Why Americans Suffer More Pain
Issue:
2008 July/Aug
Article Type:
Feature
Science is now proving what 10 years of listening to my clients’ pain stories has taught me: Personal beliefs affect pain outcomes. In addition, anthropologists have shown how culture influences personal beliefs. For an American this could mean that his or her belief about chronic pain is colored by a biomedical view, where pain is perceived and treated primarily as a function of tissue damage. Accepting the premise that most Americans and their doctors share this biomedical view, two critical questions emerge: (1) Are American chronic pain sufferers better or worse off than those in countries with alternative views? (2) If worse, what can American chronic pain sufferers learn from other cultures?
The Cost of
Catastrophizing
Ask any health-care practitioner if belief affects pain outcome, and she will more than likely answer yes. A University of Michigan Health System study recently showed that just the promise of a placebo reduced pain (see “Tracking Placebos in the Brain,” S&H March 2008). More dramatic was an experiment at Baylor College of Medicine in Houston, Texas, in which study participants were told that they would be receiving an electrical shock. Despite the fact that the apparatus was not electrified, 50 percent of the participants reported pain.
Now consider how such belief about pain might play out over the long term. Might negative beliefs adversely affect the quality of life of chronic pain sufferers? A pain study (IE Lame et al., European Journal of Pain, 9(1):15–24, Feb. 2005) concluded that catastrophizing with beliefs such as “I will only get worse” is associated with a lower quality of life rating — more so than the actual intensity of the pain.
In my practice as a neuromuscular massage therapist, my chronic pain clients who are catastrophizers seem less happy with their lives and are, most often, the hardest to treat. At one time, I believed that catastrophizing was just a psychological phenomenon. But in that assumption, I neglected to take into account the health-care system in which the chronic pain sufferer was being treated . . . that is, until 2004.
The Therapist
Becomes
the Patient
In 2004 I hurt my back and suddenly, I was a patient in the medical system that I promoted. My self-prescribed treatment of neuromuscular massage therapy was the first course of action to fail, followed by the M.D.’s meds and the chiropractor’s adjustments. With the fervor of TV’s Dr. House, I scrupulously recorded my daily pain symptoms — “Sharp pain, T12, bilateral, down to sacrum . . .” — to relay to the physical therapist in charge of my next course of treatment. As the pain got worse, I sleuthed harder for an answer. At the slightest twinge, I’d dutifully reach for the tape recorder on the nightstand and dictate into it: “T6, pain migrating around to front of ribs . . .” Then on one sleepless night I staggered into the kitchen and made a
watershed pain-management move: I trashed the tape recorder. At least for that moment, I felt great.
Fortunately, time and patience cured my pain, but this experience proved to be as valuable as my neuromuscular training. It provided me with a primer of what it might be like to have recurrent pain in a biomedical setting. My conclusion: The
“Dr. House” practice of viewing pain as simply a physical phenomenon that one needs to figure out didn’t help me deal with my pain. And my opinion regarding clients who catastrophized needed to be revised.
Yes, negative beliefs play a part in making a chronic pain syndrome more problematic, but so does a medical system that treats pain as primarily a physical phenomenon. For instance, as one treatment after another failed, my doctors and I all neglected to consider my disappointment. Instead, we continued to look for the causes of the physical phenomenon of pain, while my disappointment fueled more fear and anxiety that left me feeling helpless. I had created my own culture of pain.
The American
Way of Pain
There is evidence that Americans are more adversely affected by chronic pain than people who live in other cultures. For example, in a cross-cultural study of American and Japanese chronic low-back pain patients (Clinical Journal of Pain, 6:118–124, 1990), Americans who suffered from lower-back pain had greater psychological, social, vocational, and avocational impairment than lower-back pain sufferers in Japan.
Two years after this study, another cross-cultural back-pain study concluded that when compared to patients in five other nations, American patients’ self-perceived level of dysfunction was the worst.
There is also evidence to suggest that an integrated mind–body approach may better serve chronic pain sufferers than our typical biomedical approach. In a 1997 study on the effects of the cultural context on chronic pain (Social Science Medicine, 45(9)), researchers found that New Englanders who used a biomedical system had more treatment-related stress than Puerto Ricans who used a mind–body system. In the Puerto Rican system, chronic pain is viewed as the result of biological, psychological, and social factors — a bio-psychosocial experience. The researchers concluded that “shared views and values contributed to more supportive patient/provider relationships, and patients thus experienced less treatment-related stress.” The biomedical view supported by New England doctors and patients caused distress and alienation.
Creating Healthy
Pain Treatment
in the Biomedical
System
So what can a chronic pain sufferer in a biomedical health system do to help herself? One answer would be to do what outdoorsman Jayson Simon-Jones did. At the age of 30, this mountain guide in Crested Butte, Colorado, suffered a debilitating injury that was hard to explain to fellow guides because it was virtually invisible — he had no cast or crutches or other tactile signs of injury.
“The pain intensity often fluctuated for no rhyme or reason,” Simon-Jones remarked, “and people became skeptical that I was actually injured.” After treatments (from Rolfing to epidural injections) failed, he had back surgery. The operation eliminated the leg dragging but not all the pain. Nevertheless, Simon-Jones continues to mountain guide and rock climb today, in part due to the mind–body microcosm he created for himself. Here’s what he did:
Interview surgeons / “The first surgeon I met with was like a mechanic and the second one didn’t fill the criteria that I was told to look for,” said Simon-Jones. “But the third answered all of my questions and didn’t try to sell himself. He treated the person, not just the symptoms.” Simon-Jones chose this doctor for his personal team.
Pay out-of-pocket / Because insurance would not cover his initial consultation with his choice of doctor, Simon-Jones paid for it himself. Choice took priority over concerns about reimbursement.
Handpick post-surgery rehab
team / Simon-Jones’ team included a physical therapist and yoga and Pilates instructors. All were experts in their respective fields — and all listened to his concerns. As in the Puerto Rican mind–body model, he surrounded himself with a support system that would help minimize treatment-related stress.
Commit to returning to normal activities/ Arguably, the American injury compensatory system exacerbates the already isolating experience of being injured. According to one study (“Effect of Compensation on Emotional State and Disability in Chronic Back Pain,” Pain, 48(2):125–30, Feb. 1992), “The promise of a financial windfall on settlement of a claim could discourage workers from resuming employment after injury. Unfortunately, this course of action increases the risk of pain becoming chronic and of employment and financial hardship continuing after settlement.” Simon-Jones’ overwhelming desire to return to work served as motivation to evolve his own back-to-work plan — or rather, back-to-the-mountain plan.
Become an authority on your pain / Mindfulness allowed Simon-Jones to understand what was best for his body. He found that Pilates was safe for strengthening his abdominal muscles, while yoga provided the best stretch for his legs, hips, and back. When he felt ready, he returned to mountain guiding and rock climbing — but he carefully, slowly built his stamina on back-friendly climbs.
Losing Oneself
and One’s Pain
in the Moment
Of course, the danger of becoming an expert about one’s condition can result in overly focusing on pain, as demonstrated by my own tape-recording obsession. An antidote for this hyperfocus is to work to create lost-in-the-moment experiences.
Using MRI imaging, researchers conducting a “Lost in the Moment” study found that the regions of the brain that are activated when a person self-monitors are primarily suppressed in lost-in-the-moment experiences — e.g., watching a beautiful sunset or a great movie. These states of “self-lessness” reflect a theme in Zen teachings, add the authors of the study.
Simon-Jones’ lost-in-the-moment experiences primarily happened outdoors. This meant that his not-always-reliable back was involved. How did he keep from obsessing about reinjury — a sure way to kill “oneness”? Oddly enough, he did it by knowing his back condition intimately. For example, after the surgery, he discovered that climbing the overhangs tweaked his back. So he avoided them. He also learned that an easy climb served as a good warm-up for a more challenging one. Through garnering information like this, he learned how to climb without reinjuring himself. Once he had confidence that he wasn’t going to hurt himself, his mind was again free to get lost in the moment.
But how did Simon-Jones turn off self-monitoring when he couldn’t be outside? Recently, he experienced a recurrence of back pain of preoperation intensity. Interestingly enough, not being able to climb or mountain guide for a month forced him to turn his attention from his body to his psyche. There, he discovered emotional pain: grief (his father was diagnosed with cancer), hurt (a serious relationship ended), and fear (agonizing back pain returned, even though it was supposed to be gone forever). When he heard himself say that he would rather deal with another surgery than with his emotional pain, he realized that the mountain had sometimes been an unhealthy escape.
A student of Buddhist meditation,
Simon-Jones journeyed inward and found calmness in accepting the moment for what it was. “I didn’t need to get back to climbing,” he said, “and I wasn’t wasting energy, longing to be outside anymore.” By paying attention and accepting his physical and emotional states, he no longer feared pain. In turn, his self-monitoring to avoid pain was not in overdrive. This opened him up for lost-in-the-moment experiences throughout his daily life.
But as wonderful as all this sounds, it is important to remember that there is no magic pill. The last time I spoke with Simon-Jones, he was somber, having just come off a six-Vicodin-a-day pain episode. How did he cope? “I look inward,” he said in his mountain guide’s voice, “and I remember the pain isn’t going to be forever. It’s not going to be bad every day.”
Mark E. Liskey, B.S., C.N.M.T., is a freelance writer and owner of the Massage Institute in Berwyn, Pennsylvania. View his other articles, or e-mail questions and comments to him at markliskey.com.
Is American Pain From American Brains?
Do people from different cultures feel pain differently because they use their brains differently? That’s a question that has been raised by brain imaging work at MIT. Though the study (Psychological Science, 19:01) looked at visual perceptual tasks, it may give a new perspective on the cultural aspects of pain.
The study included 10 East Asians who had recently arrived in the United States and 10 native-born U.S. citizens. Study participants were asked to make quick perceptual judgments while in a functional magnetic resonance imaging (fMRI) scanner — a technology that maps blood-flow changes in the brain, which correspond to mental operations. Subjects were shown a sequence of stimuli consisting of lines within squares and were asked to compare each stimulus with the previous one. In some trials, they judged whether the lines were the same length, regardless of the surrounding squares (an absolute judgment of individual objects independent of context). In other trials, they decided whether the lines were in the same proportion to the squares, regardless of absolute size (a relative judgment of interdependent objects).
In previous behavioral studies of similar tasks, Americans were more accurate on absolute judgments, East Asians on relative judgments. In the current study, the tasks were intentionally easy enough so that there were no differences in performance between the two groups. Nevertheless, the two groups showed different patterns of brain activation when performing these tasks.
Americans, when making relative judgments that typically were harder for them, activated brain regions involved in attention-demanding mental tasks. They showed much less activation of these regions when making the more culturally familiar absolute judgments. East Asians showed the opposite tendency, engaging the brain’s attention system more for absolute judgments. Within both groups, stronger identification with their respective cultures was associated with a stronger culture-specific pattern of brain activation.
“Everyone uses the same attention machinery for more difficult cognitive tasks, but they are trained to use it in different ways, and it’s the culture that does the training,” explains lead researcher John Gabrieli.
It will be fascinating to discover whether our culture predisposes American brains for more pain.
Prescription for American Chronic Pain Sufferers
Adopt a mind–body perspective such as the Puerto Rican model, where chronic pain is viewed as the result of biological, psychological, and social factors.
Select health practitioners who will provide positive emotional support, especially during times when the pain intensifies or when a potential treatment proves ineffective.
Work to get “back to the mountain.” In Victoria, Australia, the state government understands the health risks of not resuming employment after injury: If an employee misses work for more than 20 consecutive days, the employer is required to provide a coordinator who devises a return-to-work plan.
Dance the therapeutic dance of back-to-the-mountain experiences and self-monitoring mindsets.
to your door!
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