Chapter 5 Integrating Relational Psychodynamic and Action Oriented Psychothepraies .

1. Chapter 5 Integrating Relational Psychodynamic and Action Oriented Psychothepraies.

2. Integrating Relational Psychodynamic and Action Oriented Psychothepraies • Doctors, let us first consider what you have learned from this chapter • How does this resonate with your own needs as a person or the clinician?

3. Integrating Relational Psychodynamic and Action Oriented Psychothepraies • In the past psychodynamic treatments for individuals with chronic pain was used as an alternative to cognitive behaviorally treatment resistant patients • Currently, more integrative psychodynamic model is being proposed

4. Integrating Relational Psychodynamic and Action Oriented Psychothepraies • The focus is on the relational dynamics that impair coping with chronic pain and the negative consequences of chronic pain on interpersonal relationships and overall adjustment • Assumption: pain like all life events occurs in a relational matrix or context. • Current and past relationships, including relationships with treatment providers play an ongoing interactive role in the development, course and treatment of chronic pain (a matrix)

5. Relational variables have been underused as a resource that can be harnessed to maximize treatment • It hasonly been considered in operant conditioning, but from a condition stimulus or reinforcing perspective • From this perspective, it is also exploring the role of past and present relational dynamics and incorporates them into a treatment approach hat addresses the unique needs of the patient.

6. Most important, this model parallels increasing efforts among CBT and family therapists to integrate treatments • Relational approaches made significant changes in conceptualizing the psychotherapy relationship, especially with respect to such qualities as authenticity, mutual influence in the co-creation of meaning • Co-creation of meaning. Consider solution focused therapy – Steve de Shazer

7. Chronic pain patients story typically captures a sense of being fundamentally alone. Even though our lives are influenced by past and current relationships • Chronic pain is a solitary experience it cannot be felt seen or even independently confirmed, yet it can has a profound impact on relationships

8. Isolation and conflict are common, as is a drastic change in social roles and the patient’s ability to participate in a mutually rewarding relationship • “Likewise, although the idiosyncratic meaning of the pain experience and, therefore, the quality of the person suffering, is difficult articulate to another, it is largely shaped by the sum total of the individual’s past and present relational experiences” (Basler, et all, 2002)

9. Classical psychoanalytic approaches to chronic pain • “Freud believed that at its source, the origin of chronic pain was an actual physical insult that the unconscious seized upon because it served to crystallize a dynamic conflict and could be used to partially gratify drives and conflicts to the subjective experience of pain and its accompanying disability and emotional responses.” • Let’s discuss this

10. Typical goal of treatment is to assist patients in becoming aware and later to renounce unconscious impulses and conflicts and entertain partial gratification through sublimation in adult roles and relationships • With pain, the analyst makes interpretations based on patient’s free association interventions which provides insight into the reason that the symptom of pain developed and the function that it served in terms of both primary and secondary gain

11. It is important to note that in this approach, it doesn’t have to be the conflict, causing the pain. The more current perspective would be how it exacerbates or maintains pain behaviors. • In this traditional approach • “interpretations were considered to be objective because the rigid treatment model prohibited the analysts involvement in the therapeutic relationship and considered him or her detached, neutral observers whose insight was not distorted by personal investment and who did not contaminate the unfolding of transference distortions by being a real person in the patient’s life.”

12. Critics dismissed these approaches for chronic pain patients as it was not grounded in research and only appropriate for small group of nonresponders • This is consistent with psychodynamic approaches and behavioral medicines history • However, CBT has had its limitations as well by not recognizing the developmental aspects of the patient’s history that may lead to the idiosyncratic interpretations of pain, contributing to their overall emotional suffering

13. Relational psychodynamic approach to personality development psychotherapy • Melanie Klein referred to internalization’s early relationships and relationship patterns • Object relations, though conceptualized as repositories of instinct base drives it paved the way for the examination of the role of actual relationship development

14. Sullivan made a dramatic break with classical analysis in the 1930s, 30s, when he suggest that it’s not the individual psyche, but the interpersonal field that is the essential unit study and therefore treatment • Does it have to be one or the other? • Why do mutually exclusive dynamics?

15. This coincided with the rise of object relations in which the basic tenet was that libido is not a pleasure seeking, but objects seeking • Bowlby’s studies also came out afterwards focusing on attachment theory, which provided much-needed empirical support for the argument that a primary and irreducible motivation of humans is attachments others

16. Mitchell (1988) coined the term relational matrix to describe the complex internalize modes of relating to others • These include affect it fully laden images and representations of the individual, others and patterns of self in interaction with others that are the end product of significant early relationships interacting with individuals environment, with his or her genetic predispositions

17. In it. In essence, it’s a biopsychosocialmodel of development • These theories assert that we are relational from the beginning, which may be a survival instinct • In classical analytic theory, personality originates in the interaction between biology or biological impulses and the external world during approximately first five years. • In contrast, the relational psychodynamic increases emphasis on the present environment, especially the actual qualities of current relationships in ongoing healthy or , pathological adaptation

18. In this model, there’s complex interactions between internalized expectations of others and their actual qualities.An emphasis on the actual qualities on people’s relational worlds has major implications with their response to persistent pain and impaired physical functioning

19. In the relational psychodynamic treatment features of the patient’s relational matrix inevitably evoke certain behaviors, thoughts and emotions therapist in these enactments are welcome to explore together • Removing the limiting and unrealistic constraints of the classically prescribed blank screen and embracing an interactional view of the psychotherapy which is more validating to the patient, builds tustand gives therapist a broader range of interventions to facilitate experiences • In a relationship of openness and safety patients have the opportunity to experience or experiment with relational dynamics, harnessing learning to potentiate the change

20. Frank and Watchel have built on the relational model incorporating action oriented interventions specifically in the concrete.

21. Interplay relational themes development, maintenance • The research suggested the psychosocial variables contribute more to the chronic pain issue at hand in the tissue damage. • From this perspective, the psychosocial variables are more relational nature and mediated in a relational manner • Therefore, antecedent interpersonal relationships can create the vulnerability that leads to developing chronic pain syndrome

22. “ vulnerabilities based on relational expenses of the past, combined with the effects of the real stressors of injury and pain on the individuals present life and relationships, reciprocally influence each other in a vicious cycle of increasingly maladaptive maladaptive coping, for the deterioration of emotional and physical health, depletion of healthy sources of social support, and increased reliance on the ever diminishing secondary gain of the sick role” • Consider the statement ever diminishing secondary gain

23. Scenario one: patient raised by emotionally detached and critical parents. Patient seeks familiarity as an adult, selecting a spouse that replicates the traits and who reacts to pain and injury with withdrawal and criticism. The adversarial and suspicious approach taken by insurance company may augment this pattern, as does the invisible nature of pain in his validation. This patient may become guarded treatment providers can become more suspicious

24. Engel in 1951 and 59 contributed much to the pain prone patient person, which included several early life experiences such as physically, verbally abusive parents harsh punitive parents overcompensated rear displays of affection for most distant parents, warm and so this solicits his child was ill apparent suffered chronic illness, pain, and various other parent-child interactions involving guilt