The Institute for Chronic Pain (ICP) recently published a content piece on the roles that shame play in the experience of pain, particularly in persistent pain. It’s an underreported topic in the field of pain management. In fact, we don’t tend to talk about it at all.

There are actually a number of topics that we don’t tend to talk about with each other — whether it’s between professionals in the healthcare community or between healthcare professionals and their patients. While no means a conclusive list, topics that remain off limits to talk about in pain management, and the subsequent alternative topics that we tend to talk about instead, are the following:

• The role that fear-avoidance plays in pain and disability from pain.

• It’s often easier with patients, for example, to talk as if objective findings, such as on MRI scans, are highly correlated with disability.

• The fact that stress, as well as anxiety, depression and trauma, can cause pain.

• It’s often easier, for example, to talk as if stress and mental health problems are solely the consequence of pain.

• The role that opioid dependency has in the long-term use of opioids, even in people who use opioids exactly as prescribed.

• It’s often easier, for example, to talk as if there is a distinct, categorical difference between opioid dependency and addiction, and not one phenomenon that occurs along a spectrum of severity.

• The role that coping has in determining whether someone uses opioids for the long-term management of pain or the role that coping has in whether one experiences pain as intolerable and therefore disabling or not.

• It’s often easier, for example, to talk as if the use of opioids or disability are the natural and inevitable consequence of severe pain for which it is impossible to engage in any other response.

• The fact that pain is not just physical, but rather is a subjective, biopsychosocial experience.

• It’s often easier, for example, to talk as if objective findings on exam, such as on MRI scans, are the sole reason for experiencing pain.

• How pain is not solely the result of things that happen to you through no fault of your own, but rather can also be the result of lifestyle and health behaviors. 

• It’s often easier to talk about how to surgically respond to objective findings, such as on MRI, than the obesity and sedentary lifestyle, for example, that can also contribute to low back or joint pain.

These topics are difficult to discuss. They often sound like blaming the patient for the pain that patients have or its problematic impact that pain has on their life. Topics related to the bi-directional relationship between pain, on the one hand, and stress, mental health, coping, lifestyle or health behaviors, on the other hand, all imply that patients have some, if only modest, degree of control. That is to say, if patients are not entirely powerless and helpless to affect their pain and overall well-being, then choices, health behavior, and lifestyle have a role in the onset and maintenance of pain, disability and the use of opioid medications. 

This conversation can be had in a productive and hopeful manner — for who doesn’t want to at least potentially, if not actually, have some control over one’s health, including pain, disability and use of opioids? Such control is, after all, a good thing, given the alternative of having no ability to affect one’s health and well-being. Nonetheless, these conversations are sensitive, and can come across as blaming. For after all, if we do in fact have some degree of control over our health and well-being, including pain, disability and use of opioids, then we must be responsible, at least in part, for our health and well-being. If we find ourselves in rough shape, then, are we not, at least in part, responsible for it? Might there not always be in the background an implied criticism of ‘why haven’t you already done something about it?’ If you haven’t, the implied criticism, lurking out there, is ‘maybe, you just want to be in pain [or on disability or on opioids].’ Thus, the acknowledgement that patients may have some degree of control over their health and well-being can take a turn of perspectives in the course of a healthcare visit and come to be seen as a blaming and stigmatizing.

Given the potential for these conversations to go poorly, it is often easier to just not have them and instead focus on those aspects of pain, such as objective findings on exam, that presumably patients have no control over. The focus of office visits thus becomes, not the sedentary lifestyle, or obesity, or ineffective coping responses, but rather the osteoarthritic changes in the joint. Thus, patients leave with only part of the story. The account of the pain, impairment or need for opioid medications as solely the inevitable consequence of a physical ailment is reassuring in its incompleteness. There’s no potential for blame because there’s no capacity for patients to feel, be or do otherwise.

Shame is the underlying factor in these topics that are off limits to talk about. It’s also the driving force in providers and patients finding something else to talk about instead. Shame is the most off limits topic of all the off limits topics. 

The Institute for Chronic Pain has a long history of discussing sensitive topics in as approachable ways as we can achieve. We do so with every effort to share and explain information in thoughtful and inclusive ways. We anticipate when topics can be taken in the wrong way and are careful to explain the non-judgmental perspective from which the reader might more accurately understand. We recognize the persistent role of stigma and write about it frequently, as we also write about ways to overcome stigma. 

We do so with the intent to educate the pain community — patients, family, and providers — on topics related to pain management and pain rehabilitation. We provide scientifically accurate health information that is approachable to all. Our hope is that the information shared on this site is approachable in two ways: one, that it translates scientifically complex material into information that is readily understandable by all; two, that the information is provided in a sensitive manner, which allows us to talk openly about topics that we need to discuss as a pain community, but that we do so without judgement, criticism or stigma.

We hope that the new content piece on Shame & Pain is helpful to you.

Date of Publication: January 30, 2022

Date of Last Modification: January 30, 2022

About the author: Murray J. McAllister, PsyD, is a pain psychologist, and founder and editor of the Institute for Chronic Pain.

Every year, a “dead zone” appears in the Gulf of Mexico due to a gigantically large algae bloom. This summer, the National Oceanic and Atmospheric Administration predicted the dead zone to be the size of both Delaware and Connecticut combined.

The origins of the dead zone are traceable to over a thousand miles away from the farms of the upper Midwest, and all points further south. The origin, in other words, is farm run-off of nutrients from manure and chemical fertilizers. 

Farmers in these states have animals that produce manure. They also use fertilizers on their fields. With time and rainfall, nutrients from these sources seep into the Mississippi and any of its countless tributaries. Making their way eventually to the Gulf of Mexico, these nutrients in the manure and fertilizers combine with the heat of the Gulf to spawn catastrophically large algal blooms that kill everything in its wake.

Well-meaning farmers of the Dakotas, say, or Minnesota, or Wisconsin, may never know of the distant consequences of their actions. As such, it’s nearly impossible, and perhaps even unfair, to hold any one person responsible. How would you ever know, for instance, that this farmer’s fertilizer applications, as opposed to that farmer’s application, led in part to the dead zone that occurs so far downstream in space and time? In general, we can rightly say that farm manure and the application of chemical fertilizer and its subsequent nutrient-rich run-off cause of the dead zone in the Gulf, but for any one particular farmer it is much harder to make a causal attribution. 

The Gulf of Mexico dead zone, along with its distant causes, is a perfect analogy to the use of prescription opioids and the resultant opioid epidemic of addiction and overdose. 

It is often helpful to use analogies and metaphors when explaining complex health topics to patients and their families. This statement is no less true when explaining the complexities of successful pain management. There are many helpful metaphors and analogies, and we have discussed a number of them previously in this blog, such as in the different ways to relate to pain or even experience pain. Another helpful analogy to explain the nature and goals of successful pain management is with the analogy to successful weight management.

It is helpful to liken pain management to weight management because weight management is often better understood by patients and their families. So, let’s review and learn about what it takes to successfully self-manage pain by looking at how it’s similar to successful weight management.

Often in discussions of chronic pain and its treatments, self-management gets neglected as a viable option. It gets forgotten about. Or perhaps it just never comes to mind when patients or providers talk about the ways to successfully manage pain. Instead, stakeholders in the field tend to focus on the use of medications or interventional procedures or surgeries.

“Why do you guys always want to know how much stress I have?” While the patient who asked this question the other day had fibromyalgia, she could have had chronic low back or neck pain, chronic daily headaches, complex regional pain syndrome, or any other chronic pain condition. She was expressing a sentiment that I often hear in one form or another.

One of the more common sentiments that chronic pain patients express is that that the profit-motive seems to have had too much of an influence on the recommendations that their healthcare providers have made over the years. After reflecting on all the years of chronic pain and all the years of failed treatments, many of which were tried again and again despite having failed to reduce pain at previous clinics, they conclude that the business side of healthcare has played too much of a role in their own care. They are now disappointed, angry, and distrustful of chronic pain management providers.

Pain management is a catchall phrase used to describe multiple types of healthcare services for pain. Pain management can include the following types of services: