to realise that their life is not currently ‘normal’ and will not be normal while they try and rectify their poor stress management.
Addressing personality styles (session 3) can help chronic pain clients to identify areas of their lives where they are putting extra pressure – and likely stress – on themselves, which will contribute to pain levels experienced. By identifying such areas individuals can start to think about whether they need to continue functioning towards the ‘7’ end of the scale or whether it is more important to take some pressure off and gravitate towards a lower number, for a better quality of life and ultimately less pain. It is a way of helping people to understand the limits of their condition more appropriately and thus to start prioritising – ‘what can I let go of in order to be able to manage my pain more effectively; what cost am I prepared to pay in order to maintain my old way of being?’
Looking in depth at negative thinking (session 4), including identifying negative thinking habits and pinning down client’s individual negative thoughts, which sabotage their stress management, is a key technique for people with chronic pain. Reality Checking for Negative Automatic Thoughts gives clients a sense of perspective about their thinking and introduces the idea that there might be a different interpretation to the one they have latched onto. It helps them to see their situation differently.
My experience of working with chronic pain sufferers (which, to date, involves clients attending a voluntary sector organisation and not having to pay for their treatment) indicates that it is often thoughts such as ‘why me’,’ what’s the point of living like this’, ‘I can’t do it’, ‘I can’t afford to do anything else – it all takes money’ [usually when I’m trying to introduce the concept of ‘meaningful activity’ or accessing therapies such as massage] and ‘nobody understands’. Such thoughts, coupled with feeling let down by your body or by life can have the effect of applying brakes to life and sidelining people who are unable to see beyond their diagnosis or the effects of their condition. Therefore it is important that there is a cognitive component to stress management training, where clients are encouraged to examine their beliefs and thoughts and to start identifying how they might be sustaining their condition.
Under stress, everything seems bigger, more important and, often, more unmanageable than it really is. Maggie Phillips (2005) states that ‘psychological beliefs, feelings, and attitudes play an important role in regulating the pain experience’. I believe that it can be important to look at ‘beliefs, feelings and attitudes’ that apply to life in general as well as pain specifically as the two are likely to be related.
Stepping back and looking at the situation in a longer term context can help one to see where this fits in with the rest of life. The cognitive components of stress management training help with this process
It is well documented that how we breathe can affect the levels of tension that we hold in our muscles (Davis et al 2000). Diaphragmatic breathing (sessions 3 & 5) is an excellent technique to teach people with chronic pain. Regularly practiced it can reduce stress levels thus contributing to reducing levels of pain experienced.
Stress Management Training is particularly suited to people with chronic pain due to the emphasis on daily relaxation and self monitoring. The different techniques taught in session 5 give people a choice of strategies for learning to improve the relaxation effects of their breathing. Teaching people to use ‘triggers’ is a simple, yet effective, way to help them tune into their breathing and moderate it to help with pain relief.
Sessions 6 & 7 build on the cognitive concepts introduced in session 4 by developing ideas on challenging negativity and introducing positive reframing and aids to positive thinking. Therefore the client is given a toolkit of identifying, challenging and reframing negative thinking which, as has already been established, is an important part of enabling chronic pain patients to move beyond their immediate feelings of disempowerment and to see a more productive future. They are also given some techniques to quickly – importantly – change their mood to one of positivity.
It is important when working with cognitive concepts that each client is able to identify their own beliefs rather than either say what they think the clinician wants to hear (as happened recently with one of my client’s; it took several attempts for her to be authentic but when she was it made much more sense and was, obviously, ‘hers’) or adopt a belief that the clinician is ‘giving’ them.
Tuck (2004) supports this: “Yet a key to successful treatment is the clinician’s understanding and acknowledgement of each person’s pain experience. The challenge of cognitive therapy is to….gradually reshape the patient’s cognitions towards a different phenomenological experience. Regardless of the causes of the pain (and these are always multi-faceted) it is the patient’s experience of the pain that is key to cognitive therapy.”
Cannone and Heffernon (2005) argue that ‘sound nutrition’ (session 8) is an important component for eliminating pain and that it is frequently overlooked. My own experience supports the importance of using exercise to moderate pain levels.
In ‘Overcoming Chronic Pain’ (2005) Cole et al describe three states of mind that people bring to any situation:
Reasonable (thinking reasonably). This is a very logical state where individuals pay attention to facts and respond to situations by planning their behaviours.
Emotional (thinking emotionally). In this state behaviour is driven by one’s emotional response to a situation. Thoughts are often extreme and facts are distorted to fit feelings.
Wise (being mindful). In this state of mind people acknowledge unpleasant symptoms without undue distress and emotions are balanced with reasonable thinking. In this state patients are able to deal with unpleasant feelings without letting such feelings take control.
Stress Management Training has the facility to take chronic pain patients who are operating primarily from an emotional state of mind and give them the tools and support to shift into a wise state of mind.
‘Acceptance’ of chronic pain, has been defined as recognising that one has a chronic condition that cannot necessarily be cured, letting go of fruitless attempts to rid oneself of pain, working towards living a satisfying life despite the pain and not equating chronic pain with disability. (Unfortunately I can’t reference this – I’ve completely lost the page I wrote the original quote on)
I hope this assignment shows that all the elements of Stress Management Training are applicable, indeed important, to working with patients with chronic pain conditions in helping them to be more accepting of their situation.
References and bibliography
Cannone, J. & Hefferon, S. (2005) Lose The Back Pain reference manual
available from http://www.losethebackpain.com
Cole et al (2005) Overcoming Chronic Pain
Robinson, London
Davis et al (2000) The Relaxation and Stress Reduction Workbook
New Harbinger Publications Inc., Oakland
Gossop, M (1982) Living With Drugs
Ashgate, Aldershot
Phillips, M (2005) http://www.losethebackpain.com/hypnosis
Tuck, D (2004) Cognitive Therapy for Chronic Pain (Introduction)
The Guildford Press, New York
Thorn, B (2004) Cognitive Therapy for Chronic Pain
The Guildford Press, New York
Deardorff, W (2003) The Spinal Chord and Pain
www.spine-health.com
Deardorff, W (2003) The Gate Control Theory of Chronic Pain
www.spine-health.com