Can chronic pain be a force that shapes how we go about responding to challenges within our environments?
Does chronic pain influence how we feel emotionally about daily activities that contribute to overall goals, and perhaps negatively bias the way we think about the process of setting and achieving goals?
I’ve already concluded that having pain doesn’t mean people can’t do what they want to do, but it certainly makes it harder and less enjoyable. Today’s post will briefly look at two theories that link emotion, cognition and pain. Once again, I’m drawing from a paper written by Hamilton, Karoly & Kitzman (2004).
These authors refer to two theories – the first being a two-factor model developed by Carver and colleagues in which it is proposed that people have two emotional regulation systems.
A behavioural activation system (BAS) associated with positive feelings when the ‘appetitive’ systems is satisfied. The appetitive system refers to a system that encourages us to approach and remain engaged with something for reward.
A behavioural inhibition system (BIS) that associates negative emotions with goals that are involved with avoiding harm.
Carver’s model proposes that emotions develop during the course of evaluating process towards a goal – if the going is good, we feel good and carry on. If the going is not so good, we feel less positive and may disengage from that goal. This emotional response influences whether we persevere or simply give up depending on our tolerance to not receiving immediate gratification. So it makes me wonder whether helping kids to learn to persist with something until they do it correctly is actually a fundamental learning experience that is needed so they can learn ’stickability’ when the going is tough.
Hamilton, Karoly and Kitzman suggest that when we think about the effect of this model of emotion on self regulation, individual adjustments to the limitations of chronic pain might reflect how sensitive each individual is to either positive feedback or negative feedback.
This might influence how we give feedback to people who are pursuing a goal – some may need just that bit more encouragement and help to overlook the times they don’t succeed, while others might need to be encouraged to see the consequences if they don’t make progress (especially in the case of losing access to help from a compensation organisation).
The Hamilton, Karoly and Kitzman paper goes on to explore the evidence supporting Carver’s model and how this might influence individual differences that we see in people adjusting to the demands of chronic pain - perhaps some people are resilient because they can draw upon small steps towards a goal that others might overlook because they are less sensitive in the BAS. Perhaps some are strongly sensitive to the BIS and as a result are more energised by avoiding the negative emotions associated with remaining ’stuck’ when coping with chronic pain. They also suggest that maybe chronic pain itself influences BAS and reduces its sensitivity (ie chronic pain reduces how ‘rewarding’ achievement feels), and/or increases the BIS sensitivity (ie makes it all the more important to avoid risky situations). As they put it ‘pain-related negative affect could have a pervasive impact on the evaluation of goal-related progress and resulting affect…whereas periodic pain flare-ups may have a state-dependent effect on BAS/BIS sensitivity.’
The second model is one I have come across in my readings – Dynamic Model of Affect (Reich, Zautra & Davis, 2003). In this model, Zautra and colleagues suggest that how well we adjust to chronic pain depends on individual differences in the structure of our emotional response, as well as the limitations we have in information processing. This model puts forward the idea that the relationship between feeling good and feeling more negative depends less on stable personality ‘traits’ than on the relationship between general mood and what is happening in the here-and-now. Once again, research is cited by Hamilton and colleagues to demonstrate that when stress is low, both positive and negative moods vary independently – we can feel both happy and irritable and this can fluctuate just because it does! During times of high stress, however, how good we feel is limited by the underlying level of negative emotion we’re experiencing.
When considering both models, Hamilton, Karoly and Kitzman suggest that Carver’s model refers to responses to individual events, whereas DMA refers to mood states that might occur over a period of time and across more than one dimension. They also suggest that the DMA gives a better description of what occurs during increased stress, when it describes that cognitive and affective processing becomes more focused on avoiding threat than on seeking reward, while during low stress, both outcomes have equivalent influence.
The final aspect of emotion and chronic pain as it related to self-regulation, and in particular, setting and achieving goals, is that some people seem to cope quite well during periods of pain flare-up, and do so positively. Zautra and colleagues call the ability to both experience negative emotional drive AND positive emotional drive ‘emotional complexity’. In terms of goals, an ‘emotionally complex’ person might be able to continue to react to positive events and ‘use that energy to fuel additional goal directed efforts’.
Attitudes towards experiencing emotions might influence the ability to be ‘emotionally complex’. If we’ve been taught that ‘feelings are bad’ and should be stifled, or that understanding and being clear about emotions is helpful, will influence how well we are able to identify the different emotions we experience, and how well we can tolerate having them. Being aware that we can experience different emotions – and cope with them – has been shown to help people keep focused on goals even during periods of high stress, high pain and limited progress.
What might these two models mean for pain management?
As therapists we might need to ‘take the emotional temperature’ of the people we are working with. If we are working with someone who is highly sensitive to being ‘ driven ‘ by avoiding negative emotions, we need to be aware of this during pain flare-ups – it might be even more important to show people that they can persist during these times than to give them lots of encouragement to try new intrinsically rewarding activities. Recording progress might help. Encouraging recognition of even small progress during flare-ups is clearly important.
…but wait, there’s more! Tomorrow: regulating emotions and coping.
Hamilton, N., Karoly, P., & Kitzman, H. (2004). Self-Regulation and Chronic Pain:The Role of Emotion Cognitive Therapy and Research, 28 (5), 559-576 DOI: 10.1023/B:COTR.0000045565.88145.76