Non-directive psychotherapy

Psychotherapy is a word to describe an age-old process. It would be better not to speak of psychotherapy, but of psychotherapies. Specialists are not the only ones who act as psychotherapists, since every human being fills this role at one time or another. Besides this, no two persons follow an identical approach. Finally, all therapists change technique constantly. The kinds of psychotherapy must therefore approach infinity.Some physicians appear to assume that only one type of psychotherapy may claim a scientific basis. Although Freud first put psychotherapy on a scientific path, there is no reason to say that Freud must be the last in this field. Over the past few years a new trend has started in psychotherapy which deserves close study. This new trend challenges some old beliefs and gives a new tool to help patients of some types. It is called non-directive or client-centered psychotherapy. This therapy does not try to solve the patient's problems for him, but rather establishes the conditions under which a patient can work out his own salvation. Each year non-directive psychotherapy grows in importance. Much can be learned from the method.     

NON-DIRECTIVE PSYCHOTHERAPY

Psychotherapy is a word to describe an age-old process. It would be better not to speak of psychotherapy, but of psychotherapies. Specialists are not the only ones who act as psychotherapists, since every human being fills this role at one time or another. Besides this, no two persons follow an identical approach. Finally, all therapists change technique constantly. The kinds of psychotherapy must therefore approach infinity.Some physicians appear to assume that only one type of psychotherapy may claim a scientific basis. Although Freud first put psychotherapy on a scientific path, there is no reason to say that Freud must be the last in this field.Over the past few years a new trend has started in psychotherapy which deserves close study. This new trend challenges some old beliefs and gives a new tool to help patients of some types. It is called non-directive or client-centered psychotherapy. This therapy does not try to solve the patient''s problems for him, but rather establishes the conditions under which a patient can work out his own salvation.Each year non-directive psychotherapy grows in importance. Much can be learned from the method.     

Companion-Animals’ Effectiveness in Managing Chronic Pain in Adult Community Members

ABSTRACT

Therapy animals have been found to alleviate pain in healthcare settings, but companion-animal owners report greater discomfort and use more analgesics than people who do not own one or more companion animals. To investigate this anomaly, 173 adults completed an online survey that included questions about themselves and any companion animal they owned, the Depression Anxiety and Stress Scales, the Numeric Pain Rating Scale, and a modified version of the Chronic Pain Coping Inventory-42. Participants were also invited to contact the researchers to expand on their responses in a semi-structured interview, to which seven owners responded. There was no significant difference between reported pain levels in owners versus non-owners. However, companion-animal owners who reported actively using human–animal interactions to manage their pain rated this as moderately helpful and reported lower pain levels than other owners. There were also no significant differences between owners’ and non-owners’ anxiety or stress levels. Companion-animal owners reported more depressive symptoms than non-owners, but owners with animals perceived as more friendly reported fewer depressive symptoms. Dog owners comprised most of the sample and, for these participants, there was a negative association between perceived dog friendliness and levels of depression and anxiety. Those with more disobedient dogs also experienced greater stress. Interviewees reported that their companion animals helped them cope with pain in many ways, including provision of social and emotional support and by providing a sense of purpose in life. These findings indicate that some, but not all, companion animals may be beneficial for participants with chronic pain. Since the benefits appear to be associated with the species and personality of the animal, and with whether the person actively uses human–animal interactions as a pain-coping mechanism, care should be taken before recommending companion-animal ownership to persons suffering from chronic pain.     

PSYCHOTHERAPY—A Concept for the Nonpsychiatric Physician

Patients tend to repeat with their physician, as with other significant people in their lives, their earlier previous patterns of behavior. The physician as well as the patient is involved in the physician-patient relationship. He will tend to respond to his patients in accordance with his earlier life experiences and his characteristic repetitive behavioral pattern. For both physician and patient, the relationship between them extends beyond the immediate reality situation.Psychotherapy is the utilization of psychological measures in the treatment of sick persons and the deliberate utilization by the physician of the physician-patient relationship for the benefit of the patient. The kind of psychotherapy that is practical and utilizable by the nonpsychiatric physician is that which uses education, reassurance, support and the management of the patient''s problems either directly or indirectly or through the intermediary of other people or agencies.The symbolic aspect of the physician-patient relationship is based essentially on the fact that a sick person, because of his anxiety and because of the threat to his physical and psychic integrity, is more dependent and more anxious than he would be if he were well, and therefore he has a correspondingly greater need for the authoritative and protective figure he finds in the physician.Psychotherapy is not directed exclusively to the treatment of flagrantly or obviously neurotic or psychotic patients. It should be and is directed to all sick persons. Limitations in psychotherapy are set by various determinants, among which are the nature of the precipitating factor in the illness, the nature of the sick person, the skill, knowledge and abilities of the physician, and the nature of the physician-patient relationship. In psychotherapy, as in all medicine, the physician should not do anything which may disturb the patient if the disturbance is of no value or if it cannot be followed through with special skills.     

疼痛患者脊髓脑脊液中强啡肽含量的分析

本文观察了疼痛患者脊髓脑脊液中强啡肽含量的变化。共收集３１例急性疼痛患者和１４例慢性疼痛患者的脊髓脑脊液,测定其中的强啡肽含量,与２７例无痛患者的结果进行比较,并结合被测者的性别、年龄、体重、血压、脉搏、体温等一般情况进行分析。结果表明,慢性痛患者脑脊液中强啡肽含量显著升高,而急性痛患者则略有降低。判别分析表明,急性痛患者的强啡肽含量及其他临床资料有明显的特点（判别准确率８２％）;慢性痛患者未见明显特征。作者认为,在更广泛地收集临床资料和检验结果的基础上,进一步研究不同病因的疼痛患者的临床特征,可能有助于对疼痛疾病进行鉴别诊断     

THE PSYCHODYNAMICS OF HYPERTENSION

Psychotherapeutic study of patients with essential hypertension shows evidence of massive repression of unacceptable feelings in many areas of the personality, predominantly feelings of rage and hostility. It appears that in the mentation of the hypertensive person, rage not only risks the loss of affection and approval by others, but is unconsciously equated by him with murderous loss of self-control. In addition, he characteristically has an inordinate fear of death.Intensive insight psychotherapy, when commenced early in a well-motivated patient, is very effective in the treatment of this disorder. As in any psychosomatic condition, the patient should be concomitantly treated by his general physician or by an internist.     

An ethical issue in the psychotherapy of pain and other symptoms

Pain presents an ethical problem in psychotherapy which it shares with other symptoms. It presents this problem because initially it does not give rise to the same expectations as overt psychological complaints such as depression or anxiety. At first glance pain appears to represent an obvious example of the traditional doctor/patient relationship...I hope to demonstrate that what began as a transaction in the medicine of organic disease, may become, before the patient recognizes it, a process of personal change of which the consequences may often not be foreseen. Such a development poses a problem in bioethics. If the development can be foreseen, the problem may be forestalled. If not, the proceedings may reflect paternalism and we need to consider if that is acceptable. The problem is not unique to pain but tends to be masked by the initial context of somatic treatment.     

Pain Perception in the Elderly Patient: An Overview of Issues

The control of pain is an issue of major importance for older patients. As the proportion of elderly persons in society grows, these problems take on particular humanitarian and economic significance. Review of the literature indicates that the sensory mechanisms subserving pain in older persons are not unique, but painful pathologic states are more likely to occur in old age. Stereotypes of the older person have led to insufficient management and overmedication of this patient population. Moreover, the complex nature of chronic pain in the aged patient has not been appreciated by health care professionals. The literature points to an urgent need for more data that will shed light on the nature of pain problems in old age.     

Le syndrome douloureux chronique pelvien chez l’homme. Quelle physiopathologie? Quel traitement?

Chronic pelvic pain, in young men or elderly men, has always been a challenge to the medical profession, raising problems of assessment and management. Chronic pelvic pain has a high prevalence, which is underestimated as indicated by the following figures: 4% to 8% of patients consulting chronic pain centres, 15% of patients consulting a urologist for symptoms of chronic prostatitis with alteration of quality of life, 70,000 cases of chronic cystitis per year in the USA. The circumstances of onset are multiple: postoperative, after minor or major trauma or postinfectious, sometimes without any particular aetiology and often in a multifactorial context. The pathophysiology is therefore vague and poorly elucidated, as only about 5% of cases of chronic prostatitis have a bacterial cause. However, any form of stimulation activates pain pathways with neurogenic inflammation followed by central sensitization and modification of neuronal plasticity, and finally chronic refractory pain with organic dysfunction. This mechanism is currently proposed in numerous publications concerning postoperative chronic pelvic pain and refractory cystitis and chronic prostatitis. The pathophysiology of these types of pain is probably therefore neurogenic. In the absence of stimulation, a pudendal nerve tunnel syndrome can be suggested. The treatment of chronic pelvic pain in men can be considered in the following way: aetiological treatment whenever possible, neurogenic medical treatment (tricyclic antidepressants for continuous pain, anticonvulsants for intermittent pain, NMDA receptor antagonists in the case of failure), treatment of organic dysfunction, pudendal nerve analgesic block in the case of suspected tunnel syndrome and global treatment of patient with impaired quality of life. In conclusion, a better pathophysiological approach to these forms of chronic pelvic pain can improve these difficult patients.     

Pregabalin,the lidocaine plaster and duloxetine in patients with refractory neuropathic pain: a systematic review

Background  

Patients frequently fail to receive adequate pain relief from, or are intolerant of, first-line therapies prescribed for neuropathic pain (NeP). This refractory chronic pain causes psychological distress and impacts patient quality of life. Published literature for treatment in refractory patients is sparse and often published as conference abstracts only. The aim of this study was to identify published data for three pharmacological treatments: pregabalin, lidocaine plaster, and duloxetine, which are typically used at 2^nd line or later in UK patients with neuropathic pain.     

ANALYTIC GROUP PSYCHOTHERAPY—For Wives and Husbands

The practice of group psychotherapy has its roots in Freudian dynamics and concepts, and varies from play group psychotherapy to analytic group psychotherapy, using the dynamics of transference, catharsis, interpretation, insight, ego building, reality, and sublimation.This presentation is based on the experience of the author with about 40 women patients formed in groups at a sanatorium. The majority were neurotic, psychoneurotic or manic-depressive. Several were psychotic. Some of the patients were treated in groups that included their husbands, after discharge from the sanatorium.Analytic group psychotherapy is a concept of an attenuated mobile and uncensored societal setting, where persons who have failed in the larger and harsher social reality may again attempt resocialization in a permissive, friendly, and protected environment. It is not to be considered the poor man''s makeshift for individual psychoanalysis. Group dynamics facilitate the regression and catharsis necessary to produce insight and ego strength, leading to more rapid recovery.Husband and wife participation in the same group led to a more tolerant acceptance by the husband of the concept of mental ailment, and empathy for the spouse.The role of the psychiatrist in group psychotherapy is very similar to that in individual psychoanalysis. He represents the reality to the patient and the group. He is objective but permissive, and not passive. Therapeutic goals are the same as in individual therapy, and may focus on the resolution of pre-oedipal conflicts or on situational maladjustments.     

Analytic group psychotherapy; for wives and husbands

The practice of group psychotherapy has its roots in Freudian dynamics and concepts, and varies from play group psychotherapy to analytic group psychotherapy, using the dynamics of transference, catharsis, interpretation, insight, ego building, reality, and sublimation.This presentation is based on the experience of the author with about 40 women patients formed in groups at a sanatorium. The majority were neurotic, psychoneurotic or manic-depressive. Several were psychotic. Some of the patients were treated in groups that included their husbands, after discharge from the sanatorium. Analytic group psychotherapy is a concept of an attenuated mobile and uncensored societal setting, where persons who have failed in the larger and harsher social reality may again attempt resocialization in a permissive, friendly, and protected environment. It is not to be considered the poor man's makeshift for individual psychoanalysis. Group dynamics facilitate the regression and catharsis necessary to produce insight and ego strength, leading to more rapid recovery. Husband and wife participation in the same group led to a more tolerant acceptance by the husband of the concept of mental ailment, and empathy for the spouse. The role of the psychiatrist in group psychotherapy is very similar to that in individual psychoanalysis. He represents the reality to the patient and the group. He is objective but permissive, and not passive. Therapeutic goals are the same as in individual therapy, and may focus on the resolution of pre-oedipal conflicts or on situational maladjustments.     

Placebo in the treatment of pain

Placebo is the use of the substance or procedure without specific activity for the condition that is trying to be healed. In medicine, benefits of placebo effect are used since 1985 and 1978 placebo effect was first scientifically confirmed. It was found that placebo induced analgesia depends on the release of endogenous opiates in the brain and that the placebo effect can be undone using the opiates antagonist naloxone. Functional magnetic resonance imaging of the brain showed that placebo analgesia was obtained regarding the activation and increased functional relationship between ant. cingulate, prefrontal, orbitofrontal, and insular cortex, nucleus accumlens, amygdala, periaqueduktalne gray matter and spinal cord. Placebo also facilitates descending inhibition of nociceptive reflexes through periacvaeductal gray substance. Placebo effect can be achieved in several ways: by using pharmacological preparations or simulation of operating or other procedures. This phenomenon is associated with perception and expectation of the patient. To achieve the effect of placebo it is essential degree of the suggestions of the person who prescribe a placebo, and the degree of belief of the person receiving the placebo. Expected effect of placebo is to achieve the same effect as the right remedy. Achieved placebo effect depends on the way of presentation. If a substance is presented as harmful, it may cause harmful effects, called 'nocebo" effect. Placebo effect is not equal in all patients, same as the real effect of the drug is not always equal in all patients. Application of placebo in terms of analgesia will cause a positive response in 35% of patients. Almost the same percentage (36%) of patients will respond to treatment with morphine in medium doses (6-8 mg). Therefore, one should remember that response to placebo does not mean that a person simulates the pain and then it is unethical to withhold the correct treatment especially in light of findings that the prefrontal cortex is activated expecting liberation of pain and how this action reduce activities in brain regions responsible for sensation of pain (thalamus, somatosensory cortex and other parts of the cortex). However, the use of placebos is ethically, legally and morally very dubious. The basis for the placebo effect is deception. It undermines honest relationship and trust between doctor and patient which is extremely important for successful treatment. Consciously giving placebos to patients for a condition that can be adequately treated, with prejudice the right of patients to the best care possible, opens up many bioethical issues. Despite all the current knowledge level, placebo effect remains still a scientific mystery.     

The extent of temperature sense and pain appreciation recovery in the dermatomes of the cauda equina roots after surgery for lumbar intervertebral disk herniation

Temperature sense and pain appreciation in the dermatomes of the cauda equina roots were estimated in patients with lumbar intervertebral disk hernias before surgery, as well as immediately and long after surgery for disk herniation. Before surgery, the temperature sense and pain appreciation were impaired not only in the dermatome of the compressed root, but also in the dermatomes located proximal and distal to it. The temperature sense was impaired more severely. The recovery of the temperature sense and pain appreciation in the dermatomes of the cauda equina roots after surgery is limited, especially in the region innervated by the compressed root. Positive changes in temperature sense and pain appreciation in different zones examined soon after surgery were observed, on average, in 55% of cases, whereas delayed positive changes were detected only in 36% of the patients. Pain appreciation (in tests with heat pain) both immediately and long after surgery was improved to a higher degree.     

Somatosensory profiles but not numbers of somatosensory abnormalities of neuropathic pain patients correspond with neuropathic pain grading

Due to the lack of a specific diagnostic tool for neuropathic pain, a grading system to categorize pain as 'definite', 'probable', 'possible' and 'unlikely' neuropathic was proposed. Somatosensory abnormalities are common in neuropathic pain and it has been suggested that a greater number of abnormalities would be present in patients with 'probable' and 'definite' grades. To test this hypothesis, we investigated the presence of somatosensory abnormalities by means of Quantitative Sensory Testing (QST) in patients with a clinical diagnosis of neuropathic pain and correlated the number of sensory abnormalities and sensory profiles to the different grades. Of patients who were clinically diagnosed with neuropathic pain, only 60% were graded as 'definite' or 'probable', while 40% were graded as 'possible' or 'unlikely' neuropathic pain. Apparently, there is a mismatch between a clinical neuropathic pain diagnosis and neuropathic pain grading. Contrary to the expectation, patients with 'probable' and 'definite' grades did not have a greater number of abnormalities. Instead, similar numbers of somatosensory abnormalities were identified for each grade. The profiles of sensory signs in 'definite' and 'probable' neuropathic pain were not significantly different, but different from the 'unlikely' grade. This latter difference could be attributed to differences in the prevalence of patients with a mixture of sensory gain and loss and with sensory loss only. The grading system allows a separation of neuropathic and non-neuropathic pain based on profiles but not on the total number of sensory abnormalities. Our findings indicate that patient selection based on grading of neuropathic pain may provide advantages in selecting homogenous groups for clinical research.     

Origins of Phantom Limb Pain

Phantom limb pain (PLP) is a chronic neuropathic pain occurring in 45–85% of patients who undergo major amputations of the upper and lower extremities. Chronic pain is physically and mentally debilitating, affecting an individual’s potential for self-care and the performance of daily living activities essential for personal and economic independence. In addition, chronic pain may lead to depression and feelings of hopelessness. A National Center for Biotechnology Information study found that in the USA alone, the annual cost of dealing with neuropathic pain is more than $600 billion, with an estimated 20 million people in the USA suffering this condition. PLP manifest predominantly during two time frames post-amputation: during days to a month and again at around 1 year. In most patients, the frequency and intensity of the chronic neuropathic pain diminish over time, but severe pain persists in about 5–10% of patients. The development and maintenance of neuropathic pain is attributed to extremity amputations causing changes in peripheral axon properties and neuronal circuitry in both the peripheral and central nervous systems: peripheral axons, dorsal root ganglia, the spinal cord, and the cortex. However, it is not clear how the changes in neuronal properties in these different locations affect neuropathic pain. Is pain initiated by one set of post-amputation changes while the pain is maintained by another set of changes? If one set of amputation-induced changes, such as those of peripheral axons, are reverted to normal, is the chronic pain reduced or eliminated, while reversing another set of neuronal changes and neuronal circuits to normal do not reduce or eliminate the pain? Or, must all the amputation-induced changes be reverted to normal for pain to be eliminated? While this review examines the mechanisms underlying the induction or maintenance of PLP, it is beyond its scope to examine the mechanisms that may permanently reduce or eliminate neuropathic pain. This paper is the first of two reviews in this journal and deals with the causes of chronic PLP development and maintenance, while the second review examines potential mechanisms that may be responsible for promoting the capacity to coping with PLP by reducing or eliminating it.     

La psychothérapie individuelle de la schizophrénie: mise en perspective de son histoire, de ses développements récents et de ses orientations nouvelles

Empirical study of long-term outcomes for persons with schizophrenia suggests that recovery is often possible. This literature also emphasizes that recovery may involve different kinds of experiences for different people with the same psychiatric condition. For some, recovery may mean symptom remission while for others it may be reflected by the achievement of psychosocial milestones. For yet others, however, to recover can involve subjective changes in how those persons experience themselves as meaningful agents in the world. For some, to recover could be to reclaim a full sense of self, a sense of self that permits to engage in relationship with others and the rigors of daily life. In this chapter, we review the potential of individual psychotherapy to address the more subjective aspects of recovery related to sense of self. We first review literature on the effectiveness of psychotherapy for persons with schizophrenia. We then discuss literature on the larger issue of how decrement in personal narrative metacognition may underpin some of the disturbance in sense of self observed in schizophrenia. Finally, we focus on how psychotherapy could be conceptualized and adapted to help enrich self-experience by addressing narrative and metacognition. Directions for future research are discussed.     

Patient-guided peripheral nerve exploration for the management of chronic localized pain

This technique represents a surgical adjunct for the management of chronic, localized pain in patients who continue to have pain despite exhaustive prior evaluation and treatment. The patient-guided approach was used in 10 patients referred with "intractable pain" and yielded good to excellent results in all but one patient. When applied selectively to cases with significantly distorted anatomy or previous failed interventions, this simple technique can minimize dissection and unnecessary resection, while offering relief to a patient population otherwise resigned to a life with chronic pain. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.     

Psychological assessment of factors affecting pain

Use of traditional stimulus-response models of pain leads to differentiation between organic and psychogenic pain, which is often not helpful, if not dangerous, in treating chronic pain. Pain does not simply reflect bodily damage but also complex psychological malfunctioning. Viewing chronic pain as an obsessional state may often help in treating the entire patient and prevent the physician from being obsessed with the patient''s obsession. Psychological assessment of pain should focus on the role of psychological processes in the multifactorial causation of the illness causing the pain, notably their role in illness-proneness in general. Also, iatrogenic psychological distress, associatively precipitated psychological conflict and illness-perpetuating psychological processes should be looked for. A serious obstacle to progress with pain problems is not lack of hard data but conceptual confusion. Before medicine can meaningfully assess psychological factors in pain problems it must first learn to perceive psychological disturbances in medical and surgical patients.     

Painful interactions: Microbial compounds and visceral pain

Visceral pain, characterized by abdominal discomfort, originates from organs in the abdominal cavity and is a characteristic symptom in patients suffering from irritable bowel syndrome, vulvodynia or interstitial cystitis. Most organs in which visceral pain originates are in contact with the external milieu and continuously exposed to microbes. In order to maintain homeostasis and prevent infections, the immune- and nervous system in these organs cooperate to sense and eliminate (harmful) microbes. Recognition of microbial components or products by receptors expressed on cells from the immune and nervous system can activate immune responses but may also cause pain. We review the microbial compounds and their receptors that could be involved in visceral pain development.