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The psychology of pain
Book Reviews
respite from unending care until the danger threshold is crossed. Chapter 4 describes the failure of the mental health professions to respond to the needs of families. The authors cite affective barriers, training deficits, and lack of community support as underlying causes. This section may be disturbing to readers who are family members, as it was to J. K., having to recognize that the profession on which they must depend neither values work with severely ill patients nor provides adequate training in techniques for working with the chronically mentally ill and their families. (“We need hands on guidance, but even the experts haven’t had much experience.“) It will also be (and should be) highly unsettling for professionals to acknowledge the extent to which we have turned our backs on a problem that is perhaps too painful, too frustrating, incurable, and underrewarded, both financially and in terms of status. In the final chapter, the committee proposes steps to ameliorate the situation. The concept of “the family psychiatrist” is put forth, which they differentiate from both a psychiatrist for the patient and a psychotherapist for the family. In this role the psychiatrist does not look for pathology in the family, but instead addresses the family’s need for information and support in dealing with the illness, is available for crises, and remains available for as long as he or she is needed. The difficult issue of confidentiality is not ignored but is presented as a clinical dilemma in balancing a resistant patient’s wishes against the family’s need to be informed. The tenets of the psychoeducational approach are listed clearly, with reference to expressed emotion theory as a skill to learn, deemphasizing its potential for once again blaming families. The book concludes with a list of nine recommendations for the mental health professions, summarizing the need to be responsive and helpful, rather than accusatory, to address inadequacies in training programs, to “take action to make care of the chronically mentally ill the highest priority of the public sector of mental health care” (how?), and to assist families in advocacy for changing commitment laws. From the perspective of a family member, the book is admirable in its message, but should emphasize even more strongly the need of families for much more practical guidance and concrete assistance than is currently available. Many families today are not looking to professionals for exoneration from blame, but for real help in terms of an
extensive support network of enlightened professionals, programing for both patients and families, more detailed ‘how to” literature, and mutual support groups, perhaps providing the kind of daily availability of support and guidance that is accessible to families of alcoholics. The strength of this book is its straightforward, clear message regarding the direction psychiatry should take to address the injustices in care of the mentally ill and their families. This is not a “how to” book, and offers too few specifics about the psychoeducational approach, the practical guidance that families crave, and specifically how to address larger political issues. What it does address is the gap that must be bridged between professionals and families if we together are to serve the best interests of the chronically mentally ill. There is presently an uneasy alliance between professionals and families, which is tainted by attitudinal remmants of psychogenic theories of mental illness as well as the devaluing of patients who make us aware of our limitations and powerlessness. Families continue to feel blamed, if not by theories of etiology, by newer theories holding them responsible for relapse rates. The book points out that families feel they have been given “responsibility without power.” The authors caution us against continuing to let families unfairly bear the burden of the failures of society to provide resources or of science to find answers. Psychiatry must not find fault without providing alternatives or guidance. Families may unjustly blame themselves for their relative’s mental illness, but they also blame the mental health system. Until we correct our shortcomings in serving the chronically mentally ill and their families, the alliance will remain fragile, and the potential for a truly effective collaboration cannot be realized. This book is a step toward building a more solid and genuine alliance between professionals and families. DANA HOLLEY,
LICSW
Coordinator, Family Education Program Somerville Mental Health Clinic Somerville, Massachusetts JOAN KEATING
Member, Family Education Program Somerville Mental Health Clinic Member, Alliance for the Mentally 111
The Psychology
of Pain (Second
Edition).
Edited by 151
Book Reviews
Richard A. Stembach. 1986 ($31.00), 256 pp.
New York: Raven Press,
The management of pain is now recognized as a major public health problem, not only inflicting tremendous personal suffering on the individual in pain and his or her family and extended social network, but also on society at large. It is estimated that in the United States the economic loss annually may be as high as $90 billion per year. Traditionally, the medical and surgical physicians have been primarily responsible for the care of individuals in pain, attempting to understand and treat pain as a process directly related to underlying noxious stimulation. Within the past decade, behavioral scientists, especially psychiatrists and psychologists, have made major contributions to the understanding of pain mechanisms, diagnosis, and management. These behavioral scientists no longer are infrequent consultants, but rather are integral members of all credible pain services. It is unfortunate that until quite recently, training programs for health professionals did little to correct the process of treating chronic pain with the acute pain model. It is time to recognize that chronic pain is not merely longlasting acute pain. In addition, it is now known that one cannot blindly generalize from experimental laboratory induced pain to clinical pain seen in a given patient population. As editor of The Psychology of Pain (second edition) and author of the chapter on Clinical Aspects of Pain, Richard Stembach (modestly) underestimates the significant impact of the first edition, which appeared in 1978. Not only did he provide the reader with a systematic literature review on the psychology of pain, but he also organized the material in such a way as to stimulate many students and neophytes in the field to appreciate the importance of applying behavioral medicine principles to pain problems. Sternbach and many of his coauthors are among the pioneers in the application of psychological principles to pain. It is fitting that Ronald Melzack is the author of the section on Neurophysiological Foundations of Pain, and he discusses the evolution of the gate control theory of pain that he and Patrick Wall proposed in 1965: In recent years, the evidence of pain has moved in the direction of recognizing the plasticity and modifiability of events in the central nervous system. The
152
psychologicalevidence lends strong support to the consideration of pain as a complex perceptual and affective experience determined by the unique past history of the individual, by the meaning of the stimulus to that person, and by the state of mind at the moment, as well as by sensory nerve patterns evoked by physical stimulation.
Two of the chapters authored by psychiatrists are especially well written. One is Harold Merskey’s Psychiatry and Pain, in which he discusses application of psychiatric methods to use with chronic pain. The other is Izzy Pilowsky’s chapter on Psychodynamic Aspects of the Pain Experience, in which there is an excellent section on abnormal illness behavior. Little attention is paid to nosology. A review of DSM-III classification relevant to pain would have been useful, since there is a recognized need to improve our accuracy in classification of pain. Students in this area are well advised to improve their acumen in distinguishing between various somatoform disorders. In addition, the concept of Pain Prone Disorder, as initially discussed by George Engel and later by Dietrich Blumer, are covered superfically and are important enough concepts to warrant more detail. Overall, however, the editor has accomplished his stated goal. He has compiled a well referenced text on the psychology of pain covering both experimental and clinical pain research.
GERALD
M. ARNOFF,
M.D.
Director of Boston Pain Center at Spaulding Rehabilitation Hospital Boston, Massachusetts
lnterfuce Between Neurology and Psychiatry. Edited by M.R. Trimble. New York: Karger, 1985 (!$48.50), 190 PP. The emergence of behavioral neurology and biological psychiatry as separate disciplines has generated a new enthusiasm for integrating the findings of neurology and psychiatry. Fruitful integration, however, requires a clear understanding of the assumptions, definitions and frames of reference involved when the terms Neurology and Psychiatry are used. For example, the psychodynamic clinician is concerned primarily with motives
respite from unending care until the danger threshold is crossed. Chapter 4 describes the failure of the mental health professions to respond to the needs of families. The authors cite affective barriers, training deficits, and lack of community support as underlying causes. This section may be disturbing to readers who are family members, as it was to J. K., having to recognize that the profession on which they must depend neither values work with severely ill patients nor provides adequate training in techniques for working with the chronically mentally ill and their families. (“We need hands on guidance, but even the experts haven’t had much experience.“) It will also be (and should be) highly unsettling for professionals to acknowledge the extent to which we have turned our backs on a problem that is perhaps too painful, too frustrating, incurable, and underrewarded, both financially and in terms of status. In the final chapter, the committee proposes steps to ameliorate the situation. The concept of “the family psychiatrist” is put forth, which they differentiate from both a psychiatrist for the patient and a psychotherapist for the family. In this role the psychiatrist does not look for pathology in the family, but instead addresses the family’s need for information and support in dealing with the illness, is available for crises, and remains available for as long as he or she is needed. The difficult issue of confidentiality is not ignored but is presented as a clinical dilemma in balancing a resistant patient’s wishes against the family’s need to be informed. The tenets of the psychoeducational approach are listed clearly, with reference to expressed emotion theory as a skill to learn, deemphasizing its potential for once again blaming families. The book concludes with a list of nine recommendations for the mental health professions, summarizing the need to be responsive and helpful, rather than accusatory, to address inadequacies in training programs, to “take action to make care of the chronically mentally ill the highest priority of the public sector of mental health care” (how?), and to assist families in advocacy for changing commitment laws. From the perspective of a family member, the book is admirable in its message, but should emphasize even more strongly the need of families for much more practical guidance and concrete assistance than is currently available. Many families today are not looking to professionals for exoneration from blame, but for real help in terms of an
extensive support network of enlightened professionals, programing for both patients and families, more detailed ‘how to” literature, and mutual support groups, perhaps providing the kind of daily availability of support and guidance that is accessible to families of alcoholics. The strength of this book is its straightforward, clear message regarding the direction psychiatry should take to address the injustices in care of the mentally ill and their families. This is not a “how to” book, and offers too few specifics about the psychoeducational approach, the practical guidance that families crave, and specifically how to address larger political issues. What it does address is the gap that must be bridged between professionals and families if we together are to serve the best interests of the chronically mentally ill. There is presently an uneasy alliance between professionals and families, which is tainted by attitudinal remmants of psychogenic theories of mental illness as well as the devaluing of patients who make us aware of our limitations and powerlessness. Families continue to feel blamed, if not by theories of etiology, by newer theories holding them responsible for relapse rates. The book points out that families feel they have been given “responsibility without power.” The authors caution us against continuing to let families unfairly bear the burden of the failures of society to provide resources or of science to find answers. Psychiatry must not find fault without providing alternatives or guidance. Families may unjustly blame themselves for their relative’s mental illness, but they also blame the mental health system. Until we correct our shortcomings in serving the chronically mentally ill and their families, the alliance will remain fragile, and the potential for a truly effective collaboration cannot be realized. This book is a step toward building a more solid and genuine alliance between professionals and families. DANA HOLLEY,
LICSW
Coordinator, Family Education Program Somerville Mental Health Clinic Somerville, Massachusetts JOAN KEATING
Member, Family Education Program Somerville Mental Health Clinic Member, Alliance for the Mentally 111
The Psychology
of Pain (Second
Edition).
Edited by 151
Book Reviews
Richard A. Stembach. 1986 ($31.00), 256 pp.
New York: Raven Press,
The management of pain is now recognized as a major public health problem, not only inflicting tremendous personal suffering on the individual in pain and his or her family and extended social network, but also on society at large. It is estimated that in the United States the economic loss annually may be as high as $90 billion per year. Traditionally, the medical and surgical physicians have been primarily responsible for the care of individuals in pain, attempting to understand and treat pain as a process directly related to underlying noxious stimulation. Within the past decade, behavioral scientists, especially psychiatrists and psychologists, have made major contributions to the understanding of pain mechanisms, diagnosis, and management. These behavioral scientists no longer are infrequent consultants, but rather are integral members of all credible pain services. It is unfortunate that until quite recently, training programs for health professionals did little to correct the process of treating chronic pain with the acute pain model. It is time to recognize that chronic pain is not merely longlasting acute pain. In addition, it is now known that one cannot blindly generalize from experimental laboratory induced pain to clinical pain seen in a given patient population. As editor of The Psychology of Pain (second edition) and author of the chapter on Clinical Aspects of Pain, Richard Stembach (modestly) underestimates the significant impact of the first edition, which appeared in 1978. Not only did he provide the reader with a systematic literature review on the psychology of pain, but he also organized the material in such a way as to stimulate many students and neophytes in the field to appreciate the importance of applying behavioral medicine principles to pain problems. Sternbach and many of his coauthors are among the pioneers in the application of psychological principles to pain. It is fitting that Ronald Melzack is the author of the section on Neurophysiological Foundations of Pain, and he discusses the evolution of the gate control theory of pain that he and Patrick Wall proposed in 1965: In recent years, the evidence of pain has moved in the direction of recognizing the plasticity and modifiability of events in the central nervous system. The
152
psychologicalevidence lends strong support to the consideration of pain as a complex perceptual and affective experience determined by the unique past history of the individual, by the meaning of the stimulus to that person, and by the state of mind at the moment, as well as by sensory nerve patterns evoked by physical stimulation.
Two of the chapters authored by psychiatrists are especially well written. One is Harold Merskey’s Psychiatry and Pain, in which he discusses application of psychiatric methods to use with chronic pain. The other is Izzy Pilowsky’s chapter on Psychodynamic Aspects of the Pain Experience, in which there is an excellent section on abnormal illness behavior. Little attention is paid to nosology. A review of DSM-III classification relevant to pain would have been useful, since there is a recognized need to improve our accuracy in classification of pain. Students in this area are well advised to improve their acumen in distinguishing between various somatoform disorders. In addition, the concept of Pain Prone Disorder, as initially discussed by George Engel and later by Dietrich Blumer, are covered superfically and are important enough concepts to warrant more detail. Overall, however, the editor has accomplished his stated goal. He has compiled a well referenced text on the psychology of pain covering both experimental and clinical pain research.
GERALD
M. ARNOFF,
M.D.
Director of Boston Pain Center at Spaulding Rehabilitation Hospital Boston, Massachusetts
lnterfuce Between Neurology and Psychiatry. Edited by M.R. Trimble. New York: Karger, 1985 (!$48.50), 190 PP. The emergence of behavioral neurology and biological psychiatry as separate disciplines has generated a new enthusiasm for integrating the findings of neurology and psychiatry. Fruitful integration, however, requires a clear understanding of the assumptions, definitions and frames of reference involved when the terms Neurology and Psychiatry are used. For example, the psychodynamic clinician is concerned primarily with motives