The treatment of persistent pain - Australian Pain Society

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Suzanne Scott Multidisciplinary Pain Centre, Royal Brisbane Hospital Robin Murray Pain Management and Research Centre, Royal North Shore Hospital Health professionals who work with individuals who have persistent pain have difficulty at times in accounting for differences in outcome when those with similar complaints respond in ways that are unpredictable. (Pearce, Cramond, Creed, (2001). Bowlby’s attachment theory fits within the biopsychosocial model of persistent pain and may explain the sometimes puzzling behaviour of these individuals. This article relates differences in treatment outcome to differences in early developmental histories and examines the influence of secure and insecure attachment styles on the response of persistent pain sufferers to treatment. Attachment theory is a robust concept that is useful for health professionals when assessing and treating persistent pain. It may explain the origins of help-seeking and self-caring behaviours of these individuals and help us to understand why certain behaviours are directed toward professionals who are caring for them. At a time of need individuals approach a carer in a particular manner and display certain behaviours that they learned within their family of origin. Children internalise experiences with caretakers and these attachment experiences become the prototype for their relationships in adult life. A child who grows up in a caring and nurturing family environment has the best chance of growing to maturity as a self confident adult with strong self respect, respect for others, and high self efficacy. In contrast, a child who has to survive in a dysfunctional family environment, has less chance of developing such strong personal resources. The quality and the type of the developmental influences on children determine their manner of attachment. Attachment behaviours become prominent when individuals are afraid or ill. They approach or avoid their carers according to their internalised model of "self" and "other" at these times. 2 The treatment of persistent pain The key constructs of this model are: 1Whether or not the attachment figure is judged to be the sort of person who in general responds to calls for support and protection, & 2Whether or not the self is judged to be the sort of person anyone, and in particular the person from whom care is sought, is likely to respond to in a helpful way. A "carer" is defined here as one with whom the person has a close emotional bond, or a health professional. When individuals have persistent pain these carers become the source and the focus of help and support. The relationship an individual sets up with any of these carers reflects their model of interpersonal relationships. In times of need, they are likely to approach a carer with the same behaviours and intensity that they brought to the relationship with an original carer such as the mother. It is suggested that this model of self and other is stable throughout life. (Ainsworth, 1982; Bowlby, 1944; George, Kaplan & Main, 1987). Attachment theory is relevant to health research and to clinicians because it has been shown that the particular behaviours that are the outcome of attachment learning determine in part, the ability of the individual to effectively manage and recover from illnesses, traumas or disabilities. Each of the models of attachment behaviour favours certain problem solving strategies. Clinicians generally consider the resources of the patient when considering ways in which information is presented or in attempting to remedy a problem. Cognitive abilities are usually taken into account, but it is less likely that the influence of emotional factors related to the individual’s attachment style will be considered. Our experiences as children influence our subsequent years at least until we are mature enough to make judgements less coloured by emotion. Bowlby made his first reports about the detrimental influences of dysfunctional families on children living within these families in 1958. He reported that attachment behaviour is organised, learned and reinforced or extinguished by social interactions within the family (Bowlby, 1958). His theories are supported by Ferster and Perrott (1968). Ainsworth, Blehar, Waters and Wall (1978) classified the attachment styles of children according to their ability to recover from separation anxiety. Because children are vulnerable when sick or afraid, these researchers suggested that a strong supportive family environment not only gives the best possible chance for a child to recover from
illness or injury, it also gives the child a view of itself that it is worth helping. This model of the self as worthwhile influences the view of other people as being helpful, dependable and trustworthy. Their sense of "felt security" then becomes stable and resilient. In contrast to secure children, children who are neglected, abused, or abandoned do not view themselves in the same manner as the secure group. These insecure children have varying views of the self and diminished confidence in others. Their model of attachment underlies a negative model of the world where they must strive to overcome difficulties in an unstable environment. The two fundamental styles of attachment are secure and insecure. The factor which is thought to be common to all insecure individuals is chronic depression. Children who are unwanted or neglected from birth are vulnerable to early onset depression, while those who are traumatised or bereaved, abused or ill are thought to become depressed as a result of the particular problem. (Bowlby, 1944). Bowlby described two sub-styles of insecure adjustment. A child who had suffered loss such as abandonment or neglect is likely to become obsessively self-reliant and dismissive of others. He labelled this group "avoidant." Avoidant or dismissive attachment style is characterised by a strong sense of self and a low opinion of the ability of others to be dependable or trustworthy. These individuals avoid being rejected by others by never allowing them to get close enough to provide care or attention. Those who have been forced to survive traumas such as prolonged illness, abuse or bereavement were posited by Bowlby to exhibit an "anxious" attachment style that is characterised by a low sense of self and a distorted view of the importance of others. However, despite this distorted sense of other’s importance, they may harbour a strong sense of resentment even though they are care-seeking (Bowlby, 1977). These individuals are typically anxious when they are confronted by health problems and find it hard to sustain involvement in treatment. Occasionally health workers come into contact with individuals who are very anxious, very wary of contact with others and ambivalent about their own care. So strongly do these individuals reject others that a fourth attachment style has been suggested (Bartholemew and Horowitz, 1991; Hazan and Shaver, 1987). This group of avoidant individuals has been labelled "fearful." The fearful group are thought to consider themselves unworthy and unlovable and expect that 3 The treatment of persistent pain others will be rejecting, untrustworthy and unavailable. By avoiding close contact with others they protect themselves from anticipated rejection (Bartholomew and Horowitz, 1991; Hazan & Shaver, 1987). It is suggested that these fearful-avoidant individuals are low in self-respect, while dismissive-avoidant individuals are higher in self respect but also regard others with suspicion (Bartholomew & Horowitz, 1991). The fundamental differences between secure and insecure attachment remain the most important aspects of this research. A secure individual seeks help when in difficulty and can make appropriate choices, consistently apply beneficial strategies to overcoming problems, remain involved in treatment and aware of their own needs. These health behaviours are very different to those of an insecure individual who may select inappropriate, ineffective or dangerous strategies to deal with health problems. Bringing together the constructs of attachment style, the role of trauma in childhood, and issues in health care, papers by Schofferman, Anderson, Hines Smith and White (1992) and Schofferman, Anderson, Hines Smith and Keene (1993) highlighted the issue of prejudicial environmental influences on the development of somatic pain. In these studies on unsuccessful outcomes of back surgery, they demonstrated a clear and significant correlation between unsuccessful lumbar spine surgery and a history of childhood traumas. This correlation was seen in single-level, multilevel, primary and repeat surgeries (Schofferman et al., 1992; Schofferman et al., 1993). These researchers maintain that recognition of predictors for unsuccessful outcome can be useful in avoiding surgery in patients whose indications for surgery are borderline. The greater challenge is to help the patient who, despite being at high psychological risk for negative outcome, has severe spinal pathology that will require surgery. Their conclusions are that preoperative psychological assessments to assess the influence of childhood traumas are critical in defining patients for whom surgery should be avoided unless overwhelming spinal pathology is present, or for those patients who have failed to improve despite previous surgery that has been technically successful.
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