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In this section, we will discuss three kinds of pain frames which act as an appraisal for the client. These three kinds of pain frames which act as appraisals are: threat; loss; and challenge.
In cognitively treating a client for chronic pain, there are several frames of stressors to take into account. In a transactional model of stress, "stress" is not an event or stimulus. Rather, it is the judgment that an event or stimulus exceeds the client’s resources, thereby endangering the client’s wellbeing. Pain frames give an insight into the client’s perceptions of pain and its effect on his or her life.
3 Types of Pain Frames
Pain Frame 1 - Threat
The first pain frame acting as an appraisal is threat. When a client views their own chronic pain as a threat to their happiness, he or she unwittingly gives more thought to the pain and less thought to other aspects of his or her life. Clients with chronic pain frequently complain of poor memory and an inability to concentrate. Because the client is overfocused on one stimulus, there is less attention devoted for other stimuli or cognitive tasks.
Terry, age 48, would have chronic back pain related to an enflamed disc. Because he believed the pain to be so unbearable, Terry began to fear the it almost every waking minute of his day. Even minor pain, such as a stiff neck, threw Terry into a panic, believing that the pain had spread all up his spinal column.
Slowly, he began to become less and less involved in his environment. He quit his daily walks with his wife because he believed that any prolonged exercise instigated his pain. In fact, he dropped any activities that required physical strain. Soon, Terry had confined himself to his home and to his office. He began to forget assignments and handed in projects late, and half-finished.
Think of your Terry. Is he or she devoting too much attention to preventing pain? How would you address this?
Pain Frame 2 - Loss
The second pain frame acting as an appraisal is loss. Clients like Terry who participate in less and less activities begin to feel a sense of grief and loss in their lives. Depressed affect, a perceived sense of helplessness, and a reduced likelihood of engaging in adaptive coping behaviors are likely to be related to this sense of loss.
Thus the pain frame of loss produces other factors to take into account later on down the road. Each of these losses contribute to the stress of a client with chronic pain, and each is an appropriate target for cognitively based pain therapy. Terry stated, "I did a lot of camping and hiking, even in my advanced age. I did a lot of wrestling with the kids. And when the back injury happened, a lot of that was taken away. I don’t feel connected to my family anymore and as for exercise, that’s all gone out the window."
Interestingly, Terry felt a disconnect from his family, even though he spent most of his time in the house where they were present. He had lost a great physical expression of affection and love. Because of this, he felt more and more detached from a caring world and further absorbed himself into his own world.
Think of your client with chronic pain. Does he or she experience a sense of loss?
Technique: Painless Reconnection
To help clients like Terry treat their fear of pain and their detachment from their surrounding environment, I asked him to try "Painless Reconnection." Terry had long thought of himself as a victim of his own body. Because of this, he had never tried to push past his own self-victimization. I asked Terry to go home and think of at least fifteen activities that do not require him to exert himself, but ones that can also include his wife and children. At first, Terry resisted the exercise, stating, "I can’t do this. All I ever knew was being active! I can’t sit on my ass and talk about my day with my family every evening!"
A few weeks later, however, Terry returned with more than thirty activities, twice as many as I had asked for. He stated, "We instituted a family game night every Wednesday and then on Monday we all get together and make sundaes or some other kind of dessert. I play video games with the kids and help them with their homework. This gives my wife a break and lets me get to know my kids. For my wife, instead of going on a walk every night, I massage her feet and she gives me a backrub. This way, we still have our own time together to just talk and be ourselves."
Think of your Terry. Would he or she benefit from Painless Reconnection?
Pain Frame 3 - Challenge
In addition to threat and loss, the third pain frame acting as an appraisal is challenge. Clients who view their pain as a challenge, not a complete interruption, have a better adaptation rate than those who obsess over it. Clients who frame their pain as a challenge believe that the potential danger posed by their pain does not outweigh their ability to cope with it. It produces feelings of convictions and commitment, and in certain situations even eagerness or excitement. Stressors are perceived more realistically and these clients self-identify themselves as a "healthy person with pain" as opposed to such clients as Terry who victimize themselves.
Chad, age 34, had broken his arm in thirteen different places and several of the bones in his hand were severely cracked in a car accident. After the injury, he had thrown himself into his physical therapy, attending all his sessions on time, even though he said he couldn’t see immediate results. Chad stated, "It hurt and I didn’t think it was helping, but I also knew how little I knew about this sort of stuff. I wanted to be able to paint again, and I thought that physical therapy would get me there.
Three years later, I opened my first exhibition of my paintings. I still feel pain. All the time, actually. But I accomplished what I wanted to and that’s all I needed." Because Chad had taken a much more positive approach to his healing, he completed it without interruption to his social life.
In this section, we discussed three kinds of pain frames which act as an appraisal for the client. These three kinds of pain frames which act as appraisals were: threat; loss; and challenge.
In the next section, we will discuss external and internal factors that affect a client’s perceptions of pain. These factors that affect a client’s perceptions of pain come under three categories, which are: biological; social; and personality.
Peer-Reviewed Journal Article References:
Akbari, F., Dehghani, M., & Mohammadi, S. (2021). Factor structure and invariance of the pain catastrophizing scale in patients with chronic pain and their spouses. Rehabilitation Psychology, 66(1), 50–56.
Bailey, S. J., McWilliams, L. A., & Dick, B. D. (2012). Expanding the social communication model of pain: Are adult attachment characteristics associated with observers' pain-related evaluations? Rehabilitation Psychology, 57(1), 27–34.
Carleton, R. N., Duranceau, S., McMillan, K. A., & Asmundson, G. J. G. (2018). Trauma, pain, and psychological distress: Attentional bias and autonomic arousal in PTSD and chronic pain. Journal of Psychophysiology, 32(2), 75–84.
Mendoza, M. E., Gertz, K. J., & Jensen, M. P. (2014). Contributions of four pain domains to the prediction of patient functioning and pain interference. Psychology & Neuroscience, 7(1), 3–8.
Salamon, K. S., & Cullinan, C. C. (2019). The integrated prevention model of pain—Chronic pain prevention in the primary care setting. Clinical Practice in Pediatric Psychology, 7(2), 183–191.
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