Chronic Pain, Self-Compassion, and Psychological Flexibility

By Grant H. Brenner

Chronic pain is a common problem, causing widespread, often silent, suffering. It not only reduces quality of life for those so afflicted, but it puts a strain on personal relationships and negatively impacts work. The CDC reports that 2016 estimates found over 20 percent of US citizens, 50 million people, reported chronic pain, costing an around $560 billion per year.

According to the NIH National Institute of Neurological Disorders and Stroke, the most common complaints include headache, lower back pain, pain from cancer, pain from arthritis, neurogenic pain (e.g. from damage to the brain or peripheral nervous system), and pain related to psychological conditions (e.g. psychogenic pain and somatic or psychosomatic conditions). Risk factors include female sex, older age, and lower socioeconomic and educational level.

What is chronic pain?

Chronic pain is complex and multi-factorial, occurring in clusters with medical and psychiatric conditions. The official definition is pain which limits life activities and/or work on most or every day for at least six months. Pain has a strong subjective component. People with depression, anxiety, trauma, dissociation, and related issues are more likely to experience problematic pain.

Chronic pain often starts with an injury. After the acute issue resolves, pain takes on a life of its own due to how pain information is processed in the nervous system. Chronic pain can also start with no identifiable injury or illness, for unclear reasons, but is often related to trauma and stress. Understanding chronic pain requires looking at both objective and subjective components.

Given the objective intensity of pain, the subjective psychological components leave a lot of wiggle room to make things better or worse. Coping, when effective, can shrink pain down to size. Coping effectively with adversity can build strength and resilience, leading to personal growth.

Chronic distress and anticipation of distress can narrow how we think about things. Chronic pain encourages entrenched negatively biased views of the world, so being able to think outside of the box is a key factor for cultivating a better quality of life.

Studying psychological flexibility, self-compassion, and chronic pain factors

According to the authors of the current study, Psychological Flexibility and Self-Compassion in Chronic Pain (Davey et al., 2020), the Psychological Flexibility model is important for understanding chronic pain because higher flexibility is associated with more effective coping.

Psychological flexibility includes three domains with underlying key processes:

• Openness is "accepting inner experiences and decentering from thoughts, also known as cognitive defusion."
• Awareness is "manifested by attunement with the present-moment and framing the self as container or perspective on experiences."
• Engagement is "characterised by committed and values-based action.”

Self-compassion is a core concept embodying positive feelings of loving kindness toward oneself, experiencing self-directed warmth, acceptance, patience, and generosity of spirit. People with depression, anxiety, trauma, and other issues often have difficulty with self-compassion, even being unconsciously afraid of it. Self-compassion can be trained through various practices, and generally improves mental health and overall personal development.

In order to better define the relationship among psychological flexibility, self-compassion, and chronic pain, along with related factors, the study authors worked with 420 patients receiving pain management in an interdisciplinary group at the Guy’s and St. Thomas’ Hospital in London.

Participants completed the following measures:

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• Brief Pain Inventory-Interference Scale (BPI-IS)
• Work and Social Adjustment Scale (WSAS)
• Patient Health Questionnaire-9 (PHQ-9)
• Pain Intensity
• Chronic Pain Acceptance Questionnaire 8 Items (CPAQ-8)
• Self-Experiences Questionnaire (SEQ)
• Committed Action Questionnaire (CAQ-8)
• Self-Compassion Scale Short-From (SCS-SF)

Findings

Both higher psychological flexibility and self-compassion significantly correlated with reduced impact of chronic pain. Higher self-compassion was associated with substantially more openness, awareness and engagement, less pain interference, better work and social adjustment, and less intense depressive symptoms.

Self-compassion (SC) and psychological flexibility (PF) were significantly correlated with each other, lending further strength to the conviction that cultivating both SC and PF are not only independently useful but are synergistic.

They found that both SC and PF were correlated with better day-to-day function and a lower burden of depressive symptoms. These relationships held after controlling for demographics including pain intensity, gender, and age.

A notable specific finding was that the openness component of PF was associated with less pain interference. Being open to new experiences appears to give unique leverage in empowering one to keep pain from getting in the way with the rest of life. As expected, however, greater pain intensity was correlated with diminished day-to-day function, and worse mood. This finding validates that the “objective” component of pain is crucial to take into account.

Redesigning one's relationship with pain

Dismissing pain complaints without understanding their severity, independent of psychological factors, creates a serious rupture. Recognizing the reality of pain is useful and necessary, respecting and honoring individuals’ unique struggles. When caregivers and loved ones don't recognize the reality of pain, not only is it a moral injury in the moment, but it is also often a repetition of earlier developmental maltreatment and neglect. Having others on board with approaching pain differently is a key aspect of pain management.

Understanding what interventions work when it comes to SC and PF is crucial. That is, does practicing self-compassion increase psychological flexibility? Does building flexibility improve compassion? If so, which specific factors of self-compassion and psychological flexibility enhance one another, building self-efficacy, adaptive resilience, and post traumatic growth during times of stress?

Pain and the threat of pain can take up too much bandwidth. Developing a sense of mastery over pain, experiencing self-efficacy, is a virtuous circle in dealing with adversity. Each little victory can add up, creating resilience and trust in oneself. The price of disappointment is high—it leads to permanently giving up, and when pain contributes to physical and mental exhaustion when one has burnout from self-care, a level of self-compassion fatigue arising from compulsive efforts at self-care.

Using approaches to train-up self-compassion, such as the Mindful Self-Compassion model, and techniques that increase psychological flexibility (and especially openness when it comes to alleviating pain interference), may help sufferers live differently. Cognitive and Dialectical Behavioral approaches may offer tools for improving flexibility, and "East-West" approaches, such as the Mindful Interoceptive Exposure Task, may help people with chronic pain, and those close with them, live more fulfilling lives free from pain interference, even when pain is present.

Once our ways of seeing ourselves, others and the world become baked-in, it’s much harder to imagine it could ever be different—even when it is obvious to someone else that things in principle could change. Mapping out that new path is very important, so that the next stage or phase can be conceptualized in advance to build a better reality.