Pain is a highly complex, integrated psychosocial phenomena that can change even when we talk about it or observe it. Emerging research in neuroscience suggests that cognition plays a large part in the pain experience. In a bio-psycho-social model of pain management, pain is thought of as a manifestation of the brains perceived levels of situational threat. Therapists should appreciate that the way we communicate can alter these perceptions and radically alter a patient’s pain experience. So how do improve our ability to influence and change pain perception?
The explanation of what is causing their pain, the prognosis (explanation of when and how the pain get better) and the explanation of the processes involved are all examples of discussion and social interaction that can alter a patient’s perception and their subsequent behaviors. How we structure these discussions and the information we provide can increase or decrease chronic pain.
Therapists often build habitual patterns of communication, choosing certain ways of ‘framing’ particular conditions in certain situations. For example, therapists will have a particular ‘spiel’ to introduce what it is they do and how they treat. They also develop frameworks for how conditions will develop and how the treatment processes will unfold. This rhetoric is extremely powerful in altering how the patient perceives their condition. For example, the use of highly medical terms, suggesting the need for medical imaging, poor prognosis, suggesting that a condition is degenerative or non-treatable may all make pain levels worse by peaking perceived threat. Whilst we should never mislead, we have to understand that altering language to reduce anxiety may actually reduce pain perception and help patient recovery.
Some may call the non-specific benefits of a treatment a placebo effect, but we see that this placebo effect can be optimized. We can and should attempt to increase the non-specific benefits of treatment through professionalism and effective communication. The more effective our communication and the more influential we are as therapists, the greater the impact we may have. The impact of our communication is determined by the level of relationship we have with the patient. The ability to communicate effectively and present our-selves positively is a key skill. On arriving at an initial consultation or assessment, it is not only the patient who is being assessed. The patient will evaluate to what extent a therapist appears professional, reputable and qualified. They will evaluate how well that therapist understands their condition and how qualified they are to deal with it. This evaluation determines what level of influence the therapist will have, to what extent their advice is followed and ultimately whether the patient will return for more treatment. It will even determine how much pain that patient is likely to experience in the future and even how successful treatment is.
Confidence and clarity is essential. Language should reflect professionalism and competence but should also ensure patient understanding. Building rapport is a key part of establishing a therapeutic relationship. Appearing engaged and interested, listening and demonstrating understanding aid rapport. Only a small amount of communication is verbal, attire, posture, expression, the clinical environment, how we dress, how we smell all communicate and play a part in determining our subsequent ability to influence.
The interesting question is should we establish patterns of patient interaction that most accurately reflect the patient’s condition or should we reframe patient perception in manner best suited to therapeutic outcome with regards to reducing chronic pain and disability? Some doctors may prescribe a placebo medication, knowing the physiological impact of the prescription will be minimal, but satisfies the patient’s need for intervention. There may be some therapeutic modalities that lack biological plausibility and scientific backing with regards to their mode of effect, but whose standard rhetoric may build perceptional models highly advantageous for recovery and for managing chronic pain. This is an interesting ethical question and not one I will go into great depth here, only to say that therapists should not intentionally deceive their patients, but information should be presented in a manner in line with reducing perceived threat, limiting catastrophization and minimizing possible psychosocial contributions to chronic pain and disability.
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