 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through AllCEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome you to today's presentation on pain, moods, and management. Throughout this presentation, we're going to go over the characteristics of pain. And if you're in a Jaco accredited program, you're probably familiar with asking about the characteristics of pain. But we're going to talk about what that looks like and the reasons that we ask those questions and how they might help us as clinicians help our clients as opposed since we're not medical people. We'll look at the effects of pain, not only on mood, but on social relationships on people's environments on people's work and just generally how they think and function. We'll help people understand their pain. We'll talk about exacerbating factors and mitigating factors and helping people figure out what is it that makes their pain worse and what can they do to make it better. And then we'll wrap up looking briefly at some medical interventions that people can consider, both oral medications as well as other things like nerve blocks. And then we'll also talk about some non-medical interventions and referrals that we might be able to make. So everybody has pain sometimes. It is not realistic to think that you should never have pain. If you never have pain, you're probably not breathing. So it's something that you need to expect and something you need to figure out a way to cope with. Now, everybody reacts differently to pain. What causes extreme pain for one person may not be a big deal to another. For example, I have a pretty high tolerance for pain when it comes to working out muscle soreness, those sorts of things. But when I got stitches as foot surgery and when they took the stitches out of my foot, I about punched the doctor. And I didn't mean to, but it was just kind of that knee jerk reaction. So my pain threshold there was really low. So depending on the person and depending on the nerve endings in that particular area, whatever it is, they may have more or less pain. And I emphasize that because too often we think, you know, that's not that big of a deal. You had a tooth out, you shouldn't worry about, you shouldn't be all concerned about the pain, it shouldn't hurt that much. But there are some people it does. And there are a lot of things that affect our pain threshold, one of them being our serotonin levels. So we'll talk about that in a little while. Our bodies are incredibly resilient. So when we have little pains when you twist your ankle when you strain a muscle, you know, I'm getting older every once in a while I'll bend over to get something out of the fridge and I'll strain my back and I'm like, Oh, that that really wasn't cool. In a couple of days, it's all better. Our bodies naturally want to find that homeostasis and naturally want to heal itself. So knowing your pain can help your doctor or physical therapist understand a little bit more about what's going on. And it can also help us as clinicians to help people deal with it because dealing with acute pain, something that's new something that's not going to last terribly long. A broken arm, something like that is much different than dealing with chronic pain, you wake up every morning and it hurts, you go to bed every night, and it still hurts. And this goes on for weeks or months or even years. You can see how just even thinking about that kind of chronic pain can be sort of overwhelming and depressing. The characteristics of the pain such as whether it's stabbing, aching, throbbing or burning. And these are questions that sometimes doctors ask and sometimes they don't ask they may just say tell me about your pain. When the last agency I went worked for went through jaco accreditation, we actually modified our assessment to ask these questions to get a clear indication about what that pain really was. Constant or intermittent. Now you can have chronic pain that's intermittent migraines are a perfect example, where this is something that happens relatively frequently, but it's not 24 7365 intermittent pain at least gives people a little bit of relief. So as a mental health clinician, one of the things I will want them to focus on is what's different during the times that you're not in pain, and let's focus and and keep a log or a journal of how often are you having these things we want those periods without pain to go to be as we go through treatment it may not remit completely. But if you can go from having a migraine three times a week to four times a month. That's a pretty big improvement. We want to know if it's stationary or radiating that can also affect how people interact with other people how people do their jobs. If you've got a stationary pain, then you kind of know what you're going to do that's going to make it worse. If it's a radiating pain. Depending on your movement it may kind of radiate move to other parts of your body. That will also help the doctors identify if it's neurological and all that kind of stuff but again we're looking at it from a mental health perspective. And then any numbness numbness is interesting because some people look at it as a blessing and some people look at it as a curse. Numbness obviously it's not hurting right now so that's better than hurting but think about somebody who has carpal tunnel they start having numbness in these first three fingers. They can't type. It's hard to even hold a spoon. They can't do manual anything with manual dexterity writing typing. Cooking I crochet a lot and when that when my hand starts acting up I have a hard time crocheting so the numbness while it's not painful is somewhat debilitating and that can be very frustrating which can make depression worse when depression gets worse than we know we also probably have a drop in serotonin which will make our pain threshold a little bit worse. So the effects of pain depression you know and that's kind of that garbage term that we talk about that has a lot of different manifestations one of them being fatigue. If you're in pain a lot you're probably not sleeping very well and sleep disturbances is next. But when you're in pain you don't get as restful of sleep you may toss you may turn you may wake up. And that keeps you from getting into that deep sleep and we know how important deep sleep is for our brain to rest and rebalance. The fatigue is also can also be draining because a lot of times your body compensates when you have pain on one side of your back for example the other side might spasm to try to balance things out. And they're constantly fighting which means you've got your muscles constantly working uses energy it can be draining on your just your general physical level of energy if your body's trying to recover and we're trying to fight against or deal with the pain that you're experiencing. And I talked about sleep disturbances not being able to get to sleep is one of them. The other thing that we look at with sleep disturbances and pain is the effect of a lot of pain medications you'll find that a lot of your opiates make you really sleepy but they don't help you get good sleep. So helping people take a look at what things are impacting your sleep aside from just your pain. Are you tossing and turning are you getting too hot are you taking medications that are upsetting your stomach or keeping you from getting good sleep. A sense of hopelessness and helplessness. I have a friend who was in a car accident and she is in chronic pain constantly and it's pretty much unremitting unremitting. She broke her back and has a rod in her back and it's you know yeah she's had a really rough time through the recovery she couldn't walk for six months. So she's made it a long way she walks now she can you know do house chores she's not able to work full time. So when she wakes up instead of focusing on all the things that she can do now that she couldn't do two years ago. Most of the time she's just faced with all the things she can't do so it's a struggle to remember how far she's come and what she's able to do. But on top of that not only just not knowing you can't do certain things but she's dealing with pain on a daily constant basis. Now sometimes it's a two on a scale of one to five and other days it's a full out five plus. So helping her look at the days that it doesn't hurt as much and being grateful if there's such a way for the days that it doesn't hurt as much and figuring out how to improve her life on those days. Another impact of pain that goes with depression is negative thoughts. When somebody's realizing that they're in pain they get angry because they're in pain they get frustrated because they can't do things they wanted to do because of their injury or their pain. It can cause stress and a that fight or flight reaction kicks in our body perceives pain as okay you're vulnerable to attack so we're going to send out the cortisol we're going to send out those stress hormones. When you're in pain you've got this sort of thing going on. Serotonin goes down and pain goes up. So we know that with cognitive behavioral therapy and a lot of other interventions that we've talked about. Our thoughts have a direct impact on our moods and when you're telling yourself that this is awful. This is unbearable. I can't do this or focusing on all of the negatives then the neuro neurochemicals responsible for reward and happiness just aren't going to be there. We need to look at some things people can do to increase their happiness and sometimes it's just a matter of distracting from the pain that they're not going to be giddy happy but something they can focus on besides the fact that their back is hurting or their knee is hurting. So interventions mindfulness encourage people to do a body scan focus on what hurts what feels good. On those areas that do hurt there are a lot of different interventions people can do at home and they can talk with their doctor about massage. Strengthening exercises physical therapy a lot of physical therapy you go to the PT but then you come home and you do those exercises all week. Yoga. There's a lot of different things that people can do once they are mindful of what hurts mindfulness also looks at the pain and says is this pain due to my injury or illness or is it due to my stress. When we're stressed think about when you're stressed does your belly get upset does your back start to hurt does your neck start to hurt you give yourself a headache. It may be one it may be all of the above it may be none but a lot of people somaticize their stress. If the pain is caused by stress or anxiety that is a whole lot more addressable if you will I don't think that's a word by us as clinicians and by the patient themselves then something some medical diagnosis. I've worked with soldiers who have been injured in combat and sometimes they are just not going to be pain free and there's nothing I can do about that there's nothing the docs can do about that. But I can help them with other types of pain and other things that are ripple reactions from the pain. Good sleep habits. If someone is taking opiates they may be sleepy a lot and they may want to sleep a lot especially if they're not able to get out and go to work because of the pain. Their circadian rhythms can get disrupted so making sure that you're not sleeping too much during the day so you're actually sleepy sleepy at night. Making sure that the medication is not making you too groggy or disrupting your. Your deep sleep. Those are the two big things with a lot of my patients who have chronic intractable pain. One of the things we do for circadian rhythm maintenance is get up about the same time in the morning and whether that's 6pm or not 6pm golly 6am or 9am whatever it is for that person about the same time every day. And get into a wake up routine we talked in the sleep presentation about a go to sleep routine. Well this is our wake up routine. Generally when it's time for you to wake up your body starts secreting cortisol anyway and for most adults it's about 8am. Not for everybody it kind of depends on your rhythms. But we want to make sure our body knows it's time to be awake so that means getting out of your jammies. It means getting up and getting some sort of sunlight and trying to do this yes every day including the weekends. If you get up at 6am during the week and you want to sleep till 8am on the weekends or 9am you know that's cool but do the same wake up routine when you get up so your body knows okay we're not just up going to the bathroom we're actually up for the duration now. This will help set that sleep eat wake cycle and get people on the right track. Have people identify things they can control that are good. Okay you can't control the pain and if you think back to us acceptance and commitment therapy we know the harder we try to control something or get rid of something that's not controllable. The worse we're going to feel so accepting the pain exists and identifying the things you can control and preferably that are good so you can control your stress you can control what you eat you can control your sleep habits and there's a lot of those things that people can control. When it comes to addressing the self esteem and self efficacy issues that a lot of people face when they have some sort of chronic pain again focusing on the the days that are good and maximizing those days and cutting themselves some slack on the bad days. None of us is equal we all have different strengths we all have good days we all have bad days and when there is a bad day you know not dwelling on it and going well this is going to really suck today. But getting up and saying okay this is not a good day. Let me be kind to myself and figure out what is it that I can do to improve the moment. And eat healthfully to support serotonin functioning. Let's make sure we're getting that myriad of vitamins minerals and amino acids in there that you get from eating colorfully anxiety people with chronic pain or even acute pain can have a lot of anxiety. I had another friend bless his heart about my age and he decided to go out motocross and he took a jump a little bit too high landed a little bit wrong and broke both of his legs compound fractures of both legs. So for six months he didn't walk and he was in a long term care facility until you know things started to get better. And he could have gotten very anxious and very depressed over the fact that he couldn't walk and he couldn't motocross which is something that he had done all of his life he had competed and all that kind of stuff. But instead he focused on the positive and what he could do, which helped keep things moving in a positive direction. On the bad days, you know I said sometimes there's good days and sometimes there's bad days, even if it's chronic pain. Sometimes there are going to be days that it's a two or three and other days it's going to be a five plus. On the days that it's a five plus sometimes people will start to fret and worry that things are getting worse. If you've known anybody who's had surgery or whatever. There are some days that you know they're on the healing path and all of a sudden they have a not good day and they start getting really worried that they've got an infection or that they've broken a suture or this or that or the other and your mind can kind of go off into a myriad of places, helping people bring back their focus to what is probable. What is probably going on right now that made my pain worse today than it was yesterday did I do a little bit more activity yesterday. So if so then it might be a very natural consequence that I'm a little more sore today. And other anxiety can center around the consequences of pain, such as lost jobs. If you can't work because of your pain, or you can't do certain types of work, or hobbies, whatever you is important to you because of your pain. That can cause anxiety when it comes to a job. You might be wondering how am I going to feed my family if I can't work anymore, because disability is not going to pay enough. You know I don't even know if I'm going to get disability and people have a lot of anxiety when it comes to especially debilitating pain. It can have negative impacts on relationships to it doesn't have to, but it can. When people are in pain, think again about some time that you've been in a lot of pain. And did you want to interact with people. Were you as kind, compassionate, patient tolerant of other people when you were in a lot of pain. Probably not. You know I think to when I had my kids and my husband and the obstetrician were sitting there talking about flying. And I'm sitting there going excuse me I'm having a contraction this has got to stop. No, it's about me right now, which is not real good for relationships. But if you are constantly bringing the focus, not only back to you but back to your pain. It can have a negative effect on relationships. Helping people understand and be cognizant of how their pain is in affecting how they interact with other people and whether interactions with other people always center back around their pain. You know that's not helpful in either situation we want to have them have beneficial productive supportive relationships that center around hobbies and fun things not their pain as much. And they may worry if they were into working out before they may worry about their fitness level if they're going to be on bed rest for six months or if they can't walk for six months. It may concern them quite a bit. If you've got someone who has an eating disorder or who has a focus, it may be it doesn't quite meet the level of eating disorder, but they have a focus on being in shape and being thin. Then anxiety can creep up about what's going to happen to my body if I can't work out for six months or a year. So interventions for anxiety. Some of the easiest ones avoid caffeine and nicotine. These are stimulants that are going to make it more likely make you more vulnerable to use a dbt term to having anxiety and to getting worried and to being kind of revved up. Educate yourself about the disorder and the probability that things will get worse. You know how likely is it that if you have your wisdom teeth out, you're going to get dry socket as long as you're following the doctor's directions. How likely is it that the worst case scenario is going to happen and doctors can tell you that if you're working with a patient who just had heart surgery. That's huge. There's going to be some pain. There's going to be some recuperation time and there's going to be a lot of fear because if a heart doesn't work, that's a big issue. So we want to help them educate themselves about the probability and what to look for and when to call the doctor. And most doctors will go through that with them, but encouraging them not to bite the bullet if they're really concerned. If they do, then they might not get the reassurance that they need and they might sit at home and stew and wonder and get themselves all revved up and make their pain worse. As I said earlier, keeping a log of the good and bad days. Focusing on how many good days are we having and how can we improve the bad days. Practicing distress tolerance skills. There are a lot of different techniques that we'll talk about for dealing with pain, but dealing with the anxiety and the frustration that you can't do this right now, or it hurts too much to do this right now. And it can be maybe you can't go to your kid's recital because it hurts too much to get out of bed. There's a commercial on for some some pain thing right now. I can't even tell you what it's for. But this guy sitting in a chair and his dog brings him the leash in its mouth and he starts to get up to try to take the dog out and the pain is just too much and he can't take the dog out. And it just breaks my heart every time just a little dog looks at him like, why won't you play with me daddy. But this is how people who are in chronic pain who can't fulfill their prior obligations their prior roles can feel so understanding and empathizing with how hard it must be to feel like you're letting people down to feel guilty to feel anxious to feel depressed and use the challenging questions worksheet to and to address anxiety provoking thoughts. If you Google challenging questions worksheet it's part of the cognitive processing therapy protocol. Basically it says what is your thought or concern. How likely is your thought or concern going to happen. What is the evidence actual evidence for it. What is the actual evidence against it. And are you using emotional reasoning or emotional reasoning or logic and there's it's a whole worksheet. It helps people take a very objective look at what's going on and figure out is this something I should really be worried about right now or am I getting worried over something that probably won't happen guilt self anger when you can't do something. You know like go take your dog out on a walk or go to your kids recital or make dinner. You may feel guilty you may be angry at yourself for not being able to fulfill that role function which can cause some people to lash out at others and push them away. It's just like fine leave me alone go get your own supper or you know whatever. This obviously has a negative effect on relationships that we want to take a look at. Think about how you would want your child or best friend to feel if they were in your position. So obviously you can't have this discussion with the dog. You know the dog doesn't understand but if your child was in a lot of pain. Would you want them feeling guilty because they couldn't attend your birthday party. Probably not you know I would be more concerned about the fact that hey my child's in pain and I want them to feel better. So take that approach when you're if you're feeling guilty that your spouse is having to do more around the house. Switch roles and say if my spouse was in this much pain. Would I be angry at him or her because he or she wasn't getting up to do the normal chores. Get rid of the shoulds I should be able to make dinner I should be able to go to work I should know but you can't. Right now you are not the person you were before the accident or the injury so what can you do right now. And decide whether it's worth using your energy to be mad at yourself in the world because this guilt. Some of us are really good at getting guilt and nurturing it. But is it a good use of energy. Does it do anything positive to help stop your pain improve your relationships or improve your energy or your sleep. Generally no so and I'm sure you have a lot of tips tools and tricks up your sleeve that you use to help clients deal with guilt. Those can come in really handy with people who have suffered some sort of an injury or have chronic pain. Grief. If you've come to any of my grief classes you know that I emphasize the fact that death is not the only loss to be grieved. If you've lost part of your independence. If you've lost part of your functioning maybe you used to be this you know a number one motocross star you know that wasn't his full occupation and he has other roles that he goes through. But it was something that he had done and competed in all his life. So my guess is he had to go through a grief process coming to the acceptance of the fact that he wasn't going to be able to do that anymore. The interventions are to work through the stages of grief for each of the losses because of the pain and there can be a lot of them. And there can be a lot of them. I'll have my clients write down what has changed since the injury or what has changed since you started experiencing this pain all the time. And then we start looking at which ones are losses which ones are things that they can't do anymore that they're holding on to that they're still trying to wrap their head around. And then we start going through each one of them and figuring out how to resolve that loss or figuring out whether it's a temporary loss you know something you can't do for a year. All right well at the end of the year maybe you'll be able to do it again self esteem. Obviously the difference between who you want to be and who you are right now. So maybe you want to be that person you were six months ago but right now you're not because you just had surgery or you're in pain. So make a list of the positive things about you right now. It's not going to be the same thing as that person. However I tried to help clients reframe pain and surviving whatever brought the pain on and surviving the pain itself in terms of a survivor story. How strong are they that they can get up despite the pain and doing these things identify one or two goals they can work toward it may not be pain related actually hopefully it's not what can you work toward. Maybe developing your stamina so you can get a part time job or even a part time volunteering position. Developing the ability to bathe yourself again or working toward finding a new hobby. My grandfather once his Parkinson's kicked in he used to make miniatures and he wasn't in pain but same kind of loss we're talking about here. He shook too much in order to make the miniatures and to paint them and he had to grieve that loss. But he identified a goal that he could work toward of a new hobby. Celebrate the small things the good things that you do the good things about yourself your successes and it can be getting up in the morning having a good day being kind to somebody else. And help people work on silencing the inner clinic it goes back to those shoulds that we talked about on the last slide. Should just add extra stress what can you do and that's what you're going to do. The other stuff we just need to figure out how to accept circadian rhythm disruption can come from not getting out of bed people are either in pain and they can't get out of bed or they're on bed rest. And you can get really sleepy just laying around all the time. If you've maybe you've stayed home one weekend and you've decided you know what I'm going to stay in my jammies and I'm going to sit on the couch and I'm going to watch football all weekend or a Netflix marathon. And you find that you really don't ever seem to wake up. So at night you're probably not sleeping quite as well because you're not getting out all that energy in your brains like is it time to sleep you kind of haven't done anything all day. So this can start causing circadian rhythm disruption. Encourage people if they're if they physically can to get out of bed if they can't and this kind of goes along with staying inside in the dark. Make sure to open the blinds sitting in your house not moving with the blinds closed makes just about anybody depressed. Not only do they need the sunlight for vitamin D and all that stuff but it helps set circadian rhythms and it'll help them feel better. Again we know vitamin D is also involved in depression mitigation. Lots of positive things about the sun. And sleeping too much. If you're taking medications or even if you're just depressed and you don't feel like getting out of bed and you're sleeping all the time. Then again eventually your circadian rhythms get out of whack. So what do we do get out of bed roughly the same time each morning. If you want to give yourself a little bit more leeway on the weekends your body will adjust to it. It's not all that rigid just like if you want to stay out late one night on the weekends. You're not going to be awake until 1am every night after that. So your body is somewhat resilient but try to get out of bed you know before noon generally a good thing. Get dressed in your day clothes out of your jammies so you don't feel as sluggish. Part of doing that for some people involves taking a shower. Some people shower at night some people shower in the morning whatever you know does it for you. But a warm shower will actually help wake you up. Turn on the lights and or sit in front of a window or get outside to get your day clock started. Get some bright light get some of those daylight bulbs. We have some they're Cree bulbs and they're LED so they're energy efficient but they are obnoxiously bright with that bright daylight. It's not the soft yellow color but it definitely helps wake us up. If you must take a nap and if you're taking opiates or just not doing a whole lot you're you're stuck at the house. You may get sleepy you may want to take a nap keep it under 45 minutes to avoid getting into that deep sleep. Encourage people to understand their pain what makes it worse if you are anxious depressed or angry does that affect your pain level. Keeping logs I keep baselines I have my clients keep baselines of how they feel what their mood is every day of the week and just a Likert scale one to five nothing too crazy. But also if they have pain they keep a pain scale one to five nothing too crazy and we can find a lot of times not always but a lot of times that as their mood. Is worse their pain is worse. What mental factors make your pain worse thinking about all the things you can't do. If you're foggy headed because of the medication that can have an impact if you're foggy headed because you're in so much pain and that's totally understandable when you're in a lot of pain it's hard to concentrate. But that can also increase frustration. Physical things that make your pain worse not getting enough sleep not stretching sitting in the wrong position. I am notorious for having very very bad posture when I'm working on the computer when I'm watching TV. And I will notice that my back hurts the next day and I'm also really bad along with physical for not stretching after I work out and then I wake up the next morning and I'm kind of like stuck in one position. I'm not recommending it you should you should always stretch. Don't do as I say not as I do. Identifying those things can help a lot toward mitigating the number of bad pain days. Environmental things that make your pain worse if you're somebody who has pain because of migraines certain fluorescent lights can make your pain worse. Fluttering lights flickering lights you know right before a ballast goes out can make your pain worse. If you've got low light somewhere and you're struggling to read because it's so dim or maybe you need glasses and you're not wearing them which is giving you a headache that can make your pain worse. So what easy environmental factors can you address. My daddy when he got old enough that he needed reading glasses was notorious for getting for forgetting them everywhere. So he ended up having five pairs of them he'd have one at the house one in the car one in the office and then a couple others who knows where. But that way wherever he was he always had reading glasses so he wouldn't get a headache and he could read the menus and things. Sometimes it's simple interventions like that if you have low back problems maybe driving in the car is uncomfortable. So what environmental modifications can you make are there any kind of pads that you can get that will help make it more comfortable to sit in the car. So think about things do an environmental assessment to see if there are things and when you sleep. That's the other big time that you're in bed for a while. Are you on a comfortable mattress. Do you have the right pillow. Talking with your physical therapist will help identify some of those issues and some of the interventions for those issues and social exacerbating factors. Sometimes people can make you feel really bad for being in pain and not being able to do stuff they kind of try to guilt you into going out. And most of the time and you know I try to give give the best interpretation of it. Most of the time I think people are trying to go to you to go out in order to get you out of the house because they think it'll make you feel better. But socially sometimes people being able to do things that you can't and you seeing them do them or putting you on guilt trips because you can't do things can make your pain. So how can you deal with those for the mitigating factors and most people have some in their toolbox they know things they do that makes the pain go away a little bit. Emotionally if they're feeling down what can they do to feel a little bit better. It still may have nothing to do with the pain. It may just be distracting themselves looking at maybe they go online and look at silly videos or I don't know what people do to make themselves happy but whatever it is do some of that. Mentally how can they make their situation better how can they help themselves focus if I'm taking medications which I'm real sensitive to medications so I get loopy easy. I take a lot of notes I keep a notepad with me or I put it on my iPhone. That way I know what I need to do what I need to get at the grocery store what I need to do at work that day. It helps me focus and maintain my concentration if I'm feeling a little bit off. Physically yoga stretching hot baths massage therapy there are a lot of things we can do that can make our pain. Somewhat less and it obviously depends on the type of pain a migraine is going to be treated differently than low back pain which will be treated differently than arthritis in your knee but understanding those speaking of arthritis now we're down to environmental. I can tell you when the weather is getting ready to change because there are sometimes like if it's getting ready to rain or get cold my joints will start to hurt a little bit. So environmental things sometimes you can't control them and it's just the way it is but some things you can control in your environment what you sleep on what you sit on your posture the temperature level in the house taking a hot bath. All of those things can help and having positive social supports who understand and take you seriously with the level of pain that you are expressing. Medical interventions Tylenol and non story steroidal anti inflammatory is there over the counter. These are things that a lot of people take they talk to their doctor they figure out which one's best. Most of the time they found that NSAIDs your ibuprofen and your leave are better at relieving pain but that's. They also have a lot of stomach side effects so it's something people need to discuss with their doctor opiates provide relief by attaching to your opioid receptors. Your body stops making natural opioids when flooded with prescription opiates so you need to be aware of this it's easy to get addicted or tolerant to opiates your body will start to adjust in a matter of days. When you stop taking prescription opioids the body often takes a few days to start making natural opioids again so your pain threshold is markedly decreased. So let's think about that person who's in a lot of pain and they start taking opiates and it feels better and they go through their prescription and you know they've healed and they're actually doing a lot better but then they stop taking the prescription opioids. Their body hasn't kicked in to start making the natural opiates again. So they start feeling more pain and they go back to the doctor and they're like Doc something's wrong. It may be obviously it's worth a medical doctor checking out if they think the pain is increased that much but helping people understand that when you stop taking opiates if you've been taking them for a couple of weeks especially. You may have some kind of what we call rebound pain and understanding that and being prepared for that helps a lot of people not freak out. Muscle relaxants like flexoril and soma can help if it's a muscular issue. Flexoril is less abusable than soma. Soma has a high frequency of abuse but muscle relaxants do help if that's where your pain is. Gabapentin has been used for brand name Neurotin for pain control for fibromyalgia and for a lot of other things where people may have pain. It's also something a medication that I've seen used in some of my patients who have who are in recovery from addictive disorders. SSRIs specifically Simbalta but anything that increases serotonin levels may help with pain levels. Nerve blocks are something that a physician can do not your general physician but a anesthesiologist to help block the pain to a certain part of your body. Obviously that's going to be a lot more aggressive of a therapy than taking some sort of oral medication but sometimes it helps people and sometimes it helps people when oral medications are not helping or if they don't want to take oral medications. And I put acupuncture and acupressure here under medical interventions just because it uses needles and it's not something you can just do at home. But there is a lot of research that has shown that acupuncture and acupressure can be very, very helpful in addressing all kinds of pain from migraines to arthritis to back pain. Guided imagery. Now these are a couple of my favorite ones. There are a lot of different guided imagery scenarios you can use. Color imagery. Think of a color you associate with pain such as red and picture the painful area of your body as red and then imagine shrinking fading or just dispersing the red. And it takes people a little while a little bit of practice to get used to this but if they're open to guided imagery this is one that can help. Not only are they seeing it disappear but they're also focusing on a color which is more tangible than some abstract pain they're feeling. Symbol imagery. Think about how the pain feels if it feels like a knife sticking into your joint. Imagine you're pulling the knife out of your joint and throwing it away. I had somebody suggest to me one time for neck and back pain to imagine angels rubbing the knots out of your upper neck and back. That was one imagery that stuck with me. Scenic imagery. And this comes completely different. We're not focusing on the pain now. We're focusing on a place that's calming and focusing all of our senses there instead of on the pain area. So your favorite vacation place when you were a kid where you want to go this summer on vacation, whatever it is but you want to take a break. Take a mental vacation from your bodily pain. Mindfulness. Alternate focus activities. Stop thinking about the pain and how to relieve it. So we want to focus on something else. Look at a vase that's in the room and look at how many colors there are. Just really focus on everything. Find a picture and see how many different things you can find in the picture. Anything to take your entire mental focus will help. Deep relaxation and breathing through the pain. When you feel the pain, especially if it's something like stabbing or throbbing, breathing through it can help you when it's worse and then exhaling. But just generally breathing through the pain can help your body relax and when it relaxes, then it can send out the all clear signal which counteracts the stress signal. Distract yourself. Sometimes it's about finding something. A Netflix show, a video, music. Loud music can sometimes distract you. Not so loud that you hurt your ears. Going outside. I like going outside and watching the birds. They're cute. Little titmice and chickadees are kind of my favorite because they just flit everywhere. Anything you can focus on that distracts you from thinking about the pain. And sometimes it just comes down to one moment at a time. Not an hour, not a day, not okay, I'm going to get through this. I'm going to get through this moment. If you've had toothache pain, getting through the moments, plural, until you can get to the dentist. Sometimes it's just taking it moment by moment and realizing that you can survive it. It sucks, but you can survive it until you can get some relief. Radical acceptance. Life can be worth living even with painful events or even with pain. Why? Encourage people to look at and answer that question for themselves. Why is life worth living despite this pain? Focusing on what they have to live for. Helping them understand that rejecting reality doesn't change it. Rejecting the fact that you're in pain and saying, no, it doesn't hurt. It doesn't change the fact that it hurts. So just accepting the fact that it hurts and you're going to have to figure out how to deal with it. Changing reality requires first accepting reality. So you accept it hurts and it sucks. Now what parts of this can you change? Accepting that pain can't be avoided and it's nature's way of signaling. Something could be wrong. Your body is healing from something or there's an injury or we may not know what causes the migraine. We may not know what causes something, but it's your body's signal that something's wrong and okay, so my body's doing its job. I wish I wish it wouldn't do it so thoroughly, but it's doing its job. Rejecting reality turns pain into suffering. So when you start to try to reject the fact that you can't do something, then not only are you rejecting this pain, but you're also starting to suffer. If I say I can do this, whatever it is, even with my pain, I'm probably making whatever the physical pain is worse and then when I'm not able to do it, it increases my suffering and sense of frustration. And refusing to accept reality can keep you stuck in unhappiness, bitterness, anger, sadness, shame or other painful emotions. So refusing to accept the fact that okay, this is going to hurt for the next three weeks or six months or I may not be able to ever run a marathon again. Accept that, refusing to grieve that loss is going to keep you stuck. Non-medical interventions. Stretching and balancing exercises. We have multiple planes. Our body wants to balance your right versus your left. So what are we talking about there? The right side of your back and the left side of your back. If one is injured, the other is going to get wonky. You know, if one's weak and the other one's strong, you're going to feel pain. So making sure there's balance there. When there's an imbalance between front and back, it can also cause pain. If your quadriceps, for example, are really, really, really strong and your hamstrings are really, really, really weak. When you start doing activities, you can actually rip your hamstring. Your body wants balance. If your abs are weak, your back may spasm and you may have sway back and low back problems. It's all about maintaining that balance. You can use ice or heat packs to address pain and going back to those, the balance and stretching exercises. Figuring out ways to make that imbalance less noticeable. And a lot of times it comes to stretching exercises or if you have scoliosis, you may have to strengthen one side of your back more in order to get it to be on the same level of strength with the other side. But once they're both equally strong, the pain actually remits. Ice or heat packs. Pretty simple at home things. One life hack that I've found that is really useful is to put, obviously, if it's safe in your household, put isopropyl alcohol in about 20% with the water when you put it in the Ziploc bag and put it in the freezer because then it never solidifies. So it's more malleable to whatever area you want to get it, but it gets really, really cold. Heat packs. They have wonderful heat packs now that you can actually put on and they stay hot for 18 hours. I can't think of a company that makes them, but it's the one that Shaq does the commercials for. And I found those to be extremely helpful if I wanted to be up moving around and I had low back pain. Massage. You can do massage on most places on yourself. Just learning how to do it, finding out what will work, what will help, or you can go get a massage. TENS units and it's so wonderful that they're becoming more available now than they were when I was younger. But it's transcutaneous electronic nerve stimulation and it's little nerve stimulation that basically bombards the nerve endings. So it doesn't notice or send a signal that there is pain and it helps the muscles relax. Improving sleep and do more things you enjoy can improve your mood and improve your serotonin levels, which will improve your pain. Stress management. Because stress causes digestive upset and pain, back pain because we carry our stress back here. Migraines and headaches because we may clench our jaws or it just causes pain that way. And jaw pain from grinding our teeth. We want to manage our stress. Stress management goes a long way towards managing other sources of pain besides maybe the initial injury. Meditation. Distract. Don't react. And identify your most important values and this is the ACT intervention again. Decide whether stressing over whatever it is you're stressing about gets you closer to or further away from your goals and values. If you Google, go on to YouTube and search for ACT matrix, M-A-T-R-I-X. The videos are a little slow but it is a really useful technique for using with clients in order to help them quickly embrace the ACT philosophy. Pain is inevitable but we know it impacts our mood, thoughts, behaviors and relationships. We can do a lot of mitigation there. It doesn't have to have significant negative consequences but we have to be aware of it first. Addressing pain will also help reduce related anxiety, depression and I use the term anger, anger, irritability, frustration, guilt. All of those are forms of anger and addressing your pain will help address some of those. Pain management can be medical or non-medical. A lot of people use a combination of both but being aware of the non-pharmacological interventions is really important for a lot of people. Because there are a lot of times you'll have pain that's not quite at the threshold you need to go to the doctor but it's enough to make you cranky. Pain management requires a comprehensive approach to addressing the physical causes of pain, your mood as a result of the pain, how to handle and interact with social supports and the effect that your pain may have on your relationships and how to get the best quality of sleep despite your pain. Are there any questions? Unfortunately for us as mental health clinicians it's really, there's really no easy way to identify psychosomatic pain. If my clients are complaining of pain I always have them go to their physician and let their doctor kind of rule out what's going on. If they have something like scoliosis or some sort of ongoing pain that they're going to be going to physical therapy for, I try to get releases of information so I can communicate with the physician and the physical therapist in order to make sure that I am aware of what pain they may be experiencing when they may be experiencing exacerbations. I know for me after I would go to my physical therapist the next two days I was in a lot more pain and then once my body got used to those new exercises it would the pain level would go down. But so it's important for me to know when my patients are going to their physical therapist and we can talk about what to do when the pain gets worse. When someone has multiple medical problems causing pain and struggling with depression and trauma which do you address first? That's a good question. My question to them would be what is it that you want to work on first? You've got all these things and they're all affecting each other. So if we start working on one you're probably going to find relief in some of the other areas. What do you think would be most efficient and effective to work on first? Alrighty everybody have an amazing weekend and I will see you next Tuesday. 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