Do you blame yourself for pushing too hard and crashing afterwards? Have you created a 40 item treatment plan in your bullet journal? Do you judge yourself for not taking all your supplements, doing your strengthening exercises, meditating, or other lifestyle treatment strategies? Of course, you probably know that all the guilt and self-blame isn’t helpful, but it’s hard to stop the voice of your inner perfectionist that says, “Why can’t I even manage to do this one thing?”

The faulty premise behind this thinking is that we have complete control over our symptoms. That it’s just a matter of finding the magic combination of treatments to end flare-ups, when really, most self-management strategies relieve symptoms, but don’t end them. Fear of losing control, and the difficult emotions of frustration, disappointment, and guilt, drive us to try harder to get it right, to get it perfect (Moinar, et al., 2016). However, what you really need to do is give yourself a break. You can’t have 100% control over the flux of your symptoms. Contrary to the voice of your inner perfectionist, it’s sometimes better to go with the flow of illness, than paddle upstream.

What is perfectionism?

Perfectionism is defined as a personality trait characterized by a drive for flawlessness, excessive self-scrutiny, and harsh self-criticism over mistakes (Linnett & Kibowski, 2018). There are three types of perfectionism: self-oriented, socially prescribed, and other-oriented (Flett et al., 2011). Let’s take a look at what each of these mean in turn. 

• Self-oriented perfectionism: setting unrealistically high standards and criticizing yourself harshly when those standards are not met. 
• Socially-prescribed perfectionism: when important others (family, friends, society as a whole) hold the individual to excessively high standards. 
• Other-oriented perfectionism: refers to the perfectionist’s judgment of others as they hold them to exacting demands.

Self-oriented perfectionism means that you set unachievable standards for yourself, and then berate yourself for failing to live up to them. Some judge themselves harshly for not succeeding at living up to their pre-illness potential, for seeing what they can accomplish while ill as paltry in comparison. You may now criticize yourself for struggling to do basic things like doing the laundry, making the bed, cooking dinner, or meeting a friend for coffee. You may push yourself beyond your limitations, or ask yourself, “Why can’t I manage to do anything?”

Before illness, you may have had ambitions to be great at whatever it was you loved doing. Perhaps you drove yourself hard in pursuit of those goals. And then along the way, you got sick. You may now blame yourself for becoming ill, seeing it as a failure. Meanwhile, such self-blame only perpetuats the cycle of toxic perfectionism!

Socially prescribed perfectionism means that important people in our lives, or society at large, hold us to unrealistic standards. We can internalize these judgments; that we’re not trying hard enough, that we aren’t productive members of society. People with chronic illness are also all too familiar with the toxic positivity evangelists, who healthsplain that all you need is the right attitude and you will be cured. This implies that it’s your bad attitude that keeps you sick today, and you aren’t doing enough to correct that.

 In addition, there is a huge amount of social pressure to seem ‘fine’ and end conversations on a positive note, regardless of reality. This form of socially prescribed perfectionism is the mask you feel you have to wear outside of your inner circle to pretend everything is ok. But sometimes, we impose this mask onto ourselves, when we could admit we’re not ok, and ask for help. In those situations, socially prescribed perfectionism gets in the way, because we want to be seen by ourselves, and others, as holding it perfectly together. The pressure to do that can feel enormous. The criticism if you don’t put on the mask can really sting.

Other-oriented perfectionism is less relevant to individuals with chronic illness, since this involves holding other people to our high standards. However there can be a disappointing reaction among some people in the chronic illness community to an individual expressing their no-end-in-sight distress. The “But have you tried…” response piles judgement on someone who is suffering. Even worse is the “But I cured myself doing…”. Expressing sympathy means acknowledging that each person’s situation is unique, and accepting others where they are at, instead of lecturing them on not trying hard enough.

How can you break free of toxic perfectionism?

 Befriend yourself. Treat yourself with the understanding and kindness of a good friend. “What would a best friend say?” is something you can ask yourself when you’re feeling anxious, guilty, critical, frustrated, or ashamed. There are 3 components of self-kindness, and one of them is to remind yourself of your common humanity:

“You’re only human.”

 “It’s ok to struggle and to not be ok.”

 “You can always try again tomorrow.”

“Maybe this is just beyond your control right now.”

It may feel very cheesy, but it’s worth it to stop the self-blame around managing your illness! There needs to be a mental counterpoint to the damaging words of your inner perfectionist. A second component of self-kindness is mindfulness. Bring yourself to the present by using your senses, to disrupt your negative self-talk. When you’re internally cringing because you feel you messed up, or berating yourself for not being better, ask yourself, right now:

What are 5 things you can see?

What is the texture of 4 things you can touch?

What are 3 things you can hear?

What are 2 things you can taste?

What is 1 thing you can smell?

 Take a few deep breaths. Remind yourself of your common humanity. Connect to a feeling of self-compassion. One amazingly effective way to do this is to put a hand over your heart for a minute, or rub your upper arms like you’re cold. Ask yourself what the best thing you can do for yourself right now would be- a cup of tea, a walk, soft PJs, a good book, a treat.

For a more formal practice, there are self-compassion mindfulness meditations (loving-kindness meditations) that you can do, in which you repeat silently to yourself goodwill wishes for your own well-being: “May I be safe, May I be peaceful, May I embody self-kindness, May I live fully,” are the ones that resonate with me. Silently repeat these phrases for a minute or two, while breathing quietly.

Here are some more resources if you struggle with your inner perfectionist:

Tara Brach, Radical Acceptance: Embracing your life with the heart of the Buddha.

Kristin Neff, Self-Compassion: The proven power of being kind yourself.

Christopher Germer, The Mindful to Self-Compassion.

Originally published in the UK Fibromyalgia magazine

Works Cited

Flett, G.L, Baricza, C., Gupta, A., Hewitt, P.L., & Endler, N.S. (2011).  Perfectionism, psychosocial impact and coping with irritable bowel disease:  A study of patients with Crohn’s disease and ulcerative colitis.  Journal of Health Psychology, 16(4), 561-71.  

Friis, A.M., Johnson, M.H., Cutfield, R.G., & Consedine, N.S. (2016).  Kindness matters:  A randomized controlled trial of a mindful self-compassion intervention improves depression, distress, and HbA1c among patients with diabetes.  Diabetes Care, 39(11), 1963-71. 

Linnett, R. J., & Kibowski, F. (2018, June 22). A closer look at multidimensional perfectionism and multidimensional self-compassion. https://doi.org/10.31234/osf.io/bcu37 

Molnar, D.S., Sirois, F.M., & Methot-Jones, T. (2016).  Trying to be perfect in an imperfect world:  Examining the role of perfectionism in the context of chronic illness.  In F.M. Sirois & D.S. Molnar (Eds.), Perfectionism, Health, and Well-Being, pp. 69-99.  Switzerland:  Springer International Publishing.

Willard, K. (2019, June 17). Perfectionism and Chronic Illness. Psychology Today. Retrieved from: https://www.psychologytoday.com/ca/blog/chronically-me/201906/perfectionism-and-chronic-illness

During Winter Solstice, we experience the shortest day, and the longest night, of the year. On this day, usually December 21st or 22nd, the sun travels on its shortest path through the sky. This occurs because the Earth rotates on a tilted axis, and winter solstice marks the time when the Northern hemisphere is tilted furthest away from the sun.

Yet, the Winter Solstice was, and is, celebrated, because, after the longest night of the year, the light begins to return, as each day becomes incrementally longer, and the Earth tilts back to towards the sun. Light is a feature of many mid-winter festivities during the long dark nights at this time of year.

If you are lucky, you can sit around a crackling fire with your family, or perhaps attempt to recreate that cozy experience by playing a fire video on your TV. In Scandinavia, a ‘yule’ log is burned in the hearth at Christmas, based on a pagan Winter Solstice tradition in which families burned logs from a specially selected tree to encourage the Sun to return once again. (Think “Deck the halls with boughs of ivy, falalala lalala/ Troll the ancient yuletide carols, falalala lalala/ See the blazing yule before us…”).

Driving or walking past houses decked out in strands of twinkling lights a crisp December evening is always uplifting. My favourite tradition is to decorate our Christmas tree with strands of lights, and watch the light reflect off of ornaments collected over the years. The tree seems to represent a bright promise that the light always returns. Evergreen represents a promise that new growth, beginnings, and renewal will return, even when everything appears to be bare and dormant.

Light as a symbol of hope is a feature of many worldwide religious festivities that occur during the late fall/winter holiday season, although the specific religions meanings vary, from lighting the menorah during Hanukkah, to lighting Advent candles on Sundays leading up to Christmas, to lighting a kinara for Kwanzaa. Personally, I like to light scented candles during the holidays because the flickering flames create a special atmosphere of warmth and cozy-ness that make home feel like a refuge from the cold, dark night outside.  

Winter solstice can be a time of reflection. In the dormancy and darkness winter represents, before the growth and activity of the warmer months, we can turn inwards, integrate the lessons learned over the past year into our sense of self and visualize where we want to go next. When the sun returns, we will be ready for new beginnings and renewal.

This year, despite omicron, chronic illness, and personal challenges, remember that the winter always gives way to spring, and the light always returns. Embrace hope! From our family to yours, Happy Holidays!

The health headlines were all abuzz this week about a new study on chronic pain out of Boulder, Colorado. The headline for the article I first read was: ‘How therapy, not pills, can nix chronic pain.‘ As a patient, and a health writer, I’m frustrated to read headlines that perpetuate a narrative that chronic pain is a psychological problem that is “all in the head.” However, I resolved to stay open to the conclusions drawn from the study.

What did the study actually say?

Pain Reprocessing Therapy (PRT) claims to shift your beliefs about the cause and threat value of chronic pain, by framing pain as a “false alarm” rather than something dangerous. By helping patients to reconceptualize their pain as a “reversible, brain-generated phenomenon,” not ongoing physical damage, the study authors concluded that PRT provides significant, durable pain relief.

A small sample of 151 individuals with low-moderate back pain were divided into three groups: a treatment group, a placebo group, and a group who received the “usual care” for back pain. The treatment group received eight one-hour sessions of a new type of therapy called Pain Reprocessing Therapy (PRT) over four-weeks. All three groups reported their pain levels at the end of the study. In addition, the researchers used fMRI imaging to determine if the therapy had changed brain activity in participants when they evoked back pain in the laboratory.

In the treatment group, 66% of participants reported being pain-free or nearly pain-free at the end of the study, compared to 20% of participants in the placebo group, and 10% in the usual care group. Even one year later, fMRI imaging showed that participants in the treatment group had a lower prefrontal cortex response to evoked back pain than the other two groups, although the meaning of this finding was unclear.

What does this study not say?

The study proves that, in a small sample of people with mild back pain, PRT reduced pain. It opens the door to further investigation on how pain perceptions held by individuals with low back pain affect pain intensity, and how learning to reappraise pain sensations as safe may help reduce pain levels. However, this is a far cry from the ‘revolution in how we understand and treat all forms of chronic pain’ that articles reporting on the study proclaim! We would need a sample size of thousands, in different settings, to confirm the findings that PRT can reduce mild low back pain. Furthermore, it is impossible to draw conclusions about how PRT would work for people with different pain conditions, like fibromyalgia, until a study is repeated in those populations.

Psychology and Pain

In some cases, chronic pain is a disorder of the pain processing system itself: sensitized nerve endings send pain signals, which are prioritized and amplified in the spinal cord, and finally interpreted as a significant, dangerous threat in the brain. Rather than “all in the head”, we can consider this type of pain to be “all in the brain and central nervous system” (far less catchy, I’m afraid). This is in contrast to conditions like arthritis, which are caused by inflammation in physical tissues like joints.

To my knowledge, no research exists showing a mechanism of action for how thoughts and emotions of the mind can control or terminate central nervous system neurons firing pain signals. The authors of this PRT study argue that other psychological pain interventions, like cognitive behavioural therapy or mindfulness, teach patients to improve their daily functioning despite pain, by learning to be less reactive to pain signals. In contrast, Pain Reprocessing Therapy, apparently teaches conscious strategies to reduce and down-regulate pain signals directly. This study shows a correlation (PRT correlates with pain reduction), and the brain imaging results were inconclusive. That is a far cry from proof of the researchers’ theory about how PRT works, showing  direct causal evidence that RPT dials down pain signals.

There are limitations to the role the brain plays in perpetuating chronic pain. For example, fibromyalgia, was, up until recently, thought to have been 100% caused by central nervous system sensitization. However, now a new body research shows fibromyalgia is also a disease of the body, including small fiber neuropathy, and immune dysregulation. Therefore, I think the claim that pain is an entirely “reversible brain-generated phenomenon” is a stretch too far.

In the past, claims that pain conditions were psychological in origin were used to discredit and disbelieve patients, particularly women.  Even though the “all in your head” narrative has been weaponized to discredit pain patients, we have to stay open to the possibility that PRT may be one tool, among many, in a chronic pain management toolkit. None of these treatments, like psychology or medication, need to be ‘either/or’. Responsible health writing plays a role in shaping these narratives.

The health headline for a medical news website stated ‘Psychology, not Pills Provide Long-lasting Pain Relief’, setting it up as one or the other, whereas the research article had the much tamer name `Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial` (albeit, in a psychiatry journal). As someone with a health condition, it’s important to notice the bias in reporting, and how that shapes the headline and article. For example, I found a reasonable headline reporting on the PRT study which says “Chronic pain treatment should include psychological interventions.” For tips on how to find credible health information, and avoid misinformation and conflicts of interest, these are some helpful tips.

Ashar YK, Gordon A, Schubiner H, et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. Published online September 29, 2021. doi:10.1001/jamapsychiatry.2021.2669