1. Kathleen Fitzgerald, PhD Melinda Blazar, MHS, PA-C

2.  Think of a time when you were in pain really in pain – what had caused the pain and what was happening to you?  Think of a time when you were suffering really suffering – what had caused the suffering and what was happening to you?  What helped relieve your pain?  What helped relieve your suffering?

3.  Was the treatment for the pain the same as the treatment for the suffering? Yes or No.  Would the treatment for the pain have relieved your suffering – and would the treatment of the suffering have relieved your pain?  Which took longer to deal with – the pain or the suffering?  Which was harder for you to deal with the pain or the suffering?

5.  Definition: “a basic bodily sensation induced by a noxious stimulus, received by naked nerve endings, characterized by physical discomfort (as pricking, throbbing, or aching), and typically leading to evasive action “ Merriam-Webster Dictionary

6.  Why do we care?  Accounts for 20% of outpatient visits, 12% of all rx’s  76.2 million Americans suffer from chronic pain  Most common cause of long term disability

7.  Take a good thorough history  Pain score  Location, radiation, quality  Temporal aspects: duration, onset, changes since onset  Constancy or intermittency  Characteristics of any breakthrough pain  Exacerbating/triggering factors  Palliative/relieving factors  Associated symptoms  Impact of pain

8.  Assessment of pain’s impact on overall QOL  Social functioning  Mood, affect, anxiety  Relationships  Work  Sleep  Exercise  Activities of daily living

9.  Every patient is different  Treatment is constantly changing  Options for treatment  NSAIDs, acetaminophen, regular dosing vs. prn, relaxation, bodywork (chiropractic manipulation, massage, acupuncture), narcotics  What works for the patient  Pain is constantly changing  Acute on chronic pain  Worsening chronic pain  Effective pain management involves TRUST

10.  Establish a pain contract  Gives clear rules/boundaries  Protects your medical license  NC Controlled Substance database  https://nccsrsph.hidinc.com https://nccsrsph.hidinc.com  Referral to pain specialist  They’ll advise, you manage  Can offer additional pain management modalities  Address co-morbid conditions  Psychiatric, chronic medical conditions  Bring awareness to attitudes/perceptions towards pain  Help them to be realistic

11. Pain Suffering

12. When suffering, treat with validation

13. Patients suffer when there is:  A crisis of meaning and identity  Fear  Vulnerability  A scary, bleak, unpredictable future  Their sense of wholeness, intactness, integrity is threatened

14.  Feel helpless  Too uncomfortable to ask these questions  Feel vulnerable – so they numb: drink, smoke, withdraw, get angry, bring certainty to uncertainty  Doctors invalidate – don’t worry, that’s no reason to get upset, etc.

15. Invalidation can lead to less adherence, withdrawal, and or anger Patients may feel invalidated when a clinician  trivializes  discounts,  Dismisses  finds easy solutions to complicated problems  focusses solely on change and motivation

16. Encompasses and surpasses empathy Clinician communicates:  Patient’s responses make sense  Acceptance – it is what it is – the patient thinks, senses and feels the way she does  Takes patients experiences seriously To validate clinician must: Search Recognize Reflect There is truth inherent in the patient’s responses

17.  Making something valid that isn’t  It is not scientific  Controlled, replicable  It does not need agreement or approval  You as the clinician may see it differently – acceptance of the patient’s experience

18. 1) Stay awake and pay attention  Eye contact, nod  Ask questions Language for suffering different than language of pain Ask:  Are you suffering/ struggling?  What about this illness is scary for you?  What does this mean to you?  What has this illness done to your life, work, family, friendships?  What are you worried it will do to your life, work, family friendships?  What has happened to your spirit?

19. 2) Accurate reflection  Use the NURSE model -  Paraphrase (don’t parrot) what patient shared  Be non-judgmental – matter of fact  You don’t have to agree or like what you hear 3) State what hasn’t been said  Educated guess – based on reading patient’s behavior and imagine what they are not saying  clinician risks being wrong -

20. 4) Use past history or biology  More holistic view - how mind and body are connected  “Of course you feel fatigue now that you are dealing with knee pain – and you can’t run with your son.”  Clinician demonstrates understanding of the patient’s circumstances

21. Normalizing  Clinician communicates the feeling, or thought is normal  Anyone is your situation may feel that way  We all have those moments  Don’t validate the invalid – that can lead to lack of trust  Look for grain of truth

22.  Radical Genuineness  Treat patient as equal in status and respect  Don’t fragilize  Recognize strengths and limits  Admit the truth of your feelings in a way that shows respect

24.  Smith H. “Definition and pathogenesis of chronic pain.” Up To Date. Accessed 12/22/12.  Smith H. “Evaluation of chronic pain in adults.” Up To Date. Accessed 1/5/12.  Coulehan JL, Schulberg CH, Block MR, Madonia MJ, Rodriguez E. “Treating depressed primary care patients improves their physical, mental, and social functioning.” Ach Intern Med. 1997;157: 1113-1120.

25.  Linehan, MM (1997). Validation & Psychotherapy. In A. Bohart & L Greensberg (Eds.), Empathy Reconsidered: New Directions in… Washington, DC: APA.  The Lancet. Volume 374. Issue 9699 Page 1414- 1415, 24 October 2009 doi:10. 1016/S0140- 6736(09)61851-1.  Meir et al., 2001 Meier D, Black A. Morrison R. The inner life of physicians and the care of the seriously ill. JAMA; 286: 3001-3014. PubMed

26.  Egan, G. (2001). Exercises in Helping Skills: A Training Manual to Accompany the Skilled Helper. (6 th Edition). Belmont: CA: Wadsworth Publishing Co.  Maslach and Leither, 1997 Maslach C, Leither MP. The truth about burnout. San Francisco: Jossey-Bass, 1997.  Cassell, E.J. Diagnosing Suffering: A Perspective. Ann Intern. Med. 1999; 131:531-534.