Constructions of chronic pain in doctor–patient relationships: bridging the communication chasm
Introduction
The transition from medical patient to chronic pain patient is expensive, confusing and distressing to those involved in the process. The sub-text of clinical talk about chronic pain is frequently underscored by implicit themes related to the character of chronic pain patients, the genuineness of their pain, their underlying motives for engaging in pain behaviour, and the frustration and helplessness of those who provide services to them. Recent sociological (sociogenic) theories of chronic pain [1], [2] have challenged the underlying assumptions of dominant biomedical (biogenic) and psychological (psychogenic) models. The biogenic theory states that pain has organic origin that may give rise to emotional sequelae such as depression and anxiety [3]. Because the biogenic theory has been the dominant model in the management of chronic pain, searching for physical damage has been an important element in the legitimation of pain.
The psychogenic theory proposes a causal role for psychological distress that may include the experience of physical as well as psychological pain. This theory is encapsulated in the DSM IV [4] classificatory system of Somatoform disorders, which are defined as those conditions that include “…the presence of physical symptoms for which there is no diagnosable general medical condition…the symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning…” (p. 445). Disorders described as somatoform include Somatisation Disorder, Conversion Disorder, Hypochondriasis, and Pain Disorder. For a diagnosis of Pain Disorder, the client meets the criterion that “Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of pain” (p. 461).
Sociogenic theory states that medical failure to legitimate (non-organic) pain leads to alienation, depression, anxiety, and renewed efforts at legitimation. This process sets up a chronic pain cycle that Williams [5] described as both “…a fountain of hope and a font of despair” (p. 1129).
Systems theory has the potential to explain the interactions outlined in the sociogenic model whereby chronic pain patients become alienated and stigmatised. Gregory Bateson [6] coined the term ‘schismogenesis’ to describe the type of escalation found in situations that are labelled ‘vicious circles,’ an example of which is the chronic pain cycle. Schismogenesis is defined as a “process of differentiation in the norms of individual behaviour resulting from cumulative interaction between individuals” (p. 41). These processes develop through the mutual reactivity of individuals to each other. Bateson identified two types of schismogenesis: symmetrical and complementary. In symmetrical relationships, the escalating behaviours of the parties would be essentially similar, as in the case of rivalry or competition. Complementary relationships involve the exchange of different, counter-balancing behaviours as in cycles of nurturance-dependence or dominance-submission. A balanced mix of these two types of interactions is called a reciprocal relationship and is considered to be the most adaptive form of dyadic interchange [7]. Systemic analysis identifies patterns or sequences related to information, stress or power transfer between dyads. These sequences may be deviation-counteracting in that they maintain equilibrium in the relationship. Alternatively, deviation-amplifying sequences lead to escalation and breaking point, whereby doctor and patient transform their relationship or separate, in a process akin to the eventual divorce of a conflicted married couple.
Complex social processes are clearly implicated in the outcome of chronic pain management given the inability of either medical diagnosis or physical impairment or function to predict therapeutic success in chronic pain treatment [8]. For example, a recent study [9] found that physicians were more likely to make an initial diagnosis that the presenting symptoms were medically explained if they perceived the doctor–patient interaction to be positive. Further, given that organic causes for symptoms can be identified in fewer than 15% of patients presenting to primary care physicians [10], and in 20% of those presenting with low back pain to orthopaedic specialists [11], the risk for the social and psychological complications of medically unexplained pain is high.
The frequent absence of clear organic pathology in the majority of presentations to medical practitioners has resulted in what Loeser and Sullivan [12] described as the disastrous combination of “pseudodiagnosis, pseudodisability…and the pseudoscience of disability determination” (pp. 61–62). They state that the danger for doctors is to engage in “…diagnosis without supporting pathology and disability determination without impairment” (p. 62). These practices contribute to excessive health care consumption and needless disability.
Referral to a chronic pain clinic is often the end of the line for many chronic pain patients. Referral usually signals that all medical avenues of treatment have been exhausted and that changes in behaviour and attitudes are the primary goals of treatment [13]. The aim of this exploratory study was to examine doctor–patient interactions through the analysis of the accounts of the experiences of “failed” chronic pain patients with their pain specialists and the experience of pain specialists with their chronic pain patients. The aims of the study were to (1) identify the explicit and implicit themes in their accounts of chronic pain; (2) assess the usefulness of a systemic theory to explain chronic pain interactions between doctors and patients; and (3) examine the therapeutic implications of these findings.
Section snippets
Sample
Participants were 20 chronic pain patients, all of whom had completed a multi-disciplinary pain clinic program. Ten were regularly attending members of a chronic pain support group. Criteria for inclusion were: aged >18 years, ability to communicate in English, all relevant/available medical and surgical treatments had been completed, a diagnosis of chronic non-malignant pain with no organically identified basis, or persistence or reported level of pain beyond what would reasonably be expected
Results
Both doctors’ and patients’ accounts were predicated upon the same four themes. These were (i) listening to and hearing the other; (ii) cause and meaning of the pain; (iii) symmetrical struggle for legitimation; and (iv) mutual de-legitimation. The overarching theme among the physicians was the perceived need to challenge and disconfirm the biogenic stance of their patients and to shift them to a psychogenic position. Physicians were heavily invested in this task, because there were no further
Discussion
The chronic pain patients in this study represented the extreme end of the chronic pain population and cannot be seen to be representative of the chronic pain population in general. Similarly, the comments made by the doctors are only relevant to this very chronic sample of pain patients. Turk and Okifuji [18] identified a number of significant differences between chronic pain patients who had been treated in a multi-disciplinary pain program compared to community samples of chronic pain
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