Relaxation/mindfulness procedures affecting attention and physical responses, as well as behavioral pacing seem somewhat consistent. What are some others and have you seen any specific ones to have significant impact in actual practice? Additionally, how compliant have you found patients in using these?
Hello, I know of Autogenetic Training. It was developed in Germany and has basically 2 elements: 1. relaxation, 2. self-suggestion. Biofeedfack etc is also possible. I think the self-suggestion part is promising. Well, the patients need of course learn how it works. This is a longer process, but with training it can be accomplished. This study could help you: http://link.springer.com/article/10.1023/A:1014576505223
Hi,
There are several different types of chronic pain, with varying underlying causes that might necessitate different psychological treatments. The methods you have mentioned seem to be effective for some types, while some others (like phantom limb pain, complex regional pain syndrome, or some forms of pain after stroke) have been partially alleviated through the use of perceptual/bodily illusions. I co-authored a review on this topic (http://www.futuremedicine.com/doi/abs/10.2217/pmt.11.20) and you will find some additional background information in this review on phantom limb pain, which also mentions psychological therapy for chronic pain in general: https://www.researchgate.net/publication/51902994_Phantom_limb_pain_after_lower_limb_trauma_origins_and_treatments?ev=prf_pub
I hope this helps :)
Article Phantom Limb Pain After Lower Limb Trauma: Origins and Treatments
Just a thought as I read Jens:
I wonder from an addiction perspective if there is a correlation between 'phantom limb pain' and 'phantom need'. By 'phantom need' I mean that call to action in the brain, that requires feeding of whatever substance or activity that allieviates the itch. Right now I'm just thinking out loud as I reflect. What's triggering this is that part of the process of freedom from addiction is enhanced through mindfullness and meditation.
(Please let me know if this leads too far from Robert's original question)
I am not too familiar with addiction research in this regard, but it is our current understanding that phantom phenomena, including phantom limb pain, are mostly based on an inability of the brain to properly adjust to the new situation, e.g. after an amputation. We have several areas in the brain that code for body perception / motor control and that are somatotopically organized. A maladaptive process in either one of these could conceivably lead to the continuing perception of a phantom limb. Reorganizational processes in the somatosensory cortex have consistently been related to the amount of phantom limb pain.
This is to say: phantom phenomena seem to be less closely related to a 'need' in the sense of craving a substance - instead, they appear to be the consequence of an inherent property of our perceptual system that can go awry after a dramatic change to the body (such as an amputation).
Thank You for that. It adds to my emerging thoughts and reflections. Needs is not the correct term, but 'ache' feels closer. Anyway I'll post again if and when I develope my thought processes better.
The compliance issue is probably the most difficult. Anyone adhering to any kind of cognitive and/or behavioral intervention for chronic pain conditions will see about 60% of the variance in the treatment effect accounted for by the patient's ability to actually practice the skills at home. I've found that truly integrated pain programs offer the highest liklihood of "good" adherence to treatment advice (based solely on my clinical experience, I do not have a reference to back that up). I'm happy to see more motivational interviewing skills incorporated into pain care, though I am uncertain about the expected increase in treatment adherence associated with the addition.
Don, just a thought, I wonder whether what Robert Moss PhD (see profile and papers on RG) calls "emotional restructuring" in his theory of "clinical biopsychology" could be useful in pain work. Bob talks about "negative emotional memories" and I wonder how these (memories of past pain experience) would impact upon current pain perception. Would be interesting to see if what Bob says holds true for pain work. Best, John
In general, cognitive behaviour approaches seems to be most effective. Obstacles for the success outside the patients body, like special attention for pain behaiviour by significant others, financial overcompensation for absences at work and legal situation, like liability. Also psychological treatments are more effective the higher the socioeconomic status of the subjects is. If you know a little German, you can find references on my internet page www.hrriskmanagement.ch
For traumatized subjects who suffer from pain and are not aware of the link, the modern bifocal multi-sensory interventions seems to be very efficient, like EMDR, TRE, EFT, hypnosis etc.
An important factor to consider is clinician attitude. A substantial literature has grown about the negative attitudes of physicians, psychologists and other health care professionals towards individuals experiencing pain and how this leads to reduced adherence to treatment protocols, exaggeration of symptoms and decreased function.
A major part of this issue is that very few medical or graduate training programs have pain as a substantive portion of their programs. This is despite knowledge that both acute and chronic pain are associated with a multitude of medical and psychological disorders. Our own research literature tells us that we need to question our attitudes about pain as health professionals and begin to teach trainees how to help those with chronic pain to be successful with treatments, rather than solely focusing on how the patients are failing.
T. Lentz
when I want to bring the answer into one sentence: explaining a good psychosomatic pain model which I believe myself, emotional clarification and processing, and in case of trauma, PTSD therapy.
Pain perception is related to maladjustment to certain factor/person in life situation, which sometimes could not be rectified. One lady suffered with severe afternoon head pain and vomiting (when her husband used to return home) for several years which disappeared after she divorced! Similarly 'restless legs' in a 10 years old boy subsided when seat of a notorious boy sitting next to him in his class was changed! Here physical pains could be attributed to a situation painful to mind of the patient. Many women do not recover from the pain of loss of generative function after tubectomy/hysterctomy and they suffer with some painful symptoms!! Such situations could be difficult to recognize and correlate unless pain is considered as a psycho-somatic phenomena. But most difficult in such cases is to make patient identify the problem and reconcile with it or resign to it which could neither be rectified nor be altered.
Hello Robert, In my office I work with neurocognitive stimulation, neurofeedback and neuromodulation to alleviate pain. Already there are researches showing the effectiveness of these resources for pain and other signals, as the depression, hallucination in schizophrenia. But there are several resources that you should to use, for instance the speech of patients and they complains. All the best, Livia.
I agree with Tanya in that too many medical people do not understand chronic pain and this is especially so in the paediatric population in which I work. Patients often come after seeing a great many medical and allied health people with stories of "it is all in your head", doing it for attention, getting out of something etc. From a psychological input, I deal with the fear of pain and the fear of re-injury/something awful that has been missed. Our team approach is get them functioning, that is back to school, social and physical activity despite the pain. Management includes focus attention willingly on other things, not avoid the pain, notice and then move on. The team approach of "rehabilation" reduces lack of compliance and motivation, but we also do parent management and education. We find education about the differences between acute and chronic pain very beneficial for compliance.
Hi, I'm a mental health nurse and psychotherapist who also suffers from chronic pain. As a few others have already said recognising the patient expereince is really important. It has taken the professionals 20 years to get to the bottom of my pain and find the genuine physical cause, its with my bones not my head - which was in doubt for a long time.
This long history of being dismissed has left its own psychological issues, not to mention the difficulty of living with pain. Recognition of my experience is vital from a therapist, pain is never 'all in your head', even if that is the cause (and in most cases I'm sceptical about that because of my own experience) the sensation of pain incorporates the whole body, it is exhausting.
I use visualisation and meditation for myself and with my patients but they are difficult techniques to master and some people don't have the imagination for visualisation. I have also had EMDR to target the trauma of being repeatedly dismissed by the very people I was relying on to help me.
I think a mutlidimensional approach to help with pain management and dealing with the psychological trauma of being in pain for so long is necessary and it often requires a mix of approaches. Teaching a patient to be compassionate towards themselves is often helpful.
I completely advocate for pain management for clients without judgement and prejudice as a health care provider. However, being an advocate for carers, I want to challenge all of us to reflect: Do we ever consider the "pain" the carer may be experiencing at any point in time. Who cares for the carer to be the best they can be?
Emily, I totally agree with everything you have said. I am a behavioural scientist. I have worked in psycho-oncological research for 13 years now, post PhD. I am also chronically ill with multiple diseases (mainly autoimmune, since childhood), but also chronic pain that is impossible for anyone to understand or "diagnose". I agree, pain can be part of "pain memory" regardless of pathology in the body, but we know so little about ongoing long-term pathology that we can never truly rule out causes.
For instance, I recently found out that I have heavy metal poisoning (from systemic candida that was exacerbated by a poor immune system due to mycoplasma infections). THIS was causing my main pain in my left thigh and other nerve pain throughout my body. It doesn't account for all pain, but it accounts for quite a lot of my multi-faceted pain experience. How could anyone have understood that!!!
We must remember that "pain" is not one disease and it doesn't have one cause... I have tried a lot of interventions, including medical and psychological. I didn't respond well to mindfulness perhaps because it doesn't always sit well with people "in crisis" mode... but more recently I have completed training in hypnosis and find this to be far superior for me (as it's easier to find what works for you - you're not being told to stick to a structure). So I highly recommend this technique (and playing with this technique) for those who have trouble with meditation... another thing that has specifically helped me, has been an Infared Sauna... and having regular holidays... (so yes, I agree with the multidimensional approach)... holidays may help me so much because of my overload at work (that's mainly my own fault, I'm a workaholic - my work gives my life meaning and in the end, that's what it's all about to keep you going). I've also published some interesting findings on pain and fatigue in cancer and how this is related to peace and meaning (aspects of quality of life) ... check it out if you have time under my ResearchGate publications!
Hi. The targets of psychological interventions in chronic pain, are based in the theory of the door pain. (Melzack & Wall, 1965). The cognitive-behavioral therapy used in the care control units of chronic pain, in Spain, work to improve de quality of life, cognitive and behavioral changes, contro of pain, relaxation skills, stop thinkink techniques. the number of patients in each group of therapy is about eleven participants seven sessions.
I suffer from chronic pain and Jon Kabot-Zinn's mindfulllness meditation that really helps me get through. Years of research went into developing it. Here is link:
http://www.amazon.com/Mindfulness-Meditation-Pain-Relief-Reclaiming/dp/1591797403.
Best, Elizabeth
We are currently trialling an on-line mindfulness programme for pain. If we could provide a very general chronic pain 6-week, one hour a week plus homework, mindfulness and educational course do you think people would want to give it a go?
Nicola,
Most certainly, in my practice as an addiction specialist counsellor, and psychotherapist I see a place for online mindfullness programmes. There is a need for efficacy and outcome effectiveness among clients. I provide a part-time contract service in a Student Health practice in a Dublin based 3rd Level College, where they have recently introduced a mindfullness based programme. University settings are one of the most fertile places for the initiation of these programmes having due regard to the ethical parametres of the programme. Looking forward to your progress.
The treatments suggested here might be expanded by including the several available programs in "Self-Managed Care for Pain". These have had remarkable success, far beyond that reported for interventions. Setting goals of functional capability with the use of coping skills that allows someone to remain active despite some pain rather than holding to the expectation of a "cure" into a pain-free condition seems to be a common feature of most of these programs. I myself wonder if some sufferers might benefit more from practices that, at least with some frequency, include regular group sessions that could counter the tendency for isolation and social withdrawal.
I have been very pleased with the quality and range of responses to this question so far. It is always helpful to hear what others are doing around the world. I thought there might be an interest in the column brain-code clinical biopsychological approach since it can explain the connection among most of the approaches/procedures mentioned in response to this question. It explains negative emotional responses can result from current or ongoing factors (e.g., pain), activation of negative emotional memories (e.g., childhood abuse by adults and peers, negative parenting styles, problematic adult relationships), and loss issues (e.g., loss of health, job, relationships). It also provides specific information on ways to deal with negative emotional memories tied to relationships (emotional restructuring) and education on loss issues. I have attached the comprehensive model description article and the specific articles on dealing with negative emotional memories (2007 article) and loss issues (just published 2 weeks ago) are on my contribution page for anyone interested. I hope we continue to have more people responding. Thank you all.
Article Psychotherapy and the Brain: The Dimensional Systems Model a...
If one thinks of chronic pain without any (more) convincing "organic" correlate (e.g., unspecific low back pain) - sometimes (in a more unidimensional biomechanistic view of the world) called "medically unexplained" - in terms of "(somatoform) pain disorder" (there are some differences in the ICD- and DSM-world), one can also find that modified psychodynamic approaches can help:
Sattel, H., C. Lahmann, H. Gundel, E. Guthrie, J. Kruse, M. Noll-Hussong, C. Ohmann, J. Ronel, M. Sack, N. Sauer, G. Schneider and P. Henningsen (2012). "Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomised controlled trial." The British journal of psychiatry : the journal of mental science 200: 60-67.
It is a slow business though, isn't it? I shall have a look at the article, it sounds interesting...I wonder about the 'modified', will it be what 'body psychotherapists' do?
I think we 'hold' our bodies (hold ourselves in our bodies) in defensive ways that over time cause pain....in much the same way as defensive psychic structures initially support the child (for example when there are attachment difficulties) but later create inflexibility and mental/relational discomfort. UNlearning these ways long-term is possible but slow, with psychotherapy. Relearning how to stand/sit/walk/run is also possible but very difficult and very complex: not one for a quick physio appointment or two, or even regular yoga, I fear. Chronic dysfunction and pain builds slowly, and so does its unravelling.
Many patients are helped by cognitive-behavioural, group, pain management centres but around the world these are rare resources and the vast majority of patients are 'fobbed off' with minor analgesics, or self medicate with alcohol or over the counter drugs that are now suspected of considerable iatrogenic health problems (including cardiovascular disease). Or, as has been said, continue to seek medical help and are met with increasing hostility from clinicians who understand only the bio-medical view of pain. We have worked with others in the UK National Health Service to develop a self-management programme, encapsulating as much of the CBT group based approach as possible. This is rapidly being adopted by many UK pain programmes to help them meet the potentially overwhelming demand for services using a 'stepped care' model. Beginning with simple self-management support (ideally including brief contacts with a health worker trained to understand its CBT basis) with triage on to a more intensive multi-disciplinary programme, or face to face work, if this is not sufficient. This approach is recommended in the British Pain Society guidelines but rarely applied, We developed the resource to try and reduce the amount of needless suffering through lack of simple advice and help with techniques like, relaxation, pacing and goal setting. In my eyes the failure to provide this to all people living with pain is a national scandal. It is possible that much chronicity would be avoided if, before hopelessness and depression sets in, people could be gently guided to create a management plan. In the UK you can usually only reach some sort of bio-psycho-social support when you've become a major management problem for your family doctor. For this reason we also sell the 'Pain Management Plan' (unfortunately rather buried) direct to the public through Amazon. Not my favoured way to get help to people but until good self-managment support from health providers becomes the norm the only way to reach people in need. A couple of brief papers describing an evaluation of the use of the PMP in three of the UKs leading pain management centres was published in the UK Pain Society Newsletter (a copy can be downloaded from here http://www.npowered.co.uk/the-pain-management-plan.htm?p=2. Obviously a full RCT would be valuable if anyone is interested? I'm too close to it run one myself and frankly, at 62years, having run RCTs on a number of useful treatments only 50% of which have been adopted in the NHS and then not widely, I am more interested in getting help directly to patients than spending 3 years producing yet more positive findings - sorry, don't want to disillusion younger researchers, I'm just running out of time! We are currently woking, with seed finance from the NHS on developing, with patients and clinicians, an app that runs on smart phones, the lite version of which would be free (the full programme will need to be moderated and will therefore be a pay for App probably for tablets and PCs) potentially this 'freemium' model could reach many more of those people who are seeking a solution but hitting a brick wall. All advice and encouragement gratefully received.
DFA Somatic Pattern Recognition combines three approaches to address the way experience is organized in the body: a physical hands-on intervention with a wavelike motion, education of movement and body awareness and a safe space for completion of interrupted emotional processes. A basic factor to be taken into account is the gravitational field of Earth. The hands-on intervention is greatly appreciated by the vast majority of clients. It eases pain, regulates myofascial tone, makes integration of body structure in the gravitationalfield possible. The combination with education of movement and body awareness enhances autonomy, because people learn to observe the way they move in life and it enables them to explore and practice alternative option of moving. The safe space for completion of interrupted emotional processes makes it possible to understand the way these processes have shaped the body and patterns of movement and behavior, to introduce novelty into the system, and to allow the body to restore its inner balance after trauma.
While it is true that clients, who naturally want to get rid of their pain, often are initially put off when I invite them to listen to the pain and have it tell them what is needed, almost all of them discover right away that it is much more painful to try to get away from the pain or to protect themselves against it, than to direct their attention towards it. When they begin to discover meanings in their sensory experience that they have associated with whatever it is they are feeling, they can revise these association and find out to what extent they are true or are based on the limited,but painful experience of a child. People who are highly invested in defending their view of themselves and the world at all cost have a hard time doing that, because their pain often is due to some kind of conflict they are not willing to acknowedge. They usually don't stay in treatment for long. But for most people it is very liberating and much pain is resolved in the process, both physical and psychological.
Much physical pain is due to an unfavorable relationship with gravity.. Being able to become aware of this relationship and find the best relationship possible at any given time is highly motivational.
However, as Isabel pointed out, it does take its time to unravel the accumulation of sensory experience leading to pain. And so a fair amount of investment in terms of money and dedication is called for.
Robert, I work at University of Otago in Christchurch, and would love to hear more about your project. I'm enthusiastic about mindfulness, but prefer to pair it with actions (yes, ACT!). I'm painfully (no pun intended) aware of the number of people who can't access tertiary level interdisciplinary pain management in New Zealand, and who remain stuck being treated in a biomedical model.
I've found that coping strategies need to be viewed within a functional and contextual framework, because my research has found that people who are naive to pain management but cope effectively with their pain tend to use coping strategies that we've traditionally thought were associated with dysfunction. Their ways of coping enable them to engage in what they value, and they become "flexibly persistent", using whatever works so they can do what they think is important. So despite moderate to high pain intensity (on VAS), they fully engage in working, leisure, family etc and are not distressed.
So perhaps we need to look a little less at what people use to cope, and a lot more at how well they achieve what they think is important. By extending their repertoire of strategies, people might be more flexible at finding ways to achieve what's important. But of course, we probably need to spend a bit more time learning how to support people to find what they're passionate about, or what's important in their lives.
In my most recent studies have used the model of self-regulation for adaptation and resolution of disease symptoms. I have not worked specifically with the pain, however, I think, the strategies of self-regulation for pain control is interesting
Trying to perform thousands of " clinical field test" in order to acumulate evidence to support the size of psychological contribution to chronic pain problems in a big public hospital (1987-2014) from a so called: "Low and middle Income Country" at Mexico have allowed us learn a lot directly from our patients and about living with persistent and in many cases medical refractory pain. As a proffesional clinical psychology researcher invited to do an initial consultanship work for a higly skilled physician group we faced with several challenges: a lack of resources: human. materials, scientific, and a big clinical request (at that time 27.000 monthly outpatients and 64% of them with pain as the main symptom) further they come from very different cultural end economic background; wich means sometimes: no words for pain or pain unfamiliar words. Carlos Fuentes a famous mexican writer said "we do not have one ,but several Mexicos". At this context we do begin using our clinical emphatic skills (listen and being close to patients "face to face" ) . We realized according to once stated by Loeser, " it is suffering not pain, that brings patients into doctors'office"(Pain and suffering. Clin J Pain 2000;16:S2-6). It has been clear that for most medical pain trained, departing from accepting a wide equivalence between "Structure equal to Function" have led them to promote outstanding advances on pain pharmacological and invasive management (mostly the short duration one) this lineal ruling approach was not appropiate for our work "pain may or may not include nociceptive activity", it according to current definitions also include emotional and cognitive factors wich have been addresed by Strichartz, B. Thompson, and Brigitte. I do agree with some of them on the multifactorial nature of chronic pain problems , but doing clinical intervention on this fields ( and many health related problems) needs a body organized into ranks stage , for us selecting and setting short time relief suffering goals has been our first intervention strategy then it comes the combination of pain self-report and autonomic ( and currently inmmunological) marker as objetive index of emotional and sometimes cognitive activity . Pain and mostly suffering is a subjetive experience but we are higly motivated to combine objetive biomarkers with (a rich) selfreport wich have made possible a "bridge" to keep a growing cooperation with medical experts. Following this path we have found that social support or the lack of it, have an outstandig importance (Porges, The Polivagal theory. 2012) to define not only the intensity perception of pain but even the vulnerability and resilence levels , therefore we have been more involved with the social -affective dimension of pain intensity. We have accumulated clinical evidence that those patients with social affective nets have more coping adaptive skills to live with pain that the contrary , recently we share some our clinical results (19 chronic pain patients wit a follow-up of 3 years) at the world congress on pain held at Milan, italy using autonomic markers (hearth rate variability) to select and train candidates to spinal cord stimulation devices wich help to increase the efficiency rate and pain relief than only follow medical criteria. Relaxation training mostly diafragmatic one, Emotional Disclosure Writing ( oral modality using an adapted century Maya's heritage the "Worry dolls") Essays (Pennebaker, JW 1989), and Hypnotic analgesia all of them with common autonomic and brain activation pathways represent for our research group "Mente-Cuerpo" from the Facultad de Psicologia, UNAM our clinical assessment and intervention tools they are non pharmacological, non invasive low cost and "friendly"for our chonic pain patients and their relatives.
I did a statistical meta-analysis of psychological interventions against - among other things - (chronic) pain. Its ancient (1994) and in Dutch, but you never know. I'll send you the book if you want.
I attach (barely readable) scans of:
- title page
- a typology of the studies I used (from after 1985 out of a broad search)
- the 26 study's analyzed, with N's and results in Cohen's d.
- the general conclusion.
Conclusions very briefly:
The background of pain is somatic and/or psychological. Psychological approaches work moderately about half of the time. Possibly the 'pain uniformity myth' is at work and different kinds of pain need more specific treatment than is usual.
Directive types of therapy are most apt, but their effectiveness isn't established.
The general conclusion is that the average effectiveness is below the level of Lipseys (1990) grand meta-analysis (moderately effective, d = 0,39), but the confidence-margin doesn’t rule out it to be just a little above it. (In the 8 target-topics I studied, it came out fourth: compliance, anxiety/fear, and life-expectancy did better, medical consumption, psychosocial functioning, depression and somatic functioning - RA mainly- did worse.) The confidence interval was favorable.
Out of the 61 studies which came through methodological selection (out of a ‘long-list’ of 866 and a shortlist of 111). Their methodological quality is in the third column: matig sterk = moderately strong (8); redelijk sterk = reasonably strong (11); zeer sterk = very strong (7).
Only 6 were exclusively aimed at pain; the others had mixed targets.
For 18 pain was the main target.
Sorts of pain, second column, also on page ‘type of study’:
5 low back pain
4 chronic pain in general
3 migraine/headache
3 in the context of cancer
3 around RA.
Mixed results with chronic pain: two do (very) well, two have non-significant results.
Patients with injury have pain but the injury either heals or it does not. In those that the injury does not heal, there is often a mechanism for chronic pain. but in those in whom the injury seems to heal but the pain persists, they often were hypervigilant prior to or after the injury and these people tend to be the ones who continue in chronic pain. In particular, patients with PTSD are much more likely to have chronic pain after an injury. Psychological treatments that address the PTSD and/or hypervigilence will be more successful. It appears in these patients that the pain rides on top of the state of alarm of the nervous system. Working to address the state of alarm and giving training to help reduce that state of alarm and the reasons for it, is important.
My dozen or so years of full-time work in a chronic pain center as a psychologist have led me to rely on the concept of pain catastrophizing, negative expectations, and pre-morbid stress and hypervigilance as important moderating factors. Patrick Frawley's comment about "pain riding on top of the state of alarm of the nervous system" is accurate. Those destined to develop chronic pain from an acute injury have certain risk markers that will interfere with healing somehow.
I use hypnosis and biofeedback a lot as "therapist helpers" to amplify the individual's often atrophied sense of coping and self-efficacy. People get stuck in the patient role, which is much more appropriate for acute than for chronic pain. Placebo responses really represent an individual's optimal self-healing capacity, and can be activated in various ways without deception.
The concept of "central desensitization" can be useful for legitimizing the validity of chronic pain; physicians and patients can look it up and find some confirmation for the phenomenon of pain seemingly out of proportion to the evident injury. This can help the patient participate in an alliance rather than waiting impatiently for the doctor to find the cure.
pain psychotherapy improved mood rather than pain.
But in combination with physical therapy (multiprofessional therapiy) it is superior.
Drs. Hall and Lenz bring up important points of attitude. This is common in any area of medicine where the physiology of the disorder is not well understood or the care is fragmented. We are often like the drunk looking for his keys under the light post because that is the only place he can see, not where the keys are. Multidisciplinary treatment and multifactorial etiology are important realities that both the patient and the practitioner have to buy into. Stages of change are also important concepts borrowed from the world of chemical dependency. Anyone who has seen the movie ,"The King's Speech" had a great example of how hard it is to change long established patterns. A treatment team is an important concept in treating chronic pain and communication between that team is an important operational component. The recovery from trauma is a hard process and the retraining of survival patterns involving hypervigilance are hard to let go of. Creating a structure the assists that process and is able to reinforce the positive changes the patient makes in that process is important for the attitude of the patient and the practitioner.
Th physical therapy is importante but the auto-tegulation is essential in the management of chronic pain
Dr Frawley
Self-regulation is an intervention process in which the goal is to arrange the patient strategies to improve their condition.
There are several authors who argue for self-regulation, in my studies I applied the model Maes 2005
recommend:
Handbook of Self-Regulatory Processes in Development: New Directions
edited by Karen Caplovitz Barrett, Nathan A. Fox, George A. Morgan, Deborah J. Fidler, Lisa A. Daunhauer
Another important issue to consider is the co-creation of the experience during and after treatment. That is, patients need to be collaborative partners in the process rather than passive ones and health practitioners need to recognise this collaboration and work together to achieve the best outcomes rather than use a top-down approach to treatment.
I think psychological and functional approaches to pain management typically do use collaborative approaches - otherwise the individual's hardly likely to maintain behaviour change when they're no longer in touch with the clinician.
Thus it's vital for the person with pain to generate why they want to manage their pain - it's not likely they'll "return to normal" but they may be able to remain engaged in occupations (activities) that tap into important values, and through doing so, develop a new identity that incorporates their pain as a small part of their overall sense of self.
Hi. Patients with chronic pain had increases in MMPI scales of D (depression) Hy (hystheria), Hs (hypochondriasis) and IS (social isolation). the theory of pain door (Melzack & Wall 1965, could be interesting to know. The cognitive-behavioral approaches are currently used iin the chronic pain units in Spain.
Hi Bronnie
Yes I agree that in pain mgt clinics might do this but by and large, many chronic pain sufferers use physiotherapists and other CAM treatments and service provisions in many instances is based on the older model of care rather than a co creation....
It's like that here in NZ too - the wider the spread of accurate pain education to health professionals, the better! Many people with chronic pain still find it hard to find help.
There is a problem in the society as well:
there more we speak of and deal with pain and pain treatment
there more we harvest pain.
Pain became a social construct construct. We chase it.
Hi, As a Clinical Hypnotherapist, in practice there are a number of ways to help the clients help themselves. One of the main questions I ask the client is " what do you get out of the pain ( as a secondary gain) and what would it be like if you dont have the pain?
there are 3 ways to approach pain relief which I can think of immediately
Direction suggestion for system change
Dissocciation
Client resource utilisation
followed by teaching the client Auto-suggestion. I find for those who really want to cope better with their pain they will continue with self-hypnosis. Those who don't perhaps secondary gain could be looked at closer. The collective positive attitude is important.
Robert - If you wish to use hypnosis adjunctively to your professional, psychological skills, you might find the following books interesting.
Eimer, Bruce E. (2008) "Hypnotize Yourself Out of Pain Right Now" Carmarethen, Wales: Crown House Publishing.
[Bruce Eimer is a clinical psychologist and chronic pain survivor himself]
Fredericks, Lillian E. (2001)" The use of Hypnosis in Surgery and Anesthesiology".Spriingfield, Illinoise:Charles Thomas Pub.
nash, Michael R. & Barnier, Amanda J. (2008) The Oxford Handbook of Hypnoasis: Theory, Research and Practice.Oxford:Oxford University Press. [See chapter 20 Hypnosis in the relief of pain and pain disorders]
I suspect that using controlled techniques to cope with chronic psychological pain can merely hide the pain in the subconscious rather than truly resolving it. Like a covered wound that festers, or like a sealed boiling pot of water, the rejected, buried, emotional pain may later erupt, or it may resurface in new and disguised forms. People must permit themselves to fully consciously experience, compassionately embrace, welcome, embrace, their emotional pain for it to be restored to the natural undivided wholeness of our energy and thereby truly resolved or healed. Only by permitting the actual experiential truth of ourselves to unfold without interference, control, or predetermined presumptive interpretation of any kind enables liberating insight and cathartic release of energy that was previously invested in blocked, rejected, feelings, as metaphorically suggested by the Biblical dictum, "You shall know the truth, and the truth will make you free." Instead of controlling, censoring, or speaking for our painful feelings and experiential states, in some predetermined, selective, way, we need to let them spontaneously speak for themselves and thereby reveal their own experiential self-understanding and flow freely into our conscious awareness, thereby enabling a cathartic release of energy invested in those painful feelings to occur.
My late father, Dr. Max Hammer, gained this insight and many other liberating, transformational psychotherapeutic insights by being open to his own psychological pain as well as by empathically communing with his clients and their emotional pain. In addition to being a very effective psychotherapist, my father was also a distinguished Professor of Clinical Psychology at the University of Maine, as well as a supervisor of graduate interns in psychotherapy for the psychology department. He, his surviving colleague Dr. Alan C. Butler, and I, are co-authors of two recently published books (January 2014) discussing the essential process of effective psychotherapy, psychological self-healing/ transformational self-help, developing psychologically healthy personal relationships, and compassionate transformation of society. The titles of our books are:
1) Psychological Healing Through Creative Self-Understanding and Self-Transformation
(ISBN: 978-1-62857-075-5)
2) Deepening Your Personal Relationships: Developing Emotional Intimacy and Good Communication. (ISBN: 978--1-61897-590-4)
These books are available from Amazon, Barnes and Noble, and my father's author website, http://sbprabooks.com/MaxHammer. That website also provides a detailed descriptions of the books and their authors. My father, Dr. Max Hammer, was also an editor and major contributor of two other books, published much earlier:
1) The Theory and Practice of Psychotherapy with Specific Disorders.
(ISBN: 0-398-02539-8; Springfield Illinois: Charles C. Thomas Publishers, 1972)
2) The Practice of Psychotherapy with Children. (No ISBN listed, Library of Congress Catalogue Card Number 67-21007. Homewood Illinois: The Dorsey Press, 1967)
I haven't access the earlier answers - bu tone tool to help clients deal with physical and psychological pain is music. Bradt, Dileo, Grocke,and Magill. (2011) did a meta-analysis of trials into the effectiveness of music for pain for cancer patients showed a moderate but significant easing of pain and a greater effect for patients' quality of life rating. Similarly, Sendelbach, Halm, Doran, Miller, and Gaillard's (2006) study into using music to ease pain for heart patients showed substantial differences in self-reported experiences of pain.
Evolutionary psychologists like Daniel Levitin, believe humans used music before they used the spoken word to communicate any number of cognitive and emotional states.
Further, if you consider music from a historical perspective, there are reports of using music for any number of psychological effects in ancient writings. Off the top of my head; the sirens used music to lure and seduce and King David (when the younger brother, shepherd boy, and general) used music to calm Saul's mental disruptions. In some more recent small n studies, music therapists like Solli, Gold, and others looked into using music to ease disorders like schizophrenia, anxiety, and depression. Studies have also been done to see if and how music helps improve compliance with treatment protocols for substance use disorder; helps families work through issues; helps the elderly and dying address end-of-life issues, and helps improve well-being and quality-of-life.
C. Brady
I have had my best outcomes by facilitating improvement in impaired sleep as the first pass approach followed by CBT focused on having the patient engage in a range of health-promoting behaviors. Extensive education regarding all aspects of treatment and the need for patient participation is essential as well. The patient is likely to be most naive about the nature of sleep as a repair and maintenance cycle. and most willing to work on this problem area. Behaviors that promote improved sleep, are also health-promoting: an approach that reduces patient resistance to activities such as exercise.
Relevant discussion here.
We did some controlled studies in the field of music therapy for patients suffering from chronic pain, all of them are published or will be. In the first one with adult chronic pain patients, we added music therapy to usual (primary) pharmacological treatment in a pain center with a wait list design, in the second one we treated children suffering from migraine with music therapy in a three arm design against pharmacological treatment and placebo pill, in the third one we we treated juvenile patients suffering from primary headache in a design with a strong control group: music therapy agains music training. I am aware that we cannot really compare these three studies. But probably some hypotheses can be drawn. The results in the first study were motivating, music therapy doubled the effects when added. The results in the third study was also good, music therapy was better than pharmacological intervention and placebo in the post-condition and batter than placebo in the follow up assessment. But in the third trial were no significant results. In sum this probably lead to the hypothesis that common factors play a relevant role. Our concept of common factors is influenced by the approach of Michael Lambert and colleagues who argue as also Wampold did, that common factor in psychotherapy are of much more relevance compared to specific factors. These authors (for example: T. Asay T. P., Lambert M. J. (1999): The empirical case for the common factors therapy: quantitative findings. In Hubble M. A., Duncan B. L., Miller S. D. (eds.): The Heart and Soul of Change – What Works in Therapy. American Psychological Association. Washington. 23-55.) argue that the working ingredients are:
Extratherapeutic Change: Those factors that are a part of the client (such as ego strength and other homeostatic mechanisms) and a part of the environment (such as fortuitous events, social support) that aid in recovery regardless of participation in therapy.
Expectancy (placebo effects): That portion of improvement that results from the client’s knowledge that he/she is being treated and from the differential credibility of specific treatment techniques and rationale.
Techniques: Those factors unique to specific therapies (such as biofeedback, hypnosis, or systematic desensitization). But the technique factor in psychotherapy research can also be seen as the experience that something professional is done.
Common Factors: Include a host of variables that are found in a variety of therapies regardless of the therapist’s theoretical orientation: such as empathy, warmth, acceptance, encouragement of risk taking, et cetera.
I think that all of them are common factors, an the last one could also be called therapeutic relation.
The patient who learns to understand the role his pain plays in his life and how to act independently will be rescued from chronic suffering. The doctor, the therapist have to support him to find this way.
More literature is coming out regarding the role of sleep in pain. If people are sleep deprived their pain threshold is low.
Tanya's comment is very relevant. My research on complexities of medical compliance point to the fact that compliance issue needs to be addressed as epiphenomenon of problematic interface between the patient and the provider system. Over the past five years I have been part of a pelvic floor multidisciplinary unit consisting of two surgeons, radiographer, gynecologist, two urologists, specialized physiotherapists and myself, clinical psychologist. Chronic pain is a very common issue in pelvic floor disorders and part of the treatment that is difficult to address. Multidisciplinary team setting is relevant for understanding and dealing with complexities of pain management as well as discussing what each discipline can provide in respect of that management. From psychological point, I find that hypnotherapy in combination with breathing techniques and relaxation has positive impact. Recording tapes with hypnotic scripts of patients' choice for home use seems to add to their compliance.
I have been amazed at the range of expertise reflected in response to this question. With over 3000 views at this point, I want to thank each of you for your valued input. Bob
Like Tanya and Zana pointed out, I agree the negative attitude of health care professionals is the critical factor in therapy of chronic pain. I`d like to go one step further and suggest, this negative attitude is caused by the frustration, that it is impossible to make chronic pain disappear - at least the memory of the pain always remains and keeps on hurting.
Patients with chronic pain either have a mechanical pain generator (.e.g arthritis, neuropathy) and /or they have something in their nervous system that keeps the pain levels up even when the physical healing is taking place(e.g hypervigilence, anger, depression, anxiety, codependency). I agree with helping the patient see what the role is that pain is playing in their life, but that is a difficult task if taken in isolation. Instead, I think it is important that they can recognize the role of the hypervigilent nervous system in keeping the pain levels up, then they can work on this.
All the difficulty challenges our efforts for a succeeding patient-doctor-relation. Here we have to get better understanding our role and the patient's needs.
Patrick: I do agree that it is "a difficult task if taken in isolation". On the other hand I think what "keeps the pain levels up even when the physical healing is taking place" is just NORMAL MEMORY -as it is just as impossible to forget willingly as it is to fall asleep willingly. It may happen, but we cannot make it happen in another individual. So I think that the main problem for BOTH patients and therapists is to accept that pain always will exist - the common effort may concentrate on defining figure and background and to tell and retell one`s story untill the pain is accepted as an unavoidable part of the own history.
I know there is some work on pain acceptance. I believe there was an instrument to measure this. Does someone know?
Patrick, the instrument is the CPAQ (Chronic Pain Acceptance Questionnaire).
e.g. McCracken, L. M., Vowles, K. E., & Eccleston, C. (2004). Acceptance of chronic pain: component analysis and a revised assessment method. Pain, 107, 159-166.
or
Vowles, K. E., McCracken, L. M., McLeod, C., & Eccleston, C. (2008). The Chronic Pain Acceptance Questionnaire: Confirmatory factor analysis and identification of patient subgroups.
Pain Management is now a specialty in most states, and as I have seen in several clinics in the greater Baltimore, Maryland area: Pain Management Clinics have three areas of concentration in which each patient must participate: Physical Therapy; Counseling by a Licensed Clinical Social Worker of Licensed Mental Health Counselor; and Pain Medication Management.. This comprehensive approach to pain management has worked quite well for most patients and has reduced the dependance on opiate based pain medications by participating patients a great deal. The counseling aspect is a very important aspect of the treatment plan, as reducing stress is crucial for these patients, many of whom are unaware of the amount of tension they are presenting in their bodies.
Hi Robert, this is very useful manual (it includes an interesting article and scale) on emotional distress and catastrophizing pain: http://sullivan-painresearch.mcgill.ca/pdf/pcs/PCSManual_English.pdf
Sullivan speaks of the relation between emotional distress and pain outcome. He points that catastrophic thinking might contribute to the development or maintenance of anxiety, fear or depression associated with pain.
A growing number of investigators use stress models and coping to explain the differences in adjustment found among persons who experience chronic pain. Jensen study (1991) found that patients who believe they can control their pain, who avoid catastrophizing about their condition, and who believe they are not severely disabled appear to function better than those who do not. Such beliefs may mediate some of the relationships between pain severity and adjustment.
Jensen, M, Turnera, J, Romanob, J, Karolyd J. ( 1991). Coping with chronic pain: a critical review of the literature, Volume 47, Issue 3, pg 249–283.
Patients with chronic pain often have hypervigilence as a foundation to the development of chronic pain. There is a close relationship between PTSD and chronic pain.
Interesting discussion. There is research done showing that pain remains under treated. As it is important to know patients' perspectives, I think it is equally important to assess what factors influence providers' decision-making when it comes to managing patients with chronic pain in various settings (clinic, surgery, etc.). I have been looking for a scale or a survey that can measure that but no luck despite the fact that there are many studies examined providers' knowledge, beliefs and attitudes. Have anyone found a good, valid survey that looks at the factors' influencing providers' decision-making in this very complex population?
I often find that client' experience of pain is multifactorial as most of you already highlighted. An interesting experience recently which actually brings clients' response to perspective confirms Sullivan's analysis that a client that "catastrophizes" pain draws attention. But not only that, when a "neutral person" i.e a person who has not been involved with the client from the onset steps in, the client's ability to cope tends to have an upward trend ( lasting or brief- it varies). We can however never dissociate the emotion and context from pain threshold at all. Another interesting angle is looking at the timing between provider impatience towards a client in pain and the ability to comfort the client who struggles to withstand pain. Few scenarios prevail 1) comforting and understanding from the onset to the end 2) understanding initially until the "client wastes their time--impatient 3) provider who pushes the client to get on with it.
However, being the provider advocate that I am it is equally important to consider the carer as an individual who needs to be nurtured and cared for in more ways than one. This is to provide an enabling environment that often yields positive outcome especially where there is consistent emotional safety net.
PS Please note my Gmail address as I am leaving Marie Stopes on Friday, but would like to continue with this rich networks, do keep in touch [email protected]
The psychodynamic point of view is interesting eg:
The crucial point is not the assessment of the pain's function but to open the person's willingness to mentalize all what is disguised by the chronic pain.
This is a practical explanation - When I am working with a client who is suffering from pain I usually pay particular attention to the clients - pain language. Whether or not the client has a secondary gain. What words he/she uses to describe the feelings of pain. Pain language is also expressed in their body talk, i.e. non-verbal communication.
Pain language can help this client identify how he 'plays out his painful role in life'' a meaning for having the pain. Changing his language can be the first step towards relief.
As a hypnotherapist I have witnessed clients have some degree of relief while in trance. Using a longer induction, visualisations, suggestions and post hypnotic suggestions can be used to 'Turn down the feeling of pain'. I find using some of the clients language adds to the trance affect. There are some specific language and metaphors which are used in suggestions.
During the therapy the client learns self-hypnosis and I message an audio hypnotic script to the client.
I generally find if the client continues to practice self-hypnosis he will have more relief.
Here is an interesting research on pain management and neuro-feedback:
At the Stanford University School, at Neuroscience & Pain Laboratory, Sean Mackey, chief of the pain management division is trying to better understand the mechanisms involved in pain in relationship to neuro-feedback.
In one study, he and colleagues performed brain scans on subjects' anterior cingulate cortices, one of the areas responsible for perceiving and controlling pain. The subjects, whose hands were intermittently heated by a probe, could watch on a screen as their brain activity increased or decreased, depending on the intensity of the pain they were feeling. Researchers suggested ways subjects could control the sensation, such as by focusing on something else or attempting to change their perception of the pain from something frightening and damaging to something neutral. After four 13-minute sessions, healthy subjects, who were included in the study, reduced their sensation of pain by 23 percent. Chronic pain patients, who learned to control their body's own pain sensations, reported an even more dramatic average reduction of 64 percent.
"We thought, maybe we can help people control their own brain activity," Mackey explains. He says researchers hope that, with increased training, patients can "reshape" the circuits responsible for pain. Mackey and his colleagues were recently awarded a $9 million grant from the National Center for Complementary and Alternative Medicine, part of the National Institutes of Health, to study the effectiveness of this neurofeedback technique and other mind-body approaches to treating chronic low back pain.
Researchers at Stanford and the Medical University of South Carolina, among others, are investigating another way to reduce pain, called transcranial magnetic stimulation, which is currently used to treat people with major depression. In this procedure, an 8-inch coil is placed on the head and an electrical current is run through it, creating a magnetic field that causes electrical changes in the brain. According to Kevin Johnson, a research associate at the Stanford pain lab, early experiments suggest that by using a high frequency electrical current to stimulate the primary motor cortex (involved in planning and executing bodily movement), the pain pathways can be disrupted.
Researchers are still puzzling over why this occurs, but it may hinge on the fact that the actions of the motor cortex are closely linked to parts of the central nervous system that control sensory perception, says Johnson. When you move your arm, for example, you can sense its motion even though your eyes may be closed. Pain also has a sensory component. "My best guess is that by stimulating the motor cortex, you're [somehow] overriding sensory perception," including the ability to sense pain, Johnson says. Mackey believes that repeated use of this kind of electrical stimulation can teach the central nervous system to develop alternative sensory pathways that ultimately reduce a patient's sensation of chronic pain.
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