Chapter 14. Psychotherapeutic Management of Chronic Pain

When the International Association for the Study of Pain (IASP) arrived at a definition of pain that included the “emotional experience,” as well as the “unpleasant sensory experience associated with actual or potential tissue damage,”1 they were acknowledging the impact of pain on our human capacity for sentience and reflection and, by extension, suffering. By the time pain has become chronic in an individual’s life, it has almost certainly achieved the status of a major source of stress. More than merely an unpleasant sensory stimulus, chronic pain can come to affect the whole individual by becoming, itself, the source of a broad range of psychosocial stressors. The following case report illustrates the extent to which this is possible.

Case 1

A 42-year-old married man was referred to a pain management center, 8 months after suffering a work-related, crush-type injury to his hand. His pain, which had been diagnosed as complex regional pain syndrome, type 1 (CRPS-1), had remained intractable to conservative measures and surgical intervention. According to the patient, several trials of medications had left him with uncomfortable mental status changes, and a reparative surgery and several procedures had exacerbated his pain considerably. He reported his distress as “worse than ever” and indicated that he was unable to work or pursue any of his previous recreational outlets. Although his primary care physician and surgeon supported his claim to disability, his worker’s compensation carrier’s representatives insisted that he should be able to return to light duty at his previous job. As a result, the patient had entered a lengthy and frustrating process of litigation, which had proved exhausting and overwhelming. As his anxiety escalated concerning his loss of income, mounting legal fees, and inability to resume work and provide for his family, he became increasingly withdrawn, irritable, and depressed. His marriage and relationships with his children and friends suffered; and, by the time he arrived at the pain management center, he reported feeling angry, helpless, hopeless, and suicidal.

Cases such as this are familiar to everyone who specializes in the treatment of chronic pain. The challenge, where successful medical resolution is concerned, is to maintain the focus on the whole of the individual’s experience, both sensory and affective, because the development and course of chronic pain represents a progressive series of complex interactions among the biologic, psychological, and social dimensions of an individual’s life. Purely physiologic explanations cannot account for its impact.2 Nor can an exclusive reliance on the interventions that spring from such a limited understanding ordinarily bring the enduring relief and solace sought by many patients with chronic pain.3

The quality, intensity, and duration of pain are influenced by a myriad of psychological and social factors, which—while they may have arisen in the context of pain—are by no means less influential or consequential than the unpleasant sensory experience arising from actual or potential tissue damage.4 Such factors may, indeed, play a critical role in the etiology, severity, exacerbation, and maintenance of pain, suffering, and disability.5 The experience of chronic pain ultimately comes to be the product of conflict between a sensory stimulus and the entire individual. It will always require some level of adaptation and adjustment, but it can, in many cases, interfere with one’s work and livelihood, recreational pursuits, relationships with family and friends, and even sexual intimacy. Through the introduction of more enduring affective changes, it can also influence one’s self-esteem and the ways in which one views oneself as a man or woman, husband or wife, father or mother, friend, member of society, and spiritual being.

With so much at stake for the patient with chronic pain, it is not surprising that psychological evaluation is a required or highly recommended feature of comprehensive evaluation in many pain management centers.6 For many patients, some form of psychological intervention is also recommended as part of the comprehensive treatment plan. Such interventions are usually prescribed to run concurrently with medical treatment and other therapies and may include one or more of many available modes of individual or group psychotherapy. When offered as part of a multidisciplinary package, psychotherapeutic approaches to managing chronic pain have demonstrated their efficacy repeatedly, and there is considerable evidence to suggest that the more effectively such interventions are integrated into a comprehensive or team approach, the greater are the chances of improvement for health and quality of life.7

With the IASP reporting an incidence of chronic pain in the United States of 70 million, and with more than 50 million being partially or totally disabled for periods ranging from a few days to a few months, a concerted multidisciplinary effort becomes even more critical to the effective marshaling of available medical resources.8 Especially for patients whose chronic pain has remained initially intractable to medical and surgical interventions, a careful plan of treatment coordinated by a team of providers can ultimately result in greatly reducing the costs of health care, as well as raising the quality of that care—improving patients’ response to treatment, level of functioning, and satisfaction—and enhancing the morale of all the providers concerned.9 Psychotherapeutic management, in this context, necessarily involves not only a multidisciplinary approach, but an interdisciplinary effort in which the interventions of each member of the team—physicians, nurses, physical therapists, medical and complementary specialists, and mental health providers—can be seen as having a psychotherapeutic impact on the patient and must be directed toward having a complementary effect on the interventions of all other members of the team.

Psychological Factors in Chronic Pain

It is, by now, a generally accepted, if not always carefully considered tenet, that stress is influential in the development, expression, and tractability of chronic pain.10 Because stress is also influential in the development and expression of somatization and other psychological symptoms, associations among chronic pain, stress, and psychiatric disorder are frequently observed and well-documented in the literature of both pain and psychiatry.11 Attempting to parse or separate these influences prematurely for the sake of treatment is frequently tantamount to disregarding the often-volatile interactions among these factors and the cyclically reinforcing relationship between chronic pain and stress.

When such a unilateral approach is taken, it often represents the attempt of physicians adhering to too strict a medical model to establish the extent to which a patient’s problem may be mental, as opposed to physical. As a result, both physician and patient may be left wondering why a clearly prescribed nerve block or medication has not achieved the expected relief. It may also lead to the premature and potentially harmful conclusion by the physician and the patient’s health insurance carrier that nothing further can be done medically or surgically to assuage the patient’s pain and that the problem is no longer a medical one but strictly a psychological one, now unrelated to a precipitating injury or historical tissue damage. What is being overlooked is the individual patient’s stress-reactivity and the enduring influence of the pain-stress cycle on the development and maintenance of chronic pain.

Stress-Reactivity and the Pain-Stress Cycle

The term stress-reactive is suggestive of a continuum of the degree to which any individual reacts to external or internal stressors, including the stressors of pain and its psychosocial sequelae. We are all on this continuum, but highly stress-reactive individuals are likely to develop a broader spectrum of more severe psychological and social concomitants or consequences, as well as to experience their pain with greater affective involvement and suffering. Less stress-reactive individuals may still experience the need to accommodate to their pain, psychologically, socially, and occupationally, but their adjustment to living with chronic pain is typically more successful and their adaptation to their limitations, more enduring.

The term pain-stress cycle is indicative of the unfolding neuropsychosocial matrix in which (1) pain tends to amplify the impact of stress while (2) stress magnifies the subjective experience of suffering associated with pain. The former occurs when a patient’s experience of pain facilitates the development of new and secondary psychosocial stressors, as in Case 1, earlier; but it may also be evident in the patient’s tendency to rely on or resort to maladaptive coping strategies, such as self-medication, social withdrawal, and the development of generalized, reactive pain behaviors. The latter refers more specifically to the contributions of heightened autonomic arousal and musculoskeletal tension in the maintenance and intensity of the experience of pain.

We have only an inchoate appreciation of how these mechanisms work and interact, but advances in our understanding of the neurophysiology and molecular biology of our perception and experience of pain strongly suggest that the influence of psychosocial factors and emotions is translated neurophysiologically into the realm of perception and behavior.12 Stress, regardless of its origin, can result in physiologic deterioration and the exacerbated experience of pain through a variety of mechanisms. Neurosignature patterns can be modulated or altered destructively by stress of psychological origin, no less than by sensory input. Because any stressor, whether external or internal, physical or psychological, can affect stress-regulation systems adversely, the resulting lesions or tissue damage can influence the neurosignature patterns that originate chronic pain.13

Seen from this perspective, the distinction between stresses of psychological versus physical origin tends to assume less importance, and a multidisciplinary or comprehensive approach to treatment becomes paramount. All models of chronic pain acknowledge the neuropsychosocial relationship and interaction between stress and pain; however, it is yet a further step to begin to understand and appreciate how this works in the life of a particular patient or how to incorporate this approach into a successful plan of treatment. In a multidisciplinary approach to treating chronic pain, therefore, making an assessment of the degree to which any patient is stress-reactive and addressing the nature of his or her unique expression of the pain-stress cycle become primary objectives of intervention in pain management.

There is a tendency to regard this as the special province or purview of the psychologist, psychiatrist, or clinical social worker, but, in a team approach, all interventions may be seen as having a psychotherapeutic action. The reassurances of the physician or nurse that a patient’s pain is being taken seriously, the verbal reinforcement to the patient by all providers that progress in pain relief and management can be achieved, and even the comforting touch of physicians, nurses, and physical therapists during examinations, procedures, or exercises—all may possess a powerful psychotherapeutic dimension. What is shared in team meetings and clinical rounds can also prove critical to all providers in assessing a patient’s progress and determining the extent to which he or she remains stress-reactive, as well as how the pain-stress cycle continues to unfold in the context of his or her family, social relationships, work, and livelihood.

Influence of Psychopathology

As the ongoing evaluation and treatment of chronic pain proceeds, one area in which psychologists, psychiatrists, and clinical social workers can be especially valuable lies in determining the extent to which psychopathology is present and influential. As psychological intervention begins, the first important consideration—one that will likely have implications for both prognosis and treatment—concerns the juxtaposition of psychological factors affecting the patient’s pain experience, especially with regard to the order, magnitude, and relative duration of influence. In some cases, psychopathology occurs as a complicating feature in the diagnosis and treatment of chronic pain and existed prior to the development of the pain syndrome. In these instances, some delineation of the premorbid or existing psychopathology becomes critical to understanding the role and meaning of pain from the patient’s perspective. In other cases, psychopathology is reactive to and arises within the context of the patient’s experience of pain, and special care may be needed to introduce the idea of and address the disorder without the patient’s feeling that the focus has been removed from his or her pain.

Chronic pain is far more prevalent among the psychiatrically disordered than in the general population, and there is considerable evidence that alterations in pain experience occur in conjunction with some psychiatric disorders, including mood disorders, anxiety disorders, and psychotic disorders.14 Prevalence rates for depression among chronic pain sufferers in clinic-based samples vary in the literature from 30% to 54%,15 with significant depressive symptoms ranging from 60% to as high as 100% in some samples.16 The question of which came first—the depression or the pain—remains controversial,17 and clinical evaluation can certainly reveal depressive symptomatology to be a premorbid or disposing influence in the development of chronic pain, as well as a comorbid one. That depression might be a consequence of chronic pain is acknowledged by many patients; but that pain might constitute the somatized expression of premorbid but unacknowledged depression or intrapsychic conflict typically meets with resistance from some patients and their families, who may find a psychiatric diagnosis both less accessible and less acceptable than a medical one.

Case 2

A 52-year-old married woman with a previous lumbar laminectomy and a well-documented history of mild, episodic, but well-managed low back pain developed an exacerbation shortly after the last of her three children left home to enter college. Her pain did not resolve as easily as it had in the past, and 2 months later, she presented to a pain management center, tearful, agitated, and in obvious distress, having exhausted her primary care physician’s ordinarily effective armamentarium of conservative treatments. Her husband reported that she had become increasingly withdrawn from her friends and previously busy schedule and now stayed mostly in bed, watching television or sleeping. With a diagnostic workup and clinical examination devoid of any findings except a few mild trigger points, the patient’s pain physicians prescribed an antidepressant, which they were careful to explain is also considered a “pain medication,” and referred her to a structured group psychotherapy program, emphasizing the importance of learning techniques for greater musculoskeletal relaxation. One month later, the patient presented for follow up, excitedly discussing her cognitive-behavioral assignments for stress management from her group and chatting with the nurses about the success of her children, with whom she had developed a frequent e-mail correspondence. She complained of occasional, mild residual pain but was not allowing this to impede the gradual resumption of her daily schedule.

In this case, the patient had little insight into the development of her reactive depression or its relationship to her worsening pain. Considering her history of surgery and episodic low back pain, it is difficult to ascribe her distress solely to somatization; but instances of pure somatization are usually difficult to document convincingly. As in most cases, this woman’s exacerbation of pain appears to stem from both physiologic and psychological factors; and, especially when discussing her experience with the patient herself, it is important not to become distracted by questions of primacy. When there is a clear, established history of a premorbid psychiatric disorder, it becomes critical to understand how such psychological factors may have contributed to the development of chronic pain and how they shape the patient’s experience of chronic pain. When there is little to suggest premorbid psychiatric influences, however, it is far more important to maintain a clinical focus on the relationship between psychological and physical factors, as a whole, as well as their ongoing interaction.

For this reason, a model reflecting the influence of stress-reactivity and the pain-stress cycle is probably more versatile and more efficacious in such cases, because it promotes a view of health that takes into account the interaction of psychological and physical factors, without the need or presumptive burden of trying to establish causal direction—an enterprise that, despite our best efforts and intentions, might easily result in harm to the patient. With such a model, psychological factors can be viewed as both amplifying pain and inhibiting successful adjustment to it, whereas chronic pain itself can be viewed as a potent psychological stressor in its own right and one that can easily give rise to other psychosocial stressors.18

The disposing premorbidity, for example, of personality disorders, depression, and posttraumatic stress in the development of chronic pain is often accepted uncritically in the clinical arena. That they are found in significantly greater proportion comorbidly is indisputable.19,20 Yet, when viewed according to a diathesis-stress model, even personality disordered and posttraumatic stress disordered behaviors may emerge for the first time and coalesce around chronic pain.21 So the question becomes less a chicken-or-egg issue of, “Which came first, the chronic pain or the psychiatric disorder?” but rather, “What approach is more helpful to the patient in understanding and assisting in the resolution, both psychologically and physically, of his or her pain?”

Somatization, according to this model, can be seen as an immature psychological defense capable either of giving rise to pain in the apparent absence of organic pathology or of complicating and magnifying pain in the established presence of organic pathology. As a defense, it simply represents the symbolic displacement of intrapsychic conflict onto the somatic sphere in an unconscious attempt to avoid distressing affects associated with psychosocial stress. All stress-reactive individuals tend to somatize, when under sustained or escalating stress; and, because we are all on a stress-reactive continuum, we all tend to express affects through our bodies to some degree. Highly stress-reactive patients may have well-documented histories of somatization and physical complaints at many sites, but any tendency toward somatization can magnify a patient’s suffering well beyond what is expectable, given the nature and extent of actual tissue damage.

Alexithymia can be a predisposing, complicating, and exacerbating feature of somatization,22 because patients who are unable to articulate their emotions and affective states in words may have few outlets, other than bodily expression, for their intrapsychic pain and discomfort. For those who have come to regard the experience of psychological distress or displays of affect as signs of weakness or occasions for shame, displacing intrapsychic conflict onto the body may also allow them to feel that they have more legitimate claims to others’ attention and the fulfillment of their needs—a phenomenon or symptom also known as secondary gain. Such constructs as alexithymia and secondary gain, in turn, raise the question of whether the phenomenologic focus of the interaction between pain and stress is more appropriately placed on psychiatric disorder or on temperament, personality traits, coping attributes, and even environmental factors, such as availability of support.23 Shifting the clinical focus too quickly to that of psychiatric disorder can discourage the patient further or even lead to the termination of treatment.

The dangers of prematurely settling on a psychiatric diagnosis are especially apparent in the case of the somatoform disorders, the common feature of which is the presence of physical symptoms suggesting a general medical condition but which cannot be completely attributed to such a condition or the effects of a substance or another mental disorder.24 The category of somatoform disorders—conversion disorder, somatization disorder, pain disorder, and hypochondriasis—may be both descriptive of a patient’s symptoms and representative of clinical observation, but too often such diagnoses represent the closing of the door to continued medical attention and intervention. So, too, the coincidence of mood, anxiety, and personality disorders should not be considered a medical end point, but rather should highlight the need for multidisciplinary approaches to the treatment of chronic pain. Psychiatric diagnosis in chronic pain is valuable only insofar as it develops a deeper and richer understanding of the patient and promotes multidisciplinary options for treatment, including that of psychotherapeutic intervention.

Preparing for Psychotherapeutic Intervention

Not all patients with chronic pain exhibit significant psychopathology, of course, or experience the complicating influences of the range of psychological factors that can affect the course of physical symptoms. Many individuals adjust well to the limitations imposed by their pain and continue to work productively and to enjoy satisfying relationships and rewarding personal interests. Most of them have no histories of premorbid psychopathology; and, by virtue of resilient temperaments, adaptive personality traits, and successful coping skills, they manage to avoid the comorbid development of psychological distress and psychiatric symptoms that can become associated with chronic pain.

Those who are less fortunate, however, include among them the most memorable and challenging patients in any primary care practice or pain management center. Their suffering is often dramatic and, even when their numbers are few, their drain on resources is considerable, when calculated in terms of time, money, and the morale of staff. Their families, other physicians, employers, and even health insurance carriers frequently become demanding agents in their behalf, even as their pain remains puzzling and intractable to an ever-lengthening list of interventions; while their escalating sense of urgency continually reminds us of our limitations as health care providers. When all else appears to have failed and all available resources have been tapped, it is a small step toward collusion with the patient’s own escalating sense of urgency to make one more referral to yet another specialist or to raise the level of pain medication, one more time; to consider one more improbable intervention or, as is often the case, to simply close the door, abandoning the patient to begin the process all over again.

It is under such circumstances that psychologists and psychiatrists frequently find the chronic pain patient at their doors. Having been told that there is nothing further that can be done, that there is no hope of further surgical or medical palliation, patients can be left to begin the process of psychologically adjusting to their pain and its sequelae in the most angry, anxious, and despairing of states. For these individuals, pain may already have become an organizing principle, and the enterprise of psychotherapeutic management is no longer only that of addressing transiently reactive mood or anxiety or difficulties with adjustment, but that of attempting to alter a way of life or effecting change at the level of personality. Chronic pain of this nature continues to call for a multidisciplinary approach, often just at a time when patients are most discouraged by or disillusioned with their medical care; and it is often a long road back to successful pain management, made far more arduous for having been consigned to being undertaken in pieces.

When psychological factors are influential in the development or maintenance of chronic pain, the greatest progress is likely to be achieved most expediently when there is not only interdisciplinary cooperation but an integrated, comprehensive plan of treatment in which all providers are working together, with the same goals in sight. Undertaking medical and psychotherapeutic approaches to chronic pain separately—or worse, sequentially—greatly reduces the chances of making global progress in patients’ adjustment to their pain, while increasing the chances that interventions from different disciplines may compete or contradict one another, leaving patients feeling confused and helpless. It can also leave physicians and psychotherapists feeling alone and unassisted in their attempts to help their patients and more likely, as a result, to communicate their own anxiety and sense of helplessness about the slowness or lack of progress back to the patient.

The patient’s developing stability and success with managing chronic pain may well depend on an abiding trust that his or her physicians are doing everything possible to offer appropriate relief and comfort through medical means, while his or her psychotherapist is doing everything possible to assist with the adjustment to what the patient sees as the emotional impact and consequences of pain. This does not mean that there is a strict division of labor, however; and patients often will turn to their physicians and nurses for emotional support and ask their psychotherapists for reassurance about medical decisions. Patients with chronic pain often ask their providers, without respect to discipline, for validation—the reassurance that their physicians, nurses, physical therapists, and psychotherapists have heard their concerns and understand their experience. Many have gone from provider to provider, encountering repeated disappointments in their search for answers, and their often challenging and sometimes provocative presentations may reflect the defensiveness, hypersensitivity, and hypervigilance of the scars, both physical and psychological, they have sustained in their search for relief and solace.

Establishing a good working alliance is, therefore, critical for all members of a multidisciplinary team. Patients’ compliance with directives and interventions and their cooperation with a plan of treatment often depend on their perception that all members of the team are working together in their behalf. When patients lose trust in their providers or sense that providers are not fully engaged in the process of helping them in their search for answers and relief, the alliance deteriorates, sometimes irredeemably. Patients’ complaints of feeling rushed, dismissed, or devalued may result, not surprisingly, in an increase in pain behaviors and dependency, as well as tendencies toward the expression of retaliatory impulses. In a multidisciplinary approach to treatment, the responsibility for maintaining the integrity of the alliance is shared among all providers, with the result that the patient’s urgency is experienced by all as less demanding or overwhelming.

When the psychologist, psychiatrist, or clinical social worker enters the scene, patients frequently need the reassurance of the rest of the team that their pain has not suddenly been relegated to the uncertain status of being purely psychological in origin, or “all in the head.” Especially in the initial psychological interview, it is reassuring to patients to be able to focus on what they know best—namely, the emotional impact of pain on their lives—and not to feel as if their beliefs and psychological defenses are being challenged or threatened. When the patient feels secure that his or her story has been heard and fully appreciated, the direction of the psychotherapist’s inquiry can turn toward a consideration of the psychological and behavioral antecedents, correlates, and sequelae of pain—all of the factors influencing the pain-stress cycle. Once the patient is willing to acknowledge and discuss the possibility that stress may contribute to his or her subjective experience of pain, the way is prepared for psychotherapeutic intervention.

It is, nevertheless, critical not to presume too much or too quickly here. A final, essential question to consider in preparing for psychotherapeutic intervention concerns the range of variables in individual temperament and personality that make psychological adjustment possible: Is the patient disposed toward making the changes necessary to facilitate more adaptive coping? Because patients vary widely in their receptiveness to making the behavioral changes that lead to more successful adjustment, their readiness for change20,25 may require continual monitoring and nurturing in psychotherapy (see Chap. 13). Suggesting to someone who is waiting for his or her physician to “fix the problem” that relaxation exercises might assist in the management of pain is unlikely to result in anything but frustration. Accurately assessing and nurturing the patient’s readiness for change, therefore, becomes one of the principal prerequisites for the successful psychotherapeutic management of chronic pain.

The psychotherapeutic treatment of pain disorder or chronic pain accompanying other psychiatric disorders may have more than one goal, including the relief of pain itself, the decrease of disability and illness-related or “pain behaviors,” the restoration of activity and the increase in functional quality of life, as well as the decrease in reliance on opioid and other analgesic or anxiolytic medications.26 Individual psychotherapy may prove to be of great benefit in achieving these goals, but it must be noted from the outset that structured group programs, whether inpatient or outpatient, have been studied more widely and demonstrated to be of greater efficacy in their application to chronic pain populations.27

The hallmark of such programs has been the successful integration of multidisciplinary approaches into a unified interdisciplinary perspective, with greater coordination of services and frequent communication among all providers. Progress in individual psychotherapy, by itself, is frequently hamstrung by a less unified, more piecemeal approach to the patient’s concerns, which may change from session to session. As a result, more structured forms of individual treatment, such as cognitive-behavioral therapy, have been developed specifically for pain patients. But individual treatment, whether combined with structured group psychotherapy or undertaken on its own, tends to work best when its approach is eclectic and includes a number of components,20 each of which may appeal to a different or succeeding stage in the patient’s receptivity or readiness for change.25

Keeping in mind that psychotherapeutic management is the concern of the entire treatment team, any intervention may, broadly speaking, have a psychotherapeutic impact on the patient. The beginning of formal psychotherapeutic intervention, however, is usually marked by a clinical interview and anamnesis administered by the psychologist, psychiatrist, or clinical social worker. Psychological testing may also be included as a means of evaluating the current level of functioning, symptoms of psychopathology, presence of psychosocial risk factors affecting prognosis, and other cultural, educational, and attitudinal indicators warranting consideration in the planning of treatment. Psychopharmacologic evaluation may be included at this stage, as well, but many pain physicians are conversant with the use of psychotropics in pain management and referral to a specialist is often considered redundant, unless the initial interventions have proven unsuccessful. Once a picture of the patient’s presenting baseline of coping and functioning emerges, ongoing and longitudinal assessments provide a measure of psychotherapeutic progress, as well as indications for appropriate changes in the treatment plan.

Psychodynamic Psychotherapy

Psychodynamic or insight-oriented and supportive psychotherapies are not usually considered treatments of choice for the chronic pain patient, precisely because their approach is less structured and more patient-directed; but they may be the logical starting point for patients whose pain and disability are sustained or exacerbated by intrapsychic conflict or unconscious motives, such as trauma or secondary gain.28 The high correlation between the history of physical or sexual abuse and the subsequent development of chronic pain is well documented in the literatures of psychiatry and pain.29–31 In patients who have suffered abuse as children or as adults or who have experienced or witnessed situations in which either death or serious injury was real or threatened, chronic pain may come to represent a means of psychologically symbolizing and organizing an unbearable traumatic event or series of events. Nor is the situation of childhood or adult abuse the only form of trauma associated with chronic pain and disability. The development of comorbid posttraumatic stress disorder is also prevalent in work-related injuries and motor vehicle accidents.32,33

Whether premorbid or comorbid, posttraumatic stress disorder remains a powerful confounding factor in many cases of chronic pain; and, for those patients with such a background, a frequently necessary step in the development of their readiness for change is the experience of making a conscious connection between their trauma and their pain. In cases in which premorbid psychopathology has contributed to the development of chronic pain and disability, an understanding of the relationship between the patient’s history and the development of his or her symptoms may prove essential in assisting him or her toward a more active role in treatment.

Case 3

A 28-year-old, recently married woman was referred to a pain management center with a 6-month history of chronic abdominal and pelvic pain of uncertain etiology. She reported having a history of episodically severe “stomach aches and cramps,” as a child, but felt that these had long since been resolved. Although similar to these early episodes, her current pain had become more intense and urgent, even to the point where walking was sometimes difficult, literally necessitating her husband’s support to get down the stairs in their home. Her anxiety had also escalated, interfering with the couple’s sexual intimacy, despite her husband’s obvious concern and willingness to assist her in whatever ways she asked. The patient agreed to enter psychotherapy but denied the impact of any stress in her life, beyond that of her pain. During the course of treatment, she disclosed to her psychotherapist that she had endured sexual abuse from her father as a child, but, again, placed no significance on its enduring influence. When asked how and when the abuse stopped, she indicated that her father typically became more solicitous of her and less likely to molest her, when she became ill. Over time, she made the connection that her pain had begun in the weeks immediately following her wedding, when the couple’s sexual intimacy had greatly increased in frequency. Wondering whether there might be a relationship between her pain and her feelings and attitudes about sex, she eventually came to the realization that her developing sexual relationship with her husband was, through no fault of her own or her husband’s, recapitulating her childhood trauma. Once she recognized that this recapitulation might have contributed to the onset of her pain, she became motivated to address the complete range of issues both influencing and influenced by her pain. Several months later, following the addition of couples therapy and a cognitive-behavioral component to her individual treatment, her pain was largely resolved, and she and her husband were reporting the mutually satisfying reintroduction of sexual intimacy to their relationship.

This case illustrates how an instance of primary somatization can become a defensive process around which a personality can coalesce unconsciously. If the impact of such a process goes unacknowledged and its possible influence, unrecognized, then the motivation for change is likely to remain insufficient. In this patient’s case, not only did she need to examine her immediate situation, but she had to recognize and accept the connections between her emotional experience and her chronic pain before she could accept a more active role in her own recovery and rehabilitation. Similarly, when the trauma of a work-related injury or motor vehicle accident triggers and recapitulates an earlier, unresolved emotional trauma, such as childhood abuse, then what appears to be a straightforward physical injury can easily become complicated by premorbid psychological factors, making pain more tenacious and less tractable. It is not unreasonable to think that many individuals suffering such injuries, but without a history of trauma in their backgrounds, might experience a few days or weeks of discomfort but otherwise emerge essentially unscathed, having put the experience behind them.

Another problem often adversely affecting a patient’s adjustment to and recovery from injury and pain is that of secondary gain, an unconscious motivation to maintain a symptom in order to gain some advantage.11 In secondary gain, the advantage is derived from symptoms that have already formed and so could not have been foreseen or sought, even unconsciously, at the time of the original injury and development of pain and other symptoms. The gain did not contribute to the formation of the symptoms, therefore, but now contributes to the maintenance of the illness and potentially to resistance toward treatment. In psychoanalytic theory, primary gain, by contrast, relates to the intrapsychic motivation that led to symptom formation in the first place, such as the need or wish to assume the sick role and to feel both cared for and taken care of, thereby keeping an internal conflict, such as fear of inadequacy or failure, out of awareness.11

Secondary gain refers to those interpersonal gratifications that, once enjoyed through the sick role, make recovery less appealing. The sympathy and concern of family and friends, preferential treatment, disability benefits, drugs, interpersonal domination, the increased comfort of a socially sanctioned change in role, and the avoidance of certain activities may all be considered forms of secondary gain. Primary gain unfolds intrapsychically, whereas secondary gain tends to manifest in an interpersonal context. A third complication is frequently the presence of tertiary gain, which is wholly external to the patient but consists of the benefits derived by family or other caretakers from reinforcing the patient’s pain behaviors.34 The suppression of familial conflict, material benefit, and the reallocation of power within the family are among the more frequently cited tertiary gains in the economy of family dynamics. Because these unconscious motives on the part of family members can have a huge impact on the treatment of the patient and because family members can often be enlisted as allies in treatment, family meetings or, in some cases, ongoing family therapy may prove necessary to the successful psychotherapeutic management of the patient with chronic pain.35

According to the strict psychoanalytic scheme, secondary gain follows primary gain, which makes it more accurately applied to instances of somatoform disorders, such as conversion and somatization. In reality, the individual obtains certain gains with any illness, and unconscious secondary gain can develop in the aftermath of actual physical injury or disease, just as easily. Identifying what a patient gains and loses—secondary losses, such as loss of a satisfying job, livelihood, and prestige—can be critical, both to diagnosis and to treatment and recovery.11 For this reason, the medical and legal scrutiny of secondary gain is frequently given great emphasis in cases of chronic pain, and it is frequently left to a psychiatric evaluation and a psychodynamic approach to treatment to attempt to discern conscious from unconscious motivations and to distinguish instances of malingering, factitious disorder, and primary somatization from the more expectable somatizing complications occurring around physical injury or illness.36

Where the medical and legal determination of disability is concerned, strong evidence of primary gain can, nevertheless, point toward a disabling condition but may change the focus of diagnosis and treatment from medical to psychological. In some cases, the effect of this shift is to exculpate employers, insurance carriers, and other litigants from any legal responsibility for compensation or even treatment. For this reason, evidence of premorbid psychopathology is often of as great an interest, legally, as whether the sum total of secondary gains outweighs the apparent secondary losses. As with the problem of measuring pain itself, there is no empirically verifiable method of accurately and reliably determining the presence or influence of primary or secondary gain in any individual’s case, but the domain of inquiry can often be approached only through psychodynamic and supportive interventions, when the patient’s welfare is the prime concern.

A number of difficulties with the traditional concept of secondary gain have called both the concept and its utility into question. Given the obvious problem of trying to discern what is conscious from what is unconscious, some clinical researchers favor definitions of secondary gain that do away with the distinction and focus instead on behaviors that appear as if the patient is seeking some expression of gain.34 This promotes a more operational definition and opens the way to empirical investigation, but it begs the clinical question of how to approach secondary gain that is genuinely unconsciously motivated. For patients who cannot seem to make significant progress in managing their pain through behavioral and cognitive-behavioral psychotherapy and techniques, an insight-oriented approach may prove the only avenue open to influencing their level of motivation.

Supportive Psychotherapy

Although psychodynamic psychotherapy tends to place the reward on insight and interpretation of unconscious conflicts, the emphasis in supportive psychotherapy is on the strengthening of ego functions and improved adaptation.37 The psychotherapist’s understanding of the patient remains psychodynamic, but the interventions are crafted to improve the patient’s level of functioning in at least two critical dimensions: firstly, to enhance the patient’s capacity for reality testing—in effect, to anticipate what others see, when they encounter him or her, and to develop a self-observing capacity for monitoring his or her own reactions and motivations—and, secondly, to bolster the patient’s healthiest psychological defenses and emotional and intellectual resources in the service of adjusting to a new set of circumstances.

The first and often necessary step in this process for many patients with chronic pain is the experience of feeling understood, usually achieved through the opportunity to tell their story to a sympathetic listener whom they perceive to be in the helping role. What patients know best and typically wish to discuss most urgently is the social, emotional, and behavioral impact of their pain on their lives. Even when they make no connection or outright deny any influence of these factors on the development and maintenance of their physical symptoms, patients need to feel that their suffering is validated and the circumstances of their misfortune are fully appreciated by their providers. Once the patient begins to trust this inchoate alliance, often made possible by the supportive efforts of psychotherapeutic management by the entire team, the collaborative development of a rationale for psychotherapy may ensue.

The major shift enabled by supportive psychotherapy, and the reason why it is frequently a necessary prerequisite step to any other psychotherapeutic intervention, lies in its approach to moving patients from a purely mechanistic understanding of their dilemma to one in which they can consider assuming an active role in their own recovery and rehabilitation. Patients whose explanatory models of pain are deterministic or who are unaware of the influence of secondary gain, often insist on medical interventions in which they may remain passive. By enhancing their capacity for reality testing, the supportive psychotherapist can assist patients in coming to see their own stress-reactivity and toward beginning to appreciate their involvement in the pain-stress cycle.

Few patients would deny that their pain is one of, if not the greatest source of stress in their lives; and this simple acknowledgment is often the beginning of a psychoeducational breakthrough. For many patients, this shift heralds their becoming more sophisticated in their understanding of the physiology and psychology of pain and in their appreciation of the differences between pain and injury, hurt and harm. At that point, many are willing to move ahead by working with a psychotherapist toward developing strategies to make the most of their own strengths and resources for coping with stress and managing pain.

Operant-Behavioral Therapy

Operant-behavioral therapy (OBT), which has its origins in learning theory, refers to the group of interventions focused principally on the observed behavior of the patient. In the operant model of pain, the reinforcing role of social and environmental factors in the development and maintenance of pain through observed pain behaviors is identified, with the behaviors themselves being targeted for intervention. This approach may prove most effective when patients demonstrate little understanding of the relationship between their pain behaviors and the underlying physiologic damage or disease,28 and it is especially useful in cases in which the subjective experience of pain appears to go well beyond any established organic basis to the point where secondary gain has become an obvious issue and persistent, often dramatic, pain behaviors have emerged.

The goal of OBT is to encourage the development and practice of more adaptive pain management strategies by establishing and reinforcing new “wellness” behaviors, while discouraging or reducing the reinforcement of “illness” or pain behaviors.7 Thus, increased self-reliance, activity, and socialization are encouraged, whereas verbal complaints, grimacing, social isolation, and overreliance on family and caretakers are discouraged. As a form of psychotherapeutic management, OBT is not limited to the setting of individual or group psychotherapy but is usually most effective, when supported by the entire team of providers, whether in the setting of office visits, physical therapy sessions, telephone contacts, or walk-in encounters.

The basis of OBT suggests that both wellness and pain behaviors can be shaped—developed, increased, reduced, or extinguished—according to the principles of operant conditioning. Reinforcement increases the likelihood that behaviors will occur, whereas punishment or the withdrawal of reinforcement decreases the likelihood of their occurrence. When attention from a provider or family member, for example, is offered solicitously in response to the patient’s facial grimacing, there is immediate reinforcement, ensuring that this pain behavior will recur and possibly become habitual. When reinforcement is withdrawn—when the behavior no longer elicits the sought-after attention—it will decrease and possibly extinguish.

Similarly, when the patient experiences an exacerbation of pain, following an increase in activity, the exacerbation itself can serve to punish any motivation toward self-reliance and the development of wellness behaviors. Finding reinforcements that can modulate or offset the negative consequences of increased activity can encourage the patient to adopt wellness behaviors, even at the cost of some discomfort. Again, because what occurs at the clinic or psychotherapist’s office is a comparatively small sampling of behavior, encouraging the patient’s consistency of motivation—through supportive interventions and his or her family’s participation in family meetings—will result in the most successful outcome. In severe or poorly tractable cases—in which it is apparent that setting limits and assisting the patient in the development of more adaptive responses on an outpatient basis is failing—an inpatient pain program, in which the highest level of operant control is possible, may become necessary.

Whether outpatient or inpatient, individual or group, informal or structured, a variety of OBT techniques can be adapted to the patient’s particular situation, including (1) pacing and graduated activity, (2) scheduling and tapering of pain medications, and (3) social reinforcement.7 Because these techniques of operant conditioning are common to the interventions of a broad range of behavioral and psychotherapeutic approaches to the management of pain, they can be employed as a milieu therapy or as an adjunct to supportive and cognitive-behavioral interventions. On the minutest of levels, no physician or nurse or psychotherapist can sit with a patient for long, without reinforcing some responses and discouraging others with as small an intervention as a facial expression, gesture, or well or poorly chosen word.38

Cognitive-Behavioral Therapy

Whereas OBT may be considered a core behavioral therapy, basic to all programs of pain management, cognitive-behavioral therapy (CBT) has more specific psychotherapeutic goals and is usually undertaken in the formal setting of individual or group psychotherapy, whether outpatient or inpatient. CBT is directed toward changing patients’ maladaptive responses to chronic pain by examining and posing alternatives to the thoughts, attitudes, and beliefs underlying them, as well as by encouraging the acquisition of new coping skills and techniques to take their place. CBT usually includes a range of behavioral components, most notably, relaxation training and keeping a pain diary; however, the emphasis is placed on modifying emotional and behavioral responses, those that tend to affect the patient’s level of functioning adversely, by challenging and restructuring their cognitive underpinnings.

The focus of CBT, therefore, is on the development of self-control and self-regulation.28 The work of treatment is often undertaken in a threefold stepwise progression, including (1) a psychoeducational phase, (2) a skills-building phase, and (3) an application phase,7 with each phase roughly corresponding to a new milestone in self-regulation and a new stage in the patient’s readiness for change.25 In CBT, the goal is the establishment of a higher level of functioning, which the patient is now motivated to sustain and has developed the skills to maintain. In the process, the patient becomes more resilient to the comorbid development of anxiety and depression, increasing his or her perception of pain as a controllable or manageable experience.

The first or psychoeducational phase of CBT is designed to enlist the patient’s efforts as an active participant in his or her own recovery and rehabilitation. It is here that what is often referred to as the mind-body model of understanding pain is introduced to the patient. Concepts, such as stress-reactivity and the pain-stress cycle, are presented in such a way as to assist the patient in the identification of those thoughts, attitudes, and beliefs that tend to make his or her pain less tractable and his or her suffering, more severe. These self-defeating cognitions typically develop under the influence of anxiety, misinformation, secondary gain, and poorly resolved intrapsychic conflicts and often lead to depression and feelings of worthlessness, hopelessness, and helplessness. When a patient believes, “I’ll never be able to work or provide for my family or have a normal life with this pain,” despair cannot be far behind. Yet most patients come to treatment with a personalized array of such poorly examined and unchallenged cognitions.

The second or skills-building phase of CBT is designed to develop cognitive strategies enabling the patient to recognize the negative impact of his or her self-defeating cognitions and replace them with self-affirming statements, emphasizing control and adaptive coping. When a patient believes, “I have faced many problems, and I can handle this one, too,” or, “I may not be able to do everything I want, but I can do much more than I previously thought,” the motivation for rejecting pain behaviors, nurturing wellness behaviors, and raising the level of activity and social interaction becomes apparent. The cognitive restructuring techniques employed in CBT not only help patients to recognize those thoughts, attitudes, and beliefs about their pain that make them feel stuck, but also encourage the systematic substitution of more stable and positive ones that are likely to facilitate treatment across all modalities, from medications and procedures to physical and complementary therapies.

Part of the skills-building phase may also be devoted to the acquisition of other supportive coping strategies, such as stress management, anger management, assertiveness training, relaxation training, and pacing. Most of these techniques are employed in the service of identifying and modifying the patient’s response to those environmental, interpersonal, and intrapsychic triggers that increase autonomic arousal and musculoskeletal tension and adversely affect the subjective experience of pain. Relaxation training, in particular, offers a broad range of behavioral techniques designed to quiet the autonomic nervous system and relieve musculoskeletal rigidity and tension. Various forms of meditation, autogenic training, guided imagery and visualization, self-hypnosis, as well as yoga and even tai chi, have been used successfully in pain management programs, with the National Institutes of Health favorably reviewing the recent empirical data in support of the efficacy of relaxation techniques in the treatment of chronic pain.39

Biofeedback is another psychoeducational and training device that allows the patient to monitor his or her ongoing progress at developing an effective regimen of relaxation techniques. During a biofeedback session, the patient is connected by surface (skin) electrodes or receptors to an electronic or computerized instrument designed to measure, amplify, and feed back physiologic information to the patient and psychotherapist or technician.40,41 The latter, in turn, assists the patient to refine and increase the efficacy of one or more relaxation techniques in order to counteract the effects of dysponesis—maladaptive compensatory bracing in response to pain—and autonomic overarousal.42

By monitoring the level of musculoskeletal tension, through surface electromyographic leads, and the level of autonomic activity, through measures of heart rate, blood pressure, blood-volume pulse wave amplitude, skin temperature, oxygen saturation, and electrodermagraphic response, patients can see firsthand the extent to which they are having success at gaining control through the practice of regular and disciplined relaxation over processes that they previously felt were unmanageable. There is sufficient and still growing evidence to suggest that biofeedback monitoring in conjunction with behavioral therapy is an effective treatment in a number of chronic pain conditions, including migraine headache, tension-type headache, disorders of intestinal motility, musculoskeletal pain, including low back pain, and Raynaud’s disease.40,43

There is also growing interest in its application as a psychoeducational tool applied to nociceptive desensitization in patients who have become so highly sensitized to pain and other noxious sensations that their pain perception appears to have an augmented affective component or heightened emotional intensity.44 In this category, we find patients who are suffering from what may represent limbically augmented pain syndromes (the LAPS hypothesis) characterized by pain that is frequently out of proportion to clinical findings and associated with neurovegetative problems and disturbances of mood.45 This group includes patients who are suffering from fibromyalgia, chronic fatigue syndrome, certain types of visceral and headache pain, chronic regional pain syndromes, and phantom pain; and biofeedback training has been shown, in some cases, to be useful by assisting these individuals to countercondition sensations of pain with sensations of relaxation, warmth, and well-being.

Biofeedback can help patients to move toward the third or application phase of CBT in which their newly acquired collection of cognitive skills, behavioral techniques, and coping strategies develops into a more enduring and adaptive approach to pain management. Cognitive-behavioral therapy concludes, then, as patients learn to apply their skills and maintain their new outlook in progressively more challenging situations.7 In this way, it becomes, not merely a collection of tools or techniques, but a template for successfully adjusting to the ongoing intrusion of chronic pain. Patients who have successfully completed courses of CBT often refer to it as though they have undergone a change in lifestyle in which relaxation exercises and pacing have become as second nature as eating breakfast and brushing one’s teeth.

Complementary Techniques

Two additional techniques or therapeutic approaches are often undertaken in the attempt to enhance pain management, whether applied on their own or combined with other individual psychotherapies in an eclectic treatment. These are hypnosis and, of more recent origin, eye movement desensitization and reprocessing (EMDR). Whether hypnosis can play an effective first-line role in the management of chronic pain remains controversial.46 As a technique for inducing genuine analgesia, it is applied far more often in the management of acute and surgical pain, and many practitioners see its principal worth in addressing chronic pain as simply that of evoking the relaxation response. For those patients who cannot master meditative techniques or comfortably employ progressive muscle relaxation, self-hypnosis can become an essential skill in the management of musculoskeletal tension and autonomic overarousal. In the case of those patients with chronic pain who have used hypnosis—whether hypnotherapy with a practitioner or self-hypnosis—to achieve analgesic relief from exacerbations or flare-ups or who use it regularly for time-limited relief or respite, additional study is needed to discern the generalizability and applicability of the technique.

EMDR is a comparatively new addition to the panoply of psychotherapeutic approaches to the management of pain, but its role in facilitating the cognitive processing of physical and emotional trauma associated with the origin of chronic pain is already promising. EMDR was developed as a precise technique, which, like hypnosis, requires specialized training for the practitioner.47 Although compatible with psychodynamic and cognitive-behavioral approaches, its techniques are directed toward the evocation of the patient’s capacity for rapid information processing to facilitate the processing of traumatic or dysfunctional thoughts and feelings.

The goal of this approach is to disengage affective memories that may be linked to pain through remembered or associated experience but not to the specific situation giving rise to pain in the present. By detaching or releasing these affective memories, EMDR restores the affective dimension of pain to a level more consonant with the actual situation giving rise to the pain. In effect, like the goal of psychodynamic psychotherapy, the result of EMDR is to separate past from present trauma, allowing the patient to process what were heretofore overwhelming emotions, focus on his or her present dilemma, and move forward in his or her recovery and rehabilitation. The possible applications of EMDR to limbically augmented pain syndromes are obvious and compelling; but, as with hypnosis, additional study is needed to discern the generalizability and criteria for applying the technique in cases of chronic pain.

The formal practice of conducting group psychotherapy with medically ill patients is nearly a century old.48 In the first recorded groups of this nature, the leaders—usually medical personnel—instructed patients on the medical aspect of their illness and encouraged them to present weekly reports to the group regarding their medical and spiritual progress.49 The goal of these groups was to help patients cope more adaptively with their illnesses by addressing issues of self-confidence, self-esteem, and physical well-being50; and what began with tuberculosis sufferers was soon extended to groups for patients with other illnesses, including asthma, cancer, irritable bowel syndrome, skin disorders, and chronic pain.

Participation in groups offers a variety of advantages for patients with chronic pain. Group psychotherapy tends to be more affordable than individual treatment for both patients and health insurance carriers, and there is increasing evidence that participation in a group reduces the number of visits and telephone calls to physicians, further relieving strain on the medical care system.51 Far more importantly, however, the effectiveness of group psychotherapy in the reduction of the psychological and physical distress accompanying chronic medical illness is well documented,50,52 and patients with a broad range of medical illnesses demonstrate improved compliance, decreased physical symptoms, decreased symptoms of anxiety and depression, and increased self-esteem.53,54

In the treatment of patients with chronic pain, three approaches have emerged as dominant: support groups, psychodynamic groups, and structured cognitive-behavioral or behavioral medicine groups.55 There is considerable evidence to suggest that groups with a strong CBT or behavioral medicine component are the most effective,7,50 but, despite their differences in theory of approach and intervention, all three models share a range of common goals for treatment. Group psychotherapy can offer patients with chronic pain (1) validation of their experience, (2) increased self-esteem, (3) decreased social isolation, (4) opportunities to express frustration appropriately and practice assertiveness, (5) enhanced reality testing through opportunities to compare experiences with others, (6) a sense of satisfaction from helping others, (7) education about the pain-stress cycle and other psychosocial and medical factors involved in chronic pain, (8) the acquisition of a new set of coping skills, (9) encouragement for the development of more adaptive strategies for stress and pain management, and (10) reduction in symptoms.

Support Groups

The most popular and numerous groups for patients with chronic pain are support groups, which are frequently led by patients themselves and are often affiliated with patient- and volunteer-staffed organizations, as opposed to medical clinics, hospitals, or professional personnel. Many of the virtual support groups, electronic bulletin boards, and chat rooms of the various on-line services may be included in this category. Their emphasis is on providing social and emotional support for their members, as well as a forum for sharing medical information, but they often lack the specific goals of acquiring new coping skills and developing more adaptive stress and pain management strategies. In certain situations, they can also promulgate the spread of misinformation and lend uncritical endorsement to maladaptive strategies for pain management.

Although support groups can be effective for many patients who would otherwise have little opportunity to compare their experiences with others and seek validation, the cohesiveness and continuity of these groups may suffer from a lack of direction or supervision. A number of factors can spark disagreements between members and lead to fragmentation of the group, including erratic attendance by some members; differences in need, level of functioning, and interpersonal skills; dominance of the discussion by stronger personalities; and differences in perceived goals. Having an assigned lay leader or even a skilled professional leader may not rule out all of these pitfalls, but it will likely ensure greater cohesion and longevity of purpose and direction.

Psychodynamic Groups

Less structured than cognitive-behavioral groups, psychodynamic group psychotherapy in the setting of chronic pain has as its goal the creation of an interpersonal laboratory in which communications among the members can be examined within the dynamics of the group.56 By observing, analyzing, and interpreting how each member relates to the group, the group’s leader—always a professional mental health specialist—can assist each member, as well as enlist each member’s help in assisting the others, to come to a better understanding of how chronic pain is affecting his or her relationships, social and occupational functioning, outlook on the world, and self-esteem. As with individual psychodynamic psychotherapy, the goal is to make the unconscious basis of conflicts and maladative defensive strategies more accessible to each member by examining the interpersonal impact that each member has on the group.

The psychotherapist in the psychodynamic group uses interventions designed to foster connections between the members and facilitate the give and take of the members’ reactions to one another. The use of maladaptive defenses or the adoption by one of the members of self-defeating or interpersonally destructive choices are examples of behaviors that are typically challenged by the psychotherapist and other group members. To consolidate these insights and therapeutic gains, the psychotherapist often will articulate the themes and shared struggles of the group in an effort to move the members toward (1) a more realistic appreciation of their situations and the impact of their communications on others, (2) a greater reliance on their own natural resources and strengths, and (3) the acquisition of new behaviors and patterns of communication, reflecting more adaptive strategies for coping and more functional and health-affirming choices.

Behavioral Medicine Groups

Behavioral medicine and mind-body medicine are terms often used to describe a model of care that addresses the effects of stress on a disease or symptom, as well as the stress of chronic illness on the individual patient. Treatment according to this model addresses the biologic, psychological, and social issues, not just the biomedical ones, with the mode of intervention being CBT. In effect, behavioral medicine groups are highly structured, time-limited CBT groups, directed toward specific populations of medical patients, such as patients with chronic pain. The varieties of intervention can include any or all of the techniques one would find in individual CBT, including relaxation training—meditation, autogenic training, hypnosis, self-hypnosis, guided imagery and visualization, and even yoga or tai chi—cognitive therapy, pacing activities, and keeping a pain diary.

Behavioral medicine has traditionally involved a multidisciplinary effort that recognized and supported the synergy created by bringing together professionals in both mind and body to focus their expertise on the treatment of medical problems, such as cardiovascular disease, cancer, and chronic pain. Such collaboration has produced considerable research in the clinical efficacy of these combined treatments and in the cost-effectiveness of offering them to patients.57 Behavioral medicine distinguishes itself from psychiatry and psychology by attending principally to the physical symptoms of patients and their effects on stress, coping, and emotions, as well as the effects of stress, coping, and emotions on the experience of physical symptoms. If psychopathology proves to be a determining factor in a particular patient’s expression of physical symptoms, then that patient is referred to psychiatric providers; however, many depressed, anxious, and even personality disordered patients with chronic pain nevertheless benefit from participation in behavioral medicine groups, along with their psychiatric care.

Applications of Behavioral Medicine Groups to Chronic Pain

In October 1995, the National Institutes of Health (NIH) convened a Technology Assessment Conference to consider the integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia.39 The consensus panel concluded that there were sufficient data to recommend the inclusion of cognitive-behavioral therapies in the treatment of chronic pain. In a review of the relevant research, the panel cited a range of findings—including that all six of six factors identified in the correlation of treatment failures of low back pain are psychosocial—and recommended the integration of relaxation techniques with conventional medical procedures as a necessary step in the successful treatment of chronic pain.

Cognitive-behavioral skills can benefit the majority of patients experiencing chronic pain, because the emphasis is on the pain-stress cycle—both the stressful effects of pain and the effects of stress on pain. Groups can, therefore, be composed of patients with different diagnoses or etiologies of pain if there are not sufficient members for a single diagnostic group. Mixing diagnoses, furthermore, may actually have advantages, because patients come to realize that the experience of pain has universal features, qualities, and consequences. This realization frequently leads, in turn, to the inevitable comparisons patients make between their circumstances, often accompanied by the observation, “Things could be worse!” One of the principal advantages of group over individual psychotherapy is the power of the experience of validation that comes from sharing a common crisis in one’s life with others who have similar experiences. That experience of psychosocial support has been shown repeatedly to have a significant positive influence on patients’ coping and the course and outcome of disease.58

A further advantage is that the format of the behavioral medicine group can be adapted to small or large numbers of patients, depending on whether the model is largely psychoeducational or more psychotherapeutic. Psychoeducational models can accommodate groups of up to 25 or 30 patients, whereas psychotherapy groups are generally limited to 6 to 10. The format of behavioral medicine groups is flexible enough, in most cases, to adjust to the needs of the setting, the credentials of the providers or leaders, and the mechanism of reimbursement. Some models even incorporate the use of patients who have previously “graduated” from the group—or who have received special training—as assistant facilitators or, with ongoing professional supervision, even as lay providers, conducting groups largely on their own.59

Goals and General Format of Behavioral Medicine Groups

Behavioral medicine groups are applied to the problem of chronic pain with three specific goals: to assist patients with (1) mastering skills for both stress and pain management, (2) mobilizing those skills routinely but especially during periods of increased stress and pain, and (3) developing self-efficacy—the belief and attitude that engaging in certain behaviors will reach a desired outcome. Encouraging patients to set and discuss the goals they hope to achieve in the group can help them to identify unrealistic expectations and engage them in taking the first steps toward the development of self-efficacy.

Ideally, the recommendation to participate in a cognitive-behavioral group is part of a coordinated multidisciplinary treatment plan, formulated after a comprehensive evaluation of the patient. There have been many attempts to predict the attributes associated with the successful completion of behavioral medicine groups, but only a few trends—and multifactorial ones, at that—have been identified.60 In general, patients who are psychologically or cognitively impaired or who exhibit disruptive behaviors or who are nonambulatory are at greatest risk for failing to enter treatment or for attrition from a group they have begun, whereas patients who demonstrate high motivation and a collaborative approach to their own medical care tend to have a high rate of completion.

Group leaders or providers may come from a variety of disciplines, including physicians, psychologists, social workers, nurses, and physical therapists, but essential criteria for their success tend to be that they (1) enjoy working with the chronic pain population, (2) have training in group therapy and group dynamics, and (3) recognize the strong influence of learned helplessness on patient compliance. A setting with pleasant surroundings and comfortable chairs, as well as mats for exercising and lying down, is most conducive to learning, when in pain; and a schedule of weekly meetings that last 1½ to 2 hours does not overtax most patients’ capacity for attention and endurance, even if reduced by the presence of pain. Most behavioral medicine groups run for 8 to 10 weeks, which appears to cover the critical period necessary for the three phases of successful CBT: (1) psychoeducation, (2) skills-building, and (3) application and maintenance.7

There is considerable latitude in the content of sessions, in the order of presentation, and in the forms of presentation. In most sessions, the time will be divided into several components, with periods allocated for (1) presentation of new instruction; (2) supervised practice of developing skills, such as relaxation techniques; (3) presentation and discussion of homework, for example, pain diaries and checklists of daily relaxation exercises; and (4) stretching and mild exercise or yoga. There are many curricula, designed specifically for behavioral medicine groups with chronic pain patients, available in commercially published workbooks.61,62 A brief description of the content proposed by one of these workbooks for ten sessions of a group for patients with chronic pain is presented in Table 14-1.61

Research has demonstrated that patients with chronic pain who participate in multidisciplinary programs with behavioral medicine groups feel less anxious, less depressed, and less pain, while simultaneously experiencing greater control, increased socialization, and a heightened sense of self-efficacy.63,64 Patients exposed to CBT programs also appear to rely on the medical system more appropriately, reducing the number of clinic visits and telephone contacts made out of frustration and fear.51,59,65,66 One patient summarized her experience of her participation in a behavioral medicine group, capturing the essence of the therapeutic goals, when she said, “I know it’s going to be a good day, because I know how to make it a good day.”61

The goal of psychotherapeutic management of chronic pain is not merely the reduction of pain but the restoration of functioning. The patient with chronic pain will always face limitations, but assisting him or her toward more successful adjustment and more adaptive strategies for coping is the role of psychotherapy in the multidisciplinary approach to pain. Successful psychotherapeutic management involves not only a multidisciplinary approach, but also an interdisciplinary effort in which the interventions of each member of the team of providers can be seen as having a psychotherapeutic impact on the patient, as well as a complementary effect on the interventions of the other providers. Assessing the degree to which any patient is stress-reactive and addressing his or her own unique expression of the pain-stress cycle may involve the application of one or more types of individual or group psychotherapy. An eclectic approach tends to offer the greatest versatility, but cognitive-behavioral therapies, whether individual or group, have demonstrated the greatest efficacy with the chronic pain population.