Chronic Pain

Chronic pain is common. About 1 in 5 young people and adults live with chronic pain. The good news is that there are effective treatments that can help you cope. Here you will learn more about chronic pain and how to manage it.

You can use any lesson at any time. However, therapy for chronic pain usually uses this order:

What is Chronic Pain?

Chronic pain can develop when you don’t expect it and can interfere with having a full life.
What is Chronic Pain Unit Guide

It’s normal to feel pain when you get injured. But when the pain lingers and starts to interrupt your daily routine, it can take over your life. People who have chronic pain can experience seemingly nonstop physical discomfort. Sometimes events will set off chronic pain when you aren’t expecting it. You might feel not only pain but also feel demoralized.

New skills can help you cope with chronic pain. You can learn to manage pain and have a meaningful life.

  • The Facts
  • Understanding Chronic Pain
  • The Symptoms
  • Treatment

The Facts

It’s Common

Have you had pain several times this week? Has the pain been occurring for 6 months or more? If so, you may suffer from chronic pain, but you are not alone. Chronic pain affects millions of people. It can happen to anyone and occurs in 20 percent of the population.

It’s Treatable

You might feel that there is nothing that will help with your chronic pain. But treatment can help you learn to manage it. You can develop a new relationship with pain and cope more easily when pain occurs.

Useful Pain

The human body is always taking in information. What’s the temperature? How’s the pressure? Is it soft or rough? These sensations get interpreted in our brain.

Pain involves the translation and transformation of sensory information deemed dangerous. If you cut your finger when you are preparing a meal, your senses give you several pieces of information. You might see a spot of blood on your finger and smell a distinct metallic tang. You may feel a tearing sensation at the site of the cut. Your nerves transmit all this information to your brain. The brain interprets the sensations as danger and then, finally, as pain.

The purpose of this kind of pain, acute pain, is to let you know you have an injury and to prevent further damage. It’s a useful tool we use to protect our bodies. Now that you are aware of your cut finger, you can clean it, cover it, and make sure it heals quickly.

Audio Tip
Dr. Francois Botha shares his understanding of chronic pain.

When Pain Becomes a Problem

Physical pain has its place in our lives. It might feel terrible, but it’s short-lived and gives us a useful signal that damage is occurring. Pain becomes problematic when it no longer keeps us from suffering further injury.

Pain is only useful when we can do something to stop more damage from happening. People who have arthritis may have lots of pain, but no medical options to cure the disease. In this way, chronic pain signals damage, but without the benefit to help to stop it.

Other forms of chronic pain may result from faulty signals. An error can happen a few different ways. Your nerves might be damaged and send wrong information to your brain. Alternatively, your brain may be hypersensitive and read the most gentle sensations as dangerous. No matter the underlying cause, your pain is a false alarm.

Chronic pain can be challenging to understand. The cause of the pain might even seem mysterious to you and your healthcare provider. Chronic pain might emerge from an injury that has healed or without a known injury at all. It might occur more often, last longer, and be more intense than acute pain.

In the past, our understanding of pain was that it developed because of an underlying physical cause. We now understand that pain can be felt even in the absence of a known root. You may have felt misunderstood or dismissed in the past. Know that your pain is real. Whether the cause is known or a complete mystery, your pain is real.

Gate Control and Neuromatrix Theories of Pain

Most people think about pain as a direct result of an injury. You might assume the worse the damage, the worse the pain. How you feel emotionally may not factor into it at all. However, the Gate Control Theory completely changes how we think about pain.

The Gate Control Theory suggests that our thoughts and emotions can influence our pain experience. The idea is that a structure in our spinal cord acts as a gate. If the gate is open, we can experience intense pain. If the gate is closed, the intensity is much lower. The theory says that the gate is more likely to be open if we are experiencing emotions that are challenging to us. You will feel more pain if you are feeling distressed or anxious than relaxed. Similarly, if you expect something to hurt, it will. On the other hand, if you are distracted or having pleasant emotions, you are less likely to feel pain.

Gate Control Theory may not explain everything about pain, but it does change our outlook. This theory helps us to understand why your relationship with pain matters. The pain you feel is not just a result of an injury. What you think and how you react to pain, play a role.

Another theory that changes how we think about pain is the Neuromatrix Theory. In the past, we imagined pain as stemming directly from injury or inflammation. Now we believe that pain results from a complex network in the brain called the Neuromatrix. This theory suggests that pain can come from any signal that the brain sees as a threat. You don’t need a physical injury to feel pain.

Other Symptoms of Chronic Pain

Most people only think about the physical symptoms of chronic pain, but it can also affect you in other ways.


When dealing with chronic pain, people often have negative thoughts. The worst might seem inevitable. You might think that your pain is endless, and nothing will ever help. Your thoughts might be made up of ideas like "unless I can completely get rid of my pain, my life is unlivable." You may believe that no one understands you or your pain. Perhaps you feel that pain affects you differently from other people, making you weak.

Poran Poregbal, RCC

It's normal to want to avoid feeling pain. But when pain is chronic, you might stop doing a lot of things that once brought you joy. You might stop doing physical activities because you associate them with pain. Social events can also become difficult. You may avoid them due to the logistics of attending. Maybe you are just sick of answering the question "How are you?". When you stop seeing your friends, you might find less healthy ways of relaxing. You may start overeating or sleeping. Your use of alcohol or other substances might become excessive. Or maybe you are passing the days online shopping.

It's reasonable to change what you do in response to your pain. But you don't want to increase your pain by losing muscle strength from lack of exercise. Avoiding your social life can lead to loneliness and feeling isolated. Dependence on substances or compulsive behaviors can lead to more stress in the long run.

Dr. Margaret Drewlo

Chronic pain can trigger a range of emotional reactions. You might feel ashamed, afraid, or abandoned. You may become frustrated if you have had chronic pain for a long time. It is common to feel fed-up with yourself or your healthcare providers. You might believe your chronic pain will never improve. These thoughts might leave you feeling hopeless or helpless. Chronic pain can often lead to tough, difficult emotions. This stress can make your pain even worse.

Karen Romanin, RN


The good news is that treatment for chronic pain can help. New skills can help you cope more easily with the pain you experience.

Remember that physical pain can happen for many reasons. It’s important to work with your family doctor or healthcare professional when you have a pain condition.


There are many types of psychotherapy or talk therapy. Kelty's Key is based on cognitive behavioral therapy. This treatment helps you to think differently about your pain. A change in mindset can help you cope more easily with your pain. As your skills increase, so will your sense of mastery over your pain condition.

Dr. Francois Botha

Well Done. You’re on Your Way.

You’ve taken the first step and learned about chronic pain. Knowledge is important. Understanding what chronic pain is and how it works will help you moving forward.

I’m using the self-help:
I’ve got an online therapist:
I’m working on my own:


Accepting your experience, moment-to-moment, can help you manage chronic pain.
Mindfulness Unit Guide

It’s natural to want your pain to go away. But the stress and anxiety that comes with wishing for change can backfire. It can cause your pain to become more intense and pull you into a cycle of despair and worry. Mindfulness can help you change the relationship between your mind and body. The practice of welcoming your experience, whether it is pleasant or not, can help you become less reactive to your pain.

  • What is Mindfulness
  • Mindfulness and Chronic Pain
  • Types of Practice
  • Overcoming Obstacles
Audio Tip
Andrea Grabovac, MD, FRCPC, shares how she explains mindfulness to clients.

What is Mindfulness?

Life will always bring ups and downs. You might not have a say in what happens to you, but you can learn to control how you react. Sometimes, this can make all the difference. Allowing yourself to spiral emotionally can make you feel a lot worse than the experience itself. Mindfulness is an ancient meditation technique for dealing with this problem.

In a nutshell, mindfulness is all about learning to become less reactive. It trains you to pay attention to what is happening, moment-to-moment, and accept it. In a way, practicing mindfulness is like being a scientist. You want to look at your experience neutrally and collect data. Be curious. What’s going on right now? How does it feel? You want to observe the present moment without wishing it were different.

By training your awareness, you can learn to respond to a situation by choice, rather than automatically. You can become more patient and open. When you are more clear-headed, you will be a lot better at solving problems and dealing with life’s downs.

Audio Tip
Tom Heah, Msc, OT, explains how mindfulness can help people with chronic pain.

Mindfulness and Chronic Pain

Living with pain is no fun. It’s normal to wish things were different or that your pain would disappear. The trouble is that the stress and frustration you hold towards your body can make things worse. Your muscles can tighten, intensifying the pain.

Mindfulness can help you break out of this cycle and let go. It can change how you view your pain and what expectations you have. In mindfulness practice, you might discover that your pain is not what you assumed. As you explore, mindfulness can help you develop a kinder and friendlier relationship with your body.

Types of Mindfulness Practice

Mindfulness is called a practice for a simple reason. The more we do it, the better we get at it. There are lots of different ways and styles to train in mindfulness. Your practice can be short, long, self-guided, audio-guided, sitting, walking, and so on.

Here are a few types of mindfulness practice to try:

Pain Desensitization Practice

If you are new to mindfulness, this 30-second meditation is a good place to start. It focuses on feeling and accepting all the small sensations that come together to form pain. With practice over time, this meditation can help reduce anxiety, improve mood, and lessen your pain.

Dr. Andrea Grabovac
Three Minute Breathing

This practice is another short mediation that you can do many times. It focuses on the present moment, our breath, and our body. This exercise is a useful tool for stepping out of your emotional autopilot. It helps ground you in the present moment and stops your thoughts and worries from spiraling.

Erin Goodman, MSc, OT
Breath and Body Awareness

This meditation shifts your focus between the painful and comfortable parts of your body. Using your breath, you can explore your body as a whole and feel the balance between pain and comfort. You can adapt this exercise to the length of time you can spare.

Sandy Patola-Moosmann, MA, RCC
Loving Kindness Meditation

If you have chronic pain, you may be hard on yourself and irritable towards the people around you. This exercise is about becoming kinder to yourself and more understanding of others. It can reduce your pain and your anger.

Dr. Andrea Grabovac
Body Scan Guided Meditation

The Body Scan is a longer meditation. It can help you become more connected to your body. The purpose is to examine each section of your body slowly. Notice the sensations, feelings, and thoughts of each moment. Sometimes, this exercise won't feel good. That's alright. It's also okay if you have areas in your body without sensation. Like all mindfulness practices, you aren't waiting for something special to happen here. The goal of the Body Scan is just to "come home" to your physical being.

Tom Heah, MSc, OT

Overcoming Obstacles

Mindfulness practice is simple but not always easy! There are a lot of challenges that might get in your way. It is important to remember that with mindfulness meditation, regular practice over time seems to have the most benefit.

"I can't sit still that long!"

It's common to feel pain while sitting still for a long time. You might also feel fidgety or antsy. The key is to find a balance. Try starting with some of the shorter practices like Pain Desensitization or Three Minute Breathing. You can do some of the longer exercises lying down or in a different position. Your ability to focus on your pain, without judging it, will build-up over time.

Dr. Margaret Drewlo
"My mind keeps wandering off."

Each time your mind drifts off in your practice, you might feel like you're failing. Don't get down on yourself. Training your awareness is hard work. No one expects you to be able to control your mind entirely at all times. When you've noticed your mind has wandered, don't worry. Just take a moment to redirect your attention back to your meditation. This shift in focus is what mindfulness is all about.

"I don't have the time."

When life is busy, even 15 minutes can be hard to set aside. Try to schedule your practice rather than doing it randomly. You may find you're always interrupted. Share your plans with your family and friends. Let them read this unit and support the work you are doing.

Dr. Margaret Drewlo
"This is so boring. I keep nodding off!"

If you find it hard to stay awake during your meditation, try sitting up instead of lying down. It can also help to do your practice earlier in the day. It's easy to fall asleep if you do your exercise right before bed.

Sean Butler, MA

Terry's Story

Ever since her car crash 5 years ago, Terry has suffered from back pain. She was frustrated. Terry believed her pain should resolve, like the cuts and bruises she had right after the accident. Even though it was long ago, Terry is still angry at the other driver. She often takes out her annoyance on her partner and children. Terry has almost given up hope that anything can help her pain.

Terry heard about using mindfulness for chronic pain. She was annoyed that anyone thought a little, "Ommmm" would do her any good. But Terry was out of other ideas. Her other coping mechanisms weren't working, and she worried that taking pain medications might get out of hand. Terry decided to try mindfulness for a month, giving herself the out to quit after that.

Terry generally had a hard time sitting still. Her therapist suggested she start small for the first few days. She tried a 1-minute practice. Terry set the timer on her phone and focused on the air moving as she breathed. She concentrated on the area where the air was easiest to feel -- her nostrils. She paid attention to the sensations as her breath moved in and out. That's all.

Terry progressed to Three Minute Breathing several times a day. She noticed that it helped her to slow down her worried thinking. Terry realized that she had a variety of sensations in her body. Surprisingly, Terry noted that her back pain wasn't consistent. She wasn't always in pain. Terry decided to stick with her practice. Months later, she could go through her day less overwhelmed and more accepting of her pain.

Good job! Time to Make Mindfulness a Habit

Download Your Worksheet

It’s best to schedule when and where you’ll do your practice every day. Protected time will help you stick to your plan and create a rhythm for your day. If you can’t meditate every day, meditate as often as you can. You’ll get the most out of mindfulness if you develop a regular long-term practice. A few minutes several times a day counts!

We have included a worksheet to record your daily meditation. Start your practice this week, and keep track of your progress.


Congratulations! You’re Learning Mindfulness

Way to go! You’ve learned how you can use mindfulness to control your reactivity. Mindfulness is a skill, and the more you practice it, the more effective it will be.

I’m using the self-help:
I’ve got an online therapist:
I’m working on my own:


Doing things the same way you used to can get you stuck in an ongoing cycle of pain flare-ups.
Pacing Unit Guide

Experiencing chronic pain can make activities that you could complete easily in the past more challenging. Pushing yourself hard to complete tasks the same way you did before can lead to pain flare-ups. Pain flare ups can make it hard to get anything done for an extended period of time. An important part of the treatment for chronic pain is to learn to manage your energy and reduce flare-ups or prolonged inactivity. In this unit, you’ll learn tools that will help you engage with activities more effectively.

  • The Boom-Bust cycle
  • Pacing activities
  • Overcoming obstacles
  • More tips

The Boom-Bust Cycle

When we are in pain, we get tired more easily and have more trouble concentrating. Pain also affects our sleep and mood which reduces our energy and mental capacity even more. We may avoid exercise which weakens our muscles. Avoiding exercise reduces our energy and actually increases pain rather than decreasing it.

It is likely that you will not be able to do as much as you did before. This can be quite upsetting and may encourage you to push through with activities to maintain your former productivity. Your nervous system is more sensitive now. Pushing through can lead to pain flare-ups that may continue for several days. During this time it will be tough to get things done. At the end of this time, you will likely be even more upset at the work that has piled up. Or you may feel excited at finally experiencing less pain again and work especially hard for the next few days to compensate for missed work, triggering another flare-up. The cycle of productivity followed by increased pain is what we call the boom-bust cycle.

Audio Tip
Heidi Lin, Msc, OT, discusses how she introduces pacing and its benefits to clients.

Pacing Activities

You can manage the boom-bust cycle by pacing your activities. Pacing activities involves creating a better balance between work and rest every day. Pacing also involves ways to reduce the energy you use in completing activities. Pacing techniques should be used even on days that have few difficulties and on days with lots of difficulties.

Using pacing on days with lots of difficulties will help you complete more activities than you used to. By using pacing on days with few difficulties you will complete fewer activities than you used to, but you may be able to complete activities more consistently and sustainably. Your total activity will increase because you are less likely to experience flare-ups. Pacing can give you a sense of increased control over your pain experience. Getting more done in the long run can improve your confidence and mood.

Changing a Current Activity

The way to get started is to select a current activity you are experiencing difficulty with. This may be an activity that you were able to do in one sitting before. Or it may be an activity that often causes you to feel exhausted and that causes flare-ups.

Name an activity that you would like to try using pacing:

Feeling Stuck?
GardeningDoing laundryShopping
WorkingWashing the carExercising
Social eventsWalkingMoving furniture


Audio Tip
Heidi Lin, Msc, OT, shares an example of breaking down an activity.

Break it Down

Before determining what is manageable for you, it can be useful to consider how you would like to break your activity down. One of the simplest options is to break the activity down by time. For example, you may do an activity for 10 minutes before taking a 10-minute break. Other options may be completing a certain number of items, completing one area at time, one type of item at a time, or one task at a time. An example of an activity being broken down in tasks is laundry which may include sorting, loading, drying, ironing, folding, and moving clothes to correct locations. Vacuuming may involve removing objects off floor, setting up the vacuum, and then going area by area. An underused option is changing up who is completing an activity. You may work on an activity for a while and then your partner, colleague, or friend can take a turn.

This is the activity you would like to try with pacing:


How are you going to break this activity down?


Audio Tip
Dr. Francois Botha discusses basic principles for taking breaks.

Implement Pacing

Now that you know how you would like to break your activity down, you can experiment to decide what one unit of activity will involve. Start doing the activity and notice how long you can go before your level of pain or fatigue increases. Also take notice of how long it takes before you start feeling the need to push through despite pain or fatigue. This will show what one unit of activity may consist of. The complete activity can now be broken down into these units.

Between each unit take a break. What you do during the break would preferably be less active and demanding. You could switch between activities that use different muscle groups or body positions. You may, for example, switch between sitting and standing. Finally, it is possible that the activity may best be spread out over several days. You may, for example, do laundry every 3 days with smaller loads rather than a big load once a week.

What will you do while taking a break from the activity?

Feeling Stuck?
Watch TVCall a friend
Mindfulness practiceRead a book
StretchingRelaxation exercises


Audio Tip
Sandy Patola-Mossman, MA, RCC, shares how she has overcome obstacles related to pacing.

Obstacles to Pacing

Integrating pacing into daily life presents challenges. Accepting your current ability to complete activities is a process. Pacing can remind you of how much you had been able to do before. You may start comparing yourself before and-after chronic pain. You may feel intense grief, sadness, or shame making it more difficult to ask for help from others when you need it.

You or others may have gotten used to things being done in a certain way. You might even believe that there is a right or correct way to do an activity. Directly or indirectly, others may express their disapproval of using pacing. Others may complete the activity themselves or “help” when you did not ask for it.

Another obstacle may be that you are already overwhelmed by your commitments and limited time. Your experience up to this point may be that your flare-ups are unpredictable. You may feel that you have little control over your life. Making changes may seem like too much to manage right now.

This is the activity you would like to try with pacing:


What will most likely prevent you from implementing pacing for this activity?



Overcoming Obstacles

You now want to consider how to overcome the obstacle you identified. You can challenge the thinking that underlies your negative feelings and allow yourself to move forward. You could learn communication skills to ask for help and express your needs to others. You can learn easier ways to complete activities and challenge the rules you or others have set in the past.

Pacing is a strategy for feeling less overwhelmed and more in control in the long run. Starting small can lead to successes that creates hope for the future and increases your energy.

This is the obstacle you identified:


How are you going to overcome this obstacle?


Audio Tip
Sandy Patola-Mossman, MA, RCC, discusses additional pacing strategies.

Make Activities Easier

There are other things you can do to make tasks easier. Many activities that we usually do standing can be done sitting down. Examples include ironing and gardening. You can also use the functions of your appliances to reduce effort. For example, setting the dryer to permanent press can reduce the need for ironing. Getting others to help out is another option. Instead of cooking all the meals for a dinner party, you could invite friends for a potluck dinner.

Getting organized can reduce the amount of energy you spend. All items used for an activity can be kept within reach. Having all the ingredients and appliances for making coffee together at a coffee-making station is one example. If your living space has several floors, you can organize your devices and working areas to reduce the use of the stairs. You could also keep tools such as cleaning materials on all floors to avoid carrying items on the stairs.

Professional Help

Occupational Therapists can teach proper body movement for completing tasks. They can also recommend helpful devices and advice on making your workplace more comfortable. Occupational Therapists can help with daily planning and recommend community resources. Physiotherapists can assist in creating a safe exercise and stretching program.

Tom's Story

Tom worked as an engineer for fifteen years. When he and his wife were able to afford a house, he was overjoyed. He was very passionate about gardening and their new home had a large garden. On weekends he worked in the garden for several hours. People in the neighborhood would often comment on the beauty of the garden. He and his wife loved entertaining in the beautiful space he created.

Three years ago things became very stressful at work. Tom felt more and more tired and had difficulty sleeping. He started experiencing frequent muscle pain. He was having trouble concentrating at work and eventually went on sick leave. Tom continued gardening but was often in severe pain for days after. He was ultimately given a diagnosis of Fibromyalgia.

The condition of the garden deteriorated. Tom was feeling depressed and helpless. He attended a three-week chronic pain program at the recommendation of his doctor. The program included several sessions on pacing. The occupational therapist in the program told him how he could reduce physical effort while gardening.

Tom made gardening a part of his daily routine. He worked for thirty minutes a day and then did relaxation exercises. He experienced fewer flare-ups and was able to restore the part of the garden visible from the patio. He invited friends for a BBQ and asked his best friend to grill the food. Despite his ongoing symptoms reconnecting with others and being able to do more improved Tom’s mood.

You've Learned a New Strategy for Completing Tasks

Download Your Worksheet

You’ve learned about why people with chronic pain often experience a boom-bust cycle. You learned about pacing and started breaking down one of your major activities. You considered obstacles to change and made a plan for dealing with those obstacles. You also learned ways in which you can make activities easier. When you started this course you may have felt that you had little control over pain and flare-ups. Keep working on pacing and you may find that you are able to sustainably do more than you can do right now. Pacing can give you a greater sense of control and accomplishment.


Congratulations! You are doing the Work.

Continue to work on introducing the principles of pacing in all your activities. If you’re feeling stuck, you can review this unit or talk to your therapist or healthcare provider.

I’m using the self-help:
I’ve got an online therapist:
I’m working on my own:

Problem Solving

When you've got a problem, you need to do more than challenge negative thoughts
Problem Solving Unit Guide

It’s easy to feel overwhelmed when facing a problem like losing your job or a close friend. When you have a problem, changing your thoughts is not the goal; you need to change your situation. In this unit, you will learn how to work through your problems and generate solutions. Take control and create a plan. Even at the worst of times, a good plan will help you get through it.

  • Naming the Problem
  • Brainstorming Solutions
  • Making a Choice
  • Taking Action
Audio Tip
Dr. Christine Korol explains how a plan can help you overcome life’s tough situations

Plan to Action

Problem-solving plans are the key to helping you face life’s challenges, big or small. Ignoring your problems doesn’t make them go away — it gives them time to get bigger. Instead, take action and make a plan to help you break down your problem and solve it once and for all. Your plan will also help boost your confidence. When you trust that you can handle whatever life throws at you, you’ll worry less and feel better.

Audio Tip
Dr. Christine Korol clarifies the difference between a 'worry' and a 'problem'

Name the Problem

So how do you make a problem-solving plan? The first step is naming the problem. It’s important to make sure you are dealing with a problem and not a worry. Worries focus on something that might happen. They usually start with the words "what if." Problems are happening right now or about to happen very soon. If you aren’t sure if you have a worry or a problem, ask yourself if it’s already happened. If the answer is yes, you’ve got a problem.

Name the problem. What's going on?

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Audio TIp
Dr. Christine Korol explains how brainstorming can lead to unexpected solutions


Once you’ve named your problem, it’s time to brainstorm possible solutions. Try to think up a few ways that you could solve your problem. It’s important not to censor yourself. Write down all your options, even if some seem silly. Sometimes the most ridiculous thought can lead you to the best solution.

If you're feeling stuck, try brainstorming with someone else. Your therapist, a good friend, or a family member can help you come up with ideas.

Try brainstorming three solutions to your problem:

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Pros and Cons

Take a look at the different options you came up with to solve your problem. What are the upsides and downsides for each possible solution? For example, if you lost your job you might consider going back to school. An upside could be that it would lead to better job opportunities. The downside could be that tuition is expensive.

What are the benefits of each of your solutions? What are the drawbacks?

Possible Solution
Possible Solution: 1.
Possible Solution: 2.
Possible Solution: 3.
Audio Tip
Dr. Christine Korol explains the benefits of having more than one solution to a problem

Make a Choice

The upsides and downsides of each solution can help you decide what to try first. Take a look at each of your possible solutions and rank them in terms of which you should try first, second and third. There’s no perfect way to rank your solutions. A solution could be ranked first because it’s easy to do, has the fewest downsides or seems the least risky.

Take a minute to order your possible solutions 1, 2, or 3. Which would you like to try first?

Possible Solution Order
Possible Solution: 1.
Possible Solution: 2.
Possible Solution: 3.

Give it a Try

Now it’s time to give your solution a try! If it doesn’t solve your problem, try another solution on your list or brainstorm some new ones. Depending on the nature of your problem, you might be able to try a few ideas at the same time. For example, if you were looking for a new job you might try a few things right away. You could let your friends know you’re looking, send your resume to a few companies and register with a headhunting agency.

Vijay's Story

Don’t remove

Vijay was having a terrible day. Work was busy and he was running late. Everything came to a head when he got into his car and it wouldn’t start. Great. Money was already tight this month. Vijay didn’t know how he’d afford to get the car fixed, and still be able to pay his mortgage and buy groceries. With help from his therapist, Vijay needed to come up with a plan to save money for this month’s expenses.

Vijay started to brainstorm some ideas. He could ask creditors to skip a payment or borrow money from family or friends. Packing a lunch for work instead of eating-out could save some cash. He could rent out the basement or sell some things online. He was sure he could find a cheaper cell phone plan and ride his bike to work. He even considered delivering flyers in the evenings, like he did when he was a teenager.

Vijay considered his options. He didn’t want to ask anyone for money. But then he remembered that his brother owed him $200 for a present they bought for their parents. He didn’t mind asking for that back, and his brother apologized for forgetting. Finding a cheaper cell phone plan was easy, but Vijay didn't want to rent out the basement. He saved more money than he expected by bringing lunch to work.

When it all added up, Vijay was able to buy groceries and make his mortgage payment! He was thrilled with what he’d managed to save over the month. He decided to keep up some of the changes to build up a cushion for the next emergency.

Your Game Plan

Download Your Worksheet

Good job! You’ve got a solution to your problem that you’re ready to try out. If it’s not effective, you’ve got a few backups ready to go. It’s helpful to fine tune your plan with your therapist and keep track of how well your solutions work out. Remember that having a solid plan can help you solve your problems. When you have fewer problems you'll have less stress and more confidence. This will make you feel better and boost your mood. Download this worksheet to save a copy of your plan and keep track of your progress.


Great Work! You’ve created a plan to solve your problem.

Remember that making a problem-solving plan will help you cope with life’s ups and downs. The steps are simple:

  1. Name the problem
  2. Brainstorm possible solutions
  3. List the upsides and downsides of each solution and rank them
  4. Test a solution
  5. Evaluate the outcome
I’m using the self-help:
I’ve got an online therapist:
I’m working on my own:

Chronic Pain Beliefs

Certain beliefs about chronic pain can work against you.
Chronic Pain Beliefs Unit Guide

A lot of people believe that they have no control over chronic pain. Some people are sure they can’t cope with it. Others develop negative beliefs about who they are and what they can do. These kinds of assumptions can prevent you from making positive changes. To better manage your chronic pain, you need to rework your negative beliefs.

  • Beliefs About Coping
  • Beliefs About Control
  • Beliefs About Yourself and Your Body
  • Challenge Your Beliefs
Audio Tip
Dr. Francois Botha discusses the biggest obstacle to people adopting a self-management approach to chronic pain.

Beliefs That Keep You Stuck

There are three types of beliefs related to chronic pain that can keep you stuck. The first kind is about coping. You may believe that chronic pain will overwhelm you. Thinking about how your pain will ruin your life will make your anxiety skyrocket. The extra stress will make your pain even worse.

The second type of belief is that you’re helpless. As though you can’t do anything to help your pain. This assumption can be a significant setback. You’re unlikely to learn new ways of managing your pain if you don’t believe they’ll work.

The third kind of belief involves negative ideas about yourself and your body. You may start seeing yourself as weak or worthless. A sense of shame and helplessness might make it harder to spend time with others. You may end up feeling isolated and alone.

What you believe affects how well you can manage your chronic pain. Challenging your negative beliefs will open you up to learning valuable coping skills.

Beliefs About Coping

Chronic pain might feel overwhelming. You may be sure that things will only get worse. When you don’t believe you can handle something, your mind can start racing. Your anxiety will kick in and grow stronger. You’ll probably forget about all the times you’ve coped well with your pain.

According to the Gate Control Theory, the more stressed and worried you feel, the more your pain will intensify. When your body is hurting more and more, the pain will get even harder to manage. This cycling between growing anxiety and stronger pain can really keep you stuck.

Take a look at some of the common beliefs about coping. Do you think you have any of these beliefs? Rate how much you believe each one to be true (where 0 = not true and 10 = very true).


Challenging Beliefs About Coping

Let’s take a look at your strongest belief and start challenging it together.


Do you know for a fact that this is true?

If you had to convince someone that this belief was not true, what would you say?

What are the benefits of holding this belief?

What are the downsides of holding this belief?

Audio Tip
Dr. Margaret Drewlo explains how she helps clients deal with worry about chronic pain.

Downplaying Your Ability to Cope

When we worry about the future, we tend to focus on the negative. You may overestimate the chances that things will go wrong. Your worries might even use language that makes your pain feel more threatening. Thoughts like “Chronic pain will destroy everything I worked for,” are pretty catastrophic. But in truth, no one knows what the future holds. Believing the worst is coming is just a guess.

You may feel sure that chronic pain will destroy your future. But when we worry, we tend to forget about our ability to cope and problem-solve. Even if things go badly, you’d probably deal with it better than you imagine. Living with chronic pain presents a lot of challenges. You’ve probably forgotten all the times you handled difficult situations in the past.

Chronic pain is hard, but it’s not necessarily overwhelming. You can learn to cope. When you start feeling more confident in your abilities, your pain will feel more manageable.

Take a moment now to re-rate your belief about coping. Do you still think it’s true?


Beliefs About Control

It’s common to believe that you have no control over your chronic pain. But this assumption can lead to a lot of problems. You might feel helpless and stop trying to change. Why learn a new skill if you don’t believe it will help? But doing nothing can leave you feeling sad and disheartened.

You may believe that only other people can help you. When you depend solely on others, you might get angry when they don’t live up to expectations. You may grow resentful if you think they are not caring enough about you.

Take a look at some of the common beliefs about control. Do you think you have any of these beliefs? Rate how much you believe each one to be true (where 0 = not true and 10 = very true).


Challenging Beliefs About Control

Let’s take a look at your strongest belief and start challenging it together.


Do you know for a fact that this is true?

If you had to convince someone that this belief was not true, what would you say?

What are the benefits of holding this belief?

What are the downsides of holding this belief?

Audio Tip
Dr. Francois Botha explains how he helps clients deal with feeling helpless.

You Can Influence Your Pain

You may have tried a lot of things to manage your chronic pain. When none of them worked, you may have felt useless and helpless. The issue isn’t that you have no control, but that you might not know the best techniques. Chronic pain might feel like a typical injury, but it’s very different. You can’t treat it the same way as a twisted ankle. This kind of pain, and how to manage it might be entirely new for your family, your friends, and you.

A step in the right direction is to learn more about what can help chronic pain. You may need to teach the people close to you about things like pacing and mindfulness. Learning to communicate your needs to others will be a powerful tool. As they understand more about chronic pain, they can become more supportive.

Once you’ve learned the skills needed to help chronic pain, you can put your effort in the right place. Taking action and making changes can increase your confidence and sense of ability. You can start seeing how your thoughts, feelings, and actions influence your pain.

Take a moment now to re-rate your belief about control. Do you still think it’s true?


Beliefs About Yourself and Your Body

Chronic pain will change your life. You won’t be able to do everything you could before. It can be especially hard if you have to stop doing something you found particularly meaningful, like a hobby or job. You might start to see yourself and your body in a negative light. You may blame yourself for not being able to do the things you’d like. As you become harder on yourself, you may withdraw from others and stop doing even more activities.

Take a look at some of the common beliefs about yourself and your body. Do you think you have any of these beliefs? Rate how much you believe each one to be true (where 0 = not true and 10 = very true).


Challenging Beliefs About Yourself and Your Body

Let’s take a look at your strongest belief and start challenging it together.


Do you know for a fact that this is true?

If you had to convince someone that this belief was not true, what would you say?

What are the benefits of holding this belief?

What are the downsides of holding this belief?

Audio Tip
Dr. Margaret Drewlo explains how she helps clients deal with feeling worthless.

You Are More Than Physical Ability

Our society holds productivity and physical ability in high regard. By living in the world we live in, you’ve probably absorbed these values too. If chronic pain has limited the power of your body, you might feel less significant or useful. If you can no longer produce things, earn an income, or stay fit, you might believe that you’re worthless. You may feel like your body has betrayed you.

But there’s more to a person than their physical capabilities. Being kind, generous, fun, or caring are just as important. You can still be valuable even if you can’t do what you could before.

Dealing with chronic pain involves a process of grief. You need to come to terms with your losses. More importantly, you need to refocus on what remains and your priorities. You can find new ways of gaining a sense of competence, connection, and pleasure. As you change, you can reflect on your identity. You haven’t become worthless, but someone who is living and coping with chronic pain.

Take a moment now to re-rate your belief about yourself and your body. Do you still think it’s true?


Good Job! You’re Challenging Your Beliefs

Download Your Worksheet

Keep challenging how you think about chronic pain. Remember that some beliefs make it harder to learn the skills you need. They can also increase your feelings of sadness, anxiety, shame, and guilt. These emotions can make your pain worse. When you challenge unhelpful beliefs, you can start to move forward. You can boost your confidence and build a better sense of worth and control. Download your worksheet and continue reworking your beliefs about chronic pain.


Well Done! You're Reworking Your Beliefs

What you think and how you feel can affect your pain. Keep working on your problematic beliefs so that you can start making positive changes.

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I’m working on my own:

Thought Challenging

Your thoughts and feelings are connected.
Thought Challenging Unit Guide

Few things in life are as important as talking to yourself kindly. If you want to achieve a goal or live a happy life, you need to talk to yourself like you are your own best friend. It’s hard to stay motivated or positive if we are too critical or feeling hopeless about a situation. When everything feels like too much, negative thinking can become routine and get in your way. In this unit, you’ll learn how to break the cycle and challenge the thoughts that keep you down.

  • Keep a Thought Diary
  • Track Unhelpful Thoughts
  • Find Evidence
  • Balance Your Thoughts
Audio Tip
Dr. Christine Korol explains how our thoughts affect our mood, not our situation

Different Perspectives

Most people believe their feelings are the result of what happens to them. If you failed a test, had a fight with your best friend, or you lost your wallet — you’re going to feel bad, right? But not everyone will react the same way, even in a tough situation. Thoughts like “I’m such an idiot” will make you feel worse, while thoughts like “I’ll do better next time” will make you feel a bit better. In the end, it’s our thoughts about things or events, not our situation, that determine how we feel.

Audio Tip
Dr. Suja Srikameswaran talks about practicing self-compassion when depressed

Why Challenge Thoughts?

When you’re worrying or feeling down, most people will tell you to “let it go.” The problem is that’s easier said than done! The only way to let go of an unhelpful thought is to challenge it enough that you no longer believe it. If you try to force yourself to think, “It’s all going to be okay,” when you don’t believe it, you’ll feel worse.

Audio Tip
Dr. Theo DeGagne talks about keeping a thought diary

Keep a Thought Diary

Sometimes, thoughts can come so quickly that you don’t notice them. The best way to track these sneaky thoughts is to keep a thought diary. Act like a detective. Keep track of the feelings and thoughts you experience in specific situations. It is important to track the strength of your feelings too. Your therapist can help you identify some of your unhelpful thoughts if you are feeling stuck.

A thought diary looks something like this:

What was happening? Feeling and Strength Thoughts
I was sitting on the couch watching TV. Sad → 60%
Anxious → 40%
Disappointed → 80%
“Will I ever get better?”
“What’s wrong with me?”

Start a Diary

Pick a situation that is troubling you right now. It may be something that just happened a moment ago. It could be something that happened in the past but still continues to bother or worry you.

What was happening?

Remember that the situation doesn't have to be the cause of your feelings. Sometimes an event causes a big reaction, like getting fired. Other times your feelings and thoughts aren't related to what you're doing. Like if you started to cry while taking a shower. You can use a thought diary for any type of situation.

750 characters remaining

Your Feelings

How do you feel right now when you think about that situation?

If it is a past event, don’t try to remember how you felt then. How do you feel at this moment when you reflect on the situation?

Select up to 5 feelings:

Rate Your Feelings

Now rate how strong your feelings are from 0-10. Remember to focus on the feelings you have right now, not during the event.

We’ll keep track of how strong your feelings are after challenging your thoughts too. This will help us see if the exercise is helpful.

Your Thoughts

What is going through your mind right now when you think about this situation?
If you’re feeling stuck, ask yourself these questions:

What does this say about me? My future? Why does this situation feel difficult? What does this say about others?

700 characters remaining

Keep Using your Diary

Good job! You’ve started to use a thought diary.

Just recording your situations, feelings and thoughts can take practice. It’s okay if you don’t feel ready to start challenging your thoughts. Keep practicing with your therapist and come back when you’re ready.

If you’ve got the hang of keeping a thought diary then it’s time to start challenging your thoughts. Keep going!

Pick the Most Unhelpful Thought

It’s common to have many thoughts about a situation. Pick the thought that causes the most trouble, anxiety or sadness. You’ll work on challenging this one thought for the rest of the exercise.

Sometimes thoughts don’t work well in thought challenging. Use these tips to pick a suitable thought:

Match Up

Make sure your thought is connected to one of your feelings about the situation. If the thought makes you feel sad, angry or some other emotion, it's a good thought to choose.

Audio Tip

Choose a thought that is testable. If your thought starts with “What if” then you can't prove it true or false. These thoughts are not good for thought challenging.

Audio Tip

Here are your thoughts. Which would you like to challenge?

Rewrite the thought you’d like to challenge and “let go” of.

500 characters remaining

Evidence for the Unhelpful Thought

Do you have any evidence that your thought is true? For example, if your thought is “Jim is mad at me,” your evidence might be that he didn’t return your call. Maybe the email he wrote you seemed cold.

People sometimes realize that they can’t find any proof to support their unhelpful thought. You might think it, but there are no facts that make it true! That makes it easier to let it go.

What evidence do you have that your unhelpful thought is true?

850 characters remaining
Audio Tip
Dr. Suja Srikameswaran explains how thought challenging can improve self-compassion

Challenge the Thought

It is almost impossible to let go of a thought if you still believe it! The best way to get rid of a thought is to challenge it until you don’t believe it anymore. To challenge a thought, you must find evidence that disagrees with it. Play devil’s advocate. Look for proof that your unhelpful thought is false or just not completely true.

For example, let’s go back to the thought “Jim is mad at me.” Evidence against this thought could be that Jim smiled at me while saying hello this morning. Sometimes his emails come off as cold when he’s busy.

Challenge your Unhelpful Thought

Here's your unhelpful thought:

What evidence do you have that this thought is not completely true? Include everything you can think of even if it seems too small to mention.

850 characters remaining
Audio Tip
Dr. Colleen Cannon discusses how to talk to yourself in a supportive way

Balanced or Helpful Thoughts

Forcing yourself to think happy thoughts won’t make you feel better. If you don’t believe a positive thought is true, it could make you feel worse. The trick to feeling better is to find a balanced or helpful thought. These thoughts take both the positive and negative evidence into account. Balanced thoughts are more encouraging and supportive than positive thoughts.

Here are some examples comparing positive versus helpful thoughts:

Positive Thoughts Balanced or Helpful Thoughts
I’m a great friend. I’m not perfect but I am a good friend. I may not always be there for my friends, but I know that this will get better as my mood improves.
I can do anything if I put my mind to it – including getting over my problems! It might take some practice, but I feel a little more hopeful that I can feel better by changing how I talk to myself.
Everybody in my life is supportive and helpful. I’m getting better at knowing who to count on in my life. I’m not 100% confident, but I’m willing to practice trusting a few people who I think are nice.

Your Balanced Thought

Take a look at your positive and negative evidence:

Use this evidence to help you make a new balanced thought. If you’re feeling stuck, don’t worry. Balanced thinking can be tricky and your therapist can help you get the hang of it.

750 characters remaining

Re-rate Your Feelings

Now that you have worked on your balanced thought, take a moment to re-rate your mood. We can compare the strength of your feelings before and after thought challenging. A drop of at least 2 or 3 points in at least one of your emotions tells us that the exercise was helpful.

Audio Tip
Dr. Christine Korol discusses the importance of practicing thought challenging

Practice Makes Perfect

Thought challenging is one of the harder things to learn in cognitive therapy. Remember that it does get easier with practice and help from your therapist. Most people find after practicing 50 or more times that they have fewer unhelpful thoughts. Also, balanced thinking becomes more automatic. Challenging your thoughts 50 times might seem like a lot, but you’ll get faster at it the more you practice.

Sean's Story

Don’t remove

Sean was finishing up his day at work when he realized that he made a typo in a company-wide memo. He always proof-reads his emails before sending and couldn’t believe he’d missed such an obvious error.

Sean’s emotions started spiralling. He felt embarrassed, angry, irritated and ashamed. “I can’t cope with normal life,” Sean thought. “I’m such an idiot. I can’t concentrate!”

But hold on! Sean began to challenge his unhelpful thoughts. He reminded himself “Everybody makes mistakes; even my boss makes typos sometimes.” He noted that “If co-workers tease me, I can handle it.” And finally, “I’m not an idiot because I just finished a big project that was very successful.”

After challenging his unhelpful thoughts, Sean was able to rework his thinking and create a balanced thought: “I’m not at my best right now, and I make mistakes, but all things considered I do more things right than wrong.” Sean noticed that self-encouragement worked better than self-criticism. He felt better, could focus on his work, and move on with his day more quickly when he shifted how he talked to himself. Sean now tries his best to be kind to himself, especially when he makes mistakes.

Good job! You’ve Created a Thought Record

Download Your Worksheet

Good job! You’ve learned how to make a thought record and challenge unhelpful thoughts. If you’ve been hard on yourself or thinking unhelpful thoughts for awhile, it can take some work to break that habit. The more you practice thinking balanced or helpful thoughts, the more natural it begins to feel. Try challenging a few thoughts a day and share them with your therapist who can help you tweak them until you don’t believe them anymore. If you have a few unhelpful thoughts that keep creeping back, it’s a good idea to write down a few balanced thoughts or responses on a card to keep as a handy reminder.


Congratulations! You’ve Started to Practice Challenging Your Thoughts

Continue making thought records and creating balanced or helpful thoughts. If you’re feeling stuck you can review this unit or talk to your therapist or healthcare provider.

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I’ve got an online therapist:
I’m working on my own:

Aligning Values

Aligning your values can increase the quality of your life
Aligning Values Unit Guide

Chronic pain can seem to put your life on hold. In this unit, you’ll learn how to discover or re-discover your values and create new goals to improve your quality of life despite having pain.

It is undeniable that chronic pain comes with losses and adjustments in your life. Sometimes you may get preoccupied with a single-minded focus on decreasing your pain to the exclusion of other aspects of your life.

To increase the overall quality of life while living with chronic pain – incorporate the losses into your life, learn to identify your current values, develop goals, and learn to prioritize.

  • Grief in Chronic Pain
  • Identifying Your Values
  • Develop Goals
  • Learn to Prioritize

Grief in Chronic Pain

It is understandable to wish chronic pain could go away permanently. It is natural to be in denial that chronic pain will actually come and go in varying intensities, often for life. No one wants to feel the emotional pain of loss. It is, however, within the vast expanse of the human experience, not outside of it. Sometimes, our very efforts not to feel the emotional pain can magnify them.

You probably never expected to be living with chronic pain or to have your chronic pain dramatically change your life. You may have once felt reassured that your pain could stop and your life could go back to the way it was before – relatively pain-free. You are reading this, so that did not happen. What now?

A central part of being able to accept a significant and unwelcome change in life such as chronic pain is to be able to recognize and face the losses you have had because of it. The grief in chronic pain is real and also unique to each individual.

Everyone will experience losses associated with chronic pain differently. For some, it is a change in the speed at which they accomplish tasks that is difficult to accept. For others, it might be the realization that they will not achieve in their career what they had hoped. For still others, the most significant loss might be the healthy or even infallible image they had of their physical self.

Your losses are real. What losses have you experienced because of chronic pain? Write as much as you like. You may experience some increased intensity of emotion in this writing, that is normal. It is important, but can be difficult to acknowledge these losses, so as you do this exercise, it’s also important to bring some compassion to yourself.


Audio Tip
Erin Goodman, MSc, OT, outlines a course of treatment that focuses on acceptance and values.

From Loss to a Transformed Life

This unit asked you to acknowledge your losses and to incorporate the limitations associated with the losses into your life. The next step is being able to improve your quality of life despite having pain by discovering your values, creating goals and prioritizing your time and energy in a way that is aligned with those values and goals. Knowing your values and then setting goals that align with them can increase your belief that you can succeed in your life and accomplish tasks that you have set out for yourself. Working toward the goals you have set for yourself helps you to be accountable to yourself and feel a renewed sense of control in your life.

Got It

Audio Tip
Dr. Francois Botha explains how he uses value clarification in therapy.

Identifying Your Values

Finding meaning in life is an individual process, best determined by our unique set of values. Values are aspirational, meaning that they will never be completely achieved.

We can differentiate between desires (such as rich, happy, and pain-free) and values (such contribution, integrity, creativity, and fun).

Chronic pain teaches us that our energy is finite. Our values give us a direction on how we want to spend our time and energy. Experiencing a significant life change such as chronic pain can motivate you to decide how you want to spend your limited time and resources.

Determining the values that are most important to you can help you gain clarity about your goals and what you want your life to stand for.

Identify the five values that are most important to you from the list below on the left and drag these one by one from the list to the teal green box underneath Your Values on the right.

Your Values
  • Beauty
  • Community
  • Compassion
  • Contribution
  • Connection
  • Creativity
  • Dignity
  • Family
  • Friendship
  • Home
  • Hope
  • Humour
  • Integrity
  • Learning
  • Love
  • Loyalty
  • Nature
  • Nurture
  • Parenting
  • Partnership
  • Play
  • Pleasure
  • Relationship
  • Safety
  • Self Expression
  • Self Respect
  • Spirituality
  • Spontaneity
  • Trust
  • Work


    Audio Tip
    Sandy Patola-Moosman, MA, RCC, explains how she helps clients set long and short-term goals.

    Develop New Goals

    Write down any ideas you have, even if you don’t think they are possible or practical. The purpose of the exercise is to get you to start thinking of a meaningful future.

    When you are determining what goals you would like to work on, you will need to ensure that your goals are meaningful and guided by your values.

    • Choose goals that move you in a direction that helps you to live your values.
    • Choose goals that are realistic, achievable, and time-framed. These guidelines help you to be specific about your goals with the result that you are more likely to achieve them.

    Once you have selected some goals, you will need to determine specific, well defined actions you want to take towards each goal. Choose actions that are realistic. You are more likely to take action when you decide to do something that is possible. The sooner you take action, the more likely other activities will not get in your way. It can be helpful to set smaller goals to start with to ensure success in achieving them, rather than a large goal.


    Audio Tip
    Dr. Margaret Drewlo explains how she helps clients set priorities.

    Learn to Prioritize

    Now that you have identified your current values and formulated goals, learning how to prioritize your time and energy can help ensure you can act on the goals you have set for yourself.

    Prioritizing is vital when you are living with chronic pain. Adapting to your new energy level and competing demands on your time on any given day is essential. Prioritizing involves a daily decision about what is most important that day and allowing yourself to let other priorities be set aside for the time being.

    When prioritizing, you will need to move towards accepting yourself and the reality of your abilities as they are, not as you think they should be or how you would like them to be. You can choose activities for your day that take you in the direction of your values and take into account where you are at this time in your life and the situation you are in. If you aren’t sure, you can ask yourself, “Is this an action that aligns with one of my goals?” “Is this an action that takes me in the direction of my goals?” “Does this action take into account my current energy level?” “Is this action realistic for me today?”

    By setting priorities we take into account that our circumstances are likely to change day-to-day. Even if we cannot accomplish everything we would like to on a given day, we can accomplish something that is important to us, and that can feel empowering.

    Download your worksheet at the end of this unit for an opportunity to try-out setting a priority.

    Anika’s Story

    Anika had been involved in a physically challenging sport as a gymnast for ten years before chronic pain emerged. Chronic pain eventually contributed to her stopping gymnastics. For a while, she tried to keep up with everything she used to do in her life. She still cared for family members, continued to volunteer at a charity connected to gymnastics and kept up with her studies in college.

    Later on, Anika stopped having her friends over, stopped going out at night, and quit her swim class, all to conserve energy. Eventually, Anika realized that she was doing a lot of things she thought she should. She was not doing a lot of things she actually enjoyed.

    While working through online chronic pain units, Anika realized she had no idea of what was really important to her anymore. Nothing seemed particularly interesting or rewarding. Although Anika was not sure of what was important to her, she did know that doing more of what she was already doing did not appeal to her. She thought that her chronic pain needed to be resolved before anything good could happen for her. She felt stuck. Anika did not know how to move forward.

    Anika completed the values exercise as part of the work she was doing in Kelty’s Key. From the reading in the course, Anika remembered that values are different from something she desires (like being rich or pain-free), or something she wants to do or achieve (goals).

    Out of many possible values, Anika determined that fun; making a lasting contribution in the world; family; home; and self-respect were her top five values. Once Anika understood her most essential values, she was able to set realistic goals that fit with her values and her current abilities.

    Fun pursuits had not been part of Anika’s day to day life for some time. She decided to try a few different things to see if they were satisfying to her, such as an online cartooning class, a two-hour jewelry making course, and a stand-up comedy class. To move towards her value of creating a lasting contribution Anika thought about setting up a scholarship at her old high school. She decided to put that idea on hold because of the ongoing financial commitment involved but offered instead to mentor students in filling out scholarship applications and crafting university personal statement essays.

    Anika discovered that her last three goals were closely connected. She already did the majority of caregiving for older family members and was committed to making sure they continued to be cared for. Spending a lot of time helping relatives do errands meant that she missed being in her own home, which was a place of comfort and nurturance for her. Anika decided to invite her siblings to divide up caring giving tasks instead of Anika doing the majority by herself. She wanted to continue to keep family central in her life but also to maintain the emotional grounding that she received by being in her home and respect herself enough to speak up for her own needs. Anika was starting to accept the reality of who she was at this time in her life. To Anika’s surprise her brothers and sisters were happy to help out in caring for the family. After adjusting her expectations of herself, and communicating with her family, Anika got to spend more time in her own home, and family relationships were improved all around.

    Good Job! You've Learned How to Align Your Values

    Download Your Worksheet

    You’ve learned about the importance of discovering or re-discovering your values. You learned about acknowledging losses that come with chronic pain. You learned about determining what your values are. You learned about choosing goals based on your values. In the past you may have hoped that chronic pain would go away. In this unit you have learned that chronic pain requires adaptation in your life. Keep working on your goals. You may find that even with chronic pain your quality of life may improve because you are spending your time and energy on things that really matter to you.


    Congratulations! You Are Doing the Work

    Continue to work on incorporating the principles of values, goals setting, and prioritizing into your life. If you’re feeling stuck, you can review this unit or talk to your therapist or healthcare provider.

    I’m using the self-help:
    I’ve got an online therapist:
    I’m working on my own:

    Core Beliefs

    Beliefs can distort experiences and thoughts.
    Core Beliefs Unit Guide

    We all have beliefs about ourselves, others and the world that we have held for a long time. These underlying beliefs can affect how we interpret our lives. If you hold a negative core belief you may have a habit of only noticing what fits in with it. This bias can get in the way of thought challenging. No matter how hard you work at it, your mood might crash whenever specific thoughts appear. To continue working through your depression or anxiety, you need to tackle your core beliefs. In this unit, you’ll learn how to break apart your core beliefs and start seeing the world from a different angle.

    • Identify a Core Belief
    • Find Evidence
    • Balance Your Belief
    • Daily Reinforcement
    Audio Tip
    Dr. Francois Botha explains what core beliefs are.

    Trapped by Core Beliefs

    If you’ve been challenging your negative thoughts for a while, you’ve probably become quite good at it. It should be easier to review your thoughts and come up with something more balanced.

    However, you may notice that some thoughts are still getting you down, despite your hard work. It may seem like you can’t shake them, no matter how much challenging you do.

    Your problematic thoughts probably fall under a general theme. Are they all about being unlikeable? Maybe they revolve around being unsafe. If this is the case, a core belief is likely keeping you stuck.

    Core beliefs are more than just a group of thoughts. They are deep-rooted ideas or assumptions about yourself, others and the world. Core beliefs tend to be rigid and not easily broken down. To overcome your anxiety or depression, you need to rework your core beliefs.

    Audio Tip
    Dr. Mahesh Menon discusses how core beliefs form and their usual content.

    Fundamental and Powerful

    You may wonder how your core beliefs formed in the first place. Where did they come from? Core beliefs are created through your life experience. When you are young, what you see, hear, and do, gets interpreted into rigid laws and rules about the world. For example, say school was hard as a child, and you got a lot of criticism or negative feedback. This experience could lead to a global belief like “I’m stupid.”

    Core beliefs, as the name suggests, tend to be central and fundamental. In fact, at their root, core beliefs focus on our ability to survive. They often fall into these categories: safety, likability, and capability. Being safe and a valued member of your community can mean life or death. From an evolutionary perspective, it’s no wonder that core beliefs are so emotionally powerful!

    Let’s explore the categories of core beliefs a bit further. Core beliefs about safety may be something like “I’m helpless,” or “The world is a dangerous place.” For likability, you may hold beliefs like “I’m unlovable,” “I’m a bad person,” or “People are judgmental.” Finally, in the capability category, you may find the beliefs “I’m incompetent,” or “It’s a dog-eat-dog world.” A core belief may fit into more than one category at a time. What they all have in common is the suggestion that you won’t prevail. There is something that may prevent you from surviving in our world.

    To protect against this threat, many people cope by creating conditions or rules. You may tell yourself “I’ll be safe as long as I’m in control,” or “I’m lovable if I can make everyone happy all the time.” You might try to live by the rule that “I’m competent as long as I don’t make any mistakes.” As you can see, these conditions tend to be nearly impossible to uphold. No one is immune from making mistakes! How can you keep everyone happy all the time? It’s only natural that you’ll eventually “fail” at maintaining these impossible standards. When this happens, your core belief is exposed, and your anxiety or depression can get even worse.

    Audio Tip
    Dr. Mahesh Menon explains why core beliefs are hard to change.

    The Selective Brain

    Think back to a time when you had an argument or debate with someone, say about politics. Did it seem like facts didn’t matter? Like nothing was going to change your friend’s mind? You were probably left wondering how your friend could completely ignore the side of the story that doesn’t fit with their political view. The same thing happens with core beliefs. It’s not just your friend, we all have selective brains!

    Imagine your mind as a house. Your core beliefs come first. They are the foundation or bedrock of the whole building. When you experience something, your brain takes in all the pieces that fit with your core belief. These experiences add bricks and walls to the house. What doesn’t match the foundation is ignored and left out. In a sense, the human brain takes shortcuts. It’s easier to cast aside experiences that don’t fit into our core beliefs than it is to tear down the house and rebuild from scratch.

    The selective power of the human mind ensures that core beliefs are always reaffirmed. The connections in your brain relating to your core beliefs are very strong. Reworking a core belief means you’ll need to look out for the experiences your mind tends to ignore. You need to offset the selective nature of your brain. It’s not easy, but you can do it.

    Audio Tip
    Dr. Francois Botha discusses how to identify a core belief.

    Find a Core Belief

    The first step to challenging a core belief is to identify one. This task may not be so easy. You may find you see the rooms and windows of the house but not the foundation. If that's the case, it may help to work in reverse. Start by writing down a common negative thought. Then ask yourself, "What does this say about me? Or others? Or the world?" Keep doing this exercise until you reach the central idea, your core belief.

    Keep in mind that core beliefs tend to fall into the categories of safety, likability, and capability. It may also help to think of a core belief as a statement starting with "I am...," "People are...," or "The world is...." Other core beliefs may start with "God is…," "My life is…," or "The universe is…"

    Start with a problematic negative thought and work down to your core belief.

    300 characters remaining

    What does this say about you, others, or the world?

    300 characters remaining

    What does this say about you, others, or the world?

    300 characters remaining

    What does this say about you, others, or the world?

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    Feeling Stuck?
    Safety:I am powerlessThe world is dangerousI am out of control
    Likability:I am unattractivePeople will reject meI am toxic
    Capability:I am ineffectiveEveryone is better than meI am defective
    Please only select one


    Audio Tip
    Dr. Margaret Drewlo explains how to identify evidence that a core belief is not entirely true.

    Challenge your Belief

    Once you've identified a core belief, you can start to challenge it. Remember that your brain is selective. It has a habit of only letting in the experiences that fit with your core belief. For this reason, it may be hard to find evidence that shows that your core belief is not true. You may need to work at it. If you are feeling stuck, there are a few things you can try. You can ask friends or family members for help or think about recent activities you've done. It may also help to look at examples in your thought diary.

    Here's your core belief:


    What evidence do you have that your core belief is not completely true? Include everything you can think of even if it seems too small to mention.

    750 characters remaining

    Balanced Beliefs

    Similar to thought challenging, the key to reworking a core belief isn’t to make it 100% positive. You need to create a balanced belief. Pretending that life is all sunshine and rainbows won’t help. You need a belief that is realistic. It should capture both the negatives and the positives about yourself, others or the world.

    Here are some examples comparing negative, positive, and balanced core beliefs:

    Negative Belief Positive Belief Balanced Belief
    I am useless. I am competent at everything. I can do certain things well, but not everything. I make mistakes sometimes, but I am also able to learn from them.
    Nobody loves me. Everybody loves me. I have a few good people in my life that love me.
    The world is better off without me. I am a really important part of this world! While my existence might not be important to the world at large, I do my best to help out my community. The people I connect with are happy I am in their lives.
    Audio Tip
    Dr. Mahesh Menon describes the important characteristics of a good balanced core belief.

    Your Balanced Core Belief

    Take a look at your evidence that does not support your core belief:


    Use this evidence to help you make a new balanced core belief. If you’re feeling stuck, don’t worry. Reworking core beliefs can be tricky and your therapist can help you get the hang of it.

    750 characters remaining
    Audio Tip
    Dr. Francois Botha discusses techniques that help reinforce a balanced core belief.

    Boost Your Belief

    Creating a balanced core belief is a good step forward, but you won’t feel real change until you reinforce it. Remember that your brain is selective and ignores information. Just writing down a new balanced belief won’t be enough to change your thinking. You need to start doing little things every day to strengthen it.

    Start by writing down experiences each day that support your new belief. Keep a diary or notebook. This exercise will help you notice what your brain tends to dismiss. You don’t need big events! Small things count. A conversation or minor situation can be good evidence for your new belief.

    Audio Tip
    Dr. Margaret Drewlo explains how to address setbacks.

    Don't Sweat It

    Some people worry when new evidence for their old belief comes up. You might panic and think that your old belief was right after all. The truth is, life happens, and sometimes things won’t go your way. Your new core belief is balanced and includes the positive and negative. Evidence that supports your old belief doesn’t automatically oppose your new one. In fact, finding the negative has never been the problem! Nobody is perfect, and that’s not the goal. Try not to sweat it and keep working on finding evidence that supports your new balanced belief.

    Adeline's Story

    Adeline always believed that if she had a good job, she was a success. At her work, she was able to climb the ranks until finally reaching her dream job as a sous chef. Unfortunately, after a few months, Adeline's boss told her it wasn't working out. Out of work, Adeline felt her world crashing down and became depressed.

    Adeline began to work through her depression with the help of a therapist. She started to reconnect with friends and challenge her negative thoughts. She also got a position volunteering at a soup kitchen. On the outside, everything seemed to be going well. But despite her hard work, Adeline's mood still plummeted every time she made a mistake. It was as though some thoughts were too strong to challenge away.

    Today, Adeline and her therapist work through her thoughts and identify a core belief. "I am incompetent and defective." They begin to look for evidence that this belief is not true. Adeline points out that she is valued and trusted by her friends. She also notes that she gets good feedback when volunteering. Adeline's therapist agrees with this evidence and suggests there is more. He reminds Adeline that she doesn't usually give herself credit for what she does well.

    Adeline and her therapist develop a new balanced belief. To help reinforce it, Adeline keeps a diary. She writes down little things that happened each day that support her new belief. This exercise helps her notice the daily achievements she was ignoring. It also stops Adeline from discrediting her abilities. A few months later, Adeline is still hard on herself when she makes a mistake. But her mood doesn't crash. She's able to see that one mistake doesn't define her.

    Good Job! You've Started Working on a Core Belief

    Download Your Worksheet

    Good job! You’ve learned about core beliefs and how to reframe them. Remember that core beliefs are deeply ingrained and will take time to break down. Keep working on your new balanced belief with your therapist. Record evidence that supports your new belief every day to help strengthen it. A diary of positive experiences can be handy to look on back on if your original core belief creeps up.


    Congratulations! You’ve Begun to Rework a Core Belief

    Continue identifying core beliefs and reworking them. Create new balanced beliefs and reinforce them with daily evidence. If you’re feeling stuck, you can review this unit or talk to your therapist or healthcare provider.

    I’m using the self-help:
    I’ve got an online therapist:
    I’m working on my own:
    Useful Tools


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