Seeing is believing?

ResearchBlogging.orgI 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:

  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



  1. It’s such an interesting comparison! I am on the “reticent” side of things, and I still remember this one appointment. My pain, which was stable for years, suddenly drastically worsened, to the point I was not coping anymore. I was seeing a doctor asking for help. At that point I have been in severe pain for 4 days in a row; I was unable to sleep more than a few hours per night during that time; I have already been to ER, was given an opioid, had a strong negative reaction and had to stop it. I felt like I was barely able to stay upright, could not think straight, and therefore had problems expressing myself coherently. I believe (as much as I can remember through the daze) that I said this to the doctor. He looked at me and said “well, but you don’t seem to be in much pain at the moment”. I have to say, I am never going to see this GP again. But it’s probably that he just couldn’t identify my pain behaviors. Certainly my friends have been known to ask things like “You are very quiet today. Is your pain particularly bad” The first time it happened, I was surprised to learn that it was noticeable even though I make a point not to complain (and yes, it was a very bad day, and I had trouble keeping up with conversation at lunch). So people around me certainly seemed to have picked up on a pattern that that doctor didn’t.

    1. What an horrible experience. Thanks for sharing, because I think the more we can reflect to health providers just how important their preconceptions are, the more we can hope health providers will reflect on their own attitudes and beliefs. Ultimately, I’d hope that people consulting with health providers will always feel heard, even if they don’t always feel happy with the outcome (if there is no “cure”).

      1. Yes, feel heard, sure. But these prejudices also seriously affect the clinical decisions doctors make. In your case of a man with CPRS, he didn’t get into pain management because doctors accepted his pain as “real”, even though he would have benefited from the psychosocial pain management. In my case I was promptly routed into “psycho-social management only”, where in fact there was need of medical intervention. The sudden and extreme pain was actually a symptom of a new issue that needed to be treated. In my instance it was the psychologist who, eventually, realised that there was something else going on there and re-referred me back to medical review. But that took a lot of time, and suffering, while I was trying to explain to him that regardless of my doctor’s notes the pain was truly different and well beyond what would be a “normal” flare-up for me.

      2. Good point Mary! Even people with chronic pain can get acute or short-term pain from another problem. A timely reminder that the person with pain is the only one who can determine what the pain is like. I wonder why there is such a tendency to see the biopsychosocial model as “either” biomedical “or” psychosocial, when it’s really “and-and”.

  2. I think something also need to be said for that person who is dealing with the pain so well. They are usually thought of as someone who has pain under control. The better one copes the harder it is for people to understand their suffering

  3. Thanks you for this wonderful article!!! Indeed, a VERY important insight too!
    I recently underwent spinal surgery, after waiting for many months. The pain I experienced during this time was often dementing. Yes, dementing – it was SO bad st times, I felt like I was going insane. It infiltrated every aspect of my life and eventually cost me my job, as my back deteriorated so quickly, I was no longer able to function in the “real world”. I also have two small children. They suffered too. My 8 year old daughter often had to cope with the neurological difficulties my condition presented – my legs collapsing from under me was the main one. She would often help me get back up again.
    My husband is a Registered Nurse and if not for his insights into chronic pain (many of which were reflected in this article) and his undying support, I feel I would no longer be married.
    The hardest part remains to be the reaction of others, especially Doctors. A person’s pain can never be quantified by another, even if they are a Medical professional. I was told a number of times, that if I wanted the Doctor to take me seriously and listen to me, I would have to remain very stoic with regard to displaying the level of pain I was experiencing.
    I hope many Doctors read this article and approach patients suffering chronic pain with more compassion and less judgement. Perhaps if they could walk a mile in our shoes, they would not be so quick to condemn those patients who are addled by their pain and seeking help in ANY form. As a patient who was on large amounts of opiates for a long period of time, we don’t like being made to feel like junkies. We don’t like having to justify our suffering each and every time we see another new practitioner. And we CERTAINLY don’t like, nor do we benefit, from Doctors who make comments such as, “well, you don’t LOOK like you’re in much pain to me”. Huzzah huzzah, Mary for your comments on this point!

    1. Thank you Sam! Your story is one that I have heard so many times and every time I feel saddened that another person has been through such a harrowing experience. If it wasn’t enough to have persistent pain, to have to contend with people expressing their judgement of others must be incredibly difficult to tolerate.
      The model this article I’ve been reading so clearly articulates that communication is both complex and situated within a context of culture, situation, social and human determinants – no wonder it’s tricky to know exactly how to interpret one another’s behaviour! But how much more important it is to really work hard to learn to listen…

  4. A very interesting and complex article – go you for persivering and seeing it through to the end! It is interesting how different doctors and patients react to the suggestion of pain and how often very little advice is given – particuarly in relation to back pain. I’d like to think that in 50 years we’ll have many more cures for various pains and illnesses which’ll be a massive help to both patient and doctor alike!

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