Pain is one of the greatest, most enduring, mysteries of medical science and the human condition. While it is broadly described as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage’, chronic pain, as experienced by millions of sufferers, continues to resist the most advanced pharmacological and remedial treatment available.322

It is also one of the most widely reported reasons for primary care attendance. According to a World Health Organization 15-country study, pain is the main reason for 22% of patients seeking medical assistance.323

The steps to follow in managing pain are:

Acknowledge the patient’s discomfort

For example, ‘I can understand how this has been disrupting your life/worrying you/stopping you from working’, etc (pacing patient’s subjective experience).

Normalize and re-orientate the patient towards progress and improvement

For example, ‘…and that’s completely understandable, considering [diagnosis, cause etc], so I’m sure you’re looking forward to feeling better/being able to move more easily/be more comfortable… aren’t you?’ (Pacing; Leading; Reframing; and Negative Framing: ‘aren’t you?’ invites agreement and concordance).

Encourage toleration of the symptom and detached observation

For example, ‘So, just for the moment, let it be the way it is and just stand back and watch it…’

Gather sensory-based data

For example, ‘So, what exactly is it [the pain] like?’; ‘What else is it like?’ (Eliciting the glyph.)

Notes:

  1. Avoid labels and interpretations (‘bad’, ‘irritating’, ‘endless’ etc) and encourage sensory-rich descriptions of the kinesthetic—for example, ‘tight’, ‘hot’, ‘like a knife’, ‘heavy, red ball’, ‘gripping’ etc.
  2. Do not lead the patient by making specific suggestions. If the patient needs help, ask: ‘If I were doing it [the pain], how would I know what it was like?’ If all else fails, ask: ‘If it had a color/shape/weight/size etc [each in turn], what would it be?’

Encourage self-regulation and discharge by deepening experience of tolerance and detached observation

For example, ‘So just let [the knife, the tight grip etc] be there and keep standing back and watching.’

 

‘Don’t actively do anything to change it. Allow it to change by itself—just stay quiet and observe…’ (Dissociation),

 

Note: Allow sufficient time for the process. Encourage the patient to allow any movement of the kinesthetic to fully continue until it has discharged or shifted to an acceptable level. Encourage to patient to describe whatever is happening out loud by asking: ‘So, what’s happening now?’ from time to time. This helps the patient notice when the symptom begins to move from stuck to moving. Since experiencing the pain and describing it involve different parts of the brain, this also helps to break down the boundary conditions of the condition.

Normalize and encourage any change that takes place. Listen especially for digital changes in sensory channels—for example, from kinesthetic to visual. This suggests dissipation is proceeding spontaneously.

Facilitate process if patient is stuck

Begin with one descriptor and suggest analog changes to test for the most effective direction to pursue

For example, ‘So, what would happen if the heavy, black cloud in your head could start to change slightly—maybe to become more of a dark gray?’; ‘What would happen if it became a little lighter/more transparent/cooler?’, etc (Sub-modality change.)

If one or other of the changes reduces the intensity of the experience, suggest, ‘So, that can continue happening in that way, and continue watching how it changes…’ (Presuppositions that the subjective experience can change, that change in the direction of greater comfort will continue.)

Notes

322. Perskey H (1979) Pain terms: a list of definitions and notes on usage recommendations by the IASP subcommittee on taxonomy. Pain 6: 249–52.

323. Gureje O, Von Korff M, Simon GE, Gater R (1998) Persistent pain and wellbeing. A World Health Organization study in primary care. JAMA 280: 147–51.