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Making the Pain Blurry: Using Acceptance and Hope as a Therapeutic Intervention for Chronic Pain
By Johnna Marcus, LICSW

The National Center for Complementary and Integrative Health (NCCIH) defines chronic pain as “pain that lasts more than several months (variously defined as three to six months, but longer than ‘normal healing’).” People with chronic pain were vulnerable to “worse health, used more health care, and had more disability than those with less severe pain” (NCCIH, 2018). Additionally, anxiety, depression, and panic can be effects of the condition. For many patients, chronic pain “has a severe detrimental effect on their social and family environment, as well as on health care services” (Dueñas et al., 2016, p. 7). It is all-consuming. As the term “chronic pain” suggests, being outside of “normal healing” can lead to feelings of being an outsider and isolated.

The Centers for Disease Control and Prevention reports that in 2019, “20.4% of adults had chronic pain that frequently limited their life or work activities in the last three months” (Zelaya et al., 2020). The determination of what constitutes chronic pain targets the frequency of pain (how many days in the past week/month did you experience pain), as well as the effects or severity of the pain (did pain limit life activities).

Despite the validity of the diagnosis of chronic pain, it is a condition that is scrutinized and questioned not only in general society but in the medical community as well. Diane Monsivais, PhD, a nurse and researcher, explains, “Cultural and social norm in the United States is the expectation for objective evidence (such as an injury) to be present if a pain condition exists” (2013, p. 3). In addition to the pain of the condition, the invalidating response to pain adds another layer of complexity. In this case study of a man in his 60s with chronic pain (“Corey”—name and identifying information have been changed to protect anonymity), we examine the importance of acceptance and hope through clinical interventions to alleviate distress.

I began working with Corey as a social worker in the Addiction Psychiatry Division at Beth Israel Deaconess Medical Center in Boston for treatment of longstanding pain. He spoke about severe, often debilitating, pain, and I wanted to find alleviation. Corey had an accident leaving him with chronic pain which has had some instances of improvement over the years but overall stayed significantly distressing, affecting quality of life. It is difficult for him to find a comfortable position, and he often resorts to hanging upside down to feel comfortable, not feeling the pressure of body weight on his spine.

After realizing some limitations of medication treatment options for chronic pain, I read about “complementary health approaches” such as acupuncture, manipulation, massage therapy, and relaxation techniques, including meditation (Nahin et al., 2016, p. 6). The American Medical Association outlines exploring a “multidisciplinary approach to treatment” such as psycho-behavioral approaches, procedural and other manual therapies, or procedural or interventional techniques. I felt much like Corey had felt earlier in recovery—frustrated and stunned. There was no one surgery or intervention, no clear timeline nor specific pill for alleviation.

I found the “chronic” aspect of chronic pain challenging in terms of conceptualization—where does chronic pain fit in with treatment planning and prognosis? Our medical system comprises timelines for healing. While it’s tempting to find ways to “fix” pain, I was brought into a space of acceptance and alignment with him. Goldberg reports in “Pain, Objectivity and History: Understanding Pain Stigma” that “ameliorating such stigma is an ethical imperative, and yet most approaches eschew even an attempt to trace connections between historical attitudes, practices and beliefs towards pain and the stigmatization so many pain sufferers currently endure” (2017). Acceptance of patient’s experience of pain and clinical alignment with patients can improve interventions. This can translate to alleviation of suffering for patients even outside of the clinical setting.

Regarding work with Corey, there are two types of pain we focus on. The first is most obvious—the physical sensation of pain. The second is perhaps more difficult to grapple with, but just as significant—his reaction to the chronic pain. A patient’s reaction to pain is complex—emotional, psychological, traumatic. “The overlap of anxiety, depression, and pain is particularly evident in chronic and sometimes disabling pain syndromes such as fibromyalgia, irritable bowel syndrome, low back pain, headaches, and nerve pain. Psychiatric disorders not only contribute to pain intensity but also to increased risk of disability.” (Harvard Health Publishing, Harvard Medical School, 2010). Corey and I work together to explore the interconnected nature to sensations of pain and these challenging feelings.

I have moved from a place of clinical uncertainty to a questioning of how else we can explore next steps in care. I have learned the importance of being present without “fixing things.” By exploring a patient’s experience and investigating adjunctive therapies such as movement analysis or deep breathing exercise, therapeutic relationships are enhanced. This can lead to acceptance of his condition while asking questions about how treatment can be enhanced. Treatment team can “emphasize the need to adopt a comprehensive and multidisciplinary approach to improve the patient’s condition and circumstances, contemplating both pharmacological treatments and nonpharmacological measures” (Dueñas, Ojeda, Salazar, Mico, & Failde, 2016, p. 10) to give patients like Corey multiple avenues of possibility and hope.

I have become more present in these weekly sessions—not looking to find a solution or plan a timeline for change. Our time together distracts from pain and takes focus off distressing sensations. Instead of discussing “cures,” we discuss how pain fits into Corey’s life. He feels pain when getting out of bed and endures it. We talk about everyday frustrations (riding in a car) and extraordinary frustrations (riding in a car on a bumpy road). I have respect for the magnitude of this struggle and the stamina with which he endures it. Talking about pain during sessions can help him manage the anxiety he feels in response to it. My hope is that interventions of acceptance translate into his daily life outside of sessions as well. His consistency in engaging in weekly sessions suggest that alleviation of distress transfers into everyday life.

I still want to be able to treat patients with more concrete and prescriptive answers. It gives me goosebumps when medical staff comes up with exact medication regimens to alleviate a patient’s immediate distress. Patients have felt as though they are “losing their minds” achieve alleviation from medications and treatments. I am learning more about the trial-and-error side too, the intangibles, and things which I have no frame of reference. This may mean that we expand the definition of what “change” and “progress” means in treatment planning.

In my most recent session with Corey, I found myself looking at images of where he feels pain, using diagrams of the nervous system we found online to identify his point of reference. He pointed to areas that have pain and the movements and positions he can move into to provide alleviation. “Even just talking about these things takes some of the pain away—it kind of blurs it a bit.” At this point in my work with Corey, I can say, “I understand how that helps.”

— Johnna Marcus, MSW, LICSW, is a social worker in the Addiction Psychiatry Division at Beth Israel Deaconess Medical Center. She can be contacted at Johnna.Marcus@gmail.com.

References
Dueñas, M., Ojeda, B., Salazar, A., Mico, J. A., Failde, I. (2016). A review of chronic pain impact on patients, their social environment and the health care system. Journal of Pain Research, 9(1), 457-467.

Goldberg, D. S. (2017). Pain, objectivity and history: understanding pain stigma. Medical Humanities, 43(4), 238-243.

Harvard Health Publishing, Harvard Medical School. (2010). The pain-anxiety-depression link. Retrieved May 28, 2021, from https://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.

Monsivais, D. B. (2013). Decreasing the stigma burden of chronic pain. Journal of the American Association of Nurse Practitioners, 25(10), 551-556.

Nahin, R. L., Boineau, R., Khalsa, P. S., Stussman, B. J., Weber, W. J. (2016). Evidence-based evaluation of complementary health approaches for pain management in the United States. Mayo Clinic Proceedings, 91(9), 1292-1306.

National Center for Complementary and Integrative Health. (2018). Chronic pain: in depth. Retrieved May 24, 2021, from https://www.nccih.nih.gov/health/chronic-pain-in-depth.

Zelaya, C. E., Dahlhamer, J. M., Lucas, J. W., & Connor, E. M. (2020). Chronic pain and high-impact chronic pain among U.S. adults, 2019. https://www.cdc.gov/nchs/products/databriefs/db390.htm.