A person with persistent pain will usually have a long and complicated story to accompany their pain. They often carry this story around like a big battered, heavy suitcase containing all of the crap and misery that has gone hand in hand with their pain since it started. As practitioners we will often notice that anger and blame are pretty quick to spill over from the baggage, smashing on the floor and blocking the way for recovery. It might be the careless driver who hit their car while checking their phone, kickstarting our patient’s journey with whiplash. The uncaring boss who never took their concerns about safety seriously and appears to be complicit in covering up the workplace incident. The surgeon who “stuffed it up”. The insurance company who denied the claim. The doctor who didn’t believe them. The list is endless and varied but the common theme is that whilst blame is often totally understandable in the circumstances, it is also unhelpful and can stop a patient from moving forward.
Why does it matter? Often the situations that are “to blame” are well and truly in the past – the people have moved on, may never have known they were “to blame” – but ultimately they don’t care! For the patient though, the power of that external blame can have a strong drive on how they view the world and ultimately view their pain. They can become so focused on the person or scenario they believe to be responsible, that they find it difficult to step over it and walk the road to recovery.
So if we recognize that blame is blocking the path, how do we address it? Often the blame can be a symptom of the fact that they feel that no one really cares or really believes their story, including all of the people who have come along subsequent to the blame. The antidote to this scenario can be simply to spend the time listening, fully getting an understanding of how things have come about. This takes time and it also takes some skill. If we can see that this listening component can be an integral part to getting better, we can start to dedicate it the time that it needs within the consult and also the training that we might need as a practitioner to get better at it. We can start to see this as an intervention in itself and place more importance on it.
Some of the key concepts that you might like to draw on to help this process are:
- Allow the time in the first place. Recognise that examination, diagnosis and treatment don’t all have to be squashed into the first consult, especially for the distressed patient. Have longer initial consults, relax and allow the patient to spend the time they need to get the information that is important to them
- Don’t interrupt too much. Trust that the bits that they will focus on are the bits that are important to them.
- Demonstrate empathy. Practitioners can feel that this is artificial, uncomfortable or forced. You don’t need to cry with the patient for them to feel that you have got the gist of the ugly bits – simply rephrasing the key concepts to demonstrate that you have got it can do the trick. The odd “that sounds really upsetting” or “you are really brave to have gone through that and still be doing as well as you are” can also go a long way to showing you care.
- Ask open ended questions – What makes you say that? What did you believe was going on at the time? Why do you think that is? Why is that?
- Give body language cues to demonstrate that you are listening and you want them to continue- you probably don’t need to take notes at this point – you can summarise the important bits later. Face the patient, make eye contact and relax. Don’t freak out when they cry (and they will if you are doing a good job of creating a safe environment for them to talk). Simply pass them the box of tissues and carry on.
Once the patient has had a good chance to be heard, you will often find that a great deal of the work has been done. Addressing the blame can then be like a lock and key scenario to moving forward – The listening component acts like WD40 on a rusty lock. If a patient feels believed and heard, they have less of a reason to hang on so tightly to the blame.
One way to address it directly might be to follow the listening with some pain education. Depending on how you prefer to do this – formally, informally while treating the patient or drip feeding it through all conversations, ultimately one of the goals is to separate the sensation of pain from tissue damage. I also like to aim to help the patient change their focus from pain to function – having them use what they can or can’t do as their benchmarks for progress rather than their pain levels.
Having now got them on your side by demonstrating that you believe them, then helping them to reconceptualise pain in a way that is more helpful to recovery, the next bit might be to address the blame – especially if you feel that it is really driving the process. One of the ways that I find works is to say something along the lines of “It sounds to me like you are still really angry with ………. – am I hearing that right?” If they are able to engage with these thoughts and they say that yes, they are, you might like to respond with something like this: “I can completely understand why you feel that way after everything that you have been through. It makes sense. In the past I have had people who have had really bad pain situations – a lot like yours, who have found that blame or anger has really held them back – that they were unable to focus on getting better because the blame was such a big deal. When they were able to let it go a bit, or at least recognize that it was unhelpful, they found they were able to focus on the future a bit more and on their progress. Once they did this, they found that things just fell into place a bit easier” You could then just leave it to the patient to comment on that as idea, or you could ask an open ended question to see if they can engage with the concept.
If they “get it” , you can easily go forward using an Acceptance and Commitment Therapy (ACT) approach. Whilst the blame is unhelpful, you don’t have to get rid of it in order to move forward. You can encourage the patient to acknowledge that the blaming thoughts are there again, allow them to be there without judging them or engaging with them and then let them go along their way. They will no doubt pop up again soon – these thinking processes become seriously engrained habits – so just repeat the process.
Over time, hopefully the patient can let go of the blame that keeps them in the past and engage more with the rehabilitation that looks towards the future.
A great resource to introduce these concepts to both practitioners and patients is this book:
There is also more information and an online course on the website
If you are interested in learning about how I use pain education in my clinical work, I am running small group seminars in Melbourne in the coming year – check the details on the website under the ‘upcoming seminars’ tab.