Cognitive Behavioral Therapy for Chronic Pain, Unpacking the Basics: Sessions 5, 6, and 7

Main points, no filter

·         Relaxation helps to reset your mind and body

·         Relaxation is active, not passive

·         Pleasant activities help to manage chronic pain and mood

·         Pleasant activities can be something simple

·         Making your world bigger makes the pain smaller

CBT-CP Relaxation Session

At some point in time, when feeling stressed or overwhelmed, you have probably been told, (or told yourself) “just breathe”. When you heard this maybe you rolled your eyes or thought, it isn’t that easy and it’s not going to help. Well, it isn’t necessarily easy, but yes, it can help. When we talk about relaxation in CBT-CP and how it can help to manage your chronic pain, sure, I am going to teach you about deep breathing, but we are also going to talk about why (and how) different types of relaxation can be beneficial.

But I have chronic pain, I relax all the time

Resting because of a pain flare or laying on a heating pad isn’t what I mean when we talk about relaxation for managing chronic pain. Listening to music, reading a book, or taking a hot bath to relax are all great activities to engage in to reduce stress and engage in self-care, but what I am talking about is what we call “active relaxation”, which probably sounds confusing and a bit backwards. Active relaxation is engaging in intentional relaxation exercises to activate your parasympathetic nervous system. That’s that good rest and digest mode our body and mind are in when we are calm. Chronic pain can keep your body’s sympathetic nervous system (that fight, flight, or freeze response) working in overdrive, so having a way to relax is important in managing pain and improving your quality of life.

Benefits of relaxation exercises in managing chronic pain

·         Increased focus

·         Improved sleep

·         Improved mood

·         Increased energy

·         Decreased tension and pain

·         Decreased heart rate and blood pressure

·         Decreased anxiety, frustration, irritability

·         Decreased stress

Relaxation not only helps to manage chronic pain by improving physical symptoms and decreasing tension in your body, but it can also help to improve mood and decrease stress. Remember when I talked about the relationship between thoughts, feelings, emotions, and pain earlier in the blog series? When we help to change one piece of the puzzle, it helps the other pieces as well.

Types of relaxation exercises you learn in CBT-CP

·         Deep breathing

·         Progressive muscle relaxation

·         Guided imagery

There are a number of relaxation exercises available, but in CBT-CP, we focus on these three. Everybody is different in terms of their preference or what exercise they feel to be the most beneficial, so this gives us the opportunity to try some out and see what works for you. You may also find that different exercises work for different things. For example, progressive muscle relaxation might help most with headaches or back pain, and imagery might help you to fall asleep.

Tips to get the most out of relaxation practice

·         Find a quiet, calming space

·         Get comfortable (your favorite chair, the bed, a yoga mat)

·         Choose a time when stress and pain are lower to practice at first (this will be different for everyone, but maybe it’s when you first wake up or after you’ve had a hot shower)

·         Reduce distractions (turn off the screens, put your phone on focus or do not disturb, and ask your partner to watch the kids and pets for a few minutes)

·         Use a script, relaxation app, or You Tube video if you find that helpful. Check out Therapy, No Filter’s youtube channel for recordings from our providers. The one below is for progressive muscle relaxation. 

We live in a world filled with noise, chaos, and distractions. So, when it comes to practicing relaxation, it is important to find the right environment for you. This is different for everyone, but what matters most is that you are not interrupted and have quiet in order to focus.

Learning relaxation is like playing a sport or learning to play an instrument. In the beginning, it can be difficult, and you need to practice. However, with enough practice, relaxation can become more automatic. The more automatic it becomes, the easier it is to turn to in times of stress, during pain flares, or when feeling overwhelmed or frustrated. Once you’ve gotten comfortable with relaxation, you can incorporate it throughout the day during stressful times or pain flares, even at the grocery store, the doctor’s office, or during a meeting at work.

But I can’t focus on relaxation

Give yourself some grace. If you have ever tried deep breathing, meditation, or any relaxation exercise, then you likely found yourself thinking about anything and everything besides the exercise. It is completely normal to be distracted by our to-do lists (or even what we need to add to our grocery list) when we are practicing relaxation. Be easy on yourself, and if you experience a distracting thought, observe the thought and then refocus on the exercise.

But I don’t have the time

Relaxation doesn’t need to take much time. While I can make a solid argument for why you should make time for yourself, especially when it comes to taking care of yourself and managing chronic pain, you honestly don’t need to set aside too much time for relaxation. Don’t get me wrong, the more time you can set aside, the more beneficial it can be. But in reality, just 10-15 minutes per day can make a difference. And once you’re a pro at relaxation, you can also use shorter versions of exercises, such as body scans, to take quick breaks throughout the day to reset your mind and body.

Now that we’ve gotten you relaxed, let’s talk about getting you back some joy and happiness too.

CBT-CP Pleasant Activities Session

Here is where you may be thinking, “I already told you I can’t do the things I love anymore because of the pain”. I understand how frustrating that can be. But this session will give us an opportunity to discover new activities, hobbies, or interests. You may not be able to run a marathon again, but that does not mean that we can’t come up with a new plan for things that bring you joy.

The impact of lack of pleasant activities

·         Isolation

·         Increased depressive symptoms

·         Increased focus on pain

·         Decreased self-esteem

·         Decreased attention

·         Negative impact on relationships

Often, when people experience chronic pain, they give up engaging in activities they previously enjoyed because those activities now exacerbate pain. The problem is, the activities aren’t replaced with something else that is positive. So, where we previously had time carved out for things that bring us joy or happiness, that time now becomes a time of sadness, frustration, isolation, or a reminder of what we have lost.

Start with brief, simple activities

·         Sit or stand outside in the sun

·         Take a picture of something you enjoy

·         Call, email, or text a friend

·         Read a book

·         Draw or paint

·         Watch a favorite movie

·         Play with a pet

When we are thinking about getting back into activities or hobbies, we often compare the who we are now to the who we were “before the pain”. This can quickly become overwhelming when we think we couldn’t possibly do the things we used to, or that we couldn’t engage in activities for as long as we did in the past. But the reality is, starting with small, intentional things can create a spark and improve our mood. You’d be amazed at what a tiny bit of Vitamin D can do.

I know, you are thinking “but it’s not the same…” I hear you. Maybe prior to chronic pain you participated in a local softball league, ran 5Ks, hiked on the weekends, or attended your child’s every practice, concert, and recital. And maybe we can’t get you back to doing those exact things. So, you’re right, it’s not the same. But that doesn’t mean that we can’t create a new normal where you can still be a part of things that are important to you. Remember that pacing I talked about last week? That’s where this comes in. We will start slow and steady. You’d be surprised at all of the different activities you can learn to pace. Reading a book, drawing a picture, playing guitar, all of these things can be broken down with pacing.

Or maybe you just want to watch your child at their sporting event, but sitting on the bleachers for an hour is just too painful. Remember when we talked about exercise like walking or movement? We can add some of that here. Nothing wrong with slowly walking next to the field while your child plays, doing some light stretching to keep from getting too tense, alternating between sitting and standing, or bringing your own folding chair that offers additional back support. Maybe there is even a parking spot where you can sit in your vehicle to watch for a bit if that helps with the pain. I realize it’s easier said than done. I mentioned before that in CBT-CP, and when managing chronic pain in general, it’s important to think outside the box to improve your quality of life. In this session, we will work together and really think outside of the box.

But I slow my friends and family down and I don’t want to be a burden

I am willing to bet that this is one of those unhelpful thoughts you experience. That it is better to not join your family on the walk, to stay home instead of going to the park, or to avoid the dinner out because you will need to stand up at times or spend too much time shifting around in your chair. I am also willing to bet that your friends, partner, and kids don’t see you as a burden at all, and would much prefer that they got to spend the time with you. When people experience chronic pain, unhelpful thought patterns emerge and negatively impact your mood and quality of life. Stay tuned in the following weeks when I unpack cognitive coping and talk about how we can work together to challenge unhelpful thought patterns.

Halfway There!

We are officially halfway through unpacking Cognitive Behavioral Therapy for Chronic Pain management, and hopefully by this point in treatment you are starting to see some positive changes. If you feel like you are ready to jump in and begin treatment, then Schedule a consult today! You can also try these skills out on your own by downloading the free Pain Coach App (here for Google Play) Pain Coach - Apps on Google Play  or (here for Apple) ‎Pain Coach by VA App - App Store. Interested in trying out some relaxation? Click here to try a Deep Breathing Exercise!