Effective Ways to Challenge Chronicity Thoughts

How much time do you spend thinking about your pain or illness? Does it consume most of your day? Just a little bit? I remember the time when I was spending a lot of time thinking about being in pain, and wondering “why me” or what my life would be like going forward etc. These are often referred to as chronicity thoughts. Happily, this was the past for me and is not my experience anymore. I know that many of you may be having this as your current experience though, so I wanted to take sometime to talk about it.

As human beings, we spend a lot of time thinking.

First of all, I want to say that this is a totally normal experience for anyone with chronic pain or a chronic illness. Our minds are literally trying to help us (or they think they are trying to help us, which is what they evolved to do). The problem is, this kind of constant thinking about pain makes our lives worse, not better. There are three types of common chronicity thoughts: (1) ruminating about being in pain/sick – I keep thinking about it, it’s all I can think about because it hurts; (2) magnifying our pain/illness – it will get worse, something terrible is going to happen; and (3) thoughts of helplessness – nothing I do makes it better, nothing I can do will ever make it better.

Are your thoughts making your life better, worse, or the same?

If you went to a doctor (Western or functional) or a therapist, they’d likely assess this with a tool called The Pain Catastrophizing Scale (PCS). My commentary is that I don’t like the name because “catastrophizing” sometimes has the connotation that it’s all in your head, but that’s not what it means in this case – it’s really referring to chronicity thoughts. The questions on the scale include:

• I worry all the time about whether the pain will end
• I feel I can’t go on
• It’s terrible and I never think it’s going to get any better.
• I wonder whether something serious will happen.
• and so (there are 13 questions total, and you self-report on a scale of 0-4 for each question, with 0 meaning not at all and 4 meaning all the time.)

Image from: https://www.endonews.com/pain-catastrophizing-perceived-injustice-and-pain-intensity-impair-life-satisfaction

So what can we do about all these chronicity thoughts? First, I will always suggest that working with a therapist is the way to go. Remember this blog is educational and not mental health/medical advice. We all have unique situations and unique thoughts, so having someone you can work with one-on-one (or in a small group) is always the way to go. I will let you know about a few different approaches. First, let’s talk about classic Cognitive Behavioural Therapy approach, where we challenge thoughts.

• Notice and name the thought: I’m having the thought that “It’s terrible and I never think it’s going to get any better.”
• Review evidence for and against the thought: For might include things like, it occurs frequently, has high intensity, a doctor’s prognosis, etc. Against might be things like, there are times of day when I don’t notice it or it’s less intense or my doctor said with this medication or these lifestyle changes it will improve
• Replace the thought with a more accurate one: This doesn’t mean being optimistic or denying anything that’s true. Instead it’s incorporating the evidence against the thought (not just for the thought which is what we tend to do). So a different thought might be: “It’s really unpleasant right now, but it might not always be this bad/constant.” (You choose a thought that works for you, this is just what might work for me.)

Image from: https://medium.com/spark-live/advantages-of-cognitive-behavioral-therapy-cbt-88bff0ab98d3

As a therapist, I am well-trained in CBT but I prefer to use Acceptance and Commitment Therapy (ACT) on myself and with clients, especially those with chronic pain/illness. There is no step-by-step way to challenge thoughts in ACT because we don’t challenge them, but here’s now I might work with them.

• Contact the present moment: ground myself my noticing and acknowledging my thoughts and feelings, while noticing what I can touch, taste, smell, hear, and see. (Here’s a guided version of this).
• Use my noticing self: the part of me that notices everything and even notices my noticing. And the similar part of me that can put myself in my shoes on the days when my pain is less. (Here’s a guided version of how to learn to do this).
• Creating distance between myself and my thoughts: This might be noticing and naming the thought. It might be reminding myself that my brain is just trying to help me and saying “thank you mind.” This might be just watching my thoughts come and stay and go in their own time (guided version of this one is here).
• Accepting my experiences: particularly physical and emotional pain that I might be going through. This could be actual sensations or emotions such as sadness or anxiety. For this I often just observe what the sensation/emotion looks like, where it is in my body, and so on. Then I send my breathe into the part of my body I feel it most intensely. Then I make some room for it, noticing that my body is bigger than it. Finally, I just allow it to be there without consuming me. (Guided version here).
• I connect with my values: what qualities of being are important to me? I know that compassion (for myself and others) is a big one that is often helpful in moments of pain, sadness, anxiety, etc. (Here’s an exercise on connecting with your values.)
• Taking an action to live by my values: So if we’re going with my above example/value than it might be doing some self-compassion work. (Here’s a guided practice). It could also be setting goals to make some of those lifestyle changes that might help. It doesn’t matter what the action is as long as it is rooted in your values. (podcast episode on how to do this available here).

Image from: https://www.youtube.com/watch?v=Tz4w0xrQfWI

So that’s it. A bunch of different ways to work with your chronicity thoughts so that hopefully you can improve your life and keep making the most of it!

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Book Review: Man’s Search for Meaning

This month I read the book, Man’s Search for Meaning by Viktor Frankl. The book is actually one of the top selling “self-help” books of all time. I put self-help in quotations because I’m not sure if that was the original intention behind Frankl writing it, but it seems that he might have recognized what it became between the years it was first published in 1946 and his death in the late 1990s. The first half of the book chronicles his experiences as a prisoner in concentration camps during the second World War, including Auschwitz. While this could be just read as an intense, heart-breaking story (and it is), the way that Frankl writes about his life experiences doesn’t come off that way. Instead, you can see his reflection and growth in his writing. It’s kind of hard to explain how that works, unless you read it for yourself. The story is also not chronological but instead jumps back and forth across his timeline in the camps to highlight pieces of the story that are connected to each other in some way.

While I don’t want to give away too much from the story, because I highly recommend that everyone read it, there were two main takeaways that I had from the first half of the book. First, is that if we believe our lives have no meaning, then we are more likely to give up when faced with difficult circumstances – and that meaning doesn’t have to be grand or anything, as the beauty of a sunset or holding the hand of a sick friend can bring some meaning for that day. Of course, as Frankl admits, in the concentration camps there was a huge element of dumb luck that you ended up in this line instead of that line (whereas that line led you to the gas chambers and this one didn’t), but for those with that luck, meaning became important. The other takeaway I had is that meaning is created by each other us, and is different for each person. It is solely up to us what that meaning is.

The second half of the book is about Logotherapy, which is a psychotherapy modality that Frankl (who was a psychiatrist) invented. It was kind of based on psychoanalysis, but with a heavy emphasis on existential philosophy, particularly meaning-making. During the second half of the book, Frankl does tell more stories from his time in the camps, integrating it with his theories about human existence and how helping people find meaning can aid with the treatment of many mental health problems. Frankl is considered one of the leaders of existential psychotherapy. Though logotherapy isn’t really used anymore, as there isn’t a huge amount of empirical evidence supporting it, it has influenced many other existentially-based therapies, including Acceptance and Commitment Therapy, which I practice. My personal beliefs are that life meaning is incredibly important, as are other existential concepts, which all humans ultimately deal with, and our ability to deal with contributes, at least partially, to our overall well-being.

Even if you aren’t interested in psychotherapy or existentialism, I highly recommend giving this book a read. There’s a reason that this is a best-selling self-help book. Many people struggle with finding meaning in their lives, especially at transitional periods, and this book can really open your eyes on how to find meaning, even in incredibly difficult circumstances. There are so many amazing quotes from this book, but I’m going to leave you with this one: “The helpless victim of a hopeless situation, facing a fate he cannot change, may rise above himself, may grow beyond himself, and by doing so change himself – he may turn personal tragedy into a triumph.”

For a podcast episode on meaning making with chronic illness, check out this one. Everyone, thank you as always for reading my posts. If you end up reading this book, let me know what your takeaways were. For now, keep making the most of it!

Choice, Growth, Freedom, Values & Acceptance

“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” – Viktor Frankl

Viktor Frankl

For those of you who are not familiar with Viktor Frankl, he is a psychiatrist, author, existential philosopher and Holocaust survivor. His belief system, which was seemingly helpful to him while he was in a concentration camp, is that life can have meaning even in the worst possible circumstances (like he himself faced) and we are motivated to continue to live when we find that meaning. Like many other existentialists, Frankl believed we had the choice to do what we wanted with the circumstances we are given, even if we don’t always get to choose the circumstances ourselves. When it comes to chronic illness – physical or mental – it can be hard to always see the choices available to us, and sometimes those choices may be more limited, but they are still there. If I am in pain today, I can choose to lie on the couch or I can choose to do some stretches. I can choose to do nothing, or I can choose to sit at the computer and write a blog post that will hopefully help someone else. Depending on your situation, your choice options will look different than mine and that’s okay. The last part of Frankl’s above quote says that “In our response lies our growth and freedom.” Personal growth, and healing journeys (check out my podcast about healing here and personal growth here) are difficult but necessary if we want to live full and rich lives, if we don’t want to give up and into our circumstances. There is so much overlap between chronic physical illness and mental illness and feelings like hopelessness and helplessness play into both. Breaking ourselves out of the cycle is the key. That often takes the form of reaching out for help, and/or using our own self-help and self-care skills to propel us forward (for example, reading self-help books about these topics can be helpful if you don’t want to or can’t afford therapy).

Meaning, choice, freedom – even with chronic illness.

Recently I have been learning a lot about Acceptance and Commitment Therapy as that is what I would like my practicum to focus on (I have to pick something that is CBT – cognitive behavioural – focused and ACT is “third-wave” and combines a lot of mindfulness). Here is a quote from the ACT training I’ve been completing.

“In this moment I’m holding my pain so that I can choose to do the things I care about.” – Timothy Gordon

Values and meaning look different for each of us.
(Vienna, 2017)

ACT is very values focused and as you can see values are closely related to life meanings which stem from growth and freedom, which stem from choice. This is a therapy with a lot of efficacy for chronic pain and chronic illness because it asks us to acceptance our pain, and helps us to move toward our values. I personally accepted my pain and my illness a long time ago. That acceptance has allowed me to do more with my life, like go back to school and start a new career, travel, exercise, write a book, and help others. These are all values of mine and they all bring my life meaning. But I didn’t have to choose to move toward any of these. I could have stayed where I was, but truth-be-told, I wasn’t happy. That realization of unhappiness sent me down this growth path which in many ways started with the acceptance piece. If you’re not happy, or you don’t know what your life meaning is or what you want it to be, I would suggest just starting with your values. What’s important to you? And then what your life would look like if you were living for those values. Now, this work is of course best done in the context of therapy, but if you’d rather some reading on the subject I would say check out the book The Happiness Trap by Russ Harris.

Acceptance can lead to new realities.

Your pain and illness don’t have to control your lives if you don’t want them to. Keep making the most of it everyone.

Pain Scales – The Enemy of Chronic Pain Warriors

Literally my least favourite question when I go into any doctor or specialist appointment is, “what is your pain like today?” or “on a scale of 1 to 10, 10 being the worst ever, how’s your pain right now?” To someone with chronic pain, these are the most useless, arbitrary questions. Here’s the thing, I understand why doctors and other healthcare professionals ask the question. They want to get a gauge on if your pain is better or worse than it has been in the past. It totally makes sense. However, there are a few things about chronic pain (and pain in general) that aren’t taken into account with this questions.

1. My perception of what a “10” is may be higher or lower than your perception of what that is.
2. I’m not always entirely sure what number I should give. Like really, what is the difference between a “6” and a “7”?
3. Often pain changes throughout the day, so just because I give it a “4” right now, doesn’t mean that it won’t be an “8” in half an hour.

Hm… I’m smiling and happy in both pictures and yet my pain is a “0” on the left, and a “7-8” on the right.

And yet, this is always the first question asked at any appointment. Sometimes I literally just want to say “I don’t know.!” How many of you feel this way to? Plus, sometimes there is this need to want to give a higher number so that the pain is taken more seriously and not just dismissed. Here’s the thing that healthcare professionals often miss – there are better ways to describe pain than using a 1-10 scale. For example, “what type of pain are you experiencing/do you experience?” “What times of day are worst for pain?” “What activities or circumstances do you notice more pain or less pain?” “Are there any points in the day when you feel little to no pain?” And so on. These questions are easier to answer, and honestly, give a more realistic perspective of my pain than me guessing at a number to give my doctor.

Just gonna throw in the random deer visiting a retirement home across the street from me.

The main model used in medicine (and psychology) right now is the biopsychosocial model (except sometimes doctors forget to use it when talking about chronic pain it seems). For those of you not familiar with this, it is the interplay between biological and psychosocial causes (or maintenance) of a medical (or psychological condition). When applying this model to chronic pain, we look at the biological causes of an illness or injury, and how psychosocial factors maintain or increase the physical sensations of pain. It’s that mind-body connection. Here’s an example: the hypothalamic-pituitary-adrenocortical (HPA) system in your brain has been associated with several chronic pain syndromes including fibromyalgia, chronic fatigue syndrome, rheumatoid arthritis, and MS. It is one of the biological causes of pain (though not necessarily the only). Psychological factors that can maintain or increase this pain include feelings of helplessness and hopelessness. Social factors and behaviours that maintain and increase pain include door diet and nutrition, lack of exercise, and substance use (including smoking). Stress is another major psychosocial factor associated with chronic pain. So, rather than asking what are pain is on a scale from 1-10, looking at these factors is likely more productive in both understanding and managing pain!

Image from: https://www.practicalpainmanagement.com/treatments/psychological/biopsychosocial-approach
The paragraph on the biopsychosocial model is cited from this article.

Let’s talk about pain management. Whether you do this on your own, or with the help of your healthcare team, here are some ways to improve your pain management (because let’s face it, chronic pain is unlikely to magically go away):

• medication compliance – taking all medication as prescribed!
• addressing psychological factors – such as anxiety – this could be through relaxation and meditative techniques or even exercise, or going to see a psychotherapist
• utilizing interdisciplinary healthcare teams – do you have a family doctor? A specialist for your illness or injury? A psychotherapist? A physical and/or occupational therapist? Anyone else who can help you with your pain? (I also have a naturopath and chiropractor for example).

Make a therapist part of your healthcare team! We’re here to help!
(just noting that I’m a therapist-in-training right now)

For anyone reading this who is not a chronic pain warrior, please remember that pain isn’t in our heads, and telling us to just deal with it isn’t helpful. In fact it can be stigmatizing, and people with chronic pain always face stigma because of a lack of understanding. We may laugh, smile and have fun, and yet be in pain at the same time. The things are not mutually exclusive. I’m going to link a few episodes of my podcast that complement this post below. For now, keep making the most of it everyone!

Mental Health and Chronic Illness

The “I Suck” Feeling

Locating Our Inner Strength

How Stress and Anxiety Manifest in the Body

Holistic Approaches to Chronic Pain