Psychosocial pain often comes hand in hand with chronic pain, and it is easy to see why. “It takes an awful long time for someone with chronic pain to come to an expert,” says Steven D. Passik, PhD, associate attending psychologist at Memorial Sloan-Kettering Cancer Center in New York City and associate professor of psychiatry at Weill Medical College of Cornell University. Whether it takes time to find the right expert, time to identify the problem, or time to try different therapeutic options, the patient with chronic pain often has a period of six months to a year before any relief is found. That can be extremely stressful.
Passik says that the chronic pain patient often experiences a host of psychosocial issues, including depression, hopelessness, lack of motivation and a suspension of pleasurable activities they may have enjoyed before the onset of pain. “It is not as easy to experience pleasure,” says Passik.
Recognizing Psychosocial PainThe therapist plays a key role in recognizing the signs of psychosocial pain and starting the patient on the road to feeling better. “[Therapists] can recognize a low level of motivation. Even if they can’t diagnose, they can refer back to the team,” Passik says.
Therapists can also be on the lookout for factors that can complicate therapy for the patient. For example, a patient taking opioids can experience a decrease in testosterone, which can lower muscle tone and make both therapeutic and recreational activities more challenging.
Additionally, it is important to understand that pain is not always a straight cause-and-effect situation. “From a chronic pain perspective, pain is multidimensional,” says Marlene McHugh, MS, RN, FNP, nurse practitioner with the Palliative Care Service at Montefiore Medical Center in the Bronx, N.Y.
For example, “sometimes physical pain is the symptom” of a psychosocial issue, McHugh says. Indications of some underlying problem that needs investigation include anxiety disorders, insomnia, unrelieved pain even on medication, depression and trouble at work.
Often, the problems extend beyond the individual patient into those who are in the patient’s life. “I see a lot of domestic and social violence that [the patient] has grown up with,” says McHugh. She says that it is critical that patients receive an individual evaluation, a family evaluation and an assessment for substance abuse. Substance abuse can come into play in different ways in different cultures, even without being defined as “abuse” by the patient.
Additionally, different periods of life may present a patient with different types of psychosocial pain. “At the end of life, [it is often] existential or spiritual pain,” she says, noting that she often sees parents at the end of life with uncontrolled pain who are also estranged or separated from a child they may not be able to say good-bye to them.
All of these situations benefit from a team approach that addresses the entire patient and family from both a physical and psychosocial angle. “The worst type of place to send people is where they just do procedures,” McHugh says.
Providing ReliefPassik believes therapists can play a key role in addressing both physical and psychosocial pain by encouraging patients to make the lifestyle changes that will put them on the path to feeling better – even if it will take some time. “Take sedentary people and put them on [an exercise program], and it takes 10 days to two weeks until they feel well again,” Passik says of the initial period of adjustment that people often go through. The therapist, Passik says, can help the patient “maintain motivation with something that will get off to a bumpy start.”
Additionally, the therapist can encourage the patient to make changes that will positively impact their health. “A person with chronic pain has less latitude to have a poor lifestyle,” Passik says. A therapist can encourage healthy eating, smoking cessation and the beginning of an exercise program, then “give them a ray of hope that they will feel better.”
These positive lifestyle steps are necessary for chronic pain patients, because medications rarely are able to provide complete relief. Passik notes that chronic pain patients may average a 60 percent reduction in pain on medications – substantial, but not complete. “The passive patient is doomed to be disappointed or worse,” says Passik. The therapist’s role, says Passik, is “setting up the right expectations about the potential benefits of medications.”
The therapist certainly does not have to go it alone, however. Sean O’Mahony, MD, medical director of the palliative care service at Montefiore Medical Center, recommends that pain care be a team approach. “The ability to get feedback from therapists is key,” he says. Such a team can include a primary care physician, a specialty care physician, a psychotherapist and therapists, such as PTs and OTs, among others.
The team approach allows all members to have types of expertise other than their own to rely upon. “A good pain practitioner recognizes that there is a skill set needed that they may not have and refer,” says McHugh, noting that they refer about 70 percent of their patients to a social worker or psychiatric evaluation.
These teams must build systems of communication and provide opportunities for all members of the team to report on patient progress. This is even more essential in a climate in which healthcare provider time is measured in minutes and billing codes. “The amount of time any medical provider has to spend is limited. It can only benefit the patient if we can benefit from therapeutic professionals,” says O’Mahony. “It is the foolish medical professional who doesn’t [take heed.]”
– Jennifer Patterson Lorenzetti is an Ohio-based freelance technology writer and the owner of Hilltop Communications. Questions and comments can be directed to editorial@therapytimes.com.
