Patients with chronic pain suffer dramatic reductions in physical, psychological, and social well-being with health-related quality of life rated lower than those with almost all other medical conditions.¹ Evidence-based practice guidelines emphasize interdisciplinary rehabilitation, integrated treatment, and patient selection criteria.² Interdisciplinary pain rehabilitation programs provide the full range of treatments for the most difficult pain syndromes within a framework of collaborative ongoing communication among team members, the patient, and other interested parties.³ Unfortunately, there is considerable variability in the type of practitioners and scope of practice of “multidisciplinary” pain clinics.⁴ A recent survey in North Carolina found that only 7% met the criteria of having a medical physician, registered nurse, physical therapist, and mental health specialist.⁵

There is substantial evidence that interdisciplinary pain rehabilitation programs improve patient functioning in a number of areas for patients with a number of chronic pain syndromes, even the severely disabled.^6–9 In a seminal review, a meta-analysis of 65 studies evaluated the efficacy of treatments in patients who attended multidisciplinary pain clinics.¹⁰ Although there were limitations, the study concluded that multidisciplinary pain clinics are efficacious. Combination treatments were superior to unimodal treatments or no treatment; treatment effects were maintained over a period of up to 7 years; and improvements were found, not only on subjective but also objective measures of effectiveness, on such variables as return to work and decreased health care utilization. More recent analyses of interdisciplinary programs that use comprehensive assessments, severity-adapted or stepped-care treatments, and rehabilitation goals demonstrate significant reductions in pain along with functional and quality of life improvements.^11,12

The goal of treating patients with chronic pain is to end disability and return people to work or other productive activities. Multidisciplinary interventions do show efficacy in returning patients to work.¹³ In a long-term follow-up study, only half of the patients remained unemployed after treatment in an inpatient pain management program.¹⁴ In a 30-month follow-up study of patients with chronic pain receiving multidisciplinary treatment, employment status was predicted by the patient’s desire to return to work, the perception of a job’s dangerousness, and the patient’s education level.¹⁵ Patients not intending to return to work were more likely to complain of their job’s excessive physical demands and reported more job dissatisfaction and feelings of disability. Individualized subjective quality of life (ISQoL) is defined as the appraisal of quality of life based on personal values, desired goal attainment, and life priorities.¹⁶ Poorer ISQoL was not predicted by work status but by higher levels of distress, pain intensity, and perceived disability.

The Pain Treatment Program (PTP) at The Johns Hopkins Hospital is a patient-centered, systematic, organized, and rational approach for restoring the benefits of health and alleviating the consequences of sickness for patients with chronic pain. The service is dedicated to rehabilitation with three guiding principles: (1) a restorative (not curative) model, (2) an active (not passive) role for the patient, and (3) an emphasis on function and independence (not comfort). The founder of the PTP, Donlin M. Long, MD, PhD, emphasized in 1972 that patients with chronic pain should receive an accurate physical diagnosis, an accurate and comprehensive psychiatric and psychosocial evaluation, and an individualization of therapy in an eclectic mode.

The critical therapeutic components of the PTP are organized around a methodology, structure, and rationale for care. The methodology includes a standardized evaluation, case formulation, and individualized treatment plan. The structure of the program exists not only within the physical environment but also a therapeutic milieu with implementation of operationalized general principles and delivery of therapies. The rationale is manifested in the design of individualized treatment plans, the applied components of the structure, and the explicit expectations for patients and staff. The overall goal is to promote rehabilitation for patients disabled by chronic pain. This focus is accomplished by providing the patient with a predictable world, avoiding distractions, gaining experience with healthy behaviors, learning from mistakes, practicing independent problem solving, and setting personal goals.

When patients with chronic pain are in need of interdisciplinary rehabilitation, they want to know the generative nature of their conditions and how to differentiate them for the sake of receiving specific and effective treatments.^17,18 The biopsychosocial approach offers only the ingredients and end products but not the recipes and processes for improvement. Multidisciplinary pain treatment functions with the same limitations.^19,20 Without the method to determine a set of unique causes and direct specific treatments, the patient receives symptomatic treatments with the expected “partial” response. Despite the involvement of more disciplines, the message is clear—cures for “organic” problems and management for “functional” problems. True interdisciplinary treatment is needed.

The cause of disability cannot be found until the investigation expands to include not only the diseases of the body but also the disruptions of the motivational rhythms of behavior, the psychological constitution of the individual, and the personal chronicle of desire and encounters.²¹ All chronic pain disorders are expressions of life under altered circumstances that affect characteristic functional capacities and generate particular behavioral expressions of disability.^22,23 The clinical distinctions allow for independently informed perspectives about the nature of chronic pain disorders and what may have happened to generate the disability. Four perspectives—diseases, behaviors, dimensions, and life stories—represent classes of disorders, and each has a common essence and logical implications for causation and treatment.^24,25 In this approach to patient care, diseases are what people have, behaviors are what people do, dimensions are what people are, and life stories are what people encounter. The formulation of a plan for a patient with chronic pain should address the contributions from each perspective to the overall presentation and inform the design of a treatment plan that can address each component of the patient’s illness.

Diseases of the brain manifest psychologically. The psychological faculties of the brain include but are not limited to consciousness, cognition, memory, language, affect, and executive functions. Abnormalities in the structures or their associated functions of these faculties are expressed in the criteria that describe the common diagnoses such as delirium, dementia, panic disorder, and major depression. However, the patient may describe deficits in these faculties with difficulty and rely on somatic symptoms (e.g., pain) as incomplete proxies for these criteria. The physical symptoms occur because the brain is malfunctioning and suggesting pathology in the body. The unifying feature of diseases is a broken part within the individual that is causing pathology.^25,26

The pathology causes the characteristic signs and symptoms typically manifested by the affliction.²³ For the patient, there is no meaningful interpretation to be understood, no individual deficiency to be addressed, and no goal that is trying to be achieved. Finding a cure may repair the broken part, prevent the initial damage from progressing, or compensate for the pathology through secondary compensatory measures.

The perspective of behavior encompasses a wide range of actions and activities. The complex behaviors of human beings are designed with purpose to achieve goals. Human consciousness is characterized by the regular, rhythmic alterations of attention and perception produced by internal drives that increase a person’s motivation toward a particular activity.^25,26 The drive pushes the individual into action. Then, after the actions, the drive is satisfied, and a state of satiety emerges. Over time, drives reemerge with subsequent effects on the individual’s perceptual attitude toward his or her setting. In addition, personal assumptions or external opportunities increase the likelihood of certain behaviors. These present a choice to the person, who must decide what action to take. After the choice is made and the behavior completed, external consequences emerge from the outcome and influence future actions. The person learns which choices are most effective. When aspects of choice and control over behavior become disrupted, physicians are asked to address the distorted goals, excessive demands, damaging consequences, and lack of responsiveness to negative feedback.^27,28 Treatment of behavioral disorders begins with regaining temporary control of the situation by stopping the behavior.^20,29 Restricting the patient’s actions and preventing these problematic behaviors eventually limit the chaos of destructive actions. This stable foundation is required for the patient to gain insight about and motivation toward appropriate choices that will result in less distress and more satisfaction.³⁰

In contrast, many mental disorders emerge not from a disease of the brain or some form of abnormal illness behavior but from a patient’s personal affective or cognitive constitution.^25,26 Each individual possesses a set of personal dimensions such as intelligence, extraversion, and neuroticism. These traits describe who a person is and are carried into the world as a set of innate capabilities of their psychological makeup. Which traits are relied upon and how much of them a person possesses will determine his or her potential to cope with different situations. Some circumstances are overwhelming and provoke a person’s vulnerability to distress. The patient cannot manage the situation and what is required because of who he or she is. Treatment for disorders of the dimensional type focuses on remediation of specific deficiencies and guidance about overcoming potential vulnerabilities through adaptations such as education about, assistance with, or modification of the particular stressors.^20,29

The life story perspective uses a narrative composed of a series of events that a person encounters and determines to be personally meaningful.^25,26 These self-reflections are the means by which a person judges the value of his or her life as a whole. They impart a sense of self as the agent of a life plan unfolding in a social setting, as well as the reflective subject experiencing and interpreting the outcome of such plans and commitments. If events are occurring as planned, then the person feels on track and successful. However, if the sequence of events results in an unexpected or disappointing outcome, the person will feel a sense of distress about this failure. Life story disorders are interpretive responses to life encounters such as grief from loss or anxiety resulting from expected threats.^27,31,32 Treatment begins with the expectation to forge a narrative of setting and sequence that suggests some role for the patient in his or her life and that illuminates the troubled state of mind as the outcome of that role and course of events.^20,29 The effective treatment of life story disorders requires reframing and reinterpreting to remoralize the patient by transforming the story into one with the potential for success and fulfillment.