I just had a manic OCD episode and washed my hands way too many times so this soap box is empty! What should I do with it? Any suggestions?
I don’t quite feel like recycling it yet so I think I might…just…stand on it.
Is that cool?
You’ve got psychosocial issues.
Have you heard that before? Of course you have because you have pelvic pain. The first few medical thoughts you pay for are that you need counseling or maybe even sex therapy. You might have been told that you need counseling before you were told that you needed pelvic floor physical therapy.
The truth is that there is truth in this. You do have psychosocial issues if you have pelvic pain. How could you not? But, the other truth is that we all have psychosocial issues. How could we all not? I’m compelled to stand on this now empty box that was once filled with unscented, white Dove soap because I’m hearing this phrase far too much in my professional life.
Allow me to explain.
What is real, what is necessary, what is evolving is this construct of explaining pain to patients. There is really good research to back up the idea that if you explain what happens to the nervous system once someone has been in pain, anxiety, fear, etc long enough, then real physiological changes happen to the body. These changes can create an exaggerated interpretation of stimulus. That means a light stroke on the back of the hand can be truly interpreted by the brain as a razor splitting the skin on the back of the hand. The observer’s reality of that act is different from the reciever’s reality of that act. The brain connected to that hand, in the case of a person with chronic pain, truly believes that someone tried to shave their hand open. And that’s scary. Like, really, really scary in so many ways. Can we count them?
- Why the fuck would someone shave your hand open?
- Truth is that there was no razor, but it’s hard to constantly remind your brain of that. One part of your brain says “calm down” while the other part says “calm down, whaaaat?!?”
- If there is this much difference between the brain’s truth and the rest of the world’s truth, then is this person in chronic pain crazy? Is all of this pain truly in their head?
It gets so sticky. It gets hairy. It gets confusing and lonely to be in this much pain for so long. The only good part of this all is that there is true science to demonstrate that this is happening to the brain and the body. The nervous system is re-wired. The collective “we” of healthcare providers doesn’t know a whole lot about how to change this, but “we” are really interested in changing this and “we” are implementing new practices to do our best to change the chronic pain nervous system.
The names that pop up are Lorimer Moseley and David Butler. They do tons of work on chronic pain – also known as central sensitization. One example of this that many people are familiar with is the concept of phantom limb pain. This is when someone has had a body part amputated, but their brain still interprets sensations of pain in that body part that is no longer there. These amputees are not crazy people, they are sane, frustrated people living with significant alterations to their nervous system. The same thing happens with pelvic pain. You can get to a place where there is no intrusive injustice taking place in or on your body, but your brain perceives that there is still a body threat and therefore your body feels pain. Remember – pain has a purpose. Pain is to protect you from harm. It’s just that with central sensitization aka chronic pain aka an altered nervous system, the nervous system gets stuck in a loop. It just plays the same “pain” message”.
Ideally, patients are given tools via reading material, actual body movement homework programs and body calming techniques to retrain the nervous system. Counseling can also be very helpful in reprogramming the negative through process that can take place when you are in chronic pain. So, how much am I using all this in my practice? Not enough.
I don’t use this enough. I don’t educate on chronic pain nervous system changes enough. I don’t harp enough because I have so much difficulty with my patient “buy in”. I struggle to be consistent with my body movement retraining programs because if a patient gets stuck, I get stuck. I don’t know how to proceed or alter my advice well enough to help the patient. I need more education to help me be a better educator.
So…can we say that is kind of the “psych” part of “psychosocial”?
What about the “social” part. What does that mean?
I think it means that, regardless of whether someone with pelvic pain is aware of it, being in pain changes their social roles. It might mean that they do less housework, it might mean they switch some of their responsibilities at work, it might mean they are having less sex with their partner, it might mean they need to ask for some help from a friend. Things are just a little or a lot different. This difference can impact a person’s identity, their relationships, etc. It can be a drastic thing where a person has taken on “pelvic pain” as their new identity, or it can be smaller like “Oh, I just don’t go to the movies anymore.”
I think that’s the “social” part of “psychosocial”. I could be wrong and if I am…it doesn’t really matter because my angst isn’t about the definition of the word, but the use of the word.
The medical community uses the term “psychosocial” as a scape goat when they do not know what to do with a patient. The pain doctor says “Oh, they say they had more pain after my nerve block, they have a lot of psychosocial issues to take care of.” The physical therapist says “The patient complains when I have them do clamshells. They say it makes their anus hurt. That doesn’t make any sense. I don’t think they want to get better.” The psychologist says “I think that the pain is serving a role in their lives. They are not ready to get better.”
My truth is that sometimes it’s true. Sometimes, and it’s rare, sometimes I do think a person has psychosocial issues and the pain might be serving a role. But…most of the time, MOST of the time, it’s just bullshit to blame a patient’s lack of progress on psychosocial issues. In most of those cases, it’s the provider that doesn’t know how to best treat that patient. Why do I say this? I say this because I’m usually the second, third or fourth physical therapist that a patient has seen and I often hear from their former providers that the patient has “psychosocial” issues. I even once asked an orthopedic surgeon to do a diagnostic procedure and he responded “Well…has the patient seen a psychiatrist?” Kudos to you, sir, for thinking about the patient’s emotional well-being, but I take that Kudos bar back because you have forgotten to do your actual job.
The psychosocial scape goat. We blame the patient – behind their backs. Should we be blaming ourselves? Eh. No. I don’t think it has to be binary. I think that it’s okay to tell a patient that we’ve taken them as far as we know how to take them at this time. I can’t tell you how many patients I want to find and pull back into my treatment room because on this day I know how to best treat them, but three months ago, one year ago, five years ago…I did not. I truly believe that all of my patients can get better with the right care. Sometimes I’m not the one that can give that right care. In that case, I believe that I need to refer to another provider. I think that’s the right thing to do and the honest thing to do. I hate to hear discharge stories of patients who were essentially “laid off” by their therapists. They didn’t do anything “wrong”, they just didn’t get better fast enough or at all.
There is the argument that as providers we can’t fix everyone. It’s true. I cannot heal all my patients. But, I do firmly believe that if I cannot help someone, then someone else can. I want to have options A, B and C available to them.
If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]