Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Pain Talk


Chronic pain is sometimes a challenging topic to discuss with patients. I’ve learned that the most important thing is to validate my patients’ experience of suffering. 

“So you’re telling me my daughter’s pain is all in her head!” Rachel’s mother yelled across the room. It had been a long two-hour chronic pain assessment for her 15-year-old daughter. A girl who was previously a straight-A student, involved in dance 26 hours a week, bubbly and always on the go, but currently presented as a timid shell of herself, barely functional due to her pain. Her mother was now at odds with her clinician. 


If you’ve explained how mental health impacts chronic pain you may be able to feel the emotion between the family and the doctor. A calm conversation sometimes quickly transitions to a room full of frustrated people, arguing rather than collaborating. During this delicate conversation, patients often hear phrases such as, “Your anxiety causes your pain,” or, “You need to fix your mental health to get better.” While both statements may hold some truth, neither account for the complexity of the biopsychosocial factors that impact chronic pain or the complex process of pain perception within the brain’s limbic system.  



Tips for having this potentially challenging discussion:  

1. Validate the patient’s experience. 

Pain is a subjective experience that only the person with pain understands. Uncertainty about their pain’s etiology or treatment can be stressful and cause anxiety; therefore, having anxiety is normal in chronic pain. The amygdala processes both pain and emotion, making emotion always part of how we perceive pain, regardless if it’s chronic pain, a broken bone, or a paper cut.  


2. If you make a mistake or mis-step, apologize.  

Well-meaning physicians make mistakes. Apologize and ask for clarification to understand what the patient heard you say, and use this information to acknowledge their concerns. 



In conclusion, in the opening scenario, I could have said, “There are many factors contributing to your daughter’s pain. While her anxiety didn’t cause her pain, it can trigger, maintain, and increase her pain. We know that for many people, having chronic pain can be stressful. So, it’s helpful for us to address anxiety as part of her treatment.”  








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.