Pain - the way forward

Until his death in August 2001 Professor Patrick D. Wall's pioneering research transformed our understanding of pain. Here he argues that our liberation from pain is a social as well as a scientific challenge

There is a common problem which affects everyone who is in pain for long periods. This problem concerns the meaning of the word "acceptance". It is one thing to accept that no one has a complete solution to a particular pain condition. It is quite another to accept that nothing can be done. To demand that the patient should accept the uselessness of all help is to condemn him to a feeling of betrayal, alienation, and depression. The result is a downward spiral, which becomes increasingly difficult to interrupt. The hospice movement teaches us a splendid example by asserting and proving that comfort and dignity can be achieved even for those whose life is ending.

The Chinese have a doctrine of recruiting the patient as a member of his own treatment team, so that patients and therapists become comrades in the best sense of the word, with its connotations of shared respect and responsibility. In Western hospitals, dominated by accountants' demands for cost-effectiveness and efficiency, a patient is lucky to be given a bed the night before an operation; he is more likely to be ordered to present himself, breakfastless, on the morning of the crucial day. The reassuring old concept of the bedside manner has disappeared, since the patient is aware of no one near the bed but a swirl of anonymous, often masked figures. Patients say, indeed, that they have had fuller and more helpful conversations with the ambulance crew or the ward cleaner than with doctors and nurses. Contemporary pressures have distanced the patient from the therapist and produced an exaggerated belief in instant solutions. Perhaps we need to train our professionals in the speciality of cooperation with the patient.

What is needed, in particular, is the creation of a therapeutic community centred on the individual patient. People who are not officially classified as highly trained are certainly capable of assuming more responsibility than they are now given. Nurses, district nurses and health visitors, physiotherapists and occupational therapists and ancillaries of various kinds have too often been arbitrarily restricted and denied the chance to use their full potential. Patient groups, formed to complain of medical neglect, have developed as mutual self-help teams. The complexities of sophisticated medicine mean that, even in the most affluent of societies, we cannot leave it to the specialist to do all that is needful. We must take on do-it-yourself responsibilities, which require education, acceptance, and encouragement.

To issue a command "to pull yourself together" to a deeply depressed, inactive patient is an obscenity. The condition of such patients is predictable and preventable, since they were plunged into it by a sequence of dismissal and neglect. They can be rescued only by great imaginative effort as well as professional help.

The experiences of a person in pain will depend significantly on his beliefs about it. Some common beliefs are unconstructive and harmful - that pain inevitably grows worse; that it is a mystery beyond comprehension; that no one, including the sufferer, can do anything about it; or that it is his own fault. These beliefs are not only false; they constitute self-fulfilling prophecies and contribute to a bad outlook. They must be challenged and indeed attacked. Obviously it is best when people question their own beliefs, but sometimes they need encouragement.

Only when victims of pain work themselves free from these beliefs - above all, the belief that nothing can be done - can they take steps toward liberation from pain. The first step is regaining the possibility of physical activity. It may well be, literally, the first step: that is, getting out of bed and putting a foot on the floor. Against all expectation, movement itself reduces pain. It reverses the physiological decline that results from inactivity. It generates a sense of well-being. It is a distraction from passive concentration on pain.

The next goal is to reawaken a sense of expectation - an orientation towards the future. Expectation may take the shape of fantasy and fancy, of dreams that cannot yet be realised, but this is all to the good. Children build happiness from their fantasies of invisible friends, talking animals, and frogs that turn into princes. We adults are much too adult; we need to relearn how to daydream, how to surrender ourselves to thoughts and feelings that do not derive from cautious calculation. When the mind is riveted to pain, this can be hard work. But it opens the door to placebo responses - in other words, to responding with hope and confidence to every kind of assistance.

The third goal is exploration. It is difficult to pursue because it is the opposite of the inactivity inherent in depression. Among other effects, depression influences the attitude to medicines. Failure to take medicines as prescribed, and failure to do the exercises prescribed by the physiotherapist, are very common among people in pain. The lack of compliance may be caused by a rejection of authority, but in most cases it is derived from a conviction that nothing will do any good. When the person who has achieved a positive attitude toward exploration takes medicine (or exercise, or food), he does so not to obey orders, but because he is actively exploring their possibilities.

Expectation, exploration, and the discarding of hampering beliefs are all feasible, but are much more likely to be attained when the patient has some support. Isolation is the worst of handicaps; a therapeutic community is a reality even when it is a community of two. But the process is reciprocal, for a positive outlook on the part of the patient invites and encourages support.

What matters, above all, is that we should look to the future. We shall never abolish pain; the human body is so constructed that a sprained ankle or blow on the head is bound to hurt. What we can overcome is a hopeless, helpless imprisonment within immutable pain. Today we know that we have a much greater power to do this than at any earlier time in history. We must resolve, year by year and incessantly, to advance humanity's power over pain.