Motivational Conflict and Pain Avoidance.

http://www.bodyinmind.org/a-new-perspective-on-avoidance-behavior-research/

I recently read some research on avoidance of behaviours which cause pain, and the effects of conflicting goals on that avoidance. The gist was that people with pain will engage in behaviours that they know will cause pain if there is motivation to do so because the behaviour will fulfil a goal that is important to them. There was also evidence that the brain helps override the pain avoidance by dulling pain signals, thus facilitating the achievement of the goal.

I found this kind of irritatingly simplistic. Of course people with chronic pain sometimes override their inclinations to avoid pain so that they can do something that is important to them. I’ve done this recently; on a bad back day, I was giving my favourite six-month-old boy a cuddle while walking around. It was uncomfortable but manageable. When my discomfort increased, I went to lay him down on the couch next to his mum, which involved bending over with a few kilograms in my arms; usually a big no-no for me, but I hadn’t really thought it through. Halfway down, my back seized and I was suddenly in intense pain.

My choice was to drop the baby and right myself, or continue in the movement causing me pain. I did not drop the baby (thank goodness!) because the goal of keeping him safe was more important to me than the goal of making the pain subside. In the moment, the decision to not avoid the pain was easy. The aftermath of that movement was five days largely bed-ridden and in agony. I would still make the same decision again.

I find this research, and the line of thinking it implies (that if it is important enough to you, you’ll do [painful thing]), problematic because it omits the consequences from the equation. When medical staff or allied health professionals see chronic pain patients, they see our present pain but not the aftermath of our actions. When I visit a physiotherapist and she asks me to bend in a certain way, the movement may not cause unbearable pain in the moment, but it may mean a week spent in bed because I pushed beyond what was comfortable. The next time I see her, she will say, “I know you can do it, I saw you do it before”, but she isn’t the one helping me get to the toilet for a week in between appointments.

To me, the equation is not:

If [importance of goal] is larger than [immediate pain of action to fulfil goal], then complete action.

It is something more complicated:

If [importance of goal requiring action] is larger than [Expected intensity + duration of pain] x [fear of that pain and consequent disability], then complete action.

It also makes me wonder where novelty comes into it. When [expected intensity + duration of pain] is novel and therefore unknown (such as when engaging in a new or unfamiliar activity), is an individual more or less likely to act? Will that vary by importance?

Personally, when the goal is more important and the potential pain is unknown, I think I am more likely to act than when a goal is important but the potential pain is known (because I can hope that the pain will not be too bad, and I know the action is important). When the goal is less important and the potential pain is unknown, I am less likely to act than when the goal is unimportant and the potential pain is known (because I am not willing to risk large potential pain and disability for a relatively unimportant goal).

How do others deal with these decisions? How do you decide when to override your pain-avoidance behaviours? And does anybody else sometimes just say, “Screw it, this isn’t important and my potential pain is likely to be huge, but I’m going out dancing anyway because I’m tired of being sick” – or is that just me? 🙂

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9 thoughts on “Motivational Conflict and Pain Avoidance.

  1. sunlight in winter

    Completely agree. I generally make my decisions based on both how much something hurts in the moment, and how much I expected it to hurt the next day, and the day after that.

    I love Body in Mind because there is no one else quite like them… but I am often frustrated by the things they publish for similar reasons. Sometimes I think this is a result of the scientific method. Studies such as this one may seem simplistic to people who live with pain because, in order to be scientifically valid, researchers can really only analyze one variable at a time.

    But sometimes it’s all too clear that the person writing has never lived with intense or chronic pain themselves. It’s disappointing because Lorimer Moseley, the founder of the group, has contributed to some amazing pain research. I guess everyone has their limitations…

    Reply
    1. jezzybel Post author

      I do love Body in Mind – if I was in the right state I’d love to work with their researchers. I think they’re advancing the field admirably and find a lot of food for thought in their research.
      I think that is in part why I’m so disappointed with items like this – I completely agree that the simplicity of the research itself is likely a limitation of the scientific method, as you need to limit the variables you are manipulating and measuring, but I think the discussion of the research was overlooking some key components.
      I find it particularly problematic since I would imagine that their information is utilised by a lot of practitioners working with pain patients, and since they are a large part of the pain research field in Australia – I think they have a responsibility to pain patients to try and relate the whole story! I know that’s probably asking a lot though 🙂

      Reply
  2. jezzybel Post author

    Uggggh. Okay, the final paragraph, which raises serious questions as to the quality of the research, should have been at the start, because when you have reason to believe the research is biased, you should not be using it as your main source of information without serious caveats.
    I agree that research indicates that, in a lot of cases, opioid use in long-term non-cancer pain is not terribly effective. The problem, which was not mentioned in the article but which many patients know too well, is that not much is effective for long-term non-cancer pain. Opioid use is often the least-worst of a bunch of bad options.
    And I hate using Endone (oxycodone). It makes me feel like I have brain damage or Alzheimers. I don’t take my full dosage on days when I don’t need it because I hate the side effects. But until medicine can offer me anything better, it’s what I’m stuck with.

    Reply
  3. jewelsonajourney

    I totally agree with you! I hate it when people try to push me to do something simply because they don’t understand that aftermath and how long it will actually take me to recover. They don’t see the days I spend in pain or the fact that after I’m done with whatever we are doing I have to go home and spend most of my time in bed resting instead of moving on to the next activity.
    The closest I ever got to explaining this to someone was by asking them to picture cutting out 6 hours of their day every day for the rest of their life and that would be a little picture of how limited my life is because of all the recovery time my body needs.
    On the other side, I totally agree, sometimes I just hate feeling like the sick girl and want to go live my life, regardless of how much it takes out of me and for how long! (although sometimes my friends see this and then try to push me into other things which starts a whole new cycle of frustrating equations…)

    Reply
    1. jezzybel Post author

      It can be such a delicate balance, can’t it, between utilising your rare good days (or occasionally deciding, screw the aftermath, I’m going for it!) and managing others’ expectations. I think what a lot of people (including medical personnel) find so difficult to wrap their head around is the variability of chronic illness – some days I can do things I can’t do 24 hours later. Complicated!

      Reply
  4. roweeee

    I don’t live with chronic pain but I have an autoimmune disease where I have periods of very low energy so I have to manage my activity levels at times and try to predict what is going to wipe me out for a few days. I have two very energetic kids aged 9 and 7 and I have been chronically ill since they were very small. This puts a lot of pressure on me to get the balance right because there are big consequences when I crash. I certainly don’t want to be driving. I have spent much of this week in bed while they have been at school but was so tired it didn’t bother me. Usually, I’d be feeling down. Experience has taught me what I largely can and can’t manage and I try to spread things out but there are days when I know I’ll struggle but I tell myself that I can rest the next day. Just get through it. That is very different, however, to dealing with chronic, ongoing pain but the processes are similar. My issue is definitely overdoing it and my mum in particular tries to get me to stop and it feels like she just wants me sitting in a chair all day. Can’t stand it but then I over do it and I can see her point. I hope this is helpful. xx Rowena

    Reply

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