An Integrated Biobehavioral

Approach

Chronic Pain

HERTA FLOR AND DENNIS C. TURK

Mission Statement

IASP® brings together scientists, clinicians, health care providers, and

policy makers to stimulate and support the study of pain and to translate

that knowledge into improved pain relief worldwide. IASP Press® pub-

lishes timely, high-quality, and reasonably priced books relating to pain

research and treatment.

Chronic Pain: An Integrated Biobehavioral Approach

Herta Flor, PhDCentral Institute of Mental Health

University of Heidelberg

Heidelberg

Germany

Dennis C. Turk, PhDDepartment of Anesthesiology & Pain Medicine

University of Washington

Seattle, Washington, USA

IASP PRESS® � SEATTLE

© 2011 IASP Press®International Association for the Study of Pain®All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

Timely topics in pain research and treatment have been selected for publication, but the information provided and opinions expressed have not involved any verifi cation of the fi ndings, conclusions, and opinions by IASP®. Th us, opinions expressed in Chronic Pain: An Integrated Biobehavioral Approach do not necessarily refl ect those of IASP or of the Offi cers and Councilors.

No responsibility is assumed by IASP for any injury and/or damage to persons or property as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the medical sciences, the publisher recommends that there should be independent veri-fi cation of diagnoses and drug dosages.

Library of Congress Cataloging-in-Publication Data

Flor, Herta. Chronic pain : an integrated biobehavioral approach / Herta Flor, Dennis C. Turk. p. cm. Includes bibliographical references and index. ISBN 978-0-931092-90-9 (alk. paper)1. Chronic pain--Treatment. 2. Chronic pain--Psychological aspects. 3. Chronic pain--Physiological aspects. I. Turk, Dennis C. II. Title. RB127.F588 2011 616’.0472--dc23 2011031442

Published by:

IASP Press®International Association for the Study of Pain111 Queen Anne Ave N, Suite 501Seattle, WA 98109-4955, USAFax: 206-283-9403www.iasp-pain.org

Printed in the United States of America

v

Contents

Foreword xiPreface xiiiAcknowledgments xvii

Part I Basic Concepts for the Assessment and Treatment of Chronic Pain

1. Basic Concepts of Pain 32. Neural Mechanisms of Pain 253. Th e Psychology of Pain 454. Psychobiological Mechanisms in Chronic Pain 89

Part II Multiaxial Assessment of Chronic Pain Patients

5. Evaluation of the Patient with Chronic Pain 1396. Assessment of Physical Pathology and Physical Functioning 1777. Psychophysiological Assessment of Chronic Pain 1998. Assessment of Characteristics of Pain and Pain Behaviors: Laboratory and Clinical Methods 2179. Psychosocial Assessment 25310. Identifying Patient Subgroups and Matching Patients with

Treatments 289

Part III Treatment of Chronic Pain

11. General Principles in the Treatment of Chronic Pain 32112. Relaxation and Biofeedback 33713. Operant Group Treatment 38314. An Introduction to the Cognitive-Behavioral Approach to Chronic Pain Management 41315. Applying the Cognitive-Behavioral Approach to Chronic Pain Management 43716. Th e Effi cacy of Psychological Treatments for Chronic Pain 49117. New Vistas on the Behavioral Treatment of Chronic Pain 509

Glossary 529Index 537

vi Contents

Appendices (CD only)

1 Initial Patient Interaction

2 Pain Assessment Interview

3 Case Example: Chronic Pain

Following a Rear-End Collision

4 Manual Tender Point Survey

5 Tübingen Pain Behavior Scale

6 Pain-Related Self-Statements

7 Pain-Related Self-Statements—

Signifi cant Other Version

8 Pain-Related Control Statements

9 Pain-Related Control Statements—

Signifi cant Other Version

10 Brief Stress Scale

11 Brief Stress Scale—Signifi cant

Other Version

12 West Haven-Yale

Multidimensional Pain Inventory

13 West Haven-Yale

Multidimensional Pain

Inventory—Signifi cant Other

Version

14 Acute Low Back Pain Screening

Questionnaire

15 Training in Progressive Muscle

Relaxation

16 Example of a Discussion with the

Patient about Homework

17 Patient Information about

Autogenic Training

18 Patient Information about

Biofeedback and Chronic Back

Pain

19 Stress Diary

20 Stress Diary and Logging of

Relaxation

21 Instruction on Biofeedback

22 Brief Relaxation with

Diaphragmatic Breathing

23 Biofeedback Training Manual

24 Sample Assessment Discussion

25 Sample Treatment Agreement

26 Operant Group Treatment:

Course of Th erapy

27 Th e Relationship of Pain and

Learning

28 Determination of Activity Goals

29 Defi nition of Activity Goals for

Homework

30 Homework Sheet Activity Curve

31 Pleasant Events Schedule

32 Sample Role-Play of Pain and

Well Behaviors and Th eir

Reinforcement

33 Sample Letter to the Referring

Physician

34 Preparation by a Referral Source

35 Introduction to Cognitive-

Behavioral Treatment

36 Introducing a Multidimensional

Model of Pain to the Patient

37 Homework Exercise for the Gate

Control Model

38 Homework: Treatment Goals and

Goal Attainment Rating

viiContents

39 Information Sheet: Information

for the Patient about Treatment

40 Patient Diary

41 Challenging Maladaptive Negative

Th inking

42 Problem Solving: Questions—

Actions—Self-Monitoring

43 Exercise Sheet for Problem Solving

and Positive Communication

44 Questions about Coping Strategies

45 Deep Relaxation with Pleasant

Imagery

46 Stress Symptoms and Responses

to Stress

47 Exercise: Th e Role of Th oughts in

Stress and Pain Situations

48 List of Stress and Coping Th oughts

49 Th e A-B-C Model

50 Exercise: Coping Th oughts

51 Exercise: Recognition of Pain-

Enhancing and Pain-Reducing

Self-Talk

52 Distraction of Attention

53 Body Focus

54 Homework Sheet: List of Methods

for Diversion from Pain

55 Two Exercises to Divert the

Patient’s Attention from Pain

56 Examples of Imagery

57 Information on Pain Medication

58 Medication Reduction Plan

59 Determining a Target Pulse and

Selecting a Physical Activity

60 Exercise Sheet: Daily Activities

61 Mutual Goal Planning

62 Questions about Pain for the

Patient and Signifi cant Other

63 Joint Activities

64 Outline of a Cognitive-Behavioral

Treatment Program

65 Ten Problems with Physical

Exercises and Th eir Solutions

Herta Flor, PhD, studied psychology at the Uni-

versities of Würzburg, Tübingen, and Yale and ob-

tained her PhD at the University of Tübingen in

1984. She is a licensed clinical psychologist with a

specialization in behavior therapy. She has held

positions as visiting professor at the University of

Pittsburgh (1985–87) and as professor of clinical

psychology at Humboldt University, Berlin (1993–

2000). Since 2000 she has served as Scientifi c Di-

rector of the Department of Neuropsychology and

Clinical Psychology at the Central Institute of

Mental Health and as a full professor at the Univer-

sity of Heidelberg. She has made important discov-

eries in the fi eld of pain and phantom phenomena,

including the cortical processing of pain-related information in humans. Her re-

search focuses on the interaction of brain and behavior, in particular the question

of how behavior and experience infl uence neural processes and how neural pro-

cesses alter behavior and experience. A special interest is in the role of implicit

learning and memory processes in the development and maintenance of chronic

pain, tinnitus, anxiety disorders, addiction, and depression. Th e methods she has

used range from experimental psychology to non-invasive brain imaging and pe-

ripheral psychophysiology. She is also actively involved in the development of

new behavioral approaches to pain and other mental disorders and teaches and

supervises clinical psychologists in cognitive-behavioral methods. She has pub-

lished more than 300 scholarly articles and has received several awards and hon-

ors, which include the Award for Basic Research of the State of Baden-Württem-

berg (2004), the German Psychology Award (2002), the Muscle Pain Research

Award (2001), the Max-Planck-Award for International Cooperation (2000), and

the German Pain Research Prize (1992 and 2000). She is also a fellow of the Ger-

man National Academy of Science Leopoldina and the Academia Europaea.

Dennis C. Turk, PhD, is the John and Emma Bon-

ica Professor of Anesthesiology and Pain Research

and Director of the Center for Pain Research on

Impact, Measurement, & Eff ectiveness (C-PRIME)

at the University of Washington. A charter mem-

ber of the International Association for the Study

of Pain and a founding member of the American

Pain Society, Dr. Turk is a fellow of the Academy of

Behavioral Medicine Research, the Society of Be-

havioral Medicine, and the American Psychologi-

cal Association. Dr. Turk is Past-President of the

American Pain Society. He is a Special Govern-

ment Employee of the United States Food and

Drug Administration. Dr. Turk has received a

number of awards, including the Award for Outstanding Scientifi c Contributions

to Health Psychology from the American Psychological Association and the Wil-

bert E. Fordyce Clinical Investigator Award from the American Pain Society,

which recognizes “individual excellence and achievements in clinical pain schol-

arship and is given to a pain professional whose total career research achieve-

ments have contributed signifi cantly to clinical practice.” Dr. Turk is currently

Editor-in-Chief of Th e Clinical Journal of Pain, Co-Chair of the Initiative on

Methods, Measurement, & Pain Assessment in Clinical Trials (IMMPACT), and

Co-Director of the Executive Committee for the Analgesic Clinical Trials Trans-

lations, Innovations, Opportunities, & Networks (ACTTION) initiative—a pub-

lic-private partnership with the U.S. Food & Drug Administration. He was a

member of the Institute of Medicine’s Committee on Advancing Pain Research,

Care, and Education. Dr. Turk has contributed over 500 publications to the health

care literature. He has authored or edited 16 volumes, most recently Th e Pain

Survival Guide: How to Reclaim Your Life (with Frits Winter) and the third edition

of the Handbook of Pain Assessment (with R. Melzack).

To my teacher and friend Niels Birbaumer, with gratitude

In memory of Irmela Florin (1938–1998), the pioneer of behavioral

medicine and behavior modifi cation in Germany

Herta Flor

To my great friend Robert H. Dworkin, who continues to pique my

interest in issues related to clinical trial design, the IMMPACT we could

have, and the ACTTION we could inspire by collaborating together. His

enthusiasm and energy are infectious and a continuing inspiration.

And to my loving and sharing wife, Lorraine, who has encouraged me

and sacrifi ced for me throughout our marriage. My career would not

have been half as successful without her enduring support.

Dennis C. Turk

xi

Foreword

To be in physical pain is to fi nd yourself in a diff erent realm—a state of being unlike

any other, a magic mountain as far removed from the familiar world as a dreamscape.

Usually, pain subsides, one wakes from it as from a nightmare, trying to forget it as

quickly as possible. But what of pain that persists? Th e longer it endures, the more

excruciating the exile becomes. Will you ever go home? you begin to wonder, home

to your normal body, thoughts, life?

Melanie Th ernstrom, Th e Pain Chronicles: Cures, Myths, Mysteries,

Prayers, Diaries, Brain Scans, Healing and the Science of Suff ering

(New York: Farrar, Straus and Giroux; 2010, p. 3)

According to the recently published report from the Institute of Medicine,

“Relieving pain: a blueprint for transforming pain prevention, care, educa-

tion and research” (2011), as many as 116 million adult Americans suff er

from common chronic pain conditions at an estimated cost of between

$560 and $630 billion annually for health care expenses and lost produc-

tivity. Pain aff ects everyone, and the toll of chronic pain on one’s sense of

self and wellbeing, on physical functioning, and on overall quality of life

can be devastating. Th e IOM report integrates the voices of persons liv-

ing with chronic pain to highlight the anguish of unremitting pain, help-

lessness and hopelessness, and the travails of the unsuccessful search for

relief. Th e quote above from author Melanie Th ernstrom, a member of

the IOM Committee that prepared the report and herself a person with

chronic pain, provides a glimpse of the personal horrors of life with persis-

tent pain, particularly the prospect of pain without end.

Advances in understanding of the mechanisms that promote the

development of chronic pain and that sustain it have been rapid in the

past several decades, and an increasing array of eff ective therapies have

been identifi ed. Th ese therapies span pharmacological, interventional,

behavioral, and rehabilitation strategies, as well as a growing number of

evidence-based complementary and alternative approaches. Yet millions

continue to suff er due to a limited response to therapy or because of bar-

riers to accessing appropriate care. Th e IOM report calls for a compre-

hensive approach to meet the moral imperative to eliminate these barriers

xii Foreword

through substantial investments in prevention, novel therapies, education

for health care professionals and the public, and research.

A major challenge facing the fi eld of pain management is the need

to expand eff orts to educate and train health care providers in the use of

evidence-based clinical assessment and therapeutic approaches. Th is is a

tough challenge as the science of pain and pain management continues to

expand at an enormous rate, making it diffi cult for educators and future

providers to maintain an up-to-date knowledge of these advances and to

build and maintain clinical competencies. Expansion of formal education

and training programs in pain management is clearly needed, and opportu-

nities for continuing education need to be increased in number and scope.

Chronic Pain: An Integrated Biobehavioral Approach, by Herta

Flor and Dennis C. Turk, two of the leading scientists and scholars in our

fi eld, off ers in a single volume the most comprehensive and in-depth view

of the fi eld currently available. Drs. Flor and Turk share their collective

knowledge and professional insights accumulated over three decades of

extraordinary contributions to the fi eld. Th e book provides a compelling

case in support of an integrative approach to clinical assessment and man-

agement of chronic pain that draws upon the state-of-the-science from the

diverse fi eld of pain management that extends from clinical neuroscience

to translational behavioral medicine science. Th e fi rst section provides an

up-to-date and highly digestible review of the foundational principles of

the multidimensional experience of chronic pain and is followed by two

sections on clinical assessment and treatment, concluding with a glimpse

at future innovations in pain care. Th ese later sections are simply extraor-

dinary in integrating theory, science, and practical information that will

be equally useful to novice and experienced clinicians, investigators, and

policy makers. Ultimately, this text promises to stand alone as the single

best source for educators and for those seeking to expand their knowledge

of the fi eld of chronic pain management. I applaud this exciting addition to

our armamentarium in meeting the challenges of the IOM and furthering

our collective eff orts to help relieve unnecessary pain and suff ering.

Robert D. Kerns, PhDNational Program Director for Pain Management, Veterans Health Administration; Director,

Pain Research, Informatics, Medical Comorbidities, and Education (PRIME) Center, VA Con-

necticut Healthcare System; Professor of Psychiatry, Neurology and Psychology, Yale University

xiii

Preface

Th is volume provides a psychobiological perspective on people who ex-

perience chronic pain and describes a comprehensive approach to their

treatment. Th e text focuses on the interaction of psychosocial (psycho-

logical, behavioral, and social) and physiological processes in people with

chronic pain and the implications that follow. In recent years, there has

been growing recognition that neither purely somatic nor completely psy-

chological models by themselves are adequate to explain the subjective

experience of chronic pain and associated disability. Our basic hypothesis

is that chronic pain is a learned response, whereby “pain memories” rather

than current nociceptive input determine much of the pain experienced.

Moreover, interdisciplinary approaches that integrate psychological prin-

ciples and approaches with traditional biomedical knowledge in the as-

sessment and treatment of people with chronic pain are more fruitful than

any single modalities, be they physical (surgery, medication, regional anes-

thesia, or neuroaugmentive interventions) or psychological (biofeedback,

counseling, or psychotherapy).

Integration of current psychological information and principles

with existing biomedical knowledge will increase our understanding of

people with various chronic pain syndromes and should lead to more

eff ective treatment outcomes and improved quality of life for those with

persistent pain. Although our emphasis is on the role of psychological

and social factors in chronic pain states, we attempt to integrate these

aspects with the current biological understanding of the neurophysiol-

ogy of nociception. In the introductory section we provide a theoretical

framework that is essential for understanding, evaluating, and success-

fully treating the person with chronic pain and not just the pain. We

give special emphasis to learning and cognitive processes (beliefs, an-

ticipation, subjective meaning, and memory) that determine how pain

is experienced.

In the second section, we focus on a comprehensive approach to

assessment. We outline our concept of multiaxial assessment and guide

xiv

the reader through the process of achieving a diff erential diagnosis that

serves as the basis for decision making and treatment planning. We pro-

vide a detailed discussion of the rationale behind and the components of

comprehensive assessment. We include specifi c recommendations for

using a set of assessment procedures, including interviews, self-report

questionnaires, behavioral observation schemes, and psychophysiologi-

cal methods. We provide a general assessment algorithm and recommend

specifi c methods that will form the basis for a comprehensive evaluation

of the chronic pain patient.

In the fi nal section, we outline three well-validated treatment ap-

proaches that have received the greatest amount of empirical support in

pain management: biofeedback and relaxation training, operant group

treatment, and cognitive-behavioral pain management. We also focus on

newer treatment methods that are based on fi ndings of learning-related

maladaptive plastic reorganization of the brain secondary to the experi-

ence of pain. Th ese insights open the avenue to innovative approaches

that may be incorporated in the treatment of chronic pain patients. We

will not provide an exhaustive review of the vast pain literature, but rather

emphasize our own empirically based view of the best evidence-based ap-

proaches to the treatment of chronic pain patients. In our discussion of

treatments, we describe the rationale behind each approach, provide de-

tailed guidelines describing how and when to implement each of the treat-

ments, and summarize outcome research supporting these methods. We

include an appendix on CD that incorporates many assessment instru-

ments as well as detailed outlines of treatment protocols to help clinicians

understand important features and nuances that can lead to successful

outcomes for many patients.

Th is volume has fi ve primary objectives:

1) Provide the reader with a thorough understanding of an integrat-

ed psychobiological model that emphasizes the crucial role of learning,

memory processes, cognitive processes, and contextual factors as the basis

for understanding people with chronic pain.

2) Present a rationale for our belief that the “pain-patient uniformity

myth” is wrong. Th at is, not all people with the same medical diagnosis

will benefi t from the identical treatment. We believe that matching both

Preface

xv

physical and psychological interventions to specifi c patient characteristics

will enhance successful treatment outcome.

3) Provide the reader with a specifi c rationale indicating how treat-

ment decisions should follow from a comprehensive assessment.

4) Demonstrate the synergy between research and clinical practice.

5) Provide the reader with suffi cient detail regarding our comprehen-

sive, multiaxial approach to assessment and treatment so that it can be

integrated into clinical practice. We include extensive details on assess-

ment and treatment methods, because we believe not only that better out-

comes can be achieved but that more meaningful research can be con-

ducted when we focus on specifi c treatments rather tan relying on vague

descriptions and treatment titles such as “operant (behavioral) therapy,”

”cognitive-behavioral therapy,” “extinction training,” ”biofeedback,” and

“multidisciplinary/interdisciplinary treatment,” all of which have idiosyn-

cratic meanings and treatment elements.

We include our e-mail addresses below and welcome readers’

comments. We hope that readers will let us know how well we have suc-

ceeded in accomplishing our objectives.

Herta Flor, PhD

herta.fl or@zi-mannheim.de

Dennis C. Turk, PhD

turkdc@u.washington.edu

Preface

Basic Concepts of Pain 5

the person experiencing pain and his or her signifi cant other. (We use the

phrase “signifi cant other” throughout this text to refer to a spouse, part-

ner, family member, friend, coworker, or employer. Moreover, “signifi cant

others” also include the health care providers with whom the person with

pain is in frequent contact.)

Despite signifi cant advances in anatomy, neurophysiology, bio-

chemistry, and medicine, pain—especially pain that has persisted beyond

the expected period of healing, which is not the result of a progressive

disease, or for which there is no identifi able physical pathology—has re-

mained an enigma for clinicians and scientists, as well as for pain suff erers.

Th ese pain syndromes, including many chronic and recurrent conditions,

have proven particularly recalcitrant to even the most advanced medical,

surgical, and pharmacological methods of treatment [25].

In this chapter, we will review the magnitude of the problem of

pain, introduce a number of key defi nitions, and describe the classifi ca-

tion of pain syndromes. Th is foundation is essential for clinicians who

want to appreciate the current state of knowledge, understand the basis

for assessment and treatment approaches, and communicate eff ectively

with patients, patient’s signifi cant others, other health care providers, and

third-party payers about the nature and scope of pain problems, treatment

planning, interventions, rehabilitation, and disability.

Foundations of Current Understanding of Pain and Pain Management

Pain only became a focus of systematic research and clinical interest with-

in the past 50 years. Prior to the 1960s, pain was relegated primarily to

the domain of sensory physiology. Clinical medicine tended to view pain

as an epiphenomenon of disease or injury—a response, and therefore of

secondary importance. Th e emphasis was on eliminating the cause of the

pain and fi nding a cure. Th e assumption was that once the physical cause

of the pain was eliminated, pain would subside and no longer represent a

signifi cant problem. Th us, pain was not viewed as something worthy of

consideration or treatment in its own right; it was only important because

it provided information about physical pathology. Otherwise, pain was

just a nuisance.

Th e Psychology of Pain 61

Th e Operant Conditioning Model of Chronic Pain

As noted in Chapter 1, the operant conditioning formulation proposed

by Fordyce [49] has substantially contributed to our understanding of

chronic pain and has had a signifi cant impact on treatment and rehabili-

tation. In Chapter 1, we mentioned that the operant model distinguishes

between the private pain experience and observable and quantifi able pain

behaviors, which are overt communications of pain, distress, and suff ering

such as moaning, grimacing, or taking medication. It is these behaviors,

rather than pain itself, that are assumed to be amenable to behavioral as-

sessment and treatment. Th e operant conditioning model proposes that

acute pain behaviors may come under the control of (be maintained by)

external contingencies of reinforcement and thus develop into a chronic

pain problem. Pain behaviors may be positively reinforced, for example,

by attention from a spouse or from health care providers [128]. Pain be-

haviors may also be maintained by the termination of unpleasant states,

such as a reduction in pain level by analgesic medication or inactivity or

the avoidance of undesirable activities such as work or unwanted sexual

activity (negative reinforcement). Also, well behaviors (functional activi-

ties including working, home-making activities, and self-care) may not be

suffi ciently reinforcing, and so the more rewarding pain behaviors may be

maintained (see Fig. 6).

R S- negativereinforcement of pain behavior

(medication intake) (pain reduction)

R S+ extinction ofwell behavior

(well behavior) (lack of positive reinforcement)

R S+ positivereinforcement of pain behavior

(moaning) (attention)

Fig. 6. Operant conditioning model of chronic pain (R = response, S = stimulus).

92 H. Flor and D.C. Turk

pain memories on all levels of the nervous system that may, over time,

maintain pain even in the absence of peripheral nociceptive input. We

propose that in chronic pain, the extinction rather than the acquisition of

these learning processes may be especially disturbed.

We have summarized the main factors that we believe contrib-

ute to the development and maintenance of chronic pain in Fig. 1. We

will describe these factors and their potential interactions in more detail

in the following sections. It is important, however, to acknowledge that

although we have isolated these four components to simplify discussion,

they all interact and are not mutually exclusive, nor intended to connote

a linear sequence.

Fig. 1. Psychobiological model of chronic pain.

Eliciting stimuli

• aversive external and/or internal stimuli

Psychophysiologicalresponse stereotypy

Pain response Maintaining processes

Predisposing factors y y

e.g., symptom-specific EMG increase

• verbal -subjective

• behavioral

• physiological -i

• nonassociativelearning

• associative learning

li it

• genetic determination

• learning

• occupational f t organic • explicit

learningfactors

Eliciting responses

• lack of coping skills, e.g., catastrophizing

• inadequate perception and interpretation of h i l i l d b dil tphysiological processes and bodily symptoms

• anticipatory anxiety

• memory of pain

• lack of self-efficacy

Evaluation of the Patient with Chronic Pain 163

Th e Pain Assessment Interview

Th e clinical interview is an integral part of the assessment of every person

with persistent pain. Th e interview serves to establish a positive, thera-

peutic relationship, to determine the treatment motivation of the patient,

and to obtain a comprehensive history of the pain problem. In addition,

the interview will focus on the identifi cation of psychosocial aspects that

may cause or maintain the pain, on the history of previous treatments, and

on the patient’s attitudes toward the pain (for preparation for referral for

a psychological evaluation, see Table IV). Th us, the interview is an impor-

tant part of the behavioral analysis. When conducting an interview with

chronic pain patients, the health care professional should focus not simply

on factual information but on specifi c thoughts and feelings of the patient

and his or her signifi cant others (spouse or partner, family, or friends). Th e

professional should observe specifi c behaviors by the patient as well as the

interaction between the patient and signifi cant others.

During an interview, it is important to adopt the patient’s perspec-

tive. Patients’ and signifi cant others’ beliefs about the cause of symptoms,

their trajectory, and benefi cial treatments will have important infl uences

on emotional adjustment and compliance with therapeutic interventions.

A habitual pattern of maladaptive thoughts may contribute to a sense

of hopelessness, dysphoria, and unwillingness to engage in activity. Th e

interviewer should determine both the patient’s and signifi cant others’

expectancies and goals for treatment and address misconceptions or ex-

pectations of outcomes that are excessively optimistic and are destined to

cause distress when these expectations are not realized.

Attention should focus on the patient’s reports of specifi c

thoughts, behaviors, emotions, and physiological responses that precede,

accompany, and follow pain episodes or exacerbations, as well as on the

environmental conditions and consequences associated with cognitive,

emotional, and behavioral responses in these situations. During the inter-

view, the health care provider should attend to the temporal association of

these cognitive, aff ective, and behavioral events and consider their speci-

fi city versus generality across situations, as well as the frequency of their

occurrence. Th ese details will help to establish salient features of the target

situations, including the controlling variables. Th e interviewer should seek

Relaxation and Biofeedback 343

their homework plan—perhaps they are too tired, the environment is

not conducive, they have a high level of pain, they are having interper-

sonal confl icts, or they may simply forget. We help patients to proac-

tively problem-solve as to what they would do when these types of im-

pediments arise. It is useful to involve the patient as much as possible in

developing the homework plan. It is essential to review homework with

the patient at the beginning of the next therapeutic session. Appendix

16 includes an illustration of how to discuss and plan homework. Table

I provides a sample homework sheet for relaxation exercises that pro-

vides a way to keep detailed records of the exercises and the problems

patients may have encountered, along with the eff ects of these prob-

lems. Notice that the therapist encourages the patient to suggest the

best times to practice and to plan how to deal with any problems that

might arise.

Charts are helpful because they serve as a reminder to practice.

Information about feelings of relaxation before and after practice sessions

can be a helpful reinforcement for the patient to keep practicing. Charts

Table I

Homework sheet for relaxation exercises

Name: __________________________________ Date: ______________________

Please make an entry on this sheet every time you perform a relaxation exercise.

Indicate the exact date and time and estimate how tense you are today and how

much pain you are feeling. Use a scale ranging from 0 = no tension and no pain to

10 = extreme tension and extreme pain. Rate your tension and your pain before

and after doing the relaxation exercise, and in the last column, describe any

problems or difficulties that occurred during the exercise.

Date and

Time

Tension PainNotes

(Successes, Problems,

Difficulties)

Before

(0–10)

After

(0–10)

Before

(0–10)

After

(0–10)

Operant Group Treatment 391

the respective type of behavior. As described below, the group can obtain

valued reinforcers by completely eliminating red cards.

An introduction to operant theory should be part of the treatment

program (an abbreviated version should be provided during the overview

of treatment before the patient agrees to participate in operant group

treatment). To reiterate the previous brief overview, the introduction in-

cludes the following components:

• Th e relationship between bodily processes and learning;

• Th e automaticity or unconscious nature of learning;

• Th e fact that conscious unlearning or relearning is possible;

• Th e concept that chronic pain is a behavior and can be learned

and unlearned.

Th e treatment goals—reduction of excessive disability, improve-

ment of everyday functioning, and better handling of any pain that may

persist—need to be emphasized. Appendix 27 gives a sample introduction

to operant thinking and operant treatment goals.

Goals and Techniques of Operant Treatment

Reducing Pain Behaviors and Enhancing Well Behaviors

An important goal of operant treatment is that patients (and therapists)

learn to identify pain behaviors and well behaviors. Several exercises in-

volve the identifi cation of pain and well behaviors in the group setting. Th e

therapist explains the concept of pain behaviors as “all behaviors that tell

Table II

Topics addressed in operant group treatment

How to deal with medication

How to increase physical activity and use correct body posture

How to decrease the ways pain interferes with:

• Family interactions

• Work or housework

• Leisure time

• Everyday activities

• Social activities

How to deal with the health care system

Introduction to the Cognitive-Behavioral Approach 425

Th e overriding message of the CBT approach, one that begins

with the initial contact and is woven throughout the fabric of treatment,

is that people are not helpless in dealing with their pain, nor do they need

to view pain as an all-encompassing determinant of their lives. Rather, a

variety of resources are available for confronting pain, and pain will come

to be viewed by patients in a more diff erentiated manner. CBT encourages

patients to maintain a problem-solving orientation and to develop a sense

of resourcefulness, instead of the feelings of helplessness and withdrawal

that create a life revolving around bed rest, physician visits, and trips to

the pharmacy.

Phases of Cognitive-Behavioral Th erapy for Pain

Phase 1: Assessment

Th e fi rst two phases of CBT, assessment and reconceptualization, are

highly interdependent. Th e assessment phase serves several distinct func-

tions, as outlined in Table VI. Assessment information is obtained by in-

terviewing patients and signifi cant others, as well as by using standardized

Table VI

Functions of the assessment phase

Establish the extent of physical impairment.

Identify levels and areas of psychological distress.

Collaboratively establish behavioral goals covering areas such as activity

level, utilization of the health care system, patterns of medication use,

and responses of significant others.

Provide detailed information about the patient’s perceptions of his or her

medical condition, opinions about previous treatments, and expectations

of the current treatment.

Analyze the patient’s occupational history and goals regarding work.

Examine the important role of significant others in the maintenance and

exacerbation of maladaptive behaviors and determine how these

individuals can be positive resources for the process of change.

Begin the reconceptualization process by helping patients and significant

others to become aware of the situational variability of the pain and the

psychological, behavioral, and social factors that influence the nature

and degree of pain.

Applying the Cognitive-Behavioral Approach 441

P: Not really.

T: Good—oh, but what happens if it rains on Tuesday, the day you

planned to begin?

P: Hmm, I didn’t think of that… I guess I would wait until Wednesday.

Th e day doesn’t really matter.

T: Right—you can set a schedule for yourself, but you can modify it if

something comes up that gets in the way. Th e important thing is to

stick to a plan. Th e details can be fl exible—the key is to begin get-

ting active again. Remember, start low and go slow! Work until you

meet your goal and not just until you feel some discomfort. Don’t do

to much or too little at the beginning.

In the interchange described above, we attempted to involve the

patient by trying to match his interest with increased activities. We tried

to make the goals specifi c and measurable. We asked the patient to keep a

record of his activities so that we could review his progress at the next ses-

sion. Finally, we had him acknowledge any concerns, anticipate any poten-

tial impediments, and think about how he would fl exibly deal with these

problems if they should arise.

Th e therapist also expresses the interrelationship and interde-

pendence of behavior and physiological processes. Psychophysiological

assessment may be of particular value by clearly demonstrating to the pa-

tient how behaviors and feelings can infl uence physiology, using the pa-

tient’s experience as an example.

T: It is very clear from your pain activity diaries that you tend to stop

doing anything and just lie down when your pain gets really bad.

P: Yeah, I guess so … it just hurts so bad that I can’t think of anything else.

T: What happens to the pain when you lie down?

P: Well, it doesn’t really go away unless I take some medication.

T: Right. What happens to your “pain gate” when you lie down and just

focus on the pain?

P: Huh, I don’t know—maybe it gets opened when I kind of focus on it.

T: Yes, and the frequent lying down may over time allow your muscles

to become weaker, and then they hurt more and more, and then more

activities cause pain, so you do even less. Th erefore, a vicious circle

is created where pain causes inactivity and inactivity leads to more

muscle weakness, more isolation, and consequently more pain. So one

®

For detailed information on these and other IASP Press publications, visit the IASP website at www.iasp-pain.org/Books

Cancer Pain: From Molecules to Suffering Editors: Judith A. Paice, Rae F. Bell, Eija A. Kalso, and Olaitan A. Soyannwo June 2010 Pharmacology of PainEditors: Pierre Beaulieu, David Lussier, Frank Porreca, and Anthony DickensonFebruary 2010

Functional Pain Syndromes: Presentation and Pathophysiology Editors: Emeran A. Mayer and M. Catherine Bushnell April 2009

Fundamentals of Musculoskeletal PainEditors: Thomas Graven-Nielsen, Lars Arendt-Nielsen, and Siegfried MenseJuly 2008

IASP brings together scientists, clinicians, health care providers, and policy makers to stimulate and support the study of pain and to translate that knowledge into improved pain relief worldwide. IASP Press publishes timely, high-quality, and reasonably priced books relating to pain research and treatment.

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