Creative Hopelessness in Chronic Pain: Why More of the Same Isn’t Working

Hey everyone. Welcome back to the podcast. Today we're diving into a powerful concept that can completely shift how we approach persistent pain in our clinical practice. If you've ever had a patient who keeps coming back saying, nothing works, but I keep trying, this episode is for you.

This is the Modern Pain Podcast with Mark Kargela.

We're gonna talk about the problem of getting stuck in the pursuit of symptom relief. How we as clinicians sometimes unknowingly reinforce that struggle and how an act based exercise called creative hopelessness can create the opening for real change. I had a patient recently, she came in after probably over a decade of really difficult times with pain ed visits probably every week to every other week due to significant pain. Had tried numerous different professionals, massage therapists, PTs, chiropractors, naturopaths dos, MDs all sorts of pain specialists. She actually asked me at our first session if I knew a good pain physician, and while I do somewhat know some decent pain physicians, I had asked her how many pain physicians have you been working with? And she said this would be number 14. And I really had to sit back and think 14. And this isn't anything to fault her, because if I was in her shoes, I'd probably be looking for the next person too. When we put people in a system where somebody out there has to have the fix for me, where I need to stop living until I find that person that has the fix so I can get on with my life after this fix is procured and a patient who's tried it all, physical therapy, injections, med supplements, second, third, fourth, even fifth, opinions and the trouble is sometimes we match their effort. We offer techniques, protocols, modalities, hope, and not in bad intentions, right? We're trained to be on that same fix it wagon as well. I know coming outta school, I surely was, but here's the question we'd rarely ask. What if it's not their body that's failing them, but the strategy they're using? The strategy that I have to sit on the sidelines of life until somebody fixes this pain for me. So in our desire to help, we often reinforce the same narrative that pain must be solved before life can be lived. And when the resolution isn't likely or takes longer than expected, this can set patients up for a loop of hope, effort, crash, despair. So let's break it down. For acute issues, pain focused care works. It's how we're trained in school. We're trained to really do a good physical examination. And again, there's nothing wrong with that. We can sometimes identify very specific tissue issues, sprain strains, rips, tears, herniated discs, things that oftentimes we would expect pain should go away. There should be a healing process. Of course, we know that some people don't navigate that healing process as others do. We though think of it like we're gonna fix the problem and pain's gonna go away. But with persistent pain, people can keep doing more of the same, chasing the next thing that will finally get rid of it. And what does this look like in clinic? It looks like patients who might feel great within session because we know that pain is not too difficult to modulate in the short term. And again, it's not to say we. Shouldn't do that at times. We should be asking, is this short term improvement in pain, having them come back to me the next session or at within at least a few sessions where we're seeing some concrete movements in life where they're starting to regain some things.'cause I know for me, I would make patients happy, they'd love their session. I could do some soft tissue work, maybe some manipulative work, manual therapy work, and they'd feel better within session. Yet I see them coming back. It's back. It's no significantly different. Maybe they had a little boost of some improvements and we saw them doing some things, but we weren't giving them the skills to navigate their pain outside the clinic walls. And they'd come back in the same, and I felt like I was stuck with these patients, not that I didn't wanna help them, but I just felt like I didn't have any more tools that I could offer them. I was exhaustion where either they got exhausted and said this is finally not working. Or I finally said, you know what? I don't think I'm really helping you. Maybe we need to refer you on now. I wish I could go back in time and get those folks back'cause I probably take a different approach, which we're gonna talk about today. When we keep offering relief based solutions to a complexity based problem, we may actually be deepening the struggle that patients have that's where creative hopelessness comes in. So what is creative? Hopelessness and hopelessness? That sounds pretty dark, So we'll get to that. It's not anything that's super negative. It's a way to just conceptualize the journey that somebody's going through, and hopefully help the patient maybe get an understanding of the journey they've been on and at least make'em realize that it's probably not getting them to the life they wanna live. It's not about giving up creative. Hopelessness is not that. It's about pausing the pattern that hasn't worked. These patients often have had numerous situations where they've tried, intervention after intervention, all with good intentions, and they engage with a healthcare system and often continues to pull and tug at these symptoms with them. ideally this is a moment of reflection that a patient can have and one of the most powerful ways that we can guide that reflection is by helping patients explore both short-term and long-term impacts of what they're doing. Start by validating their effort. You've done so much to try and get better. Look at all the things you've been doing, and you can go through a list. Again, 14 pain physicians for the one patient. You should be able to look at that patient and really validate that you've been working hard at this, you've been trying, nobody can tell you're lazy. Nobody can tell you that you haven't worked hard on this. So let's look at together at these efforts and see how they've worked out for you so far. So as you, again, you invite these patients to list out the strategies they've used, we'd maybe walk them through what kinda short term benefits, what did this give you in the moment or maybe for some short periods of time. What did it take from you? Was it costly? Did it, did you have any side effects you had to deal with at the short term? Was there any other kind of issues that you had to deal with short term wise? Then we can go into the long term benefits. Did it help you move towards the life you want? Did it move you further away? What did you notice? And then long-term cost, did it lead to frustration, financial challenges? A lot of patients who've gone through a myriad of treatments have spent a lot of money and time and sacrificed a lot of time with family, friends, and relationships to pursue some of the relief that they were after. This process, ideally, gently helps them realize that despite their genuine effort, and again, hopefully at this time you've empathized with them and really shown that you've generally validated that man, they've busted their butt, they've worked their tail off to make this thing better. But despite this effort, many of those strategies gave them temporary relief at best, but long term. Oftentimes patients won't see that they're moving significantly closer to the life they want. We need to recognize that this can be a pretty difficult realization to make for some patients. That brings out a lot of emotions. It can make it to where you have to reach for the tissue box or anger or various things that, understandably when people have to reflect back on a very difficult journey and walk themselves through that, despite all this work they've put in, they're not really getting any closer to the things they want. That can be tough. So we need to make sure we give space for that emotion to enter the room. So we also need to remind them that it's not your fault. You've been doing the best you can with the tools you had. You've been doing the things that healthcare has pushed you to do. Like I've definitely recommended patients doing the similar things when I've been in earlier stages of my career where I didn't really understand pain as well, especially complex pain like you're dealing with. Then ideally, we ask the powerful pivot question, If continuing this approach leads to more of the same. Would you be open to trying something different? And this is huge, right? Because we can't, and I can tell you, and this even within the last five years, I've still gotten on the journey of being the next person who's tried to rid the person of the symptoms they're dealing with. And again, ideally you have a clinical process to recognize that. There's probably not. With the nature of this condition, with all the things that this patient's been through, that I don't think my ego should make me think that I'm gonna miraculously be the 15th clinician that's all of a sudden gonna do something differently. I think we need to recognize that probably more that isn't gonna get the person to where they want to be, and hopefully we can position a question in a conversation where the patient can make that decision. I'm like, do you think that doing more of the same is gonna get you different, or should we try something different to maybe get us more to the things that you told me you want? This is where the door is open for the patient not to giving up, of course.'cause that's something we want to emphasize. We're not giving up, but we're gonna step off the treadmill and start in a new direction that hopefully gets us to the things that you want. It's not about losing hope, but it's about giving hope a better target. So hope not in the next intervention. Hope not in the next medication. Hope not in the next procedure, but hope in maybe a different way of approaching it as they've seen that this approach just isn't getting'em where they want. We're not abandoning them, we're just offering them a new direction. If you want to do this in the clinic, you can do it a few different ways. You can do it on a whiteboard where you're really drawing this out on a whiteboard, especially if you're in a group setting where you're doing this with groups of people. If you're with individuals, you can have just a sheet of paper. Again, you can use a whiteboard you can use a form, which we're gonna give you an option at the end that you can use in your own practice. But basically there's a column that you would then list through all these interventions. And again, we're gonna reflect after those interventions, just to validate all the work somebody's put in. Then we'll have a column where we do short term costs, short term benefits, and you can look at, to back up a little bit to the treatments, you can use this dots analogy, which Russ Harris and his act made simple book talks about. But if you're having troubles with the patients of what they've used to work with their pain, besides just like the medical interventions and medications approach, which is part of it, distraction techniques, again, people can distract to the point they're distracting themselves from a means meaningful in life where they're completely, non-present with things they need to be present with, be it their family, be it. Their work, be it whatever is meaningful to them. There's opting out strategies. So the o where they're opting out of time with their family, they're opting out of time with friends, they're opting out of any activities that might point them to their values. out of fear for pain, I. There's thinking patterns, again, thinking to distract themselves using meditation, in mindfulness in ways that we wouldn't recommend, which is where they're trying to have them use it as like an escape procedure where it's another way that they need to get their symptoms completely away from them and push them away. Where again, acceptance, commitment, therapy principles. Being able to make space for those symptoms to be present. Having a willingness to pursue valued activities with those symptoms present. Then we're gonna talk about long-term benefits and costs where we have the patient discuss what are the long-term benefits and costs of the intervention. Could be money, could be various different things, but ideally as you over view this with a patient, they can see that man, there's a bunch of maybe even short term benefits. Where, yeah, this person did get some relief and sometimes maybe even significant relief. So I think we have to be careful that we're not here to bash interventions. We're simply guiding them through and we're not saying this is great, bad or anything. We're just gonna let it the patient explore what they've done.'cause there might be some interventions within what they've been doing that have bought them the ability to pursue values where we'd say, Hey, that might be something meaningful. That you can keep in this, but let's teach you some skills so you can continue the pursuit of those valued activities that maybe even though you had that short term benefit, that you really pulled away from some of those things. But again, it becomes something you have to be careful that. They're not using that symptom relief measure or symptom modification measure as an escape measure. It's as long as it's positioned as this is a tool that allows me to point towards the things that I'm are meaningful, that are my values in life, then I think we can maybe make an argument that could be, could stay in again, I. There aren't any secondary negative health benefits or things like that. So again, we'll have a little bit of a sheet for you to take a look at these and use'em in your own practice, but it can be a powerful exercise to help people really see their journey and get a visualization of a lot of work. Put in some short-term games may be gained, but long-term they're not getting the life that they want. So then the big question becomes, now what? Okay, the patient's open to pursuing a new direction and this is where you need to have skills. This is an another way that they have to stop before the physio or chiro or massage therapist does something to do that if it's an intervention that, hey, if this buys you some opportunity to get to the things you want to do, and this is where we work on skills outside of our treatment room, that helps them really engage. And if they do have some benefits from a short-term intervention, it's not meaningful unless it gets us back to the things in life. We have to have skills and exercises. Sometimes these can be a fusion dog, cognitive diffusion exercise they use in act, especially if somebody's really fused the beliefs and thoughts around their pain, that it's not changeable that they can't move forward without pain. Different things. So this is where we can introduce different exercises. We can have metaphors and analogies work through the patient of, dropping the struggle, where if somebody's on the end of a tug of war with a pain monster in the between them is a massive, cavernous, bottomless hole. That if they keep pulling with this pain monster and the harder they're pulled, the more this pain monster pulls back, which ideally is a visualization of what they've been doing thus far, they can see that maybe the best strategy, and again, that's a lot more nuance to this conversation, would be to drop the rope and start getting back to life. So those are analogies and things we'll talk about in fu future episodes to hopefully help you all. If this idea resonates with you, I've created a short guide and worksheet you can use in your next session. It's simple, reflective, and it can be really incredibly effective with patients. So here's your challenge this week. Pick one patient who feels stuck in the cycle. Try this exercise and see what opens up. You can download that creative hopelessness guide@modernpaincare.com slash hopelessness. Let's stop pulling the rope. Let's help people drop the struggle and move forward. Thanks for listening. I'll see you in the next episode.

This has been another episode of The Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modern pain care.com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs, changing the story around pain. This is the Modern Pain Podcast.