For some time now I’ve been exploring the contribution of positive psychology on wellbeing in people with chronic pain.  Positive psychology is the ” scientific study of the strengths and virtues that enable individuals and communities to thrive”. (Seligman, ND). It strikes me that in chronic pain management, we’ve responded to the issues raised by people who don’t “live well” with their pain, leaving the group of people who do cope well largely ignored. We have much to learn, I believe, from those who have faced their situation and either been stoic – or in a surprising number, grown from their experiences.  Some excellent resources in the field of positive psychology in general can be found at The Positive Psychology Center and Authentic Happiness, and for Kiwi’s, the New Zealand Association of Positive Psychology.

Gratitude is an emotion that most people feel frequently and strongly (McCullough et al., 2002).  Most people say that feeling grateful makes them feel happy. And oddly enough, gratitude seems to emerge despite difficult circumstances – with some research suggesting that it is in times of intense personal challenge that gratitude is most prominent (Peterson & Seligman, 2003). Immediately after the earthquakes in Christchurch nearly a year ago, people frequently expressed gratitude for one another, for the workers who kept the city running, and for the simple things in life like water, shelter and social support.

The question then arises – is experiencing gratitude empirically related to psychological wellbeing? And the answer is, not unexpectedly, yes! One study showed that gratitude was associated with wellbeing more than the “big five” personality model (Wood, Joseph and Maltby, 2009). It appears that gratitude influences wellbeing in two ways: “directly, as a causal agent of well-being; and indirectly, as a means of buffering against negative states and emotions.” (Nelson, 2009).

The next question is – can we influence wellbeing by increasing gratitude? And so far, research seems to support it.  For instance, in Catherine Nelson’s 2009 review of gratitude interventions, she cites studies in which one group of participants were asked to write down five things they were grateful for each week over 10 weeks, while two other groups were asked to carry this out daily either for two weeks or three weeks. At the completion of the study, it was found that positive affect was increased, and that there appeared to be a dose-response effect. In other words, the more often gratitude was expressed, and the longer this was carried out, the more positively people felt (Emmons & McCullough,
2003).

Interestingly, although we think of gratitude as having an effect on emotion, expressing gratitude can have a direct influence on “physiological coherence”.  This is “increased synchronization between the two branches of the ANS, a shift in autonomic balance toward increased parasympathetic activity, increased heart-brain synchronization, increased vascular resonance, and entrainment between diverse physiological oscillatory systems. The coherent mode is reflected by a smooth, sine wave-like pattern in the heart rhythms (heart rhythm coherence) and a narrow-band, high-amplitude peak in the low frequency range of the HRV power spectrum, at a frequency of about 0.1 hertz.”(McCraty & Atkinson, 2003). What this means is that by expressing gratitude, we may be improving our physiological response to life events.

How do we introduce the idea of expressing gratitude when life is difficult? – for this part of my post today, I’m using my approach, because I haven’t yet found research that identifies “the best way” to do it!

My way is to begin with some mindfulness. Sitting with the person and asking them to be present with what is happening right now. This can be done through focusing the mind on breathing, really experiencing the sensations that occur while breathing – the rise and fall of the abdomen, the cool air in the nostrils when breathing in, the warmer air when breathing out, the heart beat, the weight of the body pressing against the surface of the chair or support, the warmth of hands on lap.

I then ask the person to think of something that they appreciate right then and there. I might say “What comes to mind when you think of something you’re grateful for right now.” If they seem stumped, I might suggest that they express appreciation for being able to breathe; or being able to hear – and I might guide them to sounds of nature; or having a chair to sit on – and I might guide them to experience the sensation of being supported by the chair.

I try to guide the person to identify at least four or five things they appreciate then and there, so they can experience what it feels like to mindfully notice the good that is around them, and to notice the emotions that arise from doing so.

Ongoing practice I then give people is to write down three things they appreciate or are grateful for at the end of each day just before going to sleep.  Research has shown that doing this can influence sleep quality (Wood, Joseph, Lloyd & Atkins, 2009).

So, here’s a thought: what about trying this strategy out for yourself? It’s easy, quick and has some surprising results. Let me know how it works for you.

Emmons, R.A. & McCullough, M.E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377–389.

McCraty, R. & Atkinson, M. (2003). Psychophysiological coherence. Boulder Creek, CA: HeartMath Research Center, Institude of HeartMath, Publication No. 03-016.

Nelson, C. (2009). Appreciating gratitude: Can gratitude be used as a psychological intervention to improve individual well-being? Counselling Psychology Review, 24(3-4), 38-50.

Wood, A., Joseph, S., & Linley, A. (2007). Gratitude – Parent of all virtues. The Psychologist, 20(1), 18-21.

Wood, A. M., Joseph, S., Lloyd, J., & Atkins, S. (2009). Gratitude influences sleep through the mechanism of pre-sleep cognitions. Journal of Psychosomatic Research, 66(1), 43-48.

Wood, A. M., Joseph, S., & Maltby, J. (2009). Gratitude predicts psychological well-being above the Big Five facets. Personality and Individual Differences, 46(4), 443-447.
A Wood,, S Joseph, & A. Linley (2007). Gratitude – Parent of all virtues The Psychologist, 20 (1), 18-21

• point out that pain is personal and subjective and because of this, we can’t know what it’s like to have another’s pain
• make it clear that pain and impairment and nociception and disability are not equivalent, so we shouldn’t be surprised when inconsistencies are present across various measures
• move detection of fraud (malingering or faking for financial gain) out of the health arena
• help clinicians know what to do when a patient is “inconsistent” – in a way that might help guide treatment

And it’s this last point that is the focus of today’s post – and might even be featured in more than one post.

Pain is a biopsychosocial phenomenon. Disability is also a biopsychosocial phenomenon – and it’s the disability that makes the difference between living well with pain or living as an invalid.  We could replace the word “disability” with the term “interference” because pain can interfere with anything a person wants to, or needs to do in life.  It doesn’t need to interfere completely, though, and that’s why I’m so passionate about working in pain management.  A life with chronic pain can be a very good life, but this seems to be a secret that so many health professionals don’t know, thus don’t share with the people they treat.

What should a clinician do if the person they’re seeing behaves “inconsistently”?

The first thing I’d advise is to be curious rather than suspicious – wondering rather than assuming.

“I wonder why Alex is moving more comfortably when pruning the roses than when she’s hanging out the washing?”; 

“I wonder why she says her pain is really bad today but seems relaxed and happy while chatting to the receptionist?”;

“I wonder why Chris’s questionnaires show low pain anxiety and catastrophising, but he’s having such trouble returning to work?”

This opens up opportunities for exploring the sense a person is making of his or her situation.

• Maybe it’s the effect of distraction
• Maybe it’s about “faking good” with the receptionist
• Maybe it’s “other factors” that are influencing return to work such as bullying or being socially excluded from the rest of the team

I think people generally do things for reasons that make sense at the time, also as a reflection of the information he or she has about their situation.  For this reason, it seems sensible to explore what the person thinks is going on, and in doing so, begin to generate some hypotheses about why the person is presenting in the way he or she is.  These hypotheses can be tested or verified, and resolution can be progressed.

It’s disability, or interference from pain, that is most profoundly influenced by psychological and social factors. 

By psychological, I’m referring not just to emotions as a response to experiencing pain, but the whole gamut from the attention the brain pays to the sensations that are eventually interpreted as “ouch, that hurt!”, through to the meaning of that “ouch!” as it influences future goals on the basis of what the person thinks the pain might mean – and so on.

And by social, I’m referring to responses from family (or lack of response because there are no family close by), from health professionals and their efforts to “find the cause” or believe/disbelieve the person, and ultimately to the societal attitudes towards people who have that kind of pain, and the legislative systems in which the person finds him or herself embroiled (not to mention the health systems).

For a health professional who notices that a person is not quite responding the way other people with the same impairment (ie injury, diagnosis, tissue damage, disease) responds, it’s only by working through all the above influences and generating a plausible and useful (ie testable) set of hypotheses that might explain why this person is presenting in this way at this time, that it’s possible to understand and address the next steps to help the person return to some of their important goals in life. Remember, as an observer, even the most astute clinician is filtering what they see through their own experiences, attitudes, beliefs and training.  And unfortunately, most of these influences occur without our knowledge (see here for some of the cognitive errors we all fall prey to).

For more on developing a case formulation, or set of working hypotheses, I’ve written several posts here, here , here and here – and yes, there are more, just follow the links.

My “take home” message today? Suspend judgement (it doesn’t help and usually hinders), be open to understanding the person’s reasoning for their so-called ‘inconsistency’, and work with the person to identify the hypotheses that can be tested to verify what is going on.

There is a common belief amongst some people involved in pain and pain management that a person with chronic pain should be consistent in their presentation. That is, be consistent in various settings, and consistent across various measures.  This assumes that if inconsistencies are present there must be something going on to cause suspicion about the validity of the person’s presentation.

Returning to yesterday’s post, I discussed the distinction between nociception (activation of receptors in the nervous system), pain (the experience produced by the brain once it has interpreted the nociceptive action), disability (the changes in functional performance attributed to the experience of pain), and impairment (tissue changes).  These are not the same! Today’s post refers mostly to pain and disability.

Pain is, as I keep spouting, a personal, subjective experience – you and I can’t share our pain except through our behaviour.  And even when we describe it, we can’t actually experience what it feels like to have each other’s pain. What this means is that our behaviours, or what we do, are what conveys our experience to others but only to a certain extent.

While our experience of pain remains individual, our behaviour is shaped by all the influences around us.  And just to make things more complex,  the meaning of our pain experience is shaped by what we learn and believe about pain from interactions between ourselves and all those influences that shape our behaviour. Complicated? Oh yes.

So if I grow up in a family that is generally stoic, where my complaints of pain are ignored and I see that others in my family don’t generally cry or stop doing things when they are hurt, it’s likely I’ll also be less demonstrative about my pain than another person in a family where this is not the norm.

We also learn to behave differently in different contexts. It’s common to say a few choice words when we hit our thumb with a hammer in the garage on a Saturday afternoon, but we usually wince and gasp quietly if we thump that same thumb in Church the next day!

What this means in terms of consistency is that people often do different things in different settings when they have pain – maybe when they drive from home to a clinic they’re a bit anxious about what the consultation might mean. They get out of the car and walk quite carefully into the clinic and sit down rather gingerly. They’re not sure whether they’re going to hear good news, or not. They go through the examination and consultation, and get told they’re going to try a new medication that might help. Oddly enough, as they walk back out to the car someone looking out the window might see them moving fluidly and getting into the car quite smoothly.  Suspicious minds might start to wonder if they really had “that much pain”.

Turning to assessment of pain now, it’s been said that pain assessment should incorporate a number of different dimensions. At the very least, assessment needs to consider the location of pain, the intensity and quality of pain, and some sort of measure of the interference pain has with everyday activities.  Some commentators consider pain assessment should also make a diagnosis of the type of pain disorder present (or the cause of the pain), while others also think that psychological aspects of pain need also to be included (such as pain catastrophising, measures of avoidance and measures of mood and anxiety). And of course, assessments of range of movement, strength and reflexes are also often part of a pain assessment.

Should these measures all present a “consistent” picture?

Where we hurt and what it feels like (the quality of pain) don’t directly correlate with the amount of interference a person experiences from their pain.  If I’m a pianist I might be really bothered by tingling and burning fingers, while less bothered about the same pain qualities in my feet.  If I’m really anxious about my future as a nurse, I might be really concerned about my low back pain. If I’ve developed some effective coping strategies for managing my overall body aching, I might not be particularly anxious or have low mood despite having quite intense pain.

Inconsistency between various aspects of a person’s presentation doesn’t mean they’re faking, or that their pain is not real. It does mean we need to generate some hypotheses about the relationship between the various factors that could be influencing the person’s behaviour. To decide, on the basis of our own experience (which is always limited!) that another person’s pain is not real just because we don’t understand why they are doing what they’re doing, is a judgement call we can’t make, in all honesty.  More than that, it doesn’t help work out what to do next to move the person from being disabled (or getting a benefit they don’t “deserve”) to returning to function.

Personally, determining the validity of a person’s claim to have pain is not the province of a health professional – it’s a task for administrators of a compensation scheme.  We can describe what we see, we might even make a diagnosis, but we can’t tell whether someone’s cheating the system. Bring out the investigators and be honest that health professionals can’t do what some insurers want us to.

Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0

Every now and then the old chestnut of whether it’s possible to determine if a person’s pain is “real” arises. Usually it’s in the form of an insurer, or maybe an employer, who wants to know if the pain this person is describing can possibly be as bad as the person says because

• “they don’t look like there is anything wrong”
• “there are these inconsistencies”
• “it’s taken too long for them to recover”
• “they’re not participating in their rehab”

For the avoidance of doubt, I have not been able to identify any readily available test or technology that can reliably determine what another person really experiences.

More than that, I’m not sure that it’s helpful in clinical practice to try to determine whether someone is “faking it”, and here’s why (sit back and get comfortable, this could take a while!).

Pain is not an actual or tangible thing.  We infer that someone has pain on the basis of their behaviour.  As Gatchel, Kishino and Minotti say “It is important to distinguish pain as a neurological event (nociception) from pain perception (which is subjective in nature).”  Nociception is about activation of receptors which pass through pathways to the central nervous system. Pain is the interpretation of this activation by the brain once it determines this information needs to be noticed and acted upon.  The same nociception activity in one person may not be perceived in the same way by another.

Having identified that pain is personal, we then turn to how a person responds to this event.  Gatchel, Kishino and Minotti remind us that pain, disability (the functional limitations, or behavioural expression of our individual experience of pain), and impairment (the physiological or physical findings) are not directly correlated.  While there is overlap, it’s not unusual to find someone with significant changes on x-rays and blood tests, who reports high levels of pain – but doesn’t let that stop them doing things.  At the same time, many painful conditions fail to show on x-rays or blood tests, but the person reports high levels of pain and finds it very difficult to carry out normal activities.

Why might someone’s disability from pain be greater than another persons?

That’s the million dollar question!And why it’s so important to obtain a biopsychosocial assessment of a person who is having trouble recovering because of pain.

We do need to understand the physiological processes involved in an individual’s presentation – knowing the diagnosis can be helpful, as can knowing the structural problems that underpin disability and pain.  At the same time, the science of diagnosis is not 100% reliable, and more importantly, unless there is a clear-cut treatment that can remediate the problem, searching for a diagnosis can play an important role in iatrogenic, or “resulting from the activity of physicians”, disability.

On to why identifying whether someone is faking it is unhelpful.

People with chronic pain have usually seen about 4 or 5 (or more) clinicians by the time they come to get a diagnosis of chronic pain.  Each time they see a new clinician, their history is repeated.  Clinicians are trained to find “what’s wrong” – and fix it. We get flummoxed when the person fails to “get better”. For some clinicians, it can mean repeating a treatment in the vague hope that what didn’t work the first time might work the fifth.  For others this failure can be turned on itself and (albeit inadvertently) the person with pain is seen as having “failed”. Maybe they weren’t motivated enough, maybe they didn’t really try hard enough, maybe they just don’t want to get better, maybe they don’t really have pain.

Patients can also be going through a process of feeling as though they’ve failed, maybe they’re not really motivated – maybe this pain is “all in my head”.

I don’t think many clinicians directly tell patients that they suspect they’re not really motivated, or don’t really have this much pain – but in a situation where the patient is already doubting, is anxious about recovery, and given our human tendency to jump to conclusions, it’s very easy for the person with pain to misinterpret what is going on.

In this situation – what do you think a person is likely to do if confronted by someone as to whether they might be “faking”? Hmmmm – I might just try to demonstrate how bad it is for me.  Chance of reducing disability has just dropped. And in the face of factors that reinforce disability such as family members who might be suggesting it’s risky to do anything “because the last time you did you were sore for ages!”, or coworkers who say “you look terrible, you need to go home”, or disability payments that are greater than unemployment benefits, or payment of a mortgage insurance that will make the house completely paid off – well, it’s probably quite hard to recover.

I’ve worked in pain management for 20 years or so, and I can’t tell whether someone is faking bad. I’ve met hundreds of people who say they have chronic pain, with an enormous range of factors that are working to hold the person in to their currently disabled situation. I have yet to find any medical, psychological or functional test (or combination of tests) that can determine the validity of the person’s pain and disability. And believe me, I’ve looked.

I’ll write more about this topic shortly – taking a look at psychological measures that have been suggested as ways to detect malingering or symptom magnification. I’ll also look at functional measures that supposedly show whether someone is giving “full effort”. In the meantime, I wonder whether it might be more useful to consider that a person’s self report of pain is what it is, and for clinicians to work at identifying the factors that could be responsible for maintaining disability.

Gatchel, R., Kishino, N., & Minotti, D. (2010). The Three Major Components of Behavior Used for Assessing Pain: Problems Faced When There Is Discordance Among the Three Psychological Injury and Law, 3 (3), 212-219 DOI: 10.1007/s12207-010-9081-0

The person who asked about this said the main problem was in trying to tell the person that his or her symptoms are not unique or weird, without taking away their “specialness”.  Sometimes, in trying to give accurate information, and pointing out that others have similar symptoms, the person can react as if they’re offended.  On the one hand, this person said, we are all unique and deserve to be treated as individuals and on the other hand there is a commonness in suffering that we should take comfort in.

In musing about this, I thought about some of the reasons people seek treatment.  While it’s almost a given that people are looking for alleviation of their suffering, there are a complex range of reasons that people come in to see a health provider, and not all of the reasons are evident even to the patient!

As an aside, I think it’s incredibly difficult to help some clinicians see that people think they’re logical and know the reasons for their actions, when in fact we are all influenced by an array of factors that are implicit and thus we’re not aware of their effect – more on this later.

Why do people seek treatment?

In a meta-analytic study by Ferreira, Machado, Latimer et al. (2010), the main determinants of care-seeking in back pain were

• being female (OR: 1.67; 95% CI: 1.49, 1.88),
• having had a bout of back pain before(OR: 1.45; 95% CI: 1.12, 1.86),
• having higher levels of disability (OR: 1.92; 95% CI: 1.33, 2.78),
• externalized beliefs regarding pain management (OR: 3.6; 95% CI: 2.1–6.0),
• fear of future job impairment (OR: 3.07; 95% CI: 2.33, 4.04),
• limited social functioning (OR: 3.07; 95% CI: 2.33, 4.04),
• or those engaged in sports activities (OR: 1.3; 95% CI: 1.0, 1.7)

What does this tell us?

The authors suggest that “individuals seek care based on an interaction that includes their predisposition to use health care, the available resources and their recognition for the need of care”.  They add “disability, and not pain, is the strongest determinant of care-seeking behavior in people with back pain”, and suggest that interventions need to aim at matching expectations and reducing disability rather than focusing on reducing pain.

So, what to do when a person says their pain is mysterious.

If we consider that people who seek treatment are inclined to do so as part of their belief that treatment is important, as well as tendency to look for treatment (almost like a habit), maybe we need to look at what health providers (us!) do to maintain this habit.

By saying “my pain is different”, the person may well be doing what he or she has learned before – maybe they haven’t responded as expected with another provider, and been told their pain is “different”. Maybe they’re worried that you won’t be able to help them either.  Remember that intermittent reinforcement has a powerful training effect and may be influencing the expectancy of this person – they’re anxious to let you know they are hanging hopes on doing “something”.

I suggested reflecting the “meta-message” the person is telling you. What about saying “It sounds like you’ve had some trouble getting help with your pain. From all the things people have told you about what’s going on, what do you make of it? What’s your theory?”.  At this time it’s also helpful to ask them “what does that mean for you? Where does that leave you?”.

If the person describes a belief that doesn’t sound plausible, or has some catastrophic interpretation of what might be going on (like the “herniated discs don’t usually shoot all the way to the foot”), I’d ask if it’s OK to tell them what I understand might be happening.  I then ask the person if they’d be prepared to work with me on a series of mini experiments to help us work out what is going on.

It’s worth checking in with our beliefs about why people seek help for their pain.  And establishing whether there are things we can do to help people remain active and engaged with their own health management.

Ferreira, Machado, Latimer et al (2010) concluded that “values and attitudes that individuals have about health and the use of health services can be viewed as the bridge between social structure and the perceived need for health care; it is how the status of a person in the community, or the individual’s ability to cope with presenting problems, can modify his or her perception for the need to seek care.”
Ferreira, M., Machado, G., Latimer, J., Maher, C., Ferreira, P., & Smeets, R. (2010). Factors defining care-seeking in low back pain – A meta-analysis of population based surveys European Journal of Pain, 14 (7), 7470-2147483647 DOI: 10.1016/j.ejpain.2009.11.005

Communication as action can be something like when a person groans, rates their pain as “really bad”, or goes to a clinic.  Communication as interaction can be when a person is able to communicate their distress to their partner so the partner can understand how the person is feeling.  And when that person sees a doctor, tells him or her about the pain and the doctor makes a diagnosis and then starts treatment, communication as transaction has occurred.

It’s the communication as interaction that I want to talk about today, and particularly in the case of someone in distress – because that interaction can move from simply an interaction to a transaction depending on how the communication is interpreted.  Let me explain.

A person I’ve been seeing (and don’t forget, details are modified to protect confidentiality) has low back pain.  She has completed her pain management programme but every now and then makes contact.  Yesterday I had a message given to me by our receptionist saying that Andrea had phoned, sounded really upset and could I call back as soon as possible.  This is communication as transaction – the receptionist had made a commitment to do something.

Anyway, I phoned Andrea and she did sound incredibly distressed.  Her voice wobbled and I could hear her breathing in short gasps.

“I’ve hurt my back again”, she said. “I can’t move my neck, my shoulder, and I can’t lie down, I don’t know what to do!  My doctor wants to send me to hospital. I’ve taken all the meds I’m allowed to, and they’re not working. I haven’t slept. What do I do?”

Well, to me she sounded pretty unhappy! My interpretation of her tone of voice, the panting and gasping I could hear and the words she used was that she was scared, she was struggling to maintain control, and she wanted rescuing.  This is communication as interaction.

I had a choice. I could tell her what to do. Take control of the situation and “do something” just as her doctor had.  But what would my doing so communicate to her?  Where was my belief that she had skills, she knew what to do?  And, more importantly, was this what she really wanted from our interaction?

Another option was to try to soothe her, talk her through her distress and ease her fears, to settle her down. What would my doing this communicate to her? Would it teach her that she had every right to feel upset and out of control, to fear this flare-up of pain, to avoid experiencing it?  And would I be doing this out of my concern for her, or to reduce my own distress at the rawness of her emotions?

I learned, way back in my early training, that empathy can be defined as “being able to walk an another person’s moccasins”.  Apparently this was a Native American saying to show that to really know where someone is coming from means to feel the blisters their shoes make on your feet.  Being empathic is an important part of clinical work.  But there are drawbacks – standing with another’s emotions can expose your own vulnerability, and it involves effort. It can be fatiguing.

For many clinicians, I think it’s difficult to allow someone else to feel their own feelings without wanting to “take the pain away”.  I wonder whether this is (a) what the person wants, someone to “fix the problem” and (b) teaching the person that these emotions are bad, wrong or to be feared.  And I wonder whether this response says more about the clinician’s own ability to be present with distress.

Mindfulness is about “making room for” the wide range of human emotion, in a nonjudgemental way.  Mindfulness acknowledges the presence of sadness, fear, anger, joy, desire, and allows it to pass.

My choice with Andrea was to ask her if she was prepared to sit with her feelings with me. I asked her to just breathe, to feel the flow of air in and out of her body, to feel the contact of her body on the chair, the sensation of warmth where her fingers lay on her leg, the rise and fall of her emotions as we made room for them to be present.

I asked her to be present with her pain too, to feel the sensations and to allow them to be experienced as they are instead of what she feared they represented. Because it wasn’t the actual sensations that Andrea was worried about – it was her fears that the pain wouldn’t ever go away, that she’d never be able to sleep properly again, that they’d escalate, that the pain would spread, that all the things she’d learned wouldn’t work, and she was remembering how she’d felt right back before we’d started to work on her pain management.

And together we made it through and Andrea said, with some surprise, that she felt the pain but it wasn’t bothering her as much.

Hadjistavropoulos, T., Craig, K., Duck, S., Cano, A., Goubert, L., Jackson, P., Mogil, J., Rainville, P., Sullivan, M., de C. Williams, A., Vervoort, T., & Fitzgerald, T. (2011). A biopsychosocial formulation of pain communication. Psychological Bulletin DOI: 10.1037/a0023876

I haven’t a hope of trying to summarise this paper, and I urge you to read it for yourself  – it really is an important piece of work.  The reason it’s so important is that we don’t have any idea about someone else’s pain except as it is “displayed” or communicated to us.  This has far-reaching implications for any clinician working in the field of pain management, whether acute or chronic pain.

What does it imply? Clinically, it means that if I am working with someone who has pain, all my personal beliefs and ability to interpret the verbal and nonverbal behaviours of that person come into play.  So if I’m having a bad day, perhaps I’m not attending to what the person is and isn’t saying, my interpretation can be “off”.  Similarly, if I have beliefs about what constitutes “normal” pain behaviour, and the person I’m seeing doesn’t exhibit this kind of behaviour, I can easily misinterpret this, maybe even convey skepticism or disbelief.

Included in this paper is a great discussion of social context – after all, we don’t live in isolation! And even if we did, this too would constitute a social context.  People who have pain and exhibit illness behaviour will have an effect on others around them.  We know that relationships can be negatively influenced by alterations in roles, but we also know that illness behaviour and distress can elicit additional attention and caring from others – at least in the short term.

One social context in which pain communication has a profound effect is in healthcare.  There can be an assumption or belief that we as health professionals have a neutrality about the way we view pain behaviour, yet we are not immune to our own beliefs or biases.  And we can misinterpret the behaviour of another in some rather alarming ways.

Here’s an example: a client has complex regional pain syndrome of his hand.  He has all the typical features of CRPS in that he has swelling, colour change, temperature change and so on.  He is also a guy who loves to work and is very distressed that because of his hand pain, he can no longer work, in fact for months he had to have someone else help him wash and dress because of allodynia along his whole arm – so bad that he couldn’t bear the shower water running on his arm.

Not only was this man able to show some concrete evidence that he does have “something wrong” with his hand, he was also articulate, and he wasn’t afraid to go after what he wanted.  He has been to numerous treatment providers, attended the Emergency Department and After Hours Clinics almost every week, and in his distress, he was known to sit, weeping, in the entrance foyer of the ED, refusing to leave until “someone” did “something”.

He has had over 30 anaesthetic procedures to his arm, with concurrent physiotherapy. He has been prescribed multiple medications. He has done “everything” asked of him in terms of his rehab. His functional status has not changed. And he has never been seen by a psychosocial clinician.

When I asked why he hadn’t been seen by an interdisciplinary team, the reply from one of the attending clinicians was that his pain was “genuine”, and “really severe”, and “he has always participated in his rehab” – the implication being that he didn’t need to see an interdisciplinary team because of his “motivation”.

By stark contrast, another client I’m seeing is very reticent about his pain. He doesn’t like to talk about it, he generally looks well although he moves a little cautiously.  His pain is back pain. While he’s had surgery, it’s been unsuccessful.  This client doesn’t use medication (he says because none of them help without giving him significant side effects). He is very apprehensive about seeing health professionals. He’s reluctant to participate in rehab – his view is that if he does, it increases his pain, if his pain increases, life isn’t enjoyable. He’s worried about his pain and doesn’t know what to do to move on.

This man has been seen by some of the same clinicians as the previous man – but viewed completely differently. With more than a dollop of skepticism. He doesn’t engage in the behaviour that is acceptable for a patient. Oh, and he’s been referred to an interdisciplinary team to address his “motivation”.

On the face of it, these two men both have pain, both haven’t responded to biomedical intervention, and both are significantly disabled by their pain. The one has had numerous interventions and is viewed as having “genuine” pain, while the other is seen as maybe “playing on” his pain.

I have two take-home points:

1. Both men are demonstrating pain behaviour, but how we as health professionals respond to them has been quite different and tells us more about our beliefs and attitudes than it does their “genuineness”.  Let’s think about the judgements we make about our patients.
2. Psychosocial and interdisciplinary pain management is needed by both men. It shouldn’t depend on how we view their motivation. Psychosocial input helps with distress management (the first man) as well as goal setting and anxiety management (the second man). Let’s make sure we view all pain with biopsychosocial lenses on.

Hadjistavropoulos, T., Craig, K., Duck, S., Cano, A., Goubert, L., Jackson, P., Mogil, J., Rainville, P., Sullivan, M., de C. Williams, A., Vervoort, T., & Fitzgerald, T. (2011). A biopsychosocial formulation of pain communication. Psychological Bulletin DOI: 10.1037/a0023876

The answer is, as you’d have guessed, not black and white.  In fact, as several authors and researchers have pointed out (see the references below for just two), not only is the cognitive behavioural approach to chronic pain management a mixed bag of strategies, there is very little information on the process of change that occurs during treatment.

Here’s what I’ve seen clinically – while some people are ready to change, others are not.  I need to work with this second group using motivational interviewing approaches to help them identify their own reasons for doing things differently.

This might mean creating a sense of dilemma – identifying where they are now in terms of goals and satisfaction with life, and creating awareness both of the possibility that life might be different, and what that might look like.  This helps people recognise their “stuckness” and creates momentum for change.  From there, it’s far easier to help them develop goals and start to problem-solve what needs to happen to reach them.

Another group of people are those who are relatively inflexible in their thinking and behaviour – they’re stuck not because of a dilemma, but because they’re continuing to use strategies that have worked for them in the past, but are not working now.  It’s like they have trouble working out another way of approaching problems.

A good example of this is a man who has always been fit and before his pain began was a representative sportsman. His approach was always to do more than what was required. He was stuck because doing this when he had pain created a “boom and bust” approach to activity.   For this kind of person, I like to use what Steven Hayes (ACT) likes to call “creative hopelessness” - pointing out that it’s not the methods the person is using, but their purpose. I use experiential methods to do this – gettng the person to monitor what has happened over the week, and asking him to establish what he believes: his mind and what it tells him? or his experience and whether it works.

Cognitive change doesn’t necessarily occur before behaviour change
It’s strange, but true, that despite our best efforts, twelve months after people have completed a pain management programme, few are still using the strategies we help them develop.  While some are goal setting, or using relaxation, or exercising, or even checking in with their thinking – the majority are simply getting on with life (Curran, Williams  & Potts,  2009 – doi: 10.1016/j.pain.2005.09.004). And even more strange – people who start making behavioural changes early in a pain management programme seem to do best, while those who actually complete between-session activities also seem to do best (Heapy, Otis, Marcus, et al., 2005).

Persuasion, challenging core beliefs, and education have their place – for the right reasons, at the right time, for the right person - but they don’t alter the fundamental issue alone. 

 What is that issue? It’s about an attitude shift towards “sitting with” uncomfortable thoughts and sensations, and working towards valued goals despite those thoughts and sensations.  It’s about a spirit of gentleness and willingness to recognise those thoughts and sensations as the mind’s way of solving problems – and at the same time, accepting that it’s entirely possible to do what is important despite the presence of these thoughts and sensations.

Morley, S., & Keefe, F. (2007). Getting a handle on process and change in CBT for chronic pain Pain, 127 (3), 197-198 DOI: 10.1016/j.pain.2006.10.025
Morley, S. (2004). Process and change in cognitive behaviour therapy for chronic pain Pain, 109 (3), 205-206 DOI: 10.1016/j.pain.2004.02.008

Curran, C., Williams, A. C. d. C., & Potts, H. W. W. (2009). Cognitive-behavioral therapy for persistent pain: Does adherence after treatment affect outcome? European Journal of Pain, 13(2), 178-188.