February 21, 2012

Ask a labor nurse whether psychological adjustment impacts pain intensity and you’ll get one of those eyebrow-arched, "Do you THINK?" looks. She’s seen how anxiety, loneliness, and despair magnify pain, crush resilience, and cloud a person’s cognitive coping resources -- even in the context of short-term, high-intensity pain that most often ends in a joyful moment.

Oncologists undoubtedly have seen it, too, observing a high degree of variability in how patients respond to cancer pain over the long term, as tumor spread, medication side effects, invasive interventions, and discouragement all take their toll. But as we all know, science needs evidence to prove even the most obvious points.

© IuriiSokolov/iStockphoto.com Psychosocial interventions can alleviate pain intensity in some cancer patients, but is it a realistic treatment option?

Fortunately, the numbers are in. A new meta-analysis – the sixth to explore the question – convincingly affirms the role of specific psychosocial interventions in reducing cancer pain severity and interference.

Published in the Feb. 10 issue of the Journal of Clinical Oncology, the review of 37 well-designed studies (n=4,199) found the weighted average effect size of psychosocial interventions for pain intensity was 0.34 (95% CI, 0.23 to 0.46) and for pain interference, 0.40 (95% CI, 0.21 to 0.60).

The authors termed the evidence "robust" and recommended "systematic implementation of quality-controlled psychosocial interventions as part of a multimodal approach to the management of pain in patients with cancer." That would be great, of course, but is it enough to systematically implement the specific techniques that proved their muster?

I think not.

It’s a tough order to standardize psychosocial interventions well enough to obtain meaningful, clinically relevant research results, and the studies included in the meta-analysis were no exception. The authors accepted as "psychosocial interventions" cognitive behavioral techniques, stress management, relaxation training, education, hypnosis, and other "experiential" approaches, but not "alternative therapies" such as massage or Reiki.

Humanistic, person-centered therapy championed by psychologist Carl Rogers would never make the grade in such a review, nor would narrative therapy (based on patients’ stories of themselves), nor Rollo May’s existential therapy, which faces the threat of death head-on. Family systems therapy, in which I was trained, might allow patients to see how the pressure of the roles they play within their families burden them with emotional as well as physical pain. Manipulating and stretching those roles, in many cases, could serve as physical therapy for the soul.

Would some patients be more empowered and better able to endure their pain if they were able to access such varied forms of therapy, addressing their life angst in a quiet room, guided by a competent and caring specialist in psychotherapy? I have no doubt.

But such approaches do not fit neatly into standardized 6-week workbooks and manuals.

So we test the effects of cognitive restructuring, using cartoons to enlighten patients about how they can manage their negative expectations. We lead them in deep muscle relaxation exercises. We teach patients to learn about keeping ahead of their pain with timed dosing plans and coach them about how to better talk to you, their oncologists.

It’s all good, of course.

I make liberal use of psychoeducation and cognitive behavioral therapy in my work, and even before I read the meta-analysis, I believed in their efficacy in managing physical as well as emotional pain.

But I’m biased.

I think psychosocial cancer research is not only methodologically difficult, it’s also woefully underfunded and often simplistic in its focus.

We want convenient, inexpensive answers, so protocols rely on who’s available and what’s easy to provide. Fully 63% of the intervention providers in the recent meta-analysis were nurses. Just 10% were psychologists and 2% social workers: professionals trained in a variety of techniques and therapeutic approaches applicable to people’s lives, not just their generic pain.

Would it be difficult to test the impact of more complex psychosocial interventions on cancer pain? Without question.

Is it possible that the impact would prove demonstrable, even beyond the "robust" effect sizes obtained by skill-building, educational, and cognitive approaches?

Do you THINK?

 

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