Healers have been relying on psychological insight to help
suffering patients since long before the advent of modern medicine.
Shamanism, a collection of insights and techniques in use for well
over 20,000 years and which is arguably the antecedent of the
scientific method and of allopathic medicine – as well as of
psychotherapy – is remarkably successful in relieving a wide range of
ailments, often through manipulation of the patient’s mental set,
states of consciousness and belief systems (Krippner, 2000). While
the modern clinician has an impressive array of pain medications at
her disposal, we do our patients and ourselves a great disservice if
we ignore the crucial aspects of suffering that occur in the mind of
the patient – and must therefore be addressed with psychological
sophistication. Pain is much more than a stimulus-response
interaction involving the nervous system; pain is a complex
interaction involving personality structure, sensations, thoughts,
feelings, beliefs and emotions. Each of these facets of the patient
needs to be considered in designing an appropriate treatment
protocol. In the first edition of Bonica’s classic work on the
management of pain (1953), he emphasized the importance of
psychological considerations and the danger in over-reliance upon a
mechanistic model of pain:
The crucial role of psychological and environmental factors in causing
pain in a significant number of patients only recently received
attention. As a consequence, there has emerged a sketch plan of pain
apparatus with its receptors, conducting fibers, and its standard
function, which is to be applicable to all circumstances. But … in so
doing, medicine has overlooked the fact that the activity of this
apparatus is subject to a constantly changing influence of the mind.
Note the last word of this passage. In using mind rather than brain,
Bonica reaffirms his point that it is the personality of the patient
which is crucial to both the experience of pain and its treatment (in
part II of this chapter, we will discuss the importance of the
physician’s personality in pain treatment). Indeed, one of the more
frustrating aspects of pain treatment is the frequency with which a
patient’s suffering appears to have no organic physiological source
whatsoever. In such cases, many physicians are at a loss to explain
or relieve this all-too-real suffering. The purpose of this chapter
is to offer some introductory guidance to physicians who find
themselves faced with such cases and to provoke some consideration of
many fascinating, yet generally ignored, components of successful pain
management.
You never identify yourself with the shadow cast by your body, or with
its reflection, or with the body you see in a dream or in your
imagination. Therefore, you should not identify yourself with this
living body, either.
--SHANKARA (A.D. 788-820), Viveka Chudamani (Vedic scriptures)
You are dreaming. In your dream, you are walking barefoot
through a field of red, blue and yellow wildflowers. You can feel the
soft breeze on your face, the warm earth beneath your feet, the cool
grass between your toes. Suddenly there is a sharp pain in your right
foot! You look down and see a snake with its fangs set deep into the
flesh of your foot, hot, red blood flowing over your skin.
To what extent is this experience real? Most of us would agree that
the field, flowers and snake are not real in any objective sense; they
exist only in your mind. But what of the terror you felt when the
snakeattacked? Clearly, your body responded as if your fear were
real: your heart rate increased, adrenaline rushed into your
bloodstream, you may have called out in your sleep, etc. Indeed, you
may well have experienced some or all of these physiological responses
in just reading this paragraph. It seems clear that although there
was no actual danger to the physical body presented by the dream, the
experience of fear was quite real. We might say that fear belongs to
that class of phenomena that exist in the world of experience alone.
That is, fear exists inasmuch as it is felt – regardless of the
validity of the supposed danger. The same may be said of pain. Where
there is suffering, there is pain. So, in what way – if any – is
imagined pain qualitatively different from real pain?
Physicians familiar with cases of phantom limb pain know that it is
not even necessary to have the corresponding neurological structures
in the body to feel pain and/or other sensations in an appendage which
does not physically exist. That this phenomenon is not always
attributable to trauma or neurological damage is confirmed by the fact
that children born without a given limb can experience phantom limb
sensation at that site (Ramachandran, 1994; 1996). Similarly,
patients under hypnosis often display physiological responses to
non-existent stimuli (e.g., developing blisters in response to being
“burned” with a pencil) as well as an ability to ignore stimuli which
would be considered extremely painful under normal circumstances (Hilgard
& Hilgard, 1983). The body often responds more to what we believe has
happened than to what may actually have occurred. Apparently – and
not only in dreams – we can and do feel a symbolic body that is not
our actual physiological body.
As these examples suggest, saying that the pain is all in the mind can
be both true and untrue. It can be true in the sense that the pain
may indeed by psychogenici, but it is untrue in the implication that
the pain is therefore somehow unreal. In other words, in the context
of pain treatment, physicians may need to rethink their ideas
concerning malingering patients. Given the complexity and
inscrutability of the symbolic symphony at play in any personality, it
is virtually impossible – not to say unethical – to assert that any
pain, with or without tissue damage, is somehow not real. Just as a
patient suffering from chills on a hot day is not reminded of the
ambient temperature and sent home, we should avoid further
pathologizing the patient’s all-too-real suffering by doubting its
authenticity. As we will be discussing in detail below, pain is often
an expression of non-physical issues – what we might call
psychological trauma – and is sometimes best seen as an attempt by the
subconscious to call attention to (or, conversely, to obscure) a
source of psychological suffering. While not wishing to bore the
reader with a long philosophical discussion of the nature of reality,
we would simply like to remind him that philosophers have been
attempting to demonstrated that there exists some objective reality at
all outside of our perceptual framework for millennia. None has yet
been successful. We are reminded of this humbling paradox each night
by the urgency, vividness, and profound – if transitory – reality of
our dreams.
The rest of this article will examine the phenomenon of pain from
several different perspectives. In Part I, we will examine the three
psychological tools mentioned previously in the context of shamanism:
mental set, belief system and states of consciousness. Each of these
time-tested approaches offers many opportunities for a modern
physician to relieve the suffering of her patient. Part II will offer
a brief overview of pain from an evolutionary perspective, asking: why
and how did our experience of pain develop? Following this, we will
briefly explore some of the implications for the physician or nurse
who works in a pain-control unit. We are particularly passionate
about this last subject because there is very little discussion of the
experience of the health care professional in the medical literature.
Knowing how to protect oneself must always be the first consideration
in any helping profession and – given the clear psychological dangers
of extended exposure to a constant stream of suffering patients – we
feel strongly that this point receives far less attention in the
medical literature and in medical education than it merits.
Part I.
Mental Set, Belief System and States of Consciousness
Pain as conversion symptom
Most psychologists and psychiatrists have a complicated relationship
with the work of SigmundFreud. That he is both revered and ridiculed,
loved and hated, feared and disdained seems fitting. But whatever
history decides about Freud’s work in general, his recognition of
conversion symptoms is of paramount importance. Building upon this
insight, psychologists have shown that many seemingly physical
conditions are in fact psychological distress being converted to
bodily expression. Most of the research relating repressed emotions
to pain has focused on perceived emotions such as fear, anxiety, anger
or sadness (some of this research is discussed below). But we should
keep in mind that unconscious feelings can also be involved in pain
conditions – particularly those involving chronic pain – as well as
other conditions with unclear origin (see below). In the Freudian
interpretation, these conditions arise to distract attention away from
the real problem. If a patient suffering from obsessive-compulsive
disorder has to wash his hands exactly fifty times per day -- always
at ten minute intervals -- he will have little time or energy to think
about deeper issues. Similarly, pain can often serve to deflect
attention away from deep-seated conflicts that remain unresolved in
the psyche (Wickramasekera, 1998). While this pain can sometimes be
relieved with drugs or placebos, the symptom is likely to either
return when the drug is withdrawn or to manifest in some other symptom
(Sarno, 1998). The clear lesson here is that psychogenic symptoms are
not only frustrating and mysterious; they have a purpose. Pain is a
message. The message may involve tissue damage or some difficulty in
the psyche, but if the message is ignored or silenced without
resolution, we have achieved only a short-term, symptomatic cure – and
may well be inadvertently breaking the first Hippocratic oath: to do
no harm. In cases where the origins of the pain are unclear – or the
characteristics of the pain are not clearly understood by the
physician, a psychological/psychiatric consultation can be an
invaluable help. Indeed, we strongly believe that a psychiatrist
and/or psychologist is an essential part of any well-equipped
pain-control unit. Without the sort of insight that only a
well-trained mental health professional can offer to these conditions,
misdiagnosis is extremely likely. For example, many highly respected
physicians have suggested that all chronic back pain should be assumed
to be psychogenic until proven otherwise (e.g., Sarno, 1981, 1998;
Weil, 1990). The same might be said of a long list of disorders
including but not limited to, fibromyalgia, temporomandibular joint
syndrome, carpal tunnel syndrome, many cases of chronic pain, many
dermatological disorders, irritable bowel syndrome, chronic fatigue
syndrome, eating disorders, insomnia, sexual dysfunction, and so on.
Whatever the source of the patient’s suffering, his mental set, belief
system and state(s) of consciousness will be important considerations
in choosing the best treatment protocol. Indeed, if the pain in
question is psychogenic in origin, these considerations are of
paramount importance; physiological approaches will be fruitless, at
best; they may be potentially harmful, at worst. Just as with
non-psychogenic pain, masking the symptom without a full understanding
of the message of the pain can easily lead to further damage.
Even if the pain is not psychogenic, the patient’s experience of his
pain will certainly be affected – generally amplified – by these
factors, and this experience is therefore open to modification via the
same psychological factors. In a recent book exploring developments
in cancer treatments (Lerner, 1998), for example, we read that, “there
is no question in the minds of many clinicians who work with cancer
pain that many of the psychological approaches… routinely diminish, or
sometimes even erase, cancer pain” (p. 482). The author goes on to
divide these psychological approaches to the treatment of cancer pain
into the following five categories:
1. Psychotherapy, based upon the assumption that the perception of
pain occurs within a personal and interpersonal context. The general
assumption is that dealing with critical intra- and interpersonal
issues will reduce the impact of pain.
2. Hypnosis.
3. Relaxation techniques and biofeedback. Relaxation techniques
include several types of yoga, meditation, progressive muscle
relaxation, as well as autogenic relaxation techniques that use
suggestions that the body is getting heavy, warm, or relaxed.
Biofeedback uses instruments to increase awareness of bodily states
(blood pressure, heart rate, skin temperature, brain wave activity,
and so on).
4. Cognitive approaches, including assessment of beliefs,
expectations and fears.
5. Behavioral techniques focusing on the role of environmental
reinforcement of pain.
Each of these techniques can be equally valuable for treating pain
that is not related to cancer.
In looking over this list of techniques one might use in designing a
treatment protocol, it becomes apparent how important belief
structures become in the patient’s understanding and experience of his
pain. Indeed, suffering is perhaps best defined as the narrative
structure and meaning we give to pain. Sometimes, that narrative can
profoundly alter the experience of pain. One widely cited example of
this phenomenon are the studies of wounded American soldiers in Korea
and Vietnam. Soldiers who had minor wounds that could be treated
locally consistently reported worse pain than those who had been
injured more severely, and were being sent back to the United States
for treatment. Seemingly, the meaning of the wound increased the pain
for those who were being sent back into the war and lessened it for
those who were being sent home – regardless of the actual severity of
the wounds. A study of patients suffering from chronic pain (Riley,
et al., 1988) found that, independent of the pain levels reported,
those who believed pain should inhibit their movement were the most
inhibited. In other words, the belief that pain implies disability
was more determinant of disability than the pain itself. Patients can
often attribute maladaptive meaning to their experience of pain. They
can interpret the pain as retribution for their own failings in life,
or they can see themselves as innocent victims of a cruel world. They
can link the pain (consciously or unconsciously) to rage against a
parent, sibling or spouse. These sorts of narratives impede the
patient’s ability to respond to intervention or rehabilitation.
Psychological counseling is essential in recognizing and addressing
these sorts of self-destructive interpretations.
Not all factors influencing the patient’s suffering are strictly
internal, however. One novel study, reported in Science (Ulrich,
1984), examined how pain sensitivity may be modulated by other types
of sensory input. In this retrospective study, ten years of records
at a suburban hospital were examined, noting how much pain medication
was requested by patients recovering from gallbladder surgery.
Patients who were in rooms with a view of trees from their windows
requested significantly less pain medication that those whose windows
had no view of trees. Other well-known studies have shown that
psychological variables such as having a sense of control over
treatment also dramatically alters the amount of pain medication
requested (e.g., Jully and Sibbald, 1981; Citron, et al., 1986;
Chapman and Hill, 1989). In the United States, many hospitals provide
televisions with several different 24-hour comedy channels in response
to research showing that laughter decreases reported pain severity in
patients, just as a sense of hopelessness increases such severity (DeVillis
and Blalock, 1992). Given the fact that feelings such as sadness,
fear, anxiety and boredom tend to adversely affect the patient’s
experience of pain, one wonders at the influence of the hospital
setting itself on the patient’s prognosis. Few places are more marked
by these very emotions. With this in mind, it seems clear that as
soon as medically possible, pain considerations would suggest that
moving the patient to an out-patient basis is generally advisable.
However, moving the patient to his home environment may introduce a
new set of psychological issues to consider. If the pain is in some
way related to problematic relations among family members, a negative
feedback loop is likely to develop in which the patient’s suffering is
seen as a burden or indictment by the other family members (very
complex dialogues can take place on a subconscious level without any
of the participants ever becoming fully aware of what is being
communicated) – who respond by defensively trivializing the patient’s
experience. This trivialization, in turn, may tend to provoke an
increase in the severity of chronic condition(s) and/or an increase in
the frequency of acute attacks. When the physician becomes aware of
this type of dynamic among family members, a psychological
consultation is urgently called for.
To further complicate matters, we cannot discuss the psychological
aspects of pain without considering the role of gender. It is
well-known that men and women experience pain (and practically
everything else) very differently from each other. Whether these
differences are primarily biological or cultural in origin, it is
common knowledge that women tend to have higher pain thresholds than
men. Men may also tend to find the role of being a patient more
problematic, in that the vulnerability inherent in such a role is
often a feeling quite unfamiliar and threatening to many men.
Similarly, men may attempt to mask or underreport the severity of
their pain, for fear of seeming less masculine. Ironically, this fear
may actually be amplifying the pain they are attempting to hide!
Along with sensitivity to gender issues, we should attempt to be aware
of the fact that in an increasingly heterogeneous world, cultural and
ethnic differences in our patients may significantly alter the process
of psychological assessment and treatment as well as the patient’s
experience of pain (Turner and Romano, 2001).
As our Freudian dream illustrates, the configuration of consciousness
is vitally important in how and whether any given stimulus will be
experienced as pain – or experienced at all. While allopathic
medicine makes little use of the profound relationship between
sensation and consciousness, the linkage is evident in many other
contexts. Virtually every known religious/spiritual tradition
incorporates some pain-defying rituals – from the self-flagellation,
fasting and kneeling on cold stone floors for extended periods common
to Judeo-Christian and Muslim traditions to lesser-known rituals such
as the Sun Dance (where the flesh is pierced and followers dance for
hours or days without stopping) or sweat lodge ceremonies (where
temperatures can reach 100O C for brief periods of time) of the plains
tribes in the United States (see Weil, 1980). In the Buddhist
traditions, there are many examples of ceremonies in which the
modification of consciousness is demonstrated and/or facilitated by
withstanding extremes of cold or heat, as well as maintaining
difficult positions for extended periods (see Murphy, 1992 for an
excellent review of these practices). Martial Arts training typically
involves learning various techniques for overcoming pain by
restructuring the meaning of the pain. Even body-builders attempt to
reframe the meaning of pain with the expression: “No pain, no gain.”
In the world of sexuality, many people associate either their own
experience of pain (masochism) – or that of others (sadism) – with
extreme pleasure.
On November 16th, 1895, the editors of the Journal of the American
Medical Association wrote what they thought was the obituary for
medical hypnosis. “Before many years the medical profession will drop
hypnotism as a therapeutic agent,” they wrote (JAMA,
1895;25:867-868). Luckily, they were wrong about the future of
therapeutic hypnosis. Hilgard (1979) compiled the following list of
surgical procedures performed between 1955 and 1974 during which
hypnotic pain reduction was used without chemical analgesics or
anesthetics:
· Appendectomy (Tinterow, 1960)
· Caesarean section (Kroger & DeLee, 1957; Taugher, 1958; and
Tinterow, 1960)
· Gastrostomy (Bonilla et al., 1961)
· Mammaplasty (Mason, 1955)
· Breast tumor excision (Kroger, 1963)
· Breast tissue excision (Van Dyke, 1970)
· Skin grafting, debridement, etc. (Crasilneck et al., 1956;
Tinterow, 1960; and Finer & Nylen, 1961)
· Cardiac surgery (Marmer, 1959; and Tinterow, 1960)
· Cardiac excision (Ruiz & Fernandez, 1960)
· Fractures and dislocations (Goldie, 1956; and Bernstein, 1965)
· Cervical radium implantation (Crasilneck & Jenkins, 1958)
· Curettage for endometritis (Taugher, 1958)
· Vaginal hysterectomy (Tinterow, 1960)
· Circumcision where phimosis present (Chong, 1964)
· Prostate resection (Schwarcz, 1965)
· Transurethral resection (Bowen, 1973)
· Oophorectomy (Bartlett, 1971)
· Hemorrhoidectomy (Tinterow, 1960)
· Facial nerve repair (Crasilneck & Jenkins, 1958)
· Thyroidectomy (Kroger, 1959; Chong, 1964; and Patton, 1969)
· Ligation and stripping (Tinterow, 1960)
In addition to these documented cases, there is a large clinical
literature about hypnotic analgesia in childbirth. American physician
R. V. August, for example, reported that 58 percent of 850 deliveries
for which he was responsible required no medication at all, while 38
percent required only mild analgesics such as Demerol, and only 4
percent (36 of the 850) required a local or general anesthetic
(August, 1961). In a survey of 210 childbirths reported in the
British Medical Journal, women taught autohypnosis suffered
significantly less pain during labor than women who were taught
relaxation and controlled breathing or given no training at all
(Davidson, 1962). More recent studies have come to the same
conclusions. A recent study by a panel of experts convened by the
National Institutes of Health (U.S.A.) found “strong evidence for the
use of relaxation techniques as well as hypnosis” (Richmond et al.,
1996).
Because its mechanism(s) of action remain unclear, many physicians are
hesitant to refer patients for hypnotically-facilitated psychotherapy,
despite the complete absence of any potentially harmful secondary
effects associated with these techniques. While this seems to be a
logical reaction to a somewhat mysterious phenomenon, we should not
forget that we have an incomplete understanding of many of the
medications we use regularly. The mechanisms of even the most common
pain-relief medication on earth (aspirin) was not fully understood
until more than half a century after its use became widespread! While
Prozac remains one of the best-selling drugs of all time, neurologists
continue to learn more about how it works. In fact, many accepted
medical procedures are receiving renewed scrutiny as Evidence Based
Medicine (E. B. M.) gains popularity. The results suggest that
misunderstanding the mechanism of action is more a problem than not
understanding it at all. That is to say, the discomfort many
physicians feel toward hypnosis may be due more to the fact that there
is no popularly-accepted hypothesis for how it works, rather than to
the absence of hard data supporting this hypothesis. In truth, we
probably don’t understand as much as we think we do concerning many
medical procedures. According to a recent article in the journal
Patient Care, ‘‘Some experts estimate that only 20 percent of medical
practices are based on rigorous research evidence’’ (Flaherty, et al.,
2001). The same article presents evidence contradicting the validity
of many procedures and beliefs thought to be well-documented (e.g., do
not give analgesics to patients suffering from abdominal pain,
efficacy of bed rest for acute low back pain, immobilization for
uncomplicated ankle sprains, antibiotic treatment for acute bacterial
sinusitis, and so on).
Despite all that we do not know about hypnosis, there are a few things
we do know. For example, it seems that hypnotic effects are not due
to endorphin release. Hilgard and his associates administered
naloxone, an endorphin-blocker to subjects given suggestions for pain
reduction. Because their subjects’ analgesia was not significantly
altered by the drug, it seems that hypnotic suggestion is mediated by
mechanisms other than endorphins. Further experiments confirmed these
results (Goldstein & Hilgard, 1975; and Spiegel & Leonard, 1983). We
also know that hypnotic effects are highly dependent upon the hypnotic
ability of the patient – which may be another cause for physician
discomfort. Hypnotic ability can be easily assessed by any
properly-trained psychologist or psychiatrist before attempting the
techniques. So, while there may be controversy and mystery concerning
how hypnosis works, that it often does work has been clearly
demonstrated repeatedly for well over a century.
Part II—The Evolution of Pain
Why Pain?
In the case of tissue damage, the function of pain is clear. People
suffering from pain asymbolia – who are unable to feel pain as such –
rarely live beyond 30 years of age, due to joint degradation and other
problems. It is impossible to monitor the state and functioning of
one’s body without the type of feedback that pain represents. But as
the previous section of this article makes clear, pain can be far more
than a simple a warning of damage to the physical body. Many things
that harm the body are not painful at all – alcoholic drinks, smoking
tobacco, extended periods without physical exercise, and so on. And
we all know of healthy activities that can be somewhat painful. So
physical pain -- seemingly much simpler than psychogenic pain – may
not be so simple, either.
[I]t is not a little remarkable that sympathy with the distress of
others should excite tears more freely than our own distress; and this
is certainly the case. Many a man, from whose eyes no suffering of
his own could wring a tear, has shed tears at the sufferings of a
beloved friend.
--- Charles Darwin, “The Expression of the Emotions in Man and
Animals” (1872, p. 216)
Beginning with Charles Darwin, the question of compassion has been a
problem for evolutionary scientists (see Ridley, 1996 for a full
discussion of the problem). What is the evolutionary advantage of
feeling another’s pain? Each of us has plenty of pain – both physical
and emotional – in our own life; why add other’s pain to our own
burden? Various explanations have been offered over the years, but
none has been conclusive. The question remains open and highly
perplexing to those who look for consistent rationality in human
design. Whatever the origins and purpose of compassion may be, that
it exists is certain. One of the best places to find it is in
hospitals.
In Europe, students who want to earn a lot of money generally don’t
study medicine. Here, the study and practice of medicine are not
likely to lead to significant wealth. The struggle is the same: long
years of uninterrupted study, demanding professors, intense
competition among students for limited spots in specialty training,
sleepless nights, and so on. But the list of possible rewards is
unlikely to include the five-car garage, indoor swimming pool and
10-bedroom house many American medical students bring to mind when
they need motivation to keep working. So what kind of person decides
to subject themselves to so much pressure and stress to become a
doctor in Europe?
Think of the people you work with, the people you studied with in
medical school. What were they like? Are there any characteristics
that are common to most of them? In our experience, physicians in
general – and European physicians especially – tend to be people who
are highly motivated by compassion. They choose medicine as a career
because they want to help other people in a meaningful way. Whatever
the origins of this mysterious emotion may be, it is one that most
physicians feel profoundly.
Of course, empathy for your fellow man is not enough to get you
through medical school andresidency! You have to be focused, serious,
responsible, self-sacrificing, and highly intelligent as well. You
have to respect authority and learn to absorb vast quantities of
information without wasting too much time or effort questioning the
source. You need to have a great deal of faith in science. And,
perhaps most importantly, you need to have a great deal of faith in
yourself and your abilities in order to confront life-or-death
situations. Your patients trust you in ways they trust no-one else,
and this implies a great deal of responsibility.
These are all highly admirable qualities – but they come at a price.
If we can say that there is a certain personality profile common to
many physicians – and we believe there is – then this profile
certainly contains empathy as one of its central elements. Empathy is
essential in putting patients at ease, necessary to getting a complete
medical history, and vital to the fine art of diagnosis. But empathy
can also be crippling to a physician. The suffering of patients can
seep into our own personal lives and become our own suffering. As
Darwin noted long ago, this sharing of other’s suffering is –
mysteriously but unmistakably – a basic part of human nature.
Many physicians are painfully aware of the dangers of their own
empathy and respond by walling themselves off from their patients.
Yet too little empathy can create its own set of problems. It can be
perceived by patients as coldness and arrogance, create barriers to
open communication, and interfere with accurate diagnosis.
Furthermore, this sort of emotional distance does not solve the basic
problem, and as discussed earlier, emotional problems that are ignored
or repressed without resolution simply return in other forms.
Physicians working with pain are in a particularly dangerous position
in terms of maintaining their own psychological health. If empathy is
basic to human nature, then simply being in the presence of pain is in
itself unavoidably painful. There is no way to deny or alter this
aspect of ourselves. The way this issue is generally handled in
medical education is to ignore it completely – or to teach students
that empathy is to be cultivated, while sympathy is to be avoided.
But what distinguishes one feeling from the other? To what extent can
we understand a patient’s pain without sharing some aspect of it
ourselves? To what extent can we truly understand the concept of
saltiness without having tasted salt – and recalling the experience –
ourselves? This is one area in which the disconnection between
psychology and medicine is especially unfortunate. Doctors – as
students and afterwards – are taught to deny and ignore the sometimes
traumatic effects the practice of medicine can have onthemselves.
This is similar to the all-too-common situation of the physician who
hasn’t slept for days, eats only an occasional sandwich from the
hospital cafeteria and steps outside only for a cigarette lecturing
her patients about the importance of diet, sleep and exercise! And
when the effects of this stressful, unhealthy life-style begin to take
a toll on the physician, she cannot even turn to colleagues for help
in many cases because this will then bring the shared secret of the
inherent dangers of practicing medicine into the spotlight.
With the hope of offering some support in this very difficult
situation, we would like to offer the following observations:
· It is simply not possible to be unaffected by the suffering of
our patients.
· We can deny that we are affected; we can erect walls between
ourselves and our patients, as well as within ourselves – but this is
a symptomatic response. Eventually, this conflict will be expressed –
either somatically (e.g., hypertension, heart disease, hair loss,
dermatological problems, etc.) or psychologically (e.g., “doctor burn
out,” depression, problems with alcohol or other drugs,
relationship/sexual problems, insomnia, and so on).
· Physicians – especially those working with pain – should be
aware that they are working in a highly toxic psychological
environment. Like professionals who work around radioactive
materials, physicians should constantly monitor themselves for signs
of over-exposure and take appropriate action when necessary.
· We must admit to ourselves that we are not infallible. If our
motivation is to help our patients, we have to accept the fact that
our ability to do this is compromised by too much stress, too many
hours, too many patients. Although it may feel counter-intuitive, we
do our patients and colleagues a favor by taking some time off.
· Although we are needed by our patients and colleagues, we are
not essential. Being a little selfish is a necessary part of helping
others.
· We should try to reserve time to cleanse ourselves of the
stresses of our professional lives. Exercise, meditation, guided
relaxation and hatha yoga are all excellent ways to take the mind’s
focus off our problems for a while.
· When signs of problems appear, we should not feel ashamed or
hesitant about seeking psychological help. While it is relatively
easy to treat our own infections and other minor medical problems, it
is not possible to treat our own psychological problems. An outside
perspective is essential.
Working with patients who are suffering from significant pain –
whatever its etiology – carries inherent psychological dangers for the
physician. These dangers must be acknowledged to be guarded against.
An awareness of some of the ways in which psychological distress can
manifest in the body and behavior is essential for helping our
patients, and for maintaining our own health as well. Pain may be one
of the most difficult conditions to treat, but the opportunity to help
alleviate a patient’s suffering is as important and rewarding as it is
difficult.
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i The word, psychogenic has come to replace the perfectly adequate
term psycho-somatic because of the negative connotations that gathered
around the latter term over the years. As argued in this paper, there
is no reason to suppose that a mind-body (psycho-somatic) phenomenon
is any less real simply because its etiology and treatment are more
complex and less well-understood than other ailments.
