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Pain Management: Cognitive Therapy for Chronic Pain and Fibromyalgia
Pain Management: Cognitive Therapy for Pain and Fibromyalgia

Section 20
Psychological Management of Pain Part II

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Types of pain seen from the depth psychological point of view and their treatment
Within the group of chronic pains for which psychosocial factors play an important role, several types can be distinguished. For these patients, pain has different functions and it is important for the diagnosis as well as for the treatment to know the differences:

Conversion. Conversion is the oldest mechanism (it can be traced back to Freud’s studies in last century) that is also applicable to the symptoms of pain. The basis of conversion is always an unconscious conflict between an impulse and its defense solved by the production of a symptom which itself represents a compromise. Therefore, from this viewpoint, symptoms can be regarded as creative coping strategies for otherwise unsolvable inner conflicts. In principle, that applies to all neurotic symptoms; however, the special characteristic of conversion is that the symptom is (mistakenly) expressed physically. In any case, this is the way the patient experiences it.

The narcissistic mechanism. A considerable number of patients show a specific pattern that consists of factors concerning life history, of specific personality aspects relating to them, an accident or injury and a resulting chronic pain. Experiences of helplessness in childhood, the feeling of being at the mercy of certain events (e.g. death of a parent, abuse, etc.) can lead to the development of certain personality traits. These people often try to flee into an imagination of invulnerability and power, in order to avoid these unsolvable and, in principle, almost unbearable feelings of helplessness. Often these people are also extremely achievement-orientated . After all, achievement is a field in which one can build on one’s own abilities, where one must not feel dependent on others, so that a feeling of stability, strength and self-confidence can evolve. However, the construction proves to be fragile if the efficiency of the respective person is suddenly diminished because of an injury and he becomes dependent on the aid of another person. This can lead to a re-activation of the childhood feelings of helplessness which, in turn, leads to a severe psychosocial crisis.

Everything starts to revolve around the injury and the pains; one even has the impression that the whole life is now scheduled around these persisting pains. These patients characteristically change their doctors frequently and alternately idealize them or turn away from them disappointedly. The fact that this dynamic process can be observed so frequently led to the following term for the mechanism: `psychoprothetic function of pain’, because one gets the impression that pain holds the human being together, and paradoxically gives him stability.

Psychovegetative states of tension. In general, emotions go along with physical concomitants . These concomitantsof emotions are also called emotional correlates in order to express their connection to emotions. However, particularly then when the development and differentiation of the (innate) emotions into feelings was not carried out sufficiently successfully during the early years of personality development , this can lead to disintegration. In this case, physical symptoms appear dissociated from experience and the affected persons cannot bring the min to connection with their mental processes anymore. These processes are not only used for the explanation of psychosomatic processes but also for understanding the way pain is experienced.

Therapeutic consequences. Depth psychological concepts generally assume that physical symptoms, as far as the psychosocial part of the pathogenesis is concerned, are the expression and result of disintegrated parts of emotions dating from partially disorganized relationships in early childhood. Therefore it is only consistent that the therapeutic relationship is of great importance.

For this reason, generally and not specified according to a particular symptom, a lasting curing effect can already be attributed to a supporting and empathic conversation. This could be seen in a project in which unschooled students made extensive anamnestic interviews with pain patients as part of their training.13 Above all, it could be seen that patients, if they feel that they and their chronic pain are taken seriously without having to fear becoming psychologically pathologized, are also prepared for a self-exploring co-operation. A stable work alliance and a trusting relationship need to be mentioned as main factors here.

A more specific therapeutic approach is relaxation therapy which has been used successfully for a long time now; however, its application requires a corresponding training.15 Studies testing its effectiveness show comparable results for most of the common techniques (autogenic training, progressive relaxation, biofeedback).  Further psychotherapeutic treatment requires several years of training, which is controlled by law in most countries and is partly financed by health insurance companies.

From the depth psychological point of view, treatment especially aims at the experiences the patient has made in his early relationships these are represented in the present therapeutic relationship. However, it is not so important to give the symptom (except for conversion) a symbolic communicative meaning, but rather to regard the patient’s pain a sensomotoric recording of interactive experiences he has made in his early lifetime.17 In the here and now interactive process between therapist and patient, he makes relationship experiences which correct his inner working model of the world. Here, above all, especially the emotional and therefore also the physical references are regulated in a new and more adaptable manner. Therefore, these processes are not so much bound to insight, but rather to experiencing a relationship itself. Some aspects of a therapeutic relationship are not primarily accessible to insight. So they have to be provided within the therapeutic relationship and perhaps they can be experienced on a symbolic level (i.e. accessible for language) later. The main goal of this approach which can be attributed to psychoanalysis is the reintegration of emotions into symbolic and available mental processes and, as a result, the attaining of a higher regulation level. It is no coincidence that conversations have a rather background meaning in this approach and that the way relationships are experienced physically often is the more important part of the therapeutic process. Therefore, it is also no coincidence that elements of dance therapy, music therapy and different therapies oriented on bodily experiences are successfully integrated into the approaches of depth psychology.

Behavioral Medicine Concepts. In behavioral medicine pain is considered an overall psycho-physical event, and apart from physical, also behavioral, cognitive and emotional aspects have a part in its development.21 Pain is neither a mono-causal event, nor can it be treated satisfactorily on a one-dimensional basis. Behavioral medicine, being an interdisciplinary field, deals with the exploration and treatment of primarily somatic diseases on the basis of the bio-psycho-social model, together with psychology, medicine and other disciplines. By definition, it is therefore predestined to offer an overall treatment program. In the present discussion, emphasis will be laid on the psychological aspect of the treatment spectrum.

Psychological interventions in behavioral medicine are directed to the way pain is experienced, including the accompanying feelings and thoughts, to psychophysiological changes like muscle tonus and vasotonia or other specific or unspecific stress reactions relevant for pain. Also, pain-dependant behavior like pain-easing posture and movement, and the way patients deal with pain killers.

Basically, behavioral medicine knows four behavioral, or cognitive, models having a different weighting for explaining the processes taking place when pain becomes chronic: (1) the operant model; (2) respondent learning; (3) model learning; and (4) the cognitive approach. Furthermore, there are also bio-medical influences which, for instance, result in the diathesis-stress model.21 According to these theoretic models, corresponding treatment concepts have been developed.

Operant methods
Reactions that immediately follow a certain behavior, influence behavior itself and therefore also pain-related behavior on the emotional, cognitive, physiologic and motoric levels. It can be modulated by the reaction of the affected person himself or by his environment.

That operant approach to the treatment of pain assumes that behavior patterns are only functional when they reduce pain and do not cause additional problems for the sick person. Avoiding activity and efforts may bring a short-term relief of painful and unloved activities, but in the long run it increases the risk of social isolation, the loss of self-esteem and the feeling of control, even resulting in depressive states.

Behavior-orientated methods which reduce behavior patterns compatible to pain like a pain-easing posture, avoidance behavior or complaints (e.g. through systematically not taking notice of them) and methods that increase behavior patterns incompatible to pain (like activity, ability to establish social relations, endurance, condition) are distinguished. For instance, the intention behind the systematic positive reinforcement of desired behavior is to increase the `healthy’ parts of a person and therefore to make a higher joy of living possible for this person. However, other important aspects of operant programs for pain therapy are also methods from occupational therapy and from physical therapy which should contribute to the desired increase of physical activity. The effectiveness of operant therapy against pain, especially concerning patients with back problems, could be verified in various controlled studies; however, a clear superiority of purely operant trainings compared with other psychological therapy methods against pain could not be proved.

Cognitive-behavioral approach
Cognitions determine human experiencing and behavior to a large extent. In addition to the operant factors, cognitive variables like attitudes, negative self esteem, negative mental sets, how available coping strategies and attention processes are rated, are of greatest importance for pain experience and behavior.

Pain patients have made experiences of helplessness and of not being able to control the situation. Therefore, negative expectations concerning further pain and how to deal with it have left their mark on them. They believe that they have no control over their pain, feel helpless and at the mercy of the situation. As a result, no or only inadequate coping strategies can be developed. Helplessness leads to depression, fear, inactivity, higher sensitivity for and a lesser tolerance of pain.

Therefore, it is the main goal of cognitive-behavioral interventions to reduce these feelings of helplessness and not being able to control pain and to promote the patient’s personal activity. This goal shall be achieved by modifying the behavior patterns, emotions and cognitions causing and maintaining the patient’s pain. Cognitive strategies imparted to or elaborated together with the patient are for instance: cognitive restructuring (modification of the attitudes towards and the basic assumptions about the own person and the pain problem), training in solving problems (actual status, expected status, coping strategies, advantage s and disadvantages of particular alternatives, strategic planning and assistance in translating the respective alternative into action), direction of attention (focusing on perceptions far-off from pain) as well as the use of imaginary pictures (pictures of rest, imaginary journeys, pain modulation). Studies on their effectiveness were able to verify a change in the beliefs of control and self-instructions, as well as in the actual coping with various pain syndromes (rheumatic arthritis, headaches, back pains), having the following consequences: reduction of pain intensity and functional impairments, as well as an improvement of the emotional state.
- Frischenschlager, O.; Psychological management of pain; Disability And Rehabilitation; May 2002; Vol. 24; Issue 8.

Personal Reflection Exercise #6
The preceding section contained information about the psychological management of pain part II. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 20
What mechanism of pain can lead to a re-activation of childhood feelings of helplessness which, in turn, leads to severe psychosocial crisis? Record the letter of the correct answer the CEU Answer Booklet.

 
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Pain Management: Cognitive Therapy for Pain and Fibromyalgia

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