Clinical Behavioral Medicine: Some Concepts and Procedures PDF
Preview Clinical Behavioral Medicine: Some Concepts and Procedures
CLINICAL BEHAVIORAL MEDICINE Some Concepts and Procedures CLINICAL BEHAVIORAL MEDICINE Some Concepts and Procedures Ian E. Wickramasekera, Ph.D. Professor of Psychiatry and Behavioral Sciences Director, Behavioral Medicine Clinic and Stress Disorders Research Laboratory Eastern Virginia Medical School Norfolk, Virginia SPRINGER SCIENCE+ BUSINESS MEDIA, LLC Library of Congress Cataloging in Publication Data Wickramasekera, Ian E. Clinical behavioral medicine: some concepts and procedures I Ian E. Wickramasekera. p. em. Includes bibliographies and index. ISBN 978-1-4757-9708-4 ISBN 978-1-4757-9706-0 (eBook) DOI 10.1007/978-1-4757-9706-0 1. Clinical health psychology. 2. Behavior therapy. 3. Biofeedback training. 4. Hypnotism. I. Title. [DNLM: l. Behavior Therapy. 2. Biofeedback (Psychology) 3. Hypnosis. WM 425 W637c) R726.7.W53 1988 616.89'14-dc19 88-1055 CIP © 1988 Springer Science+Business Media New York Originally published by Plenum Press, New York in 1988 Softcover reprint of the hardcover 1st edition 1988 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher 'Two things fill the mind with ever new and increasing wonder and awe the starry heavens above me and the moral law within me." -Immanuel Kant Critique of Pure Reason, 1781 PREFACE This book is an effort to integrate some clinical observations, theoretical concepts, and promising clinical procedures that relate psychological variables to physiological variables. My primary emphasis is on what psychological and behavioral concepts and procedures are most likely to enable us to influence physiological functions. The book covers ques tions that have fascinated me and with which I have struggled in daily clinical practice. What types of people are most at risk for physical disor ders or dysfunctions? Why do some people present psychosocial con flicts somatically and others behaviorally? What is the placebo effect and how does it work? How do you arrange the conditions to alter maladap tive belief systems that contribute to psychopathology and patho physiology? Do beliefs have biological consequences? When I was in private clinical practice, and even today in my medi cal school clinical practice situation, I set aside one day each week to puzzle over the theoretical questions that my clinical experience gener ates. Often isolating these underlying theoretical questions provides guidance into the most relevant empirical literature. I have found that this weekly ritual, which I started in private practice many years ago, appears to increase my clinical efficacy or at least makes clinical work more exciting. I find the unexamined clinical practice hard to endure. Kurt Lewin once said, "There is nothing so practical as a good theory." A good theory tells you what to notice, where to look for it, when to look for it, and how to look for it. Nothing can be more useful to the practic ing clinician. The practicing clinician, even more than the research scien tist, is concerned daily with the control and prediction of the behavior of individual people in their natural environments. The corrective feedback from patients can sustain humility. Predicting and controlling clinical symptoms is a very challenging task, even in the circumscribed area of clinical psychophysiology. This is not a cookbook on clinical health psychology. This book vii viii PREFACE deals directly with some salient issues in the field of clinical health psychology and risks explicit experimental predictions from new con cepts and procedures relevant to some big clinical questions. Without risking empirical disconfirmation or confirmation, there can be no ad vancement in theories or procedures. For example, what factors place people at risk for chronic stress-related somatic symptoms and what are the implications for primary prevention? What is the most effective pro cedure to lead the somatizing patient out of the somatic closet and into psychotherapy? What is the placebo effect and how can conditions be arranged to potentiate placebo effects? This book does not deal with some important issues framed as compliance, Type A behavior, and smoking cessation, and so on, because I do not think that anything profound or potent can be said about these topics as they are framed today. In fact, I do not think that anything important can be said about those topics outside the context of individual differences and specific procedures that engage those individual differences. For example, our lack of clinical efficacy in modifying those problems has much, but not all, to do with using the wrong key to open those doors. If your car does not start when I insert my car key into your ignition, I will not be so foolish as to accuse your car of "resistance." I will simply recognize that I failed to secure or copy your key. Human nature is usually responsive to a judicious combination of structural and functional approaches to disrobing her. This book, like Jerome Frank's Persuasion and Healing, is littered with promising theories and clinical procedures that need inde pendent replication, empirical testing, and refinement and revision. This book is for all curious practicing clinicians, the academic researcher who is not willing to spend his life in the methodologically sophisticated investigation of trivia, and the graduate student who wants to know some of the salient questions in the field of clinical health psychology. There may be several important issues in clinical health psychology that I have ignored because I do not have anything particularly profound or potent to say about them. This book contains several experimentally testable minitheories. Good theories are useful to a clinician in a medical setting because they help him to quickly and confidently intervene to relieve pain and suffer ing. When interventions derived from theories fail, clinical wisdom and humility can begin. A good theory directs clinical observation to those sources of variance that account for the largest chunks of variability in clinical symptoms. As my clinical experience grows I have found Lewin's comment on the practical value of theory to be profoundly true. Each patient I see is a unique configuration of myriad psychological, social, and biological factors (independent variables), and each patient is PREFACE ix immobilized to varying degrees in his capacity to work and play; by psychological, behavioral, or psychophysiological symptoms (depen dent variables). My clinical efficacy is a function of how rapidly, accu rately, and powerfully I can help each patient control and predict his clinical symptoms. A good theory tells me what of the myriad available types of information to collect and how to use it to ensure maximum control and prediction of symptoms. A good theory not only tells me what to observe, but where to observe it, when to observe it, and how to observe it. When confronted with a complex and multifaceted clinical field, nothing is so practical as the ability to quickly recognize patterns and to understand the relationship between them. Delays in the clini cian's pattern recognition time costs the patient money, pain, and suf fering. To the clinician with limited time and energy, good theory is even more important than to the researcher. This book deals with observations, theories, and procedures that are pertinent to effective practice in select areas of health psychology and behavioral medicine. The areas are selected for having procedures of known efficacy. Tautological as it might appear, the ability to reliably deliver effective clinical outcomes ("cures") is the essential and sufficient condition to generate powerful placebo effects (see Chapter 5). Some of the concepts and procedures in this book are new and represent fresh and complex ways of approaching common but difficult clinical phe nomena. I propose in Chapter 1 a theory of what factors predispose people to develop chronic stress disorders. The theory proposes a small number of underlying mechanisms that can account for a wide variety of present ing clinical complaints and to which etiology-specific therapies can be directed. Chapter 2 is about how and why the profile of illness presented to physicians has changed in the last 50 years and about the implications of this change for the training of future M.D.s and professional psychol ogists. It points out that therapy for the new chronic disorders cannot be limited to drugs and surgery. With the development of preventive behav ioral techniques and psychophysiological skills for the therapy of phys ical disorders and diseases (not mental symptoms) the mind-body di chotomy is no longer simply a philosophical debate. Drugs and surgery are not the only effective therapies for physical disease today. There is now a practical debate over the wisdom of refusing insurance reimburse ment for, for example, a conservative and promising psychophysiological therapy for chronic pain versus ready insurance reimbursement for pre dominantly ineffective mutilating surgery for chronic pain. There are also now effective psychological and behavioral therapies for other physical X PREFACE diseases and disorders (e.g., common and classic migraine). Psychol ogists are now involved in areas of therapy that were once the practice of medicine. From a legal viewpoint, are clinical health psychologists today practicing as physicians? What are the common features of the three behavioral technologies (biofeedback, hypnosis, and behavior therapy) that are the most promising alternatives to drugs and surgery for certain stress-related chronic disorders? Chapter 3 suggests that we need to stop thinking of hypnosis as something that happens to some people after a hypnotic induction, but rather as a mode of information processing into which most people can drift to varying degrees under even several naturalistic conditions (sen sory restriction, high and low physiological arousal, dependency rela tionships, etc.) It also suggests that the hypnotic mode of information processing may have survival value for humans but that it also has implications in conjunction with other factors, for the development of psychopathology and pathophysiology. Chapter 4 is about a subset of patients who present physical com plaints without physical findings or without pathophysiology for which there is specific therapy. This challenging group of patients, called "crocks," provoke anger in many MOs. Crocks are often the recipients of iatrogenic disease because of their insistence on a medical "cure" when no treatable pathophysiology can be identified. This growing group of patients (crocks) are a major factor in escalating health care costs. These patients require a systematic approach that leads them out of the somatic closet and on to the psychotherapy couch. The outlines of an effective approach (the Trojan Horse Procedure) are broadly sketched in this chapter and elaborated in Chapters 6 and 7. In Chapter 5, I propose a new experimentally testable Pavlovian theory of the placebo effect. In fact, at least one doctoral dissertation in Australia (Voudouris, 1986) and several animal studies in psycho neuroimmunology (Ader, 1981) have already verified some predictions from the theory. My conditioned response model of the placebo pro poses several counterintuitive predictions. For example, it predicts that therapists who routinely use only active ingredients will, in fact, get stronger placebo effects than therapists who use mainly inert ingre dients. The model also predicts that as science advances and therapies become increasingly specific we will get stronger placebo effects! The model identifies several conditions that will enhance placebo effects and predicts that individual differences in hypnotic ability will in the clinical situation enhance placebo responding. Chapter 6 focuses on why patients are referred to a clinical health psychologist and on the top priorities in the initial interview. It is critical PREFACE xi to assess the patient's subjective perception of his or her presenting complaints, to engage the patient in a therapeutic alliance and to secure the patient's commitment to work on change. It is critical to secure the above objectives in the first one or two sessions and to engage the patient in an aggressive therapeutic alliance focused on commitment to freedom from constraining clinical symptoms. Chapter 7 describes the Trojan Horse Procedure I have developed to lead the somaticizing patient out of the somatic closet. This procedure involves psychophysiological demonstrations, a redefinition of the problem and eventually a coinvestigational model of therapy. I also present some empirical evidence for the efficacy of the Trojan Horse Procedure. Chapter 8 makes clinically important distinctions between acute and chronic pain and proposes a new theory of the acquisition of some types of chronic pain and anxiety. It presents a case study of chronic pain with long-term follow-up. Chapter 9 focuses on how to use the High Risk Profile clinically to provide patient feedback and to plan therapy. It also focuses on the need to identify any unconscious and overlearned beliefs and behavioral re sponses which may inhibit the assimilation of current life changes. This chapter includes two case studies demonstrating the therapy of high and low hypnotizable patients. Chapter 10 examines the seven common features of several pro cedures (meditation, autogenic training, relaxation, systematic desensi tization, EMG frontal biofeedback, etc.) developed to control psycho physiological stress reactions. It points out that empirical work on self-hypnosis marks self-hypnosis as a prototype of these psycho physiological stress-reduction procedures. The chapter concludes with a new theory of three therapeutic mechanisms (enhanced hypnotizability, entry into the "allocentric" mode of perception and cognitive control of physiological functions) associated with the practice of most psycho physiological stress-reduction procedures. References Ader, R. (Ed.) Psychoneuroimmunology. New York: Academic Press, 1981. Voudouris, N.J. The role of conditioning and expectancy in placebo analgesia: An experimental analogue study. Unpublished doctoral dissertation. La Trobe University, Australia, June, 1987.
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