The Blue Collar Approach to Treating Chronic Pain
David Schwartz has worked in several areas of psychology from research to clinical applications for decades. He gave this lecture for psychology students in 2011 at Ohio University. He has learned how to manage chronic pain with attitude. This document describes the key points.
As an introduction, he described one of his first clinical experiences while treating southern coal miners who taught him what approaches were effective. He selected the title of this talk to reflect the concept that blue collar workers want to hear things in the language that they relate to on an emotional level. Actually, this approach is preferred for almost everybody, since almost everyone likes to know that they are normal, and they also want to understand what the doctor is saying.
Clients are afraid of psychiatrists. As an example he told a story about a coal miner that worked hard despite his back pain. The MRI had not shown anything so the orthopedic surgeon sent him to the psychologist. This man did not want to be seen by a psychiatrist. He was afraid of being told he was crazy. The miner yelled his answers to Dr Schwartz's question of ‘Do you have pain?’ “SURE!” ‘Do you cry with the pain?’ "YES!..... I'M NOT CRAZY! I AM NOT CRAZY.” Then in a softer tone he said the words that capture the plight of the chronic pain client: “I am not crazy, but the pain is driving me nuts!" One of our jobs is to help keep the client who is having natural side effects of severe pain from feeling as there is also something wrong with their mind. People need to be in control and not just be victims.
This coal miner did not want to be diagnosed as being crazy and he did not want to hear a bunch of big words. He needed to feel better about himself, and to have tools that he could use to help to reduce the pain by himself. If he could help himself, that would also restore the feeling of being in control.
Clients need to know that it is NORMAL for the pain to distract your mind and cause your mind to be less functional. Pain takes precedence over much of our thinking processes and it causes irregular intrusions into our regular thought processes that break up the continuity of thought. It is NORMAL to be forgetful because pain interrupts your thoughts. It is NORMAL to not think clearly. It is NORMAL to be angry. It is NORMAL to be impatient. It is NORMAL to be fatigued and sleep poorly. It is NORMAL to be depressed, and it is NORMAL for this to stress their relationships. Once you realize that experiencing the pain or trying to not experience the pain takes up the greater part of our brain’s ability to think, this is obvious. We only have a little of our brain’s function left to handle the higher mental functions, so it is logical that we have these problems.
In my practice, when my patients are being critical of themselves because of being forgetful or foggy when they are being stressed by pain or worry, I drawing a cartoon of a person with one foot on a boat dock and the other foot in a small boat. This person is carrying a heavy outboard motor with both arms so there is nothing he can grab, and when he looks down, he sees that the boat is not tied to the dock. While this person is under the physical and emotional stress of trying to avoid falling into the water or dropping the motor, he is unlikely to be able to recall anything not related to the task. With this stress, he will do a poor job of warding off any other stressors such as a fly.
If you ask a client about being forgetful, impatient, angry, depressed, or having trouble with relationships, sleep and not thinking clearly, they will usually deny it, and after months you can drag the truth out of them. It saves stress and time if the therapist says something like “In your situation it is normal for people to be forgetful, impatient, angry, depressed and not think clearly. It is also normal to have trouble with relationships in the family or significant others. Is any of that happening to you?” Then the client feels free to talk about it without feeling like he is going to be labeled as crazy. They are relieved to know that this is normal, and they are less resentful about working with a doctor when they have been shown that they are experiencing psychological side-effects that are normal under their circumstances.
It works better if doctors avoid being dictators. Most people resent being told what to do unless they are looking for an excuse to explain why the treatment failed. Doctors should not provide clients with a barrier or by treating them rigidly. “Patients” get orders from doctors, but “Clients” work with the doctor to pick the best path. If a “client” feels empowered enough to help find the best treatment, then they become “partners”. Generally the best solutions happen when doctors form a partnership with their patients.
An example of partnering is the “F8 Key” story. The client worked at a very stressful job where she worked at getting claims approved by the insurance companies. These companies purposely make it very difficult to get all of the necessary information entered into the right places, and the companies provide no help and have no compassion. Normally she spent nearly all day being very tense because she typed as carefully and as fast as she could, then she pressed the “F8 key”. She would wait in suspense for the results for 30 seconds and sometimes several minutes after that key was pressed to see if the claim was approved. As a result, she was tense all day. She knew that deep breathing therapy is a calming exercise done by repetitively taking a deep breath followed by a slow exhalation where the abdomen and surrounding muscles are permitted to relax. Deep breathing is useful in many stressful events, such as childbirth. Daily deep breathing is often used for 30 minutes during a quiet part of the day. Dr. Schwartz asked about trying deep breathing for half an hour after work, but the client found that a deep breathing in the evening did not control the overall stress. Much of her stressful emotional life is experienced at work, so the doctor asked about doing the deep breathing at frequent short times at work. The “partner” found the solution of doing deep breathing and relaxing after the “F8 key” was pressed. This turned the frequent suspenseful moments of stress into frequent periods of well deserved relaxation. So the “F8 key” became her signal to relax and she had a better result than trying to relax all at once. Since it was her idea, she was much more likely to use it and enjoy it. If he had told her exactly what she must do, it could have been viewed as a complication to an already difficult work experience.
NASCAR racing strategy is applicable to managing pain. The typical person with back pain sees himself as a hard worker, and when he has periods of reduced pain, he rushes to get everything done all at once. This person who works as hard as he can as long as he can sees himself as a “hard worker”. When the pain increases, so does the injured person’s determination and he “keeps on working until the back gets me.” This is a self-fulfilling prophecy -- the back will always get him when he abuses it. When the “back wins”, he gets depressed and lives in a lot of pain before the next cycle of back destruction. In contrast, the winners at NASCAR use strategy. Putting the pedal to the metal and running flat out will either cause the car to run out of gas, blow a tire or have a wreck, so they have to use judgment. They must do a pit stop at the right time or else they will run out of gas or the tires will blow at a location which will put them out of the race. They do not just keep on driving until the car stops – they plan pit stops so that they can finish the race. You can’t win if you don’t finish. The same strategy of planning is used by pilots. When a pilot has a ¾ fuel tank level, and an airport is near, he will refuel at the safe airport and will not keep on flying to see if they can make it to the next airport. They stop and refuel and inspect their plane while everything is working well. They protect their lives and their plane.
So what sense is there it working a bad back as hard as you can for as long as you can? When this type of work strategy is used, the person will inevitably damage the back and then finds that they cannot work for several days if ever again. If the person used a strategy of worked more carefully for shorter hours and increase work slowly the following days and he will be able to do more work over the same period of days without the “back winning”. In fact, if he is measures out his work level he can slowly increase the work level and build his strength up so that he gets stronger and even more work gets done. Neither NASCAR racing nor manual labor should use the kamikaze philosophy of working or driving until you drop. The kamikaze philosophy was designed to end in death, and that is not what the person needs.
Tight muscles cause pain over time even if there is not disk or bone pathology (yet). After enough time, the pain causes anxiety about the pain. Being anxious immediately increases tighten in our muscles. Our natural response of tightening our muscles when we hurt feeds the cycle. This loop of tightness, pain and anxiety can become a perpetual cycle. Breaking the cycle can reduce the pain, but once it has started it is very hard to shut the cycle down completely. Whether the clients admit it or not, they are afraid of the pain. They feel disempowered by the pain and they also feel disempowered by the bureaucrats (such as BWC administrators and attorneys) and the companies when waiting for treatment or diagnostic approvals.
Part of what makes pain so offensive is the “lack of control”. Clients want to be able to control the pain by themselves, not with some procedure that someone else does and not with some medicine that someone has to prescribe. Taking pills might reduce the pain for a while, but pills do not stop all of the pain and when the pills wear off, the pain comes back or even seems worse. They also know that pills can be addictive and have side-effects. Pain would be more acceptable if we could control the pain by ourselves. Massage helps, but we cannot even do that effectively ourselves. The pain sufferers need something they can do by themselves so they can reduce pain.
Here is a trick developed by Dr. France (?) that the clients can do by themselves. It usually reduces the pain a little and also reduces the anxiety and the disempowerment of pain. Even small pain reductions empower the client because it gives them control. Providing that the client is not under stress and that the forces used are very small, this technique may rarely provide profound relaxation and significant pain reductions.
The procedure steps are:
1.) Pick a painful area in your body, position yourself so that the painful area is supported without much effort on the part of the muscles, then relax the muscles of that area as deeply as you can,
2.) VERY slightly tighten the muscles. (CAUTION – do not tight the muscles very hard since that will increase the pain and prevent this procedure from working.)
3.) Relax the muscles as much as possible.
4.) Repeat steps 2 and 3 until the pain stops reducing, then stop or pick a new area. This can be done before sleep or several times a day. Sometimes it can be done in successively deeper layers of the same area to achieve a deeper relaxation. Different lays or muscle run in different directions, so it can be helpful to look at a muscle diagram so that you know what you are trying to relax.
The family, spouse or significant other often suffers because of the pain of the injured person. Some of the suffering is because of compassion, but a lot of unnecessary suffering occurs because the injured person is short-tempered and not thinking about others. Although this is normal behavior that is a consequence of the pain, it still causes heartache and strains the relationship. Here is a trick that can improve relationships – before responding to anything that sounds irritating, disrespectful or stupid, STOP. Do one deep breathing cycle (of inhaling then exhaling slowly while the abdomen relaxes) to reduce the anger, and then respond without anger. You can’t un-say harmful words. Relationships are usually worth preserving. The people around you may not feel your pain, but you do not need to give them any unnecessary pain.
Some injuries are very complicated and require psychotherapy to reduce pain and improve the quality of life. Horrible things can happen that go into the deep reaches of the subconscious mind, such as complicated automobile wrecks or war injuries.
This final paragraph was not covered in the psychology lecture and is added by C.E. Steiner, DO:
I must add some mechanical descriptions of what happens to tight tissues for completeness. Tight muscles not only stop the normal energy generation inside the muscle so that they have to switch to a process that uses very little oxygen. This changes the acidity level and energy level in the muscle. The muscles compress their own blood vessels and the blood vessels that supply the nerves. The muscles and nerves do not get the normal amount of nutrients and the lymphatic fluid recycle from the tissues is also limited. You can see a practical example of this by holding your arms out level for as long as you can. After a minute or two, the arms feel heavier. The longer they are held in the same position, the heavier they feel and this is the result of not having enough fluid flow into and out of the arm. After a while, they burn like the muscles that have chronic pain. I also need to add that tight muscles not only damage themselves and the nerves but they also damage the cartilage and disks. Using only one side of the low back muscles, it is possible to generate 1000 or much more pounds of force. 2000 or more pounds of force can be generated by the two sides of the posterior lumbar spine. The body responds to this backward force by automatically tightening deep abdominal muscles to balance the spine’s position, this can easily cause 4000 or more pounds of force to compress the spine. This compresses disks and the disks can compress nerves. When the body senses that the spinal disks are being flattened by the pressure and that muscles are pulling tightly on the bones. In order to provide more support or to protect painful tissues, the body grows more bone (osteophytes, spurs or growths from facet osteoarthritis). Relaxing chronic muscle spasms or tightness improves nutrient supply / waste removal and reduces the mechanical forces on the bones / muscles / tendons / disks / cartilage so that these tissues can get the maintenance that they need. Nerves are very soft and weak mechanically. The blood supply on the surface of nerves is like very small, with the diameter being about the size of a hair. Tight muscles frequently trap and compress nerves by squeezing them directly, or indirectly by squeezing disks or pulling bones onto the nerves. Sometimes the muscles compress whole groups of nerves, blood vessels and veins. An example of this is when the pectoralis minor muscle compresses the nerve and blood supply to the arm when the shoulder or hip is sprained or partially dislocated. Relaxing muscles is significantly helpful to the bones, cartilage, disks, nerves and muscles, and the above trick is one way that this can be done. Other ways to do this are to use a sudden release Neuromuscular Re-education treatment, or Manipulation Under Anesthesia to fool the spine into reducing the tightness level of the resting tone. Decreasing the resting tone can often reduce and sometimes eliminate chronic back, neck, leg or arm pain. Rarely the body removes osteophytes and bone spurs when the body determines that the extra bone is not needed.