FINAL COMMENTS REGARDING SELF-MANAGEMENT

Richard W. Hanson, Ph.D.

We recognize that, if given a choice, most chronic pain sufferers would prefer medical management over self-management. After all, medical management requires relatively little effort on your part. With medical management, all you have to do is do is passively go along with whatever the doctor or other health care professional tells you to do whether it be taking pills or submitting to passive physical procedures. When medical management works, all seems well and good. Of course, unlike self-management, you can't personally take any credit for its effectiveness even when it does work. Unfortunately, when pills and passive procedures don't work, you are often left feeling even more frustrated and discouraged.

Medical science together with the pharmaceutical industry are constantly looking for better and more effective ways of treating chronic pain. As indicated in the last chapter, we can all hope that these efforts will ultimately be fruitful. Meanwhile, you are left with the reality that your chronic pain persists despite the many medical management procedures which have been offered and tried.

Throughout this handbook, we have repeatedly emphasized the importance of mental and emotional factors in chronic pain. The vast majority of medical management approaches view chronic pain as a purely physical phenomenon while ignoring the importance of psychological factors.  Self-management, on the other hand, recognizes that chronic pain always involves physical, psychological, and social factors.  Even common medical procedures such as taking medications or receiving injections involve psychological factors.  It has been estimated that anywhere from a third to a half or more of the therapeutic efficacy of pain medications is due to the placebo effect, i.e., your belief or expectation that you will obtain pain relief as a result of taking a pill.  Self-management aims at turning the healing power of such positive beliefs into greater confidence in yourself rather than in drugs.  

Rather than looking for cures or passive procedures that increase your dependence on medical professionals, self-management emphasizes constructive coping.  Coping requires some effort on your part. Coping often involves the acquisition of skills and, like most other skills acquired during the course of life, it requires learning and practice. Whenever your face a problem in life and someone else comes along and solves the problem for you, you feel a certain sense of relief. But consider how much better you feel when you solve the problem on your own by making use of knowledge and skills that you have personally acquired. In addition to learning specific skills, coping may involve making use of resources in your natural environment. Drawing upon help and support from family and friends is an example of using coping resources. Other valuable coping resources may be found in your broader community. In my opinion, the primary advantage of self-management over medical management when it comes to chronic pain is that it fosters and reinforces healthy self-reliance rather than dependence on professionals.

Most of the chronic pain coping skills and resources discussed in this Handbook can be divided into one of three categories: physical focused coping, emotion focused coping, and problem focused coping.

Physical Focused Coping

Physical focused coping refers to activities on your part which can reduce or alter the physical (sensory) aspects of chronic pain. Examples of physical coping skills include the following:

• Stretching exercises, yoga postures
• Muscle toning and strengthening exercises
• Aerobic exercises
• Maintaining a healthy diet, Losing excess body fat
• Refraining from unhealthy habits such as use of tobacco, alcohol abuse, overuse of caffeine, excessive inactivity
• Sensory stimulation techniques (e.g., use of massage, heat, cold, vibration, electricity, etc.)
• Activity pacing techniques
• Improving your posture, normalizing body movement patterns, using good body mechanics
• Time-out relaxation techniques
• Mindfulness meditation
• Pain flare-up prevention techniques
• Pain diversionary activities
• Mental techniques which alter the interpretation or meaning of pain sensations

Emotion Focused Coping

Emotion focused coping is used to manage all forms of emotional distress including feelings of depression, anxiety, frustration and anger. As discussed earlier, emotional distress usually compounds the problem of chronic pain. Examples of emotion focused coping methods include:

• Use of the signal breath during times of emotional stress and tension
• Time-out relaxation or meditation techniques
• Self-hypnosis techniques
• Positive affirmations (self-reminders)
• Religious and spiritual practices including prayer, reading religious literature, attending church or synagogue, talking to a clergyman, surrendering problems to God or higher power, etc.
• Identifying and modifying irrational thoughts and cognitive distortions
• Cognitive reframing (viewing your problems in a different and more positive light) and perspective taking (e.g., viewing your problems in relation to others who have it much worse off than you) 
• Developing more positive attitudes such as healthy optimism, empathy for others, feeling grateful for your blessings (attitude of gratitude), understanding the connectedness of all persons and living things
• Working on your inner character such as becoming more patient, tolerant, and compassionate toward others
• Making use of available social supports (friends and family)
• Seeking professional help when needed for significant emotional problems such as depression, anxiety and difficulties managing anger
• Use of assertiveness and effective communication skills including active listening
• Healthy use of acceptance, reframing, and redirection
• Developing a healthy sense of humor
• Seeking opportunities to experience positive and uplifting emotional states

Problem Focused Coping

Problem focused coping may be used for addressing problems stemming directly from your chronic pain condition or other life problems which may have little to do with your pain. Examples of problem focused coping approaches include:

• Taking personal responsibility for doing something about your problems rather than simply blaming other people or external circumstances
• Setting realistic and achievable (SMART) goals
• Using relaxation techniques to gain greater mental clarity
• Use of constructive problem solving techniques such as the SODAS described earlier
• Identifying resources for obtaining additional information (e.g., talking to knowledgeable people, going to a library for information, searching the Internet)
• Acquiring new knowledge and skills either on your own or with the assistance of knowledgeable others (e.g., taking classes, going to school); the new knowledge and skills may be work related or simply for fun, enjoyment or personal growth
• Taking constructive action rather than procrastinating

Note that a particular coping method, such as time-out relaxation, can be used in more than one category depending on how and why it is used. The ultimate success of chronic pain self-management requires you to develop several skills in each of these major coping areas.

Plan for Developing Personal Coping Skills

After considering all of the principles and techniques discussed in this handbook, list the coping methods that you would like to work on to improve your own ability to self-manage chronic pain and other life problems.

Beyond Coping: Personal Growth and Development

The word "coping" typically means dealing with or managing problems and difficulties. However, a review of the coping methods listed above clearly indicates that several of them are concerned with much more than managing pain and other life difficulties. Improving your character, developing more positive attitudes, acquiring a more healthy and enriching philosophy of living, and spiritual growth all go beyond simply coping with life problems. 

One personal growth ideal which I find especially relevant and worth pursuing is that of serenity.  This concept has been used to characterize peace of mind, often in the face of difficult and challenging life circumstances.  In article by Roberts and Cunningham (1990) in Educational Gerontology, the following 10 characteristics were used to define serenity.

1. The ability to detach from desires and/or emotion and feelings
2. The ability to be in touch with an inner haven of peace and security
3. A sense of connectedness with the universe
4. A trust in the wisdom of the universe
5. The habit of actively pursuing all reasonable avenues for solving problems
6. An ability to accept situations that cannot be changed
7. A way to give unconditionally of one's self
8. Forgiveness of self and others
9. The ability to let go of the past and the future and to live in the present
10. A sense of perspective as to the importance of one's self and life events

The term "detachment," used in the first characteristic above, does not mean being oblivious to life problems or apathetic disregard of such problems. Rather, with detachment there is a recognition of problems, including chronic pain and disability, but in a manner that keeps them distinct and in proper perspective. With true serenity, chronic pain and disability are recognized as part of your lot in life, but they do not define your existence. 

As suggested in the second characteristic above, it is possible to have chronic pain and yet be in touch with an inner haven of peace and security. As discussed in this Handbook, relaxation, meditation, and visualization exercises may be useful means of accessing this inner haven of peace. 

Some may wish to substitute the word "God" or "higher power" for "universe" in the 3rd and 4th characteristics above. Keep in mind that serenity is a key component of spirituality. It may or may not be associated with particular religious beliefs and practices. The 5th and 6th characteristics of serenity highlight the importance of maintaining an active problem solving problem orientation when possible (see Chapter 7), while also accepting those situations which cannot be changed (see Chapter 8).

The 7th and 8th characteristics of serenity involve a positive and accepting attitude toward oneself and others. Of course it is difficult to feel positive and accepting of others when you have negative attitudes about yourself. As discussed in Chapter 12 (managing daily physical activities), learning to accept and value yourself, despite having chronic pain and disability, is an important goal of self-management. Forgiveness of self and others, discussed in Chapter 15, is also important to counter feelings of resentment which sometimes accompany chronic pain. As you learn to forgive and let go of past emotional pains (Chapter 16), you will find it easier to live more fully in the present (9th characteristic of serenity). For those with chronic pain and disability, letting go of the past may also involve letting go of idealized attachments to memories of one's life prior to the onset of pain. Finally, the discussion on thoughts and feelings in the cognitive therapy chapter (Chapter 10) repeatedly emphasizes the importance of maintaining a sense of perspective on oneself and life events (10th characteristic of serenity listed above).

Most important is the realization that achieving serenity does require one to get rid of pain and other life problems. By making active and regular use of all the tools discussed in this Handbook, I believe that serenity is possible despite having chronic pain and disability.

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