By Kirsten Ballard
Denial, anger, bargaining, depression, acceptance. The five stages of grief were introduced by psychiatrist Elisabeth Kübler-Ross in 1969 to describe the grieving process when you lose someone. But what about when you lose yourself?
That is what so often happens when people with an acute injury or medical procedure experience pain that becomes chronic.
From stress, to grief, to depression
Clinical health psychologist Kimeron Hardin, PhD, ABPP, FACHP, practices in the California Bay Area and has spent his career exploring the mental health aspects of medical issues.
When a body is injured, acute pain initially causes a stress response, Hardin says.
“But after the treatment doesn’t fully get rid of the pain, and you realize the medical system has run out of options to cure it—that’s when you see the stress response morph into grief, loss, and anger,” he says.
Hardin notes that grief is a normal emotional response to loss, whether it’s the loss of someone close to you or your identity, such as that of an athlete. “There is a grieving process that people go through, trying to accept this new body they have and these new limitations,” he says. When that process takes longer than expected, the grief can morph into clinical depression.
Many factors can contribute to this shift, Hardin says. People may not have the emotional support in their life to help them process their grief effectively. There is a stigma surrounding chronic pain that makes it difficult for people to share their experiences.
“Unless you’ve lived with constant, chronic pain, people don’t understand the day-to-day wear and tear of it on your psyche,” Hardin says.
The stages of transitioning to chronic pain
Shamin Ladhani, PsyD, is a pain psychologist in Wisconsin. She has worked in a pain clinic for more than 15 years and emphasizes a multidisciplinary approach to pain management.
Ladhani integrates evidence-based psychological treatments that have demonstrated effectiveness in pain management. “We talk about working with your brain when your brain is working against you, such as in chronic pain,” she explains.
Feeling isolated is a common theme with her patients. “It’s a really difficult thing because they’ve often been invalidated not only by friends and family members but also the medical establishment itself,” Ladhani shares.
She adds, “I think we have a false sense of security in health care that we can fix everything and cure everything.” This mindset leads to a lack of understanding of the complexities of chronic pain: “It’s, ‘What do you mean, you are still in pain? You had this surgery. You went through physical therapy. Now you look OK.’ And then all this judgment starts to happen.”
Ladhani sees individuals in every stage of the grief process.
First are those experiencing denial. “These are the patients who might keep going from provider to provider, looking for an answer or a ‘fix’ to their problem, struggling to believe that their pain has become chronic.”
There are the angry patients: “They say, ‘No one’s listening to me. They don’t get it. They don’t know how to fix me.’ They feel pushed around by the system.”
The bargaining patients: “They say, ‘If I just do this, it will go away. If I pray, if I go to church, if I do all the therapy you told me to do, I’ll be fine.’”
The depressed patients: “They’re starting to realize it’s been a couple months and nothing [with the pain] has changed. Their quality of life is changing.”
And finally, those who have reached acceptance: “We don’t see that at the beginning, but they finally say, ‘OK, this is me.’ They reach a new normal.”
Gwenn Herman, LCSW, DCSW, clinical director of Pain Connection at U.S. Pain Foundation, coined a sixth stage for individuals living with chronic pain: changing/reinventing yourself. Her article, “The Chronic Pain Support Group Process,” from the book Making the Invisible Visible: Chronic Pain Manual for Health Care Providers by Herman and Mary French, RN, MSW, LCSW-C, outlines the stage:
“Once sufferers have accepted that their bodies cannot do what they used to do, they need to work with it and reassess their lifestyles. If this is not done, the sufferers remain in a state of resistance, trying to prove that they are still the same people. This adds fuel to the fire and contributes to poor self-concept, which further contributes to severe depression. … They must not live in the past, their past selves. This is a rebirth.”
Start by finding someone who can help
Hardin sees people when they’ve reached the end of what medical care can reasonably offer as far as treating their pain. “That’s a really scary place when your doctor basically says, ‘I’m washing my hands. I don’t have anything else to offer about how to have the best functional level and quality of life,’” he says.
Hardin co-founded an organization called The American Association of Pain Psychology (AAPP) that has a directory of care providers. Even if an individual is not able to access a pain psychologist, Hardin recommends they find another trained mental health professional to help them through their grief as they process the fact that their acute pain has become chronic.“Go see a mental health professional,” he says. “If you can find one with training in pain, by all means, do that. If not, [another] really good mental health professional can help you with this journey.”
Where to find help
—American Association of Pain Psychology: aapainpsychology.org
—Pain Connection support groups: painconnection.org/support-groups