Techniques in Regional Anesthesia and Pain Management

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2 Techniques in Regional Anesthesia and Pain Management (2005) xx, xxx 70
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Treating chronic pain in patients suffering 80
13 from addictive disorders: The psychodynamics 81
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16 Joseph Molea, MD, FASAM, and Michael Augustyniak, MD 84

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18 From the Department of Anesthesiology, Section of Addiction Medicine, University of South Florida; and the Tampa Bay 86
19 Institute for Psychoanalytic Studies, Tampa, Florida. 87
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21 Psychodynamic treatment of addictive disorders centers on helping patients understand the meaning of
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22 the manifest symptoms in context to the individual’s life. Such intervention is aimed at finding ways 90
23 to master maladaptive modes of coping and to improve overall quality of life. Many addicts also have 91
24 physical problems that become chronic, leading to compulsive use of pain medication, disturbed body 92
image, and curtailed function. Every pain management physician is familiar with the secondary gains
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that serve to keep the patient ill even after an array of cognitive, behavioral, pharmacologic, physical,
and nutritional interventions have been used to alleviate their suffering. In these patients, the addiction 94
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27 is often found to be the most overt or dramatic expression of a complicated psychiatric picture. 95
Psychodynamic interventions aim at teasing apart the vast array of potential developmental antecedents
28 of the illness, including childhood and adult traumas, losses that have not been fully mourned, the
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29 impact of parental missteps, failed attempts at completing age-appropriate separation-individuation 97
30 processes, and lack of affirmation of the self at crucial developmental periods. Worthy of note is the 98
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31 natural nexus between Twelve Step philosophy and psychodynamic psychotherapy. When a patient 99
begins to face the powerlessness and character defects talked about in The Steps, he is outlining a
32 distinctly psychodynamic formulation for himself designed to relieve him or her from emotional pain.
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33 When addicts are challenged with morbid states that impede progress, psychodynamic psychotherapy 101
34 is uniquely suited to help the patient on his way to recovery by utilizing all the tools at his disposal in 102
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35 AQ: 6 the form of medications, motivation for diet and exercise, talk therapy, and the use of support groups. 103
© 2005 Elsevier Inc. All rights reserved.
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In contemporary psychodynamic psychotherapy and psy- Pathological antecedents of behavior (drug seeking, pain
39 choanalysis, lessons learned from previous human develop- behaviors, manipulation, emotional outburst, etc.) can echo 107
40 ment research are now helping clinicians to appreciate more earlier patterns of physical or psychological neglect, tem- 108
41 fully why interventions may have therapeutic power. Psy- peramental difficulties, and parental psychopathology.3 109
42 chodynamic interventions can be further conceptualized as 110
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providing the space for these patients’ primary reflective

43 111
functions to grow and expand, thereby giving them the
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opportunity to make dramatic revisions to the internal work- Interventions based on development
45 ing models of relationships.2 Addicted patients, once absti- 113
46 nent, who are aided to construct a life narrative in therapy The preeminent child psychoanalyst Donald Winnicott es- 114
47 may likewise be getting a “second chance” to thrive. Psy- tablished a therapeutic alliance, from a psychodynamic per- 115
48 chodynamic interventions help patients with addictive dis- spective, with all of his patients. This alliance involved the 116
orders become aware of and understand themselves and therapist forcing his or her own self to be present (even
49 when bored, angered, or repulsed) to hear patients share
117
how and why they react to others during painful episodes.
50 their stories.4 It is far easier to write a prescription or 118
51 suggest some activities or daily drills than to actually attend 119
Address reprint requests and correspondence: Joseph Molea, MD,
52 Psychotherapy Candidate, Cypress Medical Group, 5820 Cypress Street, to another person’s imbroglio. When therapists listen care- 120
53 Suite B, Tampa, FL 33607. fully, they cannot avoid being drawn into the emotions, 121
54 E-mail address: joemolea@verizon.net. conflicts, and confusions of their patients. Sometimes clini- 122
55 1084-208X/$ -see front matter © 2005 Elsevier Inc. All rights reserved. 123
doi:10.1053/j.trap.2005.10.002
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4 cians even find themselves cast into particular roles that feel patient. What, if anything, is salutary about what Freud 72
5 odd or uncomfortable. In any human relationship that car- would have called a transference/counter transference con- 73
6 ries with it intensity, intimacy, and the capacity to be swept stellation, and what, in particular, makes this phenomenon 74
away with feeling, an inevitable counterpoint to avoid, to useful when dealing with patients suffering from a sub-
7 retreat, or to close oneself off concomitantly occurs.5 Psy- stance use disorder while at the same time struggling with a
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8 choanalysts have made a study of why it becomes so hard to co-occurring pain management problem?9 In short, the phy- 76
9 listen—to take another person’s woes, joys, and discoveries sician has, in a way, “absorbed” the mood or affective state 77
10 seriously. (usually unconscious) of the patient.10 Initially, this can 78
11 Clinicians who use the psychodynamic method listen bring a startling onset of relief from symptoms, if only for 79
12 carefully to help these patients learn more effective ways of a short time. The painful feeling that was not put into words 80
processing the distressing memories, disturbing feelings, and, thus, went unaddressed in the beginning, is still subject
13 and disrupted relationships that emerge during the recount- to the salutary effects of the growing therapeutic alliance.
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14 ing of these patients’ life stories. Because the patient’s The therapeutic process allows hidden affects, emotions, 82

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15 emotional pain is often experienced as difficult to bear, the and feelings that attach themselves to and worsen current 83
16 defense mechanisms of denial, splitting, dissociation, pro- problems such as chronic pain, will, over time, become 84

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17 jective identification, and repression are adaptively used by conscious and begin to dissipate (the long-term goal of 85
18 the mind to temporarily sidestep internal anguish.6 The first psychodynamic psychotherapy), thus further decreasing the 86
step in treatment, therefore, must be the creation of a safe impact of the pain problem. In psychodynamic psychother-
19 haven where these patients grow more comfortable in shar- apy, the therapist remembers and then inquires about pre-
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20 ing aspects of the self that have stymied personal growth vious sessions. Gradually, the therapist doses back the feel- 88

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21 and have resulted in addictive behavior. ing or feelings that were successfully contained by the 89
22 The initial psychodynamic intervention does not and therapist in the previous sessions so the patient can process 90
23 should not negate the use of other treatment modalities, such them.11 91
24 as restoring adequate health, teaching patients about the Naming feelings helps patients gain a sense of mastery 92
cultural and biological roots of their illness, and judicious over them and allows them to have a more effective adap-
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use of cognitive-behavioral strategies and Twelve Step pro-
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tive repertoire of behaviors to use when encountering life’s
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grams to gainsay maladaptive patterns of coping. An exam- demands. In essence, the goal is to follow the psychoana-
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27 ple of the latter include having the patient get involved in a lytic dictum “to make the unconscious conscious” to enlarge 95
28 “relapse-prevention group,” encouraging socialization via the reflective capacities of the patient.12 When this is done, 96
29 Twelve Step participation, and/or helping the patient cir- patients are less likely to use maladaptive means (for ex- 97
30 cumvent catastrophic thinking if he or she “relapses” or ample, their addiction to medications and playing the sick 98
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believes themselves to be in relapse due to the necessity of role) because they have achieved new capacities to self-
31 narcotic pain management. The primary task of therapy lies soothe. The goal, in this case, is to relieve the patient of
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32 in “being a good enough container” for a patients’ anguish, uncomfortable affect so that the patient can deal with more 100
33 hopes, and dreams. Psychodynamically oriented clinicians pressing concerns which, over time, will be dealt with more 101
34 conceptualize this initial process of psychotherapy as con- directly in the sessions. When patients have a better sense of 102
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35 tainment.7 Metaphorically speaking, these patients must de- the hidden affects they have been harboring and can link 103
36 posit into the therapist their raw affects, vignettes of per- these feelings to important memories, conflicts, and inter- 104
sonal history, deepest questions about the meaning and personal situations with words, they have a much better
37 direction of life, and reactions to everyday dilemmas in capacity of managing crises without resorting to self med-
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personal relationships as past emotions are transported into icating, drug seeking, or other forms of acting out. In other
39 the therapeutic relationship. The process of containment is words, there is both a short- and long-term benefit to psy- 107
40 an additional but essential intervention in addicted patients chodynamic psychotherapy in this most difficult patient 108
41 in need of pain management services in order for such population.13 109
42 patients to gain respect for themselves, their lives, and their Often in patients with substance use disorders, “identifi- 110
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struggles. As therapy continues, a deeper understanding and cation with the aggressor” is a primary defense. They treat
43 appreciation of the “self” takes form, making it easier for their caregivers and therapists in a manner similar to the
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44 such patients to make life-affirming decisions that involve way they were treated in childhood.14 In these situations, 112
45 them confronting not only their illness, but also the parts of patients may express intense frustration, rage, and even 113
46 their personalities that have failed them as they have tried to loving or erotic feelings toward the therapist. This is espe- 114
47 face the reality of their addiction and their comorbidity.8 cially true when there is a history of significant physical, 115
48 sexual, or psychosocial trauma. Containment becomes the 116
primary therapeutic strategy, with therapists silently pro-
49 cessing as these patients verbalize their emotional states.
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50 With sufficient time, therapists can interpret how these 118
Clinical uses of psychodynamics
51 patients have pathologically identified with the person(s) 119
52 The dilemma brought about by attending to another per- who hurt them, and, as a result, these patients can make a 120
53 son’s affects (which are initially unspoken and often uncon- new and more salutary identification with their therapists.15 121
54 sciously held) is primary in the treatment of persons with In essence, abnormal object relationships are replaced over 122
substance use disorders. By the process of projective iden- time with healthier ones. This is easier said than done
55 tification, therapists absorb the feelings projected by the because the affects expressed and the elements of personal
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2 Molea and Augustyniak Chronic Pain and Addictive Disorders 3 70
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4 history told could be so riveting that therapists may wonder Steps emphasize a surrender to a Higher Power who will 72
5 what can constructively be done to help these patients.16 remove such defects (accomplished primarily via mentor- 73
6 When pain management physicians see intense anger ing). Psychoanalytic psychotherapy, however, promotes an 74
expressed, the physician is being placed in the role of the active process of teaching. The patient now, by identifying
7 “bad object.”17 In these situations, one assumes that these and bearing his painful affects and setting psychological
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8 patients have a need to defeat or devalue their clinicians boundaries, can grow a cohesive self with greater tolerance 76
9 based on early trauma or maladaptive family patterns. Phy- of stressors such as painful physician conditions. Using 77
10 sicians must feel comfortable with setting limits when these spirituality as a stress reducer is the primary aim of working 78
11 patients express rage. Also, firm boundaries are a corner- the twelve steps. Theoretically, by utilizing this process, the 79
12 stone for treatment because these patients learn from them addicted patient can look forward to gradually gelling his 80
and, as a result, affirm their own personal and bodily bound- fragmented consciousness into one.23-25 There is at least one
13 aries.18 Referral to a psychodynamic psychotherapist allows western psychological framework that adequately relates
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14 interpretations of the source of the anger to be made over the mind/ego and the self. The advent of psychoanalytic 82

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15 time. The capacity and willingness for therapists to assume theories of the self provides ways to respond to the recov- 83
16 the role of “bad object” is challenging but enables these ering addict’s spiritual concerns. A combination of psycho- 84

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17 patients to more effectively perform in the outside world analytic theory and self-theory has been highly effective in 85
18 and to curtail symptoms because aggression is mobilized helping agnostic patients in this realm of therapy. Psycho- 86
and channeled more adaptively, a role that few physicians analytic Psychotherapy, utilizing self theory, assumes that
19 not trained to understand such process would be willing to the core problem of the addict is mainly psychological—the
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20 tolerate.19 Gradually, these patients shift from the defensive drug is a substitution for a missing self structure resulting in 88

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21 mode of “identification with the aggressor,” in which pro- low frustration tolerance and other painful affects, including 89
22 jection was the only way to dislodge their pain to a more anxiety, depression, ambiguity, fear of the unknown, con- 90
23 adaptive, mature mode of communicating various feelings and fusion, shame, guilt, doubt, weakness, and the like. Both The 91
24 ego states. They begin to internalize new ways of working with Twelve Steps Model and The Self Psychological Model focus 92
feelings, memories, disappointments, and successes. on the addict’s experience of frustration as central to their
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understanding as to what really ails the addict.26 However, they
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differ as to the implications for diagnosis and treatment.
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27 In the Self Psychological Model, frustration is the result 95
28 Twelve Step philosophy and psychodynamic of an inability to master inevitable negative affects, the chief 96
29 psychotherapy: A nexus? one being frustration.27 In place of accepting and tolerating 97
30 a certain amount of negative, a “defect of character” (to use 98
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The major symptoms associated with addiction are feeling Twelve Step parlance) results. This defect results in a fan-
31 lost, pan confusion, emptiness, and loss of control. Associ- tasy of perfection characterized by a state of unending
99
32 ated with this cluster of feelings is a state of consciousness perfection—perfect ease. In this model, effective interven- 100
33 experienced as an unbearable deflation of personal power. tion acts to: (l) change the addict’s negative attitude about 101
34 The common description of this state of consciousness is life, converting overwhelming frustration into learning to 102
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35 called “hitting bottom.” A major purpose of alcohol and tolerate increasing dosages of frustration, leading to (2) 103
36 other addictive substances is to convert this unbearable state growing a cohesive self structure that does not involve 104
of consciousness into one that is pleasurable and, if not mood altering substances as a means of coping. From a Self
37 attainable, at least one that numbs the pain.20 Additionally, a Psychological perspective, the fragmented self is made
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preoccupation with conflicts concerning such concepts as whole to the degree that the addict learns to accept frustra-
39 meaning, purpose, and values. Together these symptoms and tion as an inevitable fact of this life and to learn how to 107
40 pathogenic ideas comprise the territory of what is commonly master it by choosing to bear it.28 Adopting this attitude 108
41 referred to as spirituality, operationally defined as a concern inevitably results in the formation of a solid self structure 109
42 with ultimate solutions (all or nothing thinking) and essences. which enables the addict to experience himself as increas- 110
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Note that these concepts may also be conceived of as concepts ingly more whole, full, worthy, adequate and the like.29
43 developed within the first year of life.21 What AA refers to as spiritual, Self Psychoanalytic theory
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44 Many believe that Alcoholics Anonymous (AA) and refers to as “psychological dichotomies.” Both address the 112
45 other Twelve Step programs only assume that spirituality is same pressing need of the patient suffering with chronic 113
46 the core issue underlying alcohol addiction. There is also a pain: a sense of spiritual loss. Combining these concepts gives 114
47 sense in which Twelve Step philosophy points to a sense of the pain management physician willing to use psycho-dynam- 115
48 something vitally missing, a part of the person’s personality ically oriented therapists a new scientific/ philosophical/psy- 116
that either is not functioning or is functioning poorly. Both chological approach in dealing with spiritual issues (including
49 the Twelve Step program and Psychoanalytic Psychother- addiction) that impact the sufferer of chronic pain.
117
50 apy may be viewed as an alternative transitional process that 118
51 aims at effecting transformations within the patient’s con- 119
52 sciousness; in essence, a change in the patient’s personality.22 120
53 With this frame of reference in mind, both approaches Summary 121
54 are forms of consciousness expansion. These concepts are 122
what the Twelve Steps refer to as “Defects of Character.” The substance abuse understood from a self-psychological
55 What distinguishes the two approaches is that the Twelve perspective is the patient’s marked inability to tolerate frus-
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4 tration and other intense negative and positive affects. Ther- 2. Levy DM: Primary affect hunger. Am J Psychiatry 94:643-652, 1937 72
apy is directed toward teaching the patient about the inev- 3. Spitz RA: Hospitalism: an inquiry into the genesis of psychiatric
5 conditions in early childhood. Psychoanal Study Child 1:53-74, 1945
73
6 itability of ambivalence and other unpleasant but existential 74
4. Winnicott DW: Maturational Processes and the Facilitating Environ-
realistic limitations and imperfections of being human. Ad- ment. London, Hagarth Press, 1965
7 ditionally, the patient is taught to ventilate his intense feel-
75
5. Winnicott DW: Human Nature. London, Free Association Books,
8 ings, to understand and to utilize the concept of ego bound- 1988 76
9 aries, and to gain the capacity to separate all that is inside 6. Stein H, Fonagy P, Ferguson K, et al: Lives through time: an ideo- 77
graphic approach to the study of resilience. Bull Menninger Clin
10 one’s body from that which is outside the skin and the
64:281-305, 2000
78
11 ability to separate the childhood pain of the past from that of 7. Wurmser L: Psychoanalytic consideration of the etiology of compul- 79
12 the present and future. sive drug use. J Am Psychoanal Assoc 22:820-843, 1974 80
The contents of consciousness distinguish between feel- 8. Balint M: Thrills and Regressions. New York, International Universi-
13 ings, thoughts, judgments, and actions.30 Psychodynamic ties Press, 1959
81
14 intervention for addicted patients struggling with co-occur- 9. Freud S: Further recommendations in the technique of psychoanalysis: 82

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15 recollection, repetition, and working through (1914), in Collected 83
ring pain management issues can provide a unique pathway
Papers (vol 2). New York, NY, Basic Books, 1959, pp 366 –376
16 to understanding these complex feelings, thoughts, and ac- 84

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10. Feldman M: Projective identification: the analyst’s involvement. Int
17 tions. Contemporary practice strives to integrate insights J Psychoanal 78:227-241, 1997 85
18 derived from drive theory, ego psychology, object relations, 11. Ogden T: On projective identification. Int J Psychoanal 60:357-373, 1979
86
self-psychology, relational and attachment theories, and in- 12. Grotstein J: Splitting and Projective Identification. Northvale, NJ,
19 tersubjectivity to claim a more thorough understanding of Jason Aronson, 1985 87
20 the antecedents of the addictive symptoms.31 Placing em-
13. Casement PH: Learning from the Patient. New York, NY, Guilford 88

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Press, 1985
21 phasis on the unique personal history of the individual and 14. Milgram S: Behavioral study of obedience. J Abnorm Soc Psychol 89
22 finding a safe haven in which to process that history are 67:371-378, 1963 90
23 cornerstones of psychodynamic treatment embraced by each 15. Lacan J: “The mirror stage” and “The subversion of the subject and the 91
of these schools of thought. dialectic of desire in the Freudian unconscious,” in Écrits: A Selection.
24 A Sheridan, translator. New York, NY, W.W. Norton, 1977 92
In closing, it is interesting to consider that when the
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powerlessness over pain that must be accepted by the pa-
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16. Rotter JB: Generalized expectancies for internal versus external con-
trol of reinforcement. Psychol Monogr 80:1-28, 1966
94
tient who suffers both addiction and chronic pain is rejected, 17. Jensen MP, Romano JM, Turner JA, et al: Patient beliefs predict
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27 they may have entered the realm of denial amenable to patient functioning: Further support for a cognitive-behavioral model 95
28 Control-Mastery theory. This theory, proposed by Joseph of chronic pain. Pain 81:95-104, 1999 96
Weiss, states that psychopathology is caused by pathogenic 18. Gatchel ??, Turk DC (eds): Psychological Approaches to Pain Man-
29 agement: A Practitioner’s Handbook. New York, NY, Guilford, pp 97
30 beliefs, ideas about oneself and the world which interfere 283-304 AQ: 2 98
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with healthy functioning.32 The acceptance that a person is 19. McCracken LM, Spertus IL, Janeck AS, et al: Behavioral dimensions
31 powerless may seem impossible when one has believed
99
of adjustment in persons with chronic pain: pain-related anxiety and
32 since infancy that one can make anything happen. This acceptance. Pain 80:283-289, 1999 100
33 dynamic has kept many an addict from “taking the first 20. Mirn SM, et al: Affective illness in substance abusers, in Mirin SM 101
(ed): Substance Abuse and Psychopathology. Washington DC, Amer-
34 step” and admitting powerlessness. Control-Mastery theory 102
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ican Psychiatric Association Press, 1984, pp 57-77 AQ: 3

35 allows the psychotherapist the ability to intervene on such 21. Keefe FJ, Lumley M, Anderson T, et al: Pain and emotion: new 103
36 unconscious beliefs and open the patient to the help that is research directions. Review of studies looking at the effects on pain of 104
available. stress, negative emotional states, catastrophizing, fear, emotional reg-
37 Contemporary psychoanalysis aims to be more “user- ulation, and treatment seeking. J Clin Psychol 57:587-607, 2001 105
38 22. The AA Service Manual Combined with Twelve Concepts for World 106
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friendly” for patients, referral sources, and therapist alike.

Service by Bill W (2004-2005 edition). New York, NY, Alcoholics
39 This article has emphasized the importance of creating a Anonymous, 2004
107
40 safe space for these patients to speak, processing the most 23. Whitfield CL: Stress management and spirituality during recovery: a 108
41 salient affects that arise in the therapeutic dyad, assessing transpersonal approach. I. Becoming. Alcohol Treat Q 1: , 1984 109
42 potential transference and counter-transference paradigms, 24. Whitfield CL: Stress management and spirituality during recovery: a
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and assisting these patients in mastering symptomatic be- transpersonal approach. II. Being. Alcohol Treat Q 1: , 1984
43 haviors by making healthier identifications with their ther- 25. Whitfield CL: Stress management and spirituality during recovery: a 111
44 transpersonal approach. III. Transforming. Alcohol Treat Q 1: , 1984 AQ: 4 112
apists. Psychodynamic theory, infant and developmental 26. Baker H, Baker M: Heinz Kohut’s self psychology: an overview. Am J
45 studies, and in-depth outcomes research are shaping the way Psychiatry 144:1-9, 1987 113
46 that psychoanalytically informed treatments are performed. 27. Basch MF: How does analysis cure? An appreciation. Psychoanalytic 114
Although the topics selected here merely sketch how psy- Inquiry 6:403-428, 1986
47 28. Kohut H: Forms and transformations of narcissism. J Am Psychoanal
115
48 chodynamic treatment may impact the practice of pain man- 116
Assoc 14:243-272, 1966
agement, it is hoped that a more sustained inquiry and more
49 frequent and earlier referrals to psychodynamically oriented
29. Cohen F, Lazarus R: Coping with the stresses of illness, in Stone GC, 117
Cohen F, Ader NE (eds): Health Psychology: A Handbook. Theories,
50 AQ: 7 practitioners will follow in its wake.1 Applications, and Challenges of a Psychological Approach to the
118
51 Health Care System. San Francisco, CA, Jossey-Bass, 1979 AQ: 5 119
52 30. Gamsa A: Is emotional status a precipitator or a consequence of pain? 120
Pain 42:183-195, 1990
53 References 31. Letham J, Slade PD, Troup JD, et al: Outline of a fear-avoidance model 121
54 of exaggerated pain perception. Behav Res Ther 21:401-408, 1983 122
1. Jensen MP, Turner JA, Romano JM, et al: Coping with chronic pain: 32. Rappoport A: How psychotherapy works: the concepts of control-
55 a critical review of the literature. Pain 47:249-483, 1991 mastery theory. Bull Am Acad Clin Psychol 8:10-14, 2002
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