Acceptance and Commitment Therapy in the Rehabilitation of a Girl With Chronic Idiopathic Pain: Are We Breaking New Ground?

Wicksell and colleagues (2005) addressed the important and currently understudied realm of chronic idiopathic musculoskeletal pain treatment in children. They presented a brief overview of empirically supported treatments for children with chronic pain, detailed their case and intervention strategy, and offered conclusions regarding the potential efficacy and effectiveness of Acceptance and Commitment Therapy (ACT) for childhood chronic idiopathic musculoskeletal pain. Our commentary is divided into several sections. We begin by providing an overview and critique for each of the case conceptualization and the intervention strategy presented. This is followed by a brief discussion of whether or not Wicksell et al.'s ACT approach is fundamentally distinct from more traditional cognitive-behavior therapy (CBT) techniques. We also consider potential mechanisms of action and suggest future research directions needed to establish empirically supported treatments for chronic idiopathic pain in children.     

Interpersonal Psychotherapy for Co-occurring Depression and Chronic Pain

Up to 37% of individuals experience chronic pain during their lifetimes. Approximately one-fourth of primary care patients with chronic pain also meet criteria for major depression. Many of these individuals fail to receive psychotherapy or other treatment for their depression; moreover when they do, physical pain is often not addressed directly. Women, socioeconomically disadvantaged individuals, African Americans and Latinos all report higher rates of pain and depression compared to other groups. This article describes a version of Interpersonal Psychotherapy tailored for patients with comorbid depression and chronic pain, Interpersonal Psychotherapy for Depression and Pain (IPT-P). While IPT-P potentially could be delivered to many different patient populations in a range of clinical settings, this article focuses on its delivery within primary care settings for socioeconomically disadvantaged women. Adaptations include a brief 8-session protocol that incorporates strategies for anticipating barriers to psychotherapy, accepting patients' conceptualization of their difficulties, encouraging patients to consider the impact of their pain on their roles and relationships, emphasizing self-care, incorporating pain management techniques, and flexible scheduling. In addition, IPT-P is designed as an adjunct to usual medical pain treatment, and seeks to engage non-treatment seeking patients in psychotherapy by focusing on accessibility and relevance of the intervention to concerns common among patients with pain. Identifying patients with comorbid depression and chronic pain and offering IPT-P as a treatment option has the potential to improve clinical outcomes for individuals with depression and chronic pain.     

Alfred Adler's Treatment as a Form of Brief Therapy

Alfred Adler was largely overlooked during his era because he viewed people as creative beings in control of their own mental health and resisted the then-standard practice of treating human beings from a pedestal with a normative body of laws. His progressive style of treatment has become more popular in an age when efficient and collaborative treatment is valued for the sake of cost-effectiveness. This article positions Adlerian psychotherapy as a form of brief therapy, effective psychotherapy that takes place in 20 sessions or fewer. The article summarizes the fundamentals of Adlerian theory, outlines the general criteria of brief psychotherapy required by managed care companies, and specifically highlights how Adlerian psychotherapy qualifies as brief psychotherapy.     

Chronic pain, meaning, and spirituality: A qualitative study of the healing process in relation to the role of meaning and spirituality

This qualitative study explores experiences of individuals with chronic pain in their attempt to find meaning in the presence of continual pain. Fifteen participants at Loma Linda University Behavioral Medicine Center were interviewed. Emerging themes from this study show that (1) meaning is initially defined as the ability to engage in productive activities and positive relationships; (2) chronic pain is perceived as the factor that removes meaning from the lives of sufferers; (3) medication is used to cope with pain, leading to addiction; (4) addiction results in greater loss of meaning; and (5) rediscovery of meaning takes place through a more complex understanding of the self that embraces suffering and thus is able to explain the interrelation of pain, emotions, and addiction. A change in self-understanding makes the reintegration of meaning possible.     

The Effectiveness of Brief Versus Intermediate Duration Psychodynamic Psychotherapy in the Treatment of Adjustment Disorder

Treatment studies and particularly psychotherapeutic treatment studies of patients suffering from an adjustment disorder are very scarce, leading to insufficient evidence regarding the efficacy of treatment in this population. Whereas timely psychotherapy is known to be of benefit in the treatment of adjustment disorders, the ideal duration of psychotherapeutic interventions is not known. This study examined whether a brief 12-session focused psychodynamic psychotherapy may be as efficient as a longer intermediate-term (1?year) psychodynamic psychotherapy in treating patients suffering from an adjustment disorder. Subjects (n?=?66) were randomly assigned to either brief or intermediate psychotherapy. They were assessed by self-report measures and clinician’s evaluation at baseline, end of therapy, and 9?months after therapy was terminated. The results showed a good overall improvement in the whole group. Furthermore, brief psychotherapy was found to be as good as intermediate psychotherapy both at the end of treatment and at follow-up. Although our study was not designed to confirm the efficacy of dynamic psychotherapy in the treatment of adjustment disorders, our results suggest that brief interventions may be good enough in adjustment disorder, thus allowing treatment of a greater number of patients without compromising for the quality and suitability of treatment.     

Time Limited Treatment and C. G. Jung's Analytical Psychology

Abstract

The work of C. G. Jung has been largely neglected in recent discussions of time-limited psychotherapy. Notwithstanding this state of affairs, this paper argues that much is to be gained from familiarity with Jung's view on treatment. A brief overview of Jung's general system of psychology is presented, and contrasts are drawn to the work of Freud. Several distinctive characteristics of Jung's view of the clinical process are then identified, and a discussion of the course of treatment is provided with a brief reference to a case of Jung's and to the author's experience working with gay men.     

Change in Symptoms and Personal Construct Structure in Anxiety Disorders: A Preliminary Study on the Effects of Constructivist Therapy

In recent years, constructivist psychotherapy has evolved as a plausible treatment for different disorders. The present study aimed to explore the effectiveness of this therapy in terms of symptom improvement and changes in the personal construct system. Forty-seven anxiety clients received brief integrative constructivist therapy. Scores on symptom and personal construct measures decreased after the treatment, but not all of them showed a statistically significant change. The percentage of clients with implicative dilemmas decreased after psychotherapy. The results provide preliminary support for the effectiveness of brief constructivist psychotherapy as a treatment for anxiety disorders in primary care services. Several limitations are acknowledged. Further controlled research is needed.     

Fundamental Dilemmas in Contemporary Psychodynamic and Insight-Oriented Psychotherapy

Contemporary psychotherapists are being called on to provide treatment with increased degrees of brevity and efficacy. To meet these demands, the practice of brief psychodynamic psychotherapy has turned to (a) the increased emphasis upon a specific psychodynamic focus for treatment versus the more comprehensive goals of longer-term treatment, and (b) the augmented use of confrontation of psychological defenses versus the enhanced use of emotional support as in more nondirective psychotherapy. Other approaches to insight-oriented psychotherapy that have been influenced by this trend include: client-centered psychotherapy with its focus upon the therapeutic relationship; existential psychotherapy with its focus upon death anxiety; and, the revitalization of interpersonal psychotherapy from its original Sullivanian conceptualization. The clinical dilemmas that limitations of time and restricted therapeutic focus place upon each of these methods of treatment are the central issues of this discussion.     

Brief therapy in adult psychiatry

Forty-one of forty-four referrals to a multidisciplinary team providing brief therapy in adult psychiatry were followed up after one year. Questionnaires were sent to attenders and their general practitioners. A good outcome was reported in 29 cases (70%) while four cases (10%) were worse. Good outcome was linked with more therapy sessions and having specific goals for treatment. Lower social class did not predict poor outcome, unlike other forms of psychotherapy. Benefit was not linked to age, sex, place of residence, duration of problem, source of referral, those attending, inpatient status or lapse from treatment. Longstanding problems did slightly less well. The 'worse' group were younger and all four were female. Training of the team took place during therapy at little extra cost without any detriment to outcome. These findings have implications for the team's approach and for the provision of psychotherapy services in general.     

Predicting the completion of an integrative and intensive outpatient chronic pain treatment with the personality assessment inventory

The effects of intensive, integrative treatments for chronic pain are affected by patient compliance, and in many cases, selecting noncompliant individuals adversely impacts the cost-effectiveness of such programs. The pretreatment identification of individuals who are at risk for dropout could assist clinicians in augmenting treatments with motivational enhancement strategies for high-risk patients or using such information to select individuals who are most likely to complete a given intervention program. In this study, we tested the ability of indicators from the Personality Assessment Inventory (PAI; Morey, 1991), administered prior to treatment, to identify individuals who dropped out of a 20-day chronic pain program. Results replicate findings from outpatient psychotherapy research in finding that PAI Mean Clinical Elevation and Treatment Process Index significantly differentiated dropouts from graduates, particularly when the Treatment Rejection scale suggested patients were motivated for treatment. We discuss these results and offer recommendations for the prediction of treatment dropout in pain settings.     

An integrated model of group psychotherapy for patients with fibromyalgia

This study examined the effectiveness of an integrated model of brief group psychotherapy for treatment of fibromyalgia syndrome, using cognitive behavioral and supportive expressive techniques. In the context of an outpatient, multidisciplinary fibromyalgia treatment program, group psychotherapy was provided to 35 patients with 21 control patients. Pre-post treatment measures of depression, anxiety, fibromyalgia impact, pain, fatigue, and morning tiredness were obtained. Using a quasi-experimental design with validated psychometric instruments, the results showed a significant decrease in pre-versus post treatment measures of depression, fibromyalgia impact, fatigue, and pain for the treatment patients, suggesting that an integrated model of group psychotherapy may have beneficial psychological and functional effects for some patients with fibromyalgia.     

Automatic processing of pain: the change of implicit pain associations after psychotherapy

This study explores the utility of a pain IAT for the assessment of dysfunctional cognitive beliefs in chronic pain patients before and after a cognitive behaviour therapy. A patient group suffering from chronic pain (N=25) treated with a 4-week cognitive behavioural psychotherapy is compared with an untreated healthy control group (N=27) at two points in time. In addition, both groups completed a self-esteem questionnaire (Rosenberg-scale) and a self-esteem IAT. In the clinical group a questionnaire assessing self-reported pain cognitions was administered. The pain IAT was able to differentiate between chronic pain patients and healthy controls before the treatment. Most important, pain-related implicit associations could be shown to change over the course of treatment in the clinical group of chronic pain patients. Results provide first evidence for an application of the IAT in chronic pain research.     

Understanding and Treating Pain in Ethnically Diverse Patients

A revolution has taken place during the past 25 years in the understanding and treatment of chronic pain. Psychologists have contributed tremendously to this revolution. However, the primary psychological models of pain treatment have failed to adequately integrate the empirical findings and theoretical understanding of the role of ethnic factors. The goal of this paper is to address this problem by demonstrating the importance of understanding ethnic factors in treating pain, providing an overview of ethnic factors in pain, and proposing guidelines for Clinical Psychologists who treat pain patients from ethnically diverse backgrounds.     

A comparison of two psychological treatments for bulimia nervosa

Two standardized psychological treatments for bulimia nervosa were studied. A cognitive behavioural approach was compared with a form of short-term focal psychotherapy. Twenty-four patients who met strict diagnostic criteria for bulimia nervosa were randomly allocated to the two treatments. All the interviews were tape-recorded so that checks on their content could be made. Assessments took place at the beginning and end of treatment, and at 4-, 8- and 12-month follow-up. None of the patients dropped out of treatment or follow-up, but 1 patient from each treatment group had to be withdrawn on clinical grounds. Patients in both groups made substantial improvements which were well maintained over the 12-month treatment-free follow-up period. The cognitive behavioural approach was superior to short-term focal psychotherapy in terms of its effect on the patients' overall clinical state, their general psychopathology and social adjustment, and their assessment of their outcome.     

A Secondary Analysis of Integrated Pediatric Chronic Pain Services Related to Cost Savings

Youth with chronic pain have high healthcare utilization and associated costs. Research supports integrated treatment; though, it’s unclear which treatments are used and cost-effective. This study expands on work that found reduced service use and cost savings following participation in an outpatient integrated pediatric pain clinic. We explored which services were commonly used and which individual (psychotherapy, medication management, acupuncture, massage, biofeedback) and/or combinations of services were associated with service use reduction and cost savings. Medication management and psychotherapy were more common than complementary integrative medicine (CIM) services. Massage services were associated with reduced inpatient costs. There were trends of fewer emergency department visits for participants who received CIM services in addition to medication management and psychotherapy, and more visits for those with biofeedback. Findings suggest that a more detailed examination of service utilization is needed to better understand cost outcomes related to the integrated treatment of pediatric chronic pain.

     

Counselling and Pain Relief

Health-care staff (e.g. doctors, nurses, physiotherapists, occupational therapists) frequently have to care for patients who suffer from conditions which cause crippling pain. Pain relief is part of such treatment. This article suggests how counselling, as a skill which every health care worker could acquire and use, may reduce the level of pain by helping the sufferer cope more effectively with it. Four principles of pain relief are considered: the therapeutic relationship; other sensory input; rest and relaxation; and the use of imagery. The discussion on pain relief centres on rest and relaxation and the use of imagery, based mainly on the work of Jung and Assagioli's model of psychosynthesis. Patients are encouraged to continue practising these pain-relieving techniques when counselling has ended. By so doing, they will acquire positive ways to escape from the world of nightmare in which sufferers from chronic pain are often held prisoners. An account is included of how a sufferer from trigeminal neuralgia benefited from one session in which imagery was used.     

Great Men: Psychoanalytic Studies by Edward Hitschmann. Foreword by Ernest Jones

Abstract

This study examined the effectiveness of an integrated model of brief group psychotherapy for treatment of fibromyalgia syndrome, using cognitive behavioral and supportive expressive techniques. In the context of an outpatient, multidisciplinary fibromyalgia treatment program, group psychotherapy was provided to 35 patients with 21 control patients. Pre–post treatment measures of depression, anxiety, fibromyalgia impact, pain, fatigue, and morning tiredness were obtained. Using a quasi–experimental design with validated psychometric instruments, the results showed a significant decrease in pre-versus post treatment measures of depression, fibromyalgia impact, fatigue, and pain for the treatment patients, suggesting that an integrated model of group psychotherapy may have beneficial psychological and functional effects for some patients with fibromyalgia.     

Adolescent Focused Psychotherapy for Adolescents with Anorexia Nervosa

The paper describes a manualized specific form on individually based developmentally oriented therapy for Anorexia Nervosa (AN) in adolescents. Adolescent focused psychotherapy for AN is derived from a self-psychology model and is designed to address key deficits in development associated with AN. Adolescents with AN are viewed as using food and weight to avoid negative affective states associated with adolescent developmental issues that they perceive as intolerable. To develop a more constructive coping style and improve self-efficacy, adolescent patients need to first learn to identify and define their emotions, and later, to tolerate emotions, particularly negative ones. In withdrawing from the environment and situations which provoke distress through self-starvation and preoccupations with food and weight, emotional and psychological development is arrested. Learning to identify and cope adaptively with emotions and developmental challenges presented by the environment form the key therapeutic targets of treatment. Specific therapeutic procedures, a case illustration and discussion of therapeutic rationale are also provided.     

Effects of pain acceptance and pain control strategies on physical impairment in individuals with chronic low back pain

Psychosocial treatments for chronic pain are effective. There is a need, however, to understand the processes involved in determining how these treatments contribute to behavior change. Control and acceptance strategies represent two potentially important processes involved in treatment, although they differ significantly in approach. Results from laboratory-based studies suggest that acceptance-oriented strategies significantly enhance pain tolerance and behavioral persistence, compared with control-oriented strategies. There is a need, however, to investigate processes of acceptance and control directly in clinical settings. The present study investigated the effects of three brief instructional sets (pain control, pain acceptance, continued practice) on demonstrated physical impairment in 74 individuals with chronic low back pain using an analogue experimental design. After controlling for baseline performance, the pain acceptance group demonstrated greater overall functioning on a set of 7 standardized physical tasks relative to the other two groups, which did not differ from one another. Further, the acceptance group exhibited a 16.3% improvement in impairment, whereas the pain control group worsened by 8.3% and the continued practice group improved by 2.5%. These results suggest that acceptance may be a key process involved in behavior change in individuals with chronic pain.