This article was downloaded by: [University of Iowa Libraries] On: 13 March 2015, At: 22:56 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
A Therapeutic Milieu for Chronic Pain Patients Dr. Richard I. Newman Ph.D. a
a b
a
, Dr. John R. Painter Ph.D. & Joel L. Seres M.D.
a
Northwest Pain Center , Portland, Oregon, USA
b
Medical Psychological Services Published online: 09 Jul 2010.
To cite this article: Dr. Richard I. Newman Ph.D. , Dr. John R. Painter Ph.D. & Joel L. Seres M.D. (1978) A Therapeutic Milieu for Chronic Pain Patients, Journal of Human Stress, 4:2, 8-12, DOI: 10.1080/0097840X.1978.9934980 To link to this article: http://dx.doi.org/10.1080/0097840X.1978.9934980
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
A Therapeutic Milieu for Chronic Pain Patients
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
Richard I. Newman, Ph.D., John R. Painter, Ph.D., and Joel L. Seres, M.D.
Traditional means of treating chronic pain have been unsuccessful in a discouraging number of cases. Pain centers have appeared within the last f e w years, offering a more comprehensive view of the whole pain problem. Pain centers address pain as a multifaceted event with social, economic, physiological, and psychological representations. In addition, the pain center constructs an atmosphere that provides every opportunity for reduction of pain, while minimizing those factors that tend to encourage its expression. Such a venture calls for a multidisciplinary approach; it further demands a rather sophisticated grasp of numerous factors which do not necessarily lend themselves to discussion with a single vocabulary. This paper will attempt to describe a number of conceptual models of chronic pain and to demonstrate how each of these models is addressed therapeutically in a multidisciplinary pain center milieu.
CONCEPTUAL MODELS OF PAIN A model in the mathematical sense may be described as a set of elements together with a consistent set of rules which relate these elements. Elements include observations and non-observable hypothetical constructs. In order to be scientifically admissable, hypothetical constructs must be linked reliably to observable events. “Pain” is a hypothetical construct in each pain model - hypothetical because it is observable only to the sufferer. Seven overlapping models of pain are addressed: the sensory, psychodynamic, operant, economic, interpersonal, cognitive, and psychophysiological elaboration models. The authors are aifiliated with the Northwest Pain Center in Portland, Oregon. where Dr. Newmati is Director. Medical Psychological Services: Dr. Painter is Director: and Dr. Seres is Clinical Psychologist.
a
The Sensory Model Verbal complaints of pain, antalgic gait, restricted range of motion, and other such behaviors represent some pathophysiological condition. Correction of the pathological condition would be assumed to terminate the behavior. This traditional model assumes an isomorphic relation between two sets of events or elements: complaints of pain on the one hand, and the underlying organic pathology on the other. Frequent failure of surgical correction to alleviate pain complaints renders the latter assumption of isomorphism untenable. The sensory model also generates assumptions about termination of pain through interruption of the transmission of the pain signal, e.g., through cordotomy. An extension of the sensory model might be termed the perceptual model. in which the transformation of the sensation into perception
Journal of Human Stress
NEWMAN, PAINTER, SERES
could be disrupted, thus reducing pain. Activities and events, both internal and external, such as distraction, depression, or anxiety, have the potential of modifying the perception of pain.
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
Psychodynarnic Models
The primary psychodynamic model for pain is conversion hysteria. Here, distortion or repression of unconscious impulses is assumed to result in a sensory disturbance, i.e., pain. The process by which such a transformation takes place is not clear, and it is certainly not available to the sufferer. Elements in the model include verbal and nonverbal reports of pain or disability, and unconscious events. Unconscious processes are hypothetical constructs; although they may be unearthed through such processes as free association, hypnosis, or amobarbital interview, “uncovering” therapies are seldom useful in alleviating chronic pain problems. The model also invokes the important concept of secondary gain, a topic discussed below. Operant Models
The operant model states that pain behavior, like any other learned behavior, falls under the control of contingent rewards or punishment. Alterations in contingencies should thus lead to changes in the behavior. Observational learning and vicarious reinforcement extend the usefulness of the model in pain rehabiliation. Economic Models
Economic models examine the “payoff’ inherent in pain, and theorize that pain is not a problem rather, it may be the solution to a problem. For a variety of reasons, the organism finds himself in a state of disequilibrium; establishing a pain problem restores equilibrium. For example, pain may serve to remove a workman from a dangerous, monotonous, or dead-end job. For the “inadequate” individual, chronic pain may save having to attempt to compete in the job market and in an active social life. For patients who have sustained brain damage, as well as for the mildly presenile individual, chronic pain may serve as a more acceptable rationale for his obvious deficits. Morton R. Weinstein’s’ disability process model is an elaborate economic model. He relates the establishment of disability to a continuum beginning with a crisis occasioned by an increase in job tension or situational tension, compounded by
June. I978
vulnerability of character, followed by some propitious injury and completed with a gradual process of achieving a state of being “honorably disabled.” It can be argued that the concept of secondary gain should be subsumed under this heading, and separation of this aspect from psychodynamic conceptualizations appears to have heuristic value. Interpersonal Models
Jay Haley,’ in his elaboration of Milton Erickson’s works, has pointed out that any symptom must be viewed in terms of its communication value. Thus, pain symptomatology and pain behavior are seen as distortions of some other statement to people in the sufferer’s immediate environment. Such statements include, but are not limited to, expressions of anger or hostility, requests for sympathy or nurturance, or projections of responsibility. Richard Sternbach’s3 transactional analysis model of pain provides a wellformulated interpersonal model, which also includes elements of the economic model. Improved patterns of communication in such models are assumed to lead to reduction of the pain-oriented transactions. Cognitive Models.
Cognitive models of pain theorize that an individual’s affective experience, and thus his experience of pain, arise from his characterization of himself and his characterization of events. That is, what he tells himself about his situation or about his sensations determine the extent to which he is disabled. The patient who defines himself as disabled is far more inconvenienced by a chronic pain problem than is the individual who sees himself as a competent, potentially productive member of society. The patient who has unrealistic expectations about pain relief is likely to view moderate amounts of discomfort as a failure of treatment, and therefore an ominous and frightening signal. A surprising number of pain patients harbor the conviction that they are suffering from a malignancy or other serious disease, as yet undiagnosed; they do not share such concerns with their doctor, for fear that they will be confirmed. It is understandable that such cognitions lead to intense levels of anxiety, and much higher levels of pain “perception.” Two specific cognitive sets, or attitudes, are worthy of mentioning in this context. The selfperception, “I am a helpless victim,” is a cognitive set leading to stultifying passivity. The patient views
9
CHRONIC PAIN PATIENTS
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
his role as requiring him to describe his suffering as clearly as possible to the doctor, who is to assume total responsibility for alleviating the pain problem. Although the patient may do a few exercises in desultory fashion, this is done merely to gain the approval of his doctor, who is then expected to reward him by “curing” his pain. An adjunct to this attitude is the belief that all suffering is bad and must be alleviated. The contrasting attitude, which is the goal of the pain center, is the following: “ I am responsible for my condition and competent to deal with my pain.” The Psychophysiological Elaboration Model
This model proposes that chronic pain, in the presence of certain situational or personality variables, leads to a constellation of physiological responses which in themselves augment the pain and may further reinforce the disability. Autonomic responses associated with the “fight or flight” phenomenon may aggravate the pain directly, as in the case of increased muscular tension or migraine headaches. Such responses also increase the subjective discomfort or suffering of the patient, rendering him more disabled and less confident in his ability to cope with work and home settings. Examples include sleep disturbances, reduction in sexual adequacy, appetite dysfunction. anxiety and tension states, hyperhidrosis and “night sweats.” chest pains. and digestive disturbances. Control of such elaborations is assumed to reduce the pain problem. THE PAIN CENTER: A THERAPEUTIC MILIEU
To be successful, the pain center must address each of these conceptual models within the context of an integrated therapeutic milieu. A description of such a milieu proceeds with a sketch of the program at the Northwest Pain Center, a discussion of the 14hour-a-day milieu philosophy, and, finally, with a consideration of each of the pain models as it applied to the program. The Northwest Pain Center is an inpatient program typically involving about 25 hospitalized patients. Patients are admitted each week following a full-day comprehensive evaluation and educational session. The program runs for three weeks in most cases, with outpatient follow-up as needed. Admissions are staggered so that new patients have secondand third-week patients as role models: this feature is enhanced by assigning a “buddy” to each inconi-
10
ing patient. The program stresses self-help through appropriate posture and body mechanics, active physical therapy, a graduated exercise program, biofeedback, relaxation techniques and autogenics training, psychotherapy, communications training, conjoint therapy, and family assessment. Additionally, a comprehensive educational program deals with the progression of pain, the causes of pain, anatomy and physiology of pain, insurance and compensation factors, psychological and communication problems encountered with chronic pain, utility and outcome of various traditional medical and surgical interventions, and the identification of individual goals and non-goals. The staff consists of a closely knit team of physicians, psychologist’s nurses, occupational therapists, physical therapists and biofeedback technicians who meet frequently to exchange information about the patient’s programs. Patients are accepted on physician referral only. Each of the conceptual models of pain is addressed in the multidisciplinary pain center approach. Patients present with features common to more than one conceptual model but for simplicity each will be discussed briefly as an individual concept. Sensory Models
Usually, the traditional medical approaches to pain have been exhausted prior to referral to the pain center; the eventual aim is to achieve selfcontrol of pain problems on the part of the patient. Modification of the sensory aspects of pain is achieved directly through training in proper body mechanics and posture, exercises, dieting where necessary, and appropriate pacing of activities. The patient becomes the responsible agent for his own management, as opposed to the “do-for” approach. These aspects of the program also address the perceptual model of pain, in that exercising and concentrating on posture serve as a distraction. Most patients are educated in the use of a transcutaneous nerve stimulator, the aim of which is to reduce or block the transmission of the pain signal to higher centers of the nervous system. Follow-up evaluations demonstrate that frequency and duration of stimulator use decline; however, many patients use the device for “flare-ups” rather than returning to prescription analgesics. Psychodynamic Models
A comprehensive psychological evaluation prior to
Jo urn ril of
Hir i n ( i n Stress
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
NEWMAN, PAINTER, SERES
admission, as well as a separate interview with the patient’s spouse, is used to determine the presence of secondary gain. A common feature of the “cureseeking” patient is a petulant, narcissistic anger which revolves around the frustration of unconscious dependency needs. These individuals are talented at eliciting tacit promises of help from the medical profession, subsequently defeating all efforts toward rehabilitation. In the pain center, such a strategy must be dealt with through consistent stressing of the self-help model, and scrupulous avoidance of implicit or explicit promises of benefit. Intensive exploration of the distant causes of psychopathology is not undertaken, nor are such ventures well-received by this population. Operant Models
Operant considerations form the basis for most day-to-day functioning in the pain center. Pain talk and pain behavior are ignored, with the explanation that talking about pain seldom does much to reduce it. Unacceptable behaviors are met with expressions of concern or affection to which the patient may have become accustomed. When patients insist on relaying complaints, they are instructed either to write the complaints down or to tape-record them for review by their doctor; this removes the reinforcement of attention from the staff. The second aspect of the operant conditioning program is consistent reinforcement of “well behavior” in an organized shaping program. Members of the staff have become keenly attuned to minor differences in behavior which can be seen as progress, and they are quick to reinforce such activities. For example, the patient may find herself or himself getting increased attention simply for smiling initially. Patients who are seen engaging themselves actively in the program are given substantial staff reinforcement. Other additional reinforcers of well behavior are used as indicated. Another important aspect of contingency management for the pain center program is the use of analgesic medications on a scheduled basis rather than “as needed.” A further advantage in the scheduled dispensing of pain medication is that the patient requesting full analgesic relief is awakened at 5:OO a.m. for that dose. A voluntary reduction is rewarded by the opportunity to sleep undisturbed for another two hours. Further, patients are given medication at the nursing station, and are obliged to
June. 1978
stand and wait; thus, the healthy behavior of being up and adhering to a schedule is rewarded. The staff is by no means the only source of reinforcement for well behavior. Most patients, particularly when they have progressed in the program to some extent, readily begin encouraging and rewarding other patients. At times, patients are observed rewarding inappropriate pain behavior by being “motherly” or overly solicitous; when this occurs, it is important to correct the behavior in individual or group discussion. Reality orientation regarding unrealistic expectations is achieved both through lectures and through frequent reminders about pacing activities. Many patients find themselves willfully overextending themselves when pain is minimal, with the inevitable result that they are “laid up” for one or two days following this endeavor. Some reduction in expectations, in conjunction with finding more appropriate goals, can assist in this problem. Successful use of the full spectrum of skills learned at the pain center - for example, appropriate posture and body mechanics, exercise, increased mobility and strength - can reinforce the patient’s cognition that he is a powerful agent in dealing with his own discomfort, rather than the helpless victim of medical and social institutions. Thus, he can face subsequent episodes of pain with considerably more confidence. Many other troubling cognitions commonly held by pain patients can be alleviated in educational sessions. For example, reactive depression is described as a common, understandable reaction to pain and disability, rather than a sign of “mental illness.” Sexual dysfunction is not proof that one is “not a whole man,” and open discussion of the phenomenon can remove some of the guilt and anxiety which tend to maintain impotence. Patients may be assured that insomnia, although annoying, is not fatal. PsychophysiologicalElaboration Model
Imbalance in the autonomic nervous system and generalized disturbance of normal homeostatic mechanisms are presented to the patients as typical, correctable problems associated with chronic pain. Pain center therapy places considerable weight in the areas of Jacobsen’s relaxation training,4 autogenics training, and biological feedback techniques. These techniques are critical in teaching the
11
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
CHRONIC PAIN PATIENTS
patient to take responsibility for treating his own illness. Previously, results of the pain program have been p u b l i ~ h e d .As ~ an example of how the models can be implemented, the following case history is presented. A 29-year-old patient with a back injury of some five years’ duration entered the pain program after two lumbar laminectomies and the implantation of a dorsal column stimulator which were not effective. The patient was using large amounts of narcotic medication. Psychologically, he was found to be depressed, passive and dependent. He was in the pain program for three weeks. At the end of that time he was off pain medication and had demonstrated improved range of mobility. He was out of bed all day and stated that he felt better than he had since he had been injured. The patient continued to do well until a death in his family and some marital problems interfered, after which his dependency needs again became evident, with an increase in sick behavior.
represented, with rest, social reinforcement, and other rewards made contingent on healthy behavior. Economic models may be dealt with during the evaluation phase and form an important basis for the decision of whether or not a patient is likely to benefit from pain center treatment. Interpersonal factors are considered both in the day-to-day interactions with the patients, and in conjoint therapy designed to improve communication patterns. Cognitive models lead to extensive education, reassurance, and attempts to foster the acceptance of responsibility on the part of the patient. Finally, the psychophysiological elaboration model demands emphasis on relaxation through a variety of modalities including biological feedback training. When the milieu is functioning smoothly, many patients find significant relief from intractable pain problems.
INDEX TERMS chronic pain, therapeutic milieu, pain treatment.
SUMMARY
Establishing a therapeutic milieu for the treatment of chronic pain is a complex endeavor, requiring an appreciation of the pain problem for a number of different theoretical orientations simultaneously. Sensory models of pain, foremost in the traditional approaches, generate training in body mechanics, posture, exercise, and pacing, and are implicated in weight reduction and transcutaneous stimulation. Psychodynamic formulations are addressed through exploration of emotions and impulses, both individually and in educational sessions. Operant models are heavily
12
REFERENCES I . Weinstein. Morton R . “The Disability Process: Contribution of Service Agencies to Client Disability,” Compr. Psychiatry. Vol. 10. September, 1969, pp. 398-405.
2. Haley. Jay. Strutegies of Psychotherapy. Grune & Stratton, New York. 1963. 3. Sternbach. Richard. Puin Patients; Traits and Treatments. Academic Press, New York, 1974. 4. Jacobsen, E. Progressive Reluxation. U . of Chicago Press. Chicago, 1938. 5. Newman. R.I., J.L. Seres, L.P. Yospe. and B. Garlington. “Multidisciplinary Treatment of Chronic Pain: Long-term Follow-up of Low-back Pain Patients.” Pain. Vol. 4. 1978. pp. 283-292.
Journal of Human Stress
Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
A Therapeutic Milieu for Chronic Pain Patients Dr. Richard I. Newman Ph.D. a
a b
a
, Dr. John R. Painter Ph.D. & Joel L. Seres M.D.
a
Northwest Pain Center , Portland, Oregon, USA
b
Medical Psychological Services Published online: 09 Jul 2010.
To cite this article: Dr. Richard I. Newman Ph.D. , Dr. John R. Painter Ph.D. & Joel L. Seres M.D. (1978) A Therapeutic Milieu for Chronic Pain Patients, Journal of Human Stress, 4:2, 8-12, DOI: 10.1080/0097840X.1978.9934980 To link to this article: http://dx.doi.org/10.1080/0097840X.1978.9934980
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
A Therapeutic Milieu for Chronic Pain Patients
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
Richard I. Newman, Ph.D., John R. Painter, Ph.D., and Joel L. Seres, M.D.
Traditional means of treating chronic pain have been unsuccessful in a discouraging number of cases. Pain centers have appeared within the last f e w years, offering a more comprehensive view of the whole pain problem. Pain centers address pain as a multifaceted event with social, economic, physiological, and psychological representations. In addition, the pain center constructs an atmosphere that provides every opportunity for reduction of pain, while minimizing those factors that tend to encourage its expression. Such a venture calls for a multidisciplinary approach; it further demands a rather sophisticated grasp of numerous factors which do not necessarily lend themselves to discussion with a single vocabulary. This paper will attempt to describe a number of conceptual models of chronic pain and to demonstrate how each of these models is addressed therapeutically in a multidisciplinary pain center milieu.
CONCEPTUAL MODELS OF PAIN A model in the mathematical sense may be described as a set of elements together with a consistent set of rules which relate these elements. Elements include observations and non-observable hypothetical constructs. In order to be scientifically admissable, hypothetical constructs must be linked reliably to observable events. “Pain” is a hypothetical construct in each pain model - hypothetical because it is observable only to the sufferer. Seven overlapping models of pain are addressed: the sensory, psychodynamic, operant, economic, interpersonal, cognitive, and psychophysiological elaboration models. The authors are aifiliated with the Northwest Pain Center in Portland, Oregon. where Dr. Newmati is Director. Medical Psychological Services: Dr. Painter is Director: and Dr. Seres is Clinical Psychologist.
a
The Sensory Model Verbal complaints of pain, antalgic gait, restricted range of motion, and other such behaviors represent some pathophysiological condition. Correction of the pathological condition would be assumed to terminate the behavior. This traditional model assumes an isomorphic relation between two sets of events or elements: complaints of pain on the one hand, and the underlying organic pathology on the other. Frequent failure of surgical correction to alleviate pain complaints renders the latter assumption of isomorphism untenable. The sensory model also generates assumptions about termination of pain through interruption of the transmission of the pain signal, e.g., through cordotomy. An extension of the sensory model might be termed the perceptual model. in which the transformation of the sensation into perception
Journal of Human Stress
NEWMAN, PAINTER, SERES
could be disrupted, thus reducing pain. Activities and events, both internal and external, such as distraction, depression, or anxiety, have the potential of modifying the perception of pain.
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
Psychodynarnic Models
The primary psychodynamic model for pain is conversion hysteria. Here, distortion or repression of unconscious impulses is assumed to result in a sensory disturbance, i.e., pain. The process by which such a transformation takes place is not clear, and it is certainly not available to the sufferer. Elements in the model include verbal and nonverbal reports of pain or disability, and unconscious events. Unconscious processes are hypothetical constructs; although they may be unearthed through such processes as free association, hypnosis, or amobarbital interview, “uncovering” therapies are seldom useful in alleviating chronic pain problems. The model also invokes the important concept of secondary gain, a topic discussed below. Operant Models
The operant model states that pain behavior, like any other learned behavior, falls under the control of contingent rewards or punishment. Alterations in contingencies should thus lead to changes in the behavior. Observational learning and vicarious reinforcement extend the usefulness of the model in pain rehabiliation. Economic Models
Economic models examine the “payoff’ inherent in pain, and theorize that pain is not a problem rather, it may be the solution to a problem. For a variety of reasons, the organism finds himself in a state of disequilibrium; establishing a pain problem restores equilibrium. For example, pain may serve to remove a workman from a dangerous, monotonous, or dead-end job. For the “inadequate” individual, chronic pain may save having to attempt to compete in the job market and in an active social life. For patients who have sustained brain damage, as well as for the mildly presenile individual, chronic pain may serve as a more acceptable rationale for his obvious deficits. Morton R. Weinstein’s’ disability process model is an elaborate economic model. He relates the establishment of disability to a continuum beginning with a crisis occasioned by an increase in job tension or situational tension, compounded by
June. I978
vulnerability of character, followed by some propitious injury and completed with a gradual process of achieving a state of being “honorably disabled.” It can be argued that the concept of secondary gain should be subsumed under this heading, and separation of this aspect from psychodynamic conceptualizations appears to have heuristic value. Interpersonal Models
Jay Haley,’ in his elaboration of Milton Erickson’s works, has pointed out that any symptom must be viewed in terms of its communication value. Thus, pain symptomatology and pain behavior are seen as distortions of some other statement to people in the sufferer’s immediate environment. Such statements include, but are not limited to, expressions of anger or hostility, requests for sympathy or nurturance, or projections of responsibility. Richard Sternbach’s3 transactional analysis model of pain provides a wellformulated interpersonal model, which also includes elements of the economic model. Improved patterns of communication in such models are assumed to lead to reduction of the pain-oriented transactions. Cognitive Models.
Cognitive models of pain theorize that an individual’s affective experience, and thus his experience of pain, arise from his characterization of himself and his characterization of events. That is, what he tells himself about his situation or about his sensations determine the extent to which he is disabled. The patient who defines himself as disabled is far more inconvenienced by a chronic pain problem than is the individual who sees himself as a competent, potentially productive member of society. The patient who has unrealistic expectations about pain relief is likely to view moderate amounts of discomfort as a failure of treatment, and therefore an ominous and frightening signal. A surprising number of pain patients harbor the conviction that they are suffering from a malignancy or other serious disease, as yet undiagnosed; they do not share such concerns with their doctor, for fear that they will be confirmed. It is understandable that such cognitions lead to intense levels of anxiety, and much higher levels of pain “perception.” Two specific cognitive sets, or attitudes, are worthy of mentioning in this context. The selfperception, “I am a helpless victim,” is a cognitive set leading to stultifying passivity. The patient views
9
CHRONIC PAIN PATIENTS
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
his role as requiring him to describe his suffering as clearly as possible to the doctor, who is to assume total responsibility for alleviating the pain problem. Although the patient may do a few exercises in desultory fashion, this is done merely to gain the approval of his doctor, who is then expected to reward him by “curing” his pain. An adjunct to this attitude is the belief that all suffering is bad and must be alleviated. The contrasting attitude, which is the goal of the pain center, is the following: “ I am responsible for my condition and competent to deal with my pain.” The Psychophysiological Elaboration Model
This model proposes that chronic pain, in the presence of certain situational or personality variables, leads to a constellation of physiological responses which in themselves augment the pain and may further reinforce the disability. Autonomic responses associated with the “fight or flight” phenomenon may aggravate the pain directly, as in the case of increased muscular tension or migraine headaches. Such responses also increase the subjective discomfort or suffering of the patient, rendering him more disabled and less confident in his ability to cope with work and home settings. Examples include sleep disturbances, reduction in sexual adequacy, appetite dysfunction. anxiety and tension states, hyperhidrosis and “night sweats.” chest pains. and digestive disturbances. Control of such elaborations is assumed to reduce the pain problem. THE PAIN CENTER: A THERAPEUTIC MILIEU
To be successful, the pain center must address each of these conceptual models within the context of an integrated therapeutic milieu. A description of such a milieu proceeds with a sketch of the program at the Northwest Pain Center, a discussion of the 14hour-a-day milieu philosophy, and, finally, with a consideration of each of the pain models as it applied to the program. The Northwest Pain Center is an inpatient program typically involving about 25 hospitalized patients. Patients are admitted each week following a full-day comprehensive evaluation and educational session. The program runs for three weeks in most cases, with outpatient follow-up as needed. Admissions are staggered so that new patients have secondand third-week patients as role models: this feature is enhanced by assigning a “buddy” to each inconi-
10
ing patient. The program stresses self-help through appropriate posture and body mechanics, active physical therapy, a graduated exercise program, biofeedback, relaxation techniques and autogenics training, psychotherapy, communications training, conjoint therapy, and family assessment. Additionally, a comprehensive educational program deals with the progression of pain, the causes of pain, anatomy and physiology of pain, insurance and compensation factors, psychological and communication problems encountered with chronic pain, utility and outcome of various traditional medical and surgical interventions, and the identification of individual goals and non-goals. The staff consists of a closely knit team of physicians, psychologist’s nurses, occupational therapists, physical therapists and biofeedback technicians who meet frequently to exchange information about the patient’s programs. Patients are accepted on physician referral only. Each of the conceptual models of pain is addressed in the multidisciplinary pain center approach. Patients present with features common to more than one conceptual model but for simplicity each will be discussed briefly as an individual concept. Sensory Models
Usually, the traditional medical approaches to pain have been exhausted prior to referral to the pain center; the eventual aim is to achieve selfcontrol of pain problems on the part of the patient. Modification of the sensory aspects of pain is achieved directly through training in proper body mechanics and posture, exercises, dieting where necessary, and appropriate pacing of activities. The patient becomes the responsible agent for his own management, as opposed to the “do-for” approach. These aspects of the program also address the perceptual model of pain, in that exercising and concentrating on posture serve as a distraction. Most patients are educated in the use of a transcutaneous nerve stimulator, the aim of which is to reduce or block the transmission of the pain signal to higher centers of the nervous system. Follow-up evaluations demonstrate that frequency and duration of stimulator use decline; however, many patients use the device for “flare-ups” rather than returning to prescription analgesics. Psychodynamic Models
A comprehensive psychological evaluation prior to
Jo urn ril of
Hir i n ( i n Stress
Downloaded by [University of Iowa Libraries] at 22:56 13 March 2015
NEWMAN, PAINTER, SERES
admission, as well as a separate interview with the patient’s spouse, is used to determine the presence of secondary gain. A common feature of the “cureseeking” patient is a petulant, narcissistic anger which revolves around the frustration of unconscious dependency needs. These individuals are talented at eliciting tacit promises of help from the medical profession, subsequently defeating all efforts toward rehabilitation. In the pain center, such a strategy must be dealt with through consistent stressing of the self-help model, and scrupulous avoidance of implicit or explicit promises of benefit. Intensive exploration of the distant causes of psychopathology is not undertaken, nor are such ventures well-received by this population. Operant Models
Operant considerations form the basis for most day-to-day functioning in the pain center. Pain talk and pain behavior are ignored, with the explanation that talking about pain seldom does much to reduce it. Unacceptable behaviors are met with expressions of concern or affection to which the patient may have become accustomed. When patients insist on relaying complaints, they are instructed either to write the complaints down or to tape-record them for review by their doctor; this removes the reinforcement of attention from the staff. The second aspect of the operant conditioning program is consistent reinforcement of “well behavior” in an organized shaping program. Members of the staff have become keenly attuned to minor differences in behavior which can be seen as progress, and they are quick to reinforce such activities. For example, the patient may find herself or himself getting increased attention simply for smiling initially. Patients who are seen engaging themselves actively in the program are given substantial staff reinforcement. Other additional reinforcers of well behavior are used as indicated. Another important aspect of contingency management for the pain center program is the use of analgesic medications on a scheduled basis rather than “as needed.” A further advantage in the scheduled dispensing of pain medication is that the patient requesting full analgesic relief is awakened at 5:OO a.m. for that dose. A voluntary reduction is rewarded by the opportunity to sleep undisturbed for another two hours. Further, patients are given medication at the nursing station, and are obliged to
June. 1978
stand and wait; thus, the healthy behavior of being up and adhering to a schedule is rewarded. The staff is by no means the only source of reinforcement for well behavior. Most patients, particularly when they have progressed in the program to some extent, readily begin encouraging and rewarding other patients. At times, patients are observed rewarding inappropriate pain behavior by being “motherly” or overly solicitous; when this occurs, it is important to correct the behavior in individual or group discussion. Reality orientation regarding unrealistic expectations is achieved both through lectures and through frequent reminders about pacing activities. Many patients find themselves willfully overextending themselves when pain is minimal, with the inevitable result that they are “laid up” for one or two days following this endeavor. Some reduction in expectations, in conjunction with finding more appropriate goals, can assist in this problem. Successful use of the full spectrum of skills learned at the pain center - for example, appropriate posture and body mechanics, exercise, increased mobility and strength - can reinforce the patient’s cognition that he is a powerful agent in dealing with his own discomfort, rather than the helpless victim of medical and social institutions. Thus, he can face subsequent episodes of pain with considerably more confidence. Many other troubling cognitions commonly held by pain patients can be alleviated in educational sessions. For example, reactive depression is described as a common, understandable reaction to pain and disability, rather than a sign of “mental illness.” Sexual dysfunction is not proof that one is “not a whole man,” and open discussion of the phenomenon can remove some of the guilt and anxiety which tend to maintain impotence. Patients may be assured that insomnia, although annoying, is not fatal. PsychophysiologicalElaboration Model
Imbalance in the autonomic nervous system and generalized disturbance of normal homeostatic mechanisms are presented to the patients as typical, correctable problems associated with chronic pain. Pain center therapy places considerable weight in the areas of Jacobsen’s relaxation training,4 autogenics training, and biological feedback techniques. These techniques are critical in teaching the
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CHRONIC PAIN PATIENTS
patient to take responsibility for treating his own illness. Previously, results of the pain program have been p u b l i ~ h e d .As ~ an example of how the models can be implemented, the following case history is presented. A 29-year-old patient with a back injury of some five years’ duration entered the pain program after two lumbar laminectomies and the implantation of a dorsal column stimulator which were not effective. The patient was using large amounts of narcotic medication. Psychologically, he was found to be depressed, passive and dependent. He was in the pain program for three weeks. At the end of that time he was off pain medication and had demonstrated improved range of mobility. He was out of bed all day and stated that he felt better than he had since he had been injured. The patient continued to do well until a death in his family and some marital problems interfered, after which his dependency needs again became evident, with an increase in sick behavior.
represented, with rest, social reinforcement, and other rewards made contingent on healthy behavior. Economic models may be dealt with during the evaluation phase and form an important basis for the decision of whether or not a patient is likely to benefit from pain center treatment. Interpersonal factors are considered both in the day-to-day interactions with the patients, and in conjoint therapy designed to improve communication patterns. Cognitive models lead to extensive education, reassurance, and attempts to foster the acceptance of responsibility on the part of the patient. Finally, the psychophysiological elaboration model demands emphasis on relaxation through a variety of modalities including biological feedback training. When the milieu is functioning smoothly, many patients find significant relief from intractable pain problems.
INDEX TERMS chronic pain, therapeutic milieu, pain treatment.
SUMMARY
Establishing a therapeutic milieu for the treatment of chronic pain is a complex endeavor, requiring an appreciation of the pain problem for a number of different theoretical orientations simultaneously. Sensory models of pain, foremost in the traditional approaches, generate training in body mechanics, posture, exercise, and pacing, and are implicated in weight reduction and transcutaneous stimulation. Psychodynamic formulations are addressed through exploration of emotions and impulses, both individually and in educational sessions. Operant models are heavily
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REFERENCES I . Weinstein. Morton R . “The Disability Process: Contribution of Service Agencies to Client Disability,” Compr. Psychiatry. Vol. 10. September, 1969, pp. 398-405.
2. Haley. Jay. Strutegies of Psychotherapy. Grune & Stratton, New York. 1963. 3. Sternbach. Richard. Puin Patients; Traits and Treatments. Academic Press, New York, 1974. 4. Jacobsen, E. Progressive Reluxation. U . of Chicago Press. Chicago, 1938. 5. Newman. R.I., J.L. Seres, L.P. Yospe. and B. Garlington. “Multidisciplinary Treatment of Chronic Pain: Long-term Follow-up of Low-back Pain Patients.” Pain. Vol. 4. 1978. pp. 283-292.
Journal of Human Stress
