October 06, 2014 — Blog Post
Health Literacy & Communicating About Pain
It’s known that literacy generally and health literacy specifically are problems in the United States. The 2003 National Assessment of Adult Literacy (NAAL) found that over 14% of Americans lacked basic literacy skills. Health literacy includes basic literacy skills but additionally know-how around medical utilization, accurate understanding of medication labels (which can involve math), and a host of other skills required for good health. Not surprisingly, health literacy rates are even lower in the US; Pfizer estimates 90 million Americans lack adequate health literacy.
Many researchers have demonstrated that people who have low health literacy levels also experience worse health outcomes across the board. One aspect of health literacy (and literacy more generally) that is less discussed is how it affects a person’s experience of chronic pain.
The language we have available to us is a critical part of how we are able to explain what our bodies feel. When a person has chronic pain, the words available to him to describe the sensation shape how he experiences the pain over time. I believe that having a wide vocabulary with which to describe pain symptoms helps equip a person to better manage pain and reduce distress. This goes beyond the utility of language to describe symptoms to a professional; the language a patient uses to describe his experience actually shapes that experience. People who struggle to find a range of words to talk about their pain lack the ability to use language for symptom relief.
There is a classic social psychology experiment by Schacter and Singer that established the two-theory factor of emotion. Participants were injected with epinephrine, which they were told was a vitamin shot. The shot made their hearts race, palms sweat, and blood pressure rise. Then, the injected participants saw people who were either visibly angry, or visibly excited. When asked to describe their own emotions, most participants chose words similar to the people they’d observed, and in many cases, joined in with similar behaviors. The resulting theory states that our emotional experience is a combination of our physical sensations, but also the explanations we find for those sensations in our environment. I’ve always felt this study is a powerful demonstration of how we can impose different sets of meanings on reality, that then become our reality.
This power has been harnessed in psychology for decades to reduce distress. We know that the mind has a powerful ability to moderate how we experience physical phenomena. The cognitive-behavioral therapy approach is rooted in this understanding, that the emotional responses we have to the world around us are largely the result of how we interpret them. Changing our interpretations to something more positive can help us reduce emotional pain.
Our experience of physical pain is similar—we respond not just to the bodily sensation, but also our verbal interpretation of what it is like. This means that someone who uses extreme and hopeless language to describe pain may feel completely consumed by it . We can help patients better manage their pain by working with them on the language they use to describe it.
One exercise we use to help people cope with pain is to have them choose a word that describes how it feels—something like “shooting,” “burning,” or “stabbing” (words to describe pain are seldom positive!). Then we coax people through an exercise using their chosen word to help transform their perception of the pain. People who describe their pain as “burning” are asked to picture a thermostat that controls their pain. They visualize slowly turning the knob on the thermostat to the left, gradually reducing the burning sensation to a more bearable warmth.
So how do we help people who lack the words to describe and manage their pain? I believe there are at least two steps we should take as health educators and providers. The first is to combat cultural norms that stop people from talking about pain at all. Stoicism not only potentially obscures dangerous signs that providers should know about, but it also denies people the opportunity to use labels as a tool to cope with pain. Ask patients about their pain, and encourage them to describe it.
Second is to help those patients who don’t have the words to describe their pain find them. We can do this with tools such as the one I discussed above, which list a comprehensive set of common “pain words” with their corresponding visualization exercises. We can use graphics and visuals to overcome written literacy issues. In conversation, we can use metaphors and stories, which have been shown to help people reduce their perception of pain (Gallagher, McAuley, & Moseley, 2013). If we can both encourage people with low health literacy to make themselves vulnerable by expressing their pain, and offer them a selection of tools to articulate it, we can make progress toward better management of chronic pain.
Gallagher, L., McAuley, J., & Moseley, G.L. (2013). A randomized-controlled trial of using a book of metaphors to reconceptualize pain and decrease catastrophizing in people with chronic pain. The Clinical Journal of Pain, 29(1), 20-25. Doi: 10.1097/AJP.0b013e3182465cf7
Schachter, S., & Singer, J. (1962). Cognitive, Social, and Physiological Determinants of Emotional State. Psychological Review, 69, pp. 379–399.