Faced with the societal emergency represented by chronic pain, with its major repercussions on both the individual and the community, this article focuses on the need for holistic and personalized care. While traditional approaches focused on drug treatment are often ineffective and addictive, he highlights the importance of a deeper understanding of the patient's experience.
Fair consideration of chronic pain and improvement of its management
The proper consideration of chronic pain and the improvement of its management are a societal priority both because of its frequency and because of its serious consequences on health and on individual and collective life. In some cases, it is even a real emergency given the significant risk of suicide. In the United States, it is estimated that nearly 11.2% of people suffer from chronic pain with a significant impact on disability, hospitalization rates and unemployment. Many North American patients are prescribed opioids despite their lack of effectiveness, side effects and dependence. (Hassan M 2018)
Long-lasting pain, like most chronic illnesses, is a complex multifactorial model. Drug treatment is not the only therapeutic key and the majority of patients who consult the hospital were not satisfied with their initial treatment. They are looking for other alternatives to feel better.
From Plato to Descartes, Western culture has constantly conveyed a mind-body dichotomy. This has led to an objectifying and rational attitude of the body sometimes reduced to an object that medicine tries to repair as best it can. As a result, bodily symptoms are often explained as pure biological events. It seems urgent to us to help people rediscover the overall meaning of their being, at multiple levels that interact with each other: biological, emotional, cognitive, relational, environmental, etc.
The provision of care, in all chronic illnesses, such as pain, must encompass different physical, psychological, personal and interpersonal spheres of the patient, to help them better understand and accept the illness that currently concerns them.
Thus, a so-called integrative approach is adapted to each patient with several therapeutic practices and coordination of the different actors involved in order to best respond to the specific problem of each person.
We consider that the patient is the main actor in his health. The role of the therapist is to promote and maintain an active and constant collaboration of the patient who becomes to a certain extent co-creator and partner of the treatment. Carl Roger underlined the importance of this helping relationship aimed at encouraging development and maturity in others, with greater flexibility in their life course. He advocates a non-directive pedagogy involving respect for autonomy and confidence in the patient's abilities. For the therapist, it is a question of focusing completely on the person who consults him by being present and available for them. Active listening promotes open-mindedness and sharing with a caring intentionality aimed at helping the person feel better despite their pain. The main core values advocated by Rogers are respect, empathy, kindness, acceptance, human warmth, honesty, simplicity and congruence. The originality of Rogers' therapy lies in its affective rather than intellectual orientation, favored by the exchange between the "client" and his therapist. The human being thus has immense resources within him, which can be exploited as long as he feels confident and thanks to the facilitative psychological capacities of the therapist. This person-centered approach aims to develop the potential for development and fulfillment.
However, there are 2 important limits to being able to effectively help these patients:
- Is the patient who consults the pain center a client of a change?
- Is he willing to participate and how far is he willing to go for change? So for example we can consider that we must suffer enough to be ready to do a 180° during certain therapeutic tasks.
In line with C. Rogers, we consider in our practice that it is the patient who decides what they want to change as a priority and as a result we strive to offer tailor-made therapy for each person. So we approach therapy as if we were going to meet the person for an unprejudiced discovery of the problem they wish to address here and now. The objective of our intervention is above all to reduce suffering whatever its origin and to improve the functional, relational and psychosocial aspects of the patient's life.
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the systemic interactional approach: advocacy to show its relevance
The strategic and systemic interactional approach seems particularly appropriate for patients suffering from chronic pain. We note that, whatever the symptomatic complaints expressed by patients, the context of life and past experiences play a considerable role, both physical pain and the moral suffering they express.
Sometimes we can be provocative by suggesting that pain could play an important role as a warning signal to implement significant changes in one's life. What do they think? So what would these changes be? We note that some are first surprised and then interested by this proposal, which in some ways is the opposite of a first position of rejection and eviction. Graham Hadley & Matthew B. Novitch (1989) propose the idea of highlighting pain that makes sense to the person. This new look at pain allows us to become aware of the attempts at ineffective solutions put in place until now to try to escape it: denial, eviction, functional and cognitive limitations and overall narrowing of the field of thought….
We then encourage the person to question themselves on a principle of usefulness to help them choose what really matters to them and allow them to consider certain changes “Does this thought or behavior help me move towards what I want for myself in my life or, on the contrary, is it preventing me from moving forward? ".
Our experience after 2 years at the pain center is part of a plea for rapid development of the field of psychotherapies in hospital pain centers. The human body, the intellect and the unconscious constitute a powerful and complex system which constantly interacts with the external world in a permanent relational context. It is easy to explain to the patient that if he implements changes in his life, the entire system in which he operates will change and in particular his relationships with others and also with himself.
To our knowledge, there are no predefined guidelines or protocols for approaching patients suffering from chronic pain in brief systemic therapy. Very little literature data is available on this specific subject while there are numerous publications concerning the management of chronic pain through hypnosis, acceptance and commitment therapy (ACT) or mindfulness meditation. For patients who above all want to improve the relief of their bodily pain: we offer as a priority the regular practice of full presence or the learning of self-hypnosis as a first intention. When a particular suffering is expressed by the patient and it is a priority therapeutic objective for him, we will use the same tools as for people who consult a therapist outside a pain center, focusing only on the complaint expressed. by the patient. We very frequently notice that it is not the pain complaint which is at the forefront but rather the expression of loneliness, abandonment wounds, assertiveness problems or traumatic events which affect the life of the person. person.
The systemic strategic model is entirely suitable and provides practical and relatively simple tools to use to help the patient get rid of a problem that bothers them in their life here and now; This is survival mode work to help him move from a “survival” mode to a “life” mode, in a more peaceful relationship with his symptoms. It allows the patient to learn to deconstruct his reality which confines him in order to escape from pain experienced as an identity and create another reality which leads him to think and act differently.
Conversational hypnosis and the use of metaphors accompany and in my view are part of systemic therapy. Likewise, certain LACT tools such as specific work on values or learning to demerge from toxic recurrent thoughts can also be very useful. In our experience, these different therapies can be used together during the same session or alternately over time as the therapeutic process evolves.
The risk for the doctor or therapist who consults in a pain center is to become locked into a sort of weariness and even a compassion that frays over time as patients repeatedly complain. This is why it is interesting to consider multifactorial care and to be able to benefit from a diversified therapeutic arsenal to offer each person tailor-made care. This diversification of practices is enriching because it stimulates the creativity of the practitioner and even the patient!
Our experience over the past 2 years at the pain center advocates for the end of a “body-mind” dualism and for an integrative and systemic medicine which takes into consideration the complexity of the person and the relational context in which they evolve from a systemic and constantly evolving.
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