psychological interventions for chronic pain: a critical review. ii operant conditioning, hypnosis,...
TRANSCRIPT
Puin, 12 ( 1982) 23-46
Elsevier Biomedical Press
23
Psychological Interventions for Chronic Pain: a Critical Review. II. Operant Conditioning, Hypnosis, and
Cognitive-Behavioral Therapy
Judith A. Turner * and C. Richard Chapman ** Universiy of Wushington Purn Center,
* Deportments of Ps.vchiutry ond Behuoiorul Sciences, and Rehuhititotron Medicine, University of
Wushington, School of Medicine, Seattle, Wash. 9819.5 and ** Deportments of Anesthesiolog??, Psychiutrv
utrd Behuviorul Sciences, and Psvchologv, .!Jrziversct,v of Washington, Seattle. Wush. 98195 (U.S.A.)
(Received 26 May 19Rl. accepted 28 May 1981)
This is the second part of a review examining the evidence for and against psychological inte~entions for chronic pain problems. Part I, published as the preceding article, dealt with relaxation training and biof~back, which have in common the rationale that pain may emerge and persist in response to disturbance in physiological processes. Studies to date evaluating the effectiveness of relaxation training and alpha, electromyographic, finger temperature, and other types of biofeedback led us to conclude, in agreement with several other recent reviews [6,67,75] that: (a) biofeedback with home practice of relaxation is effective in reducing migraine and tension headache activity, (b) relaxation training alone is also effective for migraine and tension headaches, and (c) there is no evidence that biofeedback is superior to relaxation training with these headache populations. Both approaches have largely ignored the learning processes and cognitive factors, as well as social, cultural, and economic variables that critically influence chronic pain problems.
Here we review and critically evaluate studies of the following approaches that focus on one or more of these variables: operant conditioning, hypnosis, and cognitive-behavioral therapies for chronic pain. Finally, comparative efficacy of the different interventions is considered, and suggestions are made for improvements in future research.
Operant conditioning
Fordyce and co-workers [19-241 have stimulated interest in the application of learning theory principles and operant conditioning methods for chronic pain
Please address all correspondence to the first author.
0304-3959/82/OOCO-0000/$02.75 Q 1982 Elsevier Biomedical Press
‘4
treatment, distinguis~ng between respondent pain elicited by an nntecedent stimu-
lus and operant pain behaviors. which are learned through systematic reinforcement
by positive consequences (pleasant effects of analgesics. attention and concern from others) or avoidance of aversive consequences (e.g., unpleasant job, undesired
responsibilities). The goal of the operant conditioning approach is to decrease
operant, or learned, pain behaviors, and to replace them with behaviors inconsistent with the sick role (well behaviors). In order to do this, there must be a change in
environmental contingencies (rewards and punishments following specific behaviors) so that pain behaviors are not rewarded while desired behaviors are. The ‘con- tingency management’ approach includes identification of the behaviors to be produced, decreased, maintained, eliminated and diminished; identification of effec- tive reinforcers or rewards, for the individual: and manipulation of the occurrences
of reinforcement so that rewards follow desired behaviors and do not follow pain behaviors.
Operant pain treatment programs consist of multiple interventions to accomplish the above-stated goals. Health care providers and the patient’s family are instructed to ignore pain behaviors and praise ‘healthy’ behaviors. Other treatments may include family therapy, marital therapy, vocational counseling and rehabilitation, leisure counseling, and consultation to the patient’s primary physician, attorney, and
insurance carrier, as needed. Patients in operant treatment programs may receive biofeedback or relaxation training, although these are not operant conditioning
techniques. Operant treatment programs traditionally have not included cognitive- behavioral techniques.
Table1 provides a description of various operant treatment programs and their results. The prototypical operant program was developed and described by Fordyce and his colleagues [24-261. In an inpatient setting, staff ignored patients’ pain behaviors and praised actions inconsistent with the sick role. The program also included sessions with the spouse, vocational rehabilitation, physical therapy, oc- cupational therapy, and systematic decrease of medications. These patients showed significant increases in physical therapy activities and decreases in medication intake from admission to discharge, but reported considerable pain on questionnaires completed an average of 22 months after termination of outpatient treatment. They retrospectively rated themselves as having had significant decreases in pain and increases in activity levels between admission and discharge, but no change since
discharge. Results from a similar operant program have been reported in two articles. The
program included staff inattention to pain behaviors, physical therapy, occupational
therapy, gradual elimination of pain medication, ‘work station’ assignment in the
hospital, and instruction for family members to ignore pain behaviors and reward activity. Of the 34 carefully selected patients who completed the 6-8 week program, 25 were leading ‘normal lives’ without any analgesic medication use at a 2--4 week follow-up [2]. Twenty-six of the 34 treated patients, 20 of 44 patients rejected for treatment, and 12 of 34 patients who were accepted but refused treatment agreed to participate in a 1-8 year follow-up [60]. A patient was defined as having a successful outcome if all of the following criteria were met: (1) male patients must be employed
25
unless retired; (2) retired males must be physically active at least 8 h/day; (3) women must be employed or functioning as homemakers to their own and their family’s satisfaction, and physically active at least 8 h/day; (4) not receiving compensation for pain problems; (5) no pain-related hospitalizations or surgeries since treatment; (6) no use of prescription analgesics, sedative-hypnotics, or muscle relaxants.
Of the 26 treated patients, 20 (77%) met all of these criteria, in contrast to only one of the 20 rejected patients, and none of the 12 who refused treatment. *Treated patients were using significantly fewer analgesic and sedative-hypnotic medications, and reported significantly fewer hours of pain, fewer hours of lying down, more hours standing, and more hours working per day at follow-up, as compared to pretreatment. Treated patients also showed significant increases on the ego strength scale and significant decreases on the hypochondriasis, depression, and hysteria scales of the Minnesota Multiphasic Personality Inventory (MMPI). When com- pared to the other two groups, treated patients reported significantly less drug use, fewer pain-related hospitalizations, and greater reduction in pain intensity and time spent lying down. They had significantly lower scores on the hypochondriasis, depression, and hysteria scales of the MMPI.
These studies do not provide information regarding necessary and sufficient components for the observed changes. Two studies have addressed the issue of whether contingency management alone is efficacious in changing pain behaviors. Fordyce [21] demonstrated changes in an inpatient’s pain behaviors (grimaces, moans, pain-related statements) as a consequence of staff attention. When staff withdrew attention in response to the patient’s displaying pain behaviors, such behaviors decreased to near-zero levels. When the staff then showed interest in the patient consequent to pain behavior, the behaviors rapidly increased.
Cairns and Pasino [9] studied 9 chronic low back pain hospitalized patients assigned to 3 conditions: (I) Verbal reinforcement. Levels of walking and bicycle riding were obtained for 8 baseline sessions. Beginning with session 9, the physical therapists praised the patient and conversed with him only if his reported level of activity increased over its previous level. (2) Graph, and graph plus verbal reinforce- ment Following the establishment of baselines, the daily performance levels of one activity were plotted on a graph visible above the patient’s bed for 6 sessions. Over sessions 7-12, in addition to plotting daily levels on the graph, the physical therapists verbally reinforced any increments in performance. During this time, the other activity remained under baseline conditions. After these 12 sessions, the second activity also underwent 12 sessions of extinction (baseline conditions). (3) Control. Uptime, walking, and bicycle riding distances were recorded over a 10 day period.
The investigators found that, compared to the control group, patients achieved significantly higher levels of uptime, walking, and bicycle riding under conditions of verbal reinforcement and graph plus verbal reinforcement. Although patients in the graph condition achieved somewhat higher levels of performance for walking, bicycle riding, and uptime, these levels were not significantly higher than those in the control group. The authors concluded that manipulation of sociai environment
TA
BLE
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OG
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MS
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XPE
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k.S
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PO
PU
LA
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NS
. A
ED
fK
ttA
l M
ltN
f
OU
TC
OM
ES
Au
rhor
s Pop
ula
tion
N
in
,crv
entl
on(s
) D
esig
n
CG
XIt
r0i
Dep
enden
, m
ea*u
res
Fol
iow
-up
Rea
ult
l.
For
dyc
e
e, a
l. [
23]
Low
back
pain
For
dyc
e D
iver
se
pain
et a
l. 1
241
syn
dro
me?
,
tire
enh
oo,
an
d
DW
XX
Sre
mbach
/32/
svn
dru
mes
Sre
rnh
ach
[7
0]
3
lnpat~
en,
an
d ou
t-
palien
, op
eran
t
con
diu
omn
g pro
gram
.
wit
h
sys,
emn
,ic
med
icati
on
redu
cuon
.
occu
pati
on
ther
apy.
ph
ysic
al
ther
apy
36
lnpati
en,
oper
an
,
con
dit
ion
tng
pro
gram
Ses
sion
s w
,,h
sp
ouse
.
vora
tion
al
rebab
ili-
ran
on.
ph
ysxa
l
ther
apy.
oc
cupati
onal
ther
apy,
an
d
mrd
ica-
,,on
re
du
ctio
n
als
o
mvo
lved
Inpati
ent
pro
gram
of
ph
ysic
al
ther
apy.
rela
xati
on
train
ing.
op
eran
, co
ndit
ion
ing,
grou
p
fber
apy,
m
edic
a-
txon
red
uct
ion
, b,u
ferd
back
, ,r
an
sc~,a
n~ou
s
slim
ulaf
xm,
voca
t~~n
nl
reha
bilit
atio
n. S
ome
pabe
nts
rece
ived
S
”rge
ly
1n
pau
ent
pro
gram
of
oper
an
t co
ndi,w
mn
g
an
d g
rou
p
ther
apy.
25 p
ati
enta
rc
cczv
cd
au
rgcv
Syb
lem
ati
c
case
s,u
dte
\
hnng
h
osprr
ah
rati
on:
self-r
ecor
dtn
gr.
of
ac,
iv1,1
ea. s,
aff
reco
rdm
gs
of
ph
y\,c
al
ther
apy
ac,
w,,
,es
an
d
med
icvt
ton
,n
,ake
Fn
llow
-up.
qu
ouon
nalr
u
Non
e A
nalg
cstc
m
edw
an
on
uw
pa,*
ent
pan
ra
tin
gs.
,ou
rn,q
ue,
pat”
.s
c0rc
s.
ph
ya,c
al
ilc,
ivi,y
tnL?i
(b”r
cs. M
MPI.
Fol
low
-up.
q”e
s,,o
”“aIr
e
Incr
ease
d
walk
ing.
act
tvit
y le
vels
:
dec
rease
d
med
tcatr
on
ux
X -
22 m
u
Incr
ease
d
ph
ysic
al
itf,
iviffe
s.
dec
rease
d
med
icati
on
mta
ke
from
adm
issi
on
,o d
iaxh
arg
e
At
follow
-up.
pa,,
en,r
rcpor
tcd
impro
vcm
cn,
tn
pu
n
an
d
act
ivit
y le
vrls
bet
wee
n
adm
issi
on
an
d
dxh
arg
e.
bu
t n
o ch
an
ge
sin
ce d
ach
arg
e
Non
t,
I>cc
rcase
d
pam
In
ten
sity
.
mcr
rasc
d
act
wit
s
lcrc
la
in p
rogr
am
com
ple
torl
Fow
ler
1251
Ch
ron
ic
Iow
back
pain
Ser
es a
nd
New
man
[6
5]
Low
back
pain
An
der
son
D
iver
se
pain
et a
l. [
2)
syn
dro
mes
Cai
rns
an
d
Ch
ron
ic
low
P&
no
[9]
back
pain
lgne
lzi
Div
erse
et
al. 1
431
syn
dro
mes
Div
erra
syn
dro
mes
36
100
JO
34
9
54
As
in F
ordyc
c
et a
l. [
24]
Inpatient
prog
ram
of
m
edic
ati
on
wit
hdra
wu
al.
oper
an
t co
ndit
ion
ing.
ph
ysic
al
ther
apy,
bod
y m
ech
an
ics,
bio
feed
back
. rc
lru
nti
on
train
ing
edu
cati
on
lnparienr
prog
ram
of
op
eran
t co
ndit
ion
ing.
ph
ysic
al
ther
apy,
edu
cati
on.
grou
p
ther
apy.
bio
feed
back
.
rela
xati
on.
l~ZU
W9X
~cO
”S
atm
mla
lion
Inpati
ent
oper
an
t
con
dit
ion
ing
pro
gram
. Fam
ily
ther
apy,
syst
emati
c m
edic
alion
redu
ctio
n.
occ
up
ati
on
ai
ther
ap
y,
an
d p
hy
sica
l th
era
py
als
o i
ncl
uded
lnpalim
ts
rece
ived
:
(I )
verb
al
rem
forc
emen
t by
ph
ysic
al
ther
apis
ts
for
incr
ease
d
ac1
1v*
ty:
(2)
graph
ic
an
d ve
rbal
rein
foro
eman
t of
ph
ysic
al
act
ivit
y:
or (
3)
wn
trol
co
ndit
ion
As
des
crib
ed
in
Gm
nh
oot
an
d S
tcm
bach
1321
Gro
up
O”*
fOIi
K
Mu
ltip
le
W-J
P
O”,
CO
IW
Non
e
NO
lIe
Sel
Fre
cnrd
ing
of d
arly
act
iviu
es:
staff
re
cord
ings
of
ph
ysic
nl
ther
apy
act
ivit
ies.
med
icati
on
mm
ke
Med
icati
on
use
: m
eaw
res
of
mu
scle
arr
engl
h.
mob
ibty
sew
rann
grr
of p
a”
znte
nsi
ty:
nu
rse
rati
ngs
of
pam
beh
avi
ors:
st
aff
rati
ngs
01 im
pro
vem
en*
m a
rutu
de.
m
edic
ati
on
use
. an
d ph
ysic
al
fun
ctio
nm
g at
dis
charg
e
Ph
ysIc
al
act
ivit
y
reco
rded
. bW
n
ot
rew
ard
ed
Sta
ff
reco
rdin
g of
up-
tim
e.
walk
tng.
bic
ycle
ridin
g
NO
lIe
Sel
f-re
por
t or
pain
in
ten
sity
. m
cdic
atw
n
use
. act
wit
y le
vels
Nnt
*pai
- fied
3 m
o
NO
”C
6 m
o-
7 “r
Pre
scri
pti
on
an
alg
eesw
mcd
wxc
ion
s u
sed b
y X
7%
of
pati
enrs
at
adm
issi
on.
5%
at
dis
charg
e.
an
d
22
% n
t
f”llow
”p.
1m
pr0
vcm
cnr
in s
traig
ht
leg
rais
ing
an
d e
xerc
ises
at
dix
hu
rge.
m
ain
tain
ed
a,
follow
-up
I /3 pari
enrs
le
ft
pro
gram
earl
y.
54
% o
f adm
ztre
d
paben
ts
an
d
79
%‘ o
f
com
ple
fors
w
ere
rate
d
mod
erate
ly
to m
arked
ly
un
pro
ved
in a
ctit
ilde.
m
edic
ati
on
WC
. an
d
pbyw
cal
fun
ctktn
inp
74
% o
f pr*
‘am
co
mpte
tors
lcn
dm
g n
orm
al
lwes
w
ith
out
an
alg
esic
med
icati
on
use
at
f*ll”w
-up
Hig
her
le
vels
of
upti
me.
walk
ing,
bis
ych
e ri
din
g
in g
rou
ps
I an
d 2 t
han
I”
grou
p
3
3 Y
r R
edu
ced
pam
m
len
sity
. m
edic
ati
on
use
. an
d
incr
ease
d
act
ivit
y
leve
ls
at
rotk
w-u
p.
No
diffe
ren
ces
bet
wee
n
surg
ical
an
d
non
-
surg
ical
pati
entr
TA
BL
E
1 (c
ontin
ued)
Aut
hors
P
opul
atio
n N
In
terv
entio
n(s)
D
esig
n C
ontr
ol
Dep
ende
nt
rnea
surc
i. F
ollo
u.up
R
eaul
tb
Low
ba
ck
pain
36
Low
ba
ck
piun
36
Div
erse
synd
rom
es
20
Rob
e,&
an
d
Rei
nbar
dt
[60]
Div
erse
synd
rom
es
58
As
desc
ribe
d in
Se
rcs
and
New
man
16
51
As
desc
ribe
d 1”
Sere
s an
d N
ewm
an
1651
Inpa
tient
pr
ogrt
lm
of
beha
vior
m
odif
ica-
tm”,
ph
ysic
al
reha
bilit
atio
n,
biof
eedb
ack.
rela
xatio
n tr
aini
ng.
med
icat
ion
redu
ctm
n
Inpa
tient
pr
ogra
m
of
oper
ant
cond
itmni
ng.
phys
ical
th
erap
y.
occu
patm
nal
ther
apy.
med
icat
ion
redu
ctio
n
NO
”C
Self
-rep
ort
of
med
rcat
ion
inta
ke.
heal
th
care
util
izat
ion.
pa
”
inte
nsity
: ph
ysic
al
ther
apis
t m
easu
res
of
mob
ibty
an
d ex
ew~s
e
perf
orm
ance
CiW
lp
O”f
CO
I”C
f I
) Pa
tient
s
reJe
ctcd
ior
,,Gi,t
IIC
”,
(2)
Patle
nt\
who
refu
sed
*,ea
tmC
”t
157-
21.h
In*
14-X
perf
orm
ance
. m
obrh
ty:
mo
self
-rep
ort
ques
tio”“
aire
s
3.
1;
“10
I-X
v,
Dla
char
ge
~m~r
ovcm
e”,
an
mob
ihty
. en
ercf
sc
perf
orm
ance
m
aint
a,ne
d at
foll
ow-u
p.
Med
icat
mn
use
redu
ced
at
disc
harg
e
and
f”llo
w-u
p.
Pan
inte
nsity
de
crea
sed
duri
ng
hosp
italiz
atio
n.
but
mcr
eaae
d at
disc
harg
e
Impr
oved
ph
ysul
i&tio
ni”g
an
d
decr
ease
d m
edic
atio
n
“be
at
foll
ow-u
p.
Maj
onty
of
pa
tient
s
repo
rted
th
e pa
in
wor
se.
but
bette
r ab
le
to
cope
with
it
598
of
adm
itted
pa
tx”r
\
rate
d m
oder
atel
y to
mar
kedl
y im
prov
ed
I”
attit
ude,
m
edlc
atm
”
use,
an
d ph
ysic
al
func
tlo”!
“g
at
dwha
rge
Als
o
impr
oved
w
ere
pain
.
actlw
ry
lev&
pa
in
beha
vior
s
17%
oi
th
e 2h
tr
eate
d
patie
nts
wer
e le
adin
g
norm
al
lives
at
f&
o*-
up.
com
pare
d to
I o
f the
20
pat,e
”ts
,cJe
cted
for
trea
tmen
t. an
d
none
nf
th
e I2
w
ho
&us
ed
trea
tmen
t
sell-
,atm
gs
of
paIn
inte
nsity
. ac
twty
leve
l&:
stai
r ra
tings
oi
pa”
beha
vior
s;
at
disc
harg
e.
staf
f ra
t,“@
of
chan
ges
in
attit
ude.
med
icat
ion
USC
. ph
yalc
af
func
tioni
ng.
Fol
fow
-up:
ques
tron
na,,e
Dal
y ac
tavi
ty
reco
rd.
MM
PI.
self
-rep
ort
of
med
icat
rn”
USE
.
empl
oym
ent
atat
ui.
com
pens
atio
n,
pal*
trea
tmen
ts
sinc
e
prog
ram
. pa
mre
late
d
tnte
rfer
encc
w
th
daily
ac
twile
s
-
29
contingencies can directly alter pain behaviors. Verbal reinforcement appeared to be especially powerful.
A number of authors have reported the results of hospital inpatient programs based on the Fordyce operant conditioning model, but also including non-operant techniques such as group therapy, relaxation training, biofeedback, and transcuta- neous stimulation [30,33,44,58,65,66,70,72,‘73]. Details of individual studies are pro- vided in TableI. Because these programs consist of a plethora of independent variables potentially affecting outcome, and because these are uncontrolled studies, they provide little information as to the unique contributions of contingency management techniques to reducing chronic pain behaviors.
In sum, lengthy inpatient operant treatment programs appear to increase physical activity levels and decrease medication use while the patient is in the controlled hospital environment. There is evidence from two programs that these improvements are maintained by most patients at follow-ups of from 1 to 8years. However, patients are very carefully selected for such programs, and only a small percentage of the chronic pain population is ever admitted to an inpatient operant program. Finally, there is very little information concerning whether operant treatment programs reduce subjectively experienced pain, probably because this is not usually a primary goal. More and better-designed outcome studies, in which subjective pain as well as pain-related behaviors are assessed, are clearly needed.
Cognitive-behavioral interventions
The management of pain is one of the oldest and most enduring clinical uses of hypnosis [ 161. It has been employed at times during surgery to provide analgesia since the early 19th century. However, the mechanism by which hypnosis works is not understood and has been a source of much controversy. A number of experts have contended that hypnosis produces physiological changes which mediate symp- tom relief [ 16,181. Others [7] believe that hypnosis enables patients to gain insight into how their symptoms have developed and that, once this is achieved, symptoms are eliminated. Still others [S] have argued against a hypnotic state altogether, suggesting that hypnotized subjects are engaged in a form of role-playing.
Physiological changes during hypnosis have not been firmly demonstrated. Cogni- tive mechanisms, on the other hand, do seem to play a large role in hypnosis and hypnotic analgesia, and research by Hilgard f39f has supported this. Most authors would agree that hypnosis alters the subject’s awareness of and reaction to pain 15 1,63]. Hilgard 1391 has further hypothesized that in hypnotic analgesia nociceptive information is registered but is partially blocked from consciousness. The critical components of this process, according to Hilgard, are mental relaxation, a narrowing of attention, and hei~ten~ su~estibility. Because the available evidence and current theory point to cognitive mechanisms as playing the most important role in hypnotic analgesia, we have classified hypnosis as one type of cognitive-behavioral inte~ention.
A number of studies have found hypnosis to decrease distress and increase tolerance and threshold for experimental pain [5,3 I ,49,5 I ,68,76]. Hypnosis has been reported to alleviate a wide variety of pain syndromes, as summarized in Table II. These include cancer pain [8,10,48,63,64], neck and shoulder pain [ 151, headaches [34], and phantom limb pain [14]. Many other pain syndromes have been treated with hypnosis, including trigeminal neuralgia, low back pain, whiplash injuries, and various gynecological conditions [4,17,40,46]. Yet clinical research on the use of hypnosis for pain has been sparse, and quite poor methodologically. As Sternbach 1711 has noted, most reports are case histories, lack control conditions, and employ only a few’subjects. Few clinical studies have utilized qu~tifi~ measures of pain or of process variables such as h~notizab~ity, physiolo~cal changes, etc. Although Hilgard [39] has argued that hypnotic analgesia involves more than a placebo effect or anxiety reduction, and has supported his arguments with experimental pain data, no controlled studies have compared hypnosis with a credible placebo condition for control of chronic pain.
Remarkably, even though hypnosis has been used for longer than any other psychological method of analgesia, the clinical research in this area is sparse, appallingly poor, and has failed to convincingly demonstrate that hypnosis has more than a placebo effect in relieving chronic pain. An adequate evaluation of hypnosis applied to chronic pain is needed, However, until controlled research demonstrates otherwise, we are forced to take a posture of skepticism toward the clinical lore that hypnosis is a powerful method of chronic pain alleviation.
Cognitive-behavioral therapy A recent development in the field of pain control has been the application of
cognitive-behavioral theory and techniques to the prevention and alleviation of pain. A basic assumption is that the cognitions (attitudes, beliefs, and expectations) people maintain in certain situations can determine their emotional and behavioral reac- tions to those situations [28]. As cognitive (e.g., distraction, significance of the pain for the individual) and emotional variables (e.g., anxiety) influence the experience of pain, it seems logical that the modification of cognitions could be used to aiter the pain experience. The cognitive-behavioral model does not ignore the subjective experience of pain, as does the operant model. Rather, it views suffering as one of several aspects of a complex pain problem.
Cognitive therapy is a broad term, rather loosely defined in the literature, referring to interventions that aim to correct faulty cognitions underlying emotional and behavioral disturbance [48]. Patients learn to identify distorted beliefs and to substitute more positive thoughts. They are taught specific cognitive skills, such as imagery and distraction, for coping with stressful events. Cognitive therapy consists of a number of cognitive and behavioral (e.g., relaxation training, assertion training) techniques, and thus the rather arbitrary distinction between ‘cognitive’ and ‘cogni- tive-behavioral’ therapy is a theoretical one and can probably not be made in clinical application. Therefore, all such therapies will be referred to as ‘cognitive-behavioral’ in this paper.
When applied to pain problems, co~itive-behaviors inte~entions consist of
teaching pain-control strategies such as relabeling sensations, relaxation, and imagery. They also aim to increase the patient’s awareness of events that exacerbate and actions that reduce pain, so that the patient may better avoid or deal more adaptively with pain-increasing events and utilize pain-relieving actions. Cognitive- behaviorists argue that this awareness and knowledge can give the chronic pain patient a new sense of control over pain that replaces feelings of anxiety, helpless- ness, and hopelessness. This may, in turn, change the extent to which the patient is disabled by pain.
One cognitive-behavioral intervention, called ‘stress inoculation’ by its developers, Meichenbaum and Turk [52), consists of education about pain and instruction and practice in behavioral and cognitive coping skills. This program has been found to increase tolerance and threshold in well-controlled studies of experimental pain [42,52].
A recent study found this approach to be effective in reducing clinical pain in ten patients suffering from a variety of syndromes [36]. Another evaluated several cognitive pain control strategies similar to those used in stress inoculation. Rybstein- Blinchik [61] randomly assigned 44 inpatients with diverse diagnoses to one of four conditions. In the 3 treatment conditions, patients were given conceptualizations of their pain, trained in awareness of their pain-related cog&ions, and instructed in specific cognitive strategies. For each condition, the strategy was one of the following: (1) Somatization. Patients were instructed to replace the word ‘pain’ with the phrase ‘a certain feeling’, and to analyze the sensations associated with that ‘certain feeling’. (2) Irrelevant condition. Patients were instructed to replace their current thoughts accompanying their experience of pain with new ones concerning ‘import~t events’ in their lives. (3) R&want condition. Patients were instructed to replace their current thoughts accompanying their experience of pain with new ones involving a ‘reinterpretation of this experience’, e.g., ‘I feel ticklish, ‘I feel numbness’, etc. In the control condition, patients were engaged in conversation about their pain problems.
The author found that after treatment, patients in the Relevant Condition endorsed si~ificantly milder and fewer sensory, affective, and evaluative words on the McGill Pain Questionnaire to describe their pain in comparison to the other three groups. Moreover, their ratings of pain intensity were significantly lower than those of the somati2ation and control groups. On observer ratings of pain behaviors, the Relevant Condition patients manifested significantly fewer pain behaviors than did the other 3groups. Although these results are encouraging, the study does not provide information as to behavior change outside the therapy setting, or mainte- nance of pain reduction over time.
There have been several reports of other cognitive-behavioral approaches with clinical pain syndromes. These are summarized in Table III. Levendusky and Pankratz [50] reported the case of a chronic abdominal pain patient who was taught to control his pain through a program of relaxation training, visual imagery, and cognitive relabeling, while being withdrawn from large doses of medication. At the time of discharge, the patient reported continued pain, but that he could control the discomfort more effectively with the psychological techniques than he had with analgesic medication.
TA
HI
1: I
1
HY
PN
OS
IS.
EX
PE
RIM
EN
TA
L
DE
SI<
;NS.
PO
PU
LA
TIO
NS.
AN
D
TR
EA
TM
EN
T
OU
TC
‘OM
tS
(‘cdc
rcre
utr
Pha
ntom
lt
mh
37
Hyp
noth
rrap
v .ln
d lJ
usl,a
lo
[ 141
P&
n
Sace
rdot
r 16
41
Tcd
d an
d
Kei
ley
1741
Cra
r,ln
eck
and
Hal
l [ 1
6J
Aw
hxb”
” et
al. [I
]
Gra
ham
[3
0]
Mel
Lac
k an
d
Per
ry
1531
Anx
l 13
1
Bur
n pa
,”
Div
erse
sy
ndro
mes
Ten
sion
head
ache
s.
StL
xnac
h pa
in
Div
erse
synd
rom
es
Mig
r;u”
e
head
ache
s
Vae
xy
of
synd
rom
es
Mig
rain
e he
adac
hes
I 4 2 3
47 2
24
I.55
I
Hyp
noth
erap
y
Hyp
noth
erap
y
Mus
cle
rels
xn~i
o”.
hyP
nolh
e&py
Hyp
nahe
rapy
Com
pare
d:
(I,
hypn
osis
. au
to-
hypn
osis
: (2
)
proc
hlor
pera
zine
Bas
elin
e.
the”
hy
p”os
ic
plus
ha
ndw
arm
ing
sugg
esti
ons
and
self
-hyp
nosi
s tr
ainn
ng
Com
pare
d:
<I)
hypn
osis
pl
us
nlph
n
EE
G
BF
B:
(2)
hypn
osis
al
one:
(3
, al
pha
EE
G
BF
B
clon
e
Hyp
noth
erap
y
Hyp
noth
erap
y
scw
repo
r,.
ohrc
rvcr
pdgl
”C”t
\
Tot
al
“um
ber
of
head
ache
s an
d “u
mbe
r of
in
capa
cita
ting
he
adac
hes
repo
rted
10
the
rapi
st
Self
-rrc
ordx
ng
of
head
ache
fr
eque
ncy.
dura
tm”.
m
te”a
,,y
Self
-rep
or
of
head
ache
sy
mpt
oms
Now
3. 6
. I2
“I
‘>
Non
e
9-12
mn
Non
e
x=22
II
I<>
NO
W
ca*c
<
Tot
al
“um
ber
of
head
ache
s
nnd
“um
ber
of
mca
paci
la~i
ng
head
ache
s
decr
enad
m
ore
in
grou
p I
than
in
gr
oup
2
Pat
ient
s sy
mpt
om-f
ree
or
impr
oved
at
fo
llow
-up
*mpr
o”em
e”t
0”
McG
ill
Run
Que
srio
nnai
re
in
grou
p 1,
bu
t “a
in
gr
oups
2
and
3
Com
pler
e he
adac
he
illlr
virt
ior,
i”
50
%.
som
e re
lief
in
20%
of
pa*K
”U
Paw
”,
rrpo
rwd
head
ache
re
ducb
o”
Not
e:
EM
G
= cl
cctr
omyo
grap
h.
BF
B =
bm
fecd
brck
. B
VP
; bl
ed
volu
me
puls
e:
EE
ti
- el
ectr
oenc
epha
logr
am.
TA
BL
E
III
CO
GN
ITIV
E-B
EH
AV
IOR
AL
T
HE
RA
PIE
S:
EX
PE
RIM
EN
TA
L
DF
SIG
NS.
P
OP
LII
.AT
ION
S A
ND
T
RF
AT
MF
NT
O
UT
CO
ME
S
N
Inte
rve”
t,o”
(s)
Des
ign
Con
trol
Mtt
chdl
(5
41
head
ache
s
Stud
y I.
rcla
xati
a”
trei
ning
:
(2)
rela
xati
on
trai
ning
. de
sens
itiz
atio
n.
asse
rtio
n *r
;u”m
g.
(3)
no
,rea
tmen
1
Stud
y 2:
Lev
endu
sky
Abd
0”Il
”ill
and
Pan
krat
z [5
01
pain
FG
xVt!
~ [S
S]
Ten
sion
head
ache
s
20
Com
pare
d:
<i )
de
scns
itiz
atlo
n:
(2)
rela
xati
on
fral
nlng
.
dcxn
silir
atw
”.
asse
rtio
n tr
aini
ng:
(3)
no
trea
tmen
f
I P
atiw
l ta
ught
rela
xaci
o”
and
othe
r
self
-con
trol
s1ra
tcgi
cs.
wit
hdra
w”
from
anal
gesi
c m
edic
atlo
”
1 B
asel
ine
EM
G
reco
rdin
g
and
pati
ent
self
-
mon
itor
ing,
th
en
cogn
itiv
e sk
ills
trai
ning
. th
en
EM
Ci
BF
B
Hn
lro
yd
et
al.
[4
1]
head
ache
s
hcad
achc
fr
cquc
ncy.
dura
tion
Self
-rcc
ordi
nga
of
head
ache
fr
equc
”c\.
dura
rao”
self-
,rcn
rdm
g*
d
head
ache
in
tens
,,>:
fron
tahs
E
M<;
reco
rdin
gs
head
uche
fr
eque
ncy
and
dura
tion
<ira
rp\
1 and
3.
no ch
ange
s.
Drf
fere
”ces
in
he
adac
he
Ireq
uenc
y an
d du
n,““
”
betw
een
gmup
r 2
an*
3.
but
no<
betw
een
grou
pa
I an
d 3
‘irea
rer
head
ache
re
ducu
o”
herw
ee”
grou
ps
I and
3
from
ba
selin
e fo
llow
ng
LM
G
RF
B.
mai
ntzu
trcd
dt
Mit
chel
l an
d
Wh,
te
1561
Kha
,am
i an
d D
i”ClX
pa
l”
5
Rus
h [4
4]
synd
rom
es
Lak
e r,
al.
1471
M
igra
ine
head
ache
s
24
Ryb
rtei
n-
Blin
ctbk
an
d G
rzcs
iak
1.52
)
Ryb
slei
n-
Biin
chik
16
11
Dw
erse
pa
in
44
synd
rom
es
EM
G
BF
B:
(31
wai
ting
lis
,
Com
pare
d:
(I )
self
-rec
ordi
ng
head
ache
fr
eque
ncy;
(2
.) s
elf-
reco
rdin
g
ante
cedc
n,
stre
ss
as
wel
l as
he
adac
he
freq
uenc
y (s
elf-
m
onit
orin
g):
(3)
self
-mon
ilori
ng
plus
re
laxa
tion
tr
aini
ng
and
inst
ruct
ions
,o
re
lax
in
stre
ssfu
l
situ
atio
ns:
(4)
all
of
the
abov
e pl
us
addi
tion
al
self
- m
anag
emen
, Sk
ill
tram
ing
All
pa,ie
n,s
part
icip
ated
in
:
(I )
rela
xatio
n tr
aini
ng.
EM
G
BF
B.
self
-hyp
nosi
s:
(2)
self
-mon
itor
ing
and
cogn
itiv
r m
alif
ica-
ii”
“:
(3)
fam
ily
mtc
rven
tion
Com
pare
d:
(I )
se
lf-m
onit
orin
g of
head
ache
ac
uwty
@
ai,;
ng
bst)
: (2
) fr
onta
lis
EM
G
BF
B:
(3)
fing
er
,em
pera
,ure
BF
B:
(4)
fing
er
lem
pcra
turc
B
FB
P
lus
Kat
rona
l E
m”,
lve
The
rapy
(R
ET
) G
roup
se
ssio
ns
of
stre
w
m”c
ulat
,on
Com
pare
d:
( I )
co
gnit
ive
,her
aPy
with
so
mar
izat
ion
stra
tegy
: (2
) co
gnit
ive
,her
apy
with
ir
rele
van,
um
ditio
n sf
rraf
cgy:
MU
l,,p,
e
grou
p O
utco
me
reco
rdin
gs
,n,m
si,y
O
..,J
gr”“
y *
Ih”w
cd
EM
O
rcdu
cllo
na
self
- Se
lr-r
ec”r
*l”g
r,
Of
3 In
” N
O
‘9ec
rear
e in
he
adac
he
reco
rd-
head
ache
fr
eque
ncy
freq
uenc
y I”
gr
oups
I
‘“8
and
2 45
%
redu
c,,“
”
head
ache
of
he
adac
hes
,n
grou
p
freq
uenc
y 3.
73
%
in
grou
p 4
A,
“w
follo
w-u
p.
55%
re
duct
ion
from
ha
..elin
e I”
gr
oup
3.
X3%
in
grou
p 4
Gro
up
*u,c
0r”c
Mul
,ipk
grou
p ““
Icom
e
Cro
up
outc
Om
e
Mul
tiple
gr
”“p
ou,c
”mc
Pat
ient
ra
tings
of pa
in.
anxi
ety,
de
pres
sion
.
wor
k an
d fa
mdy
ba
lisfa
cti”
“:
Sym
ptom
Che
cklis
t 90
: B
eck
Dep
ress
ion
Invc
nror
y:
Hop
elcs
~ncs
o Se
als
Self-recording of
he
adac
he
inre
nsity
.
med
icat
ion
inta
ke
McG
ill
Pain
Que
sbon
nmre
. ob
serv
er
rrtm
gs
of
pain
he
havi
nrs
McG
nll
Paz
” Q
ues,
i”nn
aire
:
“bw
rver
ra
,tngz
v of
pa
in
beha
vior
s
6,
I2
ma
Dec
reas
es
in P
ar”.
med
ican
on
use.
depr
ess,
“”
post
- ,r
ca,m
cn,
and
f”ll”
W.u
p
3 nr
u F
inge
r ,e
mpe
ra,u
rc
BF
B
alon
e an
d w
irh
RE
T
no
m”r
e ef
fect
we
than
w
aiti
ng
lis,
All
EM
Ci
BF
B
Pat
ient
s de
crea
sed
head
ache
ac
l~w
ty
,”
e2,3
of
ha
sehn
e io
vel
5 w
k P
ain
beha
vior
s an
d w
ords
us
ed
10 d
escr
ibe
pam
de
crea
sed
Gro
up
3 us
ed
few
er
pain
be
havi
ors
and
Uxw
dS
,n
desa
ibc!
pain
. co
mpa
red
,”
the
othe
r gr
oups
TA
BL
E
III
(con
tinue
d)
Aut
horb
P
opul
atio
n
S1r
nn
et
al.
[69]
Myo
fasc
ial
pam
13
dysf
unct
ion
(MPD
S)
Har
tman
an
d D
iver
se
pam
Ain
swor
th
I361
sy
ndro
mes
(3)
cogn
itive
th
erap
y
with
re
leva
nt
cond
ition
st
rate
gy:
(4)
conv
ersa
tion
only
All
patie
nts
rece
ived
rela
xatio
n tr
aini
ng.
senz
ioay
aw
a~en
es*
trai
ning
, an
d co
ping
skill
s tr
aini
ng.
Hal
f
rece
ived
m
assz
fer
mur
lr
EM
G
BF
B
duri
ng
rela
xatio
n tr
aini
ng:
for
the
othe
rs
mas
sete
r le
nsio
n w
as
reco
rded
, bu
t no
t fe
d
back
Com
pare
d : (
I )
auto
geni
c ex
erci
ses.
then
al
pha
trai
ning
.
then
st
ress
inoc
ulat
ion:
(2
)
auto
geni
c ex
eras
es.
then
st
ress
inoc
ulat
ion.
th
en
alph
a fe
edba
ck
Mul
tiple
grou
p ou
lcom
e
NO
IW
Pres
ence
of
M
PDS
sym
ptom
s.
self
-
reco
rdin
gs
of
Pam
.
EM
<>
m
~l~~
eter
te
nsio
n
reco
rdin
gr
NO
M
Dec
reaw
s I”
nlab
sete
,
ren
sron
. M
PD
S
sym
ptom
s.
and
pain
ra
tings
rn
al
l
patie
nts.
B
FB
pa
tient
s
show
ed
few
er
MPD
S sa
gns
and
low
er
pain
ra
tings
.
but
did
not
diff
er
from
no
BF
B
part
ents
I”
mas
sete
r te
nsio
n
Few
er
and
mild
er
wor
ds
wer
e us
ed
10 d
escr
ibe
pan
I”
grou
p I t
han
I”
grou
p 2
-
Not
e:
EM
(;=e
lect
rom
yogr
aph:
B
FB=b
mfe
edba
ck:
BV
P=
bl
ood
volu
me
puls
e:
EE
G
=ele
ctro
ence
phal
ogra
m
37
time of discharge, the patient reported continued pain, but that he could control the discomfort more effectively with the psychological techniques than he had with analgesic medication.
Khatami and Rush [44] reported a treatment program administered individually to 5 outpatients with chronic pain seen, on the average, for 36 weekly sessions. The 3-part program included: (1) a ‘symptom control’ component, in which patients received relaxation training, EMG biofeedback, and autohypnosis training; (2) a ‘stimulus control’ component focused on identifying and changing the way the patient evaluated and responded to pain and other stressful events; and (3)‘a ‘social system intervention’ component consisting of family therapy and inst~ctions to the family to ignore pain behaviors and positively reinforce well behaviors. Patients showed significant decreases in pain, feelings of hopelessness, analgesic medication use, and depression at the end of treatment, with improvements maintained at 6 and 12 month follow-ups.
Another group of investigators taught 13 myofascial pain dysfunction syndrome (MPDS) patients a variety of cognitive-behavioral techniques, including relaxation, stress inoculation, and assertion skills 1691. In addition, 6 of the patients were given masseter muscle EMG biofeedback during the relaxation training. After treatment, all patients showed significantly decreased muscle tension and subjective pain ratings, and fewer symptoms of MPDS. Fewer MPDS symptoms and lower pain ratings, but equivalent masseter tension levels, were noted in those patients who received biofeedback, as compared with those who did not.
A number of studies have evaluated cognitive-behavioral treatments for headaches, with the rationale that the majority of tension and migraine headaches are precipi- tated by stressful situations. If the patient can learn to control his or her cognitive and emotional reactions to specific stressful situations, headache reduction should result. Holroyd et al. [41] assessed the effectiveness of a program designed to provide skills for coping with daily life stressors as a treatment for tension headaches. Patients were assigned to either stress-coping training (recording and changing their cognitive reactions to stress), EMG biofeedback, or to a waiting list control group, and were seen ~di~dually for eight biweekly sessions. Only the stress-coping group showed substantial improvement on daily recordings of headache activity.
Mitchell and Mitchell [54] compared applied relaxation (relaxation training with instructions to relax in stressful situations), systematic desensitization (a technique pairing deep muscle relaxation with imagery of distressing objects or events), and ‘combined desensitization’ (applied relaxation, desensitization, and assertion train- ing) with migraine patients. Patients in the combined desensitization group showed significant decreases in headache activity. Patients in the relaxation and desensitiza- tion treatments did not differ from the no treatment groups.
Mitchell and White [56] attempted to assess the contribution of various compo- nents of cognitive-behavioral techniques to reduction in migraine headache activity. Twelve patients were randomly assigned to 1 of 4conditions. In this ‘dismantling’ paradigm, all 12 patients received the first inte~ention, which consisted of keeping daily records of headache frequency (self-recording) throu~out the treatment pro- gram. Three of the patients received no additional treatment, while the other nine
3x
then went on to participate in the second condition, in which they were taught to observe and record stressful events that preceded headache onset (seIf-monitoring). The 6patients assigned to the third condition then were trained in relaxation and instructed to relax in stressful situations (skill acquisition stage 1). Finally, three of these patients next received ‘skill acquisition stage 2’, i.e., training in 13 further stress coping techniques (e.g., thought stopping, assertion training). All patients par- ticipated in the treatment program for 48 weeks. It was found that neither self- recording nor self-monitoring alone produced substantial decreases in migraine frequency. However, there were significant reductions after skill acquisition stage 1, and further reductions after skill acquisition stage 2, with maintained improvement at a 12 week follow-up.
In another attempt to investigate the specific effects of various components of cognitive-behavioral treatment packages, Reeves [59] reported a systematic case study of a woman with tension headaches. The headaches remained constant over a 2 week baseline period consisting of EMG recording and self-monitoring. Cognitive skills training (focusing on substituting automatic negative thoughts with positive coping cognitions in stressful situations) resulted in a 33% reduction of headaches from baseline. EMG biofeedback and continued use of coping thoughts resulted in a further decrease in headache activity (66% from baseline). These reductions were maintained at a 6 month follow-up.
In summary, co~itive-behavioral treatment packages show potential to alleviate reported pain in a variety of pain syndromes. In the only direct comparison study of cognitive-behavioral therapy with another psychological intervention, this treatment was more effective than EMG biofeedback [41]. However, a combination of cogni- tive-behavioral therapy and EMG biofeedback has been found in other studies to be more effective than the former alone [59,69]. Unfortunately, most studies have not included objective behavioral measures (e.g., observer ratings of pain behaviors in different situations, records of medication use and health care utilization, employ- ment, activity level, etc.) and adequate follow-up. Certainly, this is a promising area for future research. There is a need to delineate which cognitive-behavioral techniques are effective in reducing various aspects of pain (subjective report, pain behaviors, etc.) in specific types of pain problems. The problem of narrowly focussed outcome measures that limited our appraisal of operant conditioning programs has appeared in a different form in the cognitive-behavioral literature. Because thorough assess- ment of outcome is critical to treatment program evaluation and comparison, we offer the following suggestions for patient assessment.
Comprehensive multidimensional assessment In order to further understanding of pain, to determine effective treatments for
specific aspects of various pain problems, to accurately evaluate a treatment, and to compare results of different studies, a comprehensive assessment of the patient is needed. This would include assessment of the physical/physiological, operant behav- ioral, cognitive-affective, psychosocial, and economic aspects of the pain problem. We propose that patients be assessed along the foIlowing dimensions.
Physiological component. A large proportion of chronic pain patients evidence
39
physical pathology, ranging from slight (of questionable clinical signifi~~ce) to very great (e.g., as in terminal cancer). Adequate assessment includes objective appraisals of these processes, and such indices will differ according to the type of pain. They may include X-rays, EMG, CAT scans, physical examination findings, etc.
Operant component. A patient’s pain behaviors may or may not reflect a large learning/conditioning component, independent of organic pathology. Useful guide- lines for judging the cont~bution of such factors have been offered by Fordyce [Zl]. Among the possible reinforcers for pain behavior are: (a) current or potential economic compensation, (b) avoidance of undesired social, vocational, or family responsibilities, (c) medications, and (d) nurturance from others. Innovation in the scaling of such variables is needed.
cognitive-behavioral ~orn~o~ent. Often, the attitudes, beliefs, att~butions and expectations of the chronic pain patient exacerbate the pain problem. The patient may focus excessively on pain and bodily processes, may have tremendous fears and worries related to the pain, and/or may feel passive, helpless, and hopeless. Assessment of these cognitive and affective factors by personality, depression, and anxiety inventories can be achieved efficiently and can provide valuable relevant info~ation.
Other factors. In order to draw conclusions regarding generalizability of findings and to make comparisons across studies, published reports need to include informa- tion on pain location, frequency, severity, chronicity, functional limitations, employ- ment status, health care utilization, and medication usage in the sample employed. Study inclusion and exclusion criteria should be specified, along with the number of original applicants, percentage of applicants accepted into, actually entering, and completing the program, and reasons for attrition.
In addition, the assessment procedure per se needs to be improved in future research. For example, it is important to include objective behavioral measures, as well as ratings by the therapist and others such as the patient’s spouse, in addition to patient self-report measures. Objective ratings of pain behavior made by an observer blind to the patient’s experimental status are desirable, in order to eliminate patient and experimenter/therapist bias.
Because of the variable nature of clinical pain over time, it is important to obtain adequate baseline measures of pain prior to the onset of treatment. The studies reviewed, with the exception of the headache literature, all too often relied upon one-shot measures of pain pre- and posttreatment. Ideally, measures should be obtained for a period of time before treatment, regularly throughout treatment, and for a period of time following treatment. Single subject designs illustrate the systematic assessment of dependent variables under multiple baseline and treatment conditions. These have undergone substantial refinement in recent years and are well suited to treatment outcome studies in the pain field. Recent texts by Hersen and Barlow [38] and ~at~hwill 1451 are useful resources in this area. Hopefully, these developments will be incorporated in future research on pain therapy, in pilot work or when group designs are not feasible. These methods could have particular applicability in the hypnosis field, where reports have typically consisted of anec- dotal case studies.
40
Finally, there is need for process as well as outcome measurement. lf a treatment has been found to alleviate pain or decrease pain behaviors, by what means is it effective? For example, does a cognitive-behavioral program alter pain report
because patients experience less n~iception, because they reinterpret noxious sensa- tions, or because they simply modify their verbal pain descriptors? Do patients in such programs really feel they have more control over their pain, and is this associated with positive outcome? With biofeedback, are changes in the targeted physiological processes associated with symptom amelioration? What other changes (e.g., perception of control) play roles in improvement? The development and use of such measures is essential in furthering understanding of how interventions alleviate pain and of the mechanisms involved in clinical pain.
Adequate controls. Unfortunately, most clinical pain studies have not employed any control conditions. Only a few have used convincing control conditions, as similar as possible to the active treatment condition(s), except for the putative active therapeutic component(s). Ideally, an adequate number of patients should be randomly assigned to control and experimental conditions, so that the groups are
matched with respect to pain location, severity and duration, age and sex, medica- tion use, etc. If a convincing control condition is not possible, a waiting list control group could be employed. Otherwise, it is impossible to determine whether posttreat-
ment changes are due to active treatment factors, or to nonspecific effects associated with the treatment and measurement processes.
Standardization and adequate description of procedures. In many reports of interventions with clinical populations, insufficient information is given about the number and length of treatment sessions, content of sessions, etc.; thus others cannot replicate these procedures. Further. in many investigations, patients within the same study received different total numbers of sessions and even somewhat different treatment procedures, p~ticularly in the reports of operant conditioning. Only if patients are systematically assigned to standardized procedures can the effectiveness of, and the optimal parameters (critical components, frequency and number of sessions, group vs. individual, etc.) for, various interventions be de-
termined. ~ompi~ance. Almost no studies reported attempts to measure degree of patient
compliance with treatment procedures. As behavioral interventions emphasize regu- lar home practice, the issue of compliance is critical. If an intervention is ineffectual. it is not known whether this is due to the failure of the technique per se, or to the
patient’s failure to use the technique. Ideally, where appropriate, patients’ perfor- mance of techniques should be assessed periodically. For example, if relaxation is
used, the investigator might obtain objective measures of relaxation such as EMG readings. In this way, the association of accurate performance of techniques with pain alleviation can be determined. If patients are not performing techniques correctly and/or regularly, reasons for this should be determined. A powerful intervention is of no value if it is not used by the patient.
Adequate follow-up. Follow-up, if performed at all, has tended to consist of questionnaires, mailed to patients at variable intervals following the end of the treatment program, on which they are asked to make retrospective ratings comparing current pain with levels at the beginning and end of the program. The validity of such retrospective, subjective data is highly questionable. Further biasing the data,
41
only a small to moderate proportion of the original sample generally returns the questionnaires, and there is no information regarding nonresponders.
A careful follow-up over long periods of time is especially important with chronic pain problems because illness behavior is often heavily reinforced by environmental contingencies and a high relapse rate is predictable. It is important not only to know whether a treatment works but also if its successes are maintained over time. Ideally, after treatment termination investigators should: (a) regularly obtain self-ratings from patients (e.g., pain diaries mailed in or read over the telephone), (b) periodi- cally obtain ratings of the patient’s pain behaviors from others such as family members, (c) request that patients return periodically for a battery of self-report and objective measures, (d) record all further treatments patients use or receive in addition to the procedure(s) under study. The difficulty of accomplishing these tasks is recognized. Contingency deposits refunded upon completion of follow-up mea- sures may be a useful technique for ensuring compliance with follow-up procedures.
To recapitulate, improvements in research strategy are necessary. There is a particular need for work with pain syndromes other than headaches, such as low back pain, facial pain, and abdominal pain. Moreover, there is every reason to investigate the efficacy of psychological interventions with problems that are linked to clear cut organic pathology such as cancer pain and arthritis. In the performance of research on therapeutic efficacy, comprehensive multidimensional evaluation of patient, process, and outcome variables will greatly enhance the conclusions that can be drawn from the results. Furthermore, the value of such research will depend heavily on the adequacy of controls involved, the standardization and adequacy of the description of the therapeutic techniques used, evaluation and report of patient compliance with the treatment regimen, and adequate follow-up to determine the long-term gains associated with such therapeutic interventions.
Final considerations
Unlike the procedures of biofeedback and relaxation training that were reviewed in the preceding section of this paper, operant conditioning and cognitive-behavioral therapies (excluding hypnosis) have addressed a wider range of chronic pain problems in a more comprehensive fashion. Operant conditioning can increase physical activity levels and decrease medication use, and these improvements appear to be maintained at long-term follow-up. Cognitive-behavioral therapy has been shown to reduce pain complaints in a number of syndromes.
Nevertheless, each of these methods has distinct limitations in perspective. Operant therapists are committed to a strict behaviorist definition of chronic pain which leads them to ignore the mental processes associated with persisting pain. Their concern is with changing pain behaviors, and the relief of the subjective state of suffering is not formally acknowledged as a goal. In turn, the cognitive-behavioral procedures do not attempt to alter environmental factors such as financial com- pensation, attention from family members consequent to displays of suffering, and use of pain to avoid undesired responsibilities. Unlike the operant programs, these
42
approaches do not include coordination with the insurance companies, the primary physician who may be over-prescribing medications, and the family who may be perpetuating the invalid role. The operant programs include closer collaboration with physician colleagues than do cognitive-behavioral therapies, both in terms of treatment such as physical rehabilitation and also in terms of consultation with the referring physician.
A direct comparison of the efficacy of these two treatments is difficult because they have different sets of goals, and the outcome measures produced by studies on both sides reflect these differences. Whereas outcome measures from operant pro- grams have emphasized return to employment and physical activity levels, those from cog~tive-behavioral treatments have largely focussed on subjective pain report. In broad terms, operant conditioning approaches have been concerned with chroni- city defined in terms of patient’s illness behavior and use of the health care system. In contrast, the costive-beha~o~sts have addressed mental events that generate, perpetuate, and exacerbate suffering.
The dichotomy between operant and cognitive-behavioral approaches may be somewhat forced. It seems likely that patients undergoing operant treatment will experience cognitive restructuring as a result if the treatment is effective. Moreover, cognitive behaviorists bring behavioral principles to bear in the management of their patients even though they exert less control over the patient’s environment. The question, then, may be less one of which camp is more correct philosophically than of which approach is more effective, efficient and less costly than the other for a given type of patient. These issues have not been explicitly addressed in research, but it is plausible that those patients whose pain is of greater chronicity and more linked to the environment may be best treated by an operant treatment approach, while for those whose pain is of shorter duration, with few secondary gains, and less physically disabling, cognitive-behavioral interventions may be more efficient. It would be valuable to compare the two approaches, alone and in combination, using a variety of behavioral and self-report outcome measures.
Together with those in the preceding paper, the studies reviewed here indicate the difficulty of carrying out outcome evaluation research in the chronic pain area. The problems are extremely complex, and many treatment packages involve a collage of interventions rather than single therapy. Large numbers of variables need to be measured over a number of time periods since the issue in question is one of pain chronicity. Researchers are thus plagued with missing data, difficulties of compli- ance, and even ethical problems in the assignment of patients to convincing control conditions. We believe that the overall quality of research can be improved if investigators take advantage of such procedures as single-subject designs and multi- variate statistical analyses including multidimensional scaling. When the latter methods are used it is necessary to collect larger numbers of subjects per study than has been reported in most research reviewed here. Results available to date are encouraging with regard to the potential utility of psychological interventions in chronic pain management, but far more comprehensive and carefully designed work is needed before clear conclusions can be drawn about what types of therapies work with what kind of chronic pain disorders.
43
Acknowledgements
Portions of this were prepared while the senior author was affiliated with the Department of Psychology, University of California, Los Angeles. Preparation of the manuscript was supported in part by a Biomedical Research Support Grant awarded through the UCLA Neuropsychiatric Institute, Los Angeles, Calif., and in part by a postdoctoral fellowship in the Department of Psychiatry and Behavioral Sciences, University of Washington (NIMH Grant MHl5973-01). Support for the second author was contributed by NINCDS Grant NS 16329-01.
The authors wish to thank Yoko Colpitts for her help in editing the manuscript.
References
I Anderson, J.A.D., Basker, M.A. and Dalton, R., Migraine and hypnotherapy, Int. J. clin. exp. Hypn., 23 (1975) 48-58.
2 Anderson, T.P., Cole, T.M., Gullickson, G., Hudgens, A. and Roberts, A.H., Behavior modification of chronic pain: a treatment program by a multidisciplinary team, Clin. Orthop.. 129 (1977) 96-100.
3 Ansel, E.L., A simple exercise to enhance response to hypnotherapy for migraine headache, Int. J. clin. exp. Hypn., 25 (1977) 68-71.
4 Barber, T.X., The effects of ‘hypnosis’ on pain: a critical review of experimental and clinical findings, Psychosom. Med., 25 (1963) 303-333.
5 Barber, T.X. and Hahn, K., Physiological and subjective responses to pain producing stimulation under hypnotic~ly suggested and wring-ima~ned ‘analgesia’. J. abnorm. Sot. Psychol.. 65 (1962) 41 l-418.
6 Blanchard, E.B., Ahles, T.A. and Shaw, E.R., Behavioral treatment of headaches. In: M. Hersen, R.M. Eisler and P.M. Miller @is.), Progress in Behavior Modification, Vol. 8, Academic Press, New York, 1979, pp. 207-247.
7 Blumenth~, L.S., H~notherapy of headache, Headache, 2 (1963) 197-202. 8 Butler, B., The use of hypnosis in the care of the cancer patient, Cancer, 7 (1954) I- 14. 9 Cairns, D. and Pasino, J., Comparison of verbal reinforcement and feedback in the operant treatment
of disability due to chronic low back pain, Behav. Ther., 8 (I 977) 62 I-630. 10 Cangello, V.M., The use of hypnotic suggestion for pain relief in malignant disease, Int. J. clin. exp.
Hypn., 9 (1961) 17-22. 1 I Carlsson. S.G. and Gale, E.N., Biofeedback treatment for muscle pain associated with the tem-
poromandibular joint, J. behav. Ther. exp. Psychiat., 7 (1976) 383-385. 12 Carlsson. S.G., Gale, E.N. and Ohman. A., Treatment of temporomandibular joint syndrome with
biofeedback training, J. Amer. dent. Ass., 9 (1975) 602-605. 13 Cedercreutz, C., Lahteenmaki, R. and Tulikoura, J., Hypnotic treatment of headache and vertigo in
skull injured patients, Int. J. clin. exp. Hypn., 24 (1976) 195-201. 14 Cedercreutz, C. and Uusitalo, E., Hypnotic treatment of phantom sensations in 37 amputees. In: J.
Lassner (Ed.), Hypnosis and Psychosomatic Medicine, Springer, New York. 1967, pp. 65-66. 15 Cheek, D.B., Therapy of persistent pain states. I. Neck and shoulder pain of five years’ duration,
Amer. J. clin. Hypn., 8 (1966) 281-286. 16 Crasilneck, H.B. and Hall, J., Clinical hypnosis in problems of pain, Amer. J. clin. Hypn.. 15 (1973)
153-160. 17 Crasilneck, H.B. and Hall, J.A., Clinical Hypnosis: Principles and Applications, Grune and Stratton,
New York, 1975. 18 Finer, B.. Mental mechanisms in the control of pain, In: H.W. Kosterlitz and L.Y. Terenius (Eds.),
Pain and Society, Verlag Chemie Gmbh. Weinheim, 1980, pp. 223-237. 19 Fordyce, W., An operant conditioning method for managing chronic pain, Postgrad. Med., 53 (1973)
123- 128.
44
20 Fordyce. W.. Treating chronic pam by contingency management. Ad\. Ncurol.. 4 (1974) SX3-5x9 2 I Fordyce, W.. Behavioral Methods for Chronic Pain and Illnea~. Moahy. St. Louis. MO., 1~76
22 Fordycc. W.. Learning processes in pain. In: R.A. Sternbach (Ed,), The Psychology of Patn. Raven Press. New York, 197X, pp. 49-72.
23 Fordvce, W.. Fowler, R.. Lehmann, J. and DeLateur. B.. Some implicati~~ns of learning in prohlcms of chronic pain, J. chron. Dis., 21 (196X) 179- 190.
24 Fordyce. W.. Fowler, R.. Lehmann. J., DeLateur. B., Sand, P. and Tretschmann. R.. Operant
conditioning in the treatment of chronic pain. Arch. phys. Med. Rehab.. 54 (1973) 39Y-40X.
2.5 Fo~lcr. R.. Operant therapy for headaches, Headache. I5 (1975) 63--6X.
26 Ciessel, A.H.. Electromyographic biofeedback and tricyclic antidepressants tn my&Gal pam-
dysfunction syndrome: psychological predictors of nutcomc. J. Amer. dent. Ass.. Y 1 ( 1975) 104X 1052.
27 (iessel, A. and Alderman, M.. Management of myofascial pain dysfunction syndrome of the
tcmporomandihular Joint by tension control training. Psychosomatics. I2 t 1971) 302-309.
28 Goldfried. M.R., The use of relaxation and cognitive relabeling as coping skills. In: R.B. Stuart (Ed,),
Behavioral Self-Management: Strategies. Tcchniqucr and Outcomea. BrunncrjMarcl. New York,
1977. pp. X2-1 16.
29 Ciottheb. H., Stritc. L., Keller. R.. Madorsky. A., Hockersmith. V.. K&man. M. and Wagner, J.,
Comprehensive rehabilitation of patients having chronic low back pain, Arch. phys. Med. Rehab.. 5X
(1977) IO-10x.
30 Graham. G.W., Hypnotic treatment for migraine headaches, Int. J. clin. exp. Hypn 23 (1975) lk4-171.
31 Greene. R. and Reyher. J.. Pain tolerance in hypnotic analgesia and imagination states. J ahnorm.
Psychol.. 79 (1972) 29-3X.
32 Greenhoot. J. and Sternbach. R., ConJoint treatment of chronic pain, Adv. Neural., 4 (1974) 5Y5-603.
33 Harding. H.C., Hypnosis and migraine or vice versa. Northw. Med.. 60 (1961) 16X- 172.
34 Harding, H.C.. Hypnosis in the treatment of migraine. In: J. Lassner (Ed.). Hypnosis and Paychn-
somatic Medicine, Springer, New York. 1967. pp. 13 I-- 134.
35 Hartley. R.B.. Hypnosis for alleviation of pain in treatment of burns: a case report. Arch phys. Med.
Rehab., 49 (196X) 39-41.
36 Hartman. L.M. and Ainsworth. K.D.. Self-regulation of chronic pain: preliminary empirical findings.
C’anad. J. Psychiat.. 25 (1980) 3X-43.
37 Hendter. N., Derogatis, L.. Avella, J. and Long. D.. EMG biofeedback in patients with chronic pain.
Dis. nerv. Syst., 3X (1977) 505-514.
3X Kersen, M. and Barlow, D., Single Case Experimental Designs. Strategies for Studying Behavior
Change. Pergamon Press. New York. 1976
39 Hilgard, E.R.. The alleviation of pain by hypnosis. Pam, I ( 1975) 2 13-23 I. 40 Hilgard, E.R., Hypnosis and pain, In: R.A. Sternbach (Ed.). The Psychology of Pain. Raven Press.
New York. 197X. pp. 2 19-240.
41 Holroyd. K-A.. Andrasik, F. and Westbrook, T.. Cognitive control of tension headache, Cngn. thcr.
Res.. l(t977) 121-133.
42 Horan. J.J., Hackett, G.. Buchanan. J.D., Stone. C.I. and Demchik-Stone, D.. Coping uaith pain: a
component analysis of stress-inoculation, Cogn. (her. Res.. I (1977) 2 I 1-22 I. 43 Ignelzi, R.. Sternbach, R. and Timmermans, Cr.. The pain ward follow-up analysis, Pain, 3 ( 1977)
277-280.
44 Khatami. M. and Rush. A.J.. A pilot study of the treatment of outpatients with chronic pain:
symptom control. stimulus control, and social system intervention, Pain, 5 (197X) 163- 172.
45 Kratochwiil. T. (Ed.), Single SubJect Research. Strategies for Evaluating Change Academic Press.
New York, 1978.
46 Kroger, W.S.. Clinical and Experimental Hypnosis, Lippincott. Philadelphia. Pa., 1977. 47 Lake, A., Rainey, J. and Papsdorf, J.. Biofeedback and rational-emotive therapy in the management of
migraine headache, J. appl. behav. Anal.. 12 (1979) 127- 140.
4X Lea, P.. Ware, P. and Monroe. R.. The hypnotic control of intractable pain, Amer. J. chn. Hypn.. 3
(1960) 3-x.
49
50
51
52
53
54
55
56
51
5x
59
60
61
62
63
64
65
66
67
45
Lenox, J.R.. Effect of hypnotic analgesia on verbal report and cardiovascular responses to ischemic
pain, J. abnorm. Psychol., 75 (1970) 199-206.
Levendusky, P. and Pankratz, L., Self-control techniques as an alternative to pain medication. J.
abnorm. Psychol., 84 (1975) 16% 169.
McGlashan. T.H.. Evans, F.J. and Ore. M.J., The nature of hypnotic analgesia and placebo response
to experimental pain, Psychosom. Med.. 31 (1969) 227-246. Meichenbaum, D. and Turk, D., The cognitive-behavioral management of anxiety, anger and pain. In:
P.O. Davidson (Ed.). The Behavioral Management of Anxiety. Depression. and Pain. Brunncr/Mazel.
New York, 1976. pp. l-34.
Melzack, R. and Perry, C.. Self-regulation of pain. The use of alpha-feedback and hypnotic training
for the control of chronic pain. l&p. Neural.. 46 (1975) 452-469.
Mitchell. K.R. and Mitchell, D.M., An exploratory treatment application of programmed behavior
therapy techniques. J. psychosom. Res., 15 (1971) 137-157.
Mitchell, K.R. and White, R.G., Self-management of tension headaches: a case study. J. hehavx. Ther.
exp. Psychiat., 7 (1976) 387-389.
Mitchell, K.R. and White, R.G., Behavioral self-management: an application to the problem of
migraine headaches, Behav. Ther.. 8 (1977) 213-222.
Newman, R., Painter. J. and Seres. J.. A therapeutic milieu for chronic pain patients. J. hum. Stress, 4
(1978) g-12.
Peck, C. and Kraft, G.. Electromyographic biofeedback for pain related to muscle tension. Arch.
Surg., I12 (1977) 889-R95.
Reeves, J.L., EMG-biofeedback reduction of tension headaches: a cognitive skills-training approach.
Biofeedback Self-Reg., I ( 1976) 2 17-227.
Roberts, A.H. and Reinhardt, L., The behavioral management of chronic pain: long-term follow-up
with comparison groups. Pain. 8 ( 1980) 15 I - 162.
Rybstein-Rlinchik, E., Effects of different cognitive strategies on chronic pain experience, J. behav.
Med., 2 (1979) 93-101.
Rybstein-Biinchik, E. and Gnesiak, R., Reinte~retative cognitive strategies in chronic pain manage-
ment, Arch. phys. Med. Rehab.. 60 (1979) 609-612.
Sacerdote, P., The place of hypnosis in the relief of severe protracted pain, Amer. J. clin. Hypn,, 4 ( 1962) 1 SC)- 157.
Sacerdote. P., Theory and practice of pain control in malignancy and other protracted or recurring painful illnesses. Int. J. clin. exp. Hypn., 18 (1970) I60- 180.
Seres, J. and Newman, R., Results of treatment of chronic low-back pain at the Portland Pain Center. J. Neurosurg., 45 (1976) 32-36.
Seres. J.L., Newman. RI., Yospe, L.P. and Garlington. B., Evaluation and management of chronic
pain by nonsurgical means. In: J. Fletcher Lee (Ed.). Pain Management: Symposium on the
Neurosurgical Treatment of Pain, Williams and Wilkins, Baltimore, Md., 1977, pp. 33-53.
Silver. B.V. and Blanchard, E.G., Biofeedback and relaxation training in the treatment of psychophysi- ologic disorders: or. are the machines really necessary?, J. behav. Med.. 1 (1978) 217-239.
68 Stacher. G.. Schuster, P,, Bauer. P.. Lahoda. R. and Schulze, D., Effects of suggestion of relaxation or
analgesia on pain threshold and pain tolerance in the waking and in the hypnotic state. J. psychosom.
Res.. 19 (1975) 259-265.
69 Stenn, P.G.. Mothersill. K.J. and Brooke, RI., Biofeedback and a cognitive behavioral approach to
treatment of myofascial pain dysfunction syndrome, Behav. Ther.. 10 (1979) 29-36.
70 Sternbach. R.A., Pain Patients-Traits and Treatments. Academic Press, New York. 1974.
71 Sternbach, R.A.. Clinical aspects of pain. In: R.A. Sternbach (Ed.). The Psychology of Pain. Raven
Press. New York. 197R. pp. 241-264.
72 Swanson, D.W.. Maruta. T. and Swenson, W.M.. Results of behavior modification in the treatment of
chronic pain, Psychosom. Med., 4 I ( 1979) 55-6 I. 73 Swanson, D.. Swenson, W., Maruta, T. and McPhee. M., Program for managing chronic pain. 1.
Program description and characteristics of patients, Mayo Clin. Proc.. 5 I (1976) 401-408.
74 Todd, F. and Kelley, R., The use of hypnosis to facilitate conditioned relaxation responses: a report of three cases, J. behav. Ther. exp. Psychiat., 4 (1970) 295-298.
46
75 Turk, D.C., Meichenbaum, D.H. and Berman, W.H., Application of biofeedback for the regulation of
pain: a critical review, Psychol. Bull., 86 (1979) 1322- 1338.
76 Zimbardo, P., Rapaport, C. and Baron, J., Pain control by hypnotic induction of motlvational states.
in: P.G. Zimbardo (Ed.), The Cognitive Control of Motivation, Scott and Foresman. Glenview. Ill , 1969, pp. 136-152.