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Why does one patient develop chronic pain and face disability, while another—with seemingly the same injuries, extent of tissue damage, and quality of medical care—recovers and returns to normal activity following a brief convalescence? Arguably, there may be biologic variables between the two that are difficult to discern medically, but a comparison, in most cases, is likely to reveal that the greater portion of the variance consists of psychosocial differences. When pain physicians wonder why a patient fails to respond to procedures and medications that have proven efficacious for many others with the same medical presentation, it is frequently the pain psychologist who can offer the most reasonable and, more importantly, functional set of hypotheses.


Although nociceptive or purely physiologic factors may instigate pain, how it is expressed by the individual, over time, suggests that what might have begun as a simple picture can become considerably more complicated and intricate through the influence of psychological and social factors. Melzack and Wall’s gate control theory emphasizes that pain cannot be fully understood without an assessment of the motivational-affective, sensory-discriminative, and cognitive-evaluative processes of the individual. Adherents to the biopsychosocial, mind-body, and behavioral medicine approaches to pain all affirm that, whereas the origin of pain may not be psychological, how one responds to it is. Assessing this response expediently and accurately may redirect the focus of a patient’s treatment, highlighting the psychosocial dimension of the patient’s experience as essential to diagnosis and successful outcome. Chronic pain may not lead to adjustment difficulties, mental disorder, and disability, but when it does, psychosocial assessment may offer the only helpful perspective on why, as well as the best hope for recovery.


Social policy and, in some instances, medical practice have lagged behind science in operationalizing the comprehensive approach to pain management. Psychological services, for example, are a requirement for pain treatment centers seeking accreditation by the Commission on Accreditation of Rehabilitation Facilities (CARF)1; yet many health insurance carriers balk at the idea of reimbursing for psychological evaluation and treatment, and there are no uniformly endorsed standards in the private sector. In medical practice, physicians who do not see their patients in a multidisciplinary setting may not involve psychological evaluation in cases of chronic pain, until considerable frustration and the question of functional versus organic origin has arisen. Ironically, by that time, the interpretation of the patient’s pain has often passed from a medical to a wholly psychological one, and the wish not to affront or unduly alarm the patient is well past consideration.


When patients are asked to see a psychologist or to complete a battery of psychological tests and questionnaires, many indeed respond defensively and, sometimes, even hostilely. For many, referral to a psychologist is tantamount to confrontation with their worst fear: “My doctor doesn’t believe me.” How the physician approaches the patient, therefore, frequently becomes the first crucial step toward putting together a comprehensive picture of what the ...

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