Mind & Body Network: Newsletters
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Mind & Body Network: Newsletters |
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Newsletter 9 Newsletter 8 Newsletter 7 Newsletter 6 Newsletter 5 Newsletter 4 Newsletter 3 Newsletter 2 Newsletter 1 |
April 2005 February 2005 October 2004 March 2004 January 2004 September 2003 May 2003 February 2003 December 2002 |
The
nature and development of fibromyalgia Psychological treatments for multiple sclerosis/ Psychological aspects of rheumatoid arthritis Psychological approaches to IBS: implications for psychological and medical treatment Learning to attend to mind-body processes/Pennebaker's narrative therapy approach Latest developments in the treatment of pain The treatment of patients with chronic fatigue syndrome Healing potential of symptoms Discussion board, Emotional Processing (Website www.emotionalprocessing.org.uk) Compliance and medical treatment |
Jane Raleigh,
Clinical Specialist in Rheumatology, Dorset County Hospital
Meherrzerin Das, Principal Clinical Psychologist, Dorset
HealthCare NHS Trust
In this talk Jane Raleigh described a piece of research that she
undertook in partial fulfilment for a masters qualification. In
her cross sectional questionnaire-based study she compared
emotional processing in women with fibromyalgia (FM) with
emotional processing in healthy female controls and in women with
rheumatoid arthritis (RA).
Jane started off her presentation with some general background information about fibromyalgia. Fibromyalgia syndrome (FM) is a disorder of widespread myalgia, increased sensitivity to mildly noxious stimuli, poor, non restorative sleep and generalised fatigue. She noted that there is considerable debate in the literature regarding the aetiology of fibromyalgia.
Jane pointed out that while FM is an increasingly common diagnosis in rheumatology outpatient clinics, existing management/treatment strategies yield poor long term results.
She noted that individuals with FM have often experienced significant emotional trauma in their lives prior to the onset of their symptoms. Evidence has indicated that individuals with FM may have some deficits in emotional processing (EP), tending to misattribute the symptoms of emotional arousal to solely somatic causes.
Jane went on to describe the samples that she recruited into her study.
§ Group 1: Individuals with FM attending the outpatient rheumatology clinics of either Dorset County or Poole Hospital (N=52).
§ Group 2: Individuals with rheumatoid arthritis attending the out-patient rheumatology clinics at Dorset County Hospital (N=34)
§ Group 3: Healthy individuals recruited from staff working at Dorset County Hospital (N=53).
Baker’s emotional processing scale (EPS) was used as a measure of emotional processing.
Jane then went on to describe the results from the studies. Here, we provide a summary of the main findings that she presented:
§ The FM group had significantly higher overall scores on the Emotional Processing Scale indicating greater overall difficulties in emotional processing than either the healthy group or the RA group.
§ The FM group also had significantly higher scores on most of the subscales of the EPS than either of the two other groups.
Overall the FM group demonstrated:
§ a more impoverished style of emotional style of emotional processing
§ more emphasis on physical orientation towards emotion
§ more suppression of emotions and their expression
§ greater inability to control the expression of emotion
Jane concluded by noting that her study highlights the role of emotional processing factors in an FM population and supports a need for psychological input in the assessment and treatment of the condition.
Fibromyalgia: the clinical picture of a mind-body conundrum
Meherzin Das’s insightful presentation was clinically oriented. She suggested her ideas lie midway on a continuum between a generalizable model (‘one size fits all’) and an individualised model (the ‘perfect fit’). Her reflections derived from psychological assessment, psychological therapy, cognitive behavioural and cognitive analytic models as well as data from the Psychotherapy File.
Meherzin noted that in the FM patients she treats there is often a recognisable history of parental patterns (such as only offering conditional care, being over demanding/neglectful/abusive). Such parental patterns can lead to maladaptive reactions and styles in children.
Meherzin described insights she has obtained from using the Psychotherapy File assessment tool:
§ Traps: fear of hurting others/appeasing/can’t say no/perfectionism/difficulty expressing emotions/feeling criticised/feeling responsible/anxious/ <give up< over-control.
§ Snags: Sabotage by external events
§ Dilemmas: Submit to demands vs. resistance/over-responsible vs. unwanted/sufficiency vs. feel deprived of care/approval vs. independence
She noted that, for such individuals, adulthood is often characterised by physical health issues, poor self-care, multiple stressors & chaos, major life events and emotional baggage.
She then provided some examples of cognitive distortions typical of such individuals, including:
§ “I’m not entitled to look after myself when there are things to be done for others”
§ “I can’t say ‘no’ to anybody…they may stop loving me”
§ “It’s better to be needed (and shattered) than feel well (and alone)”
§ “I have to cope regardless of how I feel/what I want”
§ “Some people admire the way I juggle so many balls at the same time!”
§ “Life’s too chaotic to stop and think about how to do things differently or deal with my past”
In such individuals, Meherzin noted that needs for care, love and approval/admiration are often unmet and strong emotions such as happiness and anger are often disavowed.
Meherzin went on to describe a psychological presentation typical of the patients with FM that she sees:
§ desperate, tearful
§ uncontained, messy
§ responsibility for change handed over
§ feeling out of control
§ feeling like a failure
§ terrified to improve vs. desperate to change
§ perception totally focussed on the body, pains, fatigue levels.
She described the following interpersonal behaviours as typical in patients with FM: stuck, clingy, demanding, overly grateful, apologetic and tearful, fearful of abandonment, referring to earlier strengths and handing over responsibility.
Conversely, Meherzin reported that the personal strengths of patients with FM include determination, resilience, a capacity for hard work, a commitment to sessions and a willingness to participate (if a safe environment is created).
Meherzin considered common reactions elicited in clinicians when treating individuals with FM including feeling stuck, feeling responsible, feeling trapped, feeling a sense of inertia, feeling frustrated, and feeling deskilled and helpless.
Meherzin suggested a management plan for individuals with FM that incorporated medical, physical therapy, psychological, social rehabilitation, occupational therapy and alternative remedy approaches.
Meherzin concluded her presentation by describing the main components of psychological treatment for patients with FM. These included managing pain, sleep, diet, dealing with difficult emotions and with the onset of trauma, helping the patient to develop adaptive coping strategies and increase assertiveness and unpacking and reframing historical and long term ‘baggage’.
A lively series of questions and discussion followed Meherzin’s presentat
PSYCHOLOGICAL TREATMENTS FOR MULTIPLE SCLEROSIS
Professor Peter Thomas, Professor of Health Care Statistics &
Epidemiology, IHCS, Bournemouth University and Dorset RDSU
Dr Charles Hillier, Consultant Neurologist, Poole Hospital NHS
Trust
Dr Sarah Thomas, Senior Research Fellow, Dorset RDSU
The focus of this presentation was preliminary results from the Cochrane systematic review of psychological treatments for multiple sclerosis that is being undertaken by a collaborative team from the Dorset RDSU, Poole and Royal Bournemouth Hospitals and Bournemouth University. The protocol for the research has already been published in the Cochrane Library:
Thomas PW, Thomas S, Hillier C, Galvin K, Baker R, Cole J. Psychological interventions for multiple sclerosis. The Cochrane Database of Systematic Reviews 2003, Issue 4.
The presentation was given by three members of the team. Charles Hillier, Consultant Neurologist from Poole Hospital, provided some general background about multiple sclerosis - its aetiology, prevalence, pathogenesis, the diagnostic criteria that are used and the diagnostic process. He described the range of potential symptoms experienced and delineated different types of disease progression. He described the MS Service in East Dorset and the broad scope of services and organisations involved in the care of individuals with MS including medical and nursing professions, occupational therapists, physiotherapists, dietitians, speech therapists, clinical psychologists, counsellors, MS societies, disability advisory services, social services, mobility, continence, vocational and housing services and MS clinics.
Sarah Thomas, Senior Research Fellow from the Dorset RDSU, then considered psychological factors in multiple sclerosis. She noted that psychological factors are more prominent in MS than in other chronic illnesses with comparable levels of disability and suggested this may be partly due to:
the timing and complexity of diagnosis
the heterogeneity of disease course and symptom range and severity
the tremendous uncertainty that accompanies MS
concomitants of the disease process itself
She described how the wide range of symptoms in MS means that it can impact upon nearly every aspect of an individual’s life including self identity, interpersonal relationships, family functioning, sexual functioning, employment, social support, leisure pursuits.
She noted that depression is often considered to be the ‘hallmark’ affective symptom of MS and is possibly the most psychologically debilitating symptom. It is also the most extensively researched. Literature on other psychological factors is scant. However, there may be other psychological sequelae including anxiety, anger, guilt, low self-esteem, grief, denial, pathological laughing and crying, euphoria. Approximately 50% of people with MS will develop some degree of cognitive dysfunction.
Sarah used depression in MS as an example to illustrate the complex and multi-factorial interactions that can exist between psychological factors and disease-related factors and processes.
Peter Thomas, Professor of Health Care Statistics and Epidemiology from the Dorset RDSU started off with a brief overview of the history and structure of the Cochrane Library. He then outlined the stages involved in the review process from approval of the review title, preparation of the protocol, review of the protocol, publication of the protocol, undertaking the review itself, review of the review and finally the publication of the review.
He described important factors that need to be considered when designing and undertaking a Cochrane review including: the inclusion criteria, search strategy, method of data extraction, quality of studies, statistical analysis and the structure of the review.
He described the rationale for the ‘mini-review’ framework that has been adopted and summarised the 14 trials that have been found to date. He concluded his presentation with the following points
the most robust evidence is for CBT in depression
many studies are small (risk of type II errors)
multiple significance tests make interpretation difficult
reporting of trials was sometimes poor
the importance of choice of population
the diverse nature of outcome measures used
the need for further well designed trials
Psychological
Aspects of Rheumatoid Arthritis
Dr
Paul Thompson, Consultant Rheumatologist, Poole Hospital NHS Trust
The January meeting of the Mind & Body Network at Sandbanks Hotel featured Paul Thompson exploring the interaction between a ‘person’ and a chronic disease. In three groups participants discussed the personality features of the cartoon characters Popeye, Brutus and Olive Oyl, and speculated about the likely outcomes if the characters were to find themselves faced with the scenario of a fierce dog attacking Sweet Pea……. Brutus saved himself, Olive Oyl dithered and Popeye saved the day.
Moving from cartoon characters to the clinical setting Paul asked the three groups each to consider a hypothetical rheumatology case and to feed back to the whole group what they considered was happening to the patient and what treatment they would recommend. This exercise illustrated how certain individuals – so-called ‘robust types’ function far better with rheumatoid arthritis than others who have comparable objective disease activity but poorer coping strategies; indeed, robust types often appear to have worse disease in terms of joint damage and inflammation than the others.
In summing up Paul noted that while the biomedical model may be all that is needed to cure acute illnesses, a deeper understanding of the interaction between the soma and the psyche is essential for the wise management of people with chronic diseases.
The meeting was well attended with people enthusiastically participating in the group work. The meeting was kindly sponsored by an education grant from Pfizer.
Psychological approaches
to IBS:
Implications for psychological and medical treatment
Dr Mary Reid, Senior Lecturer, IHCS, Bournemouth University
Irritable bowel syndrome has become one of the most prevalent diagnoses for cases presenting at gastroenterology outpatient clinics each week in the UK, affecting a significant proportion of the Western population. As a disorder, it can be chronic and significantly disabling for people who suffer from it. Frustrating for both doctors and patients is the relative lack of available approaches for treating it as a chronic disorder, although new, holistic approaches are being developed and evaluated. It is useful, however, to consider the factors that have made it difficult in the first place to conceptualise and treat this condition.
Until recently, diagnosing irritable bowel syndrome was unclear. Unlike inflammatory digestive disease, IBS could not be positively determined from a medical diagnostic procedure. In 1999, a shift from a disease- to symptom-based model of disorder was developed to describe functional GI disorders (Rome II, published in Gut, 1999), with the intention of incorporating a more holistic view of their genesis and treatment. Years of clinical study and observation were gathered from clinical practice and symptom clusters common and distinctive to each category were developed and involved international researchers and clinicians. These categories were based on the bodily location along with theoretical ideas about the nature of process underlying the symptom, and the qualities of the symptom cluster itself. Like the other disorders in this group, IBS is defined by symptoms, and their chronicity. They include abdominal discomfort or pain lasting at least 12 weeks, along with bloating, or other accompanying symptoms such as a change in frequency or appearance of stool, and relief upon defecation.
As far as the patient’s experience of illness is concerned, however, distinctions between disease and functional disorder may likely mean little. Irritable bowel syndrome in its more severe forms shares many symptoms with inflammatory bowel disease (e.g. Crohns disease, ulcerative colitis). Medications intended to soothe the irregular motility within the gut, or re-balance the chemistry of gut secretions and help aid digestive processes are for some patients, but may be limited in how much they help reduce symptoms, particularly over time. Many IBS sufferers agree that the impact of their symptoms tends to be underestimated. The impact of this disorder on personal functioning and psychological health can be disabling for some patients (Creed et al., 1999). This has been indicated in a number of studies reported a high incidence of co-morbid depressive, anxiety symptoms and interpersonal difficulties reported by patients (Talley et al., 1990). Although a number of self-help groups have been recently established to share information about helpful treatments and how to explore factors that increase their symptoms, it is still often difficult for IBS patients to learn about the potential causes of their symptoms and what they can do to manage them.
For a number of years, research has demonstrated a link between IBS and certain psychological characteristics or states. The idea that emotional arousal affects the gut is hardly a new one. Anyone can ‘feel gutted’ by shock or grief; or have butterflies or churning sensations in their stomach when feeling anxious or fearful. In addition, IBS patients have demonstrated a higher sensitivity to certain sensory stimulation in the gut (e.g. rectal distension), and lower thresholds to pain (Whitehead et al., 1997). More recent theoretical and empirical research have shown that this sensitivity may be caused by a lack of regulated activity between the gut and brain, which normally modulates responses to stimulation in the gut (Naliboff, Balice & Mayer, l998; Mayer, Chang & Lembo, 1998).
Other studies have shown a higher incidence of anxiety, depression, and sensitivity to novel, noxious or emotionally disturbing stimuli, or prevalent negative affect related to IBS (Lydiard & Falsetti, 1999; Eisendrath et al., 1986). Many IBS patients reveal a high frequency of negative thoughts about themselves or their expectations of others.
Of course, it is impossible to separate the cause from the impact in most of these studies, except in a few investigations where psychological symptoms have been shown to preceed GI symptoms (Whitehead et al., 1996). Certainly living with chronic gut disturbance might create some of the sensitivity, anxiety and other affective symptoms or syndromes mentioned (Drossman et al., 1999).
There is growing evidence that psychological approaches or integrative treatment can be useful in treatment. Interpersonal brief therapy has been shown to reduce gastrointestinal symptoms, improve quality of life for IBS patients (Creed et al., 2001; Guthrie, 1993). This treatment has also been shown to reduce the cost of NHS care for IBS patients. This kind of therapy attempts to help individuals learn about how they cope with interpersonal difficulties, as well as process emotional experiences more deeply. Cognitive –behavioural therapy has also demonstrated positive results, including a reduction in symptoms, and increase in self-rated health and quality of life (Green & Blanchard, 1994). CBT can be offered for individual or small groups of patients, and focuses on changing maladaptive illness perceptions or beliefs and altering coping strategies. Finally, relaxation therapy and hypnosis have been shown helpful in altering coping responses (Whorwell, Prior & Farager, 1984).
These different forms of therapy may help IBS patients in similar ways, however. Therapeutic intervention may help them develop links between events and certain kinds of conflicts people have with others, and within their own experiences, and help patients understand how their they handle difficult emotional responses such as anxiety or feelings of shame, incompetence, or fear (Read, 1999).
Although evidence is accumulating that psychotherapy and psychological treatments may be cost –effective and effective in reducing symptoms, psychological therapy or interventions as part of a multidisciplinary approach are still exceptional rather than routine. In addition, some patients may unnecessarily feel that being referred to psychotherapy or counselling does not mean their doctors believe their symptoms are all in their heads.
Finally, a number of studies examining quality of life and impacts of this condition have come to the conclusion that patients may well feel isolated when suffering their symptoms, and that others don’t understand what they go through (Sullivan et al., 2000). A patient’s health care team is not necessarily aware of her needs in relation to this illness, beyond symptom relief. There are several good reasons for this. First, it is reasonable to suspect that patients themselves may have difficulty in realising, and articulating all of their concerns related to illness and recovery, especially initially. They may worry that others do not believe their suffering, or disruption to their functioning, and therefore may feel their experience is invalidated by their illness, especially as it may not be amenable to traditional treatment.
Second, the relationship between psychological events and physical symptoms has often been difficult to track. It has been repeatedly demonstrated that trying to link stressful events and episodes of illness is difficult to achieve. Acute states of physiological disturbance have not always been associated with self-reported stress. Consider the situation where a person attempts to cope with their problems by distracting themselves from the sources of their anxiety, or by avoiding situations in which he begins to feel uncomfortable. By managing situations this way, he may remain unaware of low levels of anxiety that have been activated. It would be natural to feel that he was successfully coping, without being aware of the chronic impact this anxiety may have on internal processes (such as those occurring in the gut) over time.
Third, the same impact could occur when an individual typically inhibited her emotional responses or avoided difficult feelings needing further processing, and expression. Using certain defensive strategies that involve routine behavioural and physiological inhibition have been shown to cause disease and disorder (Weinberger, 1990), but individuals may be unaware of the link between these processes and stimuli that evoke them.
Findings like these, along with the correlational studies mentioned above, are usually given as evidence that some kind of chronic emotional distress may be linked to the maintenance of physically-based gut symptoms, at least in some patients. While there have been no investigations in which the kinds of conflicts experienced by IBS patients have been compared to other patient groups, other studies have indicated a range of chronic difficulties in interpersonal relationships, as well as the processing of traumatic experiences and emotions (such as vulnerability, humiliation and fear) related to them (Guthrie, 1993; Reid, in preparation). Helping patients become more aware of these conflicts or experiences needing personal understanding, or teach people how to increase their coping behavioural repetoire are becoming goals in psychosomatic medicine, and evidence is accumulating that approaches may be especially valuable for individuals with IBS. In addition, more sensitive approaches to uncovering patients’ concerns related to their illness, and assisting with their ability to manage their symptoms without isolating themselves from social, familial and occupational roles are also reasonable goals for recovery (Mitchell & Drossman, 1987).
References:
Creed,
F.H.,
Guthrie,
E.,
Thompson,
D.,
Ratcliffe,
J.,
Read,
N.,
&
Tomenson,
B.
(2001).
Cost effectiveness of psychodynamic interpersonal therapy and
antidepressants for chronic somatization.
Presentation to the
Society for Psychotherapy Research,
(March:
Leiden, Germany).
Creed,
F.H.,
Olden K.W.,
Svedlund J.,
Toner,
B.B.,
Whitehead,
W.E.
(1999).
Psychosocial aspects of the functional gastrointestinal disorders.
Gut,;
45 (Supp II):,
II
25-30.
Drossman,
D.A.,
Creed,
F.H.,
Olden,
K.W.,
Svedlund,
J.,Toner,
B.B.,
&
Whitehead W.E.
(1999).
Psychosocial aspects of the functional gastrointestinal disorders.
Gut,;
45 (Supp II): II 25-30.
Eisendrath,
S.J.,
Way,
LW.,
Ostroff,
J.W.,
&
Johanson,
C.A.
(1986).
Identification of psychogenic abdominal pain. Psychosomatics,27,
705-712.
Greene, B., Blanchard, E.B. (1994). Cognitive therapy for irritable bowel syndrome. Journal of Consulting Clinical Psychology, 62, 576-582.
Guthrie, E. (1993). Psychological management of patients with irritable bowel syndrome. In M. Hodes & S. Moorey (eds.), Psychological treatment in disease and illness (pp. 88-100). London: Gaskell & the Society for Psychosomatic Research
Lydiard, R.B., & Falsetti, S.A. (1999). Experience with anxiety and depression treatment studies: implications for designing irritable bowel syndrome clinical trials. The American Journal of Medicine, 107, (SI) 41-50
Mayer,
E.A.,
Chang,
L.,
&
Lembo, T. (1998).
Brain-gut interactions: implications for newer therapy.
European Journal of Surgery, Supplement to vol.
582
(S)50-5.
Mitchell, C.M., & Drossman, D.A. (1987). The irritable bowel syndrome: understanding and treating a biopsychosocial illness disorder. Annals of Behavioral Medicine, 9, 13-18.
Naliboff,
B.D.,
Balice,
G.,
&
Mayer,
E.A.
(1998).
Psychosocial moderators of quality of life in irritable bowel
syndrome.
European
Journal of Surgery
583,(S)
57-9
Read,
N.
(1999).
Harnessing
the patient’s powers of recovery: the role of the psychotherapies
in the irritable bowel syndrome. Balliere’s Clinical
Gastroenterology, 13, 473-487.
Reid M. Psychological treatment of functional abdominal pain: outcomes revealed in process and therapeutic goals for the chronic care team. (in preparation for submission to Gut, 2004).
Talley, N.J., Phillips, S.F., Bruce, B., Twomey, C.K., Zinmeister, A.R., & Melton, L.J. (1990). Relation among personality and symptoms in nonulcer dyspepsia and the irritable bowel syndrome. Gastroenterology, 99, 327-333.
Weinberger,
D.A.
(1990).
The construct validity of the repressive coping style. In
J.L.
Singer
JL
(Ed.),
Repression and dissociation: Implications for personality
theory, psychopathology, and health
.(pp.337-386).
Chicago: University of Chicago Press
Whitehead W.E.,
Crowell,
M.D.,
Davidoff,
A.L.,
Palsson,
O.S.,
&
Schuster,
M.M.
(1997).
Pain from rectal
distension in
women with irritable bowel syndrome: relationship to sexual
abuse. Digestive Diseases
&
Sciences,
42, 796-804.
Whitehead, W.E., Burnett, C.K., Cook, E.W., & Taub, E. (1996). Impact of irritable bowel syndrome on quality of life. Digestive Diseases & Sciences, 41, 2248-53.
Whorwell, P.J., Prior, A., & Faragher, E.B. (1984). Controlled trial of hypnotherapy in the treatment of severe refractory irritable bowel syndrome. Lancet, SII 1232 - 1234.
Learning to attend to mind-body processesLes' talk to the Mind-body Network provided an overview of a therapeutic approach that is being increasingly used to help patients process their sensations, thoughts and feelings. The approach is called Focusing and was developed by psychologist and philosopher Eugene Gendlin at the University of Chicago. Its practice has been relatively neglected in the U.K., and Les wished to raise awareness of the potential benefits of this approach and some of the research studies that had been done.
The talk began with some philosophical background about the difference between phenomenology and cartesian dualism. We have traditionally inherited 'packaged' terms such as emotions, cognitions, and bodily senses which tend to emphasise their separation. Focusing is based on a different philosophy that wishes to pay attention to a stream of experiencing that is complex and cannot easily be 'packaged' or defined. Here we enter the experience of a more 'fuzzy' area and this may be very relevant to understanding and dealing with mind-body interactions.
Initially, Gendlin was interested in researching the question of what is happening when people do well in psychotherapy. By focusing on the process issues involved, he and colleagues found that the difference was not to do with either the therapeutic approach taken, the content of what people talked about, or the diagnosis of the patient. Rather it had to do with the capacity of the patient to talk about their experiences in a particular way. He noticed that they paused and groped for words or images. On enquiry, they paid attention to an unclear but bodily-sensed aspect of how they were, a kind of moving back and forth between words and their bodily sense of their situation. Gendlin called this process Focusing, and found that it consistently differentiated between those that did well in psychotherapy and those that did not. A major implication of this for his therapeutic theory was that it centred on how people pay attention rather than a focus on the content of thoughts, feelings or sensations. His next question was to consider whether this process could be taught as a skill. The short answer to this was: yes, with some qualifications. A lot of research has been done since to clarify the learning and teaching of this skill to others and the benefits of such a process. Generally the process is more successful and has better outcomes when there is another person to help as a guide and companion.
The
talk concluded with a consideration of some case studies that
demonstrated the helpful application of focusing in health care
settings. In one case it showed how focusing worked with a
patient's experience of chronic physical pain in such a way as to
change both the quality of the sensations and the meaning of the
pain in helpful ways. Another study highlighted common themes
between the focusing experiences of four HIV/Aids sufferers that
led to greater experiences of felt vitality. Readers can find out
more about Focusing philosophy, training and research at http://www.focusing.org.
A
Narrative Approach to Physical DiseaseWriting
has a profound influence on individuals and society.
During the last twenty years there has been an explosion of
interest in writing for therapeutic benefits. James Pennebaker
pioneered a brief writing intervention in the late 1980s. His work
has acted as a catalyst and has made expressive writing readily
accessible as an intervention for use by health professionals
working outside as well as within the mental health realm.
In
personal accounts of his work, Pennebaker reveals that initially
he was guided by intuition rather than by theory.
He had been raised in a family in which there were
considerable levels of ill health and little expression of
emotion. He believed
that encouraging the exploration of one’s deepest thoughts would
lead to health benefits.
The
Pennebaker Writing Paradigm
The
standard Pennebaker paradigm involves getting an individual to
write freely without interruption for approximately 20 minutes on
3 to 4 consecutive days about highly emotional topics. Its
evolution as a brief intervention was largely due to pragmatic
issues such as time and resource constraints.
Benefits
ascribed to the Pennebaker paradigm include improvements in
emotional well-being and in academic performance, reduction
in self reported illness & physician visits and enhanced
immunological well-being (enhanced
T cell response, greater antibody control of latent viruses,
enhanced response to vaccination).
It
has been suggested that the primary mechanism through which the
writing paradigm works is by initiating and facilitating the
organisation of complex emotional experiences.
This has been supported by evidence from research using
textual analysis.
Much
of the early research using this paradigm was undertaken using
undergraduate students in laboratory settings.
However, more recently it has been applied to patients in
health care settings.
There
are several characteristics that make this approach particularly
appealing as a clinical intervention: it is inexpensive, it is
portable, brief, requires relatively little operator skill, is
readily deliverable in primary care, is safe and non
pharmacological.
There
is a now a substantial and growing body of literature applying
Pennebaker’s intervention across a diverse range of mental and
physical health problems including: breast cancer, post operative
recovery, chronic pelvic pain, insomnia, rheumatoid arthritis,
frequent attenders to primary care, caring for a child with autism
and body image dissatisfaction.
Findings
from research using the Pennebaker paradigm have been equivocal;
for example, in the fields of breast cancer and rheumatoid
arthritis some studies have reported patient benefits while others
have not found such benefits.
‘For the next three days I would like you to write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life. In your writing I’d like you to really let go and explore your very deepest emotions and thoughts. You might tie your topic to your relationship with others, including parents, lovers, friends, or relatives: to your past, your present or your future; or to who you have been, who you would like to be, or who you are now.
You
may write about the same general issues or experiences on all days
of writing or on different topics every day.
All of your writing will be completely confidential.
Don’t worry about spelling, sentence structure or
grammar. The only rule is that once you begin writing continue to
do so until your time is up’. (Adapted
from Pennebaker & Beall, 1986 and Pennebaker et al., 1990)
Those
randomised to the control arm had similar writing instructions
except that they related to a bland topic (‘plans for the
weekend’).
Lung
function was used as an objective outcome measure.
Secondary measures included quality of life and mood.
Follow-up was undertaken at 1 and 3 months by postal
questionnaires and a visit to the surgery for lung function tests.
The
intention was to recruit 20 patients into the pilot.
Five general practices agreed to participate and sent
letters to their patients with asthma.
Ten percent of patients responded and 10 patients were
formally recruited. There
was a high compliance rate once the patients had consented - all
10 undertook the writing exercise and completed the questionnaires
and follow-up assessments.
The
pilot study confirmed the feasibility of the study design but
obviously did not have sufficient power to confirm or dispute
effectiveness. Further
development work will incorporate some qualitative elements to
explore why we encountered resistance from GPs and the
unexpectedly low response rate from patients.
There
has been increasing discussion in the literature of methodological
issues related to the Pennebaker paradigm.
These include:
Research
has suggested that these issues are complex.
For example, in a 2 x 2 factorial design that crossed
writing topic (stressful versus neutral) with writing format
(handwritten vs typed) researchers found:
Students describing the stressful topic, compared to the neutral topic, wrote for a longer period, used more words, reported greater negative and less positive affect
Writing long hand induced greater negative affect and led to more
self rated disclosure
The
issue about the writing environment raises interesting issues.
Some suggest that bringing people into a formal setting
such as a laboratory or a GP surgery confers authority and
credibility to the intervention.
Studies that have taken place in these kinds of settings
have demonstrated the largest effect sizes.
Helen
delineated four conditions that research has suggested are
pre-requisites if writing is to be effective:
Emotional
processing
Pennebaker suggests that the exact length and arrangement of writing sessions is not critical because the intervention continues after the writing has finished in the form of post-writing processing (in thoughts, daydreams, dreams etc).
Helen
presented some questions from a medical perspective:
Helen concluded that the writing paradigm generates lots of unanswered issues but may be of enormous potential.
The
talk was followed by a lively and interesting round of questions
and comments.
Questions
1.
Is it writing that is crucial, or is it more about ‘emotional
connectedness’?
HS:
That is another area to look at - it may be that just setting
aside 20 minutes a day to oneself is effective.
2.
What is the time impact on GPs?
HS:
Minimal. The patient posts back the writing to the researcher.
3.
Did participants have a choice about what happened to their
writing?
HS:
Yes, participants were asked whether or not they would like their
writing destroyed, they all elected for it to be kept for further
analysis. It is
important that patients have a choice about what happens to their
writing but there are tensions between retention of what are
primary research data and participants’ wishes.
4.
If a GP were using the intervention therapeutically how would
he/she be followed-up? Would the patient come back to see you?
HS:
No, it is conceived of as a self-contained intervention.
1.
It would be interesting to compare the profiles of those GPs who
agreed to participate in the asthma pilot study with those who
declined.
2.
It could be that the patients who most need this intervention are
the ones who don’t think in terms of emotions i.e. who somatise
their problems
3. It seems to be two
separate interventions based on whether the participant chooses to
have their writing destroyed or not.
It seems important to disentangle the effect of writing for
one’s own use with that of knowing that your writing is going to
be read by another person. Complex boundaries of where the
intervention starts and stops.
HS:
Our plan is that if the intervention is eventually used in general
practice the writing would remain with the individual, but in
order to monitor compliance in our study we requested that
participants send their writing to the researcher. This difference
between the research method and real life could potentially alter
the effectiveness of the intervention if thinking that someone
else is interested in what you write and is going to read it
brings more therapeutic benefit to the intervention.
Pennebaker
describes how when he asked participants whether they wanted their
writing destroyed most people said no; many consider their writing
to be an artistic creation. Perhaps there are in fact three
distinct interventions depending on whether the writing is
destroyed, retained or formally analysed.
4.
Many family systems don’t encourage emotional exploration
and the writing paradigm may be giving the individual permission
to do that.
5. Writing by hand may not be preferable for everyone - for example the younger generations may write more freely using a computer keyboard than pen and paper.
Latest
Developments in the Treatment of Pain
Ms Eileen Mann, Nurse Consultant, Acute Pain Service, Poole Hospital NHS Trust
Eileen’s
talk was, as she described it, a whistle stop tour of where
research is contributing to our rapidly increasing knowledge about
pain.
She
separated the recent developments into six areas, the first of
which was the debate about where acute pain ends and chronic pain
begins. She explained
that pain is usually event related.
It starts as an acute episode, but can become fixed
depending on the nature, duration and the cause of the pain.
The age of the patient and psychosocial influences such as
pain memory, pain affect and possible genetics may also influence
susceptibility and suffering.
Preventing the development of chronic pain remains a top
priority.
Eileen
then went on to look at pain management, and how only an
assessment of the cause and possible mechanism of the pain will
provide the best chance of good pain relief.
Acute pain is relatively easy to manage, provided effective
therapy is used early. Chronic
pain, which has become established, is more difficult to treat,
especially certain types of neuropathic pain, pathological pain
states such as complex regional pain syndrome, visceral pain and
some cancer related pain. Cousins
in 2001 wrote “Despite recent advances
that make it possible to relieve chronic non-cancer pain in 70-80%
of patients, fewer than 10% actually obtain pain relief.
This is a pitiful situation”
Eileen
then detailed particular areas of recent scientific interest,
including the use of opioids in non cancer pain, the placebo
response, new drugs including cannabanoids, and non
pharmacological strategies such as cognitive behavioural therapy (CBT).
These days, there is considerable emphasis on
evidence-based heathcare, looking at areas such as which
therapies, including analgesics, work and which are no better than
a placebo.
As
an example of how evidence-based research is changing practice,
she examined the management of low back pain, and how this has
changed enormously in the last ten years, and is gradually helping
to turn the tide of low back pain disability in this country.
It is estimated to cost £10 billion annually.
Eileen
then looked at several examples of new discoveries in pain
management. These included advances in the management of neuropathic
pain, cancer pain, pain in metastatic disease and phantom limb
pain. She reported
that NSAIDs now have a central role in
pain management as they are no longer considered only for
use in arthritis. However
the extent of serious side
effects with the use of NSAIDs and the new Cox2 drugs is often not
fully recognised. On
the subject of cannabanoids, although there may be some
therapeutic advantage for certain conditions,, there is not
sufficient clinical evidence as yet. Cognitive behavioural treatment is helpful in
treating both pain and the psychological issues that may
help to maintain or amplify pain perception..
There have been seven published meta analyses showing clear
benefits of CBT. She concluded with a round up of where pain
research is at the moment. In
terms of new drugs major discoveries are still probably
a long way off, but much work is being done on improving the
delivery of current drugs and their metabolic tics.
After summing up, there was a very lively and interesting question and answer session.
Newsletter No 4 September 2003
THE TREATMENT OF PATIENTS WITH CHRONIC FATIGUE SYNDROME
Dr
Selwyn Richards, Consultant Rheumatologist, Poole Hospital NHS
Trust
Ms Claire McDermott, Research Assistant, Poole Hospital NHS
Trust
The
Parable of the Blind Men and the Elephant
‘It
was six men from Indostan
To learning much inclined
Who went to see the Elephant
Though all of them were blind.’ 1
In the poem by John Saxe, the six intrepid ‘elephant researchers’ set out to prove conclusively the true nature of the elephant. Bewildered by apparently contradictory evidence, they conclude that an elephant may be like a rope (as its tail would suggest) or a snake (as its trunk implies) or a wall, a fan, a tree or even a spear. The six resulting hypotheses create a split among the party that appears irreconcilable.
All those attending the Dorset Mind and Body Network meetings this year will have been stimulated to reflect on the mind-body split in medical science.
In the field of Chronic Fatigue Syndrome, this traditional divide has polarised medical opinion into supporters of a ‘medical model’ and supporters of a ‘psychological model’.
Clinical evidence to date has not yet managed to resolve the issue conclusively. This might be seen as a reason for frustration. Alternatively, it may be seen as a saving grace. Deprived of the convenience of compartmentalising this condition into traditional categories, researchers and clinicians have sought models for the illness which allow for a more holistic approach to treatment.
The parable of the
six visually challenged investigators from Indostan stumbling
around their intriguing but perplexing elephant, while
attempting to integrate their findings, may seem familiar to anyone
who has been involved in the field of Chronic Fatigue Syndrome.
Current clinical
evidence suggests that mechanisms involved in precipitating and
perpetuating the illness may include such diverse mechanisms as;
Central nervous system sensitisation
Chronic immune activation
Impaired perfusion of the brainstem
Hypothalamic pituitary axis dysfunction
Physical deconditioning
The Dorset CFS/ME Service supports a holistic approach to treatment, where all factors which may help recovery are acknowledged and, where possible, addressed.
Treatment
The first line of treatment offered is a fatigue management programme, designed by Occupational Therapists in collaboration with ‘expert patients’ from the Dorset ME Support Group. A cognitive behavioural approach is used to address lifestyle changes such as restructuring rest and activity (pacing), goal setting, sleep hygiene, and an opportunity to discuss emotions inherent to any chronic illness.
An observational study of this programme found that 42% of treated patients were able to return to work or training within 18 months of the programme. Improvement was reported by over 80% of patients.
A domiciliary version of the programme is now being offered to patients who are housebound or bed bound.
Basic
science research
We are collaborating with the Royal Brompton Hospital in a study of gene expression profiling which it is hoped may lead to a ‘molecular signature’ for the condition. If found and validated, this could not only lead to a means of diagnostic testing, but enable subgroups within the condition to be identified.
Pharmacological
Research
We are conducting a randomised controlled trial to investigate the effectiveness of a product believed to enhance natural killer cell activity.
The six men from Indostan were convinced that their own interpretation was infallible. It seems likely that future advances in the field of CFS will reveal connections that none of us are expecting. Until then, openness to all insights would seem to be an appropriate response to an illness where it would appear that the ‘mind-body divide’ has met its Waterloo.
Clare McDermott, Research Co-ordinator, Dorset CFS/ME Service
1. The Parable of the Blind Men and the Elephant by John Godfrey Saxe.
The
Healing Potential of Symptoms:
Working with physical
symptoms from a
psychotherapeutic viewpoint
Professor Dawn
Freshwater
Despite
some very trying circumstances which would have deterred lesser
mortals, Professor Dawn Freshwater gave a very thought provoking
talk on 12 March about the healing potential of symptoms.
Having a strong counselling, nursing and academic background,
Dawn suggested the psychotherapeutic approach as an alternative way
of conceptualising the interpretation of patient symptoms.
She emphasised that there were no right or wrong approaches
to symptom interpretation but alternatives for individual
practitioners to consider. With
reference to philosophers, nursing theorists and Jungian theory,
Dawn argued the case for illness or wellness existing on a
continuum. Throughout
her talk, there was emphasis on the polarity of health, and how this
polarity gave the gift of understanding. She referred to different levels of consciousness, and in
particular the idea of a collective consciousness of universal ideas
or images. She suggested that even fundamentals such as being could
be considered as having a “flip side” of not being.
Symptoms, she argued, were not just objective reports of
deficits of function or uncomfortable sensations.
Rather, she felt they were a subjective summation of an
individual’s experience and perception of him/her self in the
context of a larger universe. Thus,
2 patients with ostensibly the same physical problems could actually
present entirely different pictures to clinicians (and presumably be
“diagnosed” differently).
Dawn
suggested that the rush for clinicians to “label” and define a
patient’s problems may be premature, even if the patient him/her
self is keen for this to happen, and the physician may need to
embrace the discomfort of “not having all the answers”.
She felt it acceptable for physicians in particular to admit
they “don’t know” even if this goes against the grain of
conventional medical training.
Implicit in the argument was the idea that patients had an
important part to play in contributing towards their own
“diagnosis”, and that the process could well involve more than a
single consultation. A
lively debate followed the talk in which Dawn’s approach was
considered in the light of current medical thinking.
DISCUSSION
BOARD
for the
mind body network
We have now set up a discussion board for the Network. The aim of the discussion board is to add to the usefulness and success of the network. It will allow members to interact with each other on a regular basis, discuss ideas and exchange information. For example, it can be used to post details of interesting articles, courses or references you have come across, or discuss matters which have arisen from one of our meetings. To start things off, we have posted some references.
To
reach the discussion board:
1.
Log on to our website at www.rdsu.org.uk
2.
Take the link at the top of the page to the
“Mind & Body Network” page.
3.
Click the tab marked “Discussion”.
4.
You will be asked to enter the username and
password. The username is MindBody and the password is soul.
Please enter this exactly as shown here.
It is case sensitive.
4.
You will enter the discussion board.
You may post articles, search through existing articles
and view a table of contents.
5. To return to the main web, use the BACK key on the toolbar near the top left of the screen.
Emotional
Processing:
the body’s emotional immune system?
Professor Roger Baker, Consultant Clinical Psychologist,
Dorset RDSU
At the Mind & Body Network meeting on 6 February 2002, Professor Roger Baker introduced the idea of ‘Emotional Processing’ and suggested that it could be conceptualised as an emotional equivalent to the immune system.
In
1980 Rachman first introduced and defined the
concept of ‘Emotional Processing’:
“a
process whereby emotional disturbances are
absorbed
Normally when faced with negative life events most people successfully process them in such a way that they do not continue to impinge on their daily life. However, if there are deficits in the way in which a person processes an event (such as suppressing their emotions) it will make it harder to deal with its emotional impact. This may not matter for small everyday hassles, but if more serious traumas occur then failures to process may have serious consequences.
Deficits
in emotional processing have been shown to be
marked in psychological disorders such as panic
disorder, but are also implicated in physical
disease. Professor
Baker described a scale that he and his colleagues
have developed (The Emotional Processing Scale –
EPS) which attempts to measure some of the key
psychological dimensions involved in emotional
processing. The EPS can be used to provide guidance
for therapists, to measure change, to categorise
or group patients as well as a general
research tool.
The
EPS forms part of a broad programme of research
exploring the links between emotional processing and
physical and mental health. The EPS has already
been administered to a range of patient groups
including those with a diagnosis of colorectal
cancer, chronic back pain, psychological disorders
and in the future will be administered to other
diagnostic groups (fibromyalgia, chronic fatigue
syndrome, rheumatoid arthritis, ankylosing
spondylitis). The preliminary results appear
promising.
This
research programme will enable Professor Baker and
his team to determine which factors of the EPS can
distinguish different diagnostic groups and
whether particular emotional styles characterise
various physical and psychological disorders,
ultimately leading to treatment interventions to
improve blocks or problems in emotional
processing.
If you are interested in knowing more about the Emotional Processing Scale, please contact the RDSU or visit the emotional processing website at www.emotionalprocessing.org.uk
COMPLIANCE AND MEDICAL
TREATMENT
Pam Whelan,
Osteoporosis Clinical Adviser, Somerset Osteoporosis Service
The
first meeting of the Mind & Body Network was held on Monday, 18
November 2002 at the Open Golf Course, Bournemouth.
Refreshments were provided by Proctor and Gamble.
Dr Paul Thompson opened the meeting by briefly outlining the importance of a mind/body approach. Particularly in chronic disease, medical approaches were not sufficient, and what was needed was a more active collaboration between medical and psychosocial approaches. The Mind/Body Network was intended to bring together staff working in the important overlapping areas between body and mind. A programme of meetings was outlined covering topics such as fibromyalgia, chronic fatigue syndrome and pain.
The Speaker at this inaugural meeting was Pam Whelan, Osteoporosis Clinical Adviser, Somerset Osteoporosis Service, who talked on the topic of “Compliance and Medical Treatment”.
Although her talk was based on her work with patients with osteoporosis, the problems with compliance were relevant to other disciplines as was borne out by the very lively discussion which followed. Although randomised control trials might show the benefit of medical procedures and medications, it was clear that patient attitudes and understanding of the nature of the treatment was fundamental to whether they took it in the prescribed way. The massive costs to the Health Service of failure to address the psychological aspects of compliance was highlighted. Issues around patient preference and the popularity of alternative therapies and health foods and supplements were discussed. The group wondered whether we were entering an age of patient pick-and-mix medicine rather than evidence based medicine.