Marine Sgt. Jeffrey Miller (name, identifying information, and details of the case have been altered to protect the client’s confidentiality) was referred to a pain management psychologist located in his Naval Hospital orthopedic clinic. Sgt. Miller, a 26-year-old Caucasian man, was feeling anxious and depressed after injuring his neck during a helicopter rappelling mission in Afghanistan during his deployment with a Special Forces squadron. He thought it was a temporary injury, but the pain and numbness in his arms got worse over the course of several weeks. He had to be medically evacuated and was on Limited Duty while receiving care for severely injured discs. His condition had not improved with several months of steroid injections and physical therapy, and cervical fusion surgery was recommended.
Sgt. Miller reported, “I was trained to be a warrior” and said his current desk job was not rewarding and that he felt a loss of his identity as a Special Forces soldier. He felt guilty for not being with the rest of his squadron, especially since he recently learned of the suicide of one of his friends. He said that nothing seemed fun or interesting for him anymore. Sgt. Miller said that he worried frequently about his pain and wondered, “What’s going to happen? Is the pain ever going to stop?” He was afraid that he would not recover and would lose his planned military career. He was concerned that surgery would cause more problems for him and was researching as many alternatives as he could. He stayed awake at night worrying and had trouble concentrating during the day. He denied post-traumatic stress symptoms related to his deployment, except for anxiety while driving in traffic, which he felt was resolving.
Sgt. Miller commented that he would not ordinarily have seen a mental health provider, but he was willing to see the pain management psychologist because she was a part of the orthopedic clinic and was recommended by his physical therapist, a Navy Captain whom he trusted.
Chronic pain is the most common reason for medical evacuation from Iraq and Afghanistan deployments, and spinal pain is the most frequent reason for medical boards across military services. Service members face unique challenges in coping with chronic pain, including role loss, the psychological impact of combat and negotiating the limited duty/profile/medical board process.
Many mental health providers do not have specialized training in treating chronic pain and instead focus only on the emotional issues that pain patients experience. However, there are a number of effective psychological interventions that target pain directly. Cognitive behavioral therapy for pain typically involves psychoeducation about how psychological and social factors can affect pain; relaxation training to ease muscle tension and autonomic arousal; sleep hygiene and stimulus control education to help with insomnia; activity pacing to increase pleasant activities without increasing pain; and cognitive restructuring of negative thoughts and beliefs about the pain. Other frequent interventions include coping with family and marital issues related to the pain; anger management; acceptance and commitment therapy; anger management; and preparation for setbacks.
More and more often, health psychologists are working within orthopedic or pain management clinics as a part of a multidisciplinary team rather than from a separate mental health clinic. This allows for more direct, two-way communication with other care providers and can also make mental health care more acceptable to patients.
Sgt. Miller’s psychologist educated him on how his stress could be affecting his pain; using examples from his combat experiences, she introduced him to the gate control theory of pain and to the flight or fight response. Sgt. Miller gained insight on how his pain increased when he was worried or angry and how this created a vicious cycle. He learned diaphragmatic breathing, progressive muscle relaxation and positive imagery visualization to help calm his mind and body when his stress and pain were high. He established a regular sleep schedule and a soothing bedtime routine. When unable to sleep, instead of tossing and turning, he would get up and listen to calming music until he felt tired again. He began to push himself to do more pleasant activities that did not aggravate his neck pain and found that he was able to enjoy them. Sgt. Miller worked with the psychologist to identify and challenge his negative thoughts; particularly, his feelings of guilt for being away from his squadron and his anxious predictions that his pain would never end. He also discussed his grief about his friend who killed himself. Because of this suicide, Sgt. Miller resolved that he would begin to reach out and tell other Marines about his experiences receiving mental health; he thought that as a Special Forces sergeant, he would have credibility with other soldiers. Therapy was supplemented throughout by readings from The Pain Survival Guide (Turk & Winter, 2005). After 7 sessions of therapy, he felt that his symptoms of anxiety and depression had resolved. He and the therapist agreed to end treatment, but discussed indications that he would need to return.
With Sgt. Miller’s permission, the psychologist was in ongoing discussions with other members of his orthopedic treatment team. She cleared him for surgery and prepared the surgeon to address Sgt. Miller’s fears about the procedure. After a long discussion with the surgeon, Sgt. Miller agreed to the surgery and had a good recovery. He was able to return to Full Duty status and rejoin his squadron.
Emotional health has been found to be a predictor of outcomes from cervical (neck) fusion surgery, and this relationship is even stronger in lumbar (low back) surgeries. Accordingly, psychological screening is often a part of the pre-surgical workup process. It is possible that Sgt. Miller’s recovery from surgery was aided by the gains he made in therapy beforehand.
The following resources can be helpful in the treatment of chronic pain patients:
Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach Workbook by John Otis:
Part of the Treatments That Work series, this pair of books provides a structured approach to coping with chronic pain.
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Peolsson, A., Vavruch, L., & Oberg, B. (2006). Predictive factors for arm pain, neck pain, neck specific disability and health after anterior cervical decompression and fusion. ActaNeurochirugica, 148.167-173.
Sveinsdottir, V., Eriksen, H., &Reme, S. (2012). Assessing the role of cognitive behavioral therapy in the management of chronic nonspecific back pain.Journal of Pain Research, 201.371-380.
Trief, P., Ploutz-Snyder, R., & Fredrickson, B. (2006). Emotional health predicts pain and function after fusion: A prospective multicenter study. Spine, 31.823-830.