Pain is a subjective experience, which means it is influenced by an individual’s perceptions, emotions, beliefs, and cultural factors. When assessing pain, healthcare providers rely heavily on the individual’s self-report to understand the nature, intensity, and impact of their pain experience. In other words, “pain is what the patient says it is” (Miller et al., 2017). Pain is not always directly correlated with observable signs or specific physiological changes. Therefore, healthcare providers must trust and respect the individual’s self-report of pain, even if it does not align with objective measures or expectations. Validating and addressing the individual’s pain experience is essential for providing compassionate and effective care. In addition to the use of evidence-based assessment tools such as the Numeric Rating Scale (NSR), The Visual Analog Scale (VAS), and the Verbal Descriptor Scale (VDS), behavioral health observation provides a view into the unique experience of pain. Behavioral health observation can indicate pain through facial expressions, vocalizations, body movements, and decreased activity levels (Cook et al., 2012). However, pain may also be expressed through a range of emotional responses.
Pain is broken down into acute pain and chronic pain. Chronic pain is a broad term that encompasses a range of embodied experiences. It is defined as persistent or recurring pain that lasts for an extended period, typically beyond the expected healing time of an injury or illness, usually lasting for three months or longer (Chronic Pain, n.d.). For people in treatment and recovery, chronic pain may be the result of trauma, a significant medical condition(s), or both. It often presents as physically debilitating and emotionally destabilizing, placing individuals in crisis. It can lead to conditions like depression, anxiety, and even exacerbate pre-existing mental health issues.
Conversely, mental health challenges such as stress or trauma can worsen the experience of chronic pain. It is crucial for behavioral health providers to understand that chronic pain can increase vulnerability, amplify pain, and increase the risk for suicide and suicide ideations (Dydyk, 2023). Pain may also lead to long-standing substance use and isolation. Mistrust of helping professionals because of negative encounters with providers, treatment-resistant pain, and other barriers to care often prohibit participants from seeking treatment, thus continuing the crisis cycle. At Services for the UnderServed (S:US), the Treatment and Recovery Services team recognizes the critical importance of developing healthy and trusting rapport with people served, acknowledging the factors contributing to ruptures in, and barriers to essential care. Understanding pain as a crisis creates an opportunity to address the complex factors that result in distress.
S:US is one of the largest community-based health and human services organizations in New York State. It works intentionally and daily to correct societal imbalances by providing comprehensive and culturally responsive services. The agency offers treatment and recovery services to address a vast range of needs – focusing on mental health, wellness, and substance use recovery – impacted by social determinants of health. For individuals who, because of chronic pain, have experienced co-morbid mental health and substance use challenges, the emotional impact is vast and dangerous. Therefore, treatment at the S:US Wellness Works Certified Community Behavioral Health Clinic (CCBHC) provides treatment and recovery services to those individuals through person-centered and uniquely individualized interventions. The CCBHC model ensures that any individual who walks through their door has access to excellence in care for mental health and substance use treatment needs. S:US’ CCBHCs immediately connect individuals with an integrated team of professionals to assess the individual’s stated needs and extend wrap-around care.
Chronic pain often intersects with mental health in complex ways. The role of providers in treatment and recovery settings is to address the distress caused by chronic pain from a holistic approach, tending to the physiological and psychological components at the core of pain. A range of emotions accompany the body’s response to pain. “One of the most disruptive features of pain is the emotional distress. The typical emotional reaction to pain includes anxiety, fear, anger, guilt, frustration, and depression” (Linton et al., 2011). Emotional crises are deeply personal and impact functioning: individuals are unable to work, attend vocational programs, feel disorganized or disoriented, experience shame, engage in substance use to curb unwanted thoughts and feelings, or act with impulsivity. Many remain unable to actuate self-care behaviors. From a crisis management approach, it is essential to address both the physical and psychological aspects of pain management to optimize outcomes and promote healing. “The challenge is to assess risk and to manage the crisis without acting in ways that the patient experiences as invalidating or minimizing their problems while, at the same time, fostering autonomy” (British Psychological Society, 2009). Providers fortify these goals through expanded therapeutic lenses.
A case example to illustrate some of the treatment approaches used at S:US is that of EG. EG is a 60 y/o Latin man treated at the S:US Wellness Works CCBHC in Brooklyn. He was referred by his supportive residence case manager in the context of uncontrolled outbursts of anger, verbal aggression toward others, and escalated threats of violence. Following intake and evaluation, EG was given diagnoses of Bipolar Disorder, Antisocial Personality Disorder, Chronic Obstructive Pulmonary Disease, Chronic Viral Hepatitis C, Human Immunodeficiency Virus (HIV) disease, and Opioid Dependence in remission. EG self-reported chronic back pain, which contributed to significant distress. Treatment focused on the emotional components that aggravated the distress caused by pain.
Managing chronic pain often requires a comprehensive and multidisciplinary approach, involving various healthcare providers such as physicians, pain specialists, physical therapists, psychologists, and other allied health professionals (Staudt MD, 2022). EG was referred to the Psychiatric Nurse Practitioner for an evaluation to assess for medical and mental health comorbidities, and the treatment team collaborated with his medical providers and housing residence to wrap-around care and decrease the potential for harm. Twice weekly sessions mitigated against negative outcomes.
Early in treatment, EG presented as volatile, projecting anger towards the therapeutic alliance. He spoke about the lack of support and effective medical interventions specific to his pain, exacerbated by a history of trauma and years of incarceration and institutionalization. EG perceived danger around him yet suppressed the presence of fear. His emotional landscape manifested as intolerable physical pain, presenting as a cyclical crisis, impairing healthy functioning, and increasing the use of medications to self-soothe.
As EG continued to maneuver through the complexities of the therapeutic relationship, the introduction of arts-based interventions focused on his propensity to use his hands, as he is a self-identified tinker (a person who travels from place to place mending metal utensils as a way of making a living) and electrician by trade. Structured arts-based directives created space for exploration of the noted emotional content, which was previously too uncomfortable to examine. In conjunction, mindfulness-based stress reduction tools re-grounded EG, and outbursts decreased due to strategies in place to appropriately direct and hold feelings of anger and agitation. EG’s preoccupation with pain shifted to a focus on writing, meditation, and visual arts, which strengthened a more positive sense of self. EG felt safe in this alliance through the direct confrontation of misdirected anger, persistence in tolerating the discomfort with the intimacy required to maintain a therapeutic relationship, and a willingness to confront his fear and sadness.
Back spasms continued intermittently, yet the intensity of chronic pain diminished, and exploration of medical interventions resumed. EG invited vulnerability, so when pain emerged during the session, he ceased to lash out and instead allowed himself to be held by compassion. EG’s chronic pain was no longer prominent as it retreated, which allowed the re-emergence of EG as a tinker, Artist, and in relationship with providers. EG’s treatment is in accordance with S:US’ philosophy of care, “When an individual’s life is put on hold for circumstances unique to them, establishing a relationship with them is step one. It’s our guide to the services we provide. We don’t empower people. We give people the tools to empower themselves.” By understanding the contextual components of chronic pain, individuals like EG rediscover their own unique potential and strength-based skills to flourish.
If we treat chronic pain to uncover emotional pain, we create pathways to connection with self and others. While addressing the complex interplay between mental health, chronic pain, and its comorbidities, providers must pay regard to the unique needs and circumstances of everyone to develop personalized treatment. This may involve medical interventions, psychological support, lifestyle modifications, and social services to optimize outcomes and improve overall well-being.
Issy Francis, BSN, RN, is Director of Nursing and Dani York, LCAT, RDT, is Director of Clinical Support & Enhancement at Services at Services for the UnderServed (S:US).
To learn more about Services for the Underserved’s approaches to care, visit sus.org, call 212-633-6900, or email info@sus.org.
References
- Miller LE, Eldredge SA, Dalton ED. (2017) “Pain Is What the Patient Says It Is:” Nurse-Patient Communication, Information Seeking, and Pain Management. Am J Hosp Palliat Care. 2017 Dec;34(10):966-976. doi: 10.1177/1049909116661815. Epub 2016 Aug 4. PMID: 27496829.
- Cook, K., et al. (2012) J Pain Symptom Manage. Author manuscript; available in PMC 2014 Sep 1. Published in final edited form as: J Pain Symptom Manage. 2013 Sep; 46(3): 413–421. Published online 2012 Nov 15. doi: 1016/j.jpainsymman.2012.08.006.
- Dydyk, A.M. (2024), Conermann T. Chronic Pain. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-2023 Jul 21. Available from https://www.ncbi.nlm.nih.gov/books/NBK553030/.
- Chronic Pain. (n.d) The Johns Hopkins University, the John Hopkins Health System. Review. https://www.hopkinsmedicine.org/health/conditions-and-diseases/chronic-pain.
- Staudt MD., (2022) The Multidisciplinary Team in Pain Management. Neurosurg Clin N Am. 2022 Jul;33(3):241-249. doi: 10.1016/j.nec.2022.02.002. Epub 2022 May 25. PMID: 35718393.
- The British Psychological Society & The Royal College of Psychiatrists. National Collaborating Centre for Mental Health (UK). (2009. Borderline Personality Disorder: Treatment and Management. Borderline Personality Disorder: Treatment and Management. NICE Clinical Guidelines, No. 78. https://www.ncbi.nlm.nih.gov/books/NBK55407/.
- Steven J. Linton, William S. Shaw (2011). Impact of Psychological Factors in the Experience of Pain. Physical Therapy, Volume 91, Issue 5, 1 May 2011, Pages 700–711, https://doi.org/10.2522/ptj.20100330.
