Dr. Val Farmer
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Rural Mental Health & Family Relationships

Advice On How To Deal With Chronic Pain

February 1, 1999

I visited with psychologist Carl Westphal, a former colleague who moved from Fargo ND to Washington DC, about his specialty in working with patients who have chronic pain problems. He shared his ideas and advice on how people can cope with their problems.

- Attitudes about pain. Physicians need to take patients complaints of pain seriously. Even if the cause of the pain is undetermined, health care professionals need to respect the legitimacy of the pain and take time to fully hear the complaint. Patients are offended when their pain is discounted as imaginary and, "in the head."

Pain patients feel isolated and helpless. By giving deep empathy and understanding, health care professionals give invaluable support and comfort, even if the words are, "I don't understand this. I believe you." When patients are being treated as a credible informant of their own experience, this inspires trust and confidence.

- Physicians need to be comfortable with prescribing medications to relieve pain. The goal shouldn't be to get patients off of medication but to relieve suffering. Pain medications give relief so that the patients can improve their functioning.

- Primary care physicians and mental health professionals should work together. They should work as a collaborative team with the physician retaining ultimate responsibility for the patient. Management of pain is a team responsibility.

- Work to control stress and pain. Stress adds to chronic pain and chronic pain adds to stress. Westphal sees one role for the mental health professional as addressing the stress issues in the patient's life.

What are these powerful forces that affect chronic pain? Anxiety. Depression. anger. Family problems. Job dissatisfaction or unemployment. Medical uncertainty. Distortions of thinking. Guilt. Dependence.

Most patients don't sleep well. They may have financial struggles, or struggle with a loss of identity due to loss of function. The focus of treatment is on the other things that are wrong so the pain can be managed and reduced, not trying to find the cause and eliminate the pain.

- The issue needs to be changed from, "What is wrong?" to, "What can you do?" Most patients don't think about function. They think about relieving pain.

- The emphasis should be on activity. The next step is to encourage activity versus the pain patient's tendency to reduce activity. The more inactive a pain patient is, the more he or she is aware of pain. By pushing themselves to do something, pain patients get a sense of control and avoid a victim mentality. Strong interests, goals, diversions and pain distractors are important.

Take small steps toward being active instead of big ones. It seems counter-intuitive. You have to respect the pain, then push it.

Westphal lets the patient define what he or she can or is willing to do and to establish the first step. The patient also sets their own pace. Managing pain is a partnership in which you learn from one another. Communication is a key.

- Goals have to be achievable. If you can't run around the block, then go around the table 50 times. Do little things and reward yourself for it.

Chronic pain patients who struggle the most have a history of being dependent, not proactive. Also victims of abuse or acute trauma get stuck on blame and not on what they are going to do.

Westphal remains an optimist about pain management. When chronic problems don't respond to treatment, it is easy to quit trying. Carl has an expression, "What makes a problem chronic is when the incorrect solution has been applied for a longer time."

- Goals and the big picture. Another way to approach pain is to look at the big picture. Loss and change need to be accepted. Patients need to embark on a search for personal goals and spiritual connection. It is important to find value in themselves and their lives in spite not doing the things they are used to. Without goals it is easy to sink into depression.

- Get help. It is OK to get help. Patients shouldn't hesitate to use support from others. Westphal advises, "Let your friends be your friends. If you are lost, you're lost. You need to ask directions on the road map of life. Find out where you are and then you'll know where to go." There is no blame or shame in being at an unfamiliar place in life.

- Family matters. Chronic pain causes changes in the family. Sometimes the family doesn't want change. New roles and relationships have to be sorted out. Who is responsible for what? Children often have to take more responsibility. They may resist the changes.

The marital unit needs to be a strong and viable partnership. It is tempting to sink into blame, anger, and conflict. When pain or pain medications interfere with sexual functioning or desire, then the couple need to adjust their sexual expression and emphasize emotional intimacy versus sexual intimacy.

Westphal has some words of wisdom for dealing with bad pain days or flareups. The pain patient needs space. They are suffering from an illness instead of a bad relationship. The pain patient can also assist by giving a warning that he or she is tired, fatigued and irritable. It is OK to stay away and not be offended by the irritability of the pain patient.

Pain and stress are managed, not eliminated.