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It is common for patients in pain initially to reject psychological
therapies with a retort such as, ‘What does my boss have
to do with my back ache?’ I may not have an answer to that;
however, when we hook a patient up in the biofeedback lab,
and he talks about his boss, and the equipment shows various
indicators of autonomic arousal and muscle tension, he very
quickly understands that stress is affecting his body functions.
This often ‘snares’ a person into the work of examining the role
of life stresses in their pain, emotional distress, and function. It
also helps patients learn to calm themselves without a pill.
Hypnosis is another useful treatment. It helps people learn
to control body functions they normally can’t control. In
CRPS, hypnosis changes pain and circulation. It reduces autonomic
arousal, which reduces sympathetically maintained pain.
Patients must learn—and practice—self hypnosis for continued
benefit. Functional brain imaging has demonstrated that hypnosis
can reduce both physical and emotional pain responses in
the brain cortex, so that the effects of this psychological treatment
are clearly physical.
Psychotherapy is indicated when people are psychologically
troubled, when it is needed to facilitate behavioral changes,
and to help ‘jump start’ people when there is a psychogenic
component to their disability. The most common type with
pain patients is cognitive behavioral therapy—a cognitive
restructuring.
In other instances, support groups can be helpful. Pain
patients can be remarkably helpful to each other, and often help
each other find ways out of dilemmas that seemed insoluble.
People can help each other if there is a caring, trusting environment
established, and sometimes this can happen without a lot
of professional input.
At our clinic we insist on family education and therapy. In
part this is because an entire family can be adversely affected by
an illness, and in part it is to teach the family how to maintain an
environment that promotes wellness rather than regression. This
often means teaching them when not to provide care and sympathy.
Families often have pent-up anger because of the effects of
another’s chronic pain on their lives, and this can poison the
Many behaviors that
would promote recovery
are unpleasant at first.
Conversely, many things
that are very pleasant at
first can make you sick.
relationship and the patient’s attempt at recovery. It is important
to address this in order for everyone in the family to feel better.
Behavior Modification (contingency management) improves
function, helps people be distracted from pain, normalizes
mood, and improves quality of life. It is important to consistently
reinforce well behaviors and not illness behaviors. People
often mistakenly think that behavior modification means ignoring
a person with pain, which is clearly counterproductive. You
don’t ignore the person, you ignore the maladaptive behavior.
You spend more time and pay more attention, but you try to be
a friend, a companion, a playmate, or a lover—not a nurse.
Q. You run a multidisciplinary pain management clinic.
What is the value of a multidisciplinary approach?
DR. COVINGTON This is a mystery in some ways. Programs of
this sort typically treat patients who have failed to receive lasting
benefit from medications, physical therapy, psychological
therapies, and a plethora of other interventions. Yet, when they
are treated in a holistic manner that combines behavioral, medical,
and rehabilitation approaches, they may ‘blossom’ and feel
that they have truly recovered their lost selves. They begin to
play, to laugh, to function sexually, and often to earn an
income. I suspect that it is the simultaneous use of these disciplines
in an appropriate environment that helps get patients
started on a path to recovery that was not achieved with many
of these techniques in isolation.
REFERENCES
1. Ciccone DS, et al. Psychological dysfunction in patients with reflex
sympathetic dystrophy. Pain. 1997 Jul;71(3):33-33.
2. Rudy TE, Kerns RD, Turk DC. Chronic pain and depression: toward a
cognitive-behavioral mediation model. Pain. 1988 Nov;35(2):129-40.
3. Shumacker HB, Abramson DI, Posttraumatic vasomotor disorders, Surg
Gynecol Obstet 88 (1949):417-434.
4. DeGood DE, Kiernan B: Perception of fault in patients with chronic pain.
Pain. 1996;64(1):153-9.
EDWARD COVINGTON, MD
is Director of the Chronic Pain
Rehabilitation Program at the
Cleveland Clinic Foundation
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