Truth-telling can be dangerous: “How about volunteering for a trial of kneecapping, and then let’s see what you can teach people about enduring non-cancer chronic pain long-term without benefit of analgesics…” Ouch! Woah!!! Really? Is that the actual hope of “Deboruth,” the individual commenting on this perspective piece , published in the Washington Post? The article was written by Dr. James Hudson, Medical Director of the Mary Freebed Pain Rehabilitation Program in Grand Rapids, Michigan.

If kneecapping is, in fact, a true desire of the heart from this reader, I must admit, I am quite concerned, not only for the well-being of good Dr. Hudson, but also for the wellbeing of “Deboruth” and the handful of folks who cheered on his or her hobbling sentiment!

Other comments on Dr. Hudson’s “Our Dangerous Fear of Pain” post have me squirming too:

• What a complete tool. He seems to somehow be blaming the opiate crisis on people in severe pain.
• To the author …… HOGWASH. You arrogant twit.
• This man is clearly insane.
• A jack wagon like this ignorant author would have complete control over your care.
• The Post and this quack should be ashamed.

Maybe it’s the peacemaker, conflict-avoider, thin-skinned empath in me that is left reeling after scanning through the comment section of this particular article in the Post. But after reading the majority of the responses, I feel my own familiar aches and pains stirring to life! The comments ooze with anger, contempt, and malice. They make me want to rush to the defense of the author, whose article I not only agree with, but whose content I often echo at courses, with patients, and with my family and friends. In fact, when I first read these comments, the reaction that bubbled up in me was shock, indignation, then anger, culminating in judgment and blame: “How horribly unfair! Dr. Hudson is speaking the truth and these anonymous commenters are attacking him with such perverse cruelty! No wonder they hurt. They are angry, mean people, completely snowed by faulty belief systems set into motion by big pharma!”

If a perpetual fight-or-flight state can cause a nervous system to remain sensitive via alterations in cortisol and adrenaline, then, I reasoned, these folks may NEVER get better. Recalling the words of Chapman, et al.,

“A severe stressor, a cascade of stressors, or continued self-generated stress-inducing thoughts can impose a heavy allostatic load that eventually causes dysregulation in one or another subsystem.”

Just as a metal link chain subjected to tension will break at the weakest link, a person with high, increasing allostatic load will experience dysregulation in the most vulnerable organ system.” From my perspective, individuals posting such bold and cold comments seem to be in perpetual FIGHT, causing their protect-by-pain-super-system to remain on full throttle…And it’s their own dang fault because they are angry and mean (yes, I am susceptible to assigning accusations and blame…possibly like some of you reading this as well…? We are, for better or for worse, human).

But after the defensiveness and over-identification-with-a-well-intended-health-care-provider-waving-the-anti-pain-hysteria-flag subsided, I gave this scenario a bit more thought. Were the writers of these comments suffering in pain because they are angry, mean people, or are they simply behaving poorly, writing angry comments because they hurt so stinking much? Are they angry because they’ve been fed a lie, ignored, judged, disappointed, and/or flat-out robbed? Did the doctor do anything wrong by posting an article like this? What is the story behind the rage?

We have long heard the phrase, “hurting people hurt people,” and many of us have comforted ourselves and loved ones with this sentiment.”

This is important wisdom to remember, especially for clinicians seeing a high volume of folks struggling with significant pain experiences. Such clinicians run the risk of being on the receiving end of anger, skepticism, frustration, despair, and even patient-perpetuated violence, simply because we are often “just the next provider” in a long list of futile attempts at relief. Remembering that hurting people hurt people may indeed provide us with a bit of armor, resilience, and vigilance as we face the very real threat of burnout and compassion fatigue.

Research suggests that there are many meaningful correlations between anger and chronic pain. Here is one concise yet comprehensive article exploring the topic. It follows, then, that to best walk alongside people in pain, understanding anger might be of some value. The visual aid of the Anger Iceberg, from the Gottman Institute, described here, is useful.

From the iceberg, we learn that anger is often a secondary emotion, more easily expressed and more socially acceptable than fear or loneliness, guilt or grief. Like pain, anger can function as a protector. The image of the anger iceberg is particularly helpful for me when contemplating why an individual (like “Deboruth”) and even a group (pro-kneecappers and other nay-sayers) may express words I find disconcerting in forums like the Washington Post’s comments section.

Given the bottom of the anger iceberg, why are so many people frustrated, disappointed and afraid? We needn’t look much further than the health-care-industry-induced yellow flags we encounter on a routine basis to find the answer: multiple providers; conflicting diagnoses; labels of “drug seeking;” excessive use of diagnostic tests revealing scary-sounding-labels for normal, age-related changes; marginalization of trusted “alternative medicine” providers; polypharmacy; a push to taper off opioids with no replacement treatments for pain; poor or no inter-disciplinary communication; failed treatments…you see where I’m going here.

Even if we weren’t the individuals to mis-diagnose, over-treat, instill fear, or push a taper before the patient is ready, we are part of a system that has repeatedly committed these offenses at the expense of institutional trust. And patients are mad. Justifiably so. They’ve been through the ringer, and many are simply at their wits end.

Which brings me back to my key question. Did Dr. Hudson do anything wrong by writing this article that captured the attention of so many so profoundly? Did he have some of this backlash coming to him?

Personally, I applaud Dr. Hudson for his courage in writing this article, and I have a suspicion he may have been well-prepared for the fall out. Having worked in this field for a long time, he likely knew he was sticking his neck out there, and I’m hoping he has thick enough skin to realize that while the comments seemed quite personal and directed at him, that he, in fact, did a good thing in bringing this topic to light. We need to start having conversations, preferably civilized ones, about pain. These conversations need to make their way to public forums, where knowledgeable clinicians and patients can have a healthy dialogue. What is pain, really? Is it inherently bad? Should it be avoided, reduced, or flat-out killed? What should we do about the pain epidemic? How can we bring hope and relief to those struggling with longstanding, complex and debilitating pain without endangering their lives with medications known to kill? When might the judicious use of medications over the long haul actually be a reasonable plan of care? These are essential conversations that need to happen if we are to move the needle forward and bring humanity and compassion into the mix.

The unavoidable consequence of sharing a public piece like “Our Dangerous Fear of Pain” is that it will stir the pots of those who are stung by words not meant to sting. There is no way a generic piece can begin to capture the nuance of everyone’s unique struggle and story, which is why mass education to those in pain is likely to be less effective than individualized education and care. People who have endured significant pain experiences need to be able to be heard, and in the end, I believe that’s what the comments really reflect: the desire to be heard, validated, and walked alongside, vs. labeled or grouped together with others.

Fortunately for us, we DO have a luxury that Dr. Hudson did not have when it came to writing his article. We have the opportunity to LISTEN to the story, the WHOLE story, of each and every person who gives us the privilege of treating them. If we want to diffuse that anger and see people get beyond it to a place of healing and restored function, that is our mandate: listen, validate, listen, collaborate, listen, motivate, listen, celebrate.

A few tips and strategies come to mind as I ponder diffusing anger when we encounter it in the clinic. Obviously, every situation is different, but consider the following options to implement upon hearing a patient’s pain and/or health-care-experience story that is wrought with emotion:

• Acknowledge: “You’ve been through a lot.”
• Apologize: “On behalf of the health care system, and as a member of that system, I’m sorry.”
• Ask Permission: “In order to move forward from here, can we work together to find a better path?”
• Ask Specific Permission: “Can I share some information with you about how pain works?”

When you can see the walls of anger going up around your patient, consider the following options:

• Ask: “Is there something I’ve said that is not sitting well with you? Can we talk about it?”
• Normalize: “It makes sense that you would feel this way. I think I would too.”
• Share resources: “I have a great little video that many folks struggling with pain identify with. Can I share it with you and then we can chat about it?”
• Show grace: Maintain a safe space for patients to be honest. Avoid the temptation to push too fast or too hard towards what you think will free the patient from their anger, be it counseling, spirituality, journaling, or forgiveness.
• Don’t take it personal…it’s not about you. It’s about the patient.
• Reach out: talk to your colleagues in behavioral health or spiritual services and consider the best way to broach referrals when the anger barrier is proving to be beyond your scope

Patient by patient, one person, one story and one encounter at a time, we can “earn the right to go there” with people in a way that no public-facing article ever will. As we peel the layers of our patients’ stories and discover what the bottoms of their individual icebergs look like, we are likely to realize quite quickly that their anger, even if directed at us from time to time, has little to do with us personally. While we are not and should not be doormats and punching bags for our patients, we can develop our grit and thicken our skin by understanding anger, becoming the best listeners and allies our patients have ever had.

Remember, hurting people hurt people, but hurt doesn’t have to mean harm. We can forge relationships amidst that hurt, have grace within reason for behaviors that rub us wrong, and ultimately, we can be part of the turning point in someone’s pain story.