Family and friends matter

I’m going back to my series on behavioural approaches to pain management (it’s a slow process!). For the first two go here and here. Now I want to talk about the impact of family and friends on people living with pain.

The people we live with are so influential on what we do and believe about pain. It’s our parents who first taught us the relationship between the word “pain” and the experience we know as pain. It’s our parents and family who responded when we cried, who kissed it better (or not), who told us to “harden up” (or not), who took us to the doctor (or not), who showed us, through their own behaviour, how to “do pain.”

There’s a good deal of research investigating the impact of friends and family on pain behaviour (remember the distinction I make between pain-the-experience and pain behaviour or what we do when we’re sore? click). For instance, a systematic review by Snippen, de Vries, van der Burg-Vermeulen, Hagedoorn and Brouwer (2019) looked at people with chronic diseases, and the attitudes and beliefs of significant others. They found that “positive and encouraging attitudes regarding work participation, encouragement and motivating behaviour and open communication with patients” were facilitators for work participation while “positive attitudes towards sickness absence and advise, encouragement or pressure to refrain from work” were barriers to returning to work.

In another study, Burns, Post, Smith, Porter and colleagues (2019) observed spouse dyads behaviour after arguing then the person with pain undergoing a pain induction task. Spouses that believed that the patient’s pain was a mystery were significantly more likely to be perceived by the patient as giving critical/invalidating responses toward the patient during the discussion; while spouse perceptions that the patient’s pain was a mystery were related to internal and negative attributions spouses made while observing patients display pain behaviors during the structured pain behavior task (p. 1176).

In another study, this one a daily diary study with people living with osteoarthritis in their knee, found that on days when the person with pain reported more thinking the worst, their spouses were more unhappy during the day. And on the days when the partner was more irritated with the person living with pain, that person reported more thinking the worst the next morning. The link? The people with pain who were thinking the worst were also more grumpy through the day, and this was rubbing off on their partner. (Martier, Zhaoyang, Marini, Nah & Darnell, 2019).

Makes sense, doesn’t it? That when we see our loved one demonstrate that they’re sore, and they’re grumpy – and if we’re not sure they’re for real – we might be less supportive as partners than if we think their pain is for real. And over time the pattern of being sympathetic might wear thin – in fact, Chris Main (psychologist) describes a pattern of initial solicitous behaviour (the “there, there dear, I’ll fetch you a cup of tea”), then resentment (“surely you’ve recovered now?”), then anger and punitive behaviour (ignoring the person, getting irritated with them), but then feeling guilty about this (“OMG I know, it’s not your fault and I’ve been so mean”), returning to being solicitous – until the next time the partner feels fed up.

What does this mean for a behavioural approach?

Well, it’s not surprising that if one of the partners thinks the other “should be well now”, they’re likely to be unsympathetic as we begin changing the person’s behaviour. Often we’re attempting to help someone be consistent with their daily activities, and this can often begin by reducing how much should be attempted so the person can “do no more on a good day, and do no less on a bad day.”

And if the partner is really worried about the person with pain, and afraid that doing more is going to increase pain and prolong disability, it’s also not surprising that the partner is likely to be worried about us asking the person to do things differently (especially exercise!).

And don’t forget that during this time, both partners are probably trying to keep some semblance of normal going. They still have the usual household tasks to get done, to pay the bills, to get the kids to and from school, to keep in touch with extended family and friends and so on.

It’s stressful. And we add to the burden when we ask the person to do something different, whether this be doing exercises, using a mindfulness or relaxation technique, perhaps go to various appointments all around town…and if we don’t include the impact of what we expect on the partner, we’re possibly not going to have “the team” on board with the rehabilitation programme.

The very best option is to ask the person’s partner to come in to at least one of our treatment sessions, so we can spend some time talking about what we’re asking the person with pain to do, and getting an indication from the partner about their willingness to follow the programme. The next best option is to write the programme down, and include “things family can do to help” – listing the kinds of things family and friends can do (and what they should avoid doing).

You see, people we see for help never live in a vacuum. They always have a context of friends, family, home, responsibilities, expectations from them, expectations for the work we do. Forgetting about this and expecting a good result fails to recognise the embedded nature of life. Contextual factors are important, no person is an island.

Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2019). Spouse and patient beliefs and perceptions about chronic pain: effects on couple interactions and patient pain behavior. The Journal of Pain, 20(10), 1176-1186.

Martire, L. M., Zhaoyang, R., Marini, C. M., Nah, S., & Darnall, B. D. (2019). Daily and bidirectional linkages between pain catastrophizing and spouse responses. Pain, 160(12), 2841.

Snippen, N. C., de Vries, H. J., van der Burg-Vermeulen, S. J., Hagedoorn, M., & Brouwer, S. (2019). Influence of significant others on work participation of individuals with chronic diseases: a systematic review. BMJ Open, 9(1), e021742. doi: 10.1136/bmjopen-2018-021742

Talking pain – seeking validation: Social interaction in pain

While we might laugh about the so-called typical ‘I will fix it’ response of some men when their partners talk about problems (when what the woman really wants is a hug), it seems that much of our research into pain behaviour, particularly verbal expressions of pain, has missed something. I’m not a major reader of relationship literature, but I do read a lot about pain behaviour, and something I’ve noticed is the almost exclusive orientation toward the operant conditioning model when it comes to expressing pain in a social setting.

In operant model of pain behaviour, these behaviours are enacted to communicate to others. Responses to those behaviours may reinforce or punish those behaviours – and there is a good deal of evidence to support this model. It seems to be supported by evolutionary theory in that pain behaviours elicit resources from others, and serve to obtain help. One focus of therapy traditionally is to reduce the number of pain behaviours, in order to reduce the identification of the individual with helplessness or the sick role.

Cano and Williams, in this paper, suggest an alternative view of particularly verbal utterances about pain in relationships – they suggest considering an interpersonal process model of intimacy.

In this model, the things we say that disclose emotional content serve to foster and strengthen intimacy if they are met with empathy and validation. Cano and Williams state: ‘verbal communications about one’s thoughts and feelings about pain, may entail attempts to disclose emotion, recruit emotional support, and build intimacy.’
They go on to say ‘An empathic and concerned response from the partner may also contribute to intimacy. Emotional validation, including empathic responses, enhances the emotion regulation process for both partners because such responses allow each person to process stressful or aversive stimuli.’

In other words, if the partner doesn’t respond empathically, this is usually interpreted to mean rejection and disregard for the partner and usually negatively affects emotion regulation, but when the partner does respond with empathy, the relationship is stronger and more intimate.

What might this mean in therapy?
Well, up until now, operant theory has supported the idea of reducing or minimising pain behaviour, including talking about pain or eliciting emotional or practical support from a partner. This process model suggests that some types of communication may serve to improve the relationship. Validation of emotional content by the partner has in one study correlated negatively with punishing spouse responses, while invalidation correlated positively with punishing spouse responses – and the emotional content (rather than the words) made the major difference between the two types of response (Cano, Barterian & Heller, 2008).

This suggests that a simple ‘let’s eliminate the negative’ may not benefit the relationship. Strong relationships enhance coping, and relationships are strengthened when what one spouse is seeking is matched by the other spouse.

Empathy, caring, concern, and closeness may be desired when a person with pain discloses emotion, not ‘‘expertise” or problem-solving, which could signal invalidation of emotion.

This may mean clinicians helping partners (and families) learn to communicate more effectively – and something that has become very apparent to me is how poorly we as humans can communicate about pain, especially when it comes to setting boundaries, asking for help, or seeking emotional support. It takes a good deal of skill to express what it is that we really want, and to clarify or restate what we want if initially we fail to get it.

Assertiveness has a bad rap very often – it can mean all sorts of strident and aggressive ways to ‘get the point across’, when in fact it is simply about being respectful of each other and oneself.  A good number of factors can get in the way of effective communication such as long-standing scripts ‘I should be able to cope alone’, ‘I must not disagree’, ‘I don’t have the right to ask’, as well as limited skills in regulating emotions when the message isn’t received in the way it was hoped.

At the very least, something we can do as clinicians is listen to the people we are working with, and while we don’t want to reinforce helplessness (which, by the way, we will do if we offer ‘solutions’ rather than simply acknowledging the situation), we can help people feel more comfortable with difficult emotions if we ourselves can be mindful and allow ourselves to ‘sit with’ those very emotions.  By modelling effective communication ourselves, we can help validate and strengthen our relationship with the person, while not necessarily attempting to ‘fix’ or ‘reduce’ the distress.  Then we can turn the conversation to things that are good, achieved and helping the person move on.

Some brief pointers as to how:

• ask about what the person has been up to rather than how their pain is
• if they say they’ve had a hard time, acknowledge this ‘It’s been a real challenge to get here’.  Then pause – and add ‘it’s really great to see you here, how did you manage it’ as a way to move on towards positive coping
• when they foresee snags or problems, acknowledge that it’s not easy to do what we’re asking.  Then ask what they think is the ‘next best step’ towards doing what you’re currently working on.
• respond to the emotional content by empathic reflection, rather than getting caught up in how to solve the practical problem – that’s probably not what the person is asking for, and even if it is, empathy can go a long way towards helping the person accept that you are there for them rather than to ‘fix’ them

The paper by Cano and Williams goes on to discuss appropriate research strategies that might help us understand more about interactions in couples.  It’s difficult for me to read this without adding ‘if you can get the couple to come in!’ because so often people seem to think that they ‘should’ cope with ongoing pain alone.  It would be great to see far more emphasis on people and their relationships and social context in the next ‘new wave’ of chronic pain management.

Cano, A., & Williams, A. (2010). Social interaction in pain: Reinforcing pain behaviors or building intimacy? Pain, 149 (1), 9-11 DOI: 10.1016/j.pain.2009.10.010

Cano A, Barterian JA, Heller JB. Empathic and nonempathic interaction in
chronic pain couples. Clin J Pain 2008:678–84

The two faces of pain assessment

This week’s focus is on assessing or evaluating or getting to understand the experience of pain.  There are many reasons to assess someone’s pain, from trying to diagnose the kind of pain they have to attempting to see if someone is ‘real’ or not!  And shades in between.  I’m going to focus on ‘genuine’ reasons to understand someone’s pain experience rather than policing whether the person is a good actor or not, because as I’ve said before, I don’t think very often about people ‘faking’, and because I think it might be more helpful to try to see the world from the person’s eyes first.

So, given that pain is a multidimensional experience, why do I say there are two faces to pain assessment? Well the two I’m thinking of are:
(1) the experience of pain itself – location, quality, intensity etc, along with the beliefs and risk factors that influence the ‘suffering’ component of the ‘onion ring’ model described by Loeser and others.
(2) the impact of pain on function – disability, sleep loss, effect on relationships, work and so on.

I’m going to leave the first aspect for a while, and spend some time looking at the impact of pain on the individual and his/her family/community, but before I do I want to consider some basic concepts relevant to pain assessment that are essential before even beginning to think about the ‘how’ of assessment!

Firstly, all pain assessment is subjective. What that means is that as outside observers, we cannot determine whether the person is actually experiencing what they say (or indicate) they are experiencing. We can’t reliably establish whether someone is or is not carrying out activities to their full capacity. We can’t accurately determine whether a certain number of pain behaviours is the ‘correct’ amount of behaviour for the amount of nociception present.

Secondly, all behaviour is subject to the effects of learning and reinforcement that are well-established in the psychological literature (and in any two-year-old child wanting sweets!). As a result, it’s difficult to tell whether someone is behaving in a certain way because of years of learning within their family context, or whether it’s more immediate social environment demand characteristics that are influencing how the person is performing. We would all probably do more for someone that was holding a gun to our heads than for someone who looked bored (and we knew the results were going to determine whether we got some money!).

Thirdly, what we will or won’t do is also influenced by what we think we can or can’t do – and what we anticipate may happen afterwards, or what we experienced last time we attempted. A recent study of functional capacity evaluations found that even for people without chronic pain, a majority of participants experienced elevated pain the day after completing an FCE, so my guess is that some people who have chronic pain and who have completed a previous FCE may modify their performance at the next one. Our beliefs, attitudes, predictions, memories and so on determine what we are prepared to do in any context. When we look at the impact of pain on function, we need to remember this and take these factors into account.

The final area to consider today is the effect of context on performance. In many ways this is a summary of the three previous areas I’ve mentioned, but bear with me as I explain.
Many people with chronic pain report that they can carry out an activity in one setting, once, but when asked to carry it out repeatedly, and in a work setting, for example, they struggle. In the context of the real world, with all the social cues, cognitive load and need to persist and maintain activity over time, performance becomes variable. This doesn’t just happen for people with persistent pain mind you – let’s think of those Olympic athletes who may have performed well ‘at home’, but in the context of The Olympic Games in China in Front of All Those People – performance may well be very different.

I’ve only mentioned a few of the confounding factors that influence how pain may impact on a person’s daily activity in life and roles. I haven’t even started to use references – but you can bet if you come back this week, there will be more!

Pain Behaviour Activity

Having looked all over the place for some suitable activities for people to become aware of their own pain behaviour and then learn to change it, I decided to put together one of my own. Now, unlike the posts I’ve made recently, I have no research to determine its effectiveness, but I hope you’ll forgive me for this!

The basis for considering behaviour change in pain management is behavioural psychology – by selectively reinforcing ‘well’ behaviour, pain behaviours should reduce in frequency. And it certainly does work – by simply asking someone ‘what have you been up to recently’ rather than ‘how is your pain’, we are able to reinforce activity rather than elicit a list of woes! But because I also want people to develop their own awareness of their behaviour so they can independently choose to alter their patterns, I think it’s helpful to

1. become aware of what may be relatively automatic patterns
2. start to alter one behaviour at a time
3. use behavioural principles to reward well behaviour

This is the activity I chose, and a variation.
In pairs, I asked the group to ask each other this question:
“How do you know when I’m having a bad day? What do I do?”
I also gave them a list of pain behaviours to use to help them identify specific behaviours they may do.

Then I asked them to complete their own personal ‘pain thermometer’. You know how people often say they don’t have a thermometer or a plaster cast to say they have pain – well their behaviours can certainly act as a thermometer to other people!

In this activity, the thermometer is copied onto A3 paper, and the list of words and pain faces given to them to paste onto the thermometer. In pairs, they are asked to complete a pain thermometer to reflect the pain intensity and pain behaviours that they do.

The idea is to give the participants an opportunity to reflect on the range of pain behaviours they carry out, and to consider the effect on each other.

I also asked the group to carry out one of their pain behaviours to the extreme – walking from one side of the room to the other with these exaggerated behaviours. Asking the group to discuss what it was like revealed some interesting insights like ‘I don’t know what I do when I’m really sore’ to which another participant demonstrated exactly what that person does! And another said ‘I never knew how hard it was to move and how frustrating when I do these movements’.

Then I asked the group, in pairs, to choose one behaviour and discuss the impact it has on them and others – the good things about it and the not so good. Participants identified that pain behaviours can act as a warning sign to others, that they communicate very well – but have unintended effects that are not so good, like people either avoiding them, or ‘smothering’ them!

Then they chose that one behaviour and decided to spend a day learning how often they actually do it – and because they are in a group, learning to remind each other when they inadvertently revert to old habits.

All in all, I think this was an interesting activity – and hopefully will have at least increased the awareness of pain behaviours in this group. Changing the behaviours – that will take time!
If you use this activity, let me know how it works for you – and any modifications you may.

Why can he go surfing but can’t do the vacuuming?

Social contract theory is a theory drawn from evolutionary psychology – a ‘cheater detection’ system if you like. Following on from yesterdays post about detecting faking in pain, this study examines the judgements observers (in this case, friends and relatives of people with pain) in a study where four vignettes were presented. Each vignette varied in terms of four cues: the person continuing or stopping liked tasks, continuing or stopping disliked tasks, the availability of medical evidence, and the pain intensity as rated by the person.

Many variables have been studied with respect to how accurately observers judge another person’s pain – attractiveness, gender, ethnicity, social class, as well as the context (return to work or post-surgical), and the characteristics of the observer (parent, caregiver, spouse, clinician).

Results from past studies have included: unattractive patients were judged to suffer from more pain than physically attractive patients (Hadjistavropoulos et al.1990, 1996, 2000). Generally, higher reported pain intensity appeared to invite higher estimated pain intensity. When comparing sufferers’ self-reports and observers’ estimates, however, low reported pain intensities were overestimated and high reported pain intensities were underestimated (Chibnall and Tait 1995; Chibnall et al. 1997; Krokosky and Reardon 1989; Tait and Chibnall 1997; Zalon 1993).

For health professionals, some studies found no associations (Dudley and Holm 1984; Everett et al. 1994; Hamers et al. 1997; Oberst 1978; van der Does 1989), others found that less experienced observers gave higher pain estimates than did more experienced observers (Mason 1981; Perry and Heidrich 1982; Lenburg et al. 1970).

In terms of contextual cues, the absence of medical evidence to support the person’s report of pain has been associated with lower estimates of pain.

Yesterday I briefly discussed the idea of malingering being the purposeful faking of health problems in order to gain financial benefit: in this study, the evolutionary value of the ‘social contract’ is used as the theoretical model for evaluating our sensitivity to these responses. Social contracting is a situation where the ‘‘individual is required to pay a cost, or meet a requirement, to an individual (or group) in order to be eligible to receive a benefit from that individual’’ (Cosmides 1989, p.197).

It makes sense that as humans we have some systems developed to determine whether we are being exploited and that the normal ‘contract’ between people is being disturbed. There is empirical support for humans being sensitive to cues for cheating from both human and animal studies (Cosmides 1989; Gigerenzer and Hug 1992;Wilkinson 1990) – but as we saw yesterday, we can be deceived reasonably readily, so it makes sense for us to be particularly sceptical about situations where we may be manipulated.

In a situation where one person is likely to receive benefits (caring or free food, for example) because of their reported pain, it makes sense for the observer to be more aware of cues suggesting that the individual receiving the ‘benefits’ is not actually in pain (Williams 2002). This has been studied before, and it has been found that suspicion of cheating or faking leads to conservatism and underestimation of pain. This can explain why such weight is given to medical evidence by health care professionals even when the relationship between ‘evidence’ from radiology and pain, for example, is fairly weak. This is especially true in cases where time off work, or other ‘special’ treatment is given as a result of confirmation of a ‘real’ problem.

The hypotheses in this paper were:
– the combination of two behaviours (continuing liked and
stopping disliked activities) would be judged as unfair
and lead to lower pain estimates, whatever the level of
pain,
– there would be no effect on pain estimates of the
presence or absence of medical evidence, and
– pain as reported by the patient would affect pain
estimates by relatives

Although the results were from a very small group of respondents in the end (only 23% of the initial group recruited actually responded with complete questionnaires), some interesting findings were obtained.
– people who stopped doing things they liked were interpreted as ‘having to stop’, and this was perceived as fair
– people who stopped things they didn’t like but continued with things they did like, were perceived as being unfair
– behaviour of characters reporting high pain was estimated to be fairer

The authors suggest that perhaps greater pain meant greater recognition of the cost in pain incurred by doing any tasks, or that more leeway was exercised in judgements of behaviour as fair or unfair.

– more pain was attributed to patients who stopped liked tasks
– highest pain levels were assigned to patients having stopped both liked and disliked activities
– lowest pain estimates were assigned to patients who had stopped disliked but continued liked chores, the combination which also received the lowest fairness ratings

The authors comment that these findings ‘support our hypothesis concerning lowering of pain estimates by individuals close to someone with persistent pain if they judge patients to be behaving ‘‘unfairly’’, that is, ‘‘accepting the benefits’’ of having pain—of being permitted not to do some tasks—‘‘while not meeting the requirement’’—of being unable to do other preferred activities.’

– participants’ estimates were not significantly affected by presence or absence of medical findings in this sample

– higher given pain intensities led to higher estimated pain intensities
– there were systematic discrepancies in estimates since low given pain intensities were estimated as higher and high given pain intensities as lower.

Some food for thought – this is a first cut study using social contract theory as a framework for determining a priori predictions as to which cues are salient, and in which direction. I look forward to finding out more on this – it may help us help our patients reflect on their behaviour, as well as the ways in which family members interpret and respond to patient’s behaviour.

There are some limitations to this study – in particular the small sample size, and the use of written vignettes rather than video-recorded scenarios. But for making us think? I think it’s great.

If you’ve enjoyed this post, there will be more tomorrow – and don’t forget you can use the RSS feed above to subscribe, or you can simply bookmark this page and come on back! I love comments and always respond, so don’t forget to let me know what you think of the topics I cover (***pssst! I don’t bite!***)

Kappesser, J., C. Williams, A.C. (2008). Pain judgements of patients’ relatives: examining the use of social contract theory as theoretical framework. Journal of Behavioral Medicine DOI: 10.1007/s10865-008-9157-4

Faking and malingering (again!)

One of the most popular posts I’ve written on this blog concerns ‘faking’ or ‘malingering’. I’m curious about this, because even though I have been asked many times whether I have had patients that are ‘faking’, I don’t think about it very often myself. I suppose it is a subject that is dear to the heart of anyone who is concerned about ‘motivation’ – especially where entitlements to payment or other benefits are dependent on the authenticity of the person’s claim to be unable to function.

So, time to unpack the whole topic again I think.

Last time I posted I had trouble finding relevant literature – the main problem being that in academic publications where pain is being discussed, the concept of faking has been superceded by research into areas we can work with clinically. The role of determining whether malingering or faking is not one for clinicians: it properly lives within the realm of private investigators – and even then, findings are up for challenge when a person is observed behaving in one way in one setting and another in a different setting. There are so many things that influence behaviour that it’s simplistic to decide that motivation to intentionally deceive is the primary reason.

If we start with the idea that pain itself is an experience – something we can’t share with each other, in the same way we can’t share whether we see the colour blue in the same way as each other, or the taste of banana! So you and I can’t tell just how much pain any person is in.

What we depend on is behaviour – what the person actually does behaviourally when they experience pain. And you and I know that we do different things in different places even when we experience the same pain! Take the example of stubbing your toe – in your garage you’ll probably swear loudly and jump up and down. In a very quiet church? Well, we probably won’t be able to hear your swearing and your jumping might be replaced with a wince…

In another example: if someone asked you to run 200m, you might take off at a bit of a gallop, but I’ll bet that if you knew there was a large and very angry bull coming after you, you might just move a little faster!

So we know that the social environment influences pain behaviour, and we also know that beliefs about the consequences of action also influence behaviour. We know too that what people understand about the significance of their pain is also a factor that changes behaviour. If you are unaware that the tickling feeling down your leg is actually a large and venomous spider biting you, you may well ignore it, if you think the vaguely tender lump under your armpit is cancer you’ll probably pay good attention to it and ask for a medical opinion. And your reaction to this lump might be even greater if you’ve had a history of cancer in your family.

In the compensation situation, there is no doubt that the security of receiving a weekly payment can be very helpful in the initial stages of recovery from an injury. That security can become problematic when the person is being asked to undertake the relatively risky business of returning to work – What if returning to work fails? What if my pain gets so bad that I can’t keep going? What if I let my employer down?

Some of these very realistic fears can interfere with the readiness for someone to return to work – and yes, compensation means it can easier to remain in status quo than to attempt to return to work. Does this equal malingering? Is the person faking? Or would you and I feel very much the same, and be quite hesitant to risk our health and livelihood too?

Can we as health professionals ‘tell’ whether someone is intentionally faking?

The short answer is no – humans are very poor at telling whether someone is lying. That’s why movies are so successful – even though we know the people are ‘actors’!

Take a look at this clip from You Tube:

And this one:

and the truth?

For another good article on deception – if a bit cognitive – this newly published article review the latest and greatest on the art of detecting deception. It’s just too early to apply this to pain and malingering.

SIP, K., ROEPSTORFF, A., MCGREGOR, W., FRITH, C. (2008). Detecting deception: the scope and limits. Trends in Cognitive Sciences, 12(2), 48-53. DOI: 10.1016/j.tics.2007.11.008

‘Faking’ or ‘Malingering’ or ‘Exaggerated Pain Behaviour’

Hot words!!

It’s amazing how often health providers get asked directly or indirectly whether someone experiencing pain is ‘faking’ it. The short answer is the most accurate – we can’t tell. We’re not lie detectors, there is no ‘gold standard’ to work out whether someone is pretending or not, and the question is based on erroneous thinking about pain and pain behaviour.

I can almost feel the spluttering at my last sentence from some readers!

Let’s look at this more closely.

Remember the biopsychosocial model of pain states that the experience of pain and pain behaviour is influenced by three broad groups of factors: the biomedical/biophysical factors such as extent of tissue disruption at the periphery (or site of trauma), neurological changes of transmission and transduction (throughout the peripheral and central nervous system), and disturbance of the neuromatrix.

At the same time, there are psychological factors such as the level of alertness and arousal, attention, past learning, expectations, beliefs, attitudes, mood, contingencies and so on.

And there is also a range of social factors such as the presence or absence of social support, the systems in which the event occurs (such as compensation, availability of health care and technology), cultural expectations, religious beliefs at the same time as the other two factors.

Recall that pain is not the same as pain behaviour – pain behaviour is everything that we do in response to pain, including involuntary physiological responses (flushing, sweating), reflexes (withdrawal), verbal utterances (groans, gasps, requests for help), as well as complex behaviours such as reaching for medication, going to see a doctor, asking for time off work etc.

Pain behaviour is subject to all the usual influences on any behaviour – that is, operant conditioning can be involved, as well as classical conditioning. And pain behaviour has developed from the behaviour we displayed as a baby to the more complex and modulated behaviours we demonstrate now.

So, it’s easy to see that pain behaviours vary hugely between individuals even if the original trauma is exactly the same.

I can understand several things about the question ‘can you tell if he’s faking’. Pain behaviour elicits strong emotions in observers – it’s designed to do just that! It communicates, and something we like to do as humans is work out whether someone is lying or not. The problem is – we’re not very good at telling who is and is not lying (but we like to fool ourselves that we personally don’t fall for liars!).

In a litigation or compensation situation, it would be great to work out exactly ‘how much’ each pain is worth in order to give it a dollar value, and determine compensation. But – pain can’t be measured directly, we have to use pain behaviour as the next best thing – and pain behaviours are influenced by a whole lot of things. So it’s not a very reliable measure.

Another reason for wanting to know ‘is he faking’ is how far to ‘push’ the person into doing more. The underlying concern is ‘will I cause harm’. And again we really don’t have any useful measure if we try to have pain or pain behaviour as our guide. We need to use something else – radiological union perhaps, control of a load, heart rate and respiration.

BUT the question is based on the assumption that there ‘should’ be a certain amount of pain behaviour for a certain amount (or length of time since) tissue damage. And there simply isn’t.

Some allied questions….‘can’t you use functional capacity testing to work out whether someone’s faking?’ No – sorry. A functional assessment, just like any physical examination or test, tells you what the person will do, and perhaps how consistently they will do it – today. Few, if any, FCE’s have demonstrated predictive validity – that is, they don’t accurately predict how much someone will or won’t do in a day-to-day ‘real’ situation, in fact they won’t tell you what the person can and cannot do at all.

What does this ‘consistency of effort’ tell me? Just that – how consistent this person carried out this activity this time. It doesn’t predict anything, and certainly doesn’t tell whether someone is ‘faking’. People vary in their consistency of performance depending on: their initial expectation of the activity (it may have been harder or easier than they first thought); their prediction of the effect of doing that activity (they may predict they will have an increase in pain – and therefore reduce effort, or perhaps increase effort in order to convince the examiner that they are trying hard); their fear/anxiety may vary throughout an activity; their past experiences may influence what they are prepared to do. Even when given the same instructions ‘use maximal effort’ – if a person hasn’t done anything very physical for a while, ‘maximal effort’ may be hard for them to predict. Some may even be ‘saving themselves’ for activities later in the assessment battery.

But surely some people do fake! Yes – but it’s not a health or medical matter. It’s just not helpful to work out whether someone is or isn’t faking. What happens if you do somehow detect ‘faking’? Confront the person? Take their health care away? Tell them to pull themselves together?

It’s more helpful to think about what factors might be initiating and then maintaining this behaviour – then start to work on these variables to promote change.

But I’ve seen even eminent researchers use the term ‘exaggerated illness behaviour’. Yes, well, even eminent researchers can be mistaken! All that we can observe is that this person behaves in this way at this time in this setting, and the person attributes the behaviour to pain (or illness). We can only identify all the possible factors that are contributing to the maintenance of the behaviour, elicit from the person the not so good things about the situation they find themselves in (and acknowledge the good things about their situation), and help increase the importance they place on making changes, and support their confidence to start to make changes. This might mean leveraging off contingencies (reducing compensation, withdrawing spouse support) if these things are maintaining the behaviour – but it may also mean simply resolving ambivalence about the positives of moving forward.

Malingering? Faking? Exaggerating? When someone can tell me why yellow is better than blue, or find a measure of the ‘chocolateness’ of chocolate and the banana-ness of a banana, perhaps we may have found an objective pain measure. Until then, don’t ask me to work out whether someone is faking it, just ask me to help them move forward.

Oh, and just for fun – how many different words are used to suggest that someone is ‘faking’?

– functional overlay

– supratentorial factors

– a ‘genuine’ man (as opposed to a fake one, or one that is faking)

– adopting the ‘sick role’ (if someone believes they are sick/unwell, what can we expect? How many people do we see ‘adopting the well role’?)

– demonstration of non-organic signs (now that one’s actually interesting, as Gordon Waddell states very clearly in his book ‘The Back Pain Revolution’ (2nd Ed), he never intended the term to mean anything other than to suggest the person was experiencing increased psychological distress – and NEVER to be used as a means of detecting faking!)

This paper by Michael Sullivan is a little philosophical, but at the same time illustrates the points I’ve tried to make above.
This reference is from the 2001 version of the New Zealand ‘Yellow Flags’ document on acute low back pain management.

It’s actually quite hard to come up with good (quality, evidence-based) references on ‘malingering’. By far the majority of articles I located using Google, searching on the terms ‘malingering pain behaviour’ suggested that somehow ‘medical people’ or ‘psychologists’ or ‘psychiatrists’ using special tests can identify malingerers. Someone please show me the ‘special test’!! This section of the IASP Core Curriculum should put to rest this sad aspect of the management of people experiencing persistent pain. Detection of malingering is best left up to private investigators, leaving health care providers to the really difficult work of helping people recognise that change is possible, desireable and important.

For my most recent post on why people might report differently on self-report than in physical performance tests – click here

A personal bias

Now some readers have been wondering what my background is…Sometimes I feel like being rather provocative and asking why – while other times, like now, I feel like ‘fessing up.

Here is a clue: in pain management, to me the most important thing is to see people doing things differently.

That’s right, although I’m a strong believer in working with thoughts and beliefs and values and so on – if it doesn’t mean something observable changes, it didn’t work. My aim with pain management is to help people do what they want to do, to be in control so they can achieve their potential, not just ‘feel better’. Likewise with teaching – if I haven’t stimulated you to do something differently, then I’ve failed.

My reason? Well in pain management, because pain is a quale, that is, it has sensory and emotional qualities that we can’t directly share with each other, we cannot ever know how much pain another person is feeling. The only clues we have that pain is present (or not) is what the person does about it. That is, behaviours or actions. Even when the experience is an emotion, you and I can’t share the emotion except through the medium of language or action.

So we infer that pain is present on the basis of behaviours (including speech). This is one reason that, as clinicians, we can never truly say whether someone is ‘malingering’ or ‘faking’ (that’s more likely the job of a private investigator!) – and if behaviours are the only aspect of pain that we can observe, we also need to acknowledge that behaviours are subject to all the influences of any behaviour, such as contingencies and social learning as well as cognitive aspects such as attitudes, beliefs and so on.

As a result, we can do a whole heap of work with someone’s thinking, but unless they do something differently, nothing has really changed for them. If they feel more positive, hopefully we could count smiles; if they are less distressed, hopefully they will go to the Emergency Department less; maybe even return to work! We also know that if people do more, feel better about themselves, and they’re able to do more!

This isn’t new stuff – this is pretty fundamental to the operant conditioning model of pain introduced by Wilbert Fordyce in the early 1980’s onwards. By conceptualising pain behaviour as the subject of treatment, Fordyce introduced the idea of living despite pain. By noticing that reports of pain intensity vary depending on distress, depression, reinforcement from over-supportive others and so on, psychologists recognised that if pain behaviours reduce, often reports of pain intensity reduce. And more importantly, people began to live lives again. Now that’s what I’m about!

For more from the man himself, here are a couple of the original articles – plus a couple of others that are important to explain the biopsychosocial model.

Did the clue help? Do you know what ‘flavour’ health professional I started off as? Do you know what flavour health professional I am now? Does it really matter?

Fordyce, W. E. (1984). Behavioural science and chronic pain. Postgraduate Medical Journal, 60(710), 865-868.

Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioral management of chronic pain: a response to critics. Pain, 22(2), 113-125.

Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982). The modification of avoidance learning pain behaviors (Journal of Behavioral Medicine. 5(4):405-14, 1982 Dec.).

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.

Turk, D. C., & Monarch, E. S. (2002). Biopsychosocial perspective on chronic pain. In D. C. Turk & R. J. Gatchel (Eds.), Psychological approaches to pain management (2 ed., pp. 3 – 29). New York: The Guilford Press.

Oh, here are some other on-line bits and pieces on the biopsychosocial model. Firstly, a review of a video by Bob Gatchel on Pain Management using the Biopsychosocial Model…

For those who don’t think a full-on postgraduate course is possible, this on-line CME course may be helpful:
UCLA CME course

And don’t forget the University of Otago, Christchurch, papers in Pain and Pain Management – see the link to your right…