MOOCS Entendendo Dor Crônica para Viver Melhor - 06 - Como as crenças limitantes são formadas

Hello! In today's lesson I will talk about how limiting beliefs on musculoskeletal pain arise and how they can influence the way patients cope with their pain. The objectives of today's lesson are: to define limiting beliefs, to explain how they are created in regards to musculoskeletal pain and to comprehend how these beliefs can impact patients in pain.

What are beliefs? A belief is something that is accepted as true or real. It's a firmly supported opinion.

In order to understand a person's beliefs, it's very important to not judge what they are feeling, but to be open to hear them. To keep an open mind, I brought here a work of art by Michael Alfano, an American sculptor. This piece is called Soul Secrets and, in this lesson, I invite you to travel through the secrets of the soul and to thoroughly understand how limiting beliefs are created.

Regarding limiting beliefs specifically on musculoskeletal conditions, pain related to muscles, articulations and bones, it's important that we know two things. The first one is that these beliefs aren't always rational and, even when we refute such beliefs, they may still persist. An example of this are patients or people in pain that come to us and tell us that their imaging exams show a lot of deterioration, osteophyte, herniated disk and this is why they're in pain.

And when we explain to them that many people who don't experience pain also have imaging exams with these same characteristics and that there is no direct correlation between pain and findings in complementary exams, even then, the beliefs persist. The second thing about beliefs and musculoskeletal pain is that they are, oftentimes, conflicting beliefs. What does this mean?

The person in pain, when sharing their report, contradicts their own beliefs. I'm going to give an example. A person says that, due to back pain, they need to rest.

They firmly believe that resting will help them to get better. But, over the course of our conversation, during assessment, the person also says they believe that their back pain is due to having weak abdominal muscles that need to be strengthened. So, they contradict themselves, because they believe resting is the cure, but also believe they need to exercise to strengthen muscles to improve their chronic pain.

But where do these beliefs come from? How do such beliefs arise? Our beliefs start very early in our lives.

They are related to the beliefs of people in our social circle too. Beliefs are related to the neighbourhood I live in, to my culture, to my cognition, to my family, to the church I go to and to the community I am part of. Nowadays we know that race, ethnicity and culture directly affect the behavior of those in pain, the way they cope with pain.

This may also be related to the conditions each person has to access health. In a large study produced in the United States, which compared white people, people of latino descent and African-American people, they noticed that they dealt with pain in different ways. Such as, for example, when comparing white people and latinos, we notice that, in the United States, people of latino descent and women reported more pain than others, such as white men.

This may be related to these people's socioeconomic situations. For example, people of latino origin often work in informal jobs with heavier manual labour, and women often need to balance between working regular jobs and doing housework, caring for the children. When they compared white and African-American people, they also noticed differences in how they cope with pain.

White people try to ignore pain for most of the time, they don't seek auxiliary treatment and, when they do look for it, they usually want passive strategies, such as massage. African-Americans tend to have other strategies, more related to religious, emotional and even prayer oriented. So, what is more important to know now?

Now, it's obvious for us, who work with pain, that racial, ethnic and cultural differences affect the beliefs of patients in pain. And, thus, they lead to different coping behaviors. For example, cognition and poor education may change a patient's ability to understand their health process.

And the way they cope with pain may be compromised. It's up to us, health workers, to, for example, direct and guide patients with the best strategies possible so they can get better and improve their pain. But it is important to also say that patients or the beliefs of people in pain aren't the only ones that affect pain treatment, no.

The beliefs of health professionals also affects how patients may deal with their pain. I'll explain this a bit more. Professionals that don't use the biopsychosocial model, that believe that the body is like a machine that we can change the pieces, reset ou repair its pieces, tend to give advices that aren’t aligned with the biopsychosocial model, which may, on its own, create limiting beliefs.

So, professionals that say common and inappropriate things, can single-handedly create limiting beliefs. I'm going to share some examples. If a health worker says things like: if you do this exercise wrong, you will get injured.

You can never squat again. Your back can't support high-impact exercises. When a professional acts or gives advices in this way, they can foster behaviors related to fear and avoidance among patients, which may lead them to generalize it in their lives.

And, thus, such inactivity, avoidance and generalization in other life situations may lead to disability. So, now my intention is to show you how beliefs are created. In order to do so, we need to understand a model called the common sense model.

This model was elaborated by Leventhal, in 1980. As we can see in the common sense model, depicted here in this diagram, this model explains how limiting beliefs are created. I'm going to give an example related to musculoskeletal conditions.

When pain happens, for example, due to an injury, the first stage we all go through is the interpretation stage. At this stage, we take into account for interpretation the beliefs we have regarding pain, about our pain, the pain and experiences the people around us have. We also take into consideration the perception of symptoms.

Is the pain intense? Is the pain a tingling sensation? Something else we use to interpret pain occurrence are social messages or our culture.

What does society expect from me as a person in pain? And, also, the social context I'm in. Does society support me?

Does society send me a message that I can cope with pain and be socially reintegrated? In addition, my previous experiences with pain and that of my family members or of other people I know are part of how I interpret the pain I am currently feeling. And, also, guidance from health professionals.

As I've mentioned previously, guidance can be limiting or it can make me avoid everyday tasks and activities. All these pieces of information take part in the pain interpretation stage. This interpretation will be stored in my brain.

Our brains are quite organized and it represents pain as a file, as a folder. And, in these folders, it organizes the information regarding pain according to my interpretation. So, it will create an identity for my pain.

What is this pain I'm feeling, what causes this pain, what are the consequences of pain, can I control or treat it, how long did it take for me to overcome this pain and its timeline. What was the period I was in pain like. All this is stored inside my brain like a folder with files so I can access it again when a new experience occurs.

In addition to pain representation, emotional responses to pain is also stored, such as, for example, sadness, anxiety or episodes in which I was comforted by a family member. All these situations contribute to the next stage, which is stage two, the action stage. Thus, considering the stored representation and the emotional responses generated by pain, I will elaborate a response.

And said response may confirm that, if it happens again, the experience with pain will be positive, "I will overcome this", or not, as I will refute pain and maybe this experience will be negative again. The next stage is stage three, in which I evaluate the entire contextualization I have over pain. At this stage, our brains stores simple information.

Was my action or my way of coping effective regarding the pain I felt? If yes, it was effective, I can create the belief that, if I face this event again, I can overcome it again. If, in this evaluation, I consider I wasn't successful in treating my pain, I may store a limiting belief that I won't be successful in overcoming pain in a future pain occurrence.

What I'm saying here is that the way people face pain is based on the beliefs they have created about their pain. Such previous experiences are fundamental to how a patient will confirm or refute their own experiences. Pain is an individual experience.

It's a very individual perception, and this isn't very far from how other life situations we face also roll out. I'm going to give a very simple example, a roller coaster. There are people who already rode a roller coaster and decide to never do it again.

There are people who already rode a roller coaster, felt ill, felt nausea, but have decided to try it again when another opportunity comes. And there are people who already rode a roller coaster and have decided to go again whenever possible, that is, coping with pain varies according to each person. Therefore, it's very important for us to understand what are the limiting beliefs of the person in pain.

So, I want to briefly talk, because the next videos, future materials will talk about this and about strategies to overcome limiting beliefs. But I wanted to share which strategies people in pain and health workers can use to improve or to resignify limiting beliefs. First, for health professionals, training according to the biopsychosocial model and to use this model for evaluation and treatment.

Another important aspect for health workers is to use scientific evidences to guide their interventions. As for people in pain and their family members, we now know that education on pain is very important. It's important to know the entire process well to make better decisions.

In addition, the person in pain should lead their own treatment. They can't stay passive. They need to have the autonomy to make their decisions.

So, these are some simple strategies I shared to we can start reflecting on limiting beliefs. I really appreciate those who watched the lesson until now and let's keep learning. [Thank you!

Keep on learning!