CHAPTER 7: Understanding the Patient with Chronic Pain

INTRODUCTION

Asked to describe their pain, especially chronic, noncancer pain, patients often appear perplexed, stating, “I don't know. It just hurts.” Clearly, more information is needed, and obtaining the necessary details is an art. While subjective and objective methods of psychological evaluation provide one of the cornerstones of diagnosing factors important in the perpetuation of pain beyond the otherwise apparent state of healing—not to mention executing and monitoring the results of multimodal and interdisciplinary approaches to pain control and functional rehabilitation—it is vital that the treating medical professional develops a sound rapport with the patient independently of the mental health specialist. This comes about via empathy and an understanding of the patient that is best summed up by stating that the person suffering from chronic, noncancer pain needs to be heard and his or her pain validated as real. Only then can an accurate diagnosis be made to form the foundation upon which a rational treatment program can be built.

By the time most patients are referred to a pain specialist, they are often frustrated, sleep deprived, anxious, and depressed and feel angry toward those they feel have not really listened to how they have been compromised by persistent pain. To many sufferers, the message has come across as “it is in your head,” even when not intended as such. Much of that anger dissipates when patients truly feel as if they have been heard. They are then far easier to work with, and the likelihood of progress significantly increases. When such a rapport is achieved, patients generally become more open to understanding that the locus of control lies within themselves to a considerable degree and cannot be expected to appear magically from an outside source even if that source is able to guide and to provide tools useful in the healing process.

A few basic pointers are worth emphasizing here. These are not insignificant and are often noted by patients as some of the reasons that they did not feel heard. It is important to maintain eye contact and body language that emphasizes that, at least for the time spent together, the patient is the clinician's sole concern. Typing or dictating into an electronic medical record should be avoided while the patient is talking or before the interview and examination are complete. Furthermore, providing verbal feedback shows that the clinician has really grasped the essence of the patient's experience of suffering as well as the details of the pain syndrome in terms of its time of onset and the events leading up to it. Such feedback supports the notion that the patient is being taken seriously with respect to what he or she feels is important, regardless of whether or not the clinician wishes to steer the focus over time in a different direction. This cannot be emphasized enough, ...