A couple of days ago I wrote about how to raise psychosocial issues with someone who has pain, hopefully without that person thinking you’re saying it’s ‘all in your head’.
I thought today I’d cover some more about ways to find out about psychosocial factors, with some simple questions you can reword to fit your style.
My first point is repeated from last time – it’s not about ’cause’ and trying to identify whether psychosocial factors are ‘causing’ the pain problem.
Not only is this unhelpful because often the patient is very sensitive to any suggestion that they’re ‘not coping’ or ‘making the most of it’ or even ‘faking’, it’s also not accurate. Most pain problems do start with some sort of nociceptive event – a strain or some acute ’tissue issue’!
It’s really important to recognise and convey your concern that having pain is stressful, and the effects of a stressful event are experienced over a range of areas of life. If you’re able to do this, you’re well on the way to the person beginning to trust that you want to hear what the impact of pain is having on their life.
So, taking my cue from the original ‘yellow flags’ document, published in New Zealand in 1997 by the Core Health Committee and ACC, here are some of the questions you might consider using when you’re first talking about psychosocial factors with someone experiencing pain:
- What do you think is causing your pain?
- What are you expecting will help?
- What are you doing to cope with pain?
- Have you had time off work in the past with pain?
- How is your employer responding to your pain? Coworkers? Family?
- Do you think that you will be able to go back to work? When?
What you’re wanting to listen to here are signs that the person is going to have trouble recovering and getting back to normal.
The first question: ‘What do you think is causing the pain?’ is drawing out beliefs and attitudes that may be unhelpful. You can phrase this along the lines of ‘what have other doctors or health care providers told you about your pain?’, ‘what is your theory about why you have this pain?’.
Some people have very little understanding of their bodies, while others are very informed (or misinformed), and/or may have misheard what others have said, so this is a chance to identify things like catastrophising, beliefs that movement will cause more damage, mistaken biomechanical or anatomical beliefs like ‘discs crumbling away’ or ‘nerves are squashed’.
Some people are reluctant to say what they really think is going on, so this can be a question to ask again as you are carrying out an examination, or perhaps after you’ve completed your assessment of what you think is going on. It’s worthwhile reflecting (paraphrasing back) to the person what you’ve heard them say, to demonstrate that you have actually been listening, and this may open the door for them to tell you more openly about what they fear may be happening.
The second question ‘what are you expecting will help?’ is really helpful for identifying treatment expectations – either from you, or more generally. It’s useful to see whether the person identifies that things are going to get better in time, or whether they believe something else is needed such as surgery or rest or medications.
If they say ‘I don’t know – you’re the doctor/nurse/physio/occupational therapist’ – this is a good chance to ask them what they hope for in terms of outcome from treatment. Again, reflecting what you think they’ve said helps to clarify expectations – and from yesterday’s post you can see that speaking a common language to develop mutual goals is important and difficult to do!
Expectations that resting, ‘techno-fixes’, intensive investigations or passive therapy in which the person doesn’t have to do anything are not good signs for recovery, so this is an important question to ask.
The next question ‘What are you doing to cope’ is also a useful one because you can build on the helpful things the person is doing already and support their sense of control and self efficacy. At the same time, this question can be phrased and rephrased to identify some of the less ‘legal’ or more unhelpful ways of coping such as smoking cannabis, increased use of alcohol, inappropriate use of medications.
You’ll probably need to ask this question in several different ways to identify concerning behaviours, but the purpose of this question is to find out what level of self management the person has. It’s intended to explore how much they are prepared to get engaged in doing things for themselves, to search for high risk behaviour that may put them at risk for other problems such as medication over-use, and to also see the level of personal resource the person brings to the situation.
More on this later, but I hope these three questions start you on the process to exploring and helping people to manage the psychosocial factors that are affected by, and in turn affect, disability that is associated with pain.