That old mind-body thing again…


Editor’s Selection IconThis post was chosen as an Editor's Selection for ResearchBlogging.orgI am not a philosopher.  Neither am I very conversant in the arguments around consciousness.  But working in pain management means the mind-body debate is something I run into now and again.  Is pain all about the body? Is pain all about the mind? Or is it both?  Which influences the other?

This debate can often be pushed to one side in the day-to-day practicalities of helping people live well with their chronic pain, but it is often raised when we’re talking about whether it’s important to focus on reducing the underlying disease process (and hopefully reduce the pain) or whether it’s more important to help people live well despite their pain. IMHO it’s not about which is more important: it’s about when to focus on each aspect.

Anyway, suffice to say that many medical people working in, for example, orthopaedics or rheumatology don’t read about mood, anxiety, treatment expectations, or even cognitive behavioural approach to pain management.  I don’t think it’s because they don’t care about the emotions and disability in their patients, I think it’s that they have their hands full with modifying the disease processes, or trying to repair the structures that this psychological is both too difficult to read (loads of new concepts) and too far removed from what they deal with daily.

An editorial in Journal of Psychosomatic Research by Patrician Dobkin from McGill University, discusses amongst other things, the fact that rheumatologists probably won’t read some of the really important works in this edition of the journal.  What this means for patients is that an uninformed medical practitioner is unlikely to refer patients for an effective intervention like cognitive behavioural therapy for fibromyalgia.  In fact, in the Pain Management Centre I work in, referrals for people with fibromyalgia and other rheumatological disorders are few and far between – although probably we see more people with FM than rheumatoid arthritis or ankylosing spondylitis.

Dobkins suggests that if researchers want to reach medical clinicians with important information relevant to managing their patients, they need to include factors that medical people think are important – things like adherence to medication, use of health services, disability levels.  I think ensuring the title has nothing hinting of ‘psychosocial’ might also be a good idea because some medics I know of immediately think it has nothing to do with what they do, anything ‘psychosocial’ belongs to that group of ‘difficult to deal with’ patients that they’d rather refer to other clinicians who specialise ‘in that sort of thing’.

I’m quite strongly opposed to this attitude.  Not because I think psychosocial factors are more important than biomedical, but simply that people are whole people and psychosocial matters affect us all right from the moment we begin to experience pain.

After all, pain isn’t pain until the brain perceives it – and perception involves attention, decision-making, arousal levels, past learning, culture, emotion – the list goes on.  Once pain has been perceived then a person takes action – and actions are all about decision-making, arousal levels, past learning, culture, emotion – the list goes on.  Even the process of attending for health care is a psychosocial decision.

Dobkin describes a couple of studies included in this edition of the Journal of Psychosomatic Research – one by Kojima et al. is a factor analysis of psychosocial variables and disease variables in which it was found that disease activity (eg C-reactive protein, counts of swollen joints, duration of disease) was independent from psychosocial factors such as fatigue, depression, social support.  No significant associations were found between disease activity and mental or physical quality of life.

The second study she mentions is one by Graves et al, in which illness beliefs about patients RA were found to be associated with disability and qualtiy of life, and couldn’t be explained by disease status.

Does this mean that the mind and body are separate, asks Dobkin? She doesn’t think so, and neither do I.   Dobkin’s answer is that these studies remind us of ‘the two faces of medicine’ – curing and healing.  Bone loss, joint damage and C-reactive protein reflect what the medics seek to ‘cure’, while effective coping, improvements in disability and mood, anxiety and social support are all ‘in the domain of healing’.  She points out that the research process requires these to be pulled apart into small pieces that we can define and measure and investigate, but in fact they all belong to the whole person who looks for treatment and to be understood.

It reminds me a little of that post about ‘amelioration’ and ‘obliteration’ from a couple of weeks back – based on a point made by Pain for Philosophers.

It is a serious conceptual mistake to think of a patient who feels helpless and resigned in the face of her pain as (necessarily) being in two bad states:

(a) Her pain is bad to degree x

and

(b) Feeling helpless and resigned is bad to degree y.


Rather, these feelings are themselves parts of the pain. Their treatment is just as much a treatment of the pain itself as is the administration of morphine.


I’ll keep reminding myself of that (and hopefully readers of this blog too!) because it’s an important point for all of us.

The final point Dobkin makes is that we need to speak a common language – and it’s an interdisicplinary one. This means hashing out what we mean by certain terms, and the models underpinning our practice is not only inevitable, it’s vital.  We’ll talk past each other if we don’t take the time to learn from outside our own practice circle.  And that means the people we all want to help miss out.  Anyone prepared to start a translation service?

If you’ve enjoyed this post and want to read more, I blog most working days.  You can subscribe using the RSS feed link above (just click on it and most internet browsers will do the rest for you), or you can bookmark and visit.  I’m not sure whether Google Reader does the job too, that’s something for me to find out!  This blog is written for clinicians wanting to work with people who have chronic pain, and it focuses on nonpharmacologic ways of coping and living well.   I started life as an occupational therapist, got warped by psychology and I’m now completely crazy because I’m working on a PhD.  Introduce yourself if you want to hang around – and ask questions, and I’ll do my best to answer them.
Dobkin, P. (2009). Reaching rheumatologists Journal of Psychosomatic Research, 67 (5), 367-368 DOI: 10.1016/j.jpsychores.2009.09.005

8 comments

  1. Hi

    I read teh editorial you referred to and it got me thinking about what role we provide within a pain management centre / clinic. Do we have a responsibility to support these other specialist areas and ensure they know what services we offer, and who may benefit from them?

    Why to people with a FMS diagnosis stay under a rheumatologist, and why do people with a CRPS diagnosis and no significant yellow flags end up in a pain management clinic?
    The idea of cross-specialism communication sounds excellent – but is there an example you can provide of it working well?

    The service I work in has monthly meetings with Alcohol and Drug services to discuss those patients ‘caught’ between the two areas with their pain and medication use. It aims to stop the rebounding of patients who perhaps fit neither service perfectly and, as I understand, is helpful to both clinical areas.

    Would a similar relationship with rheumatology or physiotherapy outpatients (who see a large chronic population) help smooth the patient pathway?
    I’m too cynical to see that sort of thinking coming from ‘management’ as they are so compartmentalised, but there could be come genuine benefits for the patient in being involved in a ‘joined up’ health service.

    Does anyone have an example of where this happens somewhere in the world? And if so what are the pro’s and cons??

    thanks

    P

    1. Excellent points as usual!! I can see a major barrier to this happening and it’s quite simple: funding ‘silos’. If we see someone via another service, they pay, if we accept referrals from another service and pick up the management: we pay!
      I don’t know anywhere where this works except perhaps the King’s Mill Hospital, Sutton in Ashfield where Helen Sievewrite and Prof Salkovskis are picking up referrals from general medicine, endocrinology and genitourinary medicine, with a screening process using several questionnaires. This suggests a process/pathway approach is needed, (the good old patient journey), and also that people inside those services are aware of the need for (and know how to identify) people to have access to more appropriate management. I’d have thought fibromyalgia is now well-known to be a central sensitisation disorder AND that CBT approaches have strong evidence for them – but maybe that is a presumption that I shouldn’t hold. I’d love to see pathways that include not simply biomedical and social needs analysis (eg the pre-admission process used for elective hip and knee replacement surgery) but also review psychological factors – one day maybe when our healthcare managers consist of people who are not just ex-doctors, ex-nurses and professional managers?

  2. I am a gastroenterologist and about 1/3 of my patients would not improve unless I addressed the psycho-social aspects of their illness. Their perfectly real physical symptoms (occasionally severe enough to put them in the hospital) were connected closely to stresses they did not fully recognize. The good news is that most improved significantly once those problems were uncovered and treated. There is much more information about my approach at http://www.stressillness.com.

    1. Excellent point Dr Clarke! I think it’s so good to hear when doctors help people draw the links between what they’re experiencing and what else is happening in their lives – and remember that people are people who make sense of the world according to what they know about and find out about. Thanks for your comment, and I’ll visit later today!
      cheers
      Bronnie

  3. Very interesting. I take a unique approach to personal guidance that I call Transformational Coaching and Mentoring. This work brings together a multitude of my life experiences, Clinical training, and a lot of study and practicing Eastern contemplative traditions. The latter include Taoism, Zen, Mindfulness and the Theravada Abhidhamma (i.e., Buddhist Psychology) and Nondual teachings from both Tibetan and Hindu traditions.

    Feel free to read more on my blog
    Dr Dennis MacCrombie

    dennismaccrombie.com

    1. Hi Dennis
      That certainly sounds like a comprehensive blend of different philosophies and approaches. ACT uses a lot of mindfulness approaches and that ‘flexibility’ of Zen that means people are open to and aware of experiences but not judging them because it’s the judgement of these experiences that brings distress. I have certainly found that this is a real help for me, and hope to bring some of that to the people I work with. Thanks for dropping by, and yes I’ll visit your blog!
      cheers
      Bronnie

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