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On Can't and Able

People with moderate-to-severe, persistent pain often come to a pain rehabilitation program because they want more out of life. It is not so much that they are looking for outright pain relief, since they’ve had pain for so long they know it isn't going away altogether. What they are looking for instead is to be able to get back into life and do activities that they no longer do. 

While, to be sure, pain reduction is important, the ability to do more or life's activities is also important. The ability to engage in meaningful activities is one of those things that make life worth living. Perhaps, it is the ability to hold your child or grandchild, or get down on your hands and knees and play with them. Maybe, it’s going out to eat with your spouse, or going to a movie or concert or town festival. Or, perhaps, it’s the ability to go back to church, mosque or synagogue, and participate once again in your religious community’s activities. Maybe, too, it is the ability to go back to work. All of these activities, and more, bring value to life.

Regaining the ability to do some or all of these activities would be a win. It would be an important win in your effort to manage persistent pain well. 

Such is the promise of pain rehabilitation programs. Sure, most people who attend such programs don’t leave pain free. Instead, they tend to have modestly less pain (which, by the way, is true on average for all procedures, pills and therapies when it comes to moderate-to-severe, persistent pain), but the real gain is that they get their life back. They acquire the abilities to do those activities that make life meaningful again. They can have fun again. They can do things with their loved ones again. They can work again. They can participate in life again. 

Despite these positive outcomes, the prospect of really getting down to it and doing the hard work of getting your life back can also be a Image by Giorgio Trovato courtesy of Unsplashsensitive issue. For so long, you may have maintained that you can’t do these things. As such, in the background, there’s always that persistent doubt as to whether it’s really true that you can’t do the things that you say you can’t. Perhaps, it started when your spouse, friend or healthcare provider first disagreed with you and said that you really can do the things that you had said you can't. Initially, they might have meant it with a sense of optimism, as if they were trying to act as your cheerleader. With time, however, the optimistic nature of their point of view changed. Their assertions that you really can do things that you said you couldn’t became more like accusations. They came to doubt your perceptions of yourself as disabled. They may even now think you’re faking it. There’s a whole range of ways people can disagree with your understanding of yourself as disabled.

Perhaps, too, all these things that other people have said and thought about your view of yourself as disabled has occurred so many times that it is now just out there, in the background, of your day-to-day life. No one even needs to say it anymore. Your abilities and your daily activities seem always open for scrutiny by others. 

To this problem, it’s easy to slip into needing today’s disability as a means to justify your past assertions of disability, which have been previously doubted. It can become a vicious cycle: the legitimacy of your disability can involve a continual need for justifying the legitimacy of your disability. You say you can’t. They say you can. The only way, it seems, to prove to them that you can’t is to continue to be unable to do what you’ve maintained you can’t do.

Perhaps, it has even gotten into your head. In vulnerable moments, you wonder to yourself, “What if they’re right?” This doubt creeps into the back corners of your awareness, but the thought of it is too shameful to consider

As such, the immediate counter-thought is to think to yourself that you really can’t do these things. Such inner (and outer) doubt isn’t in fact true. You have persistent, severe pain. Is that not justification enough for being unable to do certain daily life activities? The answer to this rhetorical question seems obvious. You subsequently maintain your long held position that you can’t pick up your grandchildren, or attend a concert, or go back to work, or whatever the activity may be.

The inner life of someone disabled by persistent pain thus becomes marked by back-and-forth assertions of impairment and doubts of those impairments. Can’t or able, that is the question…

It’s a sensitive issue.

Into this mix, the prospect of participating in a pain rehabilitation program can seem daunting. As mentioned above, the promise of such programs is that they help people with moderate-to-severe chronic pain get back into life. A primary goal is to be able to again do things that you haven’t been able to do. To start this process, though, you have to acknowledge that it is possible. If you have long maintained to others (and even yourself) that you can’t do things like work or social activities or religious activities, how do you cross that bridge into a space where maybe, just maybe, you can come to be able to do those things?

It’s one of those odd situations in life, where hope can be threatening. Countless times in my career, I have recommended participating in a pain rehabilitation program with the promise of taking back control and in my mind I am offering hope, but am surprised when it is met with scorn: “You think I can just go back to work?!? You must have no idea how much pain I am in!” Immediately, I attempt an explanation: “No, I know you can’t work right now, but the program will help you to get back to the point where you could… It’s one of the things that pain programs do best.. In fact better than other forms of treatments…” A common patient rejoinder comes quickly, “But, you said I’d still have pain! You think it’s so easy to just go back to work with the pain I have? I suppose you think it’s just mind-over-matter?” By this point, it’s typically too late. I thought I was offering hope, but the patient leaves the visit upset and feeling invalidated

It doesn’t have to be this way, though. There is a way to hear the promise of a better life, in which it is possible to regain lost abilities. For, afterImage by Henry Co courtesy of Unsplash all, that is what rehabilitation is all about: getting back the abilities to do what you currently are unable to do, given an on-going health problem, like chronic pain. Whether it is a stroke, a traumatic brain injury, a spinal cord injury, or chronic pain, the goal of rehabilitation for these on-going conditions is to become more functional. That is to say, rehabilitation doesn’t necessarily cure these conditions, but it is a proven way to acquire the abilities to engage in meaningful life activities, despite the on-going nature of these conditions. 

From this perspective, pain rehabilitation programs can be the bridge between can’t and able. You can’t do certain activities now, but with rehabilitation you come to be able to do them.

To be sure, it is hard work and it takes time. A typical pain rehabilitation program is 3 or 4 weeks long, but they really serve to jump start you into the rehabilitation process, which you pursue for much longer. Ideally, you come to do the therapies on your own and make them part of your new lifestyle. In this process, you come to be able to do things that were once impossible for you to do.

An additional, interesting thing happens when you do. The process of rehabilitation allows you a way out of the vicious cycle of needing to justify your disability in the face of the doubts of others. The legitimacy of your past disability remains even while you engage in the hard work of rehabilitation and slowly make progress (or perhaps because of it). The work necessary to again be able to do things is out in the open and there for everyone to see. Pain rehabilitation programs thus create a space from which you can safely transition from disability to ability and it does so without any underlying shame

Indeed, more often than not, others, who may have once doubted the legitimacy of your disability, come to admire your hard work and new-found achievements. Of course, you aren’t doing it for them, but it does help. They see that coming to be able to do things you once were unable to do took work, which was guided by professionals. They see such work and recognize that it is an achievement. With effort and achievement, you leave those doubts of others in your past.

“Thank you for giving me my life back.” It’s the most common response of pain rehabilitation program patients upon their completion. Through the hard work of pain rehabilitation, patients with moderate-to-severe persistent pain can come to physically and psychologically be able to do things that were once impossible. They can engage in meaningful life activities, while at the same time liberate themselves from the need to justify their (now previous) impairments in the face of others who doubted the legitimacy of those impairments. The pain rehabilitation program served as a bridge that allowed them to cross from can’t to able.

Date of publication: 8-27-2022

Date of last modification: 8-27-2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist and consults to clinics and health systems on improving pain care. He is the founder and editor of the Institute for Chronic Pain.

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