The operant approach to chronic pain was intended to concentrate upon external pain-induced responses and the social implications of the nature of feedback. The operant model has been particularly described by Fordyce et al (1968, 1976) based upon the work of other individuals in the behavioural field, for example Skinner.
The operant theory implies that the genesis of the pain should be distinguished from pain behaviours and the articulation of pain.External displays of pain such as wincing may be conditioned just as any other type of behaviour. If the patient receives positive feedback in response to pain behaviours, they may remain after the usual time of healing for that ailment.
There is a respectable body of evidence to justify the use of the operant model in response to chronic pain, yet there is a relatively miniscule level of consensus about why they work and the validity of their theoretical foundations. The operant theory is supported by research projects that intimate the success of behavioural treatments, but there are several problematic elements in these studies which have been recently addressed. The troubling issues include the antecedent belief that all pain behaviours are dysfunctional, the obstacles to continuing the learned behaviours subsequent to treatment and the reluctance of some chronic pain patients to embrace operant modes of treatment. Essentially, the nature of the sum of the problems is dualistic, and can either be addressed as complications with interpreting pain behaviours or the inevitable failure rate that all treatments face.
These issues, salient though they are, are not exhaustive. The operant model fails to recognise the fact that the patient’s personal interpretation of their pain and the changes they are experiencing maybe important. Acknowledging this can clear the way for cognitive theories to add something to operant methods of treatment. Indeed, elements that influence behaviour in general and pain behaviour in particular are complex and multi-faceted. It is seldom evident that a single cause has led to a single effect. Although it is true that pain-related behaviours are often modified during the course of a treatment programme, it is not necessarily true that it is for the reasons uppermost in the minds of the experts monitoring them. In brief, rational thought cannot condone the notion that the operant model of chronic pain is true because treatment programmes utilising behavioural methods have been shown to alter the behaviour of patients suffering from chronic pain.
A particular assertion that has come under scrutiny is the idea that patients modify their verbal expressions of pain in response to reactions from spouses. The methods and logic that lead to this conclusion are questionable and so must be their perceived contribution to the validity of the operant model. Further, some studies claiming to provide empirical support for the operant model only partially adhere to its theoretical roots. Other studies which are more methodologically sound have suspect sample gathering procedures. The findings of these studies still hold merit for the cognitive model of chronic pain, though ardent followers of the operant model will inevitably be disappointed. The fact is that the operant model of chronic pain does not have as strong a body of empirical evidence to back it up as its patrons would like. As a result of the questionable reliability of the operant theory, many researchers have begun to actively espouse the cognitive-behavioural theories of chronic pain.
Cognitive Behavioural Account of Chronic Pains
The cognitive-behavioural approach to chronic pain purported to contain the essentials of the operant account of chronic pain, but added space for human emotions, cognitions and mental coping mechanisms. This approach, like surgical and pharmacological interventions, attempt to eliminate or reduce it. Rates of failure in achieving this have led researchers to turn from attempted pain reduction to other objectives like active rehabilitation. One study compared and contrasted two behavioural treatments for ongoing pain.The first treatment focused on abandoning strivings to overcome pain and invest more energy in achieving other aims in life. The second treatment was a traditional cognitive behavioural treatment stressing the development of pain-reducing mechanisms. The treatment incorporating acceptance and re-focussing proved more successful than attempts to master the pain in patients suffering from chronic pain.
Initial formulations of a cognitive behavioural approach to chronic pain were predicated upon the realisation that programmes with the behavioural label did not contain only behavioural content. Behavioural experts acknowledged the necessity of addressing the cognitive functioning of a patient as well as his or her behavioural patterns. At present, the role of cognition in reporting extremity of pain, endeavours to successfully deal with pain, emotions and level of pain-related incapacity is solidly documented. The relationship between cognitive functioning and pain has revealed a number of important themes. The way in which patients mentally interpret their pain is predictive of their response and their level of functioning. For example, patients to perceive their pain as an indication of more damage often spend more energy attempting to avoid their pain and become less able to function naturally as a result. Patients who catastrophise their pain may experience augmented levels of depression compared with those who do not. Depression has also been linked to behavioural functioning and both of these may be affected by the patient’s attempts to predict or control his pain.
The sum of the implications of these findings points to the near certainty that cognitive functioning must be considered when attempting to construct any comprehensive and effective model of chronic pain. The cognitive behavioural theory does not go as far as to suggest that certain cognitions lead to pain; the relationship is not as simplistic as that. There is substantial evidence to suggest that cognitive activity related to pain can help to create coping mechanisms that are either helpful or dysfunctional. The nature of the coping mechanisms can directly affect the degree to which chronic pain infringes on continued functioning.
Some behaviourists allude to the role of cognitions in their research by referring to external or environmental factors. Strict behaviourism continues to be the preferred method of treatment and as such, willcontinue to concentrate on the transformation of overt behaviours. Evidence for the need to include cognitive and other factors in dealing with chronic pain is becoming increasingly pressing, and it must be acknowledged that including one treatment session on cognitive theory and praxis does not magically transform a behavioural programme into a cognitive behavioural programme. Even the cognitive behavioural theory itself is in need of more complete incorporation of cognitive methods.There are simple questions that can be raised in the minds of chronic pain patients that may transform the way that they think about and respond to their pain. The claims of balanced research pale in comparison to the pressing needs of patients suffering daily who could benefit from cognitive interventions. Treatment for chronic pain must be addressed in terms of cognition and behaviour; even if behaviour is the founding principle upon which a treatment is based, it must be recognised that behaviour acquires meaning in a cognitive sphere.
There have been propositions to reformulate the theoretical construction of the cognitive behavioural approach. Modifications ofthe approach start with the conception that the issues arising from the presence of chronic pain stem from patient reactions to their pain.Reactions are conceptualised as covering the sum of cognitive processes and not merely external actions. Dividing characteristics between patients who are anxious and suffering a notable level o ncapacitation and those who are able to maintain a level of functioning despite their pain are not found in the sensations of pain experienced by the patient but in the content of the internal cognitive assessment the patient carries out about their own pain. Some cognitive behavioural appraisals of pain are primarily concerned with the meaning that the individual patient attributes to his or her pain.
The reformulated cognitive behavioural model of chronic pain proposes that the interaction of various phenomenon such as internal appraisals of pain, learning history, mood, avoidance behaviours and environmental influences can become habitual to an extent that negative consequences of the pain, such as level of disability, may persist despite the removal of the sensory aspect of the pain. Motor behaviours that attempt to evade the pain in some way may continue after the pain has subsided or lessened and therefore the cognitions that prompted those beliefs continue. An acute sense of worry or anxiety may heighten safety or defence mechanisms perpetuate an autonomic arousal that maintains positive feedback for the notion that there is something wrong with the patient. Additionally, psychological dysfunction such as depression or mild panic can augment the chances of patients making calculative mistakes regarding their pain including assessing the pain as being worse than it actually is. This will reinforce the cycles of avoidance that the patient has previously used.
This particular reconfiguration of the cognitive behavioural model further accepts that anxiety and other maladaptive behaviours such asmisusing medica tion can easily invoke arousal encourage the continuance of maladaptive behaviours. The model also takes into account the drive for the patient to seek reassurance about their pain and they ways that they deal with it. They attempt to reconcile any feedback received with their own beliefs about their pain and its related effects. Many chronic pain patients live with the trepidation that the continued existence of chronic pain indicates that further damage is being done to their bodies, which will in turn exacerbate the pain they experience. This may raise their levels of anxiety, which affects their ability to think rationally and calmly about their pain. They may request more medical procedures—tests or treatments—to provide empirical evidence to themselves about the state of their bodies. The reconceptualised model indicates that the response of medical professionals in these situations may unknowingly encourage this kind of cognitive presumption and therefore positively reinforce incapacity or a passive response to chronic pain.
The model articulated above is extensively based upon other cognitive behavioural models of chronic pain and can even take into account theories about the nature of the meta-cognitions of the patient. If, for example, the patient cognitively interprets the pain or cognitions related to the pain indicate something negative about them as a person, then they may make efforts to overcome or control such thoughts in attempts to protect themselves from further negative consequen ces. For example, if the patient fears that thinking about his or her pain is going to make them ‘crazy’ then they may make strong efforts to alter their thoughts about the pain in order to stop themselves from descending into mental illness. This may stem from a fear that since their physical health has deteriorated, their mental health is under threat as well. In addition, some patients may think that the more time they spend thinking about their pain, the more serious and damaging it will be. The model asserts that the more cognitive energy is spent trying not to have pain-related thoughts, the more frequent they may become and the anxiety levels of the patient may continue to rise, prompting more and more pain-related cognitions. These thoughts may increase and the patient may feel that the more they have these thoughts, the more damage they are doing to themselves. Patients can end up caught in a web of cognitive gymnastics about their chronic pain, which diverts energy from dealing with the pain in constructive ways and maintaining a satisfactory level of functioning.
The cognitions that a patient may develop concerning their chronic pain are the product of complex and intricate synthesis of experiences, cultural forces and even childhood learning. Patients do not interpret their pain only in terms of their immediate situation, but bring a variety of other elements to bear upon the way that they translate their ideas about pain and what it means into their responses to their own pain. If they have had pain in the past, or have had close relationships with individuals who have suffered pain, the express and null curriculum of their experiences will provide them with a set of beliefs about pain, what it means and what can be done about it. Cultural ideas about how to respond to pain will also affect their evaluations about the role of pain in the life of an individual. Spouseresponses can also be important factors in interpreting chronic pain.It can also be said that behaviour that demonstrates acceptance of chronic pain stems from the collaboration of past and present circumstances, as well as the emotive and interpersonal influences of the present. The way that the spouse expresses his or her beliefs about pain can either reinforce or contradict the beliefs of the patient. If the patient believes that his condition or experience of chronic pain has made him incapacitated and the spouse behaves solicitously, the patient’s beliefs about his incapacitation can be confirmed and may override any other input about the patient’s ability to function normally.
The cognitive behavioural approach has built into its tenets the capacity for the patient to learn new coping strategies and introduce new cognitions without an awareness of the reality of his or her situation. This may be particularly pertinent in the area of medication, where any form of relief from pain, whether it is actual or perceived, may be a response to thoughts that the pain is out of control and the patient is unable to carry on without the presence of medication. The cognitive behavioral approach also asserts that these types of cognitions and resulting actions are cemented together and work in partnership to perpetuate one another. If a patient thinks that performing a particular action will lead to further damage and pain, he will avoid that action. Thus, he will not discover any information to the contrary and will continue to believe that the presence of pain means that he should not engage in such an activity. Even when patients try to accomplish certain activities, if they do so utilising protective methods, they may only confirm the danger of the activity in their minds and become dependent upon the protective measure instead of achieving their full potential in functioning.
It is becoming more and more accepted that it is prudent to explore chronic pain from a cognitive behavioral approach. There are a number of reasons for this growing confidence. First, it has been asserted that the reformulated cognitive model explains the breadth of evidence more extensively than other models. Second, the hypotheses that are put forth by the model may easily be empirically tested in order to determine whether they are statistically supported and theoretically sound. This makes them infinitely more useful for the practical work of treatment, as they can offer statistically supported predictions for the type of treatment that will be most useful in various situations.Obtaining the ability to pinpoint pivotal cognitive functions should lead to accurate treatments in place of the relatively arbitrary approach sometimes implemented by professionals.
For several years, the research and treatment of chronic pain concentrated on coping mechanisms as the pre-eminent behavioural factor in adjustment. Yet when coping approaches began to be compared with other types of behavioural approaches such as acceptance of chronic pain, significant conclusions were reached regarding the potential of the respective approaches to predict disability and distress. It has been asserted that there are fundamental problems with coping as a comprehensive adjustment mechanism. The issues with coping are conceptual and empirical in nature and stem from its reliance upon cognitive responses. An empirical study demonstrated that acceptance of chronic pain led to decreased intensity of symptoms and a better quality of life. Acceptance of pain was conclusively shown to be superior to attempting to cope with pain.
It is possible that acceptance of pain may be accomplished through a variety of methods. Some of the treatments currently in use, such as those involving cognitive-behavioural methods can help to make pain more acceptable. This is true even for those cognitive-behavioural methods that focus on mastering pain. For example, it could be that diminished avoidance and augmented experience of pain as a result of more control that help patients to accept the pain in their lives. If patients are exposed to more pain they may develop diminished emotional reactions and begin to understand that pain intensity is different in various situations. This understanding can teach them that the pain they suffer is not as intense as they first thought. In addition, teaching methods of behavioural control can result in alternations to the patient’s internalised definition of a painful event, making it easier to endure.
The role of values in a contextual cognitive-behavioural approach has been assessed in terms of the relationships between the values of chronic pain patients and the success of following their daily routines. It is often easy for chronic pain patients to expend great amounts of effort struggling with pain rather than focusing their energies on living according to their values. Living according to values was defined in this particular study as acting according to what they care most about and what they want their life to stand for. If pain is not then reduced, the patient may feel that not only have their limited amounts of energy been wasted, but they have also neglected their core purposes in life, which may result in further angst and anxiety.
In a study examining the process of living according to personal values while suffering from chronic pain, 140 pain patients completed an inventory of values including categories such as family, friends, health, work and growth. The patients were also asked to record information regarding their pain, anxiety and depression. The results showed that the highest values for the patients were family and health, and the values of least importance overall were friends, growth and learning. The patients generally did not feel satisfied that they were living life according to their values, and this could be because of their level of physical and emotive functioning. The results of the study further demonstrated that those who achieved more succ ess atliving according to their values reported higher levels of acceptance, although acceptance could not reliably account for the sum of the success.
Although patients felt that overall they were not living according to their values, there was a significantly higher rate of success at living according to family values than maintaining health. In practical terms, this means that out of the areas that patients value most, they were able to achieve much more success in one area, family than the other, health.
Approaches to chronic pain that are contextually based deal with cognitive issues in a different manner than normalcogn itive-behavioural approaches. Approaches that are contextually based seek to change the operation of negative thoughts and the way in which they are experienced, which affects other behaviours. A large quantity of the work devoted to these types of approaches involves releasing maladaptive cognitive forces on behaviour and intensifying behavioural elasticity through cognitive de-fusion. Approaches that are founded upon values add an aspect to this type of treatment.Articulating values during treatment for chronic pain is equivalent to adding cognitive influences to behaviour sequences.
On a practical level, the conceptualisations of the cognitive behavioural model of chronic pain can help to explain how patients deal with their pain, particularly the cognitive and meta-cognitive interactions they have with their symptoms and other factors thatinfluence their quality of life and their approach to their pain. If,for example, the patient is in the situation where the pain persists and further tests and treatments prove unsuccessful, it may be easy for the cognitive components of the mind of the patient to feel defeated and to acquire a learned helplessness. The patient may subconsciously or even consciously feel that all of their cognitive efforts to this point have proved futile and therefore they may be paralysed by the notion that whatever cognitive energy they put into dealing with their pain will be to no avail. They may even come to believe that any further medical intervention will be of no use to them. These types of thoughts can affect the effort that patients put into their treatment.They may be less participatory and become increasingly passive even in the face of extensive medical procedures. They may cease to be emotionally and mentally invested in working with the medical professionals to achieve the best outcome possible for their situation.If patients feel that treatment will be useless and they make less effort, their treatment may not be as effective as it could have been. A treatment outcome that is less than optimal will only reinforce the patient’s sense of helplessness and they may even be dismissed as unhelpful or disengaged by medical staff. If these patients are viewed from the perspective of the cognitive behavioural model of chronic pain, however, they will be perceived not as unmotivated but as individuals with maladaptive cognitions. This understanding of their behaviour would make them prime candidates for cognitive interventions,where their chances of improvement would be quite high.
There is much empirical support for the cognitive behavioural model, and it has been found consistent with a wide scope of researchout comes. There is particularly strong support for the idea that when patients worry about their pain, they are more likely to scrutinise their pain, which removes effort and thought from other activities and may make the pain worse than it is. These findings offer support for the cognitive theory that hypervigilance and anxiety are closely related. In other studies, anxiety and stress have been found to predict ambiguous ailments in patients suffering from chronic pain, which supports the theory that hypervigilance may create or exacerbate the ill health of the patient or at least the patients perception of the state of their health.
In addition, pain-related trepidation was discovered to predict evading strategies more accurately than the intensity of the pain or the physical ailment. Here, the researchers concluded that their findings were not as supportive of the operant model of chronic pain as the cognitive behavioural model. Further, evidence exists that supports the notion that striving to avert pain-related cognitions may actually intensify pain sensations. Though it is advisable to treat this particular study with some caution, there is more substantial research to support the related notion that trying to block pain-related thoughts is counterproductive and will worsen anxiety. Related to this are the theories surrounding autonomic arousal, which have also received empirical backing. It has been asserted that patients suffering from chronic pain do not respond to pain in the same ways as patients whose pain is not chronic. This is true despite the fact that they do not demonstrate significant differences from non-chronic pain patients in other areas. When the responses of chronic pain patients are measured with regard to distressing activities, the pain levels measured increased dramatically. This was not true for normal activities. Therefore, it seems safe to adhere to a model of chronic pain in which the state of arousal prompted by particular activities directly affects the pain experienced by the patient.
Other elements in the cognitive behavioural model have also received support. In particular the role of medication and the appropriateness of use can affect patients’ complaints regarding symptoms and level of incapacity. One study examined the contrasting characteristics of chronic pain for patients whose pain could be justified by medical explanations and those whose pain could not be explained in medical terminology. The authors found remarkable variations in a number of variables, such as excessive prescribing and internal processing in the group of patients whose pain could not be medically explained. They went on to assert that when medical professionals in this type of situation intimate that it could be psychosomatic, they reinforce the patient’s self-concept of an ill person, if not physically, then mentally. Reacting in this fashion often fails to convince the patient that there is nothing wrong and instead, motivates their search for a plausible explanation for their pain. They may demand more tests and interventions in search of legitimising their pain. The important point here is that the responses of medical professionals to patient expressions of pain can have a significant impact on pain-rel atedcognitions and thus on their responses to treatment.
The sum of this evidence provides legitimisation for approaching chronic pain in a way that is much like the way that anxiety and obsessions are approached. This suggests that if obsessions can be treated, then so can maladaptive pain-related cognitions and behaviours. While the need for further research remains in certain areas, such as the clarification of the significance of safety behaviours and the effectiveness of specific cognitive behavioural intervention programmes, there is strong evidence that cognitive behavioural treatments will overtake operant treatments as the preferred method for addressing chronic pain. Sharp (2001) concludes his discussion of psychological theories of chronic pain by arriving at the destination of cognitive behavioural models akin to those used to treat anxiety. He regards the operant model as having too many problematic issues to be considered a reliable source of chronic pain treatment. He goes even further, to suggest that many of the cognitive behavioural modes currently in use are hampered by the fact that they continue to espouse behavioural principles that have outlived their usefulness. According to Sharp, reformulated cognitive theories are needed in order to satisfactorily assess patient cognitions regarding their pain. While behavioural factors should not be completely ignored, they should nonetheless always be considered within a cognitive framework. The concept of reformulating cognitive models is supported by the evidence and appears to be more helpful in finding real scientific meaning therein.
Treatments involving cognitive behaviour therapy and behaviour therapy for chronic pain in adults have been the subject of meta-analysis. The researchers recognised that there is persuasive data for the effectiveness of cognitive behavioural therapy (CBT) in augmenting the functioning ability of patients suffering from chronic pain. There is also conclusive evidence that CBT can enhance emotional states, reduce discomfort and minimise behaviour that stems from a sense of being incapacitated. However, it has been noted that in a clinical treatment context, CBT is not often presented as an option for individuals suffering from chronic pain. Physical, pharmacological and medical treatments are provided as options even though there is often less empirical evidence for their success. This study sought to do a systematic review and meta-analysis of controlled trials in this area.The researchers indentified 25 trials that were appropriate candidates for meta-analysis and compared the efficacy of CBT with various other treatments.
In this study, the experts were concerned primarily with two issues. The first was whether or not CBT is an effective treatment for chronic pain in the sense that it is better to undergo CBT than to have no treatment at all. The second issue was whether CBT was better than other available treatments which involve activity as part of the curriculum. The outcomes of the study indicated that CBT that are active in nature are effective. CBT made marked improvements in emotional state, intensity of pain and cognitive measures of coping with the pain. Additionally, pain-related behaviour and level of functioning, both in an individual and a social context were improved.
The results of this study led to the conclusion that CBT is indeed an effective treatment for chronic pain in adults. So, too, is behavioural therapy. The study raised certain issues which would be best considered in other studies, because attempting to treat chronic pain from apsychological perspective is quite a difficult endeavour. The outcomes of such treatment cannot always be broken down to determine which variable caused or helped to cause a particular outcome. Especially where psychological methodologies and cognitive evaluations are concerned, there is an ambiguity in proving the cause and effect of research methods that is not easily overcome. The treatment of chronic pain must be recognised as an ongoing and complex process with a significantly complicating number of variables involved. Even when the greatest efforts are made to ensure the independent performance of professionals and to shield the patients from any hint of bias, the narrowing of treatment and research conditions is extremely difficult.
The acceptance of chronic pain involves intentionally allowing pain, with all of its cognitive and emotional implications, to be present in one’s life, when the willingness results in increased functioning capabilities for the patient. Acceptance means responding to pain without attempting to avoid or control it and continuing to function regardless of the presence of chronic pain. Acceptance is especially pertinent when previous attempts at control or avoidance have limited the quality of the patient’s life. Patients suffering from chronic pain who take steps to accept it report fewer instances of anxiety, medical intervention and depression. Two elements are needed to produce acceptance: pain willingness and activity engagement. The development of acceptance is an ongoing process that progresses with experience of pain and relevant social factors. Further, acceptance of chronic pain involves choosing not to become embroiled in fruitless internal struggles that may increase the intensity of the pain and its ability to disrupt active functioning. Acceptance is a new psychological approach and conceives human suffering in new terms.Acceptance is located in the cognitive and behavioural approaches and therefore has empirical psychological traditions to lend it credibility.
One study demonstrated that diminishing anxiety and augmented acceptance of chronic pain might transfer sufferers from a dysfunctional coping approach to a successful one. The study empirically categorised patients suffering from chronic pain into three categories: dysfunctional, interpersonally distressed or adaptive copers. The researchers in the study believed that identifying the characteristics that distinguish one group from another may help to crystallise the behavioural mechanisms that facilitate acclimation to pain. The subjects in the study were classified according to the Multidimensional Pain Inventory and relative scores on pain acceptance and pain-related anxiety were examined. The results demonstrated that patients in the dysfunctional group cited more anxiety related to their chronic pain as well as lower acceptance of pain than those who were interpersonally distressed or copers. Add