Clinician experience of metaphor in chronic pain communication

Introduction

Chronic pain, defined as pain persisting longer than 3 months, has a prevalence rate of 19–30% in the western world [1], [2], [3]. It is a common presentation at primary care clinics, with one study finding 37.5% of adult appointments in a typical week were for chronic pain [4]. For effective pain management, the clinician-patient consultation and how pain is conveyed in order to make a diagnosis and come to a treatment decision is critical. For both parties, descriptions of pain underpin much of this communication [5].

Despite its importance, difficulties in clinician-patient pain communications are well established. For example, a comprehensive review identified that for 78% of the 80 studies examined, professionals underestimated pain compared to patients, with this number increasing to 91% of high quality studies [6]. Worryingly, underestimation was seen to increase with pain severity. A study focussing on back pain found that few medical terms used by clinicians were understood and accepted by lay participants in the way that the clinicians discussed and intended them to be [7]. Misunderstandings, resulting in negative emotional responses were also common. Additionally, patients with chronic pain have described feeling disbelieved and misunderstood by primary care providers [8].

Communicating pain experience is inherently complex. Given its subjective nature, pain is difficult for patients to describe, and this may be more so for long-term pain conditions [9]. Research has found that one method of conveying pain to others consistently used by chronic pain patients is metaphor [10], [11], [12], [13], [14]. Metaphor is defined as when a word or phrase can be understood beyond its literal meaning in the context of what is being said, for example a “stabbing” pain [15]. Conceptual Metaphor Theory posits that metaphors are more than literary devices and are in fact powerful conceptual tools used to organise and shape our reality [16]. One of the first language-based instruments in pain was the McGill Pain Questionnaire (MPQ) [17]. Still in wide use, it paved the way for incorporating language into pain assessment. The MPQ includes 78 single-word pain descriptors, many of which are metaphorical in nature, for example “cutting” and “torturing”. A recent systematic review found that using metaphors can be therapeutically valuable to people in pain, although additional research is needed to see how this may best translate into practice [18]. Pain metaphors may also be of use to clinicians; that certain disease groups use demonstrably different metaphors when communicating about their pain may support diagnosis [19]. Munday et al. [19] found evidence of associations between diagnostic groups, in particular endometriosis, complex regional pain syndrome, and neuropathic pain, and the use of certain pain metaphors. For example, they found that people with complex regional pain syndrome were significantly more likely to use metaphors relating to temperature or bodily misperception than other diagnostic groups.

However, difficulties can arise when clinicians are confronted with these metaphorical descriptions of pain. Such descriptions may contravene expected biomedical descriptors of pain, potentially leading to minimisation or dismissal by the clinician [20]. There may be a mismatch in assumptions and lack of a shared understanding, leading to miscommunication in the interaction [10]. That is, there may be an incompatibility in how patients and clinicians communicate chronic pain. While research has established the frequency and potential utility of metaphor use for both patients with chronic pain and clinicians, to the best of our knowledge, none has explored the clinician experience of pain metaphors. This study thus aims to investigate the experience of clinicians regarding patient use of metaphors in chronic pain consultations.

Methods

Results

Participants were observed to speak freely and several remarked upon the interesting and thought-provoking nature of the interview topic. Four key themes with attending subthemes were identified, which are summarised in Table 2 and described in detail below.

Discussion

This study explored health professional’s experience of metaphor in chronic pain consultations. Metaphor was found to be an important component of these consultations and four key themes were identified: Metaphor as communicative tool, Metaphor as clue, Metaphor as obstacle, and Metaphor use in treatment.

Although metaphor was seen by clinicians as an important communicative tool for patients, it is notable its use was described as having both positive and negative effects. Metaphor use engendered understanding and empathy from clinicians, through giving them a sense of the lived experience of the person with chronic pain, as well as building rapport. This may reflect the process described by Semino [24] who theorised that certain metaphorical descriptions of chronic pain may provide the basis for an empathic response through an internal embodied simulation of pain experiences. Metaphor also functioned to bridge the gap between private, subjective sensations and the outer world in order to illustrate the validity and reality of pain. This need to be believed by individuals with pain is consistent with the literature, which has often found that patients feel disbelieved and dismissed [8].

On the other hand, metaphor use was occasionally perceived to be disadvantageous for patients, leading to negative reactions, reflecting a catastrophic cognitive style and hindering treatment progress. Although not a commonly reported experience, a minority of the clinician sample spoke of irritation, frustration or general feelings of negativity towards patients using them (although this was accompanied by recognition that this was unempathetic). This negative evaluation of the person in pain may arise due to them being perceived as deceptive or unfairly trying to gain an advantage (e.g. care or financial compensation) [25]. As one participant put it “… you have the same ones that keep ringing up and saying it is the worst ever, I feel like cutting my hand off … but it is always the same ones who use these sort of metaphors. So, I think it is a bit like, you know, crying wolf sometimes, but not always … ” (R16). Most participants however viewed even potentially frustrating patient metaphors as useful data, which may have mitigated negative reactions. This result may be because our sample were individuals who had chosen to work in the chronic pain field, often for a long time – clinicians outside of this field (such as primary care providers) may have different reactions when interpreting a metaphor. In fact, one participant reported that “I think a lot of medical professionals would tend to ignore the metaphor” (R14). Worryingly, several participants spoke of patients who had been given an unhelpful metaphor by a previous clinician, for example being told they had a “crumbling spine,” a powerful image they had held onto and which then negatively influenced their beliefs and behaviour. Just as Sontag [26] criticised the militarisation of metaphors regarding illness, individual metaphors supplied by clinicians can also be harmful to patients with chronic pain. Unhelpful metaphors, particularly those framed through viewing the body as machine, can lend themselves to misinterpretation and fail those with chronic pain, who may continue to search for a fix for something ‘broken’ [27, 28]. Fixation on these unhelpful metaphors may also contribute to catastrophising and stall treatment progress.

Patient-clinician communication is vital, as it has been found that patient history reports lead to diagnosis 79% of the time, compared to physical examination (8%) and investigations (13%) [29]. In a similar way, this study found that participants utilised the rich information contained in metaphors to inform their judgments on pain type, psychopathology and the patients’ understanding of pain. The fact that pain metaphors may reflect diagnostic group has been demonstrated previously, although metaphor type was not found to reflect mood [19]. Munday et al. [19] found evidence of specific metaphorical markers for chronic pain conditions such as endometriosis, complex regional pain syndrome (CRPS), and neuropathic pain. For example, they found that participants with neuropathic pain were more likely to use metaphors relating to temperature, ‘physical damage via sharp object’, or ‘physical attack via embodied other.’ This was reflected in the current study data, with many participants speaking of metaphorical descriptions similar to those found in the Leeds Assessment of Neuropathic Symptoms and Signs; LANSS [30]. Participants appeared to clearly view metaphorical descriptions of burning, electricity, and pins and needles as indicative of neuropathic pain. Conditions such as CRPS were also described as having distinctive metaphorical descriptors, in line with previous research [19, 31]. Further, participants reported that patient metaphors gave them insights into how that person was coping with pain, in terms of distress, anxiety, or depression levels.

Due to its individuality and personal nature, participants did not view metaphor as a useful gauge of pain intensity. This view is echoed in previous research on pain descriptors, which found large amounts of variation in how people ranked them for intensity, as well as research which found no significant associations between pain metaphors and pain intensity [19, 32]. In the study of pain descriptors, 248 participants assigned a pain intensity value to 26 pain intensity descriptors using a 0–100 mm visual analogue scale. The descriptor “distressing,” for example, had a mean of 55.3 mm, but a standard deviation of 24 mm, indicating large between-person variability [32]. This variation may also apply to longer, metaphorical pain descriptions, meaning similar pain metaphors are likely to represent different pain intensity levels to each person. Although metaphor could not reliably inform pain intensity, it could be used as a personal outcome scale to assess treatment progress, often in quite personally relevant and creative ways. It could also be used to gauge a patient’s understanding of their pain and thus tailor pain education to address incorrect or unhelpful pain beliefs. For example, clinicians often used their own metaphors to explain pain concepts, with one clinician describing a metaphor of the “nervous system being like an amplifier and how again the volume’s turned up … ” (R18). However, few participants went further in terms of treating the metaphor itself as a target of intervention. If, as Lakoff and Johnson [16] assert, metaphors are powerful conceptual tools capable of shaping reality, it follows that targeting and changing maladaptive pain metaphors themselves may be of use. Indeed, participants spoke of metaphors reflecting and underpinning patient’s erroneous beliefs about pain, undermining their confidence to move and progress, and possessing significant power. The potential underutilisation of metaphor in the treatment, rather than assessment phase, may highlight a lack of knowledge, or as one participant remarked “… I don’t know how much in, across all the health professionals that we are, medicine, nursing, allied health – how much education we get in harnessing the use of metaphor to better understand, but also I think more importantly, how we can use those as tools” (R6).

Conclusions

The results of this study demonstrate that clinicians both expect patients to utilise metaphor and are able to use them to provide insight into pain type, psychopathology, and pain understanding. They also use metaphor themselves to assess progress in treatment and tailor pain education. These results suggest that clinicians should routinely encourage patients to utilise metaphor in describing their pain experience, through questions such as “Describe to me what your pain feels like.” This can not only yield useful clinical information, but may also function to address the invalidation and feelings of disbelief many patients with chronic pain report [8, 19]. Additionally, clinicians should avoid using potentially harmful or misleading metaphors when speaking with patients, as this may contribute to catastrophising and unhelpful beliefs about pain. The role of metaphor in treatment may also be underutilised, with clinicians unsure of how best to translate metaphor into clinical utility.