Psychology - Another Approach to Treating Pain

Pain is not treated by pharmacological and surgical interventions alone. It also requires another approach – the psychological approach.

Approximately 55 people interested in pain and palliative medicine gathered Nov. 21 for the year-end meeting of the Texas Medical Center’s Pain & Palliative Care Grand Rounds. Pain expert Diane Novy, Ph.D., an associate professor in The University of Texas Medical School at Houston’s Department of Anesthesiology, moderated the event.

“Psychologists are an integral part of the pain management team,” she said.

New on the pain management education front, Novy said, several pain colleagues have collaborated to put together a Web-based course on the interdisciplinary approach to pain management, open to students and all professionals involved on pain management teams.

“The course is up and running this semester,” she said. “We will offer this course every semester for awhile, before we reduce the amount of offerings.”

Class prerequisites are undergraduate or graduate student status, or instructor’s permission, and background of advanced pathophysiology and pharmacology is preferred. Those completing the course will receive two semester hour credits, and one additional clinical experience credit can be earned with permission from the faculty. For more information, call (713) 704-6569.

Kevin Smith, Ph.D., a Baylor College of Medicine Department of Anesthesiology assistant clinical professor, broached the subject of using cognitive behavioral therapy for chronic pain management.

“Chronic pain is defined as any physical pain complaint that has lasted more than three to six months,” he said.

The cognitive behavioral fields of learning behavior theory, cognitive therapy, behavioral medicine and stress management all work together to treat pain. This treatment model aims to “unlearn” unacceptable behaviors, and replace them with altered responses.

Treatments include cognitive restructuring, which involves identifying dysfunctional thoughts that people have about their pain, and teaching them to use different behaviors that will help them cope, such as biofeedback, stress management and relaxation.

There are two theoretical chronic pain models. In respondent conditioning, patients think of the original cause of pain and over-react to physiological stimuli, such as stress.

“As a result, tension is triggered and muscle tension induces pain,” he said.

With the second model, response stereotypy, patients respond by overusing certain muscle groups and not using others enough.

Smith said this often happens when people who have undergone surgery are afraid to become active again because of pain, so muscles go unused. As a result, the muscles that compensate for the unused muscles become sore from overuse.

“I’m hoping to bridge the gap between the way psychologists and specialty physicians treat pain,” Smith said.

In the medical model, traditionally, the long-term outcome nervous system injury is generally thought to be permanent, due to destroyed anatomical layers and structure, Smith said, or, the injuries will heal and motor and sensory functions will return.

“The third possibility, the cognitive behavioral model, suggests that cognitive behavioral factors can influence a patient’s outcome,” he said.

The treatment aims to ultimately reduce patients’ dysfunctional thoughts, reduce stress levels by teaching relaxation exercises, and teach them to behave differently in response to pain and stress.

Smith said these goals are achieved by a decreasing a patient’s anxiety, pain ratings, medication use and negative thoughts, and increasing sleep patterns and self worth.

“Often, the patients we see have tried every physical way to reduce pain, so we try to help them think about pain in a functional way,” he said.

Smith refers to various types of negative thinking as “stinkin’ thinkin’.”

These styles include the phrase “should,” as in, “I should be well by now.” Questions with no answers, such as, “When will my pain get better?” are often asked, and life is often viewed in black and white (for example, it is a good day or a bad day).

Accentuating the positive and eliminating the negative is key to this type of treatment.

“We try to encourage understanding feelings, without trivializing symptoms in the process,” he said.

Factors that may affect outcome are the patient’s motivation, intelligence or background, how they are medically managed, work options, environmental and organic issues, and psychosocial issues.

“Chronic pain is unmanageable if patients disregard the effects of pain on life circumstances, such as ability to work or participate in family activities. When stress caused by chronic pain is ignored, treatments are less likely to be effective,” Smith said.

Marilu Price, Ph.D., an assistant professor in The University of Texas Medical School at Houston’s Department of Anesthesiology and attending psychologist at the University Center for Pain Medicine and Rehabilitation at Memorial Hermann Hospital, addressed using biofeedback for pain conditions.

Biofeedback is a relaxation technique that shapes behavior via signals monitored through the muscles, temperature or skin. The two primary training methods used are general relaxation and surface electromyography, or sEMG. With general relaxation, the patient lounges in a comfortable recliner with eyes closed and conscious of keeping mental and physical arousal low. “Re-training” the muscles to relax using sEMG involves measuring the amount of muscle tension, ultimately making patients aware and in control of specific muscles. The process is done with the eyes open and in a variety of postures.

“Training people to relax is the hardest part of the whole process,” Price said. “It is made up of breathing from the diaphragm, progressive muscle relaxation, guided imagery or visualization, and autogenics, which means warming the hands and feet by bringing blood to them.”

Headaches, muscle pain, temporomandibular disorders, anxiety and fibromyalgia are just a few of the pain conditions treated by biofeedback.

“Practice makes perfect,” Price said. “Biofeedback is even supported as an ‘excellent treatment’ for long-term management of headaches, both migraine and tension, by the National Headache Foundation.”

After an evaluation by a psychologist or other trained professional, and eight to 12 weekly office sessions, patients must practice at home and in other settings, Price said. At a later date, many patients will come back for “booster” sessions, she added.

There are no adverse side effects from biofeedback. Other advantages include cost, which is minimal, compared to drug or surgical therapy, it empowers the patient, and most importantly, makes it possible to reduce the amount drug therapy needed.

“However, there are research limitations,” Price said. “The methodologies and reporting used are inconsistent, and it is hard to compare studies and replicate treatment. Standard treatment protocols are needed to ensure consistent criteria, and accurate diagnosis and classification.”

Stacey Bourland, Ph.D., staff psychologist at the Pain and Health Management Center, introduced motivational interviewing as applied to pain patients.

Motivational interviewing, originally used in working with substance abuse patients, is a non-confrontational method of getting to the source of pain patients’ problems.

“Motivation is the probability that a person will enter into, continue and comply with change-directed behavior,” Bourland said.

The assumptions made when interviewing patients, is that defense mechanisms, such as denial, are stable personality characteristics, and unless a they have acknowledged the diagnosis and are motivated to get help, there is little a therapist can do, she said.

“People inherently resist change, and treatment failure, refusal to comply and program drop outs are due to denial. Denial can only be managed through direct confrontation,” Bourland said.

There are a few problems with these assumptions, Bourland said. Even though direct confrontation is necessary for management, it yields poor compliance and outcomes. The therapist’s characteristics also contribute to drop out rates, compliance and outcomes.

“The key to motivation, is that it is a state of readiness for change,” she said, “and this state can be influenced.”

The counselor’s style is also a motivational tool. It can influence patient resistance – a compassionate counselor will most likely witness less resistance.

“People with behavioral problems often have conflicting feelings ... this is normal,” Bourland said. “Ambivalence is not pathological. If they feel they’re not being understood, their ‘self-defense’ mechanisms kick in. They will remain open to the idea of change if they feel they’ve been heard.”

Motivational interviewing principles include the core concept of reflective listening; weighing pros and cons; avoiding arguments, especially for a behavior change, because the client may argue against it; rolling with resistance; and supporting the patient’s belief in his or her abilities.

“Pain intervention requires the patient to be an active participant,” Bourland said. “Treatment will be effective only for those who are motivated. We believe everyone has the potential to change. Each counselor is charged with unlocking that potential and facilitating the natural change process that each person is born with.”

The 2003 Texas Medical Center Pain & Palliative Care Grand Rounds meeting dates are set for Thursday, Feb. 27, Thursday, May 22, Thursday, Aug. 28 and Thursday, Nov. 20. For additional information, contact Lori Nelson at (713) 791-8800.

NOTE – The first-ever, one-day Living with Chronic Pain Conference, sponsored by the National Chronic Pain Society, takes place Sunday, March 9 at the Edwin Hornberger Conference Center, located at 2151 W. Holcombe Blvd. Conference highlights include keynote speaker “Patch” Adams, M.D., the physician known for wearing a red, rubber clown nose to entertain both pediatric and adult patients, and made famous when Robin Williams brought his story to the big screen in 1998; and special guest, comedian Jerry Lewis, who endures chronic pain due to injuries sustained by performing decades of slapstick comedy. For more information on the conference or the National Chronic Pain Society, contact Helen Dearman, society president, at (281) 357-HOPE (4673).

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