Transcript Dynamic Psychotherapy for the Patient with Persistent Pain

Dynamic Psychotherapy for the
Patient with Persistent Pain
Dr Stephanie Oak
Liaison Psychiatry
What is Psychotherapy?
• “the talking cure”
• “conversations with a listener who is trained to
help you make sense of, and try to change,
things that are troubling you”
• Patient as active participant
• Over 200 varieties
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Behavioural
Cognitive
Person-centred / humanistic
Systems
Psychoanalytic / psychodynamic
What is dynamic psychotherapy?
• Started with the discoveries of Freud over 100 years ago
• Concerned with the meaning of experience and
behaviour
• Crystallises out of shared exploration between therapist
and patient
• Looks beyond what we know and remember to what is
buried and secret (unconscious)
• Leads us to a fuller sense of our motivations, intentions,
feelings, how we act & the way we are
• Not just for the sake of creating psychological
explanations but to help dismantle the obstacles that
stop us resolving issues or moving on in our lives.
Does dynamic psychotherapy
work?
• 5 RCT psychodynamic therapy superior to TAU
control conditions in
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IBS (Svedlund, 1983; Guthrie, 1991)
Functional dyspepsia (Hamilton et al, 2000)
Somatoform pain disorder (Monsen & Monsen, 2000)
Urethral syndrome (Baldoni et al, 1995)
• Reduction in pain and other physical symptoms,
reduced health utilisation and reduction in
psychological symptoms.
Pain as a focus for psychotherapy
• Surprisingly little psychoanalytic literature
on the subject of chronic pain
• “If Irma’s pains had an organic basis, I
could not be held responsible for curing
them; my treatment only set out to get rid
of hysterical pains” (Freud, 1900)
• Engel (1959) “the pain prone patient”
encouraged widespread adoption of
concept of “psychogenic pain”.
The pain prone patient
• Focused on psychodynamic factors involved in
pain pathogenesis
• An unconscious need to suffer
• A response to a real, threatened or fantasised loss
• Conflicts or guilt over intense aggressive or forbidden sexual
impulses
• Highlighted link between chronic pain and a
history of distressing life experiences
• Saw pain as a subjective experience, like an
affect or emotion, which, once represented
mentally, no longer needs peripheral stimulation
to be provoked.
Pain in therapy
• Psychological vulnerabilities to pain (which are
largely unconscious), can be embedded in the
neuromatrix waiting to be activated by some life
event.
• How are psychological processes operating to
determine the ultimate character of the pain
experience of the patient and it’s manner of
communication to the physician?
• Identify and explore these unconscious
vulnerabilities, and through resolution of
conflicts, alleviate symptoms.
Why patients with persistent pain
are difficult to engage
• The typical pain patient……
• Difficult to establish a rapport
• Asking them to make an extreme
conceptual shift
• Taking away their accustomed way of
coping (before you take away the pain)
Who is likely to benefit from
dynamic therapy?
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Accept the concept of an unconscious mind
Be aware of mental pain
Be ready to receive help
Have reasonable verbal skills
IBS
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One site of pain
“shorter duration”
Presence of anxiety/depression at intake
Absence of constant pain
Short term dynamic therapies for
persistent pain
Mrs A (Whale, 1992)
• Pain Clinic Addenbrooke’s Hospital, Cambridge,
UK
• Patient questionnaire
• Exclusion criteria
• All offered 1.5 hr psychodynamic assessment
• Identified an early memory + any clear focus of
unresolved psychological conflict which might be
influencing the pain
• 4 therapy sessions, 50 mins
• F/U 6 mths and 1 year
Mr B (Stern, 2003)
• St Mark’s Hospital, Middlesex, UK
• Employs a psychoanalytic psychotherapist
• 9 sessions, initially sporadically then 6
weeks in a row
• Onset of symptoms and their link with
issues surrounding loss, sexuality,
unacknowledged murderous impulses and
guilt
Mrs C (Monsen & Monsen, 2000)
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Employees of a large Norwegian office company
Fulfilled criteria for Pain Disorder (DSM IV)
Pain not associated with work-related injuries
33 sessions of psychodynamic body therapy
– Explore affect experience
– Look at how certain maladaptive experiencing or
expressive patterns are linked to other people and to
their representations of significant others
– Bodily interventions include massage grips & specific
exercises to accelerate the psychotherapeutic
process by making affects accessible to conscious
awareness