Psychological treatment for pain can range from
psychoanalysis and other forms of psychotherapy to relaxation
training, meditation, hypnosis, biofeedback, or behavior
modification. The philosophy common to all these varied
approaches is the belief that patients can do something on their
own to control their pain. That something may mean changing
attitudes, feelings, or behaviors associated with pain, or
understanding how unconscious forces and past events have
contributed to the present painful predicament.
- Psychotherapy. Freud was celebrated for demonstrating
that for some individuals physical pain symbolizes real or
imagined emotional hurts. He also noted that some individuals
develop pain or paralysis as a form of self-punishment for what
they consider to be past sins or bad behavior. Sometimes, too,
pain may be a way of punishing others. This doesn't mean that
the pain is any less real; it does mean that some pain patients
may benefit from psychoanalysis or individual or group
psychotherapy to gain insights into the meaning of their pain.
- Relaxation and meditation therapies. These forms of
training enable people to relax tense muscles, reduce anxiety,
and alter mental state. Both physical and mental tension can
make any pain worse, and in conditions such as headache or back
pain, tension may be at the root of the problem. Meditation,
which aims at producing a state of relaxed but alert awareness,
is sometimes combined with therapies that encourage people to
think of pain as something remote and apart from them. The
methods promote a sense of detachment so that the patient thinks
of the pain as confined to a particular body part over which he
or she has marvelous control. The approach may be particularly
helpful when pain is associated with fear and dread, as in
cancer.
- Hypnosis. No longer considered magic, hypnosis is a
technique in which an individual's susceptibility to suggestion
is heightened. Normal volunteers who prove to be excellent
subjects for hypnosis often report a marked reduction or
obliteration of experimentally induced pain, such as that
produced by a mild electric shock. The hypnotic state does not
lower the volunteer's heart rate, respiration, or other autonomic
responses. These physical reactions show the expected increases
normally associated with painful stimulation.
The role of hypnosis in treating chronic pain patients is
uncertain. Some studies have shown that 15 to 20 percent of
hypnotizable patients with moderate to severe pain can achieve
total relief with hypnosis. Other studies report that hypnosis
reduces anxiety and depression. By lowering the burden of
emotional suffering, pain may become more bearable.
- Biofeedback. Some individuals can learn voluntary control
over certain body activities if they are provided with
information about how the system is working -- how fast their heart
is beating, how tense are their head or neck muscles, how cold
are their hands. The information is usually supplied through
visual or auditory cues that code the body activity in some
obvious way -- a louder sound meaning an increase in muscle tension,
for example. How people use this "biofeed-back" to learn control
is not understood, but some masters of the art report that
imagery helps: They may think of a warm tropical beach, for
example, when they want to raise the temperature of their hands.
Biofeed-back may be a logical approach in pain conditions that
involve tense muscles, like tension headache or low back pain.
But results are mixed.
- Behavior modification. This psychological technique
(sometimes called operant conditioning) is aimed at changing
habits, behaviors, and attitudes that can develop in chronic pain
patients. Some patients become dependent, anxious, and
homebound -- if not bedridden. For some, too, chronic pain may be a
welcome friend, relieving them of the boredom of a dull job or
the burden of family responsibilities. These psychological
rewards -- sometimes combined with financial gains from compensation
payments or insurance -- work against improvements in the patient's
condition, and can encourage increased drug dependency, repeated
surgery, and multiple doctor and clinic visits.
There is no question that the patient feels pain. The hope
of behavior modification is that pain relief can be obtained from
a program aimed at changing the individual's lifestyle. The
program begins with a complete assessment of the painful
condition and a thorough explanation of how the program works.
It is essential to enlist the full cooperation of both the
patient and family members. The treatment is aimed at reducing
pain medication and increasing mobility and independence through
a graduated program of exercise, diet, and other activities. The
patient is rewarded for positive efforts with praise and
attention. Rewards are withheld when the patient retreats into
negative attitudes or demanding and dependent behavior.
How effective are any of these psychological treatments? Are
some superior to others? Who is most likely to benefit? Do the
benefits last? The answers are not yet in hand. Patient
selection and patient cooperation are all-important. Analysis of
individuals who have improved dramatically with one or another
of these approaches is helping to pinpoint what factors are
likely to lead to successful treatment.
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