Chapter 9

Psychological interventions

application to management of pain

Patrick J. McGrath, Jill M. Chorney, Anna Huguet and Anita M. Unruh

OVERVIEW

There is excellent evidence for the use of psychological methods to treat and manage chronic pain (Eccleston et al 2009; Palermo et al 2010). However, most scientific articles or chapters do not describe methods very well. Many methods have not been individually assessed as they often form part of the package of psychological intervention. Chapter 4 provided an overview of the psychology of pain. Chapter 8 introduced the conceptual framework of the most common psychological interventions used in pain management. In this chapter, we discuss the practical application of psychological methods. We focus on interventions that have been shown to be effective either individually or in combination with other methods to familiarize those who do not have extensive training in these methods. This short chapter is not meant to replace the years of training and supervision that a psychologist may have taken in psychological methods but to give an understanding of the specific methods that are widely used as part of an evidence-based approach to chronic pain.

The development of psychological methods has been driven by theoretical models and by clinical insight. As a result, many methods have overlapping components. Although there is an emphasis on specific techniques, it is critical to understand that good clinical practice requires several non-specific elements. The three major elements include developing a patient-oriented rather than a provider-oriented approach where the needs of the patient take precedence, developing a supportive therapeutic relationship and evaluating all interventions to ensure that more good than harm is being done.

This chapter is an applied chapter of psychological interventions. We will refer from time to time to two case scenarios. Jeremy has chronic low back pain that resulted from a fall from a ladder on a construction site. Alice has fibromyalgia that took many years to diagnose. Each section will identify resources for more information.

PATIENT EDUCATION

Description

Education, or teaching patients about chronic pain and the typical reactions to pain, is the scaffolding upon which psychological interventions depend. The purposes of education are to ensure that patients have basic knowledge about pain, to understand the diseases and disorders causing their pain, to have a shared vocabulary about pain and to correct factual errors that patients may have. Unfortunately, the content of education for pain is often not even mentioned in research reports of psychological interventions. Consequently, there is little information as to what is an appropriate type or level of educational information. In addition, education about pain is seldom a sole treatment and there are only a few studies of its specific effects. One recent study (Barsky et al 2010) found that education was as effective as cognitive–behavioural therapy or a relaxation-based intervention for pain in rheumatoid arthritis. Udermann et al (2004) found that a personalized book on chronic low back pain was able to significantly reduce symptoms in a cohort of patients. Jeremy and Alice, our fictitious patients, are likely to participate in pain education as part of their treatment in a pain clinic and will likely benefit by correcting false beliefs and gaining a helpful way of thinking about their pain.

The first element that is often included in patient education is an explanation of the physiology and anatomy of pain. Perhaps most important for the person with chronic pain is to understand the reasons why their pain acts in such a perplexing way. It is important to address the frequent lack of a direct connection between the severity of pain and the severity of known physiological damage, and the multiple complex causes of chronic pain. This discussion may include an overview of the gate control theory. Although the gate control theory (Melzack & Wall 1965) is a somewhat dated and very general theory, it provides a useful and easily understood way for patients to understand some of the most puzzling aspects of their pain. Two examples provide a good illustration for patients of the complex physiology and anatomy of pain. One example is referred pain (Murray 2009), where a pain originating in one location is felt in another. The second example is phantom limb pain (Wilkins et al 1998), where a pain is felt in a limb in the absence of that limb. These examples highlight the lack of direct connection between pain and the normal, expected relationships that are common in the healthy, intact nervous system. The role of peripheral and central sensitization (Woolf 2007) in causing the brain, the spinal cord and the peripheral nerve structures to become more sensitive in response to ongoing pain should also be discussed. Sensitization is used to explain allodynia (pain response in the absence of typically painful stimulation) and hyperaesthesia (increased sensitivity to painful stimulation).

Fear of pain and avoidance of activity or situations that may be associated with pain (see Chapter 4) cause significant problems for many people (Bailey et al 2010). For example, Jeremy may find that he is more anxious about using a ladder since his fall and may be avoiding using one on the construction site when he can. Alice may be anxious and avoidant of health professionals because she was met with so much scepticism about whether her pain was real. Alice avoids health professionals who may be recommended to her because she is anxious about being disbelieved. The pain and avoidance model is often used to highlight the differences between activity that may cause pain but will not cause harm. The model provides a framework for later strategies used to encourage activity and successful coping, and overcome debilitating patterns of thinking.

Many people who have chronic pain alternate between long periods of very little exercise and infrequent bouts of intense exercise when they recognize that they are out of shape due to prolonged inactivity. The dangers of a cycle of chronic deconditioning interspersed with intense attempts to overcome it are included in the general education about pain. The need for activity is balanced with the need to pace oneself, so as not to cause severe pain that then triggers more disability and exacerbates avoidance.

Patients are do not have sufficient understanding of the medications that they take. Both over-the-counter drugs such as acetaminophen and ibuprofen (Forward et al 1996) and prescription drugs (Banta-Green et al 2010) can be misused by underuse, overuse or failure to use the right schedule for taking the medications. Many patients have misinformation about drugs and addiction that have been fuelled by the media. As a result, knowledge of pain medications and how to use them is often a component of patient education. Sometimes, procedures and surgical approaches may also be discussed.

Patient education may include an introduction to non-medical approaches to pain management, including psychological interventions, which are discussed in this chapter, and complementary and alternative medical approaches. Patient education is often conducted early in treatment but may also be interspersed with teaching of specific skills. Patient education corrects misinformation and provides a basis for later therapeutic interventions.

Sources of more information

• Butler & Moseley (2003)

• McGrath et al (2003)

• McGrath et al (1992)

OPERANT CONDITIONING APPROACHES

Description

Operant conditioning approaches are firmly based on the operant approach developed by Skinner (1938) and elaborated over the last 50 years by others. Their use in chronic pain was popularized by Fordyce in his very well known classic work at the University of Washington (Fordyce 1976). At its simplest, pain expression is conceptualized as a behaviour much like any other behaviour, and behaviours are controlled by the antecedents and consequences of the behaviour. Functional behavioural analysis is required to pinpoint what is controlling the behaviour in each individual. Pain behaviours may include facial responses such as grimacing or avoidance behaviours such as staying in bed instead of getting up and going for a walk.

A functional analysis of pain is based on an analysis of antecedents, behaviours and consequences (ABC analysis) utilizing self-report and observation of what happened before the incident or exacerbation of pain, the antecedent (Sanders 2002). The consequences, or what happened after the incident or exacerbation of pain, would also be determined. For example, a grimace or groan might be preceded by a request to do something and followed by the withdrawal of the request. Several different patterns might be shown from a careful functional analysis. Hypotheses about functional relationships between pain, antecedents and consequences would be generated and then tested before any intervention could occur.

Operant methods include positive reinforcement, negative reinforcement, punishment, extinction and differential reinforcement. Reinforcement increases behaviour. Positive reinforcement occurs when a behaviour is followed by a pleasant or positive event. Attention to complaints is frequent positive reinforcement that increases pain behaviour. For example, if a parent pays attention to every ache and pain that a child reports and the child increases his or her report of pain, attention would be considered a positive reinforcement. Negative reinforcement involves the removal of something that increases the behaviour that is reinforced. For example, Mark, Alice’s husband, might complain about Alice’s pain, until Alice does household chores that have been bothering Mark. In this case, the Mark is negatively reinforcing Alice for doing chores.

Extinction is the withdrawal of reinforcement for a behaviour. Attempts at extinction are usually accompanied by an initial increase in the behaviour. For example, if Jeremy has been reinforced for being unable to do things because of pain by Susan’s (his partner) attention, and this reinforcement (attention) is withdrawn, Jeremy will likely become more disabled before being able to do more independently. Extinction should usually be accompanied by differential reinforcement of other, alternative, appropriate behaviour.

Punishment is an unpleasant or negative event that follows a behaviour. A supervisor who docked pay for a worker who was impaired in job functions because of pain would be attempting punishment. Operant practitioners rarely use punishment or negative reinforcement as a treatment of pain because these negative techniques lead to withdrawal, avoidance of the punisher or aggressive responses. For example, the relationship between Alice and Mark, who is complaining about household chores, will probably deteriorate; Alice will likely avoid Mark and may start complaining about Mark’s shortcomings.

Operant practitioners believe that operant methods are effective because of operant conditioning, the strengthening of patterns of behaviour because of their effects. This is described as the law of effect. Behaviours followed by positive events increase and behaviours consequated with negative events decrease.

Operant procedures seem so simple: reinforce the good, punish the bad. Nevertheless, operant strategies require careful analysis of the individual case. One event may be reinforcing for one person, but punishing for another. Moreover, complex learning histories may have developed with specific settings acting as cues for different behaviours. In addition, operant techniques such as extinction of pain complaints, if not done skilfully, can lead to unwanted results such as engendering feelings of resentment. As a result, skilled use of operant techniques is not simple.

Operant techniques are sometimes used in combination with other interventions. For example, Allen & Shriver (1997) showed that operant techniques implemented by parents significantly improved the results obtained from biofeedback treatment of headache in children.

Sources of more information

• Dahlquist (1999)

• Fordyce (1984)

COGNITIVE–BEHAVIOURAL THERAPY

Description

Cognitive–behavioural therapy (CBT) is the dominant evidence-based approach used in clinical psychology (Morley et al 1999). CBT focuses on interaction between thoughts, feelings and behaviours. Because of its broad nature, it is difficult to say which therapeutic strategies are included or omitted in CBT. It may include operant techniques and the use of relaxation or biofeedback.

The hallmark of CBT is the attempt to directly alter thoughts or cognitions. Keefe (1996) outlined a three-stage process. The first stage is patient education focused on the role that thoughts and behaviours play in pain, emphasizing that patients can have a major impact on their pain. The second stage is coping skills training. The various skills can include relaxation and cue-controlled relaxation, distraction, activity pacing, introduction of pleasant activities and cognitive restructuring. The third stage is the application of the techniques learned to the real world and the maintenance of these strategies over time. Application to the real-world environment usually involves problem solving, self-monitoring and behavioural contracting and scheduling. Maintenance is may include booster sessions. Marlatt & George (1984) provided a model for maintenance called relapse prevention. The essence of this model is to anticipate the immediate and long-term antecedents to relapse and to programme for them. Although originally developed for treatment of alcoholism, relapse prevention can also be applied to pain management to maintain learned strategies.

CBT was originally developed to treat depression and anxiety by clinician researchers such as Aaron Beck (e.g. Beck 1997) and Albert Ellis (e.g. Ellis 1998). These methods have been adapted for pain and become widespread in the treatment of chronic pain. Fundamental to CBT is the tenet that events may trigger thoughts, beliefs and evaluations that, depending on one’s proclivity, may be negative and destructive or more neutral and problem solving. For example, if Jeremy wakes up with a headache in addition to his chronic low back pain, he might interpret this event as: ‘Oh no, now I have headaches as well. Nothing ever goes right for me. I can’t have more pain. I can’t cope with this.’ Or perhaps Jeremy may say, ‘I am always going to be unhappy. Everything I do ends up awful. What have I done to make such a mess of everything?’ This pattern of thinking becomes a spiral of negative thinking that aggravates pain and interferes with coping.

Several different approaches have been explicated to interrupt negative thinking. One of the first methods and one that is still widely used is by Albert Ellis. He popularized rational emotive therapy, now known as rational emotive behaviour therapy (http://www.rebt.org/). Ellis developed a system to recognize and dispute irrational beliefs. Ellis’ ABCD method consists of recognizing that activating events are interpreted by people’s beliefs, resulting in consequences, or ABC. Disputing of the beliefs as fallacious breaks the linkage between behaviour and irrational beliefs.

According to rational emotive behaviour therapy, the irrational beliefs or dysfunctional attitudes that cause people the most difficulty have two major qualities. The first is that under the surface they have powerful demands often expressed as ‘must’, ‘should’ or ‘ought to’. Second, these irrational beliefs have derivatives that imply an extreme outcome. Jeremy’s irrational belief might be ‘People who have chronic pain cannot lead a productive life’ and ‘Because I have a headache today, I will always be having headaches.’ The derivative from these irrational beliefs might be ‘There is nothing I can do’ or ‘My life is miserable and without any positive aspects’ or ‘I am a victim of events I cannot control.’

Disputing the false beliefs and their derivatives might take the form of ‘Just because I have a headache now, doesn’t mean it will last forever. What can I do to help the headache?’ Or Jeremy might say, ‘In spite of my pain, I am doing well with my job and my friends. I have a loving family who support me.’ Another alternative is, ‘Having a headache is not the end of the world, I have managed headaches well in the past.’ These modes of thinking would lead to more rational approaches such as problem solving to ensure that the headache does not interfere with Jeremy’s life.

The tendency to assume the worst in pain situations has been aptly termed pain catastrophizing. Sullivan et al (1995)

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