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11 Articles in Volume 14, Issue #1
The WHO Pain Ladder: Do We Need Another Step?
History of Pain: The Psychosocial Assessment of Pain
Lyme Disease: A Short Primer for Pain Practitioners
Opioid Prescribing Part 1: A Practical Guide to Appropriate Documentation
Pain, Impairment, Whiplash, and the New AMA Guides: What Clinicians Need to Know
The 5 Coping Skills Every Chronic Pain Patient Needs
Demystifying Benzodiazepine Urine Drug Screen Results
Practical Pain Management: The Nation’s Premier Teaching Journal for Pain Practitioners
PPM’s Editorial Board Weighs In on WHO Ladder
Are patients taking acetaminophen (Tylenol) at risk for developing serious skin conditions?
What are some home exercises and tips to help patients manage rotator cuff injuries and pain?

The 5 Coping Skills Every Chronic Pain Patient Needs

Pain management is like a 3-legged stool—interventions, medications, and psychological education and counseling. Without all 3 legs, the stool will fall.
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When I first began work in the field of pain psychology, I wanted to be as helpful as I could be to my patients and to be seen as fully prepared and competent by my referral sources. However, as I began to read books and attend conferences “to get up to speed,” I was overwhelmed by the variety of services and offerings that experienced practitioners offered. Along with ever-present traditional cognitive-behavioral psychotherapy, I also learned about a variety of other interventions: progressive muscle relaxation; guided imagery; hypnosis; technology-assisted treatments such as virtual reality; activity pacing; sleep hygiene; patient education; psychodynamic psychotherapy; interpersonal therapy; assertiveness training; family therapy; desensitization. … The list went on and on.

When I traveled to pain conferences to learn new skills, I had trouble deciding which sessions to attend. I had no plan or schema to organize my training or my psychology services. I also did not have unlimited resources to attend every conference and learn every possible pain intervention technique.

After several years of clinical practice (it’s been 16 years now), I began to construct a schema to help organize where to start—where I should start in my continuing education and where I should start with my patients when they presented for therapy. I have presented this schema at professional meetings a few times and others tell me they have found it helpful. The following is a summary of my experience.

The Big Picture

In general, one method that helps me organize my thinking about pain treatment is Dr. Herbert Benson’s oft-used analogy of a 3-legged stool., Dr. Benson, a Harvard cardiologist who has been a pioneer in the field of mind-body interventions, has proposed that health care treatment for any chronic condition can be conceptualized as a 3-legged stool.

The first leg of the stool is made up of interventional treatments, or “passive patient” approaches. These include surgeries, injections, manipulations, and other similar treatments. For these, all the patient has to do basically is show up and be still. I refer to it as “the auto repair school of medicine.”

The second leg of the stool is made up of pharmaceutical approaches. These treatments call for action on the part of the prescriber and the patient. The prescriber writes a prescription for some sort of medication and tells the patient how to take it. The patient then is supposed to take (or apply) the medication as prescribed. It’s a joint endeavor of the provider and the patient.

Many pain practices start and end with these 2 general approaches, and offer nothing else. However, just as a stool would fall over with only 2 legs, pain treatment is truly successful only when the third leg of the stool is offered. The third leg of the stool is made up of “active patient” approaches—skills and changes that patients make to help them cope with their condition. In the treatment of heart disease and diabetes, these are often referred to as “lifestyle changes,” and providers know that they are essential to bring a chronic condition under control.

It is a similar situation in treating chronic pain disorders. While interventional and pharmaceutical interventions are important, the third leg of the stool is critical to successfully coping with pain. This third leg of the stool generally is where psychologists play a role. While a few psychological interventions are not in this domain (hypnosis in and of itself is an interventional treatment until the practitioner begins to teach self-hypnosis techniques), most psychological treatments fall into this third leg of the stool: teaching skills to patients for their ongoing practice and use. This 3-legged stool analogy has helped me organize my treatments within the context of overall treatment for chronic pain.

Once I had placed my work within the overall treatment plan for pain patients, I still needed to determine the most important lifestyle habits to teach patients. Rather than determine what the most important skills were, I found a way to organize all the possible helpful treatments into a schema that made sense to me and which then could direct my treatment planning. Thus, what I developed was a conceptualization of the 5 basic or general skills that every patient with chronic pain should work to master to have the most success in dealing with their pain condition: understanding, accepting, calming, balancing, and coping.

The First Skill: Understanding

Today, when a patient receives a medical diagnosis, one of the first things they do is go to the Internet and search for the diagnosis. (People used to go the library, but now we use search engines.) They are likely to search and read about 2 things: what is this diagnosis/condition and how is it treated. To better understand their conditions, people also seek out advice from others they trust, such as friends and family, and they ask the same 2 questions: What is this condition and how is it treated? This also leads to prognosis questions: Will I ever get better? Can this be cured?

Patients with pain conditions are no different, and by the time they seek treatment, they likely have already done some Internet searches and talked to family or friends about these issues. Sometimes they have gotten correct information and sometimes they have not. Sometimes patients have appropriate knowledge and expectations about their pain condition and sometimes they do not. So, often the first order of business is to educate the patient about his or her condition and offer a plan of care he or she will accept.

Issues that can come up in this skill area are reflected in comments such as “My body is damaged very badly and I need strong pain medication,” “I do not want any opioid medication because it is highly addicting,” “I just want someone to do surgery on me and fix this problem,” “I don’t want an injection—I hate needles and I hear the relief doesn’t last any way,” and “I have already had that (treatment) and it didn’t work” when they really didn’t have the same treatment. Questions and comments of this type often indicate that the patient needs some education to better understand some aspect of their condition or their treatment.

As a psychologist, I often receive comments similar to “I don’t need a psychologist; my pain is real and it is NOT in my head.” One major educational point I need to make with many patients is how psychology services fit into the treatment of “real pain.” I have had much success going over the concept of pain gates.3 Having patients understand the pain gates concept (an overview is usually sufficient) helps them see the value of psychological interventions in treating chronic pain. This validates why it will be helpful to address such issues as depression, anxiety, and sleep hygiene. It shows that a holistic approach to their pain may be of value and it likely is a new approach that they have not been offered before.

Last updated on: May 30, 2014