How to Manage Unmotivated Pain Patients
How do pain patients become unmotivated? Are they unmotivated before the onset of treatment or do they become unmotivated as the treatment process progresses? The focus of this article is on how to identify and treat the unmotivated chronic pain patient, and it is based on my personal experience in this area.
This initial step in the process usually starts with the primary care physician (PCP). The PCP starts the ball rolling after conducting a history and physical examination and establishing a preliminary diagnosis, which can influence the direction or path the patient will follow. The PCP may treat the patient’s pain initially, which can also include adjunctive supportive care. The numbers are impressive; according to a recent report by the Institute of Medicine of the National Academies (IOM), chronic pain conditions affect at least 116 million adults at a cost of up to $635 billion annually in direct medical treatment costs and lost productivity.1
How many of those 116 million could be classified as difficult or unmotivated patients? That depends on a number of factors. Some patients start the process with existing emotional issues, such as anger, anxiety, or depression, which may predispose the patient to transition from acute to chronic pain. Based on my experience, the process of the initial referral and subsequent treatment can greatly influence the patient’s outlook or attitude. Remember, pain generally produces a fear response. If the fear response is recognized early and treated appropriately, it can assist in mitigating subsequent emotional consequences.
I suspect that most difficult or unmotivated patients are the conditioned result of negative repetitive treatment outcomes. The hope or optimism that may exist in the beginning stages is negatively conditioned over time and results in despair and pessimism. Pain medicine by its nature is a trial-and-error process. Therefore, the more negative trials the patient experiences, the more difficult and unmotivated he or she becomes. If providers recognize and understand this process early and incorporate the services of adjunctive support personnel, including the utilization of a pain psychologist, the outcomes can improve greatly.
The PCP usually has a number of options of where to refer the patient for more specialized pain care. These options can include private pain clinics, medical school–based pain programs, and the individual pain specialist. The referral may be further influenced by insurance coverage or location. In the rural setting, options may be limited unless the patient is willing to travel long distances.
The secondary referral to a pain specialist is an important step in the process, whether it be for a diagnosis with a recommendation to go back to the PCP for follow-up care or a recommendation for repeated visits for further invasive diagnostic procedures. It is important that at this point in the process, the patient is introduced to adjunctive support care.
When I was part of a medical school pain program at Oregon Health & Science University (OHSU), a patient was required to be evaluated by all of the adjunctive staff, including a board-certified pain physician, psychologist, and physical therapist. The advantage of the multidisciplinary pain program is that all issues impacting the patient are addressed early and are incorporated into a comprehensive treatment program. If the patient has a positive and supportive experience, then the potential for hope is reinforced and counterproductive issues, such as anger and frustration, are mitigated. If the secondary referral is based on the premise that, “I have nothing further to offer; go see a pain specialist,” the patient then feels like a failure and the trial-and-error process of negative reinforcement begins.
Over the past 30 years, I have experienced many types of referrals. If my services are incorporated early in the treatment process, then I am more optimistic about the outcome. Unfortunately, this is not always the case, especially over the last 10 years as an independent provider operating in a hostile insurance environment. Many of my referrals have been in the trial-and-error treatment process with repetitive failures. These patients often do not understand why they have to see a pain psychologist. Further, they feel that nobody believes their pain is “real,” and by being referred to a pain psychologist, their pain is “all in their head” or imaginary. So by this time, these patients are often characterized as being difficult and unmotivated.
The initial visit is critical in establishing a connection with the patient. As noted, at OHSU, patients went through a full day of psychometric testing. For the past 10 years as a solo practitioner, I have relied on the clinical interview as my main source of data. Early in my career, I attended a weeklong workshop with Wilbur Fordyce, PhD. He shared his Behavioral Analysis of Pain, which I still incorporate into my initial interview with a patient. I avoid offering a psychological pain diagnosis in my report to the referring physician. Instead, I offer my clinical impression where I attempt to point out the issues that may be influencing the patient’s pain, including both strengths and weaknesses.
In addition, I utilize the model of chronic pain from Ronald Melzack, PhD, during my initial evaluation in identifying both affective and cognitive factors that are influencing the patient’s perception of pain.2 Keep in mind that a considerable number of pain patients are clinically depressed by the time they are initially evaluated by a pain specialist. I have seen ranges from a low of 60% to a high of 80%. Depression results from profound feelings of learned hopelessness and helplessness. As the patient experiences repetitive treatment failures, this sense of despair accumulates, which—in my opinion—forms the basis of why the patient appears unmotivated. From a learning perspective, this despair or the feelings of hopelessness and helplessness results from classical avoidance conditioning.
So how does a pain psychologist start to treat a depressed, unmotivated patient? The first step is the assessment of the patient’s strengths and weaknesses. Are they open and at least curious about the nature of “their” pain? (See Figure, page 46.) Are they willing to accept that it is their pain, not mine, or their other treating physicians’ pain? From a cognitive behavioral treatment perspective, this is a crucial first step. The patient needs to trust the pain psychologist and realize they are not going to question the validity of their pain. Many patients are cautious and somewhat dubious, especially after experiencing repeated treatment failures.