July 1st, 2009

Pain Management Class No. 7

Pain Management Class No. 7

In today's pain management class, after a brief recap of the various factors contributing to chronic pain mangement problems that we learned about during the previous weeks, we learned about setting and keeping boundaries, specifically by saying "No."

It can often be difficult to say no, especially in an assertive way. There is a continuum of behavior that runs from passiveness through to aggressiveness, with assertiveness in the middle. With aggressiveness, we find the following: attacking to win at all costs; it's all about "me;" "it's my way or the highway;" the person won't be happy until you say yes; etc. With passiveness, we find: it's all about others; "I'm last;" "I'll sacrifice for others;" everyone else is more important; low self-esteem (often); etc.

Both extremes usually create a stress response: aggressive people tend to have a lot of tension, and passive people tend to have depression and/or anxiety. Both activate the sympathetic nervous system, which automatically raises the heart rate, pulse, blood pressure, muscle tension and shallow breathing to prepare the body for "fight-or-flight," all of which can increase pain levels. So ideally we should strive for assertiveness when we need to say no.

Assertiveness balances your needs with the needs of others in a give-and-take process. It leads to a better balance of emotional and physiological states. It puts us in a better position for healthy cognitive processes, which lead to healthier actions.

We looked at some of the reasons it can be hard to say no: we feel guilty saying no; we fear the consequences of saying no; we feel a sense of obligation to say yes; we feel compassion and want to be able to say yes but can't (this one is the biggest reason why it's hard to say no). All of these examples have cognitive processes behind them, and as we learned in the 5th and 6th classes focusing on cognitive distortions, our thoughts about an experience can cause certain behaviors to ensue.

We learned about 5 steps we can follow to minimize the cognitive distortions for both parties involved when we need to say no:

1) We need to make a clear statement of refusal.

2) We need to acknowledge the other person's needs and wishes.

3) We need to acknowledge the other person's emotions, including any negative emotions, regarding the refusal.

4) We need to state a reason for the refusal.

5) We need to propose an alternate solution.

This assertive approach can work quite well when dealing with someone with whom we have an equitable relationship. Unfortunately, it won't work very well with an aggressive person or someone with another kind of toxic personality. And the assertive approach is not universally applicable, either. Cultural and situational factors may require a more passive or aggressive approach. For instance, if you are from a culture where the elders are respected no matter how unreasonably they are acting, then you are expected to go along no matter what, and saying no, no matter how politely, is simply not acceptable. Also, you may be in a situation of caring for an elderly senile family member where you need to be aggressive in terms of their best interests, and being merely assertive will not always achieve that goal.

Such a simple two-letter, one-syllable word has a lot of baggage. I never knew saying "No" assertively could require so much finesse.