SUPPORTIVE PSYCHOTHERAPY

For most people the experience of chronic intractable pain is a psychologically devastating event. There is a tremendous undermining of self image, issues of competency, self esteem and motivation. Helplessness and hopelessness often set in after the patient realizes that there is no chance of recovering the old life and activity level. Protracted periods of inability to work consistently add to the psychological stress. Friendships suffer, social bonds become frayed, and family relationships are maximally strained. Finances are often decimated. Divorce rates are high among this patient population. Depression is extremely common and suicidal ideation often accompanies the despairing mood. Patients become overwhelmed, bitter and angry. This is often complicated by a medical legal process that by its nature questions the integrity of patients and the veracity of their pain complaints.

The need for supportive psychotherapy is obvious, given this all too common scenario. Without this type of psychological support, many more patients with chronic pain would give up. Ironically many of the most psychologically needy patients do not get referred to psychotherapy. Physicians fear offending patients with legitimate pain complaints by bringing up the idea that they may need psychological support. The workers compensation insurance company does not want to get stuck with the bill of extensive psychiatric care, especially since many pain patients have pre-existing psychiatric histories.

The problem is that it becomes far more costly to try to treat a patient with these problems without supportive psychiatric care. When the comorbid psychiatric illness is left untreated patients often consume medical resources at an alarming rate. Interventions fail, and battles are mounted with insurance carriers. Doctor shopping and medication misuse are freqently observed and emergency room visits and hospitaliations are common. When these cases are in the workers compensation system, they become impossible to settle and medical legal costs mount. Case management is often required and functional restoration programs are frequently necessary.

Obviously it is best to make these interventions early on in the process, but this is unusual and supportive psychotherapy can be useful anywhere along this psychological cascade. It is extremely important to keep the support tied to the presenting pain complaint in a focussed treatment. Open ended psychotherapy is rarely necessary or helpful. There are cases that may be appropriate for a longer, explorative treatment, but these are the exceptions. When patients are industrial, it is important to apportion their treatment to that related to their injury and that related to other factors.

The actual approach of supportive psychotherapy is one of active listening and of helping the patient to see alternatives to the spiral in which they feel trapped. Often interventions can be made with family, insurance carrier, and other physicians. The patient can be helped to understand the process of the changes that have occured to his or her life, so that they can begin to accept the appropriate level of disablility and move on with their lives. All of this should be done in the context of helping the patient get the pain under better control by all available means. The psychotherapist should take on the role of patient advocate, but in a way that helps the patient to move forward with the decision making process that promotes establisment of a meaningful set of plans and goals. Often, before this can be accomplished, the patient needs to be given the room to express sorrow, anger and hopelessness over the losses. The patient needs a sense that the supportive psychotherapist can handle the despair and hold onto hope for the patient's recovery. The psychotherapist must help the patient understand the difference between recovering and gaining back what has been lost. Most often, reestablishing the old way of living is not possible and the patient will have to come to terms with the changes that will have to be made. The supportive psychotherapist introduces these in a gentle, but firm manner. In this type of treatment, the tool of healing is the relationship between the patient and the psychotherapist. Often this is the first trusting relationship with a professional the patient has had in a long while. It should be seen as a bridge between the psychological and social isolation experienced by patients with chronically painful disabilities and reconnection to the world.