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Living well with persistent pain – a problem solving model

Posted May 10 2012 5:05pm
Regions of the cerebral cortex associated with...

Regions of the cerebral cortex associated with pain. (Photo credit: Wikipedia)

Chronic pain is abnormal. Living well with chronic pain seems a myth, a bit of an impossibility. After all, chronic pain starts with the kind of pain that most people would expect to go away – acute pain.  Acute pain is normal and most of us will experience some painful episode today.  Acute pain goes away – either by itself, or because we’ve done something to remove the stimulus that triggered the cascade of neurological events that eventually reached the brain that produced the experience of pain.

Because chronic pain begins just like any other pain, and because acute pain generates our attention and stimulates some sort of problem solving process so we can take appropriate action, it makes sense that we apply the same problem solving strategy to the problem of chronic pain.  Eccleston and Crombez (2007) proposed that one of the ways we can view the distress, loss of function and reduced quality of life is through a model of “misdirected” problem solving.

Problem solving is often discussed as if the problem exists outside of a context. “Here’s the problem, go solve it” fails to establish the frame of reference – why is it a problem? who has the problem? what contributed to the problem? what resources are available to fix the problem?

One of the major contributions of psychology in the field of pain, particularly a cognitive behavioural model, is helping people view their problem differently. If a situation is viewed differently, the “problem” may go away, or at least be seen as manageable.

BUT, in the case of pain, mostly people start by thinking that pain is something to be cured or fixed, the pain should go away, and life should return to normal.  In the case of chronic pain, when the pain persists, the same problem solving strategies that work so well for acute pain begin to get in the way of living. Life becomes a merry-go-round of searching for relief (maybe an explanation, diagnosis, medication, surgery, new treatment), hope being raised, then very often being dashed because nothing has changed.

Eccleston and Crombez describe this cycle in terms of the function of worry.  “Where such problem solving leads to success, pain and worry abate. However, when the problem solving attempts fail to find a solution, worry is fueled. A ‘perseverance loop’ is established in which the failure of a solution to the problem of pain amplifies worry. In this loop increased worry functions to strengthen motivation to persevere in solving the problem. Problem formulation becomes narrowed and inflexible, whilst greater effort is employed repeating the same solutions. If on repeated attempts a solution is achieved, again pain and worry will stop. “

Over the past 20 years or so, cognitive behavioural approaches for helping people cope with their ongoing pain have focused on reducing distress and disability by helping people reframe the problem of persistent pain as something that can be managed.  This takes the focus off trying to remove the pain, and broadens problem solving so that people begin to look at what else can help them live well.

My research is examining how people who do live well with their pain manage to do so.  While the people I’m talking with don’t say no to new treatments, they don’t seem invested in it so that their whole lives are focused on solving the problem of pain.  Instead, they seem to view pain as “just another thing” that they deal with while they get on with the real business of living life. Some have found that having chronic pain has enthused them with a new direction in life. Others have a focus on family, or community, or work.

The context of chronic pain matters.  It’s the way that the problem of chronic pain is framed that situates and generates the range of problem solving options that are considered.  If we ask a person “what’s important in your life”, and see if they’re willing to make room for having pain present while they engage in occupations or activities that allow them to live their values, we offer people a chance to live well with their persistent pain.

Eccleston, C., & Crombez, G. (2007). Worry and chronic pain: A misdirected problem solving model PAIN, 132 (3), 233-236 DOI : 10.1016/j.pain.2007.09.014

Eccleston, C (2011). A normal psychology of chronic pain The Psychologist, 24 (6), 422-425

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