Reframing

Living with pain can impact the way that you think. Thinking is also impacted by symptoms like fatigue and depressed mood. Such symptoms often generate negative or unhelpful thoughts. These thoughts may be about:

• The way chronic pancreatitis has affected your life.
• How your symptoms have changed the way you see yourself.
• How things will be for you in the future.

What you think can actually make your symptoms worse. Negative thoughts produce negative emotions, which in turn influence how your brain processes pain signals. If the pain signals are processed against a background of negative emotion, then pain tends to be worse.

The goal of this module is to help you learn how to change unhelpful thoughts so that they do not get in the way of living your best life.

Watch the videos below to learn more about reframing and how to do it:

Think about the first time you learned how to drive a car, ride a bike, or kick a soccer ball:

• It was difficult to coordinate all of the necessary behaviors.
• Over time, however, the behavior becomes more automatic and the need for thinking about each part of the task becomes unnecessary.

When you free your mind from concentrating on a task and just simply do it, we call this "automatic thinking".

For many situations, automatic thinking is a good thing, as it is highly efficient thinking and frees up our mind to focus on other important matters.

Automatic thinking, however, can have a downside when it comes to pain. For example:

• When we first develop pain (e.g., with an injury), we tend to avoid tasks that would make it worse, we avoid social events, food, and exercise that could make it worse.
• In time we learn that these avoidance behaviors can make the pain feel better.
• We might also think about how awful the pain feels and how limiting pain can be on our future plans.
• With time, thoughts about avoiding activity to avoid pain become automatic.

Although avoiding exercise, food, and social activities can help relieve pain when it is acute (short-term), these are exactly the wrong approaches to use for dealing with chronic pain.

With chronic pain, it's important to:

• Engage in paced physical activity
• Engage in social activities, with friends and family
• Return to some form of work or purpose.
• Maintain your nutrition.

When pain becomes chronic, it is important to become aware of your automatic thoughts and potentially rethink them.

This is all easier said than done. Because automatic thoughts evolve out of learning, it can be quite difficult to challenge these thoughts and retrain your mind to think differently.

Automatic thinking can be categorized into specific thinking styles. All of these thinking styles can lead to unwanted negative thoughts when it comes to managing pain.

Here are some examples:

• Catastrophizing. This is excessive worry and/or expecting the worst-case scenario. For example, a person in pain might think:

  My pain is never going to end.

  This is the worst thing that could happen to me.

• Black and white thinking. It is when we see only two possible outcomes – one very good and one very bad. Few things in life are actually this way. Instead, outcomes usually fall along a range that can have varying degrees of "goodness" or "badness". Often negative things also have some good parts to them. For example, people who think this way may say:

  • "Everything went wrong today", even if only one thing went wrong that day.

• Ignoring the Positive. It is when a person focuses on negative events and ignores positive events. For example:

  • Think about the person who, despite their pain, leaves their house, joins friends for lunch, and has a wonderful time.

  • However, they have to cut the outing a bit short due to their pain.

  • A person who ignores the positive and magnifies the negative would focus on having cut the outing short and would discount the positive experience of enjoying time out with her friends.

• Prediction. It is when a person decides how an event will turn out before it happens. It is especially a problem when we predict a negative outcome. For example:

  • An individual might wake up and think, "I know today is going to be a bad day," despite no sign that today will be better or worse than the day before.

• Should Statements. This refers to when a person thinks, "I should do this" or "I must do that." These thoughts can cause a feeling of pressure, stress, and resentment.

  • Thoughts about what a person should or should not do can be especially upsetting because abilities change with pain conditions.

  • Often, expectations for what one should be able to accomplish do not change.

Each of these automatic thinking styles can lead to negative thoughts, which generate negative emotions and make pain worse.

Remember…

• When we talk about changing negative automatic thinking, we do not mean you should pretend everything is fine or ignore reality.
• Quite the contrary. It is best to be heavily grounded in the reality of your life situation, which oftentimes is not as awful as your negative automatic thoughts would have you believe.
• The intent here is to be aware of your thinking, as it can influence your feelings and symptoms.
• If you identify any of the negative patterns above, attempt to challenge them before they take you down an unnecessarily negative path.

There are many problems with negative automatic thoughts.

• Negative thinking is more likely to cause negative outcomes and less likely to cause positive outcomes.
• Negative thoughts can make pain, fatigue, and depression worse.
• Negative thoughts set us up for how we react to new problems or opportunities.
• If you believe that your pain will never get better, you are likely to be skeptical about opportunities to improve your pain.
• That can make it more likely that any efforts to improve your pain fail for you.
• You might even choose to skip an opportunity to better manage pain if you think that getting better is impossible.

To be efficient, automatic thinking leaves out a lot of information.

• If the situation changes (as in shifting from acute to chronic pain), automatic thoughts that you learned in acute pain situations may not work for chronic pain.
• In most cases, problematic automatic thoughts exaggerate negative aspects and minimize positive aspects. This leads to an imbalance of thoughts that focuses on the negative and ignores the positive.

Negative thoughts can lead to negativity and positive thoughts can lead to positivity. If you believe you can feel better, you are more likely to get better and do things that help you feel better.

A helpful strategy to manage negative thoughts is called "reframing." This means learning to see things in a more balanced way—not too negative or too extreme. Follow the next three main steps:

1. Identify the negative thought.
2. Question or challenge the thought.
3. Replace it with an alternative thought.

We have already talked about how negative thoughts can affect your health. Now let's focus on how to challenge those thoughts and replace them with better ones.

Start by asking yourself:

• What evidence supports this thought?
• What evidence challenges this thought?

For example, if someone thinks "The rain will never stop", that person should ask how long it has rained, when last it did not rain, and for any evidence that supports the belief that it will rain forever.

Then, look at other facts you may be ignoring. For example:

• It has rained for 6 days.
• But it was sunny the week before.
• This is the rainy season.
• Last year it rained 11 days in a row, but then the sun came out.

A more balanced thought might be:

Even though it feels like the rain won't stop, it's normal to get a lot of rain this time of year. It will stop eventually.

This thought is more accurate and less upsetting. Over time, practicing this kind of thinking can help reduce stress and even pain.

Here are some examples of reframing that relate to coping with pain:

Example 1: Susie has chronic pancreatitis. She thinks:

This fatigue is going to ruin my life.

When asked why, she says that she had to cancel plans yesterday. But she remembers another day with similar fatigue when she paced herself and still kept her plans. A new thought could be:

Yesterday didn't go well, but I can use strategies like pacing and relaxation techniques to manage better today.

Example 2: Jim has lived with chronic pancreatitis for 11 years. He thinks:

Because of my pain, I'm no longer a good parent.

He talks about chores he can't do, but also realizes he helps his kids in other ways—reading bedtime stories and helping with homework, he made decisions with his wife about an upcoming birthday party. A new thought could be:

I may not do everything I used to, but I still play an important role in my children's lives.

Reframing is not about pretending everything is perfect. It's about seeing the situation more clearly and truthfully. More balanced thoughts can help you feel better and make healthier choices.

How to reframe your thoughts?

There are 4 main steps to reframing negative automatic thoughts:

• Step 1: Choose a situation that made you feel a negative emotion, like sadness, frustration, guilt, anger, or worry.
• Step 2: List the automatic thoughts that went through your mind.
• Step 3: Identify how the thought made you feel.
• Step 4: Look at the facts for your thoughts, think creatively, and come up with more accurate and balanced thoughts.

To practice these steps, follow the next example.

STEP 1: Identify a specific situation that causes you to have negative thoughts

Example:

At the family reunion, I couldn't keep up with everyone on the hike

STEP 2: Describe the negative or unhelpful thoughts

Example:

I'm a burden to everyone

I used to lead the hikes. I should be able to do this!

My balance and strength are just going to keep getting worse

STEP 3: Describe your emotions

Example:

• Guilt, sadness
• Anger, resentment, and defeat
• Stress, worry

STEP 4: Reframe your thoughts and generate different thoughts

Example:

My family is happy to see me. It is a blessing to get to spend time with my family. I can hang out with my brother-in-law, who also has health problems.

I have always been the kind of person who tries my best no matter what. I am doing the best I can right now. I can play other roles in my family.

I can maintain my functioning by being as active as possible. My physical functioning may hold steady or get better. I have no way of knowing what the future holds.

Learning to reframe your thoughts takes practice over many days and weeks. As you practice noticing, questioning, and changing your negative automatic thoughts, it should become easier.

This alternative strategy is to let the negative thoughts remain but to recognize that thoughts are simply fleeting ideas.

• Your thoughts do not define you.
• Your thoughts do not necessarily define what is really going on.

Automatic thoughts become problems when:

• We believe the thought.
• Hold on to that thought.
• Own that thought.
• And make life decisions based on the thought.

Alternatively:

• We can have thoughts without holding, owning, or deciding based on those thoughts.
• We can have the thought, acknowledge its presence, and allow it to pass through without grabbing our focus.

Letting thoughts come and go is a skill that takes practice.

• With enough practice, a person can become very skilled at letting thoughts pass through their minds without being affected by them.

Here are some examples of how to use this approach.

• Let's start with a sample thought

  I wish I didn't have this pain

• Some people might go from this initial thought to being bothered by their pain and think

  It is really getting in the way of my life

  I am never going to achieve what I wanted in life because of this pain

• Other individuals might change their behavior in response to this thought, such as spending less time being active in hopes of decreasing their pain.

In the previous example, the individuals are "owning" the thought. They wish they did not have the pain and, as a result, act by changing their thoughts and/or behaviors to try to fix this unpleasant situation.

As an alternative, one might argue that it is perfectly reasonable to wish that one's pain was gone.

• This is simply a wish and can exist without further thought or action.
• You might add a stem to the thought by saying "I am having the thought that… I wish I didn't have this pain."
• This strategy isolates the thought for what it is, "just a thought" rather than a stimulus for additional negative thinking, action, or emotions.

Steps for letting go of thoughts

Following the steps below will allow you to practice the very basic skill of noticing and letting go of thoughts.

STEP 1

• Adopt a relaxed posture, whether you are sitting or standing.
• Pay attention to how you are breathing. Close your eyes if possible.
• Ask yourself "What am I experiencing right now?"
• Think about your emotions, what you are feeling in your body, and what thoughts you are having.

STEP 2

• Start to imagine that you are experiencing your thoughts in a new way. For example:

  • If you are having anxious, racing thoughts, imagine that your mind is like a monkey jumping from branch to branch. Each branch is a new thought that you can just notice and let go of as you jump to another thought.

  • Or, imagine your thoughts as speeding trains coming into and leaving the train station.

  • Perhaps instead of racing thoughts, you have a thought that is stuck, like a boot stuck in thick mud.

• As you observe your thoughts in a new way, picture the imaginary screen in detail and continuously bring your focus back to your body.

• Notice your breathing and what you are feeling in your body.

• Whatever imagery works best for you, imagine your thoughts to be something else (a monkey, train, boot, or something else) and just observe them.

• Just notice the thoughts and their effects on you.

• Notice that they are just thoughts.

• And then let them go.

• Allow the monkey, train, boot, etc. to dissolve.

As with reframing, mastering letting your thoughts go is a skill that must be practiced. Skills from the Relaxation Module can also help you in developing your skills at letting your thoughts go.

An additional strategy is to deliberately think positive, realistic, helpful thoughts.

• When feeling stressed or uncomfortable, you can coach yourself through the situation by focusing on thoughts that you find reassuring, centering, motivating, or helpful.
• These are sometimes called "coping thoughts".

For example, how might these thoughts make you feel?

I know there are things I can do to manage my pain (or stress, or fatigue).

I am uncomfortable at the moment but can handle it if I focus on deep breathing.

I have been through difficult things before and know I will get through this.

I can handle this.

This, too, will pass.

Stay focused on the present. What do I need to do right now?

Take a slow, deep breath.

This is not really an emergency. I can slow down and think about what to do next.

These thoughts tend to promote positive feelings, make you feel hopeful, and help you cope with symptoms.

Coping thoughts are most helpful when they are personalized to you.

Some tips to create your personal coping thoughts include:

• Think about reassuring thoughts you have used before. What has worked in the past?
• Come up with statements that are specific to your situation. For example, if you are bothered by pain, think of statements specific to coping with pain that you find helpful, soothing, or hopeful.
• Make sure your coping thoughts are positive but truthful. For example, if you struggle with pain, thinking, "I won't feel pain again" probably won't help as it isn't truthful. Instead, a more truthful and helpful thought might be, "I can use my self-management skills to reduce the pain" or "this pain flare-up will pass, just as others have."
• Keep your coping thoughts short and easy to remember. You may even want to pick one or two calming thoughts as your "mantra"/go-to statements.
• Think about what a supportive friend would say to you. And repeat this.

It can be difficult to remember your coping thoughts when under stress or feeling bad.

• We recommend that you write out several coping thoughts on a small card (a "coping card").
• Or keep your coping thoughts readily available on your mobile device so that you can easily read them when you need to.
• You might even want to write out different statements for different situations or symptoms.
• For example, have a few coping thoughts handy for pain and a few more for fatigue.
• Refer back to your coping card or coping thoughts regularly, so they become part of your self-management toolkit.

• Our ability to think about and understand our life experiences is one of our greatest strengths. However, just like so many strengths, it also carries the risk of getting in our way.
• Our hope is that the ideas shared in this section have given you the first steps towards focusing your thoughts on supporting your well-being.
• The ability to change your negative thinking is a skill that improves with practice. You get out of it what you put in.

If you are interested in learning more about these strategies, consider these self-help books:

1. For changing thoughts:

   • Wilding, C. (2010). Teach Yourself Cognitive Behavioral Therapy. Teach Yourself Books: London.

2. For learning to let your thoughts go:

   • Hayes, S. C. & Smith, S. (2005). Get Out of Your Mind and into Your Life. New Harbinger: Oakland, CA.

   • Kabat-Zinn, J. (2013). Full Catastrophe Living: using the wisdom of your body and mind to face stress, pain, and illness. Random House Publishing Group, New York, NY.

Reframe your thoughts with the help of a doctor

• If you would like more help with working with your thoughts, ask your primary care provider, specialist physician, or other trusted provider for a referral to a psychologist, social worker, or counselor.
• You can request a therapist trained in health psychology and cognitive-behavioral therapy (CBT), which is focused on changing thoughts and behaviors, or Mindfulness-based interventions or Acceptance and Commitment Therapy, which are focused more on letting go of thoughts and continuing on the desired life path.

You Can Help the Person You Care For Reframe Unhelpful Thoughts

Living with chronic pancreatitis can lead to upsetting thoughts about pain, fatigue, and limitations. These thoughts can influence mood and even worsen symptoms. Learning to reframe negative thinking is a powerful tool, and as a caregiver, you can play an important role in supporting this process.

To help someone you care about work on reframing negative thoughts:

• Be a calm, nonjudgmental listener when they share worries or frustrations.
• Gently point out when a thought sounds overly negative, such as "I'll never feel better" or "I can't do anything anymore."
• Ask helpful questions, like "What would you say to a friend who was feeling this way?" or "What else might be true about this situation?"
• Celebrate small wins or progress, even if things don't go perfectly.
• Encourage balance, not forced positivity. Remind them it's okay to feel discouraged, but also important to recognize what's still possible.
• Notice your own thoughts when things are tough.
• Practice reframing together. By doing so you can help each other stay hopeful, grounded, and emotionally resilient.