April 7, 2008

At this point in my clinical training, I have spent nearly a year on what is called the psychodiagnostic practicum. What that means is that my main job for the last year, as a psychodiagnostic extern at the Diamond Headache Clinic inpatient unit, has been to figure out what psychological factors are playing a role in our patients’ headache pain.

This is a tricky thing to do, for a number of reasons:

• It’s tricky to figure out what’s going on with anybody, psychologically. People are pretty complicated; when things go wrong, they rarely go wrong for just one reason. Typically any psychological problem will have some genetic components, some environmental components, some relational components, and some intrapsychic components. You don’t really get the luxury of pointing to one thing in someone’s past and saying you’ve found the answer.
• These people tend to be especially complicated. There’s some research to suggest that chronic pain patients are more likely to meet criteria for personality disorders than other types of patients. In my experiences, I’ve found that even those who don’t meet criteria for those diagnoses usually have pretty deep-seated ways of interacting with the world that unintentionally serve to maintain their pain status.
• Headache patients, in particular, are usually pretty resistant to psychological asssessment. This is mostly because they have gotten used to being told that the very real pain that they experience on a daily basis is “all in their head.” Usually they hear this from physicians who are simply frustrated that none of their tests come back positive and nothing they do seems to change anything. The same goes for any other type of chronic pain patient, and probably many people with IBS as well.

So what I do currently is I go into each patient’s hospital room and spend about 30-60 minutes finding out how they feel, what their life is like, what it was like growing up, what kinds of relationships they have, and what kinds of stress they experience. From this, I try to draw connections between all of the different factors, in order to figure out what kinds of psychological treatments might be effective in reducing their headache pain. If a case is particularly complicated, and if we have the time, I will administer the patient an intensive 8-hour battery of psychological tests which help me to pin-point exactly what kinds of cognitive and personality issues they face.

It’s actually quite beautiful: my entire job is to find out how people are put together and what makes them tick. What I’m especially looking for, when I conduct a psychological interview, are the parts that the patients themselves cannot possibly allow themselves to know. And when I say this, I want you to know that I am not only talking about chronic pain patients. We all have parts of ourselves and our lives that we cannot know, that we must defend against at all costs.

For now, I’d like to announce a new clinical practicum! After I finish up at Diamond Headache in June, I’ll begin a new one-year psychotherapy externship at Chicago Lakeshore Hospital’s Valeo Program, which is Chicago’s only inpatient and intensive outpatient therapy for GLBT individuals. About 50% of my patients there will be HIV positive, and about 50% of them will suffer from substance abuse disorders in addition to their other psychological troubles, which will run the gamut from anxiety and depression, to eating disorders, to identity disturbances, to personality disorders. I’ll be taking on anywhere from 4 to 8 individual patients per week, and doing 2 or 3 therapy groups each week as well.

The Valeo program is a very competitive training site, and I was selected from more than 60 applicants!