Is the systemic approach relevant in a pain center?

General description of the model applied to care

The systemic practitioner's interventions typically take place in several stages. The first consists of clearly defining the problem by carrying out a selection then a synthesis of the information given by the patient and by concretely qualifying the facts on which it would be possible to act. In the second stage, clientelization, the quality of the therapeutic alliance is essential to gradually bring the patient to adhere to the definition of the problem proposed to him and to fully engage in the therapeutic process. This creates a new space for him where he can discover new solutions. The person regains their ability to act to take charge of their problem and becomes more independent. The therapist will then have to identify and stop the patient's attempts at redundant solutions which maintain his problem. Paul Watzlawick summarizes this paradoxical formula in a powerful sentence “when the problem is the solution” (Watzlawick P., Weakland J., Fisch R., 1975). It suggests establishing a complete inventory of attempted solutions and qualifying them in collaboration with the patient as success or failure. Attempts at ineffective solutions are considered failures. The objective is to make the patient understand that the solutions he has put in place to protect himself maintain and sometimes worsen his problem.

During the consultation and in order to continue to actively involve the patient between sessions, the therapist prescribes one or more “therapeutic task(s)” to get him to act 180° away from his attempts at ineffective solutions. The accomplishment of these concrete tasks by the patient develops his autonomy by making him responsible and leads him to live corrective emotional experiences . Throughout the interventions, the person learns to modify their interactions with the environment. It behaves differently, thus creating a new dynamic balance of the different relational systems in which it evolves, and favoring the emergence of new solutions to resolve its problems.

An adapted approach for the management of chronic pain

Psychosomatic pathologies such as chronic pain or fibromyalgia can be approached according to the Palo Alto school from a different angle than that proposed by classical medicine. Thus their chronicity is perceived as if they were the result of the implementation of attempts at dysfunctional solutions by the patient in a circular dynamic. Everything happens as if, in this type of pathologies, the patient in a certain way maintains the persistence of his symptoms and even aggravates his pathology by the behaviors he adopts while trying to protect himself from pain. We frequently find two types of redundant solution attempts: fight and avoidance. These two types of behavior can be present separately or simultaneously.

Fighting pain is a normal adaptive response. We persist in doing it doggedly because we are genetically programmed to avoid pain. This is particularly true for stimuli or events external to us. When it comes to our inner world, when we try to avoid certain thoughts, sensations and emotions, quite the opposite happens. For example, when we try not to think about a dark idea, it keeps coming back to our mind. This behavior is reinforced in our Western societies because happiness is perceived as an absence of painful perception. Suffering always appears as a problem to be solved as quickly as possible. The education system transmits to us, from a very young age, multiple injunctions such as “don’t cry”, “be courageous”, “be a man”. Negative emotions are seen as abnormal and we learn to get rid of them as quickly as possible. Thus the idea that we must control our pain to regain quality of life imposes itself with implacable logic in the heads of many patients (Dione F, 2014) . This control is further reinforced by the medical system which is increasingly confronted with an obligation to produce results under penalty of suffering the torments of the legal medico if there is a suspicion of loss of opportunity for the patient. For his part, he puts all his energy into the fight. He strains himself to act as if his pain did not exist and that he could overcome it through his will alone. He does everything not to think about it, making it a point of honor to never complain. Some continually engage in action, for example by working hard. This permanent struggle mobilizes a large part of the person's cognitive and behavioral resources. Many patients are totally exhausted and sometimes even burned out. We also often notice a lack of kindness towards themselves. They can become very demanding by setting the bar very high for themselves and imposing very strict self-discipline. These are then permanent injunctions such as " don't let yourself go, "you must succeed at all costs", "you have no right to complain..." It has sometimes happened to me to notice that this rigor can be translate into real abuse of the body. This could involve practicing a sport excessively to the point of exhaustion. It is then the body which fights back with increasingly intense nociceptive messages and the person ends up understanding that they cannot continue like this. This is often what leads him as a last resort to seek help from the pain center after having exhausted all existing medication resources. These very stoic people consult the pain center late. They feel helpless and a failure and experience real resentment for what they consider to be their weakness and lack of will. It is not uncommon for generalized anxiety and depression to quickly complete this clinical picture.

It is important to help them relieve their guilt as quickly as possible by explaining to them that until now they have done their best in the context they are faced with. Fighting against their own emotions is for them the best way they have found so far to cope. We invite them to see for themselves that despite all their efforts: it doesn't work! This time for explanation is very important and contributes favorably to building the therapeutic alliance. It allows them to finally be able to lay down their weapons to share their suffering by discovering that another type of cooperation is possible with a therapist.

In a systemic approach, the patient could be asked the following questions to make them aware of the ineffectiveness of their attempts to solve their problem. “ What do you do when you’re in pain?” Are you trying to control your pain through willpower? », “Is this control effective for you? ". “How do you feel after a day of pretending the pain doesn’t exist?” “What is your struggle with pain costing you? ", "How can you begin to concretely imagine your new life without struggle? » Through these types of questions the person can be led to understand that it is perhaps their vain and ineffective struggle which is at the origin of their problems. The Palo Alto approach allows the patient to symbolically make peace with their pain. It's about being able to observe it with a certain indifference and perhaps even communicate with it instead of fighting it. The proposal is to establish a more peaceful coexistence with her. A first task could be to ask the patient to recognize the moments when their pain manifests itself and just to observe its presence and its characteristics a bit like an anthropologist who would observe a scene from a distance, as a witness and with a certain detachment. A 180 degree therapeutic task could consist of prescribing him to voluntarily summon his pain at several specific times of the day and for a specific duration. So we can say to the patient concerned: “Every morning at 9 a.m. and every evening at 9 p.m., can you go to your room alone and voluntarily call out your pain for precisely 10 minutes with the help of an alarm and this every days until our next session? ". He could also keep a sort of diary of her pain, the qualifiers he gives her and the emotions that arise when he summons her. (Nardone G, Watzlawick R, 2000).