Not too long ago I broke my ankle – badly. In the emergency room, after a healthy dose of painkillers, a nurse came by and asked how my pain was doing. Apparently, I had tears rolling down my face that were attributed to pain, which perhaps they were. She asked me if I wanted another dose of painkiller and what my pain level was. I honestly didn’t think my pain was that bad…… it was “manageable”. I told her I was fine. She gave me a stern look and asked if I had been in the military. I responded I had, and she silently gave me a knowing, exasperated look and simply pushed another dose into my IV. Apparently, the hospitals in San Antonio are too used to military folks downplaying their pain.
It's a military thing. “Suck it up and drive on” is a sort of motto. Deal with the pain – there is a mission to complete and if your issue can wait, then don’t complain. After all, there may be colleagues who are hurt worse than you. The cultural group mindset means you’re worried more about others’ injuries, as well as the impact your injuries have on the group, than your own pain. While a necessary mindset in a combat or critical mission setting, this can be a real problem in a broader scope. Active duty service members and veterans sometimes won’t complain about pain until things are really bad and their functioning has tanked. Do we see this in behavioral health? Definitely! The “suck it up and drive on” mentality very much extends to internal well-being.
I’ve seen this manifest in the client telling me what is going on with them, then hastily adding that they shouldn’t complain because they know others are worse off. Or, they have bad symptoms but are clearly downplaying them, at which point I mention that many think they shouldn’t complain because they know others have problems that are bad as well, just to see by their response if this is what is going on. This usually happens during intake or within the first couple of sessions. If this is an issue with the veteran, they may even continue to bring it up as a thought throughout treatment.
How do we deal with this? The first thing that must be recognized by providers is that this reaction is rooted within the military culture. Consider a group-based culture and their tendency to place the needs of the group first. You don’t want to be dismissive of this, insisting that the veteran should focus on their own needs above all. Instead, like with any other cultural variable, you want to work with the belief. Of course, everyone acculturates to the military culture at different levels, so how much you need to adapt your approach will depend on how strongly attached your client is to this belief. Not all military clients will even express this. So, the first step is to recognize that downplaying personal pain may be present, watching for it, and being ready to address it if it shows up.
Following are a few tips I’ve personally used and heard used by colleagues on ways to handle a client downplaying their pain. Which approach I take will depend on how the client is presenting overall.
Tip #1 – Acknowledge they are right.
Yes, there are others who experienced worse things than the client in front of you. Others definitely may be having worse problems than them. But does that mean that your client’s situation isn’t bad? I will then use a medical example, something that our larger society seems to understand better. What the whole initial statement may sound like is: “Yes, you are absolutely right. There are others who may be experiencing worse problems. But does that mean you aren’t? If someone, for example, has an amputated leg, does that mean your broken femur isn’t a problem and doesn’t need treatment?” I’ve always seen my clients quietly nod after something like this. I think that most clients are so used to others challenging them by flatly disagreeing with this statement that taking the opposite approach gives them pause and takes the wind out of their habitual argument against finding help for themselves. By acknowledging that there are people worse off, I have given a nod to their cultural belief. I have not challenged it. And, let’s face it, there are people worse off than your client. They probably even have some of these individuals within their circle of acquaintance.
Tip # 2 – Simply question if their pain is not deserving to be addressed.
This is very similar, if not almost the same, as tip #1. But it is a gentler approach that may work better with some clients. I omit the initial “Yes, there are others worse off” directness and instead more gently question if their pain and symptoms aren’t to the point that they need to be addressed as well. “Does that (others’ pain) mean that your pain isn’t bad/causing you problems/causing problems in your life?” I may spend a little time then having the client consider their pain and the ways it is impacting them and their loved ones, having them notice ways that things are not going well and could improve. I tend to use this gentler approach when my client is demonstrating more quiet, yet deep emotion, such as saying they shouldn’t complain quietly instead of making a more bold statement of fact. But which approach, #1 or #2, really depends on the overall client presentation and which I believe will be best heard and internalized.
Tip #3 – Use their “others” focus as a primary reason for treatment.
I tend to use this approach for individuals demonstrating stronger, and possibly more immovable, beliefs that they should not be complaining or “taking the treatment spot of someone else who needs it more”. (Yes, I’ve literally heard that quote more than once.) I will commend them for thinking of others, but then question if they are best able help those around them with their current symptoms. I focus on their symptoms instead of their internal pain because I find this type of query gets through to their more concrete, factual stance better. Given their symptoms, do they think they can best assist those others who may need help to the best of their ability? Or, will they be at their best to assist the group if they engage in treatment and their own symptoms improve? We then explore this a bit, entering a discussion about their specific symptoms and the impact these have on those around them. I will acknowledge their concern for friends and colleagues, but then have them focus on a smaller, more immediate group, such as their family. It is interesting how frequently the client is talking about other military members instead of more immediate loved ones when downplaying their pain. Bringing it back into their immediate sphere tends to be an eye-opening experience for them. I often include this discussion of impact on family and if they are in the best condition to be there for their family in the first two tips as well.
Regardless of how you approach this initial “suck it up and drive on” stance, it needs to be addressed right away. If it isn’t, the client is likely to either drop out after a few sessions or engage in sabotaging behaviors and thoughts that leads to less-than-optimal treatment engagement. As I mentioned already, it is pretty common for the belief to pop up every so often even after it has been addressed – old habits are hard to break, after all. But if you have already discussed it, clients will often quickly correct themselves.
Approaching this belief, that others are worse off and therefore I (the client) shouldn’t complain, is important. But how you approach it is even more so. Remember to consider the military culture, its impact on the client in front of you, and how to best work with the cultural belief instead of against it. You will find that showing respect for their concern for others will take you much farther than trying to only refocus them on their own experience.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Debra Nofziger, Psy.D., is a Military Behavioral Health Psychologist and certified Cognitive Processing Therapy Trainer with the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. Located in San Antonio, TX, she develops, maintains, and conducts virtual and in-person training related to military deployments, culture, posttraumatic stress, and other psychological and medical conditions Service members and veterans experience.