Chapter 3: Cognitive Defusion (or Thinking is not all that€¦ · Web viewThe Vicious Cycles of...

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USING YOUR BRAIN FOR PAIN

As an additional stress management tool for chronic pain

Why Is Stress Management Important for Chronic Pain?

There are at least two reasons. First, the symptoms of chronic pain are stressors in themselves. Having chronic pain reduces your ability to function, to cope, and to feel good. If your general ability to cope is reduced, then other daily stressors start to pile up. Second, in response to having chronic pain and experiencing a greater number of daily stressors, your muscles will typically tense up a lot of the time as a form of protection for what may be yet to come. This further decreases your ability to cope and you begin to feel even worse.

What Is the Stress Response?

Also known as the "Fight-or-Flight" response, the stress response is controlled by the sympathetic nervous system and had important evolutionary significance for human survival. We inherited this response from our earlier ancestors, who needed it to cope with extreme physical dangers. This response was adaptive when we were required to fight or run from predators. However, in today's society fighting or running away is seldom necessary or adaptive, yet we are still forced to deal with stress symptoms without having an appropriate outlet or release valve. The danger of prolonged stress is its wear and tear on your body. And when stress is coupled with chronic pain, the wear and tear you experience is multiplied possibly leading to additional problems such as headaches, chronic fatigue, or increased susceptibility to other illness. Under stress your body exhibits several reactions that can be noticed or measured:

Your heart rate increases You feel your heart pounding in your chest

Your blood pressure increases (Not detectable unless measured)

Your sweat level increases Your skin feels cold and clammy

Your rate of breathing changes Your breathing becomes shallow or you

breathe in gulps

Adrenaline, and other stress Your muscles contract and your hands and hormones are released in the blood feet become coldstream, causing vasoconstriction in the periphery and an increase in muscle tone. Blood flows away from the periphery (hands and feet) to theheart, lungs, and muscles

Copyright: Brigitte Sabourin, PhD, CPsych. For personal use only. Not to be copied for commercial use

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Certain acids are secreted in the You feel "butterflies", nausea, or gastrointestinal tract discomfort in your stomach

The general digestive activity You experience symptoms of diarrhea of the gastrointestinal tract is or constipation

altered

The Vicious Cycles of Stress

Throughout its effect on different systems in the body, stress affects our physical and mental health generally, our ability to sleep, and our pain level . In turn, when we are in pain or have not slept well, we are less able to effectively manage our stress levels. This results in the vicious cycle you see below.

STRESS

EFFECTS ON BEHAVIOUR AND BODY(examples: sleep, mood, pain)

In a way, stress management means developing strategies to break these vicious cycles.

You can help yourself by learning to identify what daily situations contribute to your stress response and by learning to use adaptive coping strategies to deal with these situations, which often can't be escaped or fought.

You can also manage your stress levels and chronic pain symptoms by attending to your thoughts and feelings. Negative thinking is thought to contribute to the stress response and feelings of anger or depression that some people with chronic pain experience.

What is the Association Between Thoughts, Feelings, and Chronic Pain?


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An emotion consists of Four Inter-related Components

Below is an example of an interaction between the different components of our emotional experience. Can you identify the components?

While attending a social occasion, you notice a physical sensation of pain. You think, "I hate this! If this keeps up, I'll have to leave. Why did I even bother to come when I knew this would probably happen?" You feel angry, and maybe even depressed. Then you may think, "What if I never get well?” which causes you to feel afraid. The fear sends out a stress alarm to your body, and your muscles contract and become tense. The tight muscles fatigue and cramp, causing even more discomfort. You then decide that, to avoid a potentially embarrassing or uncomfortable situation, you'd better leave. To avoid experiencing these negative feelings again, you become reluctant to attend social gatherings, which makes you feel more isolated, depressed, anxious, or angry in the long-run.

It may be difficult to know which comes first: the negative thoughts, the negative feelings, the ever-increasing physical symptoms, or the behaviours? But it is likely that whenever you think negative thoughts about your symptoms, you will probably have a resulting negative emotional and physical reaction. Conversely, whenever you experience symptoms, you will probably think negative thoughts about them, setting off a vicious cycle, unless you take steps to reverse or prevent this reaction.

There are certain types of unhelpful thinking patterns that we all fall into at times. Below are some of the more common unhelpful thinking patterns.


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Situation Specific ThoughtsLabel for

Automatic ThoughtAlternate Ways of

Thinking

The doctor didn’t spend as much time with you today as she used to

“She must have given up on me. She must think I’m a lost cause”

Mind reading "I don't know what people are thinking"

You wake up in pain. “Ugh. I’m NEVER going to be able to enjoy anything anymore”

Overgeneralization: Always, never

"This is just one example" “There are examples of times throughout the days when I can enjoy myself.

You’ve been encouraged to make changes to your diet

“I’m not going to be able to do this. I’m gonna fail completely”

Predicting the future "I don't know that things will go badly"

You are about to attend a social gathering

“I’m going to have to leave early because the pain will be too bad”

Overestimating the probability

“What are the chances? How many times has this happened before?”

You are about to attend a social gathering

“I’m going to have to leave early because the pain will be too bad”

Thinking the worst (catastrophizing)

“So what if that happens? Is it really as bad as I think? Will I survive?”

You overdid it yesterday and are experiencing a pain fare-up

“I’ve blown it now. I just might as well forget this whole self-management thing.”

All or nothing thinking

“Okay, I could have paced myself better yesterday, but I’ve been doing a lot better at pacing in general”

You did not have time to make a lunch ahead of time, and have to buy lunch at the cafeteria.

“I should be able to be organized enough to make my lunches!”

Should thinking "It would be nice, but it’s not really necessary...if it doesn't happen - or if it didn't happen, it's still okay"

You finished a project but it took you three days when it used to take you only on

“Ugh, I can’t believe it now takes me this long to do anything”

Discounting the positive

“Hey, I did it – maybe not as quickly as before, but I still did it”


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In summary, if you catch yourself saying or thinking words like “should” “always” “never”, or predicting the future or putting words or thoughts in someone else’s actions, you may be engaging in these unhelpful thoughts.

Personal Styles or Beliefs That Can Perpetuate Physical Problems

In addition to specific thoughts, certain personal styles or beliefs can influence people’s experiences with physical health problems. Many of these styles or beliefs are actually quite adaptive and rewarding when people do not experience physical health problems. However, they can be our own worst enemies when we encounter a chronic health problem for which there is no permanent remedy or cure available. This is the very reason why they are so hard to change when a chronic health problem is the seemingly immovable obstacle we need to learn how to manage. The most common of these styles or beliefs are:

Perfectionism

Excessive need for approval

Tendency to ignore physical and psychological signs of stress

Excessive need for control

You may or may not possess all or any of these traits. However, if you have been struggling to cope and to adapt to a chronic health problem, chances are you can identify with some of them.

Managing Your Stress Generating Thoughts

Once you have observed that your thinking can sometimes contribute to negative feelings, physical tension, and increased pain, what can you do? Well, simply being aware of this relationship is an important first step.

In order to reverse these tendencies, several strategies can be helpful. 1) We can challenge stress generating beliefs by reversing positions with someone else, that is, you can ask yourself what you would say to help another person experiencing your situation, or, try to think of how that person might respond to get some positive ideas. 2) You could also try to reframe the situation, that is, ask yourself if there are alternative ways to view the situation. For example, can you see the glass is half-full, as opposed to half-empty, alternatives? Can you broaden your view to see the “big picture” about what this isolated situation means in the overall scheme of things? 3) You could also employ a strategy of reality testing, in which you check things out with others to see if your view is most accurate before jumping to conclusions. Ask yourself, what are the odds of the worst-case scenario coming true? What if the worst did come to pass? How would you cope with that? Would it be as awful as you think or would you somehow get through it? These are some of the most helpful basic strategies for managing stress-generating thoughts and beliefs. We will discuss how to use these strategies and more during the pain management group.


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COPING THOUGHTS FOR MANAGING CHRONIC PAIN

Although stress management is important and can have a positive impact on your chronic pain symptoms, and physical and emotional well-being, sometimes you may require short-term thinking strategies to help you cope better. The first step is to become aware of what sorts of thoughts you have when you currently experience increases in pain. Consider these sorts of self-statements:

“I have no control over my pain.”

“I'll never get better.”

“This is going to get worse and worse until I go crazy.”

“This should never have happened to me.”

“I should have gotten better quicker than this.”

“I can't function when I experience pain.”

“No one else can really understand my condition.”

“I'll never be able to enjoy life again.”

“It's all my (job's, boss's, doctor's, family's, spouse's) fault.”

“It's all my fault that I'm in this mess.”

“I can't do many things I enjoy because of pain symptoms.”

“If I let my pain symptoms affect my work, others will thinkthere's something wrong with me.”“If I let my pain symptoms get in the way of my responsibilities, others will deem me incompetent.”

If you can identify with these sorts of self-statements, then perhaps you can consider replacing them with some coping self-statements like these:

“I can cope.”

“Relax. I can manage the pain.”

“I have managed this situation before. I can do it again.”

“I'll use relaxation strategies to cope with the situation.”

“I am learning new coping skills every day.”

“I am not a bad person because I have pain symptoms.”

“The symptoms come and go. I know how to handle them.”

“No one thinks less of me because I have these symptoms.”

“I am a good worker.”


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“I am a loving person.”

“If I let go of the tension, I will feel better.”

“I can take mini-breaks to relax when I need to.”

“My pain symptoms may be a sign that I'm working too hard.”

“My pain symptoms may be a sign that I’m not taking care of

my needs.”

Below, there is space for you to identify any stress-inducing self-statements you may have noticed from the past and counter with some coping thoughts of your own:

Stress-Inducing Self-Statements Coping Self-Statements

_______________________________ _________________________________

_______________________________ _________________________________

_______________________________ _________________________________

_______________________________ _________________________________

_______________________________ _________________________________

_______________________________ _________________________________

_______________________________ _________________________________

By becoming more aware of stress-inducing thoughts, and injecting better coping thoughts, you will have yet another strategy that you can use in difficult situations, in addition to the relaxation strategies that are a part of this program.


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Part 2:

Cognitive Defusion (or . . . You are Not your Thoughts)

Our ability to think and use language has in many ways been both a blessing and a curse. While it has allowed us to accomplish many amazing things that otherwise would never be accomplished, it also causes us to suffer in ways that until recently we could not fully understand. Fortunately, recent research has identified that it is our mind’s ability to relate (or “fuse”) events in our environment to our thoughts, feelings, behaviors, and physical sensations in virtually random ways that contributes to both our creativity (the good news) and our emotional and physical suffering (the not-so-good news). Furthermore, we have a strong tendency to do this quite automatically.

What this all means is that whenever we believe that our thoughts are what they say they are, that is, if we “buy” into them entirely at face value, we become increasingly inflexible when it comes to living life according to what is most important to us. We lose our direction. It is also very important to notice that although this chapter deals with the pitfalls of thinking per se, the principles found herein apply equally well to feelings, behaviors, and physical sensations (such as pain) that are

commonly linked to our thoughts. This chapter is all about how to “defuse” from our thoughts (and their associated feelings, behaviors, and physical sensations) particularly when they are not adaptive, in order to get our lives back on track.

Thoughts by themselves aren’t very dangerous - they are just a bunch of nonsense syllables that are going around and around.

We get ourselves into trouble when we take these words as truth and when we expect them to transfer into actions. For example, a thought such as “I’ll call my friend tonight” might get us to pick up the phone and make a call to a particular person. And the thought “I’m so depressed” may end up translating to staying in bed all day. Or “I’m so tired of being in constant pain”, if taken as literal truth may result in you identifying yourself as someone with pain who can’t do


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anything. All this from a single thought! The problem here isn’t actually the thoughts themselves, but what you do with them. There is some benefit with our reliance on words. Sometimes, making small changes in the words we use can have a huge impact on the meaning of an idea.

Take these examples:

“I would like to come to the movie with you but I am in so much pain”. “I need to do my shopping but I know how much it is going to hurt”“I’d like to go to my friend’s party, but I’m feeling so tired”.

All of these statements generally relay the inability of the speaker to perform the action. Now watch what happens when we change only one word in the sentences above:

“I would like to come to the movie with you and I am in so much pain.”“I need to do my shopping and I know how much it is going to hurt.”“I’d like to go to my friend’s party, and I’m feeling so tired”.

The second set of statements is identical to the first, except they use the word and instead of but. This small change alters the way you understand the statement to mean that you can accomplish both parts of the statement rather than one or the other. Look back at some of your pain thoughts from your “taken or missed” chart from the previous unit. Are there any statements that are but statements? “I would like to be able to help my family but I can’t because I’m so tired all of the time.” Change the wording to reflect ands wherever you have a but. This simple verbal game can give you an entirely new outlook on your disease. You can have chronic pain AND live a life you value. It doesn’t mean that you’ll now live in fantasy land, but you can trick your mind into looking at the world a bit differently by using the way our verbal minds work to your advantage.


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Question: How can changing a few simple words change the entire feeling of a sentence? Can you give one or two examples?

But what happens when you just can’t seem to let go of your difficult thoughts? That’s when it can be helpful to notice what is going through your mind but not try to control it. What this offers is the permission to have your thoughts, but to gain enough distance from your thoughts to make choices about your actions, without the influence of the ever-churning mind. Previous researchers have coined the term cognitive defusion to describe the act of getting distance from your thoughts.

Read “Leaves floating down a stream”

Different people imagine in different ways. Some see very vivid pictures as on a TV screen. Other people imagine with words, sounds, feelings, or ideas. However you imagine is absolutely fine.

In this exercise you will think whatever thoughts you think and allow them to flow, one thought after another. The purpose of the exercise is to notice when there is a shift from looking at your thoughts to looking from your thoughts. You will know that has happened when the stream stops, or you are down in the stream, or the exercise has disappeared.

Imagine that there are a bunch of leaves gathered by the bank of a peaceful, flowing stream. You are standing on the bank of the stream watching as the current continuously pulls the leaves into the gentle flow downstream. As the leaves become part of the flow, each thought you are having rests in the center of a leaf. Some people have a hard time putting thoughts into words, and they see thoughts as images. If that applies to you, put each image in the center of a leaf.

Allow yourself to get centered and begin to let your thoughts go by as the stream carries the leaves. Now here is the task. The task is simply to watch the leaves go by without having them stop and without you leaving the bank to interfere with the flow of the leaves. You are just supposed to let it flow. It is very unlikely, however, that you will be able to do this without interruption. And this is the key part of the exercise. At some point you will have the sense that the leaves have stopped flowing, or that you have lost the point of the exercise, or that you are in the stream with the leaves instead of on the bank watching them going by. When that happens, back up a few seconds and see whether you can catch what you were doing right before the leaves stopped flowing. Then go ahead and let your thoughts go back onto the leaves until they stop flowing a second time, and so on. The main thing is to notice when they stop for any reason and see whether you can catch what happened right before they


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stopped. One more thing. If the leaves never start flowing at all and you start thinking, “It’s not working,” or “I’m not doing it right,” then let that thought appear on a leaf, too.

Now get comfortable, close your eyes, and get centered. [Spend 1 or 2 minutes getting centered] Now, begin allowing the stream to catch the leaves. Staying up on the bank and letting them flow. If they stop or you find yourself in it, noting that; seeing whether you can notice what you were doing right before that happened, getting back up on the bank, and letting the leaves flow again. . . . whatever you think, just putting it on a leaf. [Spend at least 2-3 minutes working on this exercise]

There are several different alternatives to the “Leaves floating down a stream” exercise. You can perform the same exercise imagining that your thoughts are like:

Boxcars on a train, you can see all of your thoughts on separate boxcars, noticing the boxcars moving, but not getting on the train yourself.

Clouds floating, or birds flying, across the sky.

A passing parade. You can watch the floats pass by. You don’t have to climb on board.

Suitcases dropping onto a conveyor belt at the airport. You can watch them pass by, without having to pick them up.

Waves arising from the sea, then falling back in. You can watch the waves from the shore, without being swept away.

Try the following exercise: Try to catch your thoughts, feelings, memories, and bodily sensations as they pass by, and label them for exactly what they are. Say out loud to yourself exactly what it is you are doing, rather than just thinking the thought. For example, if you are thinking that you have to make supper later today, instead of saying “I have to make supper later today,” add a label to the type of event that just took place such as “I am having the thought that I have to make supper later today.” Do the same with your feelings and sensations. If you feel pain, make note of it by saying to yourself “I am having the bodily sensation of pain”. Your labels should take the following form:


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I am having the thought that.... (describe your thought) I am having the feeling of (describe your feeling) I am having the memory of ( describe your memory) I am feeling the bodily sensation of (describe the nature and location of your

bodily sensation) I am noticing the tendency to... (describe your behavioural urge or

predisposition)

Over the next week, try to catch your thoughts and label them as above. Watch what happens as you start to label your thoughts for what they are as opposed to just thinking the thought.


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