Psychology and pain management

IT WAS WONderful to see the April cover articles on the treatment of chronic pain. Chronic pain is a major health epidemic affecting millions and is now receiving the attention from the health-care system that it merits. The focus of the feature articles, however, was solely on cognitive-behavioral approaches to chronic pain. Chronic pain is a multifactorial biological and psychosocial condition. The subjective experience of pain is influenced by affective, cognitive, behavioral and cultural factors, among others. Premorbid as well as reactive psychological disorders are associated with pain outcome, and affect dysregulation, history of trauma and interpersonal functioning are believed to play a role in chronic pain experience. Contemporary psychodynamic theory addresses the role of affect, trauma and interpersonal functioning in the context of somatic suffering, and psychodynamically oriented psychologists utilize the therapeutic relationship to improve relational functioning, increase awareness of the mind-body relationship and bring about behavior change in these patients. Due to the complex biopsychosocial and multifactorial nature of chronic pain, the most suited psychotherapeutic approach is an integrated one.

Cognitive and behavioral approaches are essential in chronic pain treatment. However, a pain psychotherapy that excludes an integration of a psychodynamic understanding of the complex relationship between affect, cognition, interpersonal functioning and developmental history runs the risk of being a limited model. Pain patients warrant the best comprehensive psychological care that the profession has to offer.


Bellevue Hospital Center, New York

I WANT TO EXPRESS MY APPRECIATION to you for running recent articles on pain. My early writings dealt extensively with this topic. My conclusion was that the patient's subjective pain experience is affected not only by cultural background, the meaning of the situation and anxiety, but also by the form of the patient's spirituality. Spirituality that is expressed in an emotional-experiential manifestation ameliorates the patient's subjective pain experience.

From a counselor's perspective, the most effective way of helping the patient who is suffering with chronic pain is to "be" with the patient. This "being" involves genuine care, warmth and empathy without any particular psychological theory or religious truth. This is true regardless of whether the patient's religious orientation is rational or emotional.


Los Angeles

More on prescription privileges

DR. NEWMAN'S APPEARANCE on the NBC "Today" show to discuss the New Mexico law allowing for prescribing psychologists was well done. I would like to suggest that a few other issues be emphasized in these discussions that might help the general public to better understand the issues:

  • The PhD/PsyD psychologist must complete four years of college plus four to six years of graduate school studying the science and practice of psychology before being awarded the doctoral degree. This is then followed by a clinical internship and postdoctoral supervised training before being licensed to practice psychology. The length of training is similar to what physicians have to complete.

  • Psychologists typically spend more time with patients with psychological problems than physicians do. In fact, psychologists are the professionals who coordinate our care with physicians.

  • The research from the Department of Defense training of prescribing psychologists has demonstrated that psychologists depend on their knowledge and skills to bring about behavioral change. Psychologists were not seen to be prescribing more because of their ability to prescribe. In fact, prescribing psychologists actually prescribed medications less than psychiatrists. Psychologists were also found to be responsible prescribers without all the negative consequences that others have predicted "might" happen.


Eugene, Ore.

ALTHOUGH THE DISCRETE skills of prescription choice can be taught in a handful of seminars, the skills required for addressing medication side effects necessitate a medical education. For example, with a very difficult depression requiring MAO inhibitors, the medical complications from the patient's compliance can become quite nasty, if not life threatening. If my patient develops diarrhea soon after starting Paxil, do I know if it is a temporary side effect or an indication of food poisoning, the flu, etc.? I have always viewed psychopharmacology as a branch of internal medicine, not psychology. If psychiatrists are not available, a better standard of care for the patient would be provided if psychologists would work with the patient's internist or primary-care provider to prescribe medication. Although I could carve out a particular medical syndrome (e.g., diabetes) and spend a few hundred hours in seminars learning how to treat the disease, I suggest you do not take your relatives to see me for treatment. I would not have the concomitant skills to treat any medical crisis that could possible occur.


New York, N.Y.

'Ethics Rounds'

I FIND THE EXPERT ETHICAL advice in the March Monitor's, "Confidentiality in the treatment of adolescents" disturbing. Despite the law that says "a parent who consents on the minor's behalf generally has the right to know the content of the child's treatment," the authors claim that "good clinical treatment may require what the law generally refuses, that is, a zone of privacy." Should "good clinical practice" oppose the law, and require a therapist to withhold information needed to protect a child?

The authors seem to answer affirmatively in the vignette where mandatory reporting is deferred and left to the child. Here, a boy tells his therapists he has lied to his parent, attended all-night "rave" parties with drugs, is shoplifting and having unprotected sex with a minor girl. The therapists acquiesces to the minor's wish not to inform his parent, spends several sessions advising him of "her discomfort with...the illegal activities," and points out their risks. Over time, the boy agrees to "begin to speak to his mother about these issues." During this delay, however, high-risk activities may continue.

A parent informed at once by the therapist could take preventative action, and seek additional professional help before further harm occurs. Children have died at raves, become addicted to drugs, been arrested for theft and have experienced unwanted teen pregnancies. STDs are epidemic. Families have been emotionally and financially devastated, therapists sued and licenses revoked. This is too high a price for a minor's privacy.


Los Angeles

Executive coaching

I'VE BEEN DOING EXECUTIVE coaching since 1990 and want to offer my kudos for your well-balanced article on the subject.

I'd also like to emphasize that psychologists have a tremendous amount to contribute as coaches because we have a sophisticated understanding of human behavior and the conditions that can lead to shifts in behavior and perspective. Many of my clients are talented executives who are having problems with some aspects of their organizational relationships. Strong clinical skills are essential in working successfully with them.

I would highlight two other critical competencies for this work that might be classified under the heading of "courage." These are: 1) The ability to structure effectively the contracting phase of the relationship with all of the parties involved so that expectations are clearly understood and 2) The willingness to confront an executive and disagree when his or her behavior is inauthentic and, therefore, undermining the work.

I suggest that psychologists continue the dialogue on the background and skills for executive coaches and discuss further how psychologists who want to pursue this work can acquire those skills and background.


Hillsdale, N.Y.