Page 35 Guide to Pain Management in Low-Resource Settings

Psychological Factors in Chronic Pain 23

these activities after the end of therapy. Often, however, Educating the pain patient
therapists must not only encourage activities, but also
plan phases of rest and relaxation to make sure patients Fear of pain and anxiety about having a “serious” dis-
do not overly exert themselves. ease are important factors in the chronifi cation process.
Cognitive-emotional modifi cation strategies, Uncertainty and the lack of explanations are signifi cant
on the other hand, predominantly focus on changing factors contributing to the patient’s worries. Fearful as-
thought processes (convictions, attitudes, expecta- sumptions regarding the presence of a serious illness
tions, patterns, and “automatic” thoughts). Th ey focus have negative behavioral consequences and foster pas-
on teaching coping strategies and mechanisms. Th ese sive pain behavior. To reduce this uncertainty, patients
are various techniques that teach patients a new, more should be provided with information and knowledge
appropriate set of cognitive (and behavioral) skills to using written or graphic materials as well as videos. It
help them cope with pain and limitations. Patients is especially important that the training should not
are taught, for example, how to identify thoughts that criticize the patient’s often very simplistic somatic pain
trigger and sustain pain, how to perceive situational concept, but rather expand on the patient’s subjective
characteristics, and how to develop alternative cop- theories about the disorder, thus opening up new ways
ing strategies. If patients are taught appropriate coping of how the patient can be actively involved. Based on
techniques, they are better able to control a situation; easy-to-understand information on pain physiology and
new confi dence in their abilities leads to a decrease psychology, psychosomatic medicine, and stress man-
in feelings of helplessness, and patients become more agement, patients should be able to understand that
proactive. One of the goals of therapy is for patients to pain is not only a purely somatic phenomenon, but is
learn to monitor the function of expressing symptoms also infl uenced by psychological aspects (perception, at-
(something patients are usually not aware of) to be tention, thoughts, and feelings). Informational materials
able to better manage and manipulate their social en- are an important addition to therapist-linked activity,
vironment. Th e therapy should teach appropriate so- and patient education is an important therapeutic ele-
cial skills, for example, about how to assert one’s own ment that can form the basis for other interventions.
interests to prevent the pain behavior from taking on Successful, informative training provides patients with
this (so-called “instrumental”) function. the foundation they need to jointly develop and select
Functional problem analysis is another im- therapy goals.
portant tool of behavior therapy. During the course
of this analysis, patients and their therapists system- Relaxation techniques
atically collect information on how internal or external
events are connected to the pain experience and pain Relaxation techniques are the most commonly used
behavior. At the same time, detailed information is col- techniques in psychological pain therapy and consti-
lected on the eff ects of the behavior and the functions tute a cornerstone of cognitive-behavioral therapy.
the behavior might have (e.g., in the professional en- Th ey are eff ective because they teach patients to inten-
vironment or in personal relationships). By analyzing tionally produce a relaxation response, which is a psy-
these situations, it is possible to develop an overview chophysiological process that reduces stress and pain.
of how the pain experience is incorporated into situ- Well-done relaxation exercises can counteract short-
ational, cognitive-emotional, and behavioral aspects term physiological responses (at the neuronal level)
and how it is maintained. Th is analysis can then be and prevent a positive feedback loop between pain and
used to make further assumptions about the patient’s stress reactions, for example, by intentionally creat-
pain triggers and maintenance conditions, followed by ing a positive aff ective state. As patients progressively
goals and initiatives that could break the pain cycle. learn these techniques, they are better able to recog-
Particularly important for the analysis of these condi- nize internal tension, which also makes them more
tions is the patient’s self-observation with the help of aware of their personal stress situations and triggers
pain diaries. Th e analysis can also be the basis for the (at the cognitive level). Some techniques (e.g., progres-
patient’s own education, especially if the patient’s de- sive muscle relaxation) often lead to better body per-
scription specifi es overall assumptions regarding the ception in terms of tight muscles, which can help iden-
pain, its prognosis, and its treatment. tify stressful situations.