Treating Ghosts

The Spookiest of Pain Posts!!!

A common argument that I hear is, “Since pain is a subjective interpretation, who cares how it improves?” The reasoning goes that the pain is real to the patient, so if a treatment makes improvement to the patient’s interpretation of their pain, then the treatment is successful. That is regardless as to whether or not the treatment effects are “real”. Before we go any further, let’s defend this argument as best as we can.

This is based in the reality that pain, as a thing, is nothing more than an interpretation by a complete organism of a collection of sensory signals. In other words, the organism (human in this case) takes in information from its environment and processes it into an output, or perception, of “pain”. This means that this resultant pain is real to the patient, whether it is coming from an acute fracture of a bone or the phantom limb pain of an amputee.

Now pain equating to tissue damage is often an accurate interpretation as in the case of a fractured limb, but in some cases, it may be a misinterpretation. In these cases, such as with persistent pain, there is no empirical evidence of damaged tissue yet pain persists. Lots of things can happen here, but I am going to make an attempt to simplify the situation:

  • A sensory input occurs
  • There is a contextual history to which this information is held for analysis by the organism
  • There is a resultant play on primal fear
  • An alarm state of agency occurs

In English: The sensory input, acute or recurring, can be almost anything. The human nervous system is bombarded with information every second. The organism must decide whether or not to “listen” to that information and how to interpret it. The contextual history is complex and unique to the organism. It can be the current environment, personal history of injury, a friend with a history of an injury/persistent pain, something they saw on TV or the internet, something they were told by a medical provider, etc.

It plays on the primal fear of danger to the organism – I AM AT RISK!!! Finally, agency is established. Sometimes that collection of sensory input actually DOES mean that you are at risk (fracture for example). “What I am interpreting could be ‘real’ and caused by a dangerous agent,” in this case tissue damage. Since the possible outcome of ignoring the perceived threat could be serious (even mortal for all you know), it would be risky NOT to interpret this way. Classic Type I error.

Now, since the patient has walked into your clinic with their chief complaint of “pain”, if your treatment results in them walking out of your door with less of a perception of pain, you have succeeded right? The pain was real to the patient, therefore the treatment that reduced their pain was also real to the patient whether or not there was a specific physiological effect to their anatomy or anything else. Chief complaint was affected therefore the treatment helped. What’s wrong with that?

I will say that I understand this argument, but is it a good argument? Keep in mind, I’m asking whether or not this is a good argument, not any sort of moral question of “right” and “wrong”. Remember that an argument, or razor, can be judged by how it applies in similar situations, so let’s talk about a misinterpretation of sensory input other than pain.

Do you believe in ghosts?

I am going to take a little bit of a leap and assume that you don’t believe that ghosts are real. But are they real? What does that mean, “real”? What a funny little question. Let’s explore!

What are ghosts exactly? Some would say that ghosts are the souls of the dead still walking the earth. Well, there is no empirical evidence of that so that’s not a very well reasoned definition. A ghost is nothing more than an interpretation by a complete organism of a collection of sensory signals. This means that the organism (human in this case) takes in information from its environment and processes it into an output, or perception, of “ghost”. This means that this ghost is real to the subject. On an unrelated note, I really love the cut and paste function on my word processor…

  • A sensory input occurs
  • There is a contextual history to which this information is held for analysis by the organism
  • There is a resultant play on primal fear
  • An alarm state of agency occurs

Again, in English: The sensory input could be a noise like a creak or a “whisper”. It could be a sensation of a cold spot in the room or something brushing past you. It could even be visual like a moving shadow or what appears to be a person standing at the end of a long hallway. The contextual history as before is complex and unique to the organism. It can be the current environment like a dark and stormy night. Maybe your dog has started freaking out like he did when he saw that guy walking through your yard last year. Having emotional “unfinished business” with a loved one who has recently died. Simply having a willingness to believe in ghosts. Etc, etc, etc.

It plays on the primal fear of danger to the organism – I AM AT RISK!!! Finally, agency is established. Sometimes this collection of sensory input actually DOES mean that you are at risk (burglar for example). “What I am interpreting could be ‘real’ and caused by a dangerous agent,” in this case a malicious and unexplained entity that could be a threat (ghost). It could be tracking or even hunting you! Since the possible outcome of ignoring the perceived threat could be serious (even mortal for all you know), it would be risky NOT to interpret this way. Classic Type I error.

Treating ghosts

So how would we “treat” someone’s perception of a ghost? Actually, there are two major strategies:

  • Agree that what they perceive (ghost) IS an accurate perception but convince them that you can make it go away for them
  • Show them through reasoned education that what they are perceiving (ghost) is just an inaccurate perception and give them coping strategies for assessment and correction in the future

Strategy 1 for ghosts

The first strategy above would be what we would expect out of a psychic. “Yes! You did see a ghost but this vial of magic horseshit, when placed under your bed, will protect you from them. If you feel like they are getting worse again, come back for some more horseshit.”

Good work! You “helped” them by making them feel better when they walked out your door. The more you add context to your intervention, the greater the perceived effect. Remember, no matter how complex, smart sounding, and sense-making your explanations, the claims of how the horseshit works are still not real. Of course if they are seeing an actual burglar it may not work so well…

Strategy 2 for ghosts

The second strategy above would be considered more ethical and, in reality, more effective. “There are real threats (burglars) so let’s take a strategy to confirm that those aren’t really happening to you. I’ll make sure you have good security in your home with quality door locks that you can check before bed. I’ll help you develop coping strategies for your fear that start with reason. Is it likely that a burglar would be operating in this kind of weather? Did you hear something obviously threatening like glass breaking? I’m going to help you find relaxation strategies to address the fear issue and lower your state of arousal. Most of what I will do is related to graded exposure to make you more resilient and less fearful. Ultimately you may need a medication like an anti-anxiety drug that you can take in extreme situations.”

You will notice that the first strategy was definitely simpler. In reality, it may have a much bigger immediate effect that may even last a good long time. But, unless you actually believe in their perceived agency (ghost), you haven’t really “fixed” anything. As a matter of fact, you may have reinforced their fear and made them dependent on you for continued management of their situation.

We just sent these ghosts packing!

We just sent these ghosts packing!

You know what comes next

The patient with persistent pain. You have two major strategies in which to choose from for treatment:

  • Agree that what they perceive (injury) IS an accurate perception but convince them that you can make it go away for them
  • Show them through reasoned education that what they are perceiving (injury) is just an inaccurate perception and give them coping strategies for assessment and correction in the future

Strategy 1 for pain

Let’s look at strategy one. Cut and paste time!!! “Yes! You are getting injured but this treatment of magic horseshit, when applied by me, will stop the injury thereby making your pain better. If you feel like it is getting worse again, come back for some more horseshit.” Apply magic!!! While you’re at it, you might as well feed them some horseshit about “motor control” or whatever – Really the sky’s the limit!

Good work! You “helped” them by making them feel better when they walked out of your door. The more you add context to your intervention, the greater the perceived effect. Remember, no matter how complex, smart sounding, and sense-making your explanations, the claims of how the horseshit works are still not real. Of course if they are actually dealing with something “real” like a fracture it may not work so well…

Strategy 2 for pain

Now to strategy two. More cut and paste! “There are real threats (injuries) so let’s take a strategy to confirm that those aren’t really happening to you. I’ll perform a proper screen for known pathologies involving serious tissue damage that would be of ‘real’ concern – the reason you are actually here. I’ll help you develop coping strategies for your fear that start with reason. ‘Do I have a known incident of trauma?’ ‘Did I hear something ‘snap’ and see obvious deformity?’ I’m going to help you find relaxation strategies to address the fear issue and lower your state of arousal. Most of what I will do is related to graded exposure to make you more resilient and less fearful. Ultimately you may need a medication like an anti-anxiety drug that you can take in extreme situations.”

Again, more cut and paste. You will notice that the first strategy was definitely simpler. In reality, it may have a much bigger immediate effect that may even last a good long time. But, unless you actually believe in their perceived agency (tissue damage), you haven’t really “fixed” anything. As a matter of fact, you may have reinforced their fear and made them dependent on you for continued management of their situation.

The only thing we have to fear…

You will notice that in both situations there is an element of fear. Fear can be terribly debilitating and is often the main limitation in many patients. Sometimes I think it would be good to have that old FDR quote on the wall of the clinic:

“The only thing we have to fear is…fear itself.”
– Franklin D Roosevelt

That is the key difference between strategy one and strategy two in the above situations. Management of fear. One reinforces the fear by validating their perceived agency, the other addresses it directly through education.

Keep in mind, you should always validate their concern, “I understand why this presentation would be concerning to you.” THAT concern is real to your patient no matter what, and establishing that validation helps with therapeutic alliance. (Also do it because you are a caring human being and not a human pile of garbage.) THAT is being patient centered. But you should validate their initial perception ONLY if it is accurate. Otherwise it is dishonest and patronizing.

Now you may still be thinking, “So what if that person wants to sleep with a trinket under the bed? Like a security blanket it just makes them feel better.” I totally agree! And I’m glad that they can go and buy a trinket somewhere if they want (Yay capitalism!).

But is that who YOU are? Are you the retailer selling them a trinket or are you the professional addressing their true underlying problem?

Oh and there is one other difference: One is selling horseshit. So there’s that, too.

In summary…

  • Human beings interpret sensory inputs in many different ways in many different situations
  • Fear is scary
  • Are you reinforcing the fear by validating their perceived agency, or addressing it directly through education?
  • Are you a retailer selling a trinket or are you a professional addressing the true underlying problem?
  • The copy and paste function makes writing pieces like this much easier

The featured image on this post is “white ghosts” by Paola via Flickr.

The “…sent these ghosts packing” image on this post is “Magic Kingdom – Hitchhiking Ghosts” by Jeff Krause via Flickr.

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