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The Language of Chronic Pain: How Clinicians Can Help Patients Describe What They are Feeling

June 23, 2021
Research reveals that the use of metaphor and addressing themes such as isolation may improve provider-patient communication and aid in shared decision-making.

Several initiatives have attempted to help clinicians and patients communicate more effectively about pain. From establishing pain as the fifth vital sign in 1996 ago to adjusting pain scales from numerical to function-based, policymakers have struggled to come up with a system by which patients can accurately communicate to healthcare providers the scope and nature of their pain.

“Pain is a complex, multidimensional experience and the research is starting to show how untenable it is to reduce that to a 0-10 point scale,” Imogene Munday, researcher and PhD candidate at the University of Technology Sydney, in Sydney, Australia, told PPM. Munday and colleagues decided to address the problem in a unique way. Rather than focusing on the qualitative experience of chronic pain, as much previous research had done, they decided to focus more specifically on the language used to describe pain. The results of their research was published in Disability and Rehabilitation.1

People with chronic pain rely heavily on the use of metaphor when discussing pain. (Image: iStock)

Asking People About the Daily Impact of Chronic Pain

The team determined that qualitative research methods were more suited to their aims, in part because this would  “allow for a deep understanding of participant’s own language, thoughts and feelings."1 For this reason, they used focus groups to explore issues in a conversational way and to capture feelings and perspectives which might have been missed in a more traditional interview or survey format.

Subjects were recruited from a multi-disciplinary pain management course for people living with chronic pain. The course was being run at a large teaching hospital in Sydney. Having chronic pain and sufficient English language skills were the only requirements for participation. The final study included 16 patients, ranging in age from 22 to 74 years, 10 women and 6 men.

Participants were divided into three focus groups, which were conducted during lunch hour of the pain management course, audiotaped, and transcribed verbatim. After an initial question asking patients to describe their pain, follow-up questions were asked when necessary for elaboration, and generally focused on the effect the pain had on their lives (ie, daily function) and patients’ response to these effects.

Data was organized into five overarching themes:

1.     isolation

2.     physical sensations

3.     pain personified

4.     pain as overwhelming,

5.     coping with pain.

Sub-themes included, for example under Physical Sensations, aching, piercing, and under isolation, shame and separation from others.

Social Isolation & Metaphor Dominates Lives of Those with Chronic Pain

Patients used a variety of metaphors and descriptors to express their pain and their feelings about their pain. One patient, according to the report, noted, “…it felt like it was underneath me and that it would suck me out and I would feel that fear, that dark horrible feeling ... it was like a dark thing that wanted to suck me out.”  Another used humor rather than horror, describing her pain as being “like having a mother in law you don’t like constantly being here, running your life, telling you what to do and what not to do ... it commands you around.”1

However, the team found that the socially isolating aspect of pain was the predominate theme and was the topic of a large part of the group discussion; participants gave less time to descriptions of specific pain. Much attention was given to the fact that pain is “invisible,” meaning that others could not see their pain, increasing feelings of otherness and shame.  (More on what pain “looks” like from artists in the field)

Most significantly, the study found that patients relied heavily on the use of metaphor when discussing pain across all themes and subthemes. “This dependence on metaphor may suggest something of the nebulous, subjective nature of pain, but also of the desire to communicate it to others and to make the invisible visible,” the study’s authors wrote.1

Munday’s team also determined that very few of the words used in the McGill Pain Questionnaire (MPQ) or Short Form version (SF-MPQ-2) were used by patients, strengthening research findings that these tools are not as useful as they might be. Rather than using single adjectives to describe their pain, participants were more likely to report metaphors and sentences, suggesting that “pain language may be more complex than single word adjectives, which may alone be inadequate to capture pain’s nuanced experience.”1

They therefore suggested that pain metaphors be a potential target for interventions such as Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy, particularly when addressing pain catastrophizing. (See also, how to offer brief psychological interventions this in primary care)

Helping Patients to Describe Chronic Pain: What’s Next?

Munday’s work was a small, exploratory study and applicable only to English speakers. The authors expressed hope that further research, with larger populations and expanded methodology ­– including quantitative measurements, such as pain scales – can add further insight into the role of language in the assessment of chronic pain. They add that an exploration of communication about pain by “healthy” patients who have experienced only acute pain would be useful for comparison.

Meanwhile, clinicians can use the results of this study to create a better dialog with patients suffering from chronic pain. “If clinicians are more aware of the different metaphors and descriptions patients use, they may be less prone to dismiss these as exaggeration,” says Munday. “Also, letting a person recount their pain experience in their own words, however that may be, without judgment, can be very validating and therapeutic for that person.”

See a related report on using big data to drive patient assessment; a perspective on structural racism in pain medicine; and how to deliver effective pain mangement to patients living in under-resourced areas.



Last updated on: July 6, 2021
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Behavioral Medicine: How to Utilize Acceptance and Commitment Therapy in Primary Care
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