Dear Jennelle -
I am so sorry to see what they have been putting you through. It was not for nothing my uncle, a retired psychiatrist in Seattle, in response to inquiry for a referral I put to him a year ago, urged seriously ill CRPS patients to steer well clear of the Seattle area.
From your posts, I assuming that your pain clinic is affiliated with the Univeristy of Washington. It is my understanding, that they as heavily invested in the so-called "cognitive-behavioral" school of pain management as any place in the country. By this I mean they believe that the pain pattern experienced in the brain can be "broken" almost through sheer will alone, much as one might break a wild horse. With the most pernicious aspect of this approach being found in the notion that when the treatment is unsuccessful, it is - conveniently - on account of "resistance" of one sort or another the the patient is offering to the therapy. It also offers something of a "one size fits all approach" to the threatment of almost all forms of chronic pain. (And for both of these reasons is much beloved be the workers-compensation industry.) See, e.g., "Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain," Turner JA, Holtzman S, Mancl L.,
Pain 2007 Feb;127(3):276-86. Epub 2006 Oct 27.
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA.
jturner@u.washington.edu
Although cognitive-behavioral therapies (CBT) have been demonstrated to be effective for a variety of chronic pain problems, patients vary in their response and little is known about patient characteristics that predict or moderate treatment effects. Furthermore, although cognitive-behavioral theory posits that changes in patient beliefs and coping mediate the effects of CBT on patient outcomes, little research has systematically tested this. Therefore, we examined mediators, moderators, and predictors of treatment effects in a randomized controlled trial of CBT for chronic temporomandibular disorder (TMD) pain. Pre- to post-treatment changes in pain beliefs (control over pain, disability, and pain signals harm), catastrophizing, and self-efficacy for managing pain mediated the effects of CBT on pain, activity interference, and jaw use limitations at one year. In individual mediator analyses, change in perceived pain control was the mediator that explained the greatest proportion of the total treatment effect on each outcome. Analyzing the mediators as a group, self-efficacy had unique mediating effects beyond those of control and the other mediators. Patients who reported more pain sites, depressive symptoms, non-specific physical problems, rumination, catastrophizing, and stress before treatment had higher activity interference at one year. The effects of CBT generally did not vary according to patient baseline characteristics, suggesting that all patients potentially may be helped by this therapy. The results provide further support for cognitive-behavioral models of chronic pain and point to the potential benefits of interventions to modify specific pain-related beliefs in CBT and in other health care encounters.
PMID: 17071000 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
And for an article from another center laying this out even more starkly, see, "Behavioral medicine approaches to pain," Okifuji A, Ackerlind S,
Med Clin North Am. 2007 Jan;91(1):45-55.
Pain Research and Management Center, Department of Anesthesiology, University of Utah, 615 Arapeen Drive, Suite 200, Salt Lake City, UT 84108, USA.
akiko.okifuji@hsc.utah.edu
Managing pain patients can be a challenging task for many clinicians because of the complexity of the condition. Pain by definition is a multifactorial phenomenon for which biomedical factors interact with a web of psychosocial and behavioral factors. Behavioral medicine approaches for pain generally address specific cognitive and behavioral factors relevant to pain, thereby aiming to modify the overall pain experience and help restore functioning and quality of life in pain patients. Behavioral medicine focuses on patients' motivation to comply with a rehabilitative regimen, particularly those with chronic, disabling pain. Since patients' own commitment and active participation in a therapeutic program are critical for the successful rehabilitation, the role that behavioral medicine can play is significant. It is not unreasonable to state that success outcomes of the rehabilitative approach depend on how effectively behavioral medicine can be integrated into the overall treatment plan. Past research in general supports this assertion, demonstrating clinical benefit and cost-effectiveness of multidisciplinary interventions that include behavioral medicine. Some of the approaches listed in this paper can be incorporated into clinicians' practice regardless of specialties, and such practice will likely provide helpful venues for managing pain patients. [Emphasis added.]
PMID: 17164104 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
Finally, for an abstract to what appears to be a good article attempting to put this entire approach in perspective (and in effect on indefinate hold), see, "Cognitive-behavioral treatments for chronic pain: what works for whom?," Vlaeyen JW, Morley S,
Clin J Pain 2005 Jan-Feb;21(1):1-8. Please look at this one carefully.
Department of Medical, Clinical, and Experimental Psychology, Maastricht University, Maastricht, The Netherlands.
j.vlaeyen@dep.unimaas.nl
Since the introduction of behavioral medicine in the early 70s, cognitive-behavioral treatment interventions for chronic pain have expanded considerably. It is now well established that these interventions are effective in reducing the enormous suffering that patients with chronic pain have to bear. In addition, these interventions have potential economic benefits in that they appear to be cost-effective as well. Despite these achievements, there is still room for improvement. First, there is a substantial proportion of patients who do not appear to benefit from treatment interventions available. Second, although the effect sizes of most cognitive-behavioral treatments for chronic pain are comparable to those in psychopathology, they are quite modest. Third, there is little evidence for differential outcomes for different treatment methods. Fourth, there still is relatively little known about the specific biobehavioral mechanisms that lead to chronic pain and pain disability. One direction is to better match treatment programs to patients' characteristics. This can be done according to an "Aptitude X Treatment Interaction" framework, or from the perspective of the Moderator-Mediator distinction. In this introduction to the special series on what works for whom in cognitive-behavioral treatments for chronic pain, we review existing knowledge concerning both moderating and mediating variables in cognitive-behavioral treatments for chronic pain. We further argue in favor of theory-driven research as the only way to define specific a priori hypotheses about which patient-treatment interactions to expect. We also argue that replicated single-participant studies, with appropriate statistics, are likely to enhance new developments in this clinical research area.
PMID: 15599126 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/1...ubmed_RVDocSum
This said, you are very much in my thoughts. I am just very sorry that I didn't pick up on your earlier "
thank you all" thread.
Mike