I am glad you asked this question about movement and touch in psychotherapy. Our techniques flow from our theoretical understanding of psychopathology. In ISTDP, the patients symptoms and problems are understood as the inevitable consequence of defenses against the internal EXPERIENCE of complex, anxiety provoking feelings. Given this, we intervene in order to help the patient face, fee, and tolerate emotions without having to do anything about it – not repress it or discharge it. So, having a patient punch a pillow or stand up and push against me wouldn’t make sense in this model. That would be seen as a way to discharge or get rid of the feeling, rather than to tolerate the internal experience of it.

When it comes to the impulse or action tendency inherent in each emotion, we use visualization instead of action, to facilitate facing the impulse – again, with out DOING anything. This is because we want to get to the unconscious emotions and the memories associated with them. When a patient is mobilized and we ask them to just IMAGINE what their body wants to do, all the unconscious impulses can be faced and experienced without anyone getting hurt.

Not having trained in somatic experiencing, I can’t tell you how movement and touch facilitates their work, but I hope I have given you some sense of how ISTDP understands this.

Patricia

I don’t think I answered your question – which was why these women would feel MORE pain when anger and sadness are evoked. According to the research on somatization, especially that by Allan Abbass, this makes some sense. Somatization is the result of a defense against the experience of anxiety provoking emotions. If the defense is interrupted, but he patient is not helped to face and experience the feelings directly, without resorting to symptoms, they can get worse. That is why patient with internalizing defenses like depression and physical pain need to experience a graded approach that increases their ability to feel emotion without resorting to pathological defenses or excessive anxiety. This requires a highly skilled therapist. In any case, they are still making the point that there is clear link between physical and emotional pain.

Patricia Coughlin

Thanks for this information – how fabulous. There is also quite a lot of research on the relationship between expressed anger and reduction in pain in patients with arthritis. James Pennebaker has amassed a tremendous amount of research data on the link between emotion and immune functioning. His book, Opening Up, is a must have for anyone interesting in this fascinating topic. Many thanks for the detail you have provided. It is very valuable.

Dr. Allan Abbass has some data regarding the effectiveness of ISTDP with pain patients (everything from headaches, to back pain), all of which is very promising. This was done in a real life psychotherapy setting, where the focus was on the pain the patient was experiencing in the moment (as opposed to experimentally induced) and tracing it to the trigger – then facilitating the experience of the previously avoided emotional pain. Dr. Sarno has also done a great deal of work in the area of back pain and gotten excellent results. Somatization is one of the areas in which ISTDP seems to get better results than other therapies.

thanks again for your contribution.

Patricia Coughlin, Ph.D

Thanks for your comment, and for drawing our attention to the importance of getting effective behavioral interventions into the hands of primary care providers. Dr. Allan Abbass, at Dalhousie University in Nova Scotia, has probably done more work in this area than anyone. He has trained primary care docs to do emotion focused interviews with their patients who have chronic complaints but no medical findings, in order to assess whether psychotherapy is required. His studies also show that have a highly trained therapist in the ER to see repeat visitors who don’t have any signs of medical problems dramatically reduces symptoms, return visits and medical costs. If you google him, you will see all his research, which substantiate the cost, as well as clinical, savings from ISTDP. Now Dr. Monica Urru is training primary care physicians in Italy to do the same. It is a very fruitful area of study.

Thanks for your incisive comments! Of course it’s not JUST about emotion. It is vital that we, as therapists, help patients tolerate anxiety in the moderate range and that we facilitate multiple modes of processing. In fact, neuroscientific research suggests that changing an adult brain (which is what we are trying to do in psychotherapy) requires the activation of cognitive, emotional, physiological and interpersonal modes of experience. Focus, intensity and repetition are also necessary. ISTDP incorporates all these variables, which may explain it’s effectiveness.

Aside from these specific factors, the person of the therapist appears to be the most potent, but understudied variable in psychotherapy outcome. I will write more about this in my next blog.

Thanks for contributing to the conversation.

Patricia

Negative Emotions Increase Pain Sep 27 2010

By Michael Smith, North American Correspondent, MedPage Today

Published: September 27, 2010

Reviewed by Adam J. Carinci, MD; Instructor, Harvard Medical School and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Negative emotions such as sadness and anger increase pain in women — but the increase is similar in those with and without fibromyalgia, researchers reported.

In a cohort study among 121 women — 62 of whom were diagnosed with fibromyalgia — pain induced by an electrical stimulus was more keenly felt after the women recalled either a sadness- or anger-inducing event than after remembering a neutral event, according to Henriët van Middendorp, PhD, of Utrecht University in the Netherlands, and colleagues.

But there was “no convincing evidence for a larger pain response to anger or sadness in either study group,” van Middendorp and co-authors reported online in Arthritis Care & Research.Action Points

Discuss with patients that a recent study indicates that negative emotions such as sadness and anger may increase pain in women with and without fibromyalgia.

Also discuss that a second recent study indicates that tailored cognitive behavioral therapy and exercise training for patients with fibromyalgia are effective in improving short- and long-term psychological and physical functioning.

Instead, they argued, “the occurrence of anger and sadness appears to be a general risk factor for pain amplification” that might be attenuated by emotion regulation techniques.

Indeed, elsewhere in the journal, other Dutch researchers report that a combination of tailored cognitive behavioral therapy and exercise can significantly improve symptoms of fibromyalgia, including pain.

In a randomized controlled trial among more than 150 patients, those who received therapy had significantly reduced pain, fatigue, and functional disability (all atP<0.001) compared with patients placed on a waiting list, according to Saskia van Koulil, MSc, of Radboud University Nijmegen Medical Centre in Nijmegen, the Netherlands, and colleagues.

They also had significantly better psychological functioning and a lower impact of fibromyalgia on daily living, the researchers reported, again all at P<0.001.

Fibromyalgia is a chronic and widespread pain disorder whose causes are not known. However, in both healthy people and those with chronic pain, emotions have been shown to increase pain, van Middendorp and colleagues noted.

To test the idea that women with fibromyalgia might be more sensitive to such emotions the 121 women — 62 from three Dutch hospitals who had fibromyalgia, and 59 without the disease from the general population — were asked to recall a neutral situation, followed by recalling both an anger- and a sadness-inducing situation, in counterbalanced order.

The fibromyalgia patients were asked to report on their current pain levels after each session and — as expected — the researchers found that recalling sadness or anger increased current pain significantly (at P<0.001), compared with the neutral event.

In the induced pain experiments, women from both groups had electricity delivered to a forearm and pressed a button when they first felt the current, when it became painful, and when it became intolerable.

They found that the pain threshold of the women decreased after recalling both the anger- and sadness inducing events, compared with a neutral event. Pain tolerance fell in the same manner and all comparisons were significant at P<0.001.

But there were no differences:

Between the groups — P=0.06 for pain threshold and P=0.16 for pain tolerance

Between sadness and anger

Or between reactions to the first negative emotion and the second

In the other study, van Koulil and colleagues noted that people with fibromyalgia may react in different ways — some may restrict their activities to avoid pain, while some may attempt to keep going through pain. So they hypothesized that cognitive behavioral therapy combined with exercise tailored to those strategies might be beneficial.

To test the idea, the investigators enrolled 158 patients, of whom 84 were considered to be in the pain-avoidance group, while the remaining 74 tended to persist through pain. Within each group, patients were randomized to get immediate therapy — 16 sessions over 10 weeks — or to be put on a waiting list.

The primary outcome measures included pain, fatigue, functional disability, anxiety, negative mood, and overall impact of fibromyalgia, assessed at baseline, immediately post-treatment, and after six months.

The treatment effects were significant, suggesting that the tailored treatment "is effective in improving both short-and long-term physical and psychological outcomes," the researchers argued. "The effects were overall maintained at six months, suggesting that patients continued to benefit from the treatment."

Van Middendorp and co-authors cited a number of important limitations to their study. The use of emotion recall procedures and the attendant "difficulty of inducing a single unique emotion while minimizing the experience of other emotions … may have obfuscated the specific effects of anger versus sadness on pain."

As well, people likely vary in how intensively and accurately they experience and express a targeted emotion. "It is possible, therefore, that an autobiographical memory approach — asking people to recall, experience, and then verbally express angry and sad events — was most difficult and least successful for women with fibromyalgia," the investigators wrote.

They also noted that the controls (while free from fibromyalgia) also may have had physical and mental health symptoms or concerns and, as a result, may have been more like the fibromyalgia group.

Additionally, van Middendorp and colleagues acknowledged that findings from electrically-induced pain do not necessarily translate to other kinds of pain such as pressure pain or randomly occurring natural pain, and noted that participants were allowed to use pain and other medications before the experiment.

Van Koulil's group also cited some study limitations. The study was not blinded, they noted, and the small improvements seen in waiting list controls could have been due to the patients' expectations of treatment as well as "the intake procedure in which also patient education about the treatment was provided, they wrote.

The study was supported by the Dutch Arthritis Association. The researchers said they had no conflicts.

Primary source: Arthritis Care & Research

Source reference:

Van Middendorp H, et al "The effects of anger and sadness on clinical pain reports and experimentally-induced pain thresholds in women with and without fibromyalgia" Arthritis Care & Research 2010; DOI: 10.1002/acr.20230.

Additional source: Arthritis Care & Research

Source reference:

Van Koulil S, et al "Tailored cognitive-behavioral therapy and exercise training for high-risk fibromyalgia patients" Arthritis Care & Research 2010; DOI: 10.1002/acr.20268.