In search of the lost symptom

"The drug removes the symptom, but it does not help to deal with what has led to being sick. Psychotherapy removes the symptom and allows us to face the difficulties that led to the development of the symptom ".

Mh.

Calm. Let's keep our heads. As a basic assumption, it can work.

Psychotherapy has led to a demand for renewal in relation to a tendentially mechanistic vision, in some way functionalistic, of the human being. However, we cannot consider psychotherapy a panacea for all ills or, at least, not in the case of persistent pain. If psychotherapy has changed the view of the human being, which therefore is not a machine, it seems to have jammed on one of its fundamental premises. Pain is considered as an expression of dissociation from emotional trauma: it seems to be an axiom. But is it really an axiom? Persistent pain challenges it, in a scientific way.

Although there are predictive psychosocial factors (emotional trauma, adverse socio-family conditions ...), these are not a sufficient condition for the development of persistent pain (not all those who have persistent pain, have experienced such conditions): pain necessarily has a demonstrable and verifiable biological basis (including nociplastic pain, for which structural and functional cortical changes are appreciable - the famous pain "which is nowhere to be seen").

If pain is a problem on an organic basis, it is not human to think of treating it with exhausting psychotherapy sessions in search of lost trauma, which may not exist (and often does not exist). Rather, it would be useful to renounce the premise pain = dissociation and stop considering people with persistent pain as sick people: they have a disease, they are not their disease, provided that persistent pain is a disease, rather than a (psycho) physical condition.

Scientifically, neurosciences question the premises of psychotherapy. A person with persistent pain is not a sick person, he is a person who lives a (psycho) physical condition, but he is not to be identified with his problem, with his difficulty, with his painful condition, he is a person who needs to be treated, but not in medical terms: he needs to be accepted, tout court. The aim of “cure medically intended” is to lead to the condition prior to that of the disease: it is often not possible. Psychotherapy, accepted all these assumptions, should be genuinely open to these new demands.

The Science of Pain, is a new science, which looks at an ancient problem with new eyes. It is not possible to think of finding innovative solutions while remaining anchored to old prejudices. Psychotherapy, which at the dawn of the twentieth century became the bearer of a revolution, has the possibility of renewing itself by playing a new and very important role, giving people with persistent pain different looks and alternative tools to deal with their own experiences in a constructive and effective way , detaching itself from the old vision of which we have spoken that, in this case, demonstrates its ineffectiveness.

In the case of persistent pain, intervention on the symptom is not useful, because we act with the idea that it is the manifestation of something, of the famous "repressed trauma", while pain is not the symptom, but the manifestation: if you enter into this perspective you can try to understand how it affects the life of those who live with it constantly and therefore it becomes possible to work at different levels on pain and its manifestations, undermining the idea that there is something to cure, to try rather to understand how it is possible to increase self-efficacy and live well with pain.

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(We chose to talk about psychotherapy, not psychology, because it intervenes directly on the epistemological constructs of the personality and on the functioning of the persons themselves).

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Article written with Andrea Ghirelli, trusted friend, educator, family mediator, systemic relational counselor.

 

Sources:

Chronic pain epidemiology - where do lifestyle factors fit in? by Oliver van Hecke, corresponding author Nicola Torrance, and Blair H Smith Br J Pain. 2013 Nov; 7 (4): 209 – 217. PMC4590163

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here? by Hannah N. McKillop, and Gerard A. Banez2 Children (Basel). 2016 Dec; 3 (4): 38. Published online 2016 Nov 30. doi: 10.3390 / children3040038 PMC5184813

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and Their Efficiency by Kai McGreevy, MD, Michael M. Bottros, MD, and Srinivasa N. Raja, MD Eur J Pain Suppl. 2011 Nov 11; 5 (2): 365 – 372. PMC3217302

New concepts of pain, by Anne-Priscille Trouvina SergePerrota on Best Practice & Research Clinical Rheumatology

Bardolino Chiaretto Bentegodi, 2018

 

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Just a (wrong) word

I can seem a cold person, lonely, indifferent and devoid of feelings. Not so: I had to build an armor. Because surviving physical pain has been complicated. So complicated, that sometimes I don't know where I ended up.

It was even more complicated to survive the sense of inadequacy that caused me to fail to heal, despite all my efforts.

Up to about twenty-two, I don't think I was fully aware of the pain. There was, but it wasn't scary. It has started to be so since the summer of 2003, due to the combination of a number of factors, which I can now clearly identify (psychological, social, environmental, biological), but which at that moment completely eluded me.

In that summer, the pain, and a series of absurd symptoms, began to eat everything. I am no longer just talking about musculoskeletal pain and allodynia, but rigidity, sleep disturbances, stubborn headaches, tinnitus, irritable bowel, alterations in the perception of body temperature, tachycardia, allergic symptoms, dizziness, confused head. I felt like a crazy fly in an upside down glass. At that point I, already a loyal customer of countless physiotherapists, started my tours with doctors, who invariably resolved themselves in trips from shrinks or in bankruptcy treatment and consequent iatrogenic damage.

My pain and my "related" symptoms did not go away as planned, not as I expected, and not even as doctors, physiotherapists, osteopaths, chiropractors and shrinks were expecting.

So, at some point, I became the problem. The problem was not the pain, or my symptoms, or the tremendous situation I was in, or the treatments that didn't work. It was not those who treated me that he had insufficient knowledge about the mechanisms of persistent pain. No. I was the problem. And I was told in the face. As if I were hostile to healing.

As human beings, we generally like to think we are prepared and empathetic, but I wonder if we ever really think about the power of words. Because words build worlds. And the ones I heard from health professionals, have shaped my world and my personality.

Looking back, it's no wonder I was so ashamed of having persistent pain. No wonder I felt guilty. Because everything possible has really been done to make me feel inadequate, not so much unable to deal with the situation as directly responsible for its maintenance. I'm not saying it was done deliberately, with the intent to harm, but the result is this.

It makes no sense to deny the complexity of pain by offending the patient, yet it is what happened to me. We are people with persistent pain, not bad people, lying, fragile, incapable, uncooperative, irretrievable, condemned to pain "because of us"; we live in terrible situations, we are forced to adapt to a "standard" with which, frankly, no human being would like to confront: I know that I often say, that I am repetitive, it is just that I want to enter into your head well. Living with chronic pain is not normal.

Considering how important language is for those suffering from pain, any health professional should be prohibited from using inappropriate terms, those that end up making us feel weak, guilty (you'll end up in a wheelchair, just learn to live with it, it's the worst that I've ever seen, you only have Lourdes left) or ineffective (the pain doesn't go away because you don't want it to pass, you're like this because of yourself), crazy (you're doing it too big, you can't see anything from exams). The collection can easily be expanded. These words take us away from healing, first of all. Secondly, they are inhuman. And, in our heads of people with persistent pain, they consolidate a world of ineptitude and guilt.

A key task in pain psychology is to help people learn to reframe their inner monologue so that it becomes more realistic and supportive. Being able to catch and recognize unnecessary or unrealistic impulses is not easy, but this skill underlies many successful adaptations to persistent pain. This insight forms the basis of cognitive behavioral therapy (a form of psychotherapy that aims to change unnecessary thinking behaviors), which plays an important role in helping people live with persistent pain. Living with persistent pain, living well with pain, is a fully achievable goal, I know from personal experience. I would add that it is fully achievable in a context in which the patient is not regularly kicked by health professionals, which still often happens.

If the patient is to be guided towards a greater awareness, the same must happen for those who take care of him: health professionals should motivate people with persistent pain, offering a language that must be carefully chosen in order to take more care of the patient, not to rub against him.

When a treatment doesn't work, it's human to find someone to blame. I would avoid accusing the patient, I have already said that. I would also avoid blaming the clinician (although in this case, I admit, it takes me an effort of mercy, I'm biased). Moreover, by accusing each other, we do not have much to gain. Surely a motivated patient is one step closer to success, and a health professional aware of their limitations will know how to motivate a person, respect them, pass on the right information, when to stop and pass the baton, or choose to inquire.

I don't think health professionals are naturally evil. I believe that once we assume that the "old way of proceeding" we are used to is deleterious, just as we look for new ways for patients to help them reframe their thoughts in order to live well with pain, it must be given greater emphasis on the importance of “communicating pain well” by health professionals.

If patients wish to be helped, I assume that health care professionals want to help, so if we interpret the patient / health professional relationship as a dialectic and not as a match between opposing teams, we could achieve something good for both categories.

There is hope for everyone.

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