MHM Magazine

18 | MENTAL HEALTH MATTERS | 2025 | Issue 1 MHM Reaching a shared understanding of difficulties and ensuring the patient feels heard will enhance how well they engage with making helpful changes. Part of this is understanding that the patient may want a ‘cure’ to make the pain to go away, but that this is probably not realistic. Ensuring that interventions focus on self-management of the impact of pain, and on factors which can be changed means agreeing achievable goals which improve functioning and enhance quality of life. • Interventions will usually include offering pain education, to promote understanding of the interaction between the physical experience of pain and the role of psychological factors such as stress in persistent pain. Education about medications and other treatments can be useful too. • Learning coping strategies for improving sleep hygiene; formal problem-solving and learning to use rewards and positive experiences in line with important personal values to improve quality of life. Some patients will benefit from learning assertiveness, for example to ask for (or refuse) help from loved ones. • Balancing activity and rest by learning to ‘pace’ activity is an important contribution to treatment. Many people will either ‘over-do’ activity to the point they then have to take enforced rest – with this ‘boom and bust’ cycle making the pain worse. At the other extreme, the person might avoid any activity for fear of making the pain worse but in fact become weaker and less fit which also makes the pain worse. Starting from the current level of manageable activity and testing out gradual, step- by-step increases in what they do, allows the person to learn for themselves what they can achieve. This builds a realistic level of activity which can gradually increase despite the pain. • Learning mindfulness type meditations and relaxation techniques helps to promote calmness and acceptance, reduces muscle tension, and can help with genuine rest and wellbeing. • Using evidence-based psychological therapies such as CBT approaches to treat low mood and anxiety or trauma symptoms will increase coping and wellbeing. Building self- compassion and acceptance also enhances psychological flexibility and improves functioning and quality of life. • Planning for setbacks is an important part of treatment. Pain levels may vary, and an acute increase or ‘flare-up’ may happen from time to time. Making a plan shows the patient that a setback is not a sign their efforts to self-manage their pain are not working. Pacing activity is still important, which will mean reducing the amount the person is doing by about half, for a maximum of four to five days. Plans can include a list of who to contact for help with a friendly visit, childcare or shopping, for example. The person will also help themselves to manage because they are prepared. For example, having a playlist of music, books to read, a new meditation or relaxation exercise to try - or other less demanding activities to do when activity levels are lower because the pain is worse. Case study Monica (not her real name) aged 54 was a cleaner in a busy café, and was injured in a fall from a ladder at work four years ago. After the fall, she had severe pain in her back which radiated down her left buttock and the back of her leg. She also had shoulder pain. She had X-rays which didn’t show any injury, and she was told she’d probably sprained some muscles. Monica didn’t believe that muscles could be so painful, and worried the doctor had missed something. She tried to continue to work but was unable to do the bending and lifting needed to continue with the cleaning. She tried many painkillers and had some physiotherapy, but ‘nothing helped’. Her mood was low, and she was anxious and worried about the future. Her daughter was very caring and came often to help Monica round the house. She came for sessions of CBT, because she was ‘desperate’ and ‘willing to try anything’ – although she was also skeptical that anything psychological might help, since she was sure this pain was not ‘all in her mind’. The sessions involved understanding Monica’s current situation and history, hearing her story and the impact the pain was having on her. Not only was she in pain, she was not earning her own money anymore but depending on her daughter for various day-to- day activities too. She’d gained weight, wasn’t sleeping well, and generally felt miserable and anxious. She stopped seeing most of her friends, and said she was ‘just sitting about at home thinking about what she ‘should’ be doing. The interventions involved learning about pain and its impact and setting initial goals which included seeing more of her friends and beginning to do more around the house. She said that learning about balancing activity and rest was really important but very hard to do in practice. Relaxation sessions were helpful, and she has incorporated a ten- minute mindful breathing exercise into her day. She also learned to challenge unhelpful thoughts, and to make sure she was doing things every day that gave her a sense of achievement including giving herself a reward for sticking to her plan. Overall, the number of setbacks in her pain have reduced, although her day-to-day pain is about the same. She says she is doing more and feels better about life – more like she is back in charge instead of the pain controlling her all the time. References available on request. MHM | 2025 | Volume 12 | Issue 1 | Persistent Pain Management H