When we look at someone else, we first start by identifying the differences between that person and ourselves. It’s only later that we spend some time identifying the similarities between ourselves and that “other”.

There’s a problem in pain management today. It’s this: too few of “us” are “them” – by which I mean, there are too few people who identify as living with persistent pain working with people who are seeking help for their pain.

“Why is this a problem?” you ask… Well, it’s because it’s far too easy for “us” healthcare providers to forget that persistent pain affects people just like us. Yes, I know the stats: lots of people with persistent pain are multiply disadvantaged by socio-economic status, gender, ethnicity, age, multiple morbidities. But – and this is important – persistent pain doesn’t discriminate, but disability and distress might.

Othering was first brought to attention by Simone de Bouvier. de Bouvier was interested in the way women’s voices were hidden and often compared with men’s voices. “Why”, said men. “Are women not like us?” The answer was evident: women are not men. And in establishing that women are “other”, or “not men”, those dominant voices were able to not only elevate their own voices to prominence, but also minimise and trivialise the words of women.

There are, according to Lajos Brons, two main forms of “othering” – crude, where the assumed differences are stated; and sophisticated, where the assumed differences are stated – and seem reasonable. Let me give an example. It seems reasonable that people seeking help for their pain are needing something they don’t have. And the people they seek help from (healthcare professionals) have that something. Sensible, yes?

“What’s the problem?” you ask. Well, it’s because alongside noticing the difference between the person seeking help and “us” who might have some answers, we also begin to distance ourselves from “them”. And in doing so, we begin to dehumanise or consider that person to be different and somewhat less than us.

I don’t want to accuse readers of stigmatising people who live with pain, so let’s take a moment to unpack what I’m trying to say.

When we talk about someone who is experiencing pain and having trouble with it, we begin by trying to work out what’s going on. In the very best circumstances, we create a “third space” where we can meet one another on an equal footing – both focusing on “what’s going on here”, and neither one assuming a superior position, because while “we” the healthcare professional, might have lots of knowledge about the various factors that could be contributing to this person’s situation, “we” actually know absolutely nothing of this person’s reality, their experience. Meanwhile, the person seeking our help is the expert on what life is like with their pain, their worries, their strengths, their supports, their vulnerabilities. So we meet in the middle, and collaborate, to try to work out how we can develop something new.

Sadly, that space can be muddied by a whole lot of things. We might bring our assumptions about the “other” – that they’re afraid, they need information, they want whatever solution we provide. The person might bring their fear of being misunderstood, their memories of the last time someone “tried” to help, perhaps their idea of what we want to know. We may end up talking past one another.

Let’s see what we can assume about the person in front of us. We might think they just need to know their pain is “an output of the brain” and that “hurt doesn’t equal harm”. We might spend some time educating that person about neurobiology. We might think they need exercise. They need to lose weight. They need do more mindfulness. They need to go back to work. And so our plans for “them” are set in motion. None of these things are bad or wrong – except when we think of the person needing these things before we’ve taken the time to hear what they really want.

What does the person want? Probably like many people, they’d like someone to listen to their perspective. Then they’d like to have some daily practical problems solved: perhaps knowing that they’re not harming themselves. Then maybe some sleep management. And perhaps some time out from people telling them what to do. And maybe some explanations – but only once we’ve taken the time to listen.

“Othering” is one way health professionals maintain a professional distance. By knowing that “we” already do these things, we can feel good about what we offer “them”. But I’d like to ask: how many of us have daily, weekly, monthly goals? How many of us have set them with the SMART acronym? And how many of us have our days timetabled to make sure we do all the things expected of us? What if we have an off day? Is it OK or do we have to explain ourselves? And how many of us also live with persistent pain? I think more of us live with pain than we’re honest about…

I’ve heard “us” talk about “them” and it’s not pretty. “They” need to be more goal-focused, more persistent, more relaxed, more revved up. “They” are ‘non-copers’ anyway. “They” have always needed help for everyday life. “They” have disorganised, chaotic lives.

I wonder what would happen if “we” spent some time checking in on our assumptions about “them”? Would we find ourselves mirrored in the people we try to help? I think we would – and it might help us to remember that we’re guides, coaches, and cheering squads, but we’re no better, no worse, and just as human as “them”. Oh, and some of “us” might even be one of “them” living with pain every day….

Brons, Lajos. (2015). Othering: An analysis. Transcience, 6(1), p. 69 – 90.

de Beauvoir, S. (1949): Le deuxi`eme sexe, Paris: Gallimard, 1976.

Three questions

Yesterday I spent some time with the participants on the pain management programme talking about their experiences in the health care system.  After reading a great wee self help pain management book written by David Hall which has a chapter on how to ‘manage’ being part of the health care system, I decided it might be a good idea to talk with the group about how to make the most of their relationships with health care providers.

I was surprised to find that many of them are saying the sort of things I thought had gone from health – things like being told ‘I don’t believe in chronic pain’, ‘there must be a cause for your pain and I’ll find it’, ‘it’s really in your head’ – along with the experiences that some had of having a clear plan for managing their pain, but being told that ‘I’m the doctor, I’ll decide what happens’.  Well, really I suppose I shouldn’t have been surprised – it had taken most of the people about 4 years or so to reach the Pain Management Centre for comprehensive management of their pain.

I know that people’s recollections can be prone to error, and that people can misinterpret what is being said to them, especially when they’re in pain, but what these participants suggested was that in their journey to find out what their diagnosis was, and obtain effective management, they had found many health care providers still don’t really understand chronic pain.

The number one thing the participants wanted from any health care interaction was to be listened to
. When I asked them what this looked like, or how they would know they had been listened to, they said things like ‘they look me in the eye’, ‘they ask more questions to clarify what I’ve said’, ‘they take their time and don’t rush’, ‘they don’t assume they know what I’m coming in for’. The over-riding thing was that the health care provider wanted to know who this person was apart from their health problem.

What they didn’t like?
Being rushed, being told the same ‘prescriptive’ answers – lose weight, stop smoking, get more exercise (without finding out what is important to them!). They didn’t like health care providers using big words, or failing to write what was being discussed down. They didn’t like being referred to someone else who might only look at one aspect of their health – ‘the back’, ‘my gut’, ‘my thyroid’. They hated waiting three months for an appointment only to have 10 minutes with a doctor who hadn’t read their notes.

Participants were aware that they know more about their response to certain medications, procedures or situations than their health care provider. They may have gone through certain procedures 6, 7, or 8 times, and know what happens – but feel unheard when a health care provider over-rules and continues without taking the time to understand why the person wants something done in a certain way.

Sadly, some of the participants were so fed up with their interactions that they said they ‘switch off’, and although they may take someone else with them, they are really going along for the ride without questioning or understanding the rationale for certain procedures.  And then they don’t follow up on those recommendations…and we may wonder why…

We talked about ways to make the most of their relationships with health care providers – after all, with any chronic health problem, they are going to be spending time within the health care system, and it’s their health they’re managing. This concept is called health literacy, and it’s important.

Health literacy is

– a complex group of reading, listening, analytical, and decision-making skills, and

– the ability to apply these skills to health situations (Health Navigator)

According to the Health Navigator site, the NZ Adult Literacy & Life Skills Survey 2006 found that:

  • Low health literacy is “a stronger predictor of a person’s health than age, income, employment status, education level, and ethnicity.
  • Low health literacy can contribute to negative psychological effects and is often “hidden” to maintain dignity
  • Over 50% of NZ adults are likely to experience health literacy difficulties

If the participants in our pain management programme are anything to go by, at least one in 5 New Zealanders have difficulty reading, writing, asking questions and following health-related information.  Maybe literacy generally is poor – but as health care providers we don’t always appreciate how many people have trouble understanding our jargon.

I found the ‘three questions’ approach (again on Health Navigator!) a really simple and natural way for participants to feel OK about asking questions and making the most out of a consultation.  The ‘three questions’ are

  1. ‘What is my main problem?’
  2. ‘What do I need to do?’
  3. ‘Why is it important for me to do this?’

‘Ask me 3’ was developed by the National Patient Safety Foundation, and there are some great materials there for providers and patients.  Worth a look and some serious thinking and doing.

Today, what about making sure your consultations answer these questions – perhaps write them down, and say them to the person you’re seeing as you write down what you’ve suggested they do?
I’ve added a reference to an article on training health providers (doctors actually) in communication below (Malhotra,  Gregory,  Darvill,  Goble,  Pryce-Roberts, Lundberg, Konradsen,  & Hafstad, (2009) – points made in the article include:

The differences between how we behave in the classroom and how we are with real patients when unobserved have been highlighted; and we have attempted to explain why trainees sometimes modify their behavior in medical assessments with standardized patients for examinations as opposed to how we would perform on wards or in general practice. The teaching of communication skills will continue to develop over the forthcoming years.

For another reference, this time about the ‘patient’ side of communication, the paper by Dwamena, Mavis, Holmes-Rovner, Walsh and Loyson (2009), describes a training programme for patients, based on training given to health providers – maybe a thought we could all introduce into our pain management programmes? After all, people with chronic pain will be health users for a long time, and need to know how to make the most of what is available to them.

Overcoming pain: from pain sufferer to healthy, capable and in control
By David Hall, 2008, David Hall Training and Facilitating

Dwamena, F., Mavis, B., Holmes-Rovner, M., Walsh, K., & Loyson, A. (2009). Teaching medical interviewing to patients: The other side of the encounter Patient Education and Counseling DOI: 10.1016/j.pec.2009.07.026

Malhotra, A., Gregory, I., Darvill, E., Goble, E., Pryce-Roberts, A., Lundberg, K., Konradsen, S., & Hafstad, H. (2009). Mind the gap: Learners’ perspectives on what they learn in communication compared to how they and others behave in the real world☆☆☆ Patient Education and Counseling DOI: 10.1016/j.pec.2009.07.024