Last week I introduced you to one way I use to develop a shared understanding of the many factors influencing how and why a person seeks help for their pain. The person and I work together to understand his or her perspective. I use a range of open-ended questions and reflective listening to guide our discovery of how his/her pain affects life and emotions.
Some points to note:
- I don’t try to give explanations at this point – explanations will influence what the person says to me, and may inadvertently shape or change what he or she says without necessarily changing his or her beliefs.
- I’m not trying to make any diagnoses either. A diagnosis is just a short-hand way of lumping a bunch of symptoms together. Great for research, and great for when we have a clear treatment, but a diagnosis tells us nothing about how the problem is affecting this person at this time. And in pain we’re always looking at the person and his or her experience, because even if we successfully get rid of the pain, the person will have learned something through the experience and this will influence the person in the future.
- I’m informed by what we know about pain from research, so I’m constantly probing and looking for the relationships between factors we know will affect the person. Note that I’m not looking for tissue-level influences, but rather I’m investigating at a “person” level. This means I’m looking at psychological and sociological processes. I’m not ignoring those tissue-level factors, but I’m placing those off to one side for the moment. There are a couple of reasons for this: the first is that I’m probably not going to directly influence tissue-level factors. I don’t lay hands on people. I don’t give drugs. The second is that the person isn’t likely to be aware of those factors. They know much of their own experience (not all – but we’ll come to that), and experience and perception are the most potent drivers of what a person believes and therefore does.
- I try wherever possible to flesh out my interview with additional information. This might be from questionnaires, or observing, or clinical notes from other people. And yes, I incorporate this information with the full knowledge of the person – in fact, they’re part of the process of integrating this information.
What do I end up with?
A spaghetti junction! A diagram that looks a lot like this:
At this point I have a series of hypotheses to explain why Gerald is in this state. Together with Gerald, we’ve established that there could be some fear of pain, and in particular, fear that Gerald won’t be able to cope if his pain goes up and doesn’t settle. Gerald has also identified that he can feel helpless at these times, because he doesn’t know what else to do to manage his pain. He believes he’s getting unfit, and that’s adding to his feelings of frustration. He doesn’t want to go out with his mates because he’s irritable. He tries not to let his wife know how he’s feeling to protect her, but this adds to him feeling isolated. He doesn’t want to go back to work, not because he’s not motivated, but because he’s afraid he’ll let them down and this will add to his guilt. He doesn’t think his case manager understands this.
I could ask Gerald to list his main concerns and use these as a guide for my treatment outcomes, but I’ve recently started using a different approach. I’ll ask Gerald what he would be doing differently if his pain wasn’t such a problem to him.
Bronnie: Let’s imagine for a minute, what would you be doing differently if your pain wasn’t such a problem?
Gerald: Well, I’d be back at work, for one thing.
Bronnie: OK, and would you think you’d be back at work full time, or ease your way back in?
Gerald: Well, I think it would be sensible to ease myself back in because it’s been a while and I’m out of shape. Better to know I can do it than have a go and fail.
Bronnie: Great idea. What else would you be doing differently if your pain wasn’t such a problem?
Gerald: I’d take my wife out for dinner, it’s been hard on her while I’m so laid up and grumpy.
Bronnie: What’s your main concern about going out to dinner with your wife right now?
Gerald: I can’t sit long enough to enjoy a meal out. It all seems so hard, to get into a car, and drive to a restaurant, and sit there for three courses. I’m just too sore to do it.
Bronnie: So going to a restaurant and sitting to get there and while you’re there is going to increase your pain?
Gerald: Yeah. Is it worth it? What if it doesn’t settle? I can’t sleep and then the next day I’m shattered. I don’t think it’s worth it.
Bronnie: OK. Is there anything else you’d be doing if your pain wasn’t such a problem for you?
Gerald: I’d be going out and seeing my mates, going fishing and 4 wheel driving. I miss that. There’s no way I could do that right now.
Bronnie: What’s your main concern about going fishing, and seeing your mates at the moment?
Gerald: I’d be ready to go home before they’d even started. They’d get fed up with me slowing them down. And casting is really hard on my neck.
Bronnie: So to sum up then, it seems like there are some things you’d love to be doing, but reasons you think it would be better not to be doing them right now. If we go through them, you’d love to go back to work, but you’d like to do it gradually so you can get in shape again, and so you know you’ll succeed. You’d love to take your wife out for dinner, but the whole dinner thing feels too hard, and you’re worried that your pain will get out of hand and you won’t be able to sleep. And you’d really love to get back out with your mates again, and go fishing, but right now you think your mates would get fed up with you because you’d want to leave too early, and you wouldn’t be able to cast without setting your pain off. Does that sound about right?
Bronnie: I think there are some things we could begin to work on so you feel more confident you can handle it when your pain levels go up and down. And I think we could work on some physical things that could help you feel a bit fitter, more able to do things for longer. And finally, I think it would be great if we could help you and your wife connect a bit more, perhaps not yet at a sit-down restaurant, but perhaps there are other ways this could happen. What are your thoughts? Is there anything you’d especially like to look at?
What I’ve tried to do here is identify the underlying reasons Gerald isn’t doing things. While pain appears to be the problem, it’s not the pain it self but the fear of possible effects of pain that haven’t even happened yet that are really stopping him from doing things. And this is adding to the misery of having neck pain.
By giving Gerald the chance to tell me his dreams, we’re going beyond “I need to get rid of my pain” and into the reasons for living in the first place. People don’t just live to get rid of pain, they live to have lives full of meaning, let’s not ever forget that.