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19 Articles in Volume 19, Issue #6
Arthrofibrosis: Targeting Hormones after Childbirth to Relieve Frozen Shoulder, Inflamed Joints
Can CGRP Help Clarify Why Migraine Is More Common in Women?
Case Report: Managing Chronic Pelvic Pain in Men
CGRP Monoclonal Antibodies for Chronic Migraine: Year 1 of Clinical Use
Chronic Pelvic Pain as a Form of Complex Regional Pain Syndrome
Correspondence: Continuing the “Pain Specialist” Dialogue
Endometriosis and its Misunderstood Etiology
Evolving Management Strategies for Osteoarthritic Pain
Gamma PEMF Therapy: A Pilot Study For Its Use in Managing Opioid Addiction
Guest Editorial: Sex Differences in Pain
How to Provide Effective Pain Management to LGBTQ Individuals
Interscalene Peripheral Nerve Stimulation for Post-Operative Chronic Shoulder Pain
New ICD-11 Codes Set to Improve Pain Care in the Primary Setting
Perspective: Could NGF Antagonists Be the Safest, Most Efficacious Class of Drug We Have to Treat Pain?
Rheumatoid Arthritis and Cognition: Is There a Genetic Link?
Targeting Nerves Provides Alternative to Opioids for Joint Arthroplasty
The Sex Question in Primary and Pain Care
What is capsaicin’s role in treating osteoarthritis?
When Pain Clinicians Have to Be the Villain: Communication Strategies to Bridge the Divide

When Pain Clinicians Have to Be the Villain: Communication Strategies to Bridge the Divide

How to break the tension that often begins between providers and their patients when dealing with complex pain care, such as tapering.
Pages 16-19

What do Darth Vader, Batman’s Joker, and Hannibal Lecter all have in common? All famous pop-culture villains, they are venerable opponents to their respective protagonist. These villains often have many of the same characteristics as the “hero,” but are misguided in their pursuits. In many cases, providers and their patients may feel as though they are in a similarly combative scenario. While not necessarily “misguided,” their intentions may come across as contrary to the other’s goals. Why is this?

Patients living with chronic pain may present with several challenges. These may include social or financial problems; a lack of trust or communication with their provider; cultural differences or language barriers; cognitive impairment; severe mental health issues; addiction concerns; healthcare system concerns; personality conflicts; and more. However, throughout all of this, the patient is often expected by their provider to be open, honest, adherent to treatment, and overall motivated to get better; they may even be expected to have gratitude and display pleasure at their improvement.

Healthcare providers (HCPs), on the other hand, may make common mistakes. They may use jargon or avoid certain topics; assume understanding on behalf of the patient; not realize the patient may be afraid to assert themselves; make inappropriate jokes; or fail to explain their hospital and/or clinic’s function. In some cases, they may feel like a police officer, judge, or dealmaker. By the same token, however, HCPs are expected to be thoughtful, empathetic, non-judgmental, and competent. Bridging the divide between both individuals is needed for optimal pain management, which ultimately rests on their interdependent relationship.

Communicative challenges are often especially exacerbated when patients are being tapered down or off opioids. (Image: 123RF)

The Therapeutic Relationship

The patient–provider relationship, also referred to as the therapeutic alliance, helping alliance, or working alliance, is a psychotherapeutic factor identified by Grencavage and Norcross. Research has found that this alliance may predict treatment loyalty, agreement, and outcome across a range of patient diagnoses and treatment settings.1

The therapeutic alliance includes characteristics of the HCP and the patient that facilitates change, such as empathy, warmth, respect, genuineness, and acceptance, and is present regardless of the type of intervention (ie, encouragement and instruction, communication, and the patient-provider relationship). The patient-provider relationship acts as the key mediator between perceived helpfulness and patient satisfaction and has been found to be significantly associated with chronic pain outcomes.2-4

While effective pain management comes out of the shared responsibilities between the patient and the provider, these relationships may be challenged by occasional opposing attitudes and goals. One person may try to control the other, asserting control while the other person is left to concede. This dynamic may lead to tension, power struggles, increased feelings of stigmatization, distrust, and discomfort in treatment. The patient may want their pain to be legitimized and feel questioned. They may perceive the provider as lacking in empathy, doubting their pain as real, or being influenced by stereotypes.5

Providers may wish to avoid feeling powerless because, when it comes to chronic pain, sometimes there may be no improvements in therapy and ultimately no cure for the patient’s pain. The perception of HCPs is that they may be more concerned about other urgent health conditions, are looking for objectivity within a subjective condition, or are not taking the time to build a relationship of trust.6,7 This all leads to tension and discomfort in treatment.

Communication Strategies to Bridge the Gap

Being M.E.A.N

One area of research demonstrating the central role of patient-provider communication is in the opioid tapering process.8 Communicative challenges are often especially exacerbated when patients are being tapered down or off opioids. Matthias and colleagues conducted a study to understand communication processes specifically related to opioid tapering in order to identify best practices.8 Four themes, under the acronym M.E.A.N., emerged from their investigation:

  • Managing difficult conversations: When patients and providers did not reach a shared understanding, difficulties and misunderstandings arose.
  • Explaining: Patients needed to understand individualized reasons for tapering, beyond general, populationlevel concerns such as the potential for addiction.
  • Assuring non-abandonment: Patients needed to know that their providers would not abandon them throughout the tapering process.
  • Negotiating: Patients needed to have input, even if it was simply the rate of tapering.

It is understood that pain and opioid management are communicative activities, and that this communication is sometimes challenging. These findings underline the importance for both patients and providers to make improvements in how they communicate. Increased attention to communication has been proposed as a way to improve relationships.

Investing in Communication

Providers, for example, may improve communication by being invested right from the beginning. It is important to create a bond and let the patient tell his or her story. Providers can do this by asking patients for their ideas and requests and by inquiring as to how they see pain impacting their life. Providers should be aware of their own reactions to the patient and be open to their emotions. Providers are also encouraged to invest in the end of their relationship by educating the patient, providing a diagnosis, and engaging in shared medical decision-making.

The book Pain Relief: Managing Chronic Pain Through Traditional, Holistic, & Eastern Practices, outlines five essential components to good communication:

  • Listen: Make a conscious effort to hear what the patient is saying and what message is being communicated. Give the patient undivided attention and acknowledge them as an individual.
  • Show empathy: Try to see the world through the patient’s eyes. Use affirmations and genuinely assist in building a bond.
  • Be concise: Use summaries and communicate interest and understanding, calling attention to important elements of the discussion.
  • Ask questions and reflect: Use open-ended questions to invite explanation and bring more thought to an issue. Reflection allows the patient to hear themselves evaluate the logic or reasoning behind their statements. Use simple (eg, stay very close to what the patient said), double-sided (eg, acknowledges both sides), and amplified reflections (eg, push on an absolute statement made by the patient).
  • Watch your body language: Recognize that non-verbal communication, such as body language and gestures, also speak loudly. For example, a provider may cross their arms, which makes them look defensive. A provider holding their hands behind their back (or firmly in their pockets) may come off as rigid and stiff.

Motivational Interviewing

Another technique that may be used to improve communication for behavioral change is motivational interviewing (MI), which was developed in the early 1980s in the treatment of individuals with addictive behaviors, such as alcohol abuse, smoking, and opioid use.

There are four main principles to use when applying MI: expressing accurate empathy; developing discrepancy; avoiding argumentation and rolling with resistance; and supporting self-efficacy.9 The basic interaction techniques and skills that are used in order to enact MI are called O.A.R.S.:

  • Open-ended questions: Creating forward momentum.
  • Affirmations: Statements that recognize patient’s strengths. They assist in building rapport but are only effective when they are genuine. “You are determined to get your health back” or “I appreciate your efforts despite the discomfort you’re in.”
  • Reflective listening: This expresses interest, empathy, and understanding. “It sounds like you are in a hard place now. Tell me more.”
  • Summaries: A special type of reflection where the provider recaps what has occurred in an appointment. Summaries communicate interest, understanding, and call attention to important elements of the discussion. They may be used to shift attention or direction and prepare the patient to move forward.

Motivational interviewing principles are now being applied to the management of chronic conditions, such as traumatic brain injuries, multiple sclerosis, and chronic pain. This technique has been shown to have an effect on chronic pain patients, promoting their physical and psychological functions,10 and maintaining their compliance with exercise for coping with pain.11-13 A patient-centered, directive technique, MI aims to improve the motivation and commitment of patients to achieve behavioral changes.14-15 The approach aims to influence people in their initiation, intensity, and performance of a behavior, such as self-management skills for pain reduction.16 Motivational interviewing has been shown to affect treatment outcomes such as in functional improvement and motivation to receive treatment.10,13

Overall, the spirit of MI includes collaboration, which builds rapport and facilitates trust in the helping relationship; respect for autonomy, which recognizes that true power for change rests within the patient; and evocation, in which the provider draws out the patient’s motivations and skills for change.17

O.A.R.S in Practice

The following hypothetical conversation illustrates how a provider can explain how a patient’s treatment is progressing, while providing both education and encouragement.

Juan is a 38-year-old Veteran who has a chief complaint of neck pain. He reportedly sustained a neck injury in Iraq while he was trying to avoid explosives. He completed an initial evaluation two months ago and stated at that time that he “would like to try medical management first and would consider an injection/procedure at his next visit.” After two months, the physician has noticed that Juan was not making any progress in his pain management. When asked if he would consider an injection/procedure again, he simply shrugged. The physician decides to use O.A.R.S. to further understand Juan’s dilemma.

  • Open-ended questions: I’d like to understand a little bit about what you’re feeling right now. Can you tell me about it?
  • Reflective listening: Juan states, “I have little hope about a full recovery” and the provider says, “It sounds like you are not optimistic about the future.”
  • Summarize: “It seems as though you doubt that your neck can get better.” Juan says, “Yes.”
  • Affirmation: “Right now I can see why you are having concerns about getting better, but I believe that you will be able to move your neck and see improvement after the injection/procedure.”

Conclusion

Frontline providers and chronic pain patients are often both villainized due to the perspectives thrown at them in the patient-provider relationship. This dynamic may be especially true when discussing particular issues in pain management, which if managed poorly may lead to feelings of distrust or stigmatization. However, perceptions may be changed using simple communications strategies, despite being sometimes challenging to implement. 

Last updated on: October 7, 2019
Continue Reading:
Fear-Avoidance and Chronic Pain: Helping Patients Stuck in the Mouse Trap
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