Is it helpful to talk with clients about the psychological aspects of their pain?

I am a psychotherapist, with a specialism in trauma over the last 30 years, who has long been fascinated with the mind-body link and how we can encourage ease of physical movement with psychological and physical experiential exercises. I am also currently living with chronic pain since multiple abdominal surgeries, cancer and chemotherapy. Recently I was involved in a discussion with those interested in pain about how and whether people working with clients in pain should educate the client or patient about the psychology of pain as it is such a big part of understanding and treating pain.

I cannot disagree that education is good. I’ve run Body-Mind workshops in recent years with Alexander Teacher Imogen Ragone. I’ve written about the ideas we share with participants on our workshops in my blog here and of course have used some of my thinking in one to one sessions. I am working on a blog expanding this theme at the moment.

But I’m interested in what happens when the psychological components of pain are mentioned directly to a person in pain, who is seeking help and pain relief. Does it help or could it make things worse? Are there better ways of communicating this information?

IMG_0030In this article I want to examine how the power of a helping relationship to reduce pain can be enhanced or hindered by ‘educational’ interventions. I want to discuss how feedback can in itself be perceived as ‘threat’ and explore the wisdom of making psychological interventions (whether trained in psychotherapy or not).

Is being kind more helpful than being right?

Physical pain (including unexplained pain) is real and the pain of not being understood, the pain of not knowing why you have pain and the pain of trying to interact with others about the whole situation is real too.

If we accept that psychological factors are part of pain then we also have to believe our interventions contribute to psychological wellbeing or distress.

I want to caution you that being kind to your patient is sometimes more important than being right in the eyes of your colleagues. And as a side effect, kindness promotes the psychological well-being that aids pain relief.

While I absolutely believe my pain is ‘real’ and life altering. I accept that psychology plays a part and stress hormones are to be avoided as part of my recovery plan.

What you see is not the whole of my response

I am a therapist who accepts and understands this nontheless I am invariably upset by comments from medics or professionals about the psychological side of my pain. The only thing more unhelpful is new age thinking about how I ‘invited this’ or discussion of the lessons I must need to learn. Such unthinkingly cruel comments show a real lack of understanding of the psychology of pain, the impact of unkindness on pain (it makes it worse) as well as being extremely ableist – the assumption is that your symptom of pain means there is something wrong with you, rather than that pain is a normal part of human experience and we all experience it and cannot guarantee that however much spiritual alignment we have that we will avoid pain. I speak elsewhere about the spiritual path of pain. So leaving the out of touch, ableist, discriminatory new-agers out of it, should a body worker or doctor mention psychological factors in the experience of pain?

I love the theory, so when anyone mentions the psychological aspect of my pain to me, if YOU did, you’d see me nodding and agreeing with interest. ‘Oh, yes!’ I will say, and even provide an example. I am cognitively and rationally engaged.

I will not show you that I feel blamed, that I feel your explanation for my pain translates as, ‘it’s all your own fault because you’re not thinking about it correctly’. My feeling is irrational and I know it, so I won’t tell you about it. I will go away and deal with it on my own. Sometimes I will never return to see you and if I do I might not discuss these issues with you.

Criticism, or perceived criticism, is processed quickly and crudely – due to being a threat. My sophisticated brain is smiling and nodding, my primitive brain is experiencing threat, hurt and wounding. You might think this is unnecessary, and indeed it is, but logical, hippocampus processing is always slower than the amygdala flight or flight process that has just been switched on because of a perceived threat.

Being told something is my own fault has 50 years of history

Remember that being told something is my own fault has 50 years of history, hundreds of examples. A psychotherapy session may be a place to explore this, but this process is present, fixed and in place and not going to magically disappear in your clinic because you, or I, think it unnecessary. Self responsibility is often entangled in victim blaming that it isn’t easy for someone to grasp the concept without touching their pain about something else.

This is what I’m attempting to say. You may be right, I may cognitively agree with you. But push an emotional button that makes me feel blamed and misunderstood and the emotional reaction takes place. I can limit it somewhat with my logic but I can’t stop it. The stress hormones are released and this doesn’t help pain.

Does an explanation help?

Society demands explanation of pain. It doesn’t like inexplicable discomfort in any shape of form. Thus your patient demands an explanation of their pain and you may feel pressured to provide it.

But is it the explanation they want? Or do they want a way of answering all the people who are commenting on their pain and asking for explanation? Maybe an explanation will get society off their backs? Or maybe an explanation will show them that you believe them? Or maybe the explanation will give them hope that the pain can be lessened? Do they want an explanation or do they want to be believed, offered hope, have a justification for their need for soothing and special care?

“Who cares why?” I sometimes think, “I just want to be believed and want the pain to stop”. I have an oncologist, a neurologist, a rheumatologist and a GP and bear in mind that each time I visit one of these the odds of me seeing someone I’ve never met before are more likely than not. They all have theories on my pain – and they all contradict each other and themselves. It’s interesting but it’s not helpful to me. Occasionally their theories are just plain wrong and ill informed, most of the time I already know what they are telling me. (I don’t bother communicating this as I don’t want to prolong the chat, I’m just waiting for them to stop talking and start doing.)

I’m just waiting for them to stop talking and start doing

Whether it’s nerves trapped from adhesions, an autoimmune response to cancer, nerve damage from the platinum in my meds, muscle damage from steroids, fibromyalgia or a psychological response to trauma… I feel better when I receive kindness, gentle attention (ideally with touch) and feel validated as a human being and relaxed. The training of my wellness team is various including acupuncture, osteopathy and reflexology. But I don’t believe it is the explanation of their theory or the depth of their training that helps me. I believe it’s their attitude. And let’s face it even the surgeons don’t think they can fix the adhesions and scar tissue and surgical hernia. I don’t expect people to fix me. Theories are fascinating but they change.

IMG_1315When people ask me why I can’t walk more than a few steps at the moment, it’s hard to say, ‘I don’t honestly know’. I want a good answer and reasonable theory, but I feel a bit hopeless and scrutinized, people don’t find it easy to accept that I am in genuine pain and I can’t explain the cause. I believe this is due to their inability to accept my discomfort, their problem with life that can at anytime bring unexpected pain and loss.  It’s too awful to contemplate that there might be no explanation for my pain, worse, no cure. So they will push for explanation, suggest wise, magical or ridiculous cures and be critical if I don’t comply. When I get a label from a professional, my first response is relief that now I have something I can tell people who badger for explanation! However, I don’t think that this type of explanation for my pain lessens my pain, it might lessen the pain in the neck of all the questions from people.

…they will push for explanation,

suggest wise, magical or ridiculous cures

and be critical if I don’t comply…

My experiences have also taught me that whatever is believed now may easily be disproved later. Current theories are only there to be improved upon and developed or even discredited. The doctors are often wrong and contradictory, as are the researchers and the body workers. I’m grateful for good intentions but wary of any theory that sets itself up as fact.

So the explanation of how my psychology affects the situation, may not be a fact, simply a theory, given under pressure to make everyone feel better. It could bring relief but it could cause stress. If someone who does not know starts to discuss the psychological aspects of my pain, it’s too contaminated for me with victim blaming, dismissal and the smugness of the well, to be neutral in terms of psychological impact. I am interested in your theories of my pain, but a hint of blaming me? Not matter how logical I am, no matter how much I am interested, it sets me back a long, long way.

It’s been very hard work for me as a patient to compassionately allow the truthful narrative, ‘I really don’t feel good can you help me feel better?’. I feel as if I ought to, need to have a clear diagnosis in order to gain treatment. This isn’t true though.

I have experienced euphoria at having my pain explained (the doctors looked very worried, ‘does this woman realise she has advanced cancer?’) but this was because the explanation of my pain went hand in hand with, ‘we are going to DO something about this’. Remember in the 6 months prior to diagnosis I had been a good and compliant patient, going to pain clinic, practicing relaxation, continuing my meditation practice and self-hypnosis. I had had ‘unexplained’ pain for a long time and the cancer explained it and (woo hoo!) that felt less stressful than unexplained pain. It was an end to all the theorising. This is an example of explanation relieving pain but was it the explanation or the hope offered by the treatment plan and the confidence of the doctors?

The cause was a tumour, not my wrong thinking. I was feeling better because I was believed and I was offered hope and help. As soon as you enter the world of cancer, kindness is all around you. No one blames you. For my time in treatment, I just relaxed and let go.

The psychological element you wish to educate your client in is a theory and you do not know how it exactly it applies to them. You could be over or under emphasising it, you could be delivering it in a helpful or harmful manner.

The cause was a tumour, not my wrong thinking

If you’re an effective practitioner you are already affecting your client in a psychologically beneficial way through your current treatment of them. You are often not trained in psychological intervention and you don’t need to add anything to a practice that is working.

Let’s look at the psychological work you are doing. You are providing space to understand and space to be believed, you are valuing the idea of exploring and finding one’s individual truth. You have the client’s trust as a kind, safe, wise person who will help. Do you want to jeopardise that by adding in ‘educational information’ that may push the ‘threat’ button (may feel like criticism) and set a cycle of stress hormones off?

You are already affecting your client in a psychologically beneficial way

Never underestimate the power of the healing relationship. The therapeutic alliance, brings about healing and change, and you have this with your patient. The healing relationship of trust and good intention is one of the most valuable parts of treatment and I’d hate for that to be compromised simply because the practitioner wants to tell the client something that they learned on their last workshop.

Two ways that are not going to push the threat button are experiential exercises and learning, which have no right or wrong outcome, where the curiosity is shared between helper and helped. And secondly, generalized information that is not given in a specific way to the client, such as a book or a video link that may be of interest, ‘see what you think’.

IMG_1478Having a third party deliver some of the education is useful. If the client’s esteemed practitioner tells them something it’s harder for them to critically evaluate and accept or reject. It’s less loaded from someone they don’t know on YouTube. The client can watch and think and come back and give a truly honest response to the clip. It wasn’t their therapist on stage doing the TED talk, and the talk wasn’t about them, it was about pain and psychology. As a patient it’s always enjoyable to feel the experience of a practitioner treating you like a colleague, a fellow detective on the case, sharing ideas. Educating a client assumes we are right and that the client needs educating, how much more helpful to engage in discussion together and to let the client educate you.

‘creative adaptations’

In psychotherapy I like to call what some might call, ‘neuroses’, ‘creative adaptations’ instead. Just as our bodily habits adapt to protect us from threat of pain and remain stuck, our neuroses do the same, it’s the best job someone can do with their body and mind at present. Trying to straighten out someone’s head is just as foolhardy as straightening out their body. It’s a balanced system with a lot of creative adjustments, all interconnected. In psychotherapy we work slowly, slowly, believing a person cannot remove a supporting wall without some preparation!

By all means underline their own understanding of the psychological side of their pain, such as their expression of feeling better when they are happier. But be wary of offering psychological explanations, I’ve had 12 years training and 30 years experience as a psychotherapist and I don’t offer psychological explanations.

On the workshops we run, and in one to ones in the therapy room, I might do fun exercises with people include inviting them to think a thought such as, ‘I can’t do it’ or, ‘I must do it’ and see if they can experience how their body responds to doing a physical task while they think that thought. If you do this, don’t make it personal to the individual.

My favourite intervention for my own pain at the moment, is a Restorative Yoga class where we gently move and experience movement. My teacher talks about mapping the movements as ‘options’ and ‘choices’, she talks about not moving in a way that hurts but always with ease. We work minutely with little movements, stopping and assessing and noticing. I absolutely love it and learn each week about new tensions I haven’t noticed I am holding. I’m open to receiving this information because the teacher isn’t directing it at me personally and the set up is that of no right or wrong, no goal, just exploration.

As a psychotherapist I would often have a stunning insight, years of training and decades of experience meant I could not help it. Sometimes I would say, ‘does the situation with A feel at all connected to what you’re now telling me about B?’ They would pause, ‘No’, they would say. Months later they would say, in all innocence, ‘I’ve always thought that A and B quite obviously connected and no-one, not even you, has seen it!’ and I’d go back to my notes, yes, I had seen it and I had mentioned it months ago. They had not heard me. They had rejected it. This was not because I was wrong but because I was ahead of where they were.

The thing is I LOVE psychotherapy and if I’m honest I do like a good ‘whodunit’ and the whole mystery of a person’s complexity. But solving the mystery before the client is not helpful, it’s about my own excitement and my own ego.

Create an environment of enquiry safe from judgment and therapist ego

When you are teaching someone chess, the thinking necessary for them to win can’t be magically planted into their brain by you. Its best to give little pieces of info as you go along when certain things happen. The person builds up the mindset and develops the skill of seeing the game. You also have to let them win without saying, ‘if you do x, y and z you could have me in check mate’. All that does is show YOUR knowledge and skill, not develop the new pathways in their brain.

Teaching is not about telling someone information. The more it is left to the student the more truthful and useful their conclusions will be. Therapists have to be very careful about their power to give conclusions to clients deliberately or accidentally.

The only way that works in teaching chess, in psychotherapy or in explaining pain, is to create an environment of enquiry safe from judgment and therapist ego.






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