- Psychological Factors in the Control of Cancer Pain
Pain is frequently, though not always, associated with cancer. The degree of pain depends on a variety of factors including the site and extensiveness of the primary tumour and metastases (secondary tumour sites). However, the pain experience of cancer patients, and therefore the quality of life is also influenced by psychological factors.
A recent study of 86 women with breast cancer that had spread to other parts of the body found three factors that were significantly associated with cancer pain: requests for the use of analgaesics, mood disturbance (as measured by a psychological test), and belief that the pain indicated a worsening of the illness. By contrast, nearness to death and site of the metastases were not significantly associated with pain. In other words, psychological factors are at least as important as physical factors in determining cancer pain, and therefore in determining quality of life.
Of course, pain and illness can lead to changes in moods and emotions, creating anxiety and depression which in turn undermine the patient's ability to manage pain. But many patients with well-documented physical lesions can respond to psychological approaches aimed at improving their overall functioning, including pain control, where they are highly motivated.
A psychological approach to a patient is intended to strengthen the person's own resources through paying attention to the patient's self-esteem and exploring ways of increasing it and expanding the patient's awareness of his or her inner life, and of the extent to which this can affect experiences of self, family, work, and illness. Thus it involves more than just a focus on pain control, and includes a focus on the individual's overall psychological adjustment.
The use of psychological techniques assumes that patients are motivated and committed to work by themselves outside the therapeutic setting. Goals can be set which are realistic, and achievable, but the patient must spend a certain amount of time daily using procedures such as imagery or self-hypnosis that are a part of such techniques. It just doesn't work if patients are simply passive recipients of such treatment.
One of the very effective ways of getting some control over pain is the use of procedures aimed at learning to alter attentional processes. Many people start with excellent skills with regard to the focussing of attention. They have always been able to lose themselves in books, movies, or music, or to immerse themselves in the beautiful experiences of the moment, like a brilliant sunset. But people can learn to do these things better, and in so doing they can learn how to make their pain less important. It makes sense. If you are focusing intently on a movie you are not focusing so strongly on the pain.
There are at least six strategies of attention shifting, used with active imagining, or self-hypnosis that may be used to control cancer pain:
* Directly blocking awareness of pain through the development of a sensation such as numbness, which most people have experienced at some time or another, and which can often be imagined effectively enough to recreate the experience. Sometimes the numbness can be created more easily in some parts of the body, then imaginatively transferred to other parts by touching the painful area.
If the patient is unable to create a feeling of numbness, another sensation may do the job. It is often quite easy for people to imagine themselves floating in a warm bath, or lying in the sun and enjoying the warmth of the sun on their skin. These nice warm feelings can be imagined extending throughout the body.
* Substituting another feeling (such as pressure) for the pain, may make the sensation more tolerable.
* Moving the perception of the pain to a smaller or less vulnerable part of the body seems to be within many people's capabilities. Achieving such an effect diminishes the significance of the pain, and thus helps create feelings of mastery.
* Altering the meaning of the pain so that it becomes less important and less debilitating may be helpful for some. For instance, it can be seen as a signal for the individual's attention so that some kind of treatment can occur, or as an indication of life, and therefore of hope.
* Increasing tolerance for the pain may occur if the individual can begin to assign it less significance in daily life, seeing it as just something predictable that is there, so that it will not receive special attention. People can practise such a process by deliberately creating opportunities for distraction. One of my first patients with chronic back pain decided to learn about using computers and found that as his interest and involvement increased his awareness of his back pain decreased.
Particularly effective is to imagine being in a very pleasant place, and attending to all of the experiences that would go with that place. Or a person might switch attention to the feelings in a comfortable, or non-painful part of the body, such as the delicate sensation of rubbing the fingertips together.
* In extreme cases individuals may be encouraged to dissociate perception of the body from their awareness, feeling as though the painful area is outside of them. It might sound an extreme idea, but such dissociation is a typical effect of deep relaxation or hypnosis.
We know that as many as fifty percent of patients can gain significant pain relief through such procedures, though improvements are sometimes gradual and improve over time. While many people can learn to restructure their pain experience and diminish the amount of pain and suffering accompanying cancer, they may also experience a greater sense of mastery and control over their illness and treatment.
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