A Solid Foundation for Recovery from Chronic Pain

Building a solid foundation and psychological anchor for recovery is essential in order to position oneself for a more favorable outcome in chronic disease, and especially in chronic pain. This can be achieved by self-examination, reflection, and journaling on the following subjects: meaning, acceptance, and expectation.

The reason for this particular sequence is that until one understands something thoroughly, one doesn’t really know what needs to be accepted, and one can only know what to expect after acceptance has occurred regarding one’s new situation and challenges, as well as accepting a plausible plan to effectively deal with them.

So, we start with Meaning.

In a previous posting, we looked at the cause of chronic pain using the learning model theory and discussed how chronic pain develops, expands, and changes over time. This in itself provides meaning as to chronic pain. The learning theory was selected as everyone has had some form of education and has developed various skills. 

But what does chronic pain mean to the individual? People generally react differently to chronic pain, and this is largely determined by the personal meaning that they assign to it. Interview ten people with chronic pain and you’ll get as many different versions as to what it means to them. In Victor Frankl's classic book, “Man's Search for Meaning,” he noted that prisoners in Nazi controlled concentration camps had a better chance of survival, even if aged and frail, when they could find some sort of meaning in their suffering, whereas younger and fitter prisoners who saw their situation as mindless suffering without meaning, an entirely understandable conclusion to arrive at given the circumstances, were less likely to survive.

It therefore appears that the personal meaning we assign to challenging situations can affect our resilience. For some people, chronic pain is so mysterious and seemingly inescapable that they may have a feeling that they have been ‘singled out’ or even punished by life or the universe, some going as far as believing that they are even somehow to blame for it, all of which is, of course, false. This is precisely the type of personal meaning that causes ongoing problems, as the person feels that pain has been imposed on them like a jail sentence, and there is often the notion that they are probably helpless or paralyzed to do anything about it. 

On the other hand, someone else with chronic pain could be one who eventually comes to believe that life is full of a variety of setbacks and challenges, and that when they look back, they have already overcome so many of them and have learned from these experiences. Obviously, that’s a whole lot easier to say than to truly embrace when they have chronic pain, but the point is, those who can realize this type of personal meaning, and clearly see a future for themselves beyond pain, tend to do better, whereas the inescapable punishment type of personal meaning doesn’t support much hope. As we know, some with chronic pain eventually report transformation on certain fronts, such as being grateful for the opportunities that each day presents and for becoming more mindful of how they use their time. 

Patients need to consider these two opposing scenarios and see whether there's any way to move towards the narrative of hope. It's not easy, but it is very helpful, and great things can start with simple awareness. When their personal meaning is no longer merely seen as a tragedy or a major setback, then they are already in a better place.

Acceptance 

Sadly, what we often see as a huge barrier to recovery from chronic pain is lack of acceptance. Of course, it isn't easy to accept something unpleasant, but it is necessary, because it's impossible to adequately plan to go forward when someone does not accept their current situation. The most common reason for this is fear, but sometimes it’s anger and blame, and occasionally a sense of lack of closure, where certain individuals have a feeling that something has either been missed in terms of their diagnosis or that there are specific treatments that may be available, and that could be of benefit that have not yet been offered to them. In my experience, this is seldom the case.

Remaining in denial of something that has already happened only robs one of the time required to effect the necessary changes. Some of those who particularly struggle with this issue, have possibly suffered work injuries that were caused by the negligence of co-workers, understandably leaving a deep sense of injustice. Please note that when discussing acceptance, I am not including forgiveness, although that would be helpful, where possible. Forgiveness is a completely different dynamic, and like all processes, it usually takes its own time, but this doesn't stop us from accepting the situation.

Remember too, that in both acceptance and forgiveness, one does it for oneself and not for other involved parties. The value generated is added to one’s own life, as it's buying one the time and freeing enormous amounts of energy that can be well used elsewhere.

Remember too, that in both acceptance and forgiveness, one does it for oneself and not for other involved parties. The value generated is added to one’s own life, as it's buying one the time and freeing enormous amounts of energy that can be well used elsewhere.

When a family tragically loses their home in a natural disaster, of course there is shock, disbelief and sorrow that follows, but until acceptance of the loss occurs, clearing, recovery and rebuilding is unlikely to take place. Acceptance isn't merely passivity or throwing in the towel, it’s a brave leap forward in order to take back control. One cannot accept any remedial plan or treatment until one has accepted that such a plan is even needed. 

Acceptance makes life calmer, less chaotic and can energize one, as there is no longer any need to constantly fight and resist what has already happened. Chronic resistance will simply sap one’s energy. 

Finally, once an individual has reached a level of acceptance of what has happened, as well as where exactly they are at present regarding their condition, and have comfort with their treatment plan, then their expectations are way more likely to be positive. 

Expectation

It is easy to say that we should expect good things but a very different story for us to truly believe it. So how does one come to expect good things?  Usually, the necessary work needs to be done to secure a good outcome, which in this case means being completely clear regarding one’s understanding of the current position, one’s desire or goal, and where one stands in relation to achieving this. There needs to be commitment to a plan that is plausible and achievable and a willingness to spend the requisite time. When one has clarity regarding the situation and commitment to the plan, one can more realistically expect a better if not good outcome.

Sociologists, psychologists, and others have thoroughly studied the concept of expectation that has been linked to the phenomenon of the self-fulfilling prophecy which has been known for centuries.

It’s thought to work like this. Once a person buys into their goal and holds a positive expectation of achieving it, they may well adopt behaviors and thinking patterns that are more associated with the desired outcome and may put in extra time and diligence towards their goal. They are also more likely to be aware of and seek out opportunities that could help them reach their new goals. All these approaches would make success more likely, of course.

Expectation is also closely associated with what in medicine we call the placebo effect, where having the expectation of positive results leads to improvement, even when there is no scientific explanation for the effect.

Expectation is also closely associated with what in medicine we call the placebo effect, where having the expectation of positive results leads to improvement, even when there is no scientific explanation for the effect. Scientific study has also shown that placebos still work even when people know that they’re receiving pills with no active ingredients. Then there is the reverse situation called the nocebo effect, where people expecting a negative event, have a negative outcome, for example from taking a harmless medication or treatment, again with no scientific explanation.

We regularly see patients in pain management programs who have more positive expectations of success than most, go on to do better than those who don’t even consider what exactly their expectations include. Sometimes poor expectation is merely an indication that the person doesn't intend to fully engage in what is required of them. It needs to be remembered as well that what will change one’s situation way more than the good advice that is dispensed, is the good advice on which one will choose to act.

Just think back on your own most cherished life achievements. Did you really start working on any of these objectives while having poor expectations about the outcome?

These sequenced foundational elements, meaning-acceptance-expectation, have all been widely studied in the context of chronic pain, and are not only relevant to chronic pain recovery, but to almost all chronic diseases. 

For someone dealing with chronic pain, a single severe pain flare-up can set them back, making them want to suspend their efforts at recovery. At these times, being anchored into something solid of which they themselves have been the author, is extremely helpful, allowing them to view their current struggle more easily as a ‘snapshot’ rather than the ‘movie’ of their life.

The foundation of meaning-acceptance-expectation can be achieved through journaling, which is both an important discovery and therapeutic tool in chronic diseases.

The foundation of meaning-acceptance-expectation can be achieved through journaling, which is both an important discovery and therapeutic tool in chronic diseases. As there is much to be said about journaling, a later, stand-alone posting devoted to this subject will be provided, as it also impacts heavily on problematic disease narratives, unhelpful thought and behavior patterns, and mood.

As a physician and clinician, I simply must add an analogy that to some may come across as somewhat tangential, but I do see obvious parallels between these three foundational pain treatment components, and what is considered as the A-B-C mantra of emergency room work.

In the acute ER room, the team is almost always under pressure that can often be extreme, as many of the ER interventions are lifesaving. In physician training, and later in practice, when the going gets rough, one always reverts to A-B-C, which represents, A- first make sure that the airway is patent and unobstructed, B- Check to see whether the patient is breathing spontaneously and the way they're breathing, and C- cardiac, check the heart, how fast, forceful, and regularly it is beating.

For those outside the profession, this may sound banal in its simplicity, prompting questions as to how helpful it could possibly be. I can only say that I know several highly experienced ER physicians, all of whom claim that they are still grounded by the timeless A-B-C sequence, especially in the stressful and sometimes horrific situations that they are routinely called to counter, when it helps them to center themselves and sharpen their focus. 

It simply works!

In the next two editions we will consider some of the major pitfalls that commonly bedevil or even sabotage initial self-help efforts: chronic stress, unhelpful thinking patterns and toxic illness or disease narratives.

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Discover Healthscape, my health and wellness podcast on VoiceAmerica. Healthscape focuses on health resilience, self-help interventions in chronic physical and mental diseases, especially chronic pain, and emerging issues in medicine.

Check out my book “The Language of Pain” – Fast Forward Your Recovery to Stop Hurting- a self-help book for those with chronic pain and their caregivers.