____________________________________________________________ The Intersection of Pain and Culture
The concept of continuing social roles and not taking time to rest despite pain may be more common among racial and ethnic minority groups [178]. Practitioners can include educa- tion on the importance of balancing rest and self-care along with the challenges of continuing with life roles [178]. Practitioners should also consider health literacy and English proficiency when working with immigrants and racial minori- ties [141]. Reader-friendly materials in a variety of languages are needed to disseminate pain information. Finally, it is important to keep in mind that racial/ethnic minority patients often have less access to research and news regarding new therapies, medications, and treatments to pain. Therefore, it is important to provide education and information [210]. ROLE OF COUNSELING Because pain is a multifaceted phenomenon, it is important for patients to consider pursuing an integrated system of care for their pain. This involves looking into the emotional and psychologic component of pain [117]. Mental health and social service providers can assist patients in identifying and discussing the meanings of their pain experience. Many racial and ethnic minority patients do not adhere to a dichotomy between the mind and body and may be more open to talking about pain’s link to their emotions and life circumstances. A study conducted with patients at a pain center compared the attitudes of Puerto Rican patients with non-Hispanic White patients [45]. White patients disclosed feeling that their pain was being discounted or negated if their physicians asked psychosocial-related questions about the pain. In general, these patients wanted pharmacologic interventions and were upset by suggestions that their pain was potentially psychologically and/or emotionally rooted [45]. However, the Puerto Rican patients did not express any complaints when their physi- cians inquired about family, community, relationships, and other psychosocial factors that might be linked to their pain symptoms [45]. Cognitive-behavioral therapies have been widely employed for patients being treated for chronic pain. Alone, this type of therapy does not relieve pain symptoms [28]. Instead, tech- niques such as reframing, guided imagery, distraction, and identifying cognitive distortions such as catastrophizing and black-and-white thinking (i.e., all or nothing) can help patients understand how cognitions can influence pain and related behaviors [119; 209]. For patients who tend to catastrophize, practitioners can provide education on the deleterious impact negative thoughts and emotions can have on experiences of pain. Relaxation techniques can also be included in patient education [201]. The resultant improvements in coping can enhance quality of life [28]. There are five main goals when working from this paradigm [117; 209]:
• Reframing with patients that their pain is manageable (i.e., patients can be taught to have the positive attitude that they have control over their pain) • Assisting patients to monitor and track their pain symptoms and link their symptoms to external and internal psychosocial challenges • Teaching new ways for patients to think about their problems (i.e., identifying maladaptive cognitive distortions) and new ways of coping • Challenging maladaptive thoughts and teaching use of calming statements • Educating patients about different ways to use relaxation techniques as coping techniques Because religion and spirituality are central to the lives of many racial and ethnic minority patients, it is important to understand how they use religion and spirituality to under- stand and cope with their pain symptoms [120]. Practitioners may employ cognitive-behavioral techniques to help patients identify religious cognitive distortion. An example of a pain- related cognition is: “Pain is a symptom of guilt.” A religious cognition might be: “God is good and fair. My pain is a symp- tom of my guilt from sin.” This then yields a cognitive distor- tion: “My pain is a consequence of my sins, and I deserve it” [119]. Practitioners can teach patients to identify these types of cognitive distortions, challenge their validity, and identify problem-solving strategies, reframing, and positive reappraisals [119; 209]. These patients should be encouraged to employ positive religious coping strategies such as prayer, meditation, and confession. ALTERNATIVE REMEDIES Practitioners should explore both traditional biomedical pain management interventions and non-traditional alterna- tive remedies (as appropriate) when working with racial and ethnic minority patients. Complementary self-management approaches for pain can be generally classified as mind/body approaches or natural products [152]. Self-management is a common and primary method of managing pain among Asian immigrants. Use of exercise, traditional Chinese medicine, nutrition, and general physical activity are typical and per- ceived as culturally appropriate [178]. Mind/body approaches include meditation, yoga, acupunc- ture, and breathing techniques. Natural products include herbs, vitamins, and topical ointments [152]. Some patients may be more receptive to traditional healing methods (e.g., herbal remedies, traditional healers) [72]. In focus groups, Native American participants reported using a range of alternative therapies for pain, including acupuncture, massage, chiropractic treatment, and guided imagery [149].
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