Perspective
DR. BELL is chief executive officer and president of Community Mental Health Council Inc. in Chicago and serves as director of public and community psychiatry at the University of Illinoisat Chicago.
People who have chronic pain are extraordinarily clear about the devastating impact this problem has on their psychological balance. The resulting sense of helplessness often generates a great deal of grief, depression, stress, pessimism, and loneliness.
People who have never experienced severe, chronic pain, however, have no idea how disruptive it can be. Because of this, they may erroneously assume (and even suggest) that the pain is purely psychological or a sign of weakness of character or will–sentiments that further isolate and alienate the sufferers.
This isolation is exacerbated by the current health care culture. Although some understanding exists of the medical conundrum of pain, the psychiatric ramifications are very much an afterthought. The proactive approach of considering mind and body takes a back seat to the mechanistic approach of trying to heal the physical body while ignoring the mind.
This approach is rather typical of Western medicine and has its origins as far back as the Descartes doctrine of the distinction between the mind and body.
Because Western medicine focuses so intently on the mechanistic view of life and well-being, we don't have evidence of the efficacy of other, more esoteric forms of healing, such as acupuncture, meditation, prayer, and support group activities. We won't be able to collect such evidence until Western health care providers routinely begin to embrace non-Western approaches to health care that address issues of both the mind and the body.
Fortunately, science may be taking us in that direction. The mechanism of pain has been connected to the serotoninergic neurotransmitter system in the brain and body, which is also linked to depression. This connection suggests a potential route for therapeutic benefit of antidepressant medications for chronic pain.
Bridging the mind/body gap in our management of chronic pain is not impossible, but doing so does require a critical culture shift in which neither element takes a backseat to the other.
Pain Relief Is a Phone Call Away
Patients suffering from chronic, nonmalignant pain generally have to come to terms with the fact that finding a cure for their symptoms is an elusive goal. A more reasonable treatment target is pain management, often through some combination of analgesic medication and behavior modification.
In fact, numerous studies have shown that behavioral interventions–particularly cognitive-behavioral therapy (CBT) and self-regulatory techniques such as biofeedback and hypnosis–can significantly reduce pain intensity and improve emotional and physical functioning.
Ideally, after participating in a behavioral intervention, patients will regularly access and employ the various coping strategies they've acquired. Realistically, the likelihood that they will do so diminishes over time.
Although it may not be feasible to conduct open-ended behavioral intervention groups, pain specialists at the University of Vermont in Burlington may have developed the next best thing. Therapeutic Interactive Voice Response (TIVR) was developed to enhance the therapeutic outcome of patients who have completed a course of group CBT for chronic pain and to minimize their reliance on pharmacologic painkillers.
The first component of the TIVR enhancement is a daily self-monitoring questionnaire. Patients access the computerized interactive telephone system and respond by touch-pad to a series of questions that measure coping, perceived pain control, mood, medication, and stress. The objective is to improve self-monitoring of pain behavior, coping skills, and medication use, said TIVR principal investigator Dr. Magdalena R. Naylor, director of the university's MindBody Medicine Clinic.
If patients desire a coping skills “refresher,” they can access a didactic review that provides a verbal review of the various pain management skills learned during the CBT intervention, such as relaxation response, positive self-talk, cognitive restructuring, and distraction techniques.
The final component is a monthly feedback message: A therapist analyzes computer-collated, patient-specific data from the telephone response system and records a personalized message for participants summarizing the daily reports and offering insight into potential problem areas. This element is critical to the efficacy of the system, according to Dr. Naylor, as it is a vehicle for valuable feedback and an ongoing positive connection with the therapist.
In a pilot test of TIVR in a group of 10 middle-aged patients with severe, chronic musculoskeletal pain, regular use of the TIVR both maintained and strengthened the therapeutic gains associated with the CBT intervention (J. Pain 2002;3:429–38).
The Vermont investigators are currently replicating the TIVR study in a randomized, controlled trial.