A collaborative approach in the treatment of chronic pain

The impact of chronic pain on patients and their families can be devastating, with significant disruption and progressive deterioration of many life functions and roles. Typically, chronic pain patients have exhausted all standard medical treatment alternatives without finding relief from the pain. For chronic pain patients and their families, this leads to dependency on the health-care system which leaves patients and their families feeling helpless and hopeless in their struggle to survive their pain experiences. Assessment and treatment of chronic pain requires a comprehensive approach based on a multidimensional conceptualisation of pain that addresses cognitive, affective, behavioural, as well as sensory factors in the pain experience. A cognitive-behavioural treatment programme consisting of (a) a comprehensive multidimensional assessment, (b) a reconceptualisation aspect, (c) a skills acquisition phase, (d) a skills application, maintenance, and generalisation component, and (e) relapse prevention, is outlined. Emphasis is given to the important inter-related roles of the collaborative therapeutic relationship, reconceptualisation of the pain experience, and coping skills training, leading to self-management of life with pain as the ultimate treatment objective.     

Effects of Behavioral Group Therapy on chronic Pain

Abstract

Benign chronic pain is frequently reported among rehabilitation patients. The present study investigates a behavioral treatment model used with 3 consecutive groups of 8 chronic pain outpatients. The behavioral strategy used was to identify specific pain behaviors such as verbal expression of pain, consumption of analgesics and inactivity and to teach the patient to modify these patterns. The treatment was provided by a rehabilitation team and included contingency management of pain behaviors, applied relaxation and social skills training. Results showed significant 6 month follow-up reductions in the expression of pain, analgesics intake and level of rest for the group as a whole subsequent to intervention. In addition, two thirds of the group were engaged in formal pre-occupational training at follow-up.     

Behaviorism Och Marxism - Ett Omaka Par

Six moderately retarded 1 adults with undesirable behaviours such as noncompliance and physical aggression were taught more appropriate responses with a social learning package. Training consisted of seven daily "report card" measures checked plus (did not occcur) or minus (did occur) for each target behaviour. Instructions and feedback were provided after every training session by staff as was praise for appropriate behaviour. Short periods of social isolation were used after daily training when a minus was reported in any training period that day. During treatment, 21 of 22 target behaviours decreased in frequency. Seven months after treatment, 20 target behaviours were still well below baseline levels.     

The use of brief focal psychotherapy in the treatment of chronic pain

Material is presented from brief focal psychotherapy used in the treatment of four patients with chronic pain refractory to multiple forms of treatment. The value from therapy for each patient is described in terms of actual pain relief, in improvement in understanding the interpretation of past trauma into present bodily symptoms, and in subsequent ability to cope with the pain. Three reported treatment to have improved their pain; one reported an improvement in her ability to cope with it and consequent improvement in lifestyle. The place of pathological mourning in the aetiology of such pain is considered, together with a discussion on the constant finding of denial or displacement of intense anger towards important past figures and its manifestation in the transference. A discussion of the place of brief focal psychotherapy as a time- and cost-effective intervention in the treatment of chronic pain is presented.     

Attention Deficit Disorder,Anxiety Disorder,and Learning Disabilities

Abstract

This article details an individualized psychoeducational model designed to treat a child with interrelated psychological and developmental issues whose psychic functioning was deteriorating within the traditional educational system. The team had leeway to function outside of the educational system to create an individualized, remedial, psychoeducational program. At the time we began the program, her diagnostic picture included: Anxiety Disorder, Attention Deficit/Hyperactivity Disorder, and Learning Disabilities. The treatment team consisted of an education specialist, two additional part-time teachers, a clinical social worker, an occupational therapist, a consulting senior child psychoanalyst, and the child's mother. The results at the close of the first school year are examined. Perspectives informing the psychoanalytic aspects of this case include Winnicottian and Fairbairnian Object Relations Theory and therapeutic milieu model.     

Assessing pain behaviour of low-back pain patients in real time: concurrent validity and examiner sensitivity

Several systems for measuring pain behaviour have been developed for clinical settings. The present study reports on a real-time system for coding five categories of pain behaviour for low-back pain patients: guarding, touching, sounds, words, and facial expression. Unique features of the system are the use of refined measures of facial expression and integration of the measurements with a standardized physical examination. 176 sub-acute and chronic low-back pain patients underwent a physical examination while their pain behaviour was coded. Concurrent measures of subjective pain, medically-incongruent signs, and independent global ratings of pain behaviour were taken. Analyses indicated that the pain behaviours, particularly guarding and facial expression, varied systematically with the alternative measures, supporting the concurrent validity of the behaviour observation system. While pain behaviours, especially use of words and facial expressions, were significantly associated with the examiners' independent ratings, the strength of the associations suggested that, in the absence of direct training, examiners' performance was relatively poor. Implications for training of clinicians in detecting pain behaviour are discussed.     

Asking men about domestic violence and abuse in a family medicine context: Help seeking and views on the general practitioner role

Reflecting the higher prevalence of domestic violence and abuse experienced by women, and the recognised health impacts of such abuse, studies have focused on the responses of health-care practitioners to women in heterosexual relationships. Comparatively few studies have looked at the health impacts or help-seeking of men who may be perpetrators and/or victims of abuse within intimate relationships. In this paper we report on help seeking and the health professional's role based on a survey of 1368 men attending 16 general practices in the southwest of England and 31 interviews with a sample of survey respondents. The survey had a number of questions on experience or perpetration of behaviours which could be considered abusive, on whether respondents had ever been asked about such behaviours by health-care professionals, and on whether they had ever sought formal or informal help for such behaviours. Men were most likely to seek informal support from friends or family. The next most likely source of support was the family doctor. This paper suggests that health-care practitioners in general, and family doctors in particular, have a role in asking male patients about the experience or perpetration of domestic abuse and need training to do so effectively and safely.     

The impact of group leaders' behaviour on parents acquisition of key parenting skills during parent training

BackgroundParent training (PT) is identified as the most effective intervention for the treatment of conduct disorder (CD). Intervention observational outcomes are often reported as summarised composite scores, providing an overview of overall construct change.Methods and aimsParents of children aged 3–5 years identified ‘at risk’ of developing CD were randomly allocated to either PT intervention or waiting list control group. Parent and child behaviours were assessed before and after the intervention period. The current paper aims to establish which individual observed parenting categories change as a result of PT, and which specific observed leader categories predict these changes.ResultsControlling for baseline scores, ANCOVA demonstrated changes in parent praise and reflective behaviours as significant post-intervention. One-way ANOVAs demonstrated higher levels of leader praise and reflective behaviours resulted in greater change in parental praise and reflective behaviours respectively. Regression analyses indicated these leader behaviours predict positive change in parental praise and reflective behaviours for intervention families.ConclusionsComposite observational scores provide an account of behaviour constructs, whereas individual behaviour categories provide an insight into the core components of these constructs. The results suggest praise and reflection as key leader behaviours that influence the mechanisms of change in parenting behaviours as a result of PT.     

Fear-then-relief,legitimizing a paltry contribution,and charity

IntroductionThe compliance literature describes multiple techniques of social influence. Some of them have proven effective at inducing compliance in the charity domain. One such technique is referred to as legitimizing a paltry contribution (LPC). There are theoretical grounds on which it can be assumed that this technique will be particularly effective in conditions in which a person feels relief from fear.ObjectiveThe aim of the study was to examine whether people who experience fear-relief sequences are more susceptible to the LPC technique than those in a neutral emotional state.MethodIn two field studies, some people experienced relief from fear, while others remained in a neutral emotional state. The participants were then asked to donate to a worthy cause. A request was formulated either in a standard way, or with the phrase “even a penny will help”.ResultsThe two experiments yielded consistent results. It turned out that the LPC technique was particularly effective when participants had experienced relief from fear.ConclusionsThe aforementioned pattern of results is important for the development of theoretical knowledge about techniques of social influence, and has direct practical implications.     

Flor,H., & Turk,D. C. (2011)Chronic Pain: An Integrated Biobehavioral Approach Seattle: IASP Press

Chronic pain is a significant health-care problem that impacts millions of Americans and costs our economy billions of dollars each year. Research indicates that cognitive behavioral therapy (CBT) can be an effective approach for teaching individuals with chronic pain ways of managing their pain more effectively. In Chronic Pain: An Integrated Biobehavioral Approach, Drs. Dennis Turk and Herta Flor (2011) provide a well-written and clear product that skillfully integrates pain-relevant science and research with information that is directly relevant for clinical practice. This book is highly recommended for any clinician interested in working with patients who have 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.     

The role of pain behaviour and family caregiver responses in the link between pain catastrophising and pain intensity: A moderated mediation model

Objectives: This study investigated the mediating role of pain behaviours in the association between pain catastrophising and pain intensity and explored the moderating role of family caregivers’ responses to pain in the link between pain behaviours and pain intensity.

Methods: The sample consisted of 154 chronic pain patients and their family caregivers. Patients completed questionnaires regarding pain intensity, pain catastrophising, pain behaviours and their caregivers’ responses to their pain. Family caregivers reported their responses to the patients’ pain.

Results: Pain catastrophising was associated with pain intensity (r = 0.37) and pain behaviours partly mediated this association. The positive association between pain behaviours and pain intensity was significant only if patients reported that their family caregivers showed high levels of solicitous (effect = .49) and distracting responses (effect = .58), and if caregivers reported to show high levels of solicitous responses (effect = .51). No support was found for negative responses as a moderator neither based on patients’ perception of negative responses nor based on caregivers’ perception of negative responses.

Conclusions: The findings are in line with the idea that family caregivers’ solicitous and distracting responses convey to patients that their condition is serious, which may reinforce patients’ pain and pain behaviours, especially in those who catastrophise.     

Culture,psychology and ecology: An interview with Theodore Roszak

Objectives: This study investigates the efficacy of a standard cognitive behavioral group-program for chronic pain, in comparison with the same group program that integrates an existential perspective at treatment conclusion, 3-month, and 6-month follow-up. Design: This study is a quasi-experimental clinical trial with two treatment groups. Methods: We included 113 patients suffering from chronic pain who had been accepted for treatment at an interdisciplinary pain center. In addition to the specific therapy program, the patients received intense interdisciplinary treatment. Outcome measures include both pain-related disability and pain severity. Repeated-measures analyses of variance (ANOVAs) were used to test statistical significance, followed by tests of simple contrasts with pre-treatment as a reference-point. Results: Results indicated that the integration of an existential perspective leads to significantly lowered pain-related disability than the classic cognitive behavioral group-program. Additionally, existential aspects seem to be particularly important for patients with a spiritual orientation. The findings from this study support the importance of considering specific existential aspects in the cognitive-behavioral approach in treating chronic illness.     

Simone Weil’s Passion Mysticism: The Paradox of Chronic Pain and the Transformation of the Cross

Simone Weil’s theology is deeply connected to her experiences with chronic pain. Pain is paradoxical in that it is an essentially private phenomenon yet it simultaneously demands to be shared with another. Weil’s life and thought exemplify both aspects of this paradox, demonstrating how her pain alienated her from her own body and from others, and how her thought found full expression as she attempted to share experiences with pain. Weil’s experience of pain was transformed in her passion mysticism, the deep connection she felt with the crucified Christ. In this connection, the most unbearable aspect of her pain, the threat, which it presented to her very self through annihilation, was absorbed into the cross and transformed by God’s love. While this did not necessarily diminish Weil’s pain, the meaning it had for her as a person was transformed through an encounter with Christ crucified, in which she experienced God’s suffering along with her.     

THE EFFECT OF EXPERIMENTER FACIAL ORIENTATION DURING IMITATION MAINTENANCE1

The training and maintenance of imitative responding has become an important therapeutic process with language-handicapped children, as indicated by Garcia and DeHaven (American Journal of Mental Deficiency, 1974, 79 , 169–178). Typically a training “package” is used, that might entail the use of operant shaping, fading, reinforcement, and punishment techniques designed to increase correct imitation and decrease incorrect responding. Only recently have studies begun to concentrate on the components of these training “packages”. Steinman (Journal of Applied Behavior Analysis, 1970, 3 , 159–167) highlighted the roles played by less conspicuous but functionally important components of these packages. The present study attempted to provide a systematic extension of this work within an applied context. Using subjects who were responding at high levels during an imitation-maintenance procedure, experimenter facial orientation (experimenter's eyes and head oriented towards the subject's face and head), was systematically manipulated for experimentally determined “types” of imitative behavior. Differential responding within these parameters provided an evaluation of facial orientation as a functional component within this training package. Three retarded children participated in the study. Two types of topographically different imitative responses were defined for experimental purposes (“standing” and “sitting”). Each subject progressed through four conditions of the study, which called for the reinforcement of all imitative responses. But during preselected conditions, experimenter facial orientation was removed from the therapeutic package for one of the two topographical types of imitation. Results indicated that imitation of the two topographical types of models was dependent on the presence of experimenter facial orientation within the experimental procedure.     

The effects of a goal-setting package on the performance of speed skaters

Abstract

The purpose of the study was to assess the effectiveness of a goal-setting package on objective and subjective measures of speed skating performance. Participants were four female skaters ranging in age from 12–17 years. A single-subject design, the multiple baseline across individuals, was used to evaluate the intervention package. One participant remained at baseline for the duration of the study to control for training effects. The results provide support for utilizing a goal-setting package in an athletic setting. During practices, laps and drills completed increased, while off-task behaviors decreased. Racing times obtained in practice and competitions improved for all three experimental participants. A social validity assessment provided further support for the effectiveness of the intervention.