For me, the biggest challenge to staying therapeutic is patients with chronic pain who are highly medicated, highly drug-seeking, and have great tolerance to medications—especially patients who rate their pain high at “20 out of 10” and yet are moving around as if they have no pain. I’ve had patients who want meds to sleep, yet they drink coffee all day and into the evening. This is not something that’s going to change among my patient population. What could help me stay therapeutic in these encounters?
I feel my own judgment of your patients rising, even as I review your poignant question. I was raised with the idea that there was nobility in managing one’s suffering, including physical pain. To complain—much less to use drugs to manage discomfort—was to be weak. So much for growing up in rural Indiana, with Depression-era parents!
But the truth is that pain often brings on regression. We want someone to make it better, and we return to earlier developmental stages in our lives: when we cried and cried and no one came; or when we learned that the only way we could arouse attention or empathy from others was if we made a great deal of noise; or when we concluded that no one was reliable (including ourselves) and that drugs provided a way out of the limbo of impotence and passivity (now there’s an irony!).
As clinicians, we have certainly learned that not much teaching actually sinks in when people are in a regressed state. We have seen how little value there is in telling someone who is rating his pain “20 out of 10” that this is impossible; or that it’s a little silly to drink coffee and then demand meds for sleep; or that we think they have had enough of one medication or another.
We have also learned that we’re unlikely to change longstanding personality traits or medication habits—much less addictions, or proneness to complaining—during a brief hospital stay.
So what in the world can we do?
What happens when we return to wondering? Remember: wondering doesn’t mean searching for answers. Sometimes answers come, and sometimes they don’t. The point of wondering is never to solve the problem; it is to alter our own state of mind with respect to the patient and with respect to the issue. Wondering helps us to detach a little, replacing annoyance or judgment with curiosity—replacing a judging mind with an open mind. Just as we would when our own little child declares absolutely that he’s “dying” after falling off his skateboard and scraping the dickens out of his leg, we find ourselves smiling just a little, displaying a tiny bit of empathy, and responding, “You are?! Oh, my. I hope not!” as we go about the task of fixing him up. We don’t argue or judge or even engage, really—except in the detached, but compassionate way that enables us to apply some immediate care.
So what if our response to the “20 out of 10” response to the pain rating inquiry were: “Whoa! That’s a lot of pain!” And that’s it. No judging, no arguing, no didactic lessons, no re-orienting the patient to “reality”—just acknowledging the patient’s relationship to his or her own pain in a way that suggests we are open, curious, not necessarily convinced, and still right there, present and attentive to the person in front of us.
What if our response to excessive or irrational use of—or demand for—pain or sleep meds were simply to sit attentively with the patient and ask for more information—a sort of open-ended curiosity about the patient’s experience of injury and pain. Oddly, since both children and regressed grownups rev up their greatest neediness and demandingness when they think they are going to be denied what they want or need, our very act of open-minded interest may take the edge off the ferocity and irrationality of the patient’s request. Maybe the bottom-line need was merely: “I want someone to know how much this hurts,” or “I need someone to catch on to how scared I am about not being able to sleep…(or about my surgery in the morning).”
Try this, and let us know what happens. Remember: The wondering has to be genuine. The open-mindedness has to be real. Just as our children catch on quickly when we’re faking it (or using a strategy on them), grownups in pain will not respond if we’re just “managing” them.
It would be cool, wouldn’t it, if our jobs got easier and the patient felt better, if we showed genuine understanding of their predicament, while not reacting too much to their declarations and demands about pain.
~ Michael Trout