The pain psychologist Rachel Zoffness expains why pain is a “biopsychosocial phenomenon“…. Ezra Klein, New York Times columnist

I get the evolutionary biology argument that pain communicates vital information about injuries, but I’d still prefer my nervous system to send me a text or an email.

 

You're on fire today

 

To be fair, in the podcast she does say that if a patient with 'chronic' pain shows up to her clinic without having had full/thorough biomedical workup (I cant remember the exact terms she uses but she talks about x rays, scans etc) then she makes sure those get done first before she starts treatment, because the pain that has been seen as 'chronic' might actually be acute - ie the warning sign that something is wrong & that shouldnt get missed.

but for me thats where the whole thing falls down.....

I mean it cant be denied that the brain sometimes, somehow, creates pain without the presence of damage/harm in bodily tissues - otherwise people wouldnt get phantom limb pain...

But the idea that full/thorough biomedical work up will comprehensively rule out tissue damage (the 'bio' part of BPS), is completely erroneous.

I dont have an issue with people trying this stuff. Or it being explored in cases of chroinc pain... Because I know myself that when my mood is low, my experience of pain is much worse than when its not. (although I must say that the suggestion that the fight/flight response makes pain worse i find to be simply not true, since the more anxious/angry i am the less pain i feel. Always. Which i assume is down to the action of adrenaline).

My issue is with the assumption that medically unexplained = medically unexplainable, & therefore rudimentary or even extensive testing that shows up nothing, is sufficient to say FOR CERTAIN that the pain people are feeling is 'hurt' rather 'harm', & can therefore be treated as the brain 'misfiring' or being over sensitised. Because in our current state of knowledge we can NEVER be sure there is nothing there.

She makes very clear in the podcast that shes talking about chronic pain & NOT acute pain (eg broken leg/tumour). And i dont take issue with the notion that exploring how one's emotional state might be making your experience of the pain worse. But its the certainty that is so dangerous. Its the assumption that 'if X isnt found, it must be Y'. Because as has been mentioned, if the treatment for Y doesnt work the patient gets the blame, when in fact the reason it didnt work may well be that wasnt Y in the first place. But rather the pain was there indicating 'harm', all along, we are just not medically advanced enough to know why or what the harm was.

And its why it really p*sses me off that she talks about seeing CFS patients and 'motivation being important in recovery'.
The assumption that sensory sensitivities can be overcome by gradually desensitising your brain to the stimulus so it no longer reacts.... i tried it, extensively, it doesnt work, indeed the opposite is true.
And i am sure she wouldnt say to me 'oh, perhaps its something else then', but rather would assume that i must be doing it wrong or have some unconscious reason for staying sensitive that we needed to 'weed out'.

Its that attitude to which i fervently object.

If it were a simple case of, "well it might be this, does that resonate with you? shall we try it?" Then i think thats fine, personally, because i know that i had lower back ache when i was in an emotionally abusive relationship that magically disappeared when i escaped it. (that might be pure coincidence of course, but it sure would have helped me if someone had offed me some psychosocial support at the time & may have helped me escape sooner).

But it isnt offered like that, it is offered as a definite "We find no organic issue after testing, or, we think you're in more pain than your injury should cause.... ERGO.... It MUST be a psychosocial problem"

I object, passionately, to the certainty.

 

Re 'The tale of 2 nails'

she writes

. I was under the impression that the brain had no pain receptors, so would not have been able to use pain as an alert for damage to the cerebral cortex?

 

I agree. Think of all those stories of people performing heroic, and painful, deeds to save their loved ones in accidents or disasters. Do they notice the pain with all the adrenaline going? No, they don't.

 

Generally, they simply separate acute pain, real pain, from chronic pain, "learned" pain. So it should only work on that "learned" pain, which they probably think they're avoiding because they think it right by not falling for the wrong thinking. Or whatever. Until it actually happens to them, I guess.

Magical thinking, unchanged from medieval times or even before. It's applied differently, but it's the same: making their own current experience as the universal standard. Anything not understood can be magified, turned into some mind instead of matter BS. There are tales like this in every era.

 

Which is very effective, but only short term. And has a cost, probably heavy if sustained too long. Just like focusing on pain to work through a peak can work, but it's not sustainable at all. It can work for seconds, minutes maybe, but it exhausts energy reserves, it's not realistic to keep this going indefinitely.

They're simply mixing up different concepts and basically ignoring time as a relevant factor. The same idea where if someone can stand up and answer to their own name, they can basically work full-time and go on with their merry lives. Which all makes as much sense as putting someone in skates and assessing that being able to make a single lap means you can play a pro game in the NHL right now. It's just delusional fantasy.

 

https://www.newharbinger.com/9781684036448/the-pain-management-workbook

Link above is Zoffness' pain management workbook. Free download of some tools.

What bothers me in the workbook is the relentless positivity, insisting that you can change how the pain disorder impacts your life by just employing small achievable (CBT) goals and then accomplishing increasing amounts of normal activity.

This is not possible for me. I have tried this for 26 years and all it does is backfire. Less is more. Slow down. A little is best.

But try to poke holes in the dogma---see the rabid or vapid comments section in the NYTimes of the article.

I would also posit that we have very little "-social" in the biopsychosocial theorum. For one, in the West, and especially the USA, we live in an atomized world (perhaps not the recently immigrated, living in extended families). There is not much credence given over to the group, family, tribe. Identity is individual, personal.

Add to that the experience of being shut away from most activities (being disabled) and the experience of being disbelieved by those whose role is supposed to be helpful.

So, one must develop an almost entirely personal world with an independent mind.

Hence the social in biopsychosocial barely exists for us.

 

Agreed. We can never be absolutely certain every possibility causing chronic pain has been checked.

Due to stigmatized diseases, and certain groups of unpopular patients, disdain and neglect may interfere with thorough biomedical work ups.

The guarantee that thorough testing has been done for these groups is not worth the paper it's written on.

 

I'd take this a bit further. I assume you mean that we can't be certain right now, but I think that this uncertainty is just as inevitable as the uncertainty principle in quantum physics. The human body is simply too vast and complex to know as a black box that cannot be disturbed, unlike a machine that can be taken apart.

Even in an imaginary Star Trek future with medical scanners, it's not realistic to be able to make out every single thing happening. This is why the current model of healthcare is to check for certain things that are known to be significant, there's no such thing as a "full health checkup" yet, and there may never be. Not anymore than we can check the entire planet for missing people, it's just not feasible.

We are constantly exposed to all sorts of things that can affect the body, from chemicals to pathogens to just plain bad luck when things that don't cause problem in isolation may become harmful in circumstances so specific it wouldn't be possible to know, even after the fact.

The need to know the cause and pathophysiology is something medicine will have to grow out of, it's not even realistic. Medicine has to be able to deal with sick people, no matter why or how they are sick. And not with quackery and woo, obviously, which has been the only model.

The future of medicine likely goes through AIs available all the time, it's clear that current model of extensively training too few people works horribly, especially with its top-down authoritarian culture that too easily sees patients as hysterical children that are so easy to kick out of the office. And biases. And opinions, politics, personal dislikes, etc.

I still see that all the time from MDs and it's maddening. It's "so easy" to neglect patients. Never any elaboration on that. Do they mean technically easy, as in the push of a button? Or morally easy? As in they don't think twice about it since they never know what happens. Or just plain don't believe. Also so easy.

We need self-serve medicine, or at least partly self-serve. Having to wait for people who can't fully do their job never works out.

 

Zoffness' work is, in a word, platitudinous.

 

Dangerous on several fronts as it is with M.E., at first it might make you push through the symptoms you already have causing damage.

Then in the long term it teaches you to ignore symptoms or wish them away completely ignoring that something new might have reared it's ugly head and you'd better have it checked out.

Then there's the effect on whoever is treating you also getting his head filled with this garbage and perhaps not taking your complaints seriously.

The final nail is that when you apply for much needed benefits and getting turned down because if you wanted to be better you would be better so why would you deserve our help?

 

Psychological treatment may help for inconsequential pain (I doubt it but may be) but it is counter-productive for consequential pain.