Psychiatry - December 2008 - (Page 25)

acknowledge what they still have to offer. Case example: knitting together a good-enough life. Ms. D, a 27-year-old woman, was not of the generation of women who identified themselves with keeping the home fires burning, but rather had established a strong sense of herself through her work. Now, she was not only unable to work outside the home, but not even able to do basic household tasks. Folding laundry would send shooting pain down her legs. Giving her son a hug brought tears to her eyes, and they were not those of joy. In her recovery, she had learned to knit, and the irony was not lost on her that an injury sustained at a job which entailed hard physical labor had caused her to turn to a traditional domestic task to obtain relief. Psychiatrist: How have you been functioning lately? Patient: (with a bitter tone and tears evident) I can’t do a damn thing! Psychiatrist: (meeting her stare directly) Not being able to do anything is very hard for a gogetter such as yourself. Patient: I used to be a goddamn welder! I used to lift weights! I used to carry my son up hills in a backpack! Psychiatrist: Your injury has brought about a lot of losses. Patient: (tearful…nodding) Psychiatrist: (silent) Patient: I just can’t deal with this…I was so proud of my work…now I can’t do anything…I’m useless. Psychiatrist: I understand that you’re feeling angry, overwhelmed, and useless, not to mention that you’re in pain, but I have to respectfully disagree with you about the useless part. Patient: (looking dubious) Psychiatrist: In our last session you told me you went to your son’s school play. Patient: (rolling her eyes) I was hurting the whole time. Psychiatrist: But you went! You are very important to your son…I’m guessing he was very glad to have you there. 25 Patient: (reluctantly) He was…I know he was sad when I missed his last soccer match. Psychiatrist: But then you made the decision that even if you were in pain, you were going to try to be there for him, and you have been. Patient: Big deal…I can’t afford to buy him an MP3 player. Psychiatrist: It is a big deal! Your physical presence for him is one of the best gifts you can offer him. It’s an expensive gift too, because you have to save up your energy all day to give him that gift. Patient: Tell him that when he’s pressuring me for the MP3. Psychiatrist: Some things you’ll just have to know within yourself. He might not get it until he is a parent himself. Patient: (nodding but somewhat dismissively) Psychiatrist: You’re also doing a lot for him when you acknowledge his disappointment and just allow him to feel the way he’s feeling. Patient: He does get past things pretty quick when I just sit with him. Psychiatrist: He gets the double message that you support him and that you are bigger than his feelings and you are okay with those feelings. Patient: Yeah, maybe, but even so…I can’t go roller-skating with him anymore…I won’t get in tickle fights… Psychiatrist: Do you remember the session we had in which you realized how you’ve always felt you weren’t good enough, even before the accident? How you’ve always felt a need to do more… Patient: (nodding tentatively) Psychiatrist: Do you think that could be happening now with your son? That you’re not giving yourself permission to just be a “good-enough” mother? Patient: What I’m doing seems so inadequate. Psychiatrist: (looking at her quizzically) Patient: Oh my gosh… Psychiatrist: A bit like the example we came up with before about [VOLUME 5, how the knitting you’ve taken up again is never fancy enough or soft enough or beautiful enough? Patient: And how my Dad always thought sitting and doing hand work was so useless… Psychiatrist: How else could you look at it? Patient: It’s something I’m working on—to be able to provide gifts and things for my family in a way I can do now, even with the pain… Psychiatrist: (smiling) By George, I think she’s got it! Patient: (returning smile and appearing much less distraught) PRACTICE POINT: BEING PRACTICAL AND HELPING THE PATIENT RETURN TO A “NEW NORMAL” In working with pain patients, often the therapy will need to be very pragmatic, including elements of both supportive therapy and cognitive therapy.25,24 No matter what therapeutic model is employed, chronic pain patients frequently get derailed back into a relatively dependent state and exhibit a compulsion to voice their pain story again, seeking reassurance and acknowledgement of their struggle. While it is important to do so, over time you will be able to decrease the amount of time spent reiterating and reassuring, and spend more time recognizing the strides they are making toward a meaningful life in the face of pain. Often simple advice is called for, such as recommending individuals learn to balance activity and rest. They will need to learn that doing too little physical exertion or stretching can sometimes be almost as uncomfortable as doing too much, and they should be encouraged to build up to 30 minutes daily of aerobic activity of a tolerable type. If walking is too painful, then exercise bicycling or water exercise can be encouraged. They can stretch even if chair bound. They can be taught to “save up” their energy for meaningful activities, such as outings with family or friends. Any of these recommendations can be 12, DECEMBER] NUMBER Psychiatry 2008 25

Table of Contents Feed for the Digital Edition of Psychiatry - December 2008

Psychiatry - December 2008 Editor’s Message Contents Editorial Advisory Board Antidepressant Prescribing by Specialty and Treatment of Premenstrual Dysmorphic Disorder Pain, Pain, Go Away: Antidepressants and Pain Management Why Psychotherapy Helps the Patient in Chronic Pain General Medical Drugs Associated with Depression Katatonia: A New Conceptual Understanding of Catatonia and a New Rating Scale Thermoregulation and the Role of Calcium Signalling in Neurotransmission Cognition and Schizophrenia: Is There a Role for Cognitive Assessments in Diagnosis and Treatment? Journal Watch Information for Authors

Psychiatry - December 2008

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