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.
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.
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.
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.
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.