| HOME > Chronic pain > Know your enemy |
by Moira A Smith
First written 1997-98; revised version
"Models of chronic pain management through denial are based on the proposition that chronic pain occurs as a consequence of compensation and inappropriate treatment. Moreover, they emphasize the outmoded concept that soft tissue injuries heal after six weeks, and they cling to increasingly irrelevant behavioural models of chronic pain." - The denial of chronic pain by Robert W Teasell MD FRCPC
Contents
Introduction
In their own words (articles on chronic pain)
Conclusion
Appendix: an Australian Fibromyalgia expert speaks
The examples in this article of what I called "the rehabilitation
model of chronic pain" are mainly Canadian; there is no particular reason
for this apart from the availability of material at the time when I wrote it.
However, Prof Geoffrey Littlejohn of the University of Melbourne in Australia
has published papers from the same point of view and in very similar language
- see the Appendix.
See also a pain patient's account of treatment
in an Australian pain clinic.
On this page are links to some articles which reveal what many doctors and rehabilitation experts believe about you - the chronic pain patient - and what they consider is the best way to treat you. They are written from the standpoint of what I call the "rehabilitation model" of pain management.
According to this model, because your pain persists longer than the six months allowed for tissue to heal, and has no observable cause, there must be "psychosocial" reasons for your "pain behaviour" and for your choosing to play the "sick role". Either you've become addicted to your medication, and would prefer to be in pain so you can keep getting it, or you have found that people treat you better and life is easier when you're in pain. (It seems more obviously ridiculous when stated in plain language. There is not much plain language in the following articles.) The diagnosis is not "chronic pain", but "chronic pain syndrome" - and there is a big difference.
In the rehabilitation model of pain management, the goal of treatment is to prevent us playing the "sick" role of relying on compensation or social security payments, and return us to the "adult" world of work. This is the way rehabilitation people think, because they are paid - by the state, or your employer, or an insurance company - to get you back to work. They are not paid to state that: "this person is in pain and can't work, they are ill with chronic pain". That is why they say instead: "This person may be in pain but that doesn't mean they can't work. In fact, we believe that getting them back to work despite their pain is the kindest thing in the end." Money talks.
The authors of these articles don't believe you are malingering (let's face it, the evidence that you are in pain is too obvious for them to get away with that one); they admit your pain is "real", but they do believe that you are in pain because deep down, unconsciously, you prefer it that way. The implication is subtle and hidden within language that may seem sympathetic because your suffering is acknowledged. But don't be misled: these articles are not about helping you, they are not even - despite their titles - about how your pain can be treated.
So don't expect to be prescribed adequate pain medication by these guys. In fact, according to the rehabilitation model of pain management, prescribing pain medication (as in the "biomedical model") is the worst thing anyone can do for us. Instead they will help you unlearn your "pain behaviours" (grimacing, groaning etc) so that you can become a psychologically healthy adult once more, ready to resume your place in the economic system.
Now read on ...
Chronic Pain Assessment and Treatment - by Alan Brandis, Ph.D, of Atlanta Area Psychological Associates PC.
This article will serve as an introduction to the rehabilitation model of pain management. It contains, among other things, an explanation of how we unconsciously learn to be in pain so that other people will do things for us:
... as painful as pain is, it has covert emotional bonuses and rewards that can come with it. For example, it does not take long to find out that family members go out of their way to accommodate the person in pain, taking over their responsibilities and letting them out of obligations ...
and so we can take drugs to get high:
Taking medicine for pain can also be a factor that prolongs and maintains the Chronic Pain condition. Most painkillers have powerful effects on other parts of the central nervous system, not just on the pain receptors, and they produce a feeling of euphoria (a "high") or they relieve anxiety. Again unconsciously, there is a powerful tendency to seek the emotional state that one gets from the drugs, but to justify taking the drug one must be in pain.
Because these reactions are unconscious, there is presumably no point in the patient protesting that this just isn't true. Yet this model doesn't explain why people who live alone, with no family to help them, have chronic pain. It also ignores the well-known fact that people who take strong pain medication round the clock get no "high" at all from their normal dose.
Pain is a Blind Guide in Injury Management - by Kelly Patrick Flannigan, MD; an article which originally appeared on the website of Summit Injury Management, a firm which states its philosophy thus:
Healthy, responsible and productive individuals are the necessary building blocks of a healthy society. We believe that every adult individual has the right and obligation to contribute to the development of the social fabric in which they exist. [my emphasis]
(Whatever happened to "From each according to their ability, to each according to their need"?)
Again, we are told that dispensing pain killing drugs is inappropriate:
When pain has persisted beyond the expected soft tissue healing time, and signs of tissue pathology cannot be demonstrated, the biomedical model of disease no longer provides an effective basis for patient management.
and that the pain is due not to physical causes, but to the attitude of the patient:
[In some] cases ... the physical disorder provides an incomplete explanation for the individual’s occupation of the sick role ... This is particularly true when the person seems unable or unwilling to "get well".
Flannigan warns the physician against the trap of being on the patient's side when the insurance company is reluctant to believe the patient can't return to work:
The physician’s role will ... often evolve to include meeting the patient’s expectation that the physician will "protect" the patient from the interests of third parties, which interests almost invariably take the form of pressure to return the patient to pre-injury responsibilities [ie work]. There may be anger arising from a sense of injustice and entitlement. There may also be anger focussed on the physician for being unhelpful or the employer or other parties seen as responsible for the original injury.
In the face of these pressures, the doctor can strengthen his resolve and resolve any ethical doubts about where his duty lies by remembering that, where chronic pain is concerned, one must be cruel to be kind:
It is in this increasingly complex situation of persisting pain and disability that there is the greatest danger of the physician contributing to the severity of the patient’s illness through defense and medical justification of symptom-guided inactivity.
Successful Management of Chronic Pain Syndrome - by John C. Clifford, MD, FRCPC, at the website of Canadian Rehabilitative Consultants.
Another doctor of the "stoic" school, this author agrees that "if patients with chronic pain syndrome continue to receive traditional medical management [including, presumably, pain killing drugs], their pain symptoms often increase" and "continuing to equate chronic pain with a significant loss in function [in other words, disability] is often unnecessary and inappropriate".
As long as it's made clear to the patient that being in pain is of no importance (presumably the patient's views are immaterial in making this judgement), all that's needed is to get them fit again so they can return to work:
It must be emphasized to the patient that the purpose of the exercise is to increase function, not to reduce pain. As the patient exercises, pain might increase; however, pain need not interfere with rehabilitation.
This article makes difficult reading, and not only because of the numerous uncorrected scanning errors and yellow italic text on a bright green background. The author's description of the ideal rehabilitation schedule is quite terrifying: it is to include dates for achieving objectives which "should not be continually readjusted in response to exacerbations of pain"; while the doctor should reassess the patient
at fixed, predetermined intervals rather than in response to variations in pain perception ... [and] assume that exacerbations of pain will occur as activity levels are increased.
Earlier, the doctor was told that "well-meaning but ill advised advice" to the patient to pace themselves or adjust to their disability, could delay or prevent rehabilitation. Participation in such a program must be a harrowing experience. No wonder the author warns that, if the rehabilitation program is not successful, "the patient could remain dissatisfied, bitter, dysfunctional, and angry".
Chronic Pain Study - by TJ Murray, OC, MD, FRCPC, FACP, Professor of Medicine Department of Medicine (Division of Neurology) Dalhousie University, on the website of the Workers Compensation Board of Nova Scotia. Beginning by stating:
I have tried to be as objective as possible, taking the stance that I am on no one's "side" in this matter. Although commissioned by the Workers Compensation Board of Nova Scotia ...
this writer demonstrates that, despite his protestations of scientific objectivity, "he who pays the piper" still calls this particular tune:
As time goes on and the symptoms continue ... the chronic pain patient can often be noted to adopt features and behaviours that are referred to as "pain behaviours", and may adopt the sick role and become more limited than one would expect from the physical findings ... The approach of medical investigation and treatment, the attitude of family and supporters, and the mechanisms of Workers Compensation Board and social agencies may become important factors by providing "rewards" for remaining unwell ...
He insists that "early return to work despite pain is essential" but warns his professional audience:
Unfortunately, unless handled sensitively and with good information, the patient perceives that treating them in other than the medical model for acute pain means that the physicians thinks it is "all in my head".
One wonders why! But in a real sense, the author is differentiating between the pain itself and the person's "in the head" response. He does this by separating out the concept of pain from that of "suffering":
A football player, injuring their leg, will often accept it without any apparent suffering, and regards it as an annoyance that may impede or end their play in the game. He often gets up, limps a little and then attempts to "run it out". In other circumstances a person ... may refuse to move, and .... will often express a lot of pain and suffering behaviour
What determines a person's response to pain, he says, citing another researcher called Cassell, is their personality, hopes, and fears. Beliefs about whether the pain is under control are also important: if a person fears that their pain will be become unmanageable, their suffering is increased.
It is difficult to argue with this conclusion (although one might point out that to compare a middle-aged chronic pain patient with a young fit footballer is hardly fair play). Unfortunately it allows him to state that chronic pain has no physical cause, and therefore should not be treated medically. It allows him to point out that "The usual pain medications are unsuccessful" and use this to support his argument, without addressing the question of whether the "usual pain medications" are appropriate or being prescribed in high enough doses. It allows him to agree - with every appearance of sympathy - that chronic pain patients are suffering, yet at the same time use this observation to surreptitiously push the issue of their pain aside, in favour of nebulous psychological factors:
To understand the condition of chronic pain better, it is helpful to think in terms of "suffering". I say this because the word "pain" evokes the concept of acute pain, when it is clear that these patients are suffering, and that the suffering is often painful, but that there are other components of suffering as well. They are suffering with disturbed sleep, negative mood and sometimes depression, feelings of insecurity and lowered self worth, and feelings that they are severely impaired, even more impaired than they obviously are.
Nowhere does he acknowledge the possibility that disturbed sleep, depression
and low self esteem could be the
This idea of the "pain behaviour", rather than the pain, as the problem to be solved, is a hallmark of the rehabilitation model of chronic pain management. It is a very useful concept, because a person's behaviour is seen as being under his or her control. If they don't get better, it's not because the rehabilitation program has failed to help them - it's because they are not trying hard enough, or have their own reasons for not wanting to get better, or are inadequate in some way. And the author can quote studies to support this idea: he says researchers have noted that those pain patients who don't get better "have been dissatisfied in their jobs and had problems in their personal lives". Many of us will recognise this attitude as "Blame the Victim".
A chronic pain sufferer who undergoes treatment by people with attitudes and beliefs like those described above is in a no-win situation. All evidence of the efforts you have made to find relief - for example, having seen numerous doctors, being "on a first-name basis with at least one pharmacist" (Brandis), or avoiding painful activities - will be used to label you as a problem patient. And any signs of distress such as "overly dramatic verbal expressions of pain", "hostility", "steady deterioration of symptoms" and "frequent emergency room attendance" (Clifford) will be interpreted as suggesting that "complex psychosocial factors" are contributing to your pain, rather than an indication that the program is just not helping.
Fortunately, there is another approach to the management of chronic pain, as you will see from the articles listed under Politics of Pain Relief. It's a more compassionate approach, and one that does not belittle the sufferer or deny the validity of their experience. It is backed up by real scientific evidence that chronic pain is a physiological state of harm; and that opiate medication on a regular long-term basis can be both helpful and safe.
PS Skip Baker of the American Society for Action on Pain advises: "Pain Patients should stay away from any "clinic" that calls itself "Pain Management" because that means treating the pain by "managing it" without opioids by grinning and suffering through it. On the other hand, "Pain Medicine" clinics are for treating pain using opioids that God gave us to stop the agony."
One of Australia's leading rheumatologists and "fibromyalgia experts", Dr Geoffrey Littlejohn, author of Rheumatism: a Consumer's Guide, has long held "all in your head" views about fibromyalgia which have, however, tended to be concealed from patients.
In a 1998 article in the Medical Journal of Australia, he said: "Easy entry into compensation systems allows chronic pain syndromes, such as fibromyalgia, to manifest more easily", and "It may be that specifically excluding patients with fibromyalgia syndrome from compensation .. could mean earlier resolution of their problem". [Whose problem?]
Littlejohn suggested instead that the best management for fibromyalgia is:
Psychologically based ... patients are encouraged to return to normal work, recreational and household activities instead of being advised to rest until the pain resolves ... As ability increases, the patient regains self-esteem and psychological well-being and a number of feedback cycles are broken.
(He did not say what happens in those cases where increasing activity causes relapse and more pain -- presumably this would be the result of inappropriate beliefs!)
In the article from which these quotes are taken*, he focuses so strongly on fibromyalgia arising from accident or work-related injury that the casual reader might never realise that FM is often slow-onset or triggered by other factors. This is strong evidence supporting the idea that compensation and disability insurance issues are driving the "blame the patient" view of chronic pain.
*Geoffrey O Littlejohn, "Fibromyalgia syndrome and disability: the neurogenic model" (MJA 1998; 168: 398-401).
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last revised 15 July 2006