Psychological Dimension of Pain Management
Providing treatment services for chronic pain patients requires a complex set of skills and awareness. There are unique challenges, approaches, and outcomes that need to be considered both in the physical and psychological dimensions. The following article is designed to provide an understanding of the psychological issues faced by providers and patients alike. Being sensitive to these issues and integrating respective approaches when working with pain patients can go a long way toward having a positive and therapeutic outcome for all concerned.
Myths and Misunderstandings about Pain
A recent telephone survey in 2002 demonstrated that Americans have little understanding about pain and its treatment. The Partners for Understanding Pain surveyed 1,000 adults and found that many held beliefs contrary to established facts about pain and its treatment.1 A few examples cited by the survey are as follows:
- Although pain is the primary cause of disability in the U.S., almost two-thirds of those surveyed attributed it to some other cause.
- Although most physicians have very little training in the treatment and diagnosis of pain, the majority of respondents were confident that their primary care physician could effectively diagnose (79%) and treat (83%) any pain problem they might have.
- Although most pain medications, including opioids, rarely cause addiction when prescribed for pain, more than 75% surveyed were concerned about addiction resulting from prescribed pain drugs.
- Although 80% of those who have ongoing pain are in the 24-64 age group, respondents mostly believed that the typical person with chronic pain is 65 or older.
- Little understanding that “doctor shopping” may be more related to issues of “pseudo-addiction” (i.e., under-treatment) and the lack of sympathetic care from providers.
Evolution of Pain Management
The field of pain management evolved out of the frustration of physicians and surgeons who were faced with the fact that many patients were not responding to the usual types of medical intervention. Even though new and evolving surgical procedures were being used more frequently, many patients were experiencing poor outcomes. Even for those patients who had a positive surgical intervention, continuing pain and problems in functioning were frustrating both patients and providers alike.
Added to this quandary is the fact that, in recent years, medicine has become more of a business due to the influence of managed care in limiting care, limiting the amount of time that physicians can spend with patients, and limiting the problem focus that is allowed to be discussed in any one physician visit. Patients feel that they have not had enough time with their physicians who, in turn, feel the pressure to see more patients in less time.
Pain management is a field that was first developed by the field of psychology in helping patients focus on finding solutions to complex health care problems. While the technical aspects of medicine rightly have a focus on disease prevention, treatment of acute problems, and diagnosing specific problem issues, psychology offers treatment modalities for those problems that do not clearly fit the purely technical model.
Because “health psychology” has had a strong tradition in the learning and academic models, the focus has been somewhat different than traditional medicine approaches. Though study, diagnosis and treatment are important, the emphasis in health psychology and behavioral medicine is on finding multiple-model solutions that can involve the patient in a more active manner of self-care.
Much of what patients experience in the medical system is as a recipient of passive modalities of treatment, i.e., patients “receive care.” In a pain management/behavioral medicine approach, however, the patient is involved in a bio-psycho-social-cognitive-behavioral-practical approach to treatment that is active, educational, directive, and evolving relative to the needs of each patient.
Rather than label an individual’s condition, the focus is on finding active solutions through the use of information, discussion, direction, homework assignments, various active (not passive) biofeedback instruments and related modalities. The object is for the patient to learn how to control muscles, nerves, blood vessels, and other bodily systems, in addition to learning what exercises work for them to reduce tension, spasms, etc. For example, the patient learns, and is able to demonstrate, active techniques for myofascial soft-tissue care to reduce tight muscles, trigger points, and to improve stretching abilities. This approach includes learning relaxation, relaxed breathing, and other techniques to reduce internal anxiety as well as high autonomic arousal. However, behavioral medicine interventions for pain management that do not employ a directed, structured, focused, and active approach that incorporate all of these (and more) modalities, is typically ineffective and misdirected.2,3,4
Psychological testing can be used not only to diagnose but, more importantly, to also identify areas that are blocking the patient’s progress. Such tests can also be used as part of the therapy process to assist the patient in coming to understand how their style, issues in handling problems, etc., are complicating their recovery. This is based partially on the premise that when there is an injury, the trauma not only affects the injured area, but actually affects the entire person. Such a response is an expected adjustment reaction to any stressor/injury process which need not progress to a chronic condition as long as the individual is involved as an active participant in the entire process.
A comprehensive pain management approach to treatment requires information that can help the patient in dealing with relapses and flare-ups. This helps empower the individual to know that they can handle the expected times when their symptoms return so that they do not feel like a helpless victim. It is crucial to note that these pain management techniques do not rule out a coordinated approach involving physical and medical therapies. The addition of psychological approaches as a central component of a pain management strategy assists the patient in removing blocks to progress so that they can make better use of the physical treatment approaches.
The primary goal is to assist the patient in moving forward toward resolution, achieve closure, and become functional again—at least to some extent. This approach does not focus on other non-injury related psychological issues even though these are considered, discussed, and dealt with as they relate to the style and manner of how the patient responds to life and functioning. The purpose is to assist the patient in understanding how their own personal style of coping, interacting and handling blocks or problems may affect them in the course of their recovery.