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A Positive Case Formulation for Chronic Pain

Posted Jun 23 2009 5:21pm

The past couple of days I’ve looked at resilience, strengths and growth as part of assessing a person with chronic pain. The rationale is that although we are often seeking to provide support for deficits, or develop strengths, I wonder whether we always appreciate what people already have used to live with their pain.

To illustrate how we might include positive coping resources, I thought I’d provide a case study, based on a real person but with details somewhat disguised to protect confidentiality.


Kevin is an ex-mechanic with low back pain that hasn’t responded well to nerve blocks.
He’s had his pain for about three years now, moved away from fixing motors and is now trying to return to work in a completely different occupation – parts sales. The problems he identifies are difficulty bending, reaching and sustaining any sitting or standing position for more than 20 minutes.

He readily acknowledges that he avoids doing things that ‘might’ hurt – but at the same time appreciates that his pain can come ‘out of the blue’, sometimes affecting him when he’s doing something he often does, like doing up his shoelaces, and sometimes not. This has made him somewhat cautious about all movements, and to look at him, it’s easy to see that he holds himself in a ramrod-straight and upright position at all times.

He has difficulty selectively recruiting and relaxing muscles as he moves, and at the same time as moving, he hardly breathes. He’s recently acknowledged that he’s feeling out of control of his moods, and that his family life is pretty strained.

Doesn’t sound terribly positive, does it?!
A typical formulation might suggest that he has a pain-related anxiety with avoidance, heightened physiological arousal, and very strong beliefs about how things ’should’ be, along with poor motor control leading to erratic recruitment of muscles which also lead to altered sensory input to and from the neuromatrix.

Treatment might include giving him a cognitive model for his pain – such as introducing him to the pain-related anxiety and avoidance model, following an exposure-based programme for reducing his fear of specific movements, guiding movement patterns so he can obtain more accurate feedback from his body to his brain, helping him develop more flexible cognitions around what is and is not OK, and helping him reduce his physiological arousal through relaxation or other self regulation strategies.

All of these approaches might help him, and address some of the underlying deficits in his coping, but it does look like an incredibly enormous amount of work and quite a daunting list of ‘problems’ to ’solve’! I wonder what would happen if we looked at some of his strengths?

He has demonstrated the ability to persevere despite not obtaining immediate results, he has very high standards and usually achieves them, he continues to focus on the future and the goals he wants to reach, he is a sensitive man, aware of other people’s emotions, he has a stable work record and loved his original job but has shown determination and flexibility in being able to find new work, he has a stable mental health history, he has a strong family unit and a high level of commitment to his family.

What these strengths suggest to me is that once he has a direction and knows what to do next, Kevin will be able to follow a plan for quite some time without needing immediate results to keep him focused. He’s shown this in a number of ways in his life, and like everything, it has both helpful and not so helpful aspects! It can mean that he perseveres with inappropriate or unhelpful strategies too – but once he’s got an idea or goal in mind, he doesn’t give up readily.

His sensitivity to others emotions means that he is quite reserved in his own emotional responses, while being careful not to irritate or anger others. This means his relationships are very stable – but he wears the cost of this at times because he can fail to acknowledge his own needs. It also means he works very hard to interpret what other people may be feeling without needing to ask. Although this can be a problem for him, because he can feel responsible for other people’s emotions (because he feels he should be able to absorb his own emotions without burdening others), it also means he can learn to alter his own behaviour, notably pain behaviour, which can be helpful in the long term to reduce disability. It helps to minimise unhelpful communication of pain to others in his life. Given some guidance to identify the inadvertent signals he is currently sending, he will be able to monitor his own pain behaviour and modify it appropriately.

His close family connection provides him both with emotional support and motivation or drive to pursue new avenues for growth. Although as I’ve noted above, this could lead him to feel overly responsible for his family’s feelings and prevent him from acknowledging his own needs and seeking support, it also provides impetus for him to take steps and find ways to obtain new employment. He is prepared to try risky new things in order to maintain his home relationships. It’s like a stable platform from which he can look at new possibilities. Perhaps by encouraging his family members to be included in his pain management, he can strengthen his relationships, and begin to draw strength from them rather than always being the source of strength for others.

Getting a different picture of Kevin now? Rather than seeing him as a person with a whole lot of needs that cause trouble, Kevin looks much more like the competent man he was before his pain developed and started to derail his life.

Something I love about pain management is that the people I work with have all had areas of effectiveness prior to their pain problem. Every person brings their own resources to their situation, although sometimes the ways they’ve been using them in the new situation may not always be as effective in the long-term as they’d like. I think my job is to work with people to help them discover how to build on their strengths, and use them in a flexible and adaptable way.

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