A number of psychological interventions have been developed for patients with chronic pain, with a large body of research supporting their efficacy. Before reviewing the approaches with the greatest empirical support, it is important to consider the plight of a person with chronic pain, the role of psychological factors, and the mechanisms involved in the experience of chronic pain because these factors serve as the basis for the development of treatment modalities. The various psychological models and conceptualizations of chronic pain will then be outlined and the most commonly used treatment interventions described.
Note that the term patient will be used to designate individuals when they are in the health care provider’s office, clinic, or hospital and the term person to designate those with chronic pain when they are outside the confines of health care facilities. This is an important distinction because chronic pain is by definition not curable and can persist over extended periods, for years and even decades. Persons with a chronic pain syndrome must learn how to adapt and self-manage their pain, associated symptoms, and lives. Chronic pain might be viewed as analogous to diabetes; in the physician’s office a person with diabetes is a diabetic patient but, at all other times, is someone who has to learn how to live with diabetes. This involves carrying out all the necessary activities—routinely testing glucose levels (if insulin dependent), taking medication orally or injecting with insulin, maintaining an appropriate diet, modulating exercise patterns, and monitoring skin for infections. All these activities occur outside the formal health care system. Similar behavior is required of those with various types of chronic pain. In the absence of cure, self-management becomes critical.
Plight of the Person with Chronic Pain
People with chronic and recurrent acute pain (e.g., migraine, trigeminal neuralgia, sickle cell episodes) often feel rejected by the very elements of society that exist to serve them. They lose faith and may become frustrated and irritated when the health care system that initially might have created expectations for cure turns its back when treatments prove ineffective. They feel victimized and traumatized by repeated and invasive medical procedures; they become disillusioned and feel disbelief when it seems as though medical professionals expect them to find the cause of the pain on their own and when they have to convince skeptical providers to take their symptoms seriously.
Although patients with acute pain can often obtain relief from primary health care providers, people with persistent pain become enmeshed in the medical system as they shuttle from physician to laboratory test to imaging procedure to medical specialist in a frustrating quest to have their pain diagnosed and successfully treated, if not eliminated completely. Thus, at the same time that returning to work and earning an income become less possible, medical bills for unsuccessful treatments accumulate. This experience of “medical limbo”—the presence of a painful condition that in the absence of acceptable pathology might have psychiatric causation, suggests malingering, or perhaps might even be an undiagnosed but potentially progressive disease—is itself a source of significant and persistent stress that can initiate emotional distress or aggravate a premorbid psychiatric condition.
People with chronic pain reside in a complex and costly world that is also populated by their significant others, health care providers, employers, and third-party payers. Family members feel increasingly hopeless and distressed as medical costs, disability, and emotional suffering mount while income and available treatment options decline. Health care providers grow increasingly frustrated and feel defeated and ineffective as available treatment options are exhausted while the pain condition remains a mystery and may worsen. Employers, who are already resentful of growing workers’ compensation benefits, pay higher costs while productivity suffers because the employee frequently calls in sick or cannot perform at the usual level (“presenteeism”). Third-party payers watch as health care expenditures soar with repeated diagnostic tests and treatments, often with inconclusive results. Over time, the legitimacy of the individual’s report of pain may be questioned because often a medical reason fails to substantiate the cause of the symptoms.
People with chronic pain may begin to feel that their health care providers, employers, and even family members are blaming them when their condition does not respond to treatment as expected. Some may suggest that the individual is complaining excessively to receive attention, avoid undesirable activities, or be relieved from onerous obligations (e.g., gainful employment, household responsibilities). Others may suggest that the pain reported is not real, people reporting unremitting pain are feigning or exaggerating their symptoms, and it is all in their heads, “psychogenic.” Third-party payers may even suggest that the individual is intentionally exaggerating the pain to obtain financial gain, whereas others may attribute the reported symptoms to the desire to obtain mood-altering medications. In this way, people reporting pain may come to be regarded as wimps, crocks, or fakes.
As a result of these attitudes and the absence of cure or even substantial relief, those with chronic pain may withdraw from society, lose their jobs, alienate family and friends, and become more and more isolated, despondent, depressed, and in general demoralized . Their bodies, the health care system, and their significant others have let them down. They may even believe that they have failed themselves as they relinquish their usual activities and responsibilities because of symptoms that are intractable but frequently almost invisible when not validated by objective pathologic findings. This emotional distress, however, can be exacerbated by other factors, including fear, inadequate or maladaptive support systems, inadequate personal and material coping resources, treatment-induced (iatrogenic) complications, overuse of potent drugs, inability to work, financial difficulties, prolonged litigation, disruption of usual activities, and sleep disturbance.
Fear of pain or movement and injury or reinjury is an important contributor to the disability associated with several chronic pain disorders, including back pain and fibromyalgia syndrome. People with chronic pain often anticipate that certain activities will increase their pain or induce further injury. These fears may contribute to avoidance of activity and subsequently greater physical deconditioning, emotional distress, and ultimately, greater disability. Their failure to engage in activities prevents them from obtaining any corrective feedback about the association between activity and pain and injury.
In addition to fear of movement, people with persistent pain may be anxious about the meaning of their symptoms for the future—will their pain increase, will their physical capacity diminish, will they have progressive disability and ultimately end up in a wheelchair or become bedridden? In addition to these anxieties, people in pain may fear that others will not believe that they are suffering or will tell them that they are beyond help and will just have to “learn to live with it.” Such fears can contribute to additional emotional distress and increased physiologic arousal, which may directly exacerbate and maintain the pain. Living with persistent pain conditions requires considerable emotional resilience. It tends to deplete people’s emotional reserves and taxes not only the individual but also the capability of family, friends, coworkers, and employers to provide support.
Chronic pain is estimated to be present in up to 30% of the adult U.S. population. If we assume that most people do not live alone but in a social context with significant others, more than the majority of the population may be affected directly or indirectly. Pain is expensive; health care and indirect costs associated with disability compensation, lost tax revenues, retraining, less than optimal performance on the job, and legal fees exceed $550 billion each year. To put it bluntly, pain hurts—it hurts the person with the symptoms, it hurts significant others, and it hurts society.
Despite advances in knowledge of the neurophysiology of pain and the development of new pharmacologic agents with analgesic properties, sophisticated surgical interventions, and advanced technologies (e.g., spinal cord stimulation, implantable drug delivery systems), cure of pain has eluded the best efforts of health care providers. Regardless of the treatment, the amount of pain reduction averages only about 35%; less than 50% of persons treated with these interventions obtain even this result, and the extent of improvement in emotional, physical, and social functioning is often below this level.
As noted, chronic pain is by definition incurable. People with chronic pain continually confront noxious sensations and other aversive symptoms that affect every aspect of their lives—social, emotional, interpersonal, and economic, as well as physical. Thus, those with chronic pain are faced with managing their symptoms on their own. Faced with this task, the common response is, “How?”
It is well to recall Bonica’s comment in the preface to the first edition (1954) of his seminal work The Management of Pain (and repeated in the third edition almost 50 years later):
The crucial role of psychological and environmental factors in causing pain in a significant number of patients only recently received attention. As a consequence, there has emerged a sketch plan of pain apparatus with its receptors, conducting fibers, and its standard function which [ sic ] is to be applicable to all circumstances. But…in so doing, medicine has overlooked the fact that the activity of this apparatus is subject to a constantly changing influence of the mind.
Based on the overview provided, two conclusions should be obvious: (1) psychological factors play a significant role in the experience, maintenance, and exacerbation, if not the cause, of pain, and (2) because there are no cures for chronic pain and some level of pain will persist in most people with chronic pain regardless of treatment, psychological approaches may be useful complements to more traditional medical and surgical approaches.
Psychological Formulations of Chronic Pain
A number of different psychological perspectives on chronic pain have evolved over time. It is important to consider these initially because psychological treatments are based on different, and at times competing, psychological principles.
Psychogenic View
As is frequently the case in medicine, when physical explanations seem inadequate or when the results of treatment are inconsistent, reports of pain are attributed to a psychological cause (i.e., psychogenic). Although psychogenic views of pain have been discussed since the formulation of psychodynamic theory, a psychodynamic perspective on chronic pain was first described systematically in the 1960s, when people with pain were viewed as having compulsive and masochistic tendencies, inhibited aggressive needs, and feelings of guilt—“pain-prone personalities.” It was commonly believed that people with pain had childhood histories fraught with emotional abuse, family dysfunction (e.g., parental quarrels, divorce), illness or death of a parent, early responsibilities, and high motivation toward achievement. Some studies reported associations between chronic pain and childhood trauma, although the findings are not consistent.
Based on the psychogenic perspective, assessment of those with chronic pain is directed toward identifying the psychopathologic tendencies that instigate and maintain pain. Although evidence to support this model is scarce, the American Psychiatric Association has created a psychiatric diagnosis, somatoform pain disorder. Diagnosis of a pain disorder requires that the person’s report of pain be inconsistent with the anatomic distribution of the nervous system or, if it mimics a known disease entity, cannot be adequately accounted for by organic pathology after extensive diagnostic evaluation. Even in the presence of a medical condition that may cause pain, psychological factors may be implicated, and thus the person may receive a psychiatric diagnosis of “pain disorder associated with both psychological factors and a general medical condition.”
It is assumed that reports of pain will cease once the psychogenic mechanisms have been resolved. Treatment is geared toward helping patients gain insight into the underlying maladaptive psychological contributors.
Empirical evidence supporting the psychogenic view is scarce. A number of people with chronic pain do not exhibit significant psychopathology. Furthermore, insight-oriented psychotherapy has not been shown to be effective in reducing symptoms in most patients with chronic pain. Studies have suggested that the emotional distress observed in patients with chronic pain more typically occurs in response to the persistence of pain and is not a causal agent and may resolve once the pain is treated adequately. The psychogenic model has thus come under scrutiny and may be flawed in its view of chronic pain.
Behavioral Formulations
According to the classical or respondent conditioning model, if a painful stimulus is repeatedly paired with a neutral stimulus, the neutral stimulus will by itself come to elicit a pain response. For example, a person who experienced pain after performing a treadmill exercise may become conditioned to experience a negative emotional response to the presence of the treadmill and to any stimulus associated with it (e.g., physical therapist, gym). The negative emotional reaction might instigate tensing of muscle in anticipation, thereby exacerbating the pain and further reinforcing the association between the stimulus and pain. Based on this conditioned correlation, people with chronic pain may avoid activities previously associated with onset or exacerbation of the pain.
In 1976, Fordyce extended operant conditioning to chronic pain. This view proposes that acute pain behavior (e.g., avoidance of activity for fear of pain) may come under the control of external contingencies of reinforcement (i.e., responses increase or decrease as a function of their reinforcing consequences) and thus develop into a persistent pain problem. Fordyce underscored that because there is no objective means of measuring pain, the only way that we can know of other people’s pain is by their behavior, expressed verbally or nonverbally. Overt pain behavior includes verbal reports, paralinguistic vocalizations (e.g., sighs, moans), motor activity, facial expressions, body postures and gesturing (limping, rubbing a painful body part, grimacing), functional limitations (e.g., reclining for extensive periods, inactivity), and behavior designed to reduce pain (e.g., taking medication, use of the health care system).
The central features of pain behavior are that behavior is (1) a source of communication and (2) observable. Observable behavior is capable of eliciting a response, and the consequences of the behavior will influence subsequent behavior. Through a learning process, behaviors that receive positive consequences will more likely be maintained, whereas types of behavior that fail to achieve positive consequences or that receive negative consequences will be less likely to occur (i.e., extinguished). Pain behavior may be positively reinforced directly, such as by attention from a spouse or health care provider, monetary compensation, or avoidance of undesirable activity. It may also be maintained by escape from noxious stimulation through the use of drugs or rest or by avoidance of undesirable activities such as work. In addition, “well behavior” (e.g., activity, working) may not be positively reinforcing and the more rewarding pain behavior may therefore be maintained.
The operant conditioning model does not concern itself with the initial cause of pain. Rather, it considers pain an internal subjective experience that can be directly assessed and may be maintained even after an initial physical basis of the pain has resolved. The pain behavior originally elicited by organic factors as a result of injury or disease may come to occur, totally or in part, in response to reinforcing environmental events.
It is important, however, not to make the mistake of viewing pain behavior as synonymous with malingering. Malingering involves consciously and purposely faking a symptom such as pain for some gain, usually financial. Contrary to the beliefs of many third-party payers, there is little support for the contention that outright faking of pain for financial gain is prevalent.
The social learning model emphasizes that behavior can be learned not only by actual reinforcement of behavior but also by observation of what happens to others. This is a particularly powerful way of learning when the others being observed are judged to be similar to the observer. For example, a middle-aged man might learn what to expect by observing how other middle-aged men with similar medical problems are treated, as opposed to observing young women with a very different pain disorder. Thus, the development and maintenance of pain behavior may occur by observational learning and modeling processes. Specifically, people can acquire responses that were not previously in their behavioral repertoire by the observation of others performing these activities. Expectations and actual behavioral responses to nociceptive stimulation are based, at least partially, on people’s prior learning histories.
Children develop attitudes about health and health care and about the perception and interpretation of symptoms and physiologic processes from their relatives and others whom they confront in their social environment. They learn how others respond to injury and disease and thus may ignore or over-respond to symptoms that they experience based on the behavior modeled in childhood. For example, children of chronic pain patients have been shown to exhibit more pain-related responses during stressful times or exhibit more illness behavior (e.g., complaining, days absent, visit to the school nurse) than children of healthy parents based on what they have observed and learned at home.
Expectations and actual behavioral responses to nociceptive stimulation are based partially on prior social learning history. Models can influence the expression, localization, and methods of coping with pain. Even physiologic responses may be conditioned during observation of others in pain.
A central construct of the social learning perspective is self-efficacy. This is a personal expectation that is particularly important for patients with chronic pain. A self-efficacy expectation is defined as a personal conviction that a course of action (e.g., performing the required behavior) can successfully be executed to produce a desired outcome in a given situation. Given sufficient motivation to engage in a behavior, it is a person’s self-efficacy beliefs that determine the choice of activities that the person will initiate, the amount of effort that will be expended, and how long the individual will persist in the face of obstacles and aversive experiences. In this way, self-efficacy plays an important role in therapeutic change.
Efficacy judgments are based on four sources of information regarding one’s capabilities, listed in descending order of effect : (1) one’s own past performance at the task or similar tasks; (2) the performance accomplishments of others who are perceived to be similar to oneself; (3) verbal persuasion by others that one is capable; and (4) perception of one’s own state of physiologic arousal, which in turn is partly determined by previous estimation of efficacy. Performance mastery can then be achieved by encouraging people to undertake subtasks that are initially attainable but become increasingly difficult and to subsequently approach the desired level of performance. It is important to remember that coping behavior is influenced by a person’s beliefs that the demands of a situation do not exceed her or his coping resources.
How people interpret, respond to, and cope with illness is determined by cultural norms and perceptions of self-efficacy. These two sets of factors contribute to the marked variability in response to objectively similar degrees of physical pathology noted by health care providers.
Gate Control Model
Though not a psychological formulation itself, the gate control model was the first to popularize the importance of central psychological factors in perception of pain. Perhaps the most important contribution of the gate control theory is the way in which it changed thinking about pain perception. Melzack and Casey differentiated three systems related to the processing of nociceptive stimulation, all thought to contribute to the subjective experience of pain—sensory-discriminative, motivational-affective, and cognitive-evaluative. Thus, the gate control theory specifically includes psychological factors as an integral aspect of the pain experience. It emphasizes central nervous system mechanisms and provides a physiologic basis for the role of psychological factors in chronic pain.
The gate control model contradicts the notion that pain is either somatic or psychogenic. Instead, it postulates that both factors have potentiating and moderating effects. According to this model, both the central and peripheral nervous systems interact to contribute to the experience of pain. It is not only these physical factors that guide the brain’s interpretation of painful stimuli that are at the center of this model; psychological factors (e.g., thoughts, beliefs, emotions) are also actively involved.
Before formulation of the gate control theory by Melzack and Wall, psychological processes were largely dismissed as reactions to pain. Although the physiologic details of the gate control model have been challenged, it has had a substantial impact on basic research and can be credited as a source of inspiration for diverse clinical applications to control or manage pain, including neurophysiologically based procedures (e.g., neural stimulation techniques involving peripheral nerves and collateral processes in the dorsal columns of the spinal cord), pharmacologic advances, behavioral treatments, and interventions that target modification of the attentional and perceptual processes involved in the pain experience.
Cognitive-Behavioral Perspective
The cognitive-behavioral (CB) model, perhaps the most commonly accepted model for the psychological treatment of individuals with chronic pain, incorporates many of the psychological variables previously described—anticipation, avoidance, and contingencies of reinforcement—but suggests that cognitive factors rather than conditioning factors are of central importance. The model proposes that conditioned reactions are largely self-activated on the basis of learned expectations rather than being automatically evoked. The model suggests that behavior and emotions are influenced by interpretations of events, and emphasis is placed on how people’s beliefs and attitudes interact with physical, affective, and behavioral factors. In other words, it is the individual’s information processing that results in anticipatory anxiety and avoidance. The critical factor, therefore, is that people learn to anticipate and predict events and to express appropriate reactions.
In the CB model, people with pain are viewed as having negative expectations about their own ability to control certain motor skills without pain. Moreover, people with chronic pain tend to believe that they have limited control over their pain. Such negative maladaptive appraisals about the situation and personal efficacy may reinforce the experience of demoralization, inactivity, and over-reaction to nociceptive stimulation. These appraisals and expectations are postulated to have an effect on behavior by leading to reduced effort and activity, which may contribute to increased psychological distress (helplessness) and subsequent physical limitations. If one accepts that pain is a complex subjective phenomenon that is uniquely experienced by each person, knowledge about idiosyncratic beliefs, appraisals, and coping ability becomes critical for optimal treatment planning and for evaluating treatment outcome accurately.
Several important factors may facilitate or disrupt people’s sense of control: their beliefs and appraisals, their expectations about pain, their ability to cope, their social supports, their disorder, the medicolegal and health care systems, and their employers. These factors also influence patients’ investment in treatment, acceptance of responsibility, perceptions of disability, adherence to treatment recommendations, support from significant others, expectations for treatment, and acceptance of treatment rationale.
Cognitive interpretations also affect how people experiencing pain present their symptoms to others, including health care providers. Overt communication of pain, suffering, and distress will enlist responses that may reinforce the pain behavior and impressions about the seriousness, severity, and uncontrollability of the pain. That is, complaints of pain may induce physicians to prescribe more potent medications, order additional diagnostic tests, and in some cases, perform surgery. Significant others may express sympathy, excuse the person with chronic pain from responsibilities, and encourage passivity, thereby fostering further physical deconditioning.
People with persistent pain often have negative expectations about their own ability and responsibility to exert any control over their pain and frequently view themselves as helpless. Such negative maladaptive appraisals about their condition, situation, and personal efficacy in controlling their pain and problems associated with the pain reinforce their experience of demoralization, inactivity, and over-reaction to nociceptive stimulation. These cognitive appraisals are posited to have an effect on behavior by leading to reduced effort, less perseverance in the face of difficulty, lowered activity level, and increased psychological distress. It should be obvious that the CB perspective integrates the operant conditioning emphasis on external reinforcement with the respondent view of conditioned avoidance within the framework of information processing.
The CB perspective on pain management focuses on providing patients techniques to gain a sense of control over the effects of pain on their lives, as well as on actually modifying the affective, behavioral, cognitive, and sensory facets of the experience. Behavioral experiences help show persons with pain that they are capable of more than they assumed, thereby increasing their sense of personal competence. Cognitive techniques (e.g., self-monitoring to identify the relationships among thoughts, mood, and behavior; distraction using imagery; and problem solving, described below) help place affective, behavioral, cognitive, and sensory responses under the person’s control.
The assumption is that long-term maintenance of behavioral changes will occur only if the person with pain has learned to attribute success to his or her own efforts. It has been suggested that such treatments can result in changes in beliefs about pain, coping style, and reported pain severity, as well as in direct behavioral changes. Treatment that results in increases in perceived control over pain and decreased catastrophizing also results in decreases in pain severity and functional disability. When successful rehabilitation occurs, there is a major shift from beliefs about helplessness and passivity to resourcefulness and ability to function regardless of pain, as well as a shift from an illness conviction to a rehabilitation conviction.
A number of studies have supported the contribution of cognitive factors to pain and disability. These studies have consistently demonstrated that individuals’ attitudes, beliefs, and expectations about their plight, themselves, personal coping strategies, and the health care system affect reports of pain, activity, disability, and response to treatment. For example, people respond to medical conditions in part based on their subjective ideas about their illness and symptoms. When pain is interpreted as signifying ongoing tissue damage or a progressive disease, it is likely to produce considerably more suffering and behavioral dysfunction than if it is viewed as being the result of a stable problem that is expected to improve.
Once beliefs and expectations are formed, they become stable, rigid, and relatively impervious to modification. Individuals with chronic pain tend to avoid experiences (e.g., physical activity) that could invalidate their beliefs (disconfirmations) and guide their behavior in accordance with these beliefs, even in situations in which these beliefs are no longer valid. It is thus essential for people with chronic pain to develop adaptive beliefs about the relationships among impairment, pain, suffering, and disability and to de-emphasize the role of experienced pain in their regulation of functioning.
Distorted thinking can also contribute to the maintenance and exacerbation of pain. A particularly potent and pernicious thinking style that has been observed in people with chronic pain is catastrophizing—holding negative thoughts about one’s situation and interpreting even minor problems as major catastrophes. Research has indicated that people who spontaneously use more catastrophizing thoughts report more pain than do those who do not catastrophize.
Coping strategies, or a person’s specific ways of adjusting to or minimizing pain and distress, act to alter both the perception of pain intensity and the ability to manage or tolerate pain and continue daily activities. Overt behavioral coping strategies include rest, medication, and the use of relaxation. Covert coping strategies include various means of distracting oneself from pain, reassuring oneself that the pain will diminish, seeking information, and problem solving.
Active coping strategies, such as efforts to function despite pain or distracting oneself from pain, tend to be associated with adaptive functioning, and passive coping strategies, such as depending on others for help with pain control, avoiding activities because of fear of pain or injury, self-medication, and alcohol, tend to be related to greater pain and depression. Regardless of the type of coping strategy, if people with chronic pain are instructed in the use of adaptive coping strategies, their rating of the intensity of the pain decreases and their tolerance of the pain increases. Thus, the perspective on how people function and the emphasis on facilitating self-management are more important than any specific cognitive or behavioral techniques used to bring about changes in thinking and behavior.
Biopsychosocial Model
Although the gate control theory introduced the role of psychological factors in the maintenance of pain symptoms, it focused primarily on the basic anatomy and neurophysiology of pain. The biopsychosocial model, which expands the CB model of pain, views illness as a dynamic and reciprocal interaction between biologic, psychological, and sociocultural variables that shape the experience and the response to pain. What is unique about this model is that it takes into consideration the influence of higher-order cognition, including perception and appraisal. It accepts that people are active processors of information and that behavior, emotions, and even physiology are influenced by interpretation of events rather than solely by physiologic factors. People with chronic pain may therefore have negative expectations about their own ability and responsibility to exert any control over their pain. Moreover, those with pain behavior elicit responses from significant others that can reinforce adaptive and maladaptive modes of thinking, feeling, and behaving.
The biopsychosocial model presumes some form of physical pathology or at least physical changes in muscles, joints, or nerves that generate nociceptive input to the brain. At the periphery, nociceptive fibers transmit sensations that may or may not be interpreted as pain. Such sensation is not pain until subjected to higher-order psychological and mental processing that involves perception, appraisal, and behavior. Perception entails the interpretation of nociceptive input and identifies the type of pain (e.g., sharp, burning, punishing). Appraisal involves the meaning attributed to the pain and influences subsequent behavior. A person may choose to ignore the pain and continue working, walking, socializing, and engaging in previous levels of activity or may choose to leave work, refrain from activities, and assume the sick role. In turn, this interpersonal role is shaped by responses from significant others that may promote the healthy response or the sick role. The biopsychosocial model has been instrumental in the development of CB treatment approaches for chronic pain, including assessment and intervention (described later in this chapter).
Family Systems Perspective
In family systems—and this could be expanded to significant others, not only to traditional concepts of nuclear families—the individual and his or her behavior are placed within a social unit. The family is viewed as an interactional unit, and family members (significant others) have a profound impact on each other’s emotions, thoughts, and behavior. Thus, the functioning of family members is interdependent, and family relationships are important for not only psychological but also physical health.
Increasing evidence supports the concept that family members contribute to behavioral risk factors such as smoking, lack of exercise, and poor diet, which can influence the development of numerous chronic illnesses, as well as compliance or noncompliance with treatment regimens. Additionally, families influence the development of chronic pain via operant theory. As noted, expressions of acute pain (e.g., reporting pain, grimacing, avoidance of activity, use of pain medication), because they are overt and observable, may be reinforced through expressions of concern from family members. Furthermore, in support of this idea, a number of investigators have found that spousal attentiveness to expressions of pain is positively correlated with higher levels of reported pain, pain behavior frequency, and disability.
The experience of chronic stress within the family has also been hypothesized to contribute to the development of chronic illness. Specifically, chronic stress may play an important role in the sympathetic nervous system and endocrine dysregulation often found in chronic pain patients.
As noted, pain does not take place in isolation but in a social context. Pain does not occur solely in people’s bodies, nor does it occur solely in their brains, but rather it occurs in their lives. The emphasis on the role of significant others is important. It reminds us that treating a chronic pain patient successfully requires that we not only assess and treat the patient but also target significant others, who can be supportive but can also be impediments to rehabilitation when they are overly punitive or solicitous.
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