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Book Review: Coping with Chronic Pain: A Guide to Patient Self-Management

Much as the now familiar Beck model, Persons' approach proposes that psychiatric or psychological problems occur at two levels: superficial or overt difficulties such as anxiety attacks, depressed mood, suicidal ideation or phobia; and, underlying psychological mechanisms, such as hidden, irrational beliefs about the self. The latter are tacit assumptions or early maladaptive schemata which concern autonomy, self-worth, and social connectiveness. The book also focuses on cognitions, behavioural and mood as well as the interdependence of these components. The role ofcase formulation in this context is to become the guide to treatment. First, it helps the therapist understand the relationship among the problems (the patient has already stated and clarified these in a limited list). Second, it helps the therapist choose a treatment modality, an intervention strategy, and a point of intervention. Likewise, it helps predict behaviour, understand and manage compliance and therapeutic relationship difficulties, and addresses treatment resistance or indeed failure. The format of case formulation is described in one of the first chapters. It involves the establishment of a list ofproblems; proposes an underlying mechanism; accounts for the way in which this mechanism produces the problems on the list; explains the precipitants ofthe current problems and the origins ofthe mechanism in the patient's early life; and finally, predicts obstacles to treatment based on the formulation. The first three chapters explain the formulation model, the establishment of the problem lists and the techniques of case formulation. The book then describes at great length more conventional and better known behavioural interventions which have been the object of several research and clinical papers. Likewise, it identifies, in a Beck-inspired fashion, dysfunctional thinking and techniques to modify this parameter. An entire chapter is devoted to homework, and the rationale for its use. It reviews the empirical evidence for its effectiveness and how the formulation makes it a logical assignment. The formulation also addresses how to anticipate obstacles in treatment and how to manage these difficulties, whether they be the patient's or the therapist's. Indeed, it elaborates on the therapist's problems in establishing homework assignments and his/her own cognitions about why it is not working out. Its most innovative but much needed chapter addresses the therapeutic relationship itself. It reviews the empirical findings concerning the therapeutic relationship, its impact on outcome and it goes to some length to demonstrate that one should not limit oneself to the traditional behaviourist view: that it is the therapist's task to establish a comfortable, positive and working relationship only. In this book, this role is enhanced by the case formulation because the therapist takes into account the origins of the central theme as well as the precipitants of the current problems and so he is able to be more specific in his intervention concerning the therapeutic alliance. The author goes through several practical situations including lateness, missed payment and other resistances to demonstrate how these patterns fit with the individual patients. The therapeutic relationship is not only a repetition in therapy of what goes on outside the sessions but also a tool for change. It allows the therapist to help identify the underlying irrational belief using the therapy itself as a focus. The author however, cautions that one should be prudent. Difficulties obviously are addressed in a non punitive, problem-solving fashion, and are considered analogous to the other problems ofthe patient, but given a higher priority obviously because if the difficulties are not resolved the therapy will not be successful. She also is concerned with specific problems such as compliance, dependency, passivity, and helplessness. Another helpful chapter directs our attention to the assessment and treatment of suicidality using the same model, therefore taking into consideration cognitions, behaviours, and moods and the role of case formulation in alleviating hopelessness. The last chapter appropriately concerns cognitive therapy for the therapist and identifies, to some length, irrational perceptions of control, belief in one's competence, feelings about the patient's anger. It describes how to apply cognitive interventions to one's own thoughts and mood to prevent distortion, inordinate fear of failure and unproductivity. This short book is eminently readable both for the experienced therapist and the novice. It is abundantly illustrated by clinical examples which are well written, and clinically relevant. While it focuses on technique, it draws sufficiently on the theory to explain some of the mechanisms in clear and concise terms. Because of its central theme: case formulation, it is coherent and not just a collage of techniques. It proposes that interventions are best planned in a context of systematic evaluation ofthe problems and the formulation of explanations about the underlying mechanisms that determined these problems. Because of the author's background, it is comprehensive in its suggested interventions at an appropriate behavioral and cognitive level.