Learning to "Live With" Chronic Pain: Lessons From Mrs. Tandy

Paul Arnstein, PhD, APRN, BC

Topics in Advanced Practice Nursing eJournal. 2007;7(1) 

In This Article

Coping Skills Training

Among the different coping skills taught, practiced, and mastered in the cognitive-behavioral treatment program (for example, problem solving and assertiveness), cognitive reframing techniques were most important in Mrs. Tandy's case. A turning point for her seemed to occur between the fifth and sixth weeks of the program. At this point, her diary helped her understand her pain and tease out the part of it that was driven by her emotional distress. She had:

  • Mastered the relaxation and imagery techniques;

  • Cut down on dietary sugars; and

  • Learned to pace her activities.

She was taking her medications as prescribed and tolerating them well.

However, one day she entered the room where the group was held and slammed her book down on the table, expressing her disgust with the "stupid homework assignment." The assignment that was so frustrating to her was to cognitively reframe an upsetting situation. She wanted to know what happens if the identified "distorted thought" was, in fact, true? With her permission, we explored her circumstance as a group.

The thought that was so upsetting to her was, "I'll never dance again." She tried to see if this thought fit the definition of identified patterns of distorted thinking. For example, was she:

  • Magnifying;

  • Overgeneralizing;

  • Catastrophizing;

  • Jumping to conclusions; or

  • Engaging in other types of errant thinking?

She was unable to see how her thought fit those patterns, and she was unable to challenge the truthfulness or helpfulness of this disturbing thought. She claimed to have spent 4 hours trying to challenge the truthfulness of this upsetting statement at home, and even in the group was unable to see the upsetting self-statement, "I'll never dance again," as anything less than 100% true.

Given that the usual approach to reframing the disturbing thought (ie, replacing it with a more truthful and helpful thought) was ineffective, we used an alternative approach as suggested by Caudill.[29] Rather than challenge her upsetting thought, we accepted her most troubling thought, "I'll never dance again," as 100% true and then asked her the question, "So why does that bother you; what's the worst thing that can happen?" Her response revealed that this "truth" bothered her because as outgoing President of the Dance Club, if she could not dance, others would not want her to go to the club (her only social activity). The second thought, "People won't want me at the Dance Club," was validated as a statement she believed, again, to be 100% true. So, we asked the questions again: If that is 100% true why does that bother you; what is the worst thing that can happen? Similarly, we followed this train of thinking, "catastrophizing" through 3 more "truths" until she realized the worst (most upsetting) thing that could happen was to "be alone."

After this realization, we systematically went back over the statements she believed to be 100% true and challenged them. The first statement, "I'll never dance again," was revealed as an overgeneralization, because she could still fox-trot or waltz; it was the swing and the rumba she was unable to do.

The second statement, that she would be unwelcome at the club, was first recognized as a distortion of the "jumping to conclusion" variety. Referring to a different self-test she completed as homework revealed that she is emotionally vulnerable in settings where exposed to the possibility of criticism by others. This is related to a commonly held and deeply rooted value or perceived need for the approval of others to feel good about herself.

Once Mrs. Tandy could admit to how important the social connections are in her life, she was able to recognize that she has been feeling socially isolated from her friends and family since the time when she cared for her ill and abusive husband. For many years, her only escape from the stresses of her family problems, and her only major connection to the community, had been her involvement with the Dance Club. No wonder the threat of losing this connection was so upsetting!

The outpouring of support from other patients in the group was very moving. They validated how likeable she was and reassured her that they would continue to socialize with her, even if the dance club members would not. The next week, she was meticulously dressed, smiling and laughing as she declared, "I went dancing!"

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