Unconscious Processes and the Undertreatment of Pain

During their presentation Friday at PAINWeek 2010, "Unconscious Processes and the Undertreatment of Pain: Illustrations from Clinical Narratives and Poetry," Nance K. Cunningham, PhD, and Howard F. Stein, PhD, discussed "unconscious reasons” for ineffective pain assessment and management and several aspects of what they referred to as "the medical culture" that may affect professional responses to observing and responding to patients in pain. They also identified ways in which psychodynamic processes may create defenses against empathy.

Cunningham and Stein asked the audience to consider several questions that focused on the subjects of empathy, projection, and medical objectivity and their relationship to pain management: What is the relationship between neuro-imaging of empathy, objectivity/subjectivity, and working with patients in pain? What is groundbreaking about the work of Passik et al, and Craig when considering problems of caregiver empathy? How can clinician empathy generate bona fide medical evidence? What role do projection and projective identification play in the assessment and treatment of pain? Can you give examples from your practice/experience of unconscious factors that led to undertreatment of pain?

Stein said that as far back as he can remember, "pain has been the physician's nemesis. Clinicians' complaints about pain patients have persisted and been similar for decades." He said that through the narratives and labels many clinicians use to describe the process of pain management, clinicians "often project their own bad self, the repudiated self, on to the patient. They observe their own ghost in the patient, and only will recognize later that they and the patient have something in common." He also stated that "clinicians have a need for certainty as part of 'competence.' In the medical culture, the word and concept of 'subjectivity' is often looked at with a sneer as something to be avoided. There is no room in the medical culture for uncertainty or the use of the imagination."

Cunningham noted that there are several frequently cited professional barriers to effective pain assessment and management, including clinicians' lack of knowledge about how to assess, document, and treat pain (stemming in part from fear and uncertainty over regulatory and law enforcement scrutiny of prescribing practices, especially when using opioids). She said that there have been several studies that examined these barriers in terms of clinicians' beliefs and attitudes (for example, clinicians often assume that patients' pain is not as severe as the patient claims it is).

Cunningham and Stein discussed the "unconscious reasons" that contribute to ineffective pain assessment and treatment, offering several "senses" or definitions of the term (including "out of awareness" or habitual unconscious that does not allow one to step back and objectively observe one's environment, and the "dynamic unconscious," the "driving concept" that informs how and why clinicians approach their interactions with patients). They explained how these unconscious reasons contribute to clinicians' attitudes, motivations, biases, and assumptions when it comes to observing, interacting with, and treating patients who are suffering from pain. Stein also addressed the tension between medical professionals' claims of objectivity and the inherently subjective nature not only of the experience of pain, but also of observing a person who is in pain and the feelings, thoughts, and emotions this generates in the observer. Cunningham said that "empathy consequent to witnessing another in pain is always subjective. It is the experience we associate with seeing actual or potential tissue damage in another. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore an emotional experience."

She cited several examples from the literature on pain management and provider empathy, including Passik et al, on "the influence of out-of-awareness biases that may affect physicians' ability to hear patients," and Craig et al, which looked at neuroimaging studies of pain that show that some of the same parts of the brain are affected in the person in pain and the person who is witness to that pain. These responses in the witness are "part automatic distress and part conscious regulation," said Cunningham. Other research has shown that "automatic activation of the threat system may be lessened by the context and characteristics of the witness, and that the experience may be so overwhelming that other-oriented responses are impossible," said Cunnigham. Another study found that "physicians are able to 'down-regulate their pain empathy response,' making it possible to more easily provide assistance or provide no assistance at all."

Many and varied psychodynamic processes at work in the medical culture engender "defenses against empathy," said Cunningham. These include "counter-transference, denial, splitting and projective identification, counter-identification, rationalization, the 'self of the clinician as unconscious model,' group counter-transference, and enactment." She said that although "professional self-reflection has been considered a solution to the undertreatment of pain," this can best be done "in a psychological context of safety with another person or small group, together with a willingness to accept ambiguity and uncertainty." She said only a person "who has been attentively and empathically listened to can venture the risk to listen deeply to another person."

Stein and Cunningham described the "semantic network or constellation" that many clinicians construct in response to "catastrophizing patients." Practitioners who interact with these patients characterize them as "dramatic, attention-seeking, demanding" patients who "exaggerate or amplify the severity of their pain." They are called "weak, wimps, whiners, and bad patients," said Stein. To illustrate this, he read a poem that he wrote, titled "Lessons for a Cowboy Doctor":

Before he was a doctorHe was a cowboy -Prided himself on the horsesHe’d broken and rode,Did the rodeo circuit for a time.He often told me he couldn’t understandPatients who couldn’t take pain,Always demanded pills or shots,Something for pain in the back,Pain in the shoulder,Pain in the neck —Pain no X-ray could substantiateMost of the time."I watched my daddy die from cancer,"He explained. "Daddy was no whiner. You knew from his face that he hurt,But he never asked, never gave in.He had that West Texas pride.""But let me tell you about my Nasal polyp," he continued."A couple of weeks ago I had it cut out and neverHurt so much in my life.Would you believe I even wrote myselfA prescription and gave myself a shot?""Who knows? —maybe next timeA patient comes into the officeComplaining of pain, I’ll think twiceBefore I write him off as some kind of wimp."

Copyright Howard F. Stein