UNDERSTANDING THE RELATIONSHIP BETWEEN

PAIN AND SUFFERINGKathleen Fitzgerald, PhD

Melinda Blazar, MHS, PA-C

Writing activity Think of a time when you were in pain

really in pain – what had caused the pain and what was happening to you?

Think of a time when you were suffering really suffering – what had caused the suffering and what was happening to you?

What helped relieve your pain? What helped relieve your suffering?

Writing activity Was the treatment for the pain the same as

the treatment for the suffering? Yes or No. Would the treatment for the pain have

relieved your suffering – and would the treatment of the suffering have relieved your pain?

Which took longer to deal with – the pain or the suffering?

Which was harder for you to deal with the pain or the suffering?

PAIN

What is PAIN? Definition: “a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action “ Merriam-Webster Dictionary

Why do we care about pain?

Why do we care? Accounts for 20% of outpatient visits, 12% of

all rx’s 76.2 million Americans suffer from chronic

pain Most common cause of long term disability

How do we assess pain? Take a good thorough history

Pain score Location, radiation, quality Temporal aspects: duration, onset, changes

since onset Constancy or intermittency Characteristics of any breakthrough pain Exacerbating/triggering factors Palliative/relieving factors Associated symptoms Impact of pain

Assessing the IMPACT of pain Assessment of pain’s impact on overall

QOL Social functioning Mood, affect, anxiety Relationships Work Sleep Exercise Activities of daily living

Why pain management is difficult

Every patient is different Treatment is constantly changing

Options for treatment NSAIDs, acetaminophen, regular dosing vs. prn,

relaxation, bodywork (chiropractic manipulation, massage, acupuncture), narcotics

What works for the patient Pain is constantly changing

Acute on chronic pain Worsening chronic pain

Effective pain management involves TRUST

Tools to help Establish a pain contract

Gives clear rules/boundaries Protects your medical license

NC Controlled Substance database https://nccsrsph.hidinc.com

Referral to pain specialist They’ll advise, you manage Can offer additional pain management modalities

Address co-morbid conditions Psychiatric, chronic medical conditions

Bring awareness to attitudes/perceptions towards pain Help them to be realistic

Association of pain and suffering

Pain

Suffering

SUFFERINGWhen suffering, treat with

validation

SufferingPatients suffer when there is: A crisis of meaning and identity Fear Vulnerability A scary, bleak, unpredictable future Their sense of wholeness, intactness,

integrity is threatened

What happens to the doctors Feel helpless Too uncomfortable to ask these questions Feel vulnerable – so they numb:

drink, smoke, withdraw, get angry, bring certainty to uncertainty Doctors invalidate – don’t worry, that’s no

reason to get upset, etc.

InvalidationInvalidation can lead to less adherence, withdrawal, and or angerPatients may feel invalidated when a clinician trivializes discounts, Dismisses finds easy solutions to complicated

problems focusses solely on change and motivation

Validation

Encompasses and surpasses empathyClinician communicates: Patient’s responses make sense Acceptance – it is what it is – the patient thinks,

senses and feels the way she does Takes patients experiences seriously

To validate clinician must:Search Recognize Reflect There is truth inherent in the patient’s responses

What validation is not Making something valid that isn’t It is not scientific Controlled, replicable It does not need agreement or approval You as the clinician may see it differently

– acceptance of the patient’s experience

6 levels of validation 1) Stay awake and pay attention

Eye contact, nod Ask questions

Language for suffering different than language of pain Ask:

Are you suffering/ struggling? What about this illness is scary for you? What does this mean to you? What has this illness done to your life, work, family,

friendships? What are you worried it will do to your life, work, family

friendships? What has happened to your spirit?

Level 2 and 32) Accurate reflection Use the NURSE model - Paraphrase (don’t parrot) what patient shared Be non-judgmental – matter of fact You don’t have to agree or like what you hear

3) State what hasn’t been said Educated guess – based on reading patient’s

behavior and imagine what they are not saying

clinician risks being wrong -

Level 44) Use past history or biology More holistic view - how mind and body

are connected “Of course you feel fatigue now that you

are dealing with knee pain – and you can’t run with your son.”

Clinician demonstrates understanding of the patient’s circumstances

Level 5Normalizing Clinician communicates the feeling, or

thought is normal Anyone is your situation may feel that

way We all have those moments Don’t validate the invalid – that can lead

to lack of trust Look for grain of truth

Level 6 Radical Genuineness Treat patient as equal in status and

respect Don’t fragilize Recognize strengths and limits Admit the truth of your feelings in a way

that shows respect

INTERACTIVE ROLE PLAY

References Smith H. “Definition and pathogenesis of

chronic pain.” Up To Date. Accessed 12/22/12.

Smith H. “Evaluation of chronic pain in adults.” Up To Date. Accessed 1/5/12.

Coulehan JL, Schulberg CH, Block MR, Madonia MJ, Rodriguez E. “Treating depressed primary care patients improves their physical, mental, and social functioning.” Ach Intern Med. 1997;157: 1113-1120.

References Linehan, MM (1997). Validation &

Psychotherapy. In A. Bohart & L Greensberg (Eds.), Empathy Reconsidered: New Directions in… Washington, DC: APA.

The Lancet. Volume 374. Issue 9699 Page 1414-1415, 24 October 2009 doi:10. 1016/S0140-6736(09)61851-1.

Meir et al., 2001 Meier D, Black A. Morrison R. The inner life of physicians and the care of the seriously ill. JAMA; 286: 3001-3014. PubMed

References Egan, G. (2001). Exercises in Helping

Skills: A Training Manual to Accompany the Skilled Helper. (6th Edition). Belmont: CA: Wadsworth Publishing Co.

Maslach and Leither, 1997 Maslach C, Leither MP. The truth about burnout. San Francisco: Jossey-Bass, 1997.

Cassell, E.J. Diagnosing Suffering: A Perspective. Ann Intern. Med. 1999; 131:531-534.