Page 33 Guide to Pain Management in Low-Resource Settings

Psychological Factors in Chronic Pain 21

Psychological pain therapy go slowly in the right direction than quickly in the
wrong direction”).
Psychological interventions play a well-established role • Medications must be taken in accordance with a
in pain therapy. Th ey are an integrative component of schedule and not just when needed.
medical care and have also been successfully used for • Gradually confront situations that create anxiety
patients with somatic disorders. Together with psycho- (e.g., lifting heavy objects, rotation movements,
therapeutic techniques, they can be used as an alterna- or sudden movements).
tive or an addition to medical and surgical procedures. • Behavioral changes are not given as doctor’s or-
Patients with chronic pain usually need psychological ders, but are taught through carefully worded in-
therapy, because psychosocial factors play a crucial role formation (education).
in the chronicity of pain and are also a decisive factor in • Psychological therapy is combined with medical
terms of enabling the patient to return to work. and physiotherapeutic procedures.
Below is a list of psychological interventions and Interdisciplinary teams, with a biopsychosocial
their usual therapy targets. Th e targets refer both to indi- treatment concept, do not distinguish between somatic
vidual and group therapy. Th e interventions may be used and the psychological factors, but treat both simulta-
within the context of various therapies and require diff er- neously within their individual specialties and through
ent levels of psychological expertise, as shown in Table 1. consultation with one another.
Due to the strong focus on physical processes,
certain processes such as biofeedback and physical and
Behavioral therapy interventions
psychological activation are particularly well received by
many patients. Patients with chronic pain often feel in- Psychological pain therapy methods attempt to change
capable of doing something about their pain themselves. pain behavior and pain cognition. Behavioral processes
Due to many failed therapies, they have become passive are geared toward changing obvious behaviors such as
and feel hopeless and depressed. Th erefore, one main taking medication and using the health care system, as
goal of psychological pain therapies is to decrease the well as other aspects relating to general professional,
patient’s subjective feeling of helplessness. private, and leisure activities. Th ey focus particularly
Th e patient’s active involvement is not always on passive avoidance behaviors, a pathological behavior
helpful, particularly if the patient cannot actively man- showing anxious avoidance of physical and social activ-
age and change what is going on. Th is can occur if free- ity. One signifi cant aspect of this therapy is to increase
dom from pain is seen as the only therapy target. It is activity levels. Th is step is accompanied by extensive ed-
not uncommon that the resulting disappointment, with ucation initiatives that help reduce anxiety and increase
its far-reaching impact on all areas of life, becomes the motivation to successfully complete this phase.
patient’s actual problem. One of the “protection factors” Th e goal of therapy is to reduce passive pain be-
against depression is the patient’s fl exibility in adjusting havior and to establish more active forms of behavior.
personal goals: a lack of fl exibility results in intense pain Th e therapy begins with the development of a list of ob-
and depression. jectives that specify what the patient wants to achieve,
Acceptance does not equal resignation, but e.g., to be able to go to the soccer stadium again. Th ese
allows for: objectives must be realistic, tangible, and positive; com-
• Not giving up the fi ght against pain, plex or more diffi cult objectives can be addressed suc-
• A realistic confrontation of the pain, and cessively, and unfavorable conditions must be care-
• Interest in positive everyday activities. fully taken into consideration. It does not make sense
Th e most important psychological therapies are to encourage a patient to return to work and to make
based on the principles of the theory of learning and this an objective if this is unlikely, due to the conditions
have led to the following rules: on the job market. A better therapy objective might be
• Let the patient fi nd out his or limits with regard to achieve better quality of life by getting involved in
to activities such as walking, sitting, or climbing meaningful leisure activities. Expanding one’s activi-
stairs, with no signifi cant pain increase. ties also makes social reintegration (with family, friends,
• Plan together gradual, systematic, and regular in- and associates) more likely. Th e support patients receive
creases and set realistic interim goals (“better to in therapy makes it more likely that they will continue