Stress is dominant in patients with depression and chronic low back pain. A qualitative study of psychotherapeutic interventions for patients with non-specific low back pain of 3–12 months’ duration

Research problem and aim

The rationale for studying psychotherapeutic treatment is that there continues to be a degree of uncertainty in back pain research as to which treatment best benefits patients with a chronic and complex pain problem. It is assumed that by studying psychotherapeutic treatment, one can gain insight into, and glean new knowledge about, which conditions are significant when helping patients with CLBP and depression manage their situation better.

The aim of the study was to investigate how the selected psychotherapeutic treatments can influence a patient’s capacity to cope with CLBP when it is coupled with depression.

Theoretical framework

Gestalt therapy [9] was chosen as the theoretical framework for the study, and this form of psychological therapy was employed as the intervention by the first author in the sessions. Gestalt means “a meaningful whole” and the whole is always more than, and different from, the sum of its parts. In Gestalt therapy, the meta-theory is existentialism, the psychological theory is Gestalt psychology and the method is phenomenological. In addition, there are diverse therapeutic techniques. The foundational idea of Gestalt therapy is that adults can choose how to lead their lives and they are at all times responsible for their own choices and actions. The phenomenological approach is a psychological method of holistically describing experienced phenomena. Increased acknowledgement of oneself often occurs in here-and-now situations, where client/patient and therapist meet.

The Somatic Experiencing® method (SE-method) was also used in the intervention [10, 11] because some of the participants had experienced traumatic events. SE is a psychotherapeutic method with a psycho-physiological basis that helps to resolve and heal the symptoms of trauma. The method can be effective in reducing stress reactions for anyone who has experienced something overwhelming. It is an effective complement to Gestalt therapy.

Selection of participants

The participants were drawn from a randomised study of patients with non-specific LBP [15] who had been referred to The Spine Centre of Southern Denmark. They were 18–60 years of age and were screened for depression. Out of a total of 130 patients, 46 had mild or moderate depression, measured by the Beck Depression Inventory Scale (BDI). They were offered a series of six psychotherapeutic sessions, while simultaneously receiving cross-disciplinary somatic treatment for their LBP. All had had LBP for between 3 and 12 months and were either currently on sick leave or had been on sick leave during the previous year. Many of the patients did not complete all psychotherapeutic sessions.

Data collection

The data collection is inspired by Spradley’s ethnographic method [16], which includes interaction and field notes. The data consisted of field notes in the form of written reports, drafted after each psychotherapeutic session. It was therefore the psychotherapist’s immediate perception, narrative and description of the situation, based on the patient’s narrative, statements, emotional expressions and body language. Quotations from patients were included in the written notes. The written reports from sessions on the six included patients were viewed as a continuous text that totalled 33 pages. This data became the foundation for the work and analysis in the study.

Data processing

The processing of the data was based on the Ricoeur-inspired method that consisted of analysis and interpretation at three levels: naive reading, structural analysis and critical interpretation and discussion. The analysis and interpretation were performed by both the first and second authors.

Structural analysis

Subsequently, a structural analysis was carried out, which had an explicit function. Here the text was analysed based on units of meaning, (what is said) and units of significance (what is being talked about). Topics were drawn out that were reflected in the entire text material, in order to identify some common themes. The text was analysed on the basis of not only the text in the form of direct quotations, but also the meaning behind the content, as a first interpretation of what was being talked about, in order to let themes emerge. In Figure 1, the movement from units of meaning to units of significance and to the emergence of themes is illustrated. The arrows in the diagram make it clear how there was a continuous forwards and backwards movement throughout the entire analysis process. In this way, the process is not just viewed as a progressive, linear process, but as a process where analysis and interpretation occur continuously between the parts and the whole. The process is seen as a dialectic process between explanation and understanding. Such a process helps to strengthen the rationale and arguments underpinning the themes that emerged.

Critical interpretation and discussion

The themes were analysed, interpreted and discussed in relation to the theory and other research results.

In this final part of the analysis, there is movement from the individual patient to the study cohort, or from the specific to the general.

Ethical considerations

As a basic starting point, the randomised study, Individual screening-based biopsychosocial services for patients with non-specific low back pain, was approved by the Ethics Committee of the Region of Southern Denmark (nr. VF-20060062). All participants signed a written informed consent. In the current qualitative study, no names are given. To ensure confidentiality of the participants, the study was designed according to the Ethical Guidelines for Nursing Research in the Nordic Countries (Northern Nurses´ Federation, 2003) [17]. A request to the Danish Regional Research Ethics Committee confirmed that no formal ethical approval was required for this type of study.

The significance of previous experiences

The analysis showed how previous experiences influenced the patients’ present life and functioning, and hence, their CLBP. For example, the loss of a close relative had triggered anger and sorrow that could have led to self-destructive behaviour, as evidenced by the following statement:

"“I am angry that my sister allowed herself to die and leave her daughter, who was a year old. I wished that I was dead instead. It is really sad to talk about it. I have been on the ropes since then.”"

It is well known that bereaved people can have an unconscious urge to ‘be in the grave themselves’ and can lose a grip on their own lives.

And another statement:

"“I took so much Somadril, just the thought of it makes me nauseous. I was saturated in medicine. I don’t understand how it’s so easy to get prescribed medicine. It was the Somadril that put me completely down in the depths. I felt that I had no idea what I was doing, when I took so much medicine. And it was not to commit suicide that I took so much and was hospitalised.”"

Throughout the quotation, a feeling of sorrow was expressed, which is thought to have caused self-destructive behaviour in the form of medicine overdose. Other themes that came up in the study were self-blame and shame. Self-blame means I have done something wrong and shame means I am wrong. Self-blame thus focuses on the action and can be healthy, if one really has done something inappropriate to another person, as this can sometimes be rectified. In contrast, however, shame is ranked with sin and inferiority [18]. From the above quotation, it seems that the patient felt it was shameful to take so much medicine, and went on the defensive by projecting the blame onto the general practitioner who prescribed the medicine, as it was too uncomfortable for the patient to admit responsibility.

Other previous experiences turned out to relate to being let down during childhood. One patient, who as an eight year old had been forced to act as an adult at home for an alcoholic mother and an absent father, made the following statement:

"“I grew up with a mother who was always drunk and from the age of eight I had to be ‘mother’ for my two younger siblings, and made sure that they did not realise that she came home drunk or saw that I cleaned up vomit in the stairway.”"

The quotation suggests a feeling of being let down. An unhealthy and reversed mother-child/father-child relationship, where the child takes responsibility for the parent, in this case the mother, is seldom something the person is conscious of, since they don’t know of any other way. From additional notes taken during the interview, it was seen how the patient, now as an adult, despite pain, depression, stress and a poor financial situation, still had to spend most of her free time being a mother for her own mother without herself receiving any support. Theoretically speaking, we can speak of the concepts of victim, saviour and the violation triangle, also called the drama triangle[19]. In the classic model, the child is the victim, while the mother is the saviour and the father is the violator, e.g. verbal violator. The child learns this behaviour. In the case under study, the mother was both victim and violator, and the patient saviour of her mother. In the individual therapy, the patient developed insight and showed that she was able to alter her behaviour towards her mother, and begin to take responsibility for herself and express her own needs, instead of being violated and manipulated.

The data also included a description of a sudden event that seemed to be the cause of fear of becoming paralysed. The patient fell down backwards three metres. The written quotation was as follows:

"“I fell off a front loader truck, and fell three metres. I was hoisted up and apparently was told that I was about to be lowered, but I didn’t hear that and we didn’t have eye contact, as we normally do. I didn’t register the message and suddenly I lost my balance and fell backwards. Something happened in my back and I couldn’t get up and run away. That’s what I have done all the other times I’ve fallen off ladders and the like. I wanted to crawl away, but I couldn’t move my muscles, I could only lift one leg a bit.”"

In the quotation, the patient describes how, after a sudden fall, he felt unable to move. He was terrified and went into a state of shock with the fear of becoming paralysed, although he was not paralysed. It can be assumed that he had a survival response, where the body instinctively reacted with a freeze response [20], an effect of the autonomic nervous system, where the fight or flight response was not possible. Often in such a situation, the body will reserve activated energy, that is, the energy that in a split second was activated for survival but was not used. After a violent event, there is a need for peace and calm in the following hours to regulate the autonomic nervous system. Conversely, in certain situations, symptoms can subsequently arise such as feelings of unrest, aggression, powerlessness, depression, sleep disturbance, tiredness, pain and muscle tension and a lack of capacity to carry out tasks. Ten months after the fall, in the session with the psychotherapist, following was reported:

"“I was hospitalised, but was told that there was nothing wrong with me. I was given morphine, so finally I could sit up and the following day I was expected to go and get my own food, if I wanted something to eat."

"It wasn’t a pleasant experience, and I can’t stand hospitals - they smell of death. I have witnessed so many deaths: my friends who drove themselves to their deaths, my grandparents and a close friend who died at 19."

"So I wanted to get home quickly from the hospital and did so, but was in a lot of pain at home. At home, I cry a lot. Before the accident I was a lively guy who went round helping everyone.”"

The quotation expressed how the patient experienced a lack of calm, care and security. Furthermore, he felt that “the hospital smelled of death”, which gave him stress, anxiety and discomfort, which was why he chose to discharge himself. The fall caused a fractured vertebra and concomitant severe pain that prevented the patient from doing his usual activities; the experience of shock probably remained in the body and he subsequently developed depression and experienced powerlessness.

From a psychological viewpoint, the SE treatment was directed to help the patient to acknowledge that he had survived and to bodily integrate the fact that the danger had passed. [21]. Furthermore, it created an opportunity for him to complete his flight response which subsequently allowed the stress and fear to subside.

Perspective

As a result of the above-mentioned findings from the current study, a wider perspective could be introduced in the screening of patients with back pain for stress symptoms. Stress can be related to pain and a high depression score, and furthermore to traumatic events.

In the Spine Centre of Southern Denmark, analyzes have shown, via the screening questionnaire, Harvard Trauma Questionnaire (HTQ) Part 4, that out of 3,500 patients, 5% scored symptoms equivalent to Post Traumatic Stress Disorder (PTSD). Another 5% scored stress equivalent to sub-clinical PTSD, that is, lacking 1–2 symptoms on the full score on HTQ. This scoring was related to an event, e.g. a traffic accident, fall trauma, work injury or violence of various kinds.

More sophisticated tools for screening for stress and depression symptoms may help to lead to sub-grouping of patients and subsequent individually adapted psychological interventions. Thus, the road can be paved to increase the future success rate of treatment for patients with CLBP, an initiative that may be significant for the individual patient, the health care system and the society as a whole.