Introduction

Pain can be, of course, a naturally distressing and impairing experience. When in pain, we tend to be alarmed and react with grimacing, guarding, resting, or stopping any activities associated with pain. In these ways, we can see how pain involves distress and impairment.

Indeed, we might go as far as the International Association for the Study of Pain (IASP) in acknowledging that such emotional and behavioral aspects of pain are part and parcel of the very experience of pain itself. Often quoted, the IASP defines pain as an “unpleasant sensory and emotional experience… associated with actual or potential tissue damage” (IASP, 2012). In other words, pain is a sensation, of course, but it isn’t any old sensation. It’s a distressing sensation. Tickles and itches are also sensations, but tickles make us giggle and itches are aggravating, at least until we feel the relief that comes from scratching. Sensations thus have an emotional aspect, which in part is what differentiates them from one another. Pain’s emotional aspect is distress or alarm. Pain is an inherently alarming sensation in which we automatically exhibit grimacing, groaning, bracing, or guarding behaviors that lead to stopping activities and resting. These latter emotional-behavioral expressions of pain are referred to as pain behaviors.

Unchosen nature of pain behaviors

The sensory, emotional and behavioral aspects of pain are typically not chosen. We do not have a certain sensation and, upon reflection, choose to become alarmed and express it by groaning or grimacing and protecting the painful area. No, the distress and associated behaviors occur along with a certain sensation and are part and parcel of the experience of pain. They occur reflexively or automatically, without intentionality or choice.

We might put the point in terms of an equation:

Pain = sensation + emotional alarm + reflexive behavioral avoidance

The essential variables of the equation occur in most any experience of pain. Let’s take an example. Suppose we are hiking through a forest and I accidentally step into a hole in the trail and break my ankle. Without reflection or intentional choice, I begin to have a sensation in my ankle, become alarmed, grimace, call out, and reflexively engage in protective or guarding behaviors. It all happens in an instant and automatically.

All of these variables are what we call “pain”.

Bringing pain behaviors under voluntary control

Pain behaviors are typically reflexive and not the result of intentional decision-making because we lack awareness of when we will feel pain. Pain, in other words, takes us by surprise. Without ever thinking about it, we grimace, garb at the painful part of the body, and exclaim “ouch!” or some other expletive.

In the broken ankle example above, I have no reason to anticipate the pain of the broken ankle. Rather, I simply and unwittingly step in the hole and the injury occurs. With the pain of the broken ankle, I grimace, brace, favor my ankle, and exclaim a painful utterance.

In cases of chronic pain, an important difference typically occurs. It’s the fact that chronic pain is persistent or repetitively present under certain circumstances. This persistent or repetitive nature lends itself to being aware enough to anticipate pain.

Suppose I have chronic low back pain. It’s a persistent dull ache that is always present. Whenever I get up from a chair or sit down on a chair, though, I additionally experience a sharp stabbing pain. It occurs most every time I sit down or get up and it has done so for years. Suppose further that because of the pain I also tend to grimace and hold my back stiffly, and whenever I sit down I tend to brace myself and let out an audible sigh.

The persistent and repetitive nature of chronic pain offers an opportunity that doesn’t occur in cases of acute pain, such as when I unwittingly step into a hole and break my ankle. The opportunity is that the persistent and repetitive nature of chronic pain allows for bringing a degree of awareness to the pain and even to anticipate it. With this degree of awareness, it becomes possible to develop greater intentionality with regard to pain behaviors. That is to say, one might begin to practice bringing pain behaviors under greater voluntary control.

In the example of chronic low back pain with repetitive stabbing pain upon sitting down or getting up from a chair, I could set out to bring my awareness to it and make an effort to control my grimacing, bracing and exclamations whenever I sit down or get up from sitting.

Of course, it would take some practice. There’s no pain behavior switch that can be turned off like a light switch. Rather, it would take repetitive practice to bring awareness to the pain and to anticipate it, such as when sitting down, and make an effort to control its behavioral expression. With practice, one could gain greater and greater voluntary control over pain behaviors and even the sense of alarm that goes along with the sensation.

The process of practicing thus involves bringing awareness to pain and its behavioral expression, anticipating pain, and the practice of choosing a different set of behaviors than the reflexive and automatic behaviors associated with pain. It could also involve reassuring self-talk that you know what your pain is, that you have it no matter what you do or don’t do, and, as such, the pain of chronic pain isn’t always signaling harm. Your chronic pain, you remind yourself, is like a broken fire alarm that keeps sounding the alarm whether there’s smoke or not. So, when you sit down and experience the sharp stabbing pain, the pain you experience isn’t necessarily signaling that the sitting motion is injuring you. The dull ache that you feel at all times of the day whatever you do or don’t do isn’t signaling that you are continuously injuring your back. Rather, the pain you experience is chronic pain and you experience it whether you are injuring yourself or not. The purpose of this reassuring self-talk is to begin turning down the sense of alarm that accompanies the sensation of pain. The goal would be to remain emotionally grounded in the presence of pain. With your increased awareness of pain, you might, for instance, take a deep breath to calm yourself and clear your head before sitting down and experiencing the sharp stabbing sensation. The improved emotional control over pain lends itself to improved control of the behavioral expressions of pain.

Imagine a day when you still experience the same level of pain that you do today, but you are no longer alarmed by it, and you confidently engage in life activities without any degree of vigilance to pain or fearful bracing and guarding. No one would ever know that you have the pain that you do. When, on some occasion, you tell them about the severe pain that you do in fact experience, they’d believe you and say something like, “Wow, you cope so well with it.”

Coping well with pain involves controlling pain behaviors

After all, what is coping well with pain? Coping isn’t getting rid of the pain, but rather putting up with pain. It’s tolerating pain. Now, everyone tolerates pain. It’s not ever a question of whether you or anyone else tolerates pain or not. Rather, coping involves a question of degrees. How well does one cope? Coping, as I like to say, occurs along a spectrum from low levels of coping to high levels of coping.

If we understand that coping or pain tolerance occurs along a spectrum, then we can recognize that no matter where you are on the coping spectrum you can always get better at it. Reducing the emotional distress and behavioral avoidance of pain is a way to get better at coping with pain.

Suppose we worked with a woman who experienced recurrent migraine headache. She had migraines most every day and she preferred to lie in bed with the shades drawn and the lights off when experiencing a migraine. Over the years, she found herself engaging in these behaviors more and more. She came to a chronic pain rehabilitation program because she wanted more out of life. She also needed to keep her job. When she forced herself to remain at work, she tended to rub her temples and the back of her neck on a persistent basis. She tended to have a grimace on her face and also sighed frequently.

When we initially brought up the recommendation to begin practicing controlling her emotional alarm and pain behaviors, she was offended. She thought we were judging her and asked rhetorically ‘what else am I supposed to do?’ We acknowledged, just as we did above, that such alarm and behavioral avoidance of pain is normal and natural. The point is that no one is judging her because engaging in these behaviors is normal.

We pointed out, though, she was coming to the program to learn how to cope better with pain and that if she’d trust us and practice what we were teaching her, she would in fact learn to cope better with pain.

So, she began to practice bringing her awareness to the pain and how she was coping with it. She recognized that, even though it was painful to remain erect and out of bed, it was safe for her to do. She acknowledged, in other words, it wasn’t injuring her or harming her to remain at work even though her head pounded. With such awareness, she further considered that she could make a value cost-benefit decision in which she weighed the value of pain reduction by remaining home in bed in the dark versus remaining at work, secure in her job, and involved in meaningful activities that brought value to her life.

She subsequently began, over time, to choose the latter. She made a concerted effort to remain grounded in the presence of her pain and redirect her attention to work or other valued-life activities. She would catch herself sighing and rubbing her temples and remind herself to stop and get involved in the activities she was pursuing.

We gently and respectfully pointed out such behaviors to her to help her in becoming more aware of them. She trusted us that we weren’t just picking on her, but helping her to cope more effectively with pain.

She came to conclude that if she were home on a Friday night watching a movie and wanted to rub her temples, it would be okay; but she wanted to be able to have the wherewithal to keep herself from engaging in such behaviors if, for examples, she were at a work meeting with colleagues or in a job interview. In the latter situations, it would be better for her to be able to cope with pain without engaging in such behaviors.

With effort, practice and openness to feedback, she came to be able to remain at work, engaged in the activities of work, even though she had a migraine. People stopped worrying about her at work and she stopped worrying that her job was in jeopardy. She felt self-confident in the presence of pain. She felt productive and proud of herself. Her career path was again heading in the right direction.

Even though she continued to have migraines, they were nowhere near as distressing and impairing as they once were. In other words, She had learned to cope really well with her pain.

Conclusion

Reducing pain behaviors is a long-standing recommendation in chronic pain rehabilitation because it is a way to learn to cope better with pain. It takes coaching from providers who you trust and who are gentle and respectful in their feedback. It takes time and effort. It also takes repetitive practice. However, it is also possible. It’s possible to learn to cope better with pain and reducing pain behaviors is a way to do it.

References

International Association for the Study of Pain (IASP). 2012. IASP taxonomy. Retrieved from: https://www.iasp-pain.org/Taxonomy. 

Date of publication: October 9, 2017

Date of last modification: October 9, 2017

About the author: Dr. Murray J. McAllister is a pain psychologist and the founder and editor of 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 chronic pain that is approachable to patients and their families.