Adopting an Attitude that You're Healthy despite having Chronic Pain: Coping with Pain Series

Chronic pain rehabilitation programs are a traditional and effective treatment for chronic pain. Such programs are based on cognitive-behavioral principles that aim to change how you experience pain. By doing so, chronic pain rehabilitation programs help you to a) reduce pain and b) return to meaningful life activities even though some level of pain may persist. In other words, by participating in chronic pain rehabilitation, you change your relationship to chronic pain. You no longer perceive pain as an alarming and disabling condition, but develop the know-how to understand your pain as a benign condition that no longer needs to disrupt or prevent your daily life activities.

Wouldn’t it be good to become so competent at dealing with persistent pain that you no longer are disabled by it?

Pain would continue to occur, of course, but it would now be occurring in the background of your day-to-day life. The reasonable activities of life, like work and family activities, would become what occupies your time and attention, not pain. Again, wouldn’t it be good to learn how to do it?

Everyday, people with moderate to severe chronic pain learn to do it in chronic pain rehabilitation programss across the world.

There are countless strategies for coping better with pain, which can be learned in chronic pain rehabilitation programs. One strategy, which has been taught ever since there have been such programs, is to adopt an attitude that you remain a healthy person even though you have chronic pain. By assuming this attitude, you come to change your understanding of how you should relate to chronic, or persistent, pain.

Do you remain a healthy person when having persistent pain?

Like many questions in life, the answer to the above question depends on whom you ask. There may or may not be a universally correct answer for all people across all conditions and all situations. Pragmatically, however, the answer is important because it can determine how well you cope with persistent pain.

Many people with persistent pain consider themselves injured or ill. It’s common, for instance, for those with chronic low back or neck pain to think of themselves as injured. Another possibility is that individuals with such pain might have been told they have degenerative disc disease and as such they consider themselves to have a disease of the spine. Still others might consider migraine headache (aka, “sick headache”) or fibromyalgia as an illness. In all these scenarios of thinking of pain as the result of injury or illness, the implication is that you are unhealthy.

Indeed, this way of understanding pain goes hand in hand with seeking healthcare for it. It’s what sick or injured people do. You go to the doctor in order to get better. In this light, pain medications are often thought of as “medicine”.

It can also lead those who conceptualize chronic pain in this manner to engage in other behaviors associated with injury or illness, such as stopping life activities, staying home from work, and resting. It’s what injured or sick people do to get healthier, right?

Together, these beliefs and behaviors make up what’s called the sick role. They are the normal ways of understanding yourself as injured or ill and therefore what you do when you think of yourself in this manner.

Is there really any other way of thinking about it?Healthy Person Exercising

For many, this way of relating to chronic pain doesn’t involve a choice. It’s just how they experience pain. The presence of pain is simply and necessarily a sign of injury or illness for which there is nothing you can do but stay home and remain inactive. It’s never questioned and when it is, such questioning is perceived as invalidating or stigmatizing the reality of the pain as it is experienced.

This way of experiencing pain is apparent when people express such beliefs as “I can’t work” or “I can’t go to my kids ball game this afternoon” or “I have to take pain medicines.” For them, the presence of pain requires certain behaviors like staying home and resting or taking pain medicines. Open discussion of other possible ways of reacting to pain is perceived with skepticism at best and as invalidating or stigmatizing at worst. “You just don’t understand,” they might say. There really is nothing else they might do in the presence of pain, for its very experience requires that one must stay home, rest or take pain medicines. It’s just how it is.

What we are trying to articulate is the underlying conceptual framework or categories through which people experience pain.

Or, more specifically, we’re trying to articulate the conceptual lens through which some people experience pain (see also, Jensen, et al, 1999).

Do all people experience persistent pain in this manner?

While the above noted ways of experiencing pain are common, they are not universal to all people with chronic pain. We know, for instance, from empirical research but also from everyday experience, that some people with moderate to severe pain don’t take opioid pain medicines or don’t perceive themselves as disabled and so remain at work (see, for example, this article here).

For them, the presence of pain doesn’t rise to any level of urgency that requires action. It’s experienced as inconvenient or bothersome, but largely normal. “It’s just what happens when you get old” or “My migraines are a barometer that tells me I’m not taking care of myself very well” or “I heard that back pain is just something we have because early humans stood up on two feet” or “Doesn’t everybody have back pain?” Notice the lack of alarm or urgency with which these people experience pain. They have pain, but there’s no need to do anything about it. They accept it as normal. They don’t enjoy it, of course, but neither are they distressed by it. Pain is something we have and it's accepted as a bothersome fact of life that we put up with.

One way in which people experience pain in this manner is that they don’t understand pain as a health problem. In other words, pain lies outside of the conceptual categories of health or disease or injury. For them, knees and hips and backs and stomachs and necks and heads hurt because that’s how we’re made. It just comes with the territory of playing sports or getting older or getting stressed. It’s the given. It’s not abnormal. It’s normal.

This conceptual lens through which they perceive pain has for them no bearing on whether they are healthy or not. They might, for instance, consider themselves healthy even though they have to mind their persistent knee pain because of the sports they play. Indeed, the presence of chronic pain can sometimes serve as the cause of maintaining a healthy lifestyle. “I have a desk job and so when I sit all the time my back tends to hurt a lot and so it makes me insistent that I block my lunch hour so that I can walk everyday.” “I’m prone to migraines, almost everyone in my family gets them, and so I really have to stay on top of my stress and get regular exercise.”

Notice in these scenarios that pain isn’t understood as in itself an injury or illness. Rather, it’s due to playing sports or sitting too much or getting older or having too much stress. These ways of understanding pain don’t lead to illness behaviors such as staying home or resting or taking pain medicines. Indeed, it just might never occur to them that they should respond to their pain by staying home or taking pain medicine.

To learn to cope better, you have to be open to learning how

What we are trying to do in this discussion of contrasting experiences of pain is to articulate the underlying conceptual frameworks with which people understand pain. Pain is a complex subjective experience and we are attempting to make apparent the possible differences in the subjectivity of these experiences. Pain may be a universally human sensation, but it is subjectively experienced differently by different people in part because different people perceive pain through different conceptual frameworks.

For some, the sensation falls into the categories of injury or illness and poor health. From this way of understanding and perceiving pain, pain is an abnormal sensation that requires actions that sick or injured people do: seeking the advice of healthcare providers, getting tests and medical procedures, staying home from work, resting and taking medicines.

For still others, the sensation of pain falls into different conceptual categories, such as a sign of a hard fought sports game or getting really good work outs or getting older or sitting too much or having too much stress. From these ways of experiencing the sensation, there’s no sense of urgency to do something about it. It’s because they are understood as normal experiences.

The observation of these differences involves no intention to stigmatize. There are times, of course, when pain is due to injury or illness. Acute pain, for instance, is commonly the result of an acute injury or illness. So, it is not inherently wrong to conceptualize pain within the frameworks of injury or illness.

Not all pain, however, falls into these categories and it is sometimes in the best interest of those with chronic, or persistent, pain to begin to understand their pain differently.

It’s possible to learn how to experience pain differently. You have to be open to learning and it helps if you can learn from teachers or coaches within a non-judgmental or stigma-free environment. People with moderate to severe chronic pain learn everyday in chronic pain rehabilitation programs across the world.

Adopting an attitude that you remain healthy despite persistent pain

More often than not, if you see healthcare providers for chronic pain, they will encourage you to remain active, use the painful body part, exercise, manage your stress, stay at work, and try not to take opioid pain medications. Sound familiar? Despite these common recommendations, there’s often little instruction as to how to do these things when actually having pain. In fact, it almost seems impossible because the presence of pain seems to demand that you rest, guard or stay off the painful body part, stay home and take pain medicines. So impossible, it seems, that maybe they don’t really get how much pain you have or otherwise they wouldn’t recommend doing things that you know you can’t do.

With the discussion above, however, we can now begin to articulate how you might actually go about engaging in these recommendations, despite how impossible it might seem at first. It starts with adopting an attitude that you are healthy even though you have chronic pain.

Begin by reflecting on this essay. Consider the possibility that understanding your chronic pain as a long-lasting injury or illness leads naturally to behaviors that healthcare providers recommend against doing: staying home from work, resting, guarding the painful body part, taking pain medicines. This combination of beliefs, perceptions and behaviors lead to what we call identifying with the sick role. It puts you in a dependent role to your healthcare providers, on whom you rely to make you better. It also often puts you in a dependent role to family members, on whom you rely to take up the slack of what you can’t do. However, healthcare providers don’t have many effective ways to make you better, short of helping you to engage in the above recommendations. Reliance on family can foster guilt in you or increased stress and conflict with them. So, in all, experiencing pain through the lens of the sick role doesn’t typically amount to much improvement and sometimes it can even make your overall situation in life worse.

Maybe, then, it’s time to re-think how you think about pain.

Once you decide that it is in your interest to be open to learning new ways to respond to pain, then practice thinking of yourself as a healthy person with persistent pain. Recognize that healthy people have pain, even persistent, or chronic, pain. Low back pain, for instance, is by far the most common form of chronic pain and to manage it well you have to engage in behaviors that healthy people do – stay active, remain at work, use your back, get regular exercise, manage your stress, and maintain a healthy weight.

To adopt the attitude that you remain healthy despite having persistent pain, it helps to recognize that persistent pain is common. A third or more of the population has persistent pain. As we age, pain becomes increasingly more common (Fayaz, et al., 2016). It isn’t, therefore, abnormal to have chronic pain.

From this understanding, the occurrence of persistent back, neck, joint or head pain doesn’t have to be cause for alarm. It’s not signaling a state of urgency. Pain can be accepted as a fact of life. Many of us, as we get older, have a harder time keeping weight off. This biological condition isn’t a pathological condition of illness, but rather just something that is accepted. Most forms of chronic pain can be considered in a similar light – not something that is a pathological condition of illness or injury, but just something that tends to happen. It may occur because of sedentary lifestyles or sports activities or age or stress or maybe we don't even question why because it happens to so many of us. From this way of understanding it, pain isn’t abnormal and it's not alarming, but just bothersome.

This way of experiencing pain seems considerably more preferable than experiencing it as an abnormal and alarming event for which valued life activities must be given up. Rather, pain is something for which you stay active. Motion is lotion, as the old saying goes. Experiencing it this way, pain persists, but occurs in the background of daily life in which you stay active, remain at work, get regular exercise, manage your stress, maintain a healthy weight, and otherwise engage in the healthy behaviors of the healthy person you are.

Now that’s what really good pain management looks like.

References

Fayaz, A, Croft, P., Langford, R M., & Jones, G. T. (2016). Prevalence of chronic pain in the UK: A systematic review and meta-analysis of general population studies. BMJ Open, 6, e010364. doi: 10.1136/bmjopen-2015-010364

Jensen, M. A., Romano, J. M., Turner, J. A., Good, A., Wald, L. H. (1999). Patient beliefs predict patient functioning: Further support for a cognitive-behavioral model of chronic pain. Pain, 81(1-2), 95-104. doi: 10.1016/S0304-3959(99)00005-6

Date of publication: October 7, 2018

Date of last modification: October 7, 2018

About the author: Dr. Murray J. McAllister is the editor at the Institute for Chronic Pain (ICP). The ICP is an educational and public policy think tank. Our mission is to lead the field in making pain management more empirically supported and to make that empirically-supported pain management more publicly acessible. To achieve these ends, the ICP provides scientifically accurate information on pain that is approachable to patients and their families.

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