Sunday, April 2, 2017

Who Should Be Managing your Fibro?

Primary Care Physicians are inundated with Fibromyalgia and Chronic Fatigue cases. In the current climate of managed care,  an ill patient receives an average of 10-15 minutes of attention from the well-meaning doctor, and leaves with a prescription or a referral. A person with Fibro often gets bounced around to a number of specialists, including rheumatologists, neurologists and orthopedists before returning to the PCP without answers or solutions. This causes a great deal of frustration for both doctor and patient, and that frustration often leads to less attentive care rather than more.

Many physicians are now prepared to offer a diagnosis of Fibromyalgia based on the presence of pain points, following a reasonable diagnostic process of elimination of other conditions. This does represent progress as compared to ten years ago, when there was less understanding of the condition and therefore, less compassionate, less comprehensive care. However, there has not been as much progress in the area of management of care. People with Fibro require a certain touch, and that is often outside of the availability and skill set of the PCP.

According to the most current information available, the largest number of people with Fibro benefit the most from a multimodal treatment approach. Some combination of medications, alternative treatments, nutrition and exercise seems to offer the most consistent relief for chronic pain and other symptoms of Fibro, and success of these treatments is augmented significantly by the addition of cognitive behavioural therapy. However, in most cases the primary care physician is not in a position to manage such an array of treatments and has neither the time nor attention to manage the needs of these patients effectively.

As an alternative, the job of management could be transferred to the cognitive behavioural therapist, who is not only more versed in treatments available, but is uniquely suited to assist the patient in managing day to day functioning, and this greatly increases the likelihood the patient will comply with the treatments recommended by the physician and/or psychiatrist.

Fibromyalgia is painful and debilitating. Effective treatment requires innovation, focus and perseverance, and we can get there.

Sara Halevi Kalech is a Cognitive Behavioral Therapist specializing in the treatment of Fibromyalgia and CFS. She will be presenting a series of training courses on this topic for physicians, psychiatrists and mental health professionals in Israel in May and June. For more information visit

Tuesday, March 21, 2017

Why are Teenagers Getting Fibro?

There are many things that are unique about adolescence. It is a developmentally tumultuous time that involves many physical and emotional systems. When a teenager is having a normal day, they are inundated with hormones, physical growth, emotional confusion and intensive brain activity. Introduce stress and sometimes the balance is tipped a bit too much. Teenagers are suffering from stress-related and stress-induced illnesses like never before. Recent studies suggest that seven percent of all teens suffer from chronic illnesses like Fibromyalgia or Chronic Fatigue Syndrome. While these illnesses have traditionally been far more common among women and girls than men or boys, this is beginning to shift. There is no known cause for Fibro, and as of yet, no known cure. There are many treatment options, but unfortunately no one treatment helps everyone.

One thing we do know, however, is that stress is a huge factor in the onset of chronic illness, and Fibromyalgia has been gaining popularity among teenagers at an alarming rate. Defined as a collection of pain points throughout the body, Fibromyalgia is a debilitating, intractable and mysterious condition. It is a long and arduous process to diagnose in adults, and even more so in teens. If you believe your teenager might have Fibromyalgia, it is essential that your doctor eliminate as many other possible conditions that may be life threatening. Fibro is annoying and hard to live with, but not fatal.

So, why are teenagers coming down with Fibro? There are a number of possible explanations. The most obvious is stress. Teenagers are under incredible amounts of stress while they juggle their insecurities and shortcomings in a competitive and success-driven adult world. They are inundated with information and flooded by constant communication without end. They are less physically active than ever, yet more stimulated than ever.

I heard a theory this week that people are stressed because of the lack of face-to-face contact, as so much of our social interaction is done online. The natural triggers for the parasympathetic nervous system, the part responsible for calming, are less available when we are communicating remotely. All of these things combined make for a stressed out teen population.

I worked with a teenage girl a few years ago who climbed into bed with a virus and didn't get up for three months. She is doing great now, but had to work very hard to find her way out of the fog. There were a few things about her case that were uniquely teen: One, she was torn between pleasing her parents and doing what seemed right for her. Two, she enjoyed being at home with her mom while she was ill.

During the course of our work together, she used the tools of CBT to shift her thinking enough to get well and stay that way. The good news is that teens are naturally flexible in their minds and are more responsive to treatment than most adults.

So, if your teen has unexplained chronic pain and fatigue, speak to your doctor about Fibromyalgia as a possible diagnosis.

Sara Halevi Kalech, MA CBT is now available by Skype, anywhere in the world. Email her at and get help today.

Monday, January 2, 2017

How Fear Makes Pain Worse

Everyone experiences pain. There are no exceptions to this. In graduate school I often heard a well-worn phrase, "everyone's pain hurts." That was brought to teach us not to judge our clients, to accept that everyone has a different ability to tolerate pain, and so we should never think we would tolerate someone else's pain better than they do. One difference in the various degrees to which people tolerate pain seems to be the amount of fear the client engages in response to the pain.

This is a sophisticated partnership. As soon as the brain receives the pain signal, the fear instinct kicks in. This is a beautiful thing, as the signal for pain tells the primitive basic survival instinct that the body is in danger. The fear reflex brings with it a series of mechanisms that assist the fight or flight instinct, many of which are recognisable: muscles tense, breathing becomes rapid and shallow in order to increase oxygen flow to the muscles, and the mind shifts its focus to become hyper aware of the painful sensations it wants to avoid.

The problem with allowing the fear reflex to take over is that it prepares us for something that never comes. The experience of pain that is not being induced by a lion's jaw clamping down on our thighs is exacerbated by the stress reaction. In other words, once the fear kicks in, bringing a host of physical and psychological responses with it, all of that preparedness just sits there, making us anxious. And, this makes the pain even worse!

So, what do we do if the body is NOT in danger?

We can stop the pain-fear reflex from happening.With mindfulness and other meditation techniques, we can unlearn this primal pattern of pain-fear and undo the process of gearing up for fight or flight. We can learn to talk ourselves down from the hyper-alert readiness state, and relax our bodies. Once we unwrap all the layers of fear and stress, an amazing thing happens: The pain hurts less.

As it turns out, fear is far more painful than just pain. The pain we experience with Fibro will not do us any actual harm. We have nothing to fear from this pain. It's just pain. It's not dangerous. When we allow this message into our deeper being, we hurt less. I encourage you to try it.

Need help managing your chronic pain or illness? Contact me to set up a Skype counselling session. Email me

Wednesday, December 14, 2016

Open the Jar

Clearly, pain is in the body. So when people tell Fibro sufferers "it's all in your head," it's not only unhelpful but it's offensive. Truly, pain is in your body — and in your head. Nerve centers are responsible for carrying pain signals to the brain, which, of course, is in your head. The mind-body connection is not optional, it's all-encompassing and real. We Fibro heroes and heroines know better than anyone that pain affects both the body and the mind. In other words, just because it's in my head doesn't mean it's not also in my body.

The question I am often asked is:

"Can I affect the pain in my body with my mind?"

My answer is a resounding "YES!"

Don't believe me? Try opening a jar. If you strain to open the jar and fail, your hand hurts. If you apply the exact amount of effort and then succeed in opening the jar, your hand does NOT hurt. Why is that? Here's what happened: When you succeeded in opening the jar, your brain gave a little "hurray!" and released a little endorphins. That took care of any bit of pain that might have remained from the effort. Was that a physiological response? No. It was cognitive. Your mind told your body how to handle the situation. That is exceptionally good news. You have the power to affect your pain.

Now, I'm not saying you should be pain free just by thinking differently about your pain, but I do believe it is possible to significantly improve your quality of life by addressing your cognitive process. We start with learning to listen to the messages we tell ourselves. Let's start today by having a few little "hurray!" moments, celebrating even the smallest victories.

Next time: Mind the Pain

Thursday, August 11, 2016

The Fibromyalgia Dialectic: Finding the Balance Between Rest and Move

One of the most confusing aspects of Fibro is that often the person suffering does not know whether to rest more or to move more. These two ideas seem to be diametrically opposed. The truth is, they are both right. And that’s the confusing part.

There is a new and growing trend in treatment called DBT — Dialectical Behavior Therapy. The dialectic addresses two states of mind that seem to be opposites, but actually coexist: the need to accept wherever we are in the moment and the need to change. For the ideal therapeutic result, both the therapist and the patient must understand that they are both true, and operative in the moment. For Fibro patients, they are often caught between the body’s desire to stay still — as interpreted through the amount of pain being perceived, and the knowledge that motion may relieve pain.

It is no secret that exercise helps Fibro, and in fact helps all kinds of chronic pain and illness. The problem with the Fibro sufferer is that they are thinking two things at once:

Mind says, “Go to the pool! Take a walk! You’ll feel so much better!”

Body says, “Accept me where I am! Listen, I’m telling you to rest!”

This is often followed by, “If you go for that walk/swim/yoga class you’ll pay a price. You’ll feel worse later. You’ll over do it. And the pain will be worse tomorrow.”

Pain is then multiplied by the added layer of fear, and motion no longer seems possible.

The therapeutic goal is to recognize that these ideas can and do exist together in the mind, and that does not mean you stay stuck. The secret to successful treatment is to find the balance, and not allow fear to dominate the internal conversation.

Acknowledge pain. Move gently. Allow for healing as a possibility. Be a warrior.

Sunday, August 7, 2016

A Better Model for Treatment of Fibromyalgia

It is estimated that over 5 million Americans suffer from Fibromyalgia, most of them women, the vast majority of those over 40. Fibro is clinically defined as pain in a number of points throughout the body, and symptoms can also include fatigue, sleep disorder, nausea, headaches, memory loss and depression. Pain and other symptoms can range from mild to severe, and from acute to chronic. While a number of medical treatments have emerged in the last few years, no one treatment helps everyone, and in some cases, treatments that work for a while stop being helpful.

Many doctors feel defeated by Fibro. It’s complicated to treat and Fibro patients are frequently ill. Many physicians are now referring Fibro cases for CBT. This is a great step and can be the key to successful management, even cure. So, how does it work? Let’s take a look:

Now, all of these treatments can be helpful. A combination of these treatments may be the ideal cocktail for lifelong management of Fibro symptoms. However, if the patient is like most of mine, they are not in either a mental or physical state to pursue any treatment that involves getting up out of bed. As it is presented, this treatment model overwhelms the Fibro sufferer with guilt, as they now know how many things they are not doing to help themselves, in addition to being in constant pain. This compounds depression and keeps people in bed.

So, practitioners would be more effective if they learned to think about the treatment model differently. The central goal is to improve the person’s quality of life, which begins with increasing basic level of functioning. When a person is in extreme pain, can’t sleep, and is also depressed, it is not likely that person will be able to get to the gym. So, here is my alternative treatment model:

In this model, the therapist focuses on helping the patient recognize destructive patterns of thought and behavior that keep them stuck.

People often ask me if I believe Fibromyalgia is “all in your head.” I don’t. I think pain and suffering in the body are real. I do believe that there is an emotional/psychological component though, and often the gateway to successful treatment is through the thoughts and feelings. This is also why traditional western medicine is not very successful as a treatment model.

Fibromyalgia is a complex condition, but it can be treated and managed well. A word of caution, though: If someone tells you they have the one cure that works for everyone, try someone else. It’s just not true. But we’ll keep at it until we find one that works for you.

(this post first appeared on Get Help Israel)

Monday, November 26, 2012

Depression with FMS and CFS

Depression can be viewed as both a symptom of fibro and a co-morbid condition. Often when a teenager is finally referred to me for fibro he will report a long-standing depression. Childhood onset depression is slippery and often overlooked. Interestingly enough, symptoms of depression in children and teenagers can include vague aches and pains,[1] particularly headaches and back pain often associated with fibro. As a co-morbid condition, depression is virtually indistinguishable from fibro. Chronic pain and illness are depressing. The question may be whether fibro is a symptom of depression or depression a symptom of fibro, or whether they are simply partners. In either case, it is important to note:
-       Fibro symptoms are known to be alleviated in many cases by SSRIs (like Prozac), SNRIs (like Cymbalta) and other anti-depressant groups[2]
-       SSRIs can cause detrimental side effects and suicidal ideation
-       While psychodynamic therapy might help adults with depression, it is not a good therapeutic choice for an adolescent. Go with CBT.
-       Ritalin can cause or exacerbate depression in teens[3]
-       A severe depression may require hospitalization
 In every case, depression should be taken seriously; it's a serious matter.

[1] Your adolescent - depressive disorders. American Academy of Child and Adolescent Psychiatry. 

[3] Talking Back to Ritalin, Revised : 
What Doctors Aren't Telling You About Stimulants and ADHD
by Peter Breggin, M.D.  Perseus Books, 2001