I am slowly wending my way through a long, complex and incredibly important article by a group of researchers and clinicians writing about the social element of pain. The basic premise of this paper is that while pain is a private experience, we are social creatures. As social creatures, we communicate about things that are important to survival – and because pain is one way for the brain to signal to an individual that “something dangerous or might be dangerous is happening”, once pain is experienced, for the most part we begin to signal this to others around us.
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:
- 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.
- 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