Chapter 8

Psychological interventions

a conceptual perspective

Michael J.L. Sullivan and Tsipora Mankovsky-Arnold

The crossroads of pain, psychology and intervention have a long history. Paradoxically, interventions of antiquity for psychological problems were more concerned with the infliction of pain than its alleviation. Archaeological records suggests that shaman of the Stone Age bored holes in the skulls of ‘affected’ individuals, an intervention now referred to as trepanation, in order to provide an escape route for evil spirits (Selling 1943). The practice of trepanation endured well into the Middle Ages, with priests using metal implements to drill holes in individuals’ skulls to rid the body of the evil spirits that possessed it (White 1896). Torturous techniques such as immersion in cold water, flogging, starving and burning were later adopted by medical practitioners of mental institutions as techniques to calm or control agitated patients.

There remain vestiges of the conceptual models of antiquity in current models of the psychology of chronic pain. The notion that some form of noxious agent is locked within the individual with chronic pain and must be released in order to bring about a cure continues to find expression in many domains of mental health practice associated with chronic pain (Blumer & Heilbronn 1982; Sternbach 1974). For example, Freudian theory suggests that certain psychological conflicts suppressed from consciousness can be converted into physical symptoms such as pain and disability. Unfortunately, many of the psychodynamic variables implicated as causative of chronic pain have been poorly defined, impossible to measure or couched within theoretical frameworks that have minimal value for either conceptualizing or treating chronic pain (Ferrari & Russell 1997; Sternbach 1974; Weintraub 1988).

Despite a century of clinical, empirical and theoretical discussions on the causes and treatment of chronic pain there is a sense that advance, considered in terms of either conceptual understanding or treatment effectiveness, has been modest. The prevalence of pain-related disability has been increasing steadily in spite of numerous prevention and intervention initiatives that have been launched to date (Gosselin 2004; Waddell 1998). Persistent musculoskeletal pain continues to be the most costly non-malignant health condition affecting the working-age population in most industrialized countries (Cats-Baril & Frymoyer 1991; Fordyce 1995; Kuorinka & Forcier 1995; Sullivan & Frank 2000).

The lack of progress in effective management of chronic pain can be attributed to a number of factors. A central issue concerns the lack of consensus on how chronic pain should be conceptualized. In current literature, there is still debate about whether chronic pain is a legitimate physical condition or represents the expression of some form of psychological dysfunction (Abbass 2008; Blumer & Heilbronn 1982). Faced with a situation where patients present with physical symptoms with no discernible organic pathology to the medical practitioner, the ‘leap to the head’ might appear like a reasonable approach to managing the pain patient. Even today, it is not uncommon in medical reports to see reference to terms such as ‘symptom amplification’, ‘pain magnification’ or ‘functional overlay’. These terms are pejorative, place blame on the patient for lack of treatment response and are more likely to impede than foster effective clinical management of a chronic pain condition.

According to the DSM IV, most chronic pain conditions would meet the criteria for a diagnosis of ‘Pain disorder associated with a medical condition’ (American Psychiatric Association Press 1994). Pain disorder is classified as one of the somatoform disorders. The essential feature of somatoform disorders is that psychological conflicts have been transformed into physical symptoms (Ford 1995). The inclusion of chronic pain phenomena within the taxonomy of psychiatric disorders perpetuates the view that mental health issues are at the root of, as opposed to the consequence of, chronic pain and encourages the undesirable clinical practice of diagnosis by exclusion (Weintraub 1988).

In many domains of intervention, there is an increasing call for the application of evidence-based principles in clinical practice (Fordyce et al 1985). It has been argued that the clinician has an ethical responsibility to provide treatments that have been shown to be effective and not to provide treatments that have been shown to be ineffective. However, a quick glance at the interventions used in typical pain treatment centres reveals all too clearly that many of the interventions are not evidence-based, and many interventions continue to be used even though they have been shown to be clearly ineffective (Fordyce et al 1982; Forrest 2002; Fullop-Miller 1938).

It has been suggested that in pain treatment centres many of the interventions used might be more aptly described as compassion-driven as opposed to evidence-driven. Clinicians intervene because they do not want to see their patients suffer. The problem with compassion-based medicine is that it frequently proceeds in the absence of supporting evidence of efficacy and, in the case of chronic conditions, might persist indefinitely.

This chapter briefly reviews psychological approaches to the management of pain-related health conditions and pain-related disability. The review is selective as opposed to exhaustive, with emphasis on interventions that have been systematically evaluated. An attempt is also made to describe different psychological interventions for pain from a historical perspective in order to sketch the evolution of psychological perspectives on the treatment of pain over time. Where possible, references to clinical manuals are provided for readers who are interested in learning more about the specific intervention techniques described.

PSYCHOLOGICAL TREATMENT OF PAIN

Perhaps one of the earliest persuasive demonstrations of the role of psychosocial factors in pain perception came from the work of Anton Mesmer in the late 1700s (Forrest 2002; Fullop-Miller 1938). Mesmer found that magnets applied to the body of an ailing person appeared to alleviate pain and suffering. Later, Mesmer believed that the ‘vital magnetism’ emanated not from within the magnets, but from within his own body (Fullop-Miller 1938). He claimed he was able to alleviate pain and suffering simply by passing his hands over ailing persons.

Mesmer’s treatment became so popular that he was unable to treat all the patients who sought his help. The demand for his treatment led him to develop ways of treating many individuals at once. Mesmer built ‘baquets’ to facilitate the treatment of several individuals at once. The baquet was a large tub built of wood and filled with water and pieces of glass and metal. Once the baquet had been infused with Mesmer’s healing magnetism, patients would gather around it, place large metal rods into it and touch one end of the rod to the part of their body that was in pain. The healing forces of vital magnetism flowed up the metal rod and into the body of the ailing person, thus curing them of their affliction (Forrest 2002).

Anecdotal reports make reference to hundreds of patients who were ‘cured’ with Mesmer’s treatment (Forrest 2002). In the days of Mesmer, it was believed that magnetism was the essential ingredient of these cures. Today, most would consider that psychological factors such as beliefs or expectancies were the essential ingredients of the cures Mesmer was able to achieve with his treatment.

Beecher’s (1946) naturalistic observations of war casualties are often cited as a catalyst for the development of contemporary models of the psychology of pain. Working as a military physician, Beecher was struck by the wide range of soldiers’ responses to injury and pain. He provided vivid descriptions of soldiers who had sustained severe wounds in combat yet did not request narcotics to alleviate their pain. He suggested that for many soldiers, the wounds may have represented their ‘ticket to safety’ and that their pain experience may have been lessened by this positive reinterpretation.

By the mid 1960s, mounting clinical and scientific evidence was calling for a model of pain that would consider both the physiological and psychological mechanisms involved in pain perception. The call was most compellingly answered by Melzack and Wall’s Gate Control Theory of Pain (Melzack & Wall 1965). From an applied perspective, the work of Melzack and Wall evolved into behavioural conceptualizations of pain (Fordyce 1976), contributing ultimately to the development of biopsychosocial models of pain (Gatchel et al 2007; Turk 2002). Biopsychosocial models propose that a complete understanding of pain experience and pain-related outcomes requires consideration of physical, psychological and social factors (Gatchel et al 2007; Keefe & France 1999; Turk 1996; Waddell 1998).

BEHAVIOURAL/OPERANT PROGRAMMES

The first programmes that specifically targeted the psychological aspects of pain-related disability were based on the view that pain-related disability was a form of ‘behaviour’ that was maintained by reinforcement contingencies. In the 1960s and 1970s, William Fordyce and his colleagues applied the concepts of learning theory to the problem of chronic pain (Fordyce et al 1968, 1976). The focus of Fordyce’s approach to treatment was not on reducing the experience of pain, but on reducing the overt display of pain. The targets selected for treatment were pain behaviours such as distress vocalizations, facial grimacing, limping, guarding, medication intake, activity withdrawal and activity avoidance (Fordyce et al 1982).

The first behavioural approaches to the management of pain and disability were conducted within inpatient settings that permitted systematic observation of pain behaviours, as well control over environmental contingencies influencing pain behaviour (Fordyce 1976). Staff were trained to monitor pain behaviour and to selectively reinforce ‘well behaviours’ and selectively ignore ‘pain behaviours’ (Fordyce et al 1982). The results of several studies revealed that the manipulation of reinforcement contingencies could exert a powerful influence on the frequency of display of pain behaviours (Fordyce et al 1985). The manipulation of reinforcement contingencies was also applied to other domains of pain-related behaviour and shown to be effective in reducing medication intake, reducing downtime and maximizing participation in goal-directed activity.

A number of clinical trials on the efficacy of behavioural treatments for the reduction of pain and disability yielded positive findings (Sanders 1996). However, given the significant resources required to implement contingency management interventions, issues concerning the cost-efficacy of behavioural therapy for pain and disability were raised. Concern was also raised over the maintenance of treatment gains since reinforcement contingencies outside the clinic setting could not be readily controlled. In order to increase access and reduce costs, behavioural treatments were modified to permit their administration on an outpatient basis. This change in delivery format compromised to some degree the control over environmental contingencies and required greater reliance on self-monitoring and self-report measures (Sanders 1996).

BACK SCHOOLS

Although back schools were first developed in the late 1960s, the first published reports of the benefits of back schools only appeared in the literature in the early 1980s (Zachrisson-Forsell 1981). The structure and content of back schools reflected the prevailing view of the time that ‘information’ or ‘knowledge’ could be powerful tools to effect change in behaviour (e.g. pain-elated disability) (Heymans et al 2005).

Back schools vary widely in terms of content, duration and the intervention disciplines used to administer the programme. The duration of back school interventions has ranged from a single information session to a 2-month inpatient programme (van Tulder et al 2000). Back school interventions have tended to use group formats with a didactic format where participants might be exposed to information about biomechanics, posture, ergonomics, exercises, nutrition, weight loss, attitudes, beliefs and coping. As a function of the type of information being provided, the interventionist might be a physician, physiotherapist, occupational therapist, nurse or psychologist (Linton & Kamwendo 1987).

The marked differences across back schools have presented significant challenges to the systematic assessment of their efficacy (van Tulder et al 2000). A recent review of randomized clinical trails of back school programmes concluded that (a) back schools yielded benefit relative to treatment-as-usual interventions, (b) the treatment effect size was small and (c) back school programmes implemented within occupational settings appeared to yield the most positive outcomes (Heymans et al 2005).

COGNITIVE-BEHAVIOURAL PROGRAMMES

Cognitive-behavioural programmes for the management of pain and pain-related disability began to appear in the 1980s (Turk et al 1983). Cognitive-behavioural programmes incorporated concepts drawn from earlier behavioural approaches as well as information-based approaches used in back schools. The objective of many cognitive-behavioural programmes is to equip individuals with the psychological tools necessary to adequately meet the challenges of persistent pain (Linton & Ryberg 2001; Linton et al 1989; Turk et al 1983).

Cognitive-behavioural interventions are currently considered the psychological treatment of choice for individuals coping with chronic pain and disability (Gatchel et al 2007; Linton 2000; Turk 2002). A number of clinical trials have demonstrated that these types of interventions can assist individuals in learning to manage or control their pain symptoms and lead to clinically significant decreases in emotional distress (Linton 2000; Linton & Ryberg 2001; Turk 2002; Williams et al 1996

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