Factors to Be Addressed in Psychotherapy

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Regardless of the psychotherapeutic approach undertaken, there are certain essential psychological components of the pain experience that are likely to be the focus of therapy. Some of these might be more central to a particular psy-chotherapeutic approach than others.

Affect

Chronic pain is associated with a wide range of psychosocial problems, including strained relationships, alienation from others, problems with depression and anger, and loss experiences (e.g., bodily integrity, self-efficacy). The psychological experiences of patients with chronic pain may include significant mood disturbances. These in turn may have an impact on thought patterns and belief systems, all of which may profoundly influence the pain experience and the extent to which patients adapt to their condition, adhere to treatment, and participate in the work of rehabilitation.

Little can be done to facilitate rehabilitation and restoration of functioning unless comorbid mood disorders are addressed and treated. Given that the neu-rophysiology and neuroanatomy of pain processing pathways overlap with those of affective processing and experience, pain perception and mood states (e.g., depression and anxiety) have mutually reciprocal relationships. Thus, affective states may influence pain perception, pain reporting, and pain-related behaviors. For example, the severity of a patient's depressive symptoms has been shown to predict the number and severity of pain complaints (Hawley and Wolfe 1988). Depression is a significant predictor of average daily pain (Affleck et al. 1991).

The experience and expression of anger may have an impact on chronic pain. Higher levels of anger (as well as depression and anxiety) are found among patients with chronic low back pain than are found among asymptomatic control subjects (Feuerstein 1986). Poorly managed anger adversely affects pain levels. In one study, patients with chronic tension headache differed from control subjects in their experience and expression of anger (Hatch et al. 1991). Headache patients were prone to hostility (i.e., feelings of resentment, suspicion, and mistrust), anger arousal (i.e., perceiving situations as annoying or frustrating and aroused to anger frequently), and anger suppression (i.e., being more likely to suppress angry feelings once aroused). However, once overtly angry, headache patients tended to expend less control over the expression of anger than control subjects. Taken together, these studies suggest that modulation of anger and hostility might be a major determinant of the experience of certain chronic pain conditions (Burns 1997).

In the context of psychotherapy, a patient's unpleasant emotions may be focused on to reduce distress. Emotions—including anger—contain information value. The patient can become empowered by using the information gleaned from these emotions. So, for anger, the emotion might serve as a signal that one's rights have been violated, one's needs are not being met, an injustice has been done, or one is compromising oneself. Recognizing this, patients may possibly expend less energy suppressing anger and instead engage in measures such as determining how their needs are not being met and what action to take. The experience of anger is likely to contribute to physical discomfort when there is a conflict around the expression of anger and there are high levels of hostility.

Table 6-2. Psychotherapy interventions employed to facilitate access of emotions

Help patients to

Identify and label feelings. Recognize affect as a signal. Identify the precipitant for the feelings.

Express feelings with words instead of actions (e.g., substance abuse, excessive narcotic use, suicide gestures). Reduce anhedonia. Take better care of themselves. Determine what can be done with unpleasant feelings (e.g., use judicious expression of emotions, take constructive action).

Psychotherapy may be particularly useful in assisting patients with pain to manage unpleasant emotional states. The basic approach is outlined in Table 6-2. However, the approaches differ. Psychodynamically oriented approaches might consider how emotions were dealt with and managed earlier in development. The strategy invoked is to demonstrate how such approaches, when employed in adulthood, are ineffective in producing growth. CBT, on the other hand, is more focused on here-and-now experiences, problem solving, and development of effective coping strategies.

Factors that contribute to impairments in regulating emotions are outlined in Table 6-3. Certain disorders—for example, posttraumatic stress disorder and dissociative and somatoform disorders—are characterized by an inability to access emotions, leading to affective blunting, somatic amplification, or both. Even among pain patients without comorbid Axis I disorders, there may be a propensity to employ defenses (e.g., isolation of affect and alexithymia) that shield them from intolerable emotions (Beutler et al. 1986).

Defenses

Early psychodynamic conceptualizations of pain emphasized that the symptoms of pain serve a function (see Table 6-4), such as allowing one to cope with unpleasant emotions, allowing one to enlist the support of others, or serving as a way to expiate guilt. Such conceptualizations have been difficult to corroborate empirically (Weisberg and Keefe 1999) but nonetheless illustrate that conflicts and defenses against those conflicts may have an impact on the experience of pain.

Table 6-3. Reasons why emotions are poorly identified and regulated

Patient fears that if emotions are expressed He or she will be abandoned.

The emotions (experienced as intense states) might lead to some catastrophic result (e.g., rage-filled reaction). Patient has not learned that emotions can be expressed appropriately. Patient has not had good role models for the effective expression of emotion

(e.g., had parent who had tantrums). Patient is unable to access emotions because of posttraumatic stress disorder, dissociative disorders, personality disorders, or substance abuse disorders. Patient is using emotional defenses (e.g., isolation of affect, alexithymia).

Defenses serve to reduce the access of intolerable affective states or impulses from awareness. For example, if a person cannot tolerate an unpleasant emotion (e.g., anger), he or she might project that emotion onto others (e.g., the therapist), leading to potential disruptions in relationships (e.g., the doctor-patient relationship). Primitive defenses might also include projective identification, whereby the patient enlists the object onto whom he or she has projected to act out the patient's aggressive impulses. Such strategies may potentially undermine relationships and exasperate available support systems. Additional defenses accompanying chronic pain include denial, reaction formation, and repression (Tauschke et al. 1990).

Table 6-4. Early psychodynamic conceptualizations of pain

Proponent

Concept

Freud (1893) Psychological distress is expressed through somatic complaints.

Chronic pain is similar to mourning. Szasz (1957) Pain serves a symbolic function for emotions that are difficult to tolerate and therefore remain unexpressed. Pain diverts attention away from the emotion and underlying conflict.

Pain provides one with a basis for seeking assistance from others. Engel (1959) Pain serves to

Absolve one from guilt.

Distract one from aggressive impulses.

Rationalize failure and justify one's persistent perception of being defeated.

Patients with chronic pain may have deficits in self-regulation brought on by difficulties in managing affect and behavior. For example, alexithymia, present among those who demonstrate asymbolic and concrete thinking, is characterized by the patient's inability to identify and communicate feeling states (Krystal 1982). Just as often, the person's feelings are vague, ill defined, and confusing. These factors may lead to impairments in self-regulation that could bring about generalized states of distress and acting out in ways that undermine treatment, disturb relationships, and exacerbate life problems. For example, intense feelings may be temporarily dissipated in several ways: by focusing on pain (instead of the unpleasant emotion), through use of analgesics that can produce changes in one's emotional states (e.g., opiates), and through abuse of substances.

In examining the therapist-patient relationship, the therapist can be aware of the defenses employed and can redirect the patient's attention to the problematic emotions that may be underlying the defense. As with addressing unpleasant emotional states, the goals of therapy may be to assist the patient with identifying the utility of his or her defenses, replacing destructive or primitive defenses, and substituting healthier defenses (e.g., humor, sublimation).

A number of higher-level defenses may be employed in the management of unpleasant emotional states. Of these, humor can be quite effective. Patients who are humorless are prone to being overwhelmed by the ordinary vicissitudes of life. Similarly, loss of humor among those enlisted to assist in the care of the patient might signal impending burnout. In experimental paradigms, individuals exposed to painful stimuli had greater pain tolerability when exposed to laughter-inducing tapes than persons who used distracting mental tasks (e.g., calculating mental arithmetic) or those who were not given any instruction about strategies to use with regard to tolerating pain (Cogan et al. 1987).

A question arises as to whether laughter is the same as humor. Laughter is really a reaction to a laughter-provoking event, whereas humor is a defense employed to diffuse the emotional valence of one's actions. Humor is a mechanism of distancing oneself from life stressors, examining one's own actions, and so forth. Nonetheless, the utility of humor with regard to pain has been long advocated.

Belief Systems and Cognitive Distortions

One's beliefs can have an impact on pain, treatment, and response to treatment. Belief systems (or schemata) are of three major types. One type includes belief systems that are broad and encompass aspects and beliefs about one's life, world, relationships, and so forth. The second type comprises those belief systems that are considered to be more stable, influencing one's relationships, work ethic, and manner of relating to others—these would be commensurate with personality characteristics. The third type includes belief systems that are more or less specific to the pain experience. The stable beliefs affecting personality style as well as those pertaining specifically to pain are likely to influence coping and adaptation to the entire pain experience. They can be evaluated by various assessment techniques (DeGood and Tait 2001) and might become some of the grist for the mill in psychotherapeutic interventions. These beliefs can affect coping strategies and are likely to be of relevance in interventions such as cognitive-behavioral, dynamic, and supportive therapies. A person with a grin-and-bear-it schema would approach pain brought on by physical therapy differently from the person who views pain as reflecting a serious pathologic state. For the latter patient, activity might be construed as dangerous. A person who believes that pain is equivalent to disability may be more inclined to neglect usual responsibilities than one who does not.

Expectations and beliefs about treatment are likewise likely to have an impact on a person's response to pain and on a patient's treatment adherence. Thus, the patient's perception of his or her role (e.g., proactive, informed, and instrumental versus passive, uninformed, and dependent on the physician's interventions) will likely affect treatment adherence and willingness to explore possible treatment interventions. Similarly, the patient might have expectations about the role of the physician and others involved in the multidisciplinary treatment of pain. A patient's expectation might be that to be effective, a treatment must entirely alleviate pain and discomfort. In reality, however, a more plausible approach might be to expect some relief along with improved adaptation and quality of life. For some patients, such improvements can fall short of expectations. Some patients see the role of treatment to be exclusively medically based, whereas others might be amenable to recognizing that psychological variables can, and often do, reduce pain and improve life quality. Similarly, expectations of treatment outcome are likely to have an impact on one's expectations of recovery, rehabilitation, and restoration of function.

Belief systems can arise from one's early developmental experiences, earlier life experiences, earlier experiences with the medical community (either direct or indirect through the medical encounters shared with others who were ill), and relationships with others. Beliefs shape expectations, not only about recovery and rehabilitation but also about what one can expect out of life in general (e.g., shaping one's sense of future hope versus helplessness). Such belief systems influence how one views oneself, shaping one's sense of self-efficacy, autonomy, and self-esteem (Seligman 1990).

In addition to belief systems, the patient's cognitive styles and propensity toward cognitive distortions (see also Chapter 3, "Evaluation of the Pain Patient," of this book) are likely to reduce self-efficacy, hamper development of effective coping, drain the patient's support systems, accentuate unpleasant emotional states (e.g., anger, anxiety, depression), and exacerbate pain. For example, catastrophizing (i.e., the tendency to view and expect the worst in response to pain) has been seen as a cognitive approach that may predispose one to heightened pain (Sullivan et al. 1998). Cognitive distortions such as this can be determined, or at least influenced, by mood states (e.g., depression, anxiety). Because depression often coexists with unremitting pain, it becomes difficult to determine whether catastrophizing is a result of pain and predisposes one to depression, or whether pain and comorbid depression result in a tendency to catastrophize.

Catastrophizing may consist of three distinct cognitive distortions: rumination, magnification, and helplessness (Sullivan et al. 1995). The clinician's identification of these distortions, ascertained by careful clinical inquiry (see also Chapter 3 of this book) and perhaps by use of assessment scales, could be pivotal to understanding the psychological, emotional, and other disabling aspects of pain. The goal of cognitive-behavioral strategies is to address these distortions. When these distortions are altered, the patient may more effectively cope, may experience less emotional distress, and may overcome some of the disabling aspects of the pain.

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