Chronic pain is like… The clinical use of analogy and metaphor in the treatment of chronic pain in children
“Metaphors may be as necessary to illness as they are to literature,
Rachael Coakley and Neil Schechter
In this paper, we will review and catalog some of the analogies and metaphors that can be used to describe chronic pain and its treatment to children and their families. There are many reasons why, particularly in the field of chronic pain, it is valuable to use creative analogies and metaphors to explain complex medical phenomenon. Analogies and metaphors, it seems, may help patients to understand the complexity of chronic pain in an accessible way that likely reduces resistance and helps them to rethink preconceived notions about pain. If a clinician is explaining how heart failure impacts the body, he or she is creating the knowledge base of the patient. When a clinician is discussing how chronic pain can occur or persist without ongoing disease or trauma, he or she must undo the patient’s intuitive understanding of pain, which stems primarily from a lifetime of experiencing acute pain and differs in many important ways from the experience of chronic pain.
Providers in the field of pain medicine need to be prepared to fully engage in a creative explanation of chronic pain that promotes diagnostic clarity and sets the stage for effective treatment. Many families present to pain clinics feeling defensive and disengaged because they were told by other providers (or perceive they were told) that their child’s pain is likely the result of a psychological disorder. They may also carry a sense of frustration and hopelessness because despite extensive evaluation and intensive treatment, they perceive that nothing seems to have helped their child’s pain and incapacitation. Additionally, many of the treatments for chronic pain can seem counterintuitive for parents and children (i.e. increased activity, psychological therapy) and the provider must have effective strategies for helping patients to reconceptualize their understanding of pain and pain treatment. There is clear evidence demonstrating that accurate knowledge about the biology of pain is associated with increased pain thresholds, reduced frequency of pain, improved functioning and reduced catastrophizing (Moseley, 2002; Moseley et al., 2004). And there is emerging research to show that the use of metaphors is more effective as compared to standard educational interventions when it comes to helping patients understand the complexity of chronic pain (Gallagher et al., 2013).
The analogies and metaphors that will be discussed within this article can provide a template to explain the onset, maintenance, and treatment of chronic pain in a clear, meaningful, and jargon-free way. We recognize that many seasoned clinicians already have developed unique and creative analogies or metaphors of their own. We offer these, however, with the hope that they will spur new ways for those who care for children with chronic pain to explain this confusing phenomenon. We also hope that the use of these child- and family-friendly explanations will help to foster the growth of a strong provider-patient alliance that may in turn improve the long-term trajectory of a family’s experience with chronic pain.
The past decade has witnessed an outpouring of research that has clarified our understanding of chronic pain. Through our increasing knowledge of the role of the hypothalamic pituitary axis, descending noxious inhibitory control, pain genetics, autonomic nervous system, immune system, and the neurochemistry and neurophysiology of the transmission of nociceptive information, we have come to appreciate the concept of central sensitization which describes the process by which nerves can become hypersensitive to noxious or minimally noxious stimuli. This explains how a variety of factors (e.g. genetic predispositions, inflammation, trauma, previous pain experience, anxiety, depression, stresses of all types) can create a vulnerability to pain that various triggers can then amplify. Children’s experience of pain is further influenced by their interactions with their parents as well as social modeling. It is evident; therefore, that the etiology of chronic pain cannot be reduced to the traditional dichotomous view that it is either physical or psychological. It is far more complex, and consideration of all the factors that influence the experience of pain is necessary to help us to understand why a noxious stimulus may create persistent pain in one individual and not another.
Implicit in this model which emphasizes the complex multifactorial notion of pain perception is the need for a multidisciplinary approach to pain that often includes physical, psychological, and pharmacological interventions. It is critical for families to understand that reducing their child’s experience of pain may require a cadre of interventions, none of which necessarily imply causation. For example, suggesting increased physical activity in fibromyalgia does not imply that decreased activity was responsible for its onset. Similarly, use of psychological strategies to dampen nerve hyperarousal does not imply psychological origin as the sole etiology for the problem.
Although it is always important that a clinician explain any medical condition or treatment to families in a way that can be easily understood, it is particularly important when dealing with chronic pain. We know that the sooner families are comfortable with the idea that pain can, and often does, persist without a clear underlying etiology, and that the recovery from chronic pain requires a multidisciplinary approach, the sooner they can interrupt the chronic pain cycle and begin the recovery process (Lindley et al., 2005).
So, how can we best explain the complicated and often counterintuitive nature of chronic pain treatment to parents and children? How do we get families to understand that chronic pain is indeed a medical problem that needs treatment, though the treatments may be different from what the family has expected? And how do we create a strong alliance with families that will halt their search for more medical solutions and encourage them to truly engage in a multidisciplinary plan of treatment? We propose that the use of analogy or metaphor may provide a creative inroad to these challenging aspects of care that are inherent in our practice. Providers may also find that a simple quick sketch or visual aid can readily accompany many of the following explanations and may help to further solidify the concrete visual elements that are described within these analogies and metaphors.
Below we review many of the pain analogies we have collected from books, manuscripts, Internet resources, and our esteemed colleagues. We have classified the analogies into four explanatory groups: (a) the difference between acute and chronic pain, (b) pain transmission/spreading, (c) factors that impact the experience of pain, and (d) pain rehabilitation.
The difference between acute and chronic pain. It appears that the nociceptive pathway evolved, at least in part, to protect the organism from harm by alerting him or her to pending danger. For example, the pain that emanates from walking on a broken leg may prevent the further damage that will accrue with additional weight bearing. Similarly, the searing pain associated with inadvertently placing your hand on a hot stove will cause reflexive withdrawal, which will minimize additional burning. We know that individuals with the rare anomaly of congenital insensitivity to pain often have missing digits, poorly healed fractures, and persistent infections because that alerting system is not present. In chronic pain, as opposed to acute pain, pain has lost its protective function; as opposed to congenital insensitivity to pain, it is always present even if there is no danger. Several analogies have evolved to describe this phenomenon.
Pain transmission. Over the past 20 years we have gained tremendous knowledge in our understanding of pain transmission and nociception. This is very important for families to understand in non-technical terms. Reducing the severity and frequency of pain transmission is a major goal of treatment and families need to understand how we conceptualize and approach that goal.
Factors that affect the experience of pain. Pain is influenced by many factors including the amount of attention given to the pain, the meaning that is ascribed to the pain, past experience, family history, and both physical and emotional stressors. There are several analogies that help people to understand that the interpretation of the pain stimulus plays an important part in how much suffering and disability is associated with pain.
Pain rehabilitation. Motivating patients to participate in a multidisciplinary approach to care is an important aspect in pain treatment. The analogies below help to frame the recovery from chronic pain. By likening this process to something familiar, patients may be more inclined to feel they can be successful with recovery.
By the time patients finally make their way to a pain clinician, they often feel frustrated, confused and dismissed. Additionally, most patients are in a diagnostic holding pattern - unable to engage in treatment because they don’t fully understand the problem, much less the treatments that are indicated. For this reason, it is critical that pain clinicians find a way to help them understand the complex nature of chronic pain and build an alliance that can help foster improved long-term outcomes.
Explaining the physiology and treatment of chronic pain in an accessible way to children and families not only demystifies the often counterintuitive world of chronic pain, but may further promote a strong alliance between provider and patient which can translate to improved long-term outcomes (Smith, 1995). In our clinical experience we have found that the use of analogies and metaphors can be a very useful way to help explain the often complex nature of chronic pain and chronic pain rehabilitation. Additionally, emerging research provides empirical support for this approach. In a recent blinded randomized-controlled partial cross-over trial, Gallagher and associates found that the use of metaphor increases knowledge of pain biology and decreases catastrophic thought processes about pain and injury when compared to general educational approaches (i.e. psychoeducation, advice giving; Gallagher, et al., 2012). Of course, these pain explanations are not sufficient on their own and we recognize their utility as part of a broader discussion about chronic pain and pain treatment. Moreover, we suggest that providers who use these analogies have a comprehensive understanding of the underlying mechanisms that they are trying to explain.
There are enormous deficits in our research base regarding teaching tools for chronic pain education. We have identified no evidence that compares the efficacy or comprehensibility of these particular analogies and metaphors, examines whether or not their use directly fosters additional adherence with medical advice, reduces subsequent doctor shopping, or yields better outcomes. It is clear, however, that our historic approach to explaining pain to children and families has been suboptimal. New approaches are clearly necessary and it is our hope that this paper stimulates discussion and research into new ways to convey important information to families, which may result in improved confidence in our care, increased adherence to our prescribed interventions, and, most importantly, improved outcomes.
Cite as: Coakley R, Schechter N. Chronic pain is like… The clinical use of analogy and metaphor in the treatment of chronic pain in children. Pediatric Pain Letter 2013;15(1):1-8. www.childpain.org/ppl
We greatly appreciate the input of a number of experienced clinicians and thank our colleagues for sharing their metaphors on pain. We regret that we were unable to include everyone’s suggestions and want to express our gratitude to all colleagues who sent contributions on this topic: Susan Tupper, Simon Cohen, Carl von Baeyer, Ken Goldschneider, Gary Walco, Stacy Remke, Amy Baxter, Allen Finley, Fiona Campbell, Laura Simons. We also wish to acknowledge Casey Lawless and Elizabeth Carpino for their contributions to this paper.
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