Marilyn S. Jacobs, PhD, works in a highly specialized area of mind-body medicine: assessing and treating people who are considering surgery to relieve intense pain.
"It involves basic science, clinical medicine, psychology, psychiatry, end-of-life issues--even religion and politics," says the Los Angeles practitioner.
The area also fascinates her from a psychological perspective: Research confirms that pain has a large perceptual component, such that two people with the same degree of physical trauma can experience pain very differently depending on their psychological states. Therefore, behavioral interventions--sometimes in conjunction with surgery--can make a huge difference in the quality of people's lives, and psychologists play a crucial role in that work, she says.
Jacobs has worked in the pain arena for 17 years, first at CIGNA Health Plans, then at the University of California, Los Angeles (UCLA) Pain Management Center and now in private practice. In all three settings, she has collaborated with pain medicine specialist Joshua P. Prager, MD, to identify good candidates for the surgeries in which Prager specializes. Pain physicians recommend surgery only when a tiered approach of less invasive method such as medications, physical therapy, biofeedback and injections have failed.
Psychology's relevance in evaluating and treating pain goes back to Freud's studies in hysteria, Jacobs notes. But it gained scientific credibility in the 1960s when physicians began observing that patients' pain complaints and loss of functionality did not always coincide with tissue damage. As pain interventions evolved to include surgeries that would require people to take active roles in their rehabilitation, practitioners increasingly saw the need for psychological evaluations that could assess people's ability to cope with more invasive treatments.
Jacobs's expertise is crucial to his professional success, says Prager, who directs the Center for Rehabilitation of Pain Syndromes (CRPS) at the UCLA Medical Plaza.
"Dr. Jacobs is invaluable in helping me figure out the patient," he says. "If you merely take a person's pain away, but they're the same person they were before surgery, they're usually not very well-equipped to start dealing with life again."
At CRPS, Prager consults with many patients who have disabling, multifaceted and longstanding pain problems, many of whom have not had any type of behavioral intervention for their pain.
Patients have a variety of issues to confront. Some, for example, may come to rely on pain to organize their emotions, and without it, feel ill-equipped to deal with normal life problems, Prager says. In addition, the trauma of physical pain can be significant and cause losses in functioning, relationships and social roles that can't be completely repaired, even if the pain is reduced.
"That is where psychological insights are crucial," says Jacobs. "They help us to understand the mental processes that accompany the pain experience."
Prager conducts two types of surgeries for patients who have not benefited from more conservative approaches, including people with spinal problems and central nervous system diseases. Using a technique called neurostimulation, he implants an electrical generator in the buttock that is attached to a wire tunneled under the skin to a location near the spine where the pain originates. The generator emits an electrical impulse that alters pain signals to the brain.
With the other surgery, neuraxial drug administration, he implants a pump in the abdomen that is attached to a catheter, again positioned near the locus of pain in the spine. The device delivers regular microdoses of pain medication to the site, allowing the patient to benefit from a lower dose of opiates or other pain medications, thereby reducing or eliminating side effects such as cognitive impairment, drowsiness and constipation.
Because the surgeries require significant recovery time and mental adjustment--as an example, the stimulator emits a continuous low vibration in place of the pain--it is vital that people be psychologically prepared to cope with the device on a long-term basis. In addition, patients must be prepared to accept the reality that their pain will not completely disappear: Because the techniques reduce pain by just 60 percent to 80 percent, patients need to develop psychological coping techniques, Jacobs says.
"The technology is life-changing for selected patients," she says, "but they have to be well-suited and well-prepared."
What makes a patient a good candidate? To answer that question, Jacobs conducts a psychological evaluation prior to surgery and provides therapy to candidates who aren't immediately ready for surgery but could be if treated for problems such as severe anxiety or mood disorders, suicidal thinking, substance abuse or other emotional patterns that can influence pain perception.
In the psychological evaluation, Jacobs talks with candidates about their experience with pain and pain treatments, as well as about their emotional states, current living situations and their developmental histories. She also performs a mental status exam and administers psychological testing using measures standardized on medical and psychiatric patients. If possible, she interviews the patient's significant other as well.
Factors that may lead her to decide that a patient is not suitable include severe psychological symptoms, chemical dependency, unrealistic expectations of the device and poor response to past pain treatments.
"If a person's emotional problems are sufficiently severe, it will be difficult for them to change their perception of pain despite the objective benefits of the implantable device," she says.
After the evaluation, Jacobs and Prager discuss their findings. Typically, they consider about a third of candidates ready for surgery and another third too physically or psychologically vulnerable to undertake it. With the remaining third, they recommend more evaluation--either a weeklong, noninvasive trial that mimics the surgery and includes observations on how the person is coping, or short-term therapy that includes the trial at the end.
In therapy, Jacobs uses both cognitive behavioral and contemporary psychoanalytic techniques to better understand patients' perception of and adaptation to pain. Psychoanalytic therapies are especially helpful, she finds, because they provide an understanding of the personal meaning of the person's pain. If patients feel their pain experience is understood, she says, they can change their perceptions of their pain, which in turn can improve their functioning.
Therapy, she adds, can help some patients prepare to cope with the challenges of surgery and its aftermath.
"Medicine today is so dominated by evidence-based practice and technology that physicians often don't have time to take the subjective experience of the patient into account," she says.
Needed: More psychologists
Given psychologists' contributions, pain physicians not only respect colleagues like Jacobs but are eager to find them, Prager says. However, few psychologists are trained specifically to work with pain patients, he says, though many psychologists work with pain patients in hospitals, pain services and private practices throughout the country.
Clinical and health psychologists can overcome this void through several means, such as choosing rotations in pain services as part of their internships and working with pain medicine physicians. Jacobs herself supervises health psychology interns at the UCLA department of psychiatry and Biobehavioral Sciences Medical Psychology Program and teaches physicians in training at the UCLA Pain Management Fellowship Program.
Reimbursement can be thorny for a variety of reasons, Jacobs admits, including difficulty getting authorization from third-party payers. (An exception is Medicare, which doesn't require prior authorization.) She does maintain contracts with several health-maintenance organizations; she also charges many of her patients up front and some at reduced fees, rather than going through the insurance system.
Despite these obstacles, Jacobs strongly encourages anyone interested in applying psychology to medicine to consider working in this compelling and growing area.
"Psychologists have a tremendous potential to improve the outcome of the medical care of pain patients," she says. "It is very rewarding to see the impact we can have on increasing the effectiveness of medical treatment and reducing people's suffering."
Tori DeAngelis is a writer in Syracuse, N.Y.
Heckler, David R., et al. (2007). Presurgical behavioral medicine evaluation (PBME) for implantable devices for pain management: A 1-year prospective study. Pain Practice, 7(2), 110-122.
Prager, J. & Jacobs, M. (2001). Evaluation of patients for implantable pain modalities: medical and behavioral assessment. Clinical Journal of Pain, 17(3), 206-214.
The American Academy of Pain Medicine, www.painmed.org. The organization's 25th annual meeting is Jan. 28-31, 2009, in Honolulu.
The American Pain Society, www.ampainsoc.org. The society's 28th annual scientific meeting is May 6-9, 2009, in San Diego.
For more information on the surgical procedures and devices described here, visit the Web sites of the following manufacturers, whose devices all have been approved by the Food and Drug Administration:
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