ElysiaBronsonRCC
Newcomer
I'm a Registered Clinical Counsellor in British Columbia and my caseload is entirely chronic pain, chronic illness and trauma. I also live with several chronic pain conditions myself, including post-surgical occipital nerve stimulation. So I've spent a lot of hours in both chairs, and this post comes out of the friction between them.
I want to start by saying the obvious thing sincerely, because what follows could be misread. The work this community does is real work. Threat appraisal changes pain. Learned protective patterns can be unlearned. People who were told their spine was crumbling have gotten their lives back by taking the danger out of the signal. I'm not here to relitigate any of that, and I don't think the mechanism is in question.
What I keep running into is a narrower problem, and it's the one I'd like to hear how people here handle.
It's the patient for whom the work helps partway.
They do the reading. They do the writing. They stop bracing. And something genuinely shifts — the flares get shorter, the fear drops, they get back to work, they sleep. But they don't arrive at the ending they were promised. They land somewhere around half or two-thirds of the life they had, and then they stall there.
Here's what I see happen next, and it's the part that worries me. Because the framing they were handed was binary — this is reversible, and recovery is available to you if you do the work — a partial outcome doesn't read to them as a partial outcome. It reads as a verdict about them. They didn't dig deep enough. They're still repressing something. They didn't believe hard enough. I have heard all three of those sentences, in almost those words, from people who had in fact improved substantially.
And then the mechanism this community understands better than anyone turns around and bites. Because "I am failing at getting better" is not a neutral thought. It is a threat signal. It raises vigilance, it raises muscle guarding, it raises the volume on everything. The story about the failure becomes a driver of the symptoms. We end up with an approach that is genuinely effective producing a subgroup of people who are worse off for having tried it — not because the model is wrong, but because it was claimed more completely than it can deliver.
I don't think the fix is to teach less of it. I think the fix is in how we set the target at the start.
A physician colleague put something to me a while ago that I've been borrowing ever since. She said that clinically, she doesn't think in terms of recovery. She thinks in terms of remission and relapse prevention. That's ordinary medical vocabulary and it has been enormously useful to me, because it does something the recovery frame can't: it makes a substantial-but-incomplete result into a real clinical outcome instead of an unfinished one. Sixty percent better, held steadily, with a plan for flares, is a success in that vocabulary. In the recovery vocabulary it's a person who hasn't got there yet.
So what I do now, at the start rather than at the point of stall, is name a spectrum out loud. Something close to: here is what this work reliably does, here is the range of how far it takes people, and here is how we'll know it's working. Symptom load comes down. Function goes up. Flares get shorter and less frightening, and you learn to handle one without losing three weeks. Any of those is a real win and we're going to count them as wins when they happen.
I also say, explicitly, that if you improve and then plateau, that's information about your physiology and not a report card on your effort. And I keep a door open — if something isn't adding up, we look again at what else might be going on rather than pushing harder on the psychological work. Some people have more than one thing happening at once. Saying that at the outset costs almost nothing and it means the plateau, if it comes, arrives inside a frame that can hold it.
The clearest example I've worked with was someone with POTS. She had done a great deal of nervous-system work by the time we met, and it had genuinely helped — her fear of her own symptoms had come way down, she'd stopped bracing through every episode, and that mattered. But she was still greying out when she stood up, and she had begun to read that as evidence she hadn't done the work properly. What she actually needed was treatment for low blood volume. You cannot think your way into more blood. Once that was addressed she improved in a way no amount of further psychological work was ever going to produce — and the nervous-system work she'd already done is a large part of why she could handle the months it took to get there. Both of those things were true at once. Neither was a substitute for the other, and the story she'd been telling herself in between — that she was the problem — was the only part that wasn't useful to anyone.
Which brings me to the question I actually can't settle, and why I'm posting rather than writing this somewhere else.
The obvious objection to everything above is that belief is load-bearing here. If I tell someone on day one that this might take them 60% of the way, have I just handed them a ceiling? Does naming the spectrum early cost me the conviction that makes the work function at all? There's a version of this where I'm being scrupulously honest and also less effective, and I don't think that's a trade I get to dismiss just because honesty feels better.
I've gone back and forth on it for a few years now and I haven't landed. My current compromise is to be unhedged about the mechanism and honest about the range — full confidence that this is worth doing, no promises about where it ends. But I hold that loosely.
So: for those of you working with people who improve substantially but not completely — how do you frame the target at the outset? Do you name the range, or do you protect the belief and deal with the plateau if it arrives? And if you've watched someone take a partial result as a personal failure, what actually helped?
Elysia Bronson, MA, RCC — chronic pain, chronic illness and trauma. Abbotsford, British Columbia.
I want to start by saying the obvious thing sincerely, because what follows could be misread. The work this community does is real work. Threat appraisal changes pain. Learned protective patterns can be unlearned. People who were told their spine was crumbling have gotten their lives back by taking the danger out of the signal. I'm not here to relitigate any of that, and I don't think the mechanism is in question.
What I keep running into is a narrower problem, and it's the one I'd like to hear how people here handle.
It's the patient for whom the work helps partway.
They do the reading. They do the writing. They stop bracing. And something genuinely shifts — the flares get shorter, the fear drops, they get back to work, they sleep. But they don't arrive at the ending they were promised. They land somewhere around half or two-thirds of the life they had, and then they stall there.
Here's what I see happen next, and it's the part that worries me. Because the framing they were handed was binary — this is reversible, and recovery is available to you if you do the work — a partial outcome doesn't read to them as a partial outcome. It reads as a verdict about them. They didn't dig deep enough. They're still repressing something. They didn't believe hard enough. I have heard all three of those sentences, in almost those words, from people who had in fact improved substantially.
And then the mechanism this community understands better than anyone turns around and bites. Because "I am failing at getting better" is not a neutral thought. It is a threat signal. It raises vigilance, it raises muscle guarding, it raises the volume on everything. The story about the failure becomes a driver of the symptoms. We end up with an approach that is genuinely effective producing a subgroup of people who are worse off for having tried it — not because the model is wrong, but because it was claimed more completely than it can deliver.
I don't think the fix is to teach less of it. I think the fix is in how we set the target at the start.
A physician colleague put something to me a while ago that I've been borrowing ever since. She said that clinically, she doesn't think in terms of recovery. She thinks in terms of remission and relapse prevention. That's ordinary medical vocabulary and it has been enormously useful to me, because it does something the recovery frame can't: it makes a substantial-but-incomplete result into a real clinical outcome instead of an unfinished one. Sixty percent better, held steadily, with a plan for flares, is a success in that vocabulary. In the recovery vocabulary it's a person who hasn't got there yet.
So what I do now, at the start rather than at the point of stall, is name a spectrum out loud. Something close to: here is what this work reliably does, here is the range of how far it takes people, and here is how we'll know it's working. Symptom load comes down. Function goes up. Flares get shorter and less frightening, and you learn to handle one without losing three weeks. Any of those is a real win and we're going to count them as wins when they happen.
I also say, explicitly, that if you improve and then plateau, that's information about your physiology and not a report card on your effort. And I keep a door open — if something isn't adding up, we look again at what else might be going on rather than pushing harder on the psychological work. Some people have more than one thing happening at once. Saying that at the outset costs almost nothing and it means the plateau, if it comes, arrives inside a frame that can hold it.
The clearest example I've worked with was someone with POTS. She had done a great deal of nervous-system work by the time we met, and it had genuinely helped — her fear of her own symptoms had come way down, she'd stopped bracing through every episode, and that mattered. But she was still greying out when she stood up, and she had begun to read that as evidence she hadn't done the work properly. What she actually needed was treatment for low blood volume. You cannot think your way into more blood. Once that was addressed she improved in a way no amount of further psychological work was ever going to produce — and the nervous-system work she'd already done is a large part of why she could handle the months it took to get there. Both of those things were true at once. Neither was a substitute for the other, and the story she'd been telling herself in between — that she was the problem — was the only part that wasn't useful to anyone.
Which brings me to the question I actually can't settle, and why I'm posting rather than writing this somewhere else.
The obvious objection to everything above is that belief is load-bearing here. If I tell someone on day one that this might take them 60% of the way, have I just handed them a ceiling? Does naming the spectrum early cost me the conviction that makes the work function at all? There's a version of this where I'm being scrupulously honest and also less effective, and I don't think that's a trade I get to dismiss just because honesty feels better.
I've gone back and forth on it for a few years now and I haven't landed. My current compromise is to be unhedged about the mechanism and honest about the range — full confidence that this is worth doing, no promises about where it ends. But I hold that loosely.
So: for those of you working with people who improve substantially but not completely — how do you frame the target at the outset? Do you name the range, or do you protect the belief and deal with the plateau if it arrives? And if you've watched someone take a partial result as a personal failure, what actually helped?
Elysia Bronson, MA, RCC — chronic pain, chronic illness and trauma. Abbotsford, British Columbia.
