A collection of postings on a range of issues is available on our website (www.mjacksongroup.ca). This month’s post is again from Ken Pope’s listserv, where he kindly provides daily summaries of current articles in the field.
Psychological Science in the Public Interest includes an article: “Psychological Interventions for the Treatment of Chronic Pain in Adults.”
The authors are Mary A. Driscoll, Robert R. Edwards, William C. Becker, Ted J. Kaptchuk, & Robert D. Kerns.
Here’s how it opens:
Psychological approaches for managing chronic pain are widely recognized as significant components of an integrated, evidence-based, patient-centered, multimodal, and interdisciplinary care plan. However, a significant gap exists between the evidence for the effectiveness of several psychological interventions and their routine availability and use in clinical care. This article is intended to address that gap by providing a comprehensive examination of these approaches in the context of foundational principles of chronic pain and chronic-pain management and articulating future directions for research and innovations in practice.
The review begins by offering a definition and a brief overview of theories of chronic pain that inform the science and contemporary models of chronic-pain management. The biopsychosocial perspective is employed to highlight the multidimensional nature of chronic pain and to explicate psychological and social or contextual factors thought to contribute to the development, maintenance, and exacerbation of the pain experience. Gaps in scientific knowledge and practice are also discussed.
The overview is followed by a more detailed consideration of the theoretical and empirical foundations of psychological treatments for chronic pain. Specific categories of psychological treatments will be described, followed by a narrative review of the empirical evidence supporting their efficacy and effectiveness, whether delivered alone or in the context of multimodal and interdisciplinary care. Later, general and specific mechanisms hypothesized to underlie the efficacy or effectiveness of these approaches, models for integrating psychological interventions into multimodal, patient-centered pain care, and evidence supporting these models will be discussed. A critical review of that evidence follows, where key components of successful integrated-care models and the value added by psychological treatments are highlighted.
Other important issues that may affect the effectiveness of psychological treatments for chronic pain are described, including overlapping pain conditions, high rates of observed medical and mental health comorbidities and health-risk behaviors, and individual differences and disparities. Important assessment and measurement issues, including phenotyping and outcome measurement, biomarkers, modifiers and mediators of effects, and advances in the use of technology-assisted assessments are also addressed. In addition, observed barriers to timely and equitable access to psychological treatments for chronic pain will be discussed, highlighting patient, provider, and organizational or systemic barriers.
Fig. 1. Biopsychosocial model of chronic pain (based on the work of Engel, 1978).
Excerpt: “Relaxation training interventions are perhaps the oldest and most widely used of the SRTs. Relaxation training is a broad term that encapsulates various strategies that target the purposeful activation of the parasympathetic nervous system. In so doing, these strategies down-regulate the stress response and the sympathetic nervous system. As the former response diminishes, the heart slows down; breathing deepens, muscles relax, the body regains its ability to repair strained tissue, and pain decreases. Deep breathing, progressive muscle relaxation, and visual imagery are all examples of relaxation strategies that were at one time used as stand-alone pain-management strategies or embedded into biofeedback and other self-regulatory interventions. Older reviews demonstrated that relaxation has some utility in reducing the severity and frequency of headaches (Turner & Chapman, 1982). At least one recent review of chronic nonmalignant pain suggests that when used as a stand-alone intervention, relaxation is not associated with improvements in pain intensity (Jeffrey et al., 2016) but may be associated with an improved ability to manage pain and decreased use of analgesics (Jeffrey et al., 2016; Turk et al., 2008). Although relaxation training can be deployed independently, it is typically delivered as one of many pain self-management strategies in the context of other psychological interventions or multidisciplinary treatment programs for chronic pain.”
Excerpt: “Biofeedback is effective for a variety of painful conditions, though the evidence supporting its use is perhaps most widely chronicled with respect to back pain (Sielski et al., 2017). Indeed, one large, recent meta-analysis revealed a small to moderate uncontrolled effect on pain intensity that was stable over long-term follow-up and effects on pain and muscle tension that were comparable to those of active control treatments (Sielski et al., 2017). Findings in this meta-analysis suggested that biofeedback also successfully produced small to medium long-term effects on depression, disability, muscle tension, and cognitive coping. As the length and frequency of biofeedback sessions increased, greater improvements in pain-related disability were observed. Though effective, biofeedback requires specially trained personnel and the requisite equipment to do it; this equipment can be pricey, and trained clinicians are often in short supply.”
Excerpt: “No discussion of SRTs for chronic pain would be complete without including hypnosis, also called hypnotic analgesia. Though acknowledged to treat pain since the 1800s, hypnosis was formally adapted for use with chronic pain and subjected to rigorous evaluation only over the past 20 years. There is great variation in the delivery, active components, and, indeed, the very definition of hypnosis. This variation may contribute to its limited uptake in the broader field of nonpharmacologic interventions for chronic pain (M. P. Jensen & Patterson, 2014).”
Originally described by Fordyce in the 1960s, operant-conditioning models of chronic pain rely heavily on learning theory. Fordyce argued that in contrast to the prevailing view of pain as a subjective, internal experience, pain manifests in behaviors that are observable to others and hence subject to external contingencies in the same manner as any other behavior (Fordyce, 1976). According to this model, maladaptive pain behaviors consistent with the “sick” role (e.g., complaints of pain, withdrawal from normal activities, grimacing) may be reinforced by positive consequences (e.g., care from loved ones, analgesic highs, disability compensation) or the avoidance of unwanted outcomes (e.g., work, participation in undesired activities). Operant-behavioral interventions seek to sever these unhealthy conditioned associations and replace them with healthier behaviors that encourage individuals to abandon the “sick” role for a “well” one.
Operant-behavioral interventions first identify the maladaptive contingencies that reinforce pain behaviors; they then promote more adaptive behaviors that are desired (e.g., self-management behaviors such as exercise, participation in activities or chores). Therapeutic interventions are founded on core principles of contingency management and simultaneously target (a) elimination of the positive consequences and avoidant reinforcements that follow pain behaviors and (b) social reinforcement of desired behaviors. Early tests of operant-behavioral interventions were conducted in intensive residential treatment programs in which professional staff delivered positive reinforcements (most commonly praise) for adaptive “well” behaviors while ignoring pain behaviors. These programs emphasized engagement in goal-directed behavioral therapies, including structured exercise programs and other social activities led by psychologists and physical, occupational, and vocational therapists.
Excerpt: “Among the psychological approaches to chronic pain, CBT-CP [CBT for Chronic Pain] has emerged as the gold standard in self-management. It has been widely studied and found to be largely effective across various pain conditions and populations (Ehde et al., 2014; Williams et al., 2012). Compared with standard care, CBT-CP yields greater improvements with respect to pain intensity, physical functioning, catastrophizing, and mood. Many randomized controlled trials (RCTs) have investigated the use of CBT-CP for pain. Several comprehensive meta-analyses of trials comparing CBT-CP with other active interventions based on cognitive-behavioral principles have revealed that CBT-CP prompts significant improvements in pain, physical functioning, mood, coping, and social functioning (Eccleston et al., 2009; Hoffman et al., 2007; Williams et al., 2012). Indeed, a 2012 Cochrane review of psychological interventions for chronic pain (excluding headache) that examined 35 trials revealed a small to moderate advantage for CBT-CP compared with active controls on measures of disability and catastrophizing, but not on pain or mood, and a small to moderate advantage compared with treatment as usual on measures of pain, disability, catastrophizing, and mood (Williams et al., 2012). Thus, findings from these meta-analyses have largely supported CBT-CP as an effective treatment for chronic pain. Indeed, compared with more traditional medical approaches, CBT-CP emerges as not only more clinically effective but also more cost-effective (Gatchel & Okifuji, 2006; Turk & Burwinkle, 2005). CBT-CP has also been successfully tailored for specific types of pain (e.g., back pain, fibromyalgia; Williams et al., 2012) and populations (e.g., children, adults with low literacy, patients with neurological conditions; Ehde et al., 2014). Although traditionally delivered in face-to-face settings, CBT-CP has been successfully adapted for delivery in a variety of formats (e.g., Web-based, telephone-based, interactive voice response) to improve access; in terms of outcomes, these adapted formats are comparable to traditional ones (Heapy et al., 2015). Given the high volume and quality of research supporting the effectiveness of CBT-CP for pain self-management, the NPS emphasizes the inclusion of these programs as standard components of sound pain care and advocates for both public and private insurers to cover them.”
Excerpt: “Informed by both Skinnerian operant behaviorism and core principles of cognitive social learning theory, Hayes proposed a “third-generation” cognitive-behavioral approach termed acceptance and commitment therapy (ACT) as an alternative to operant-behavioral interventions and CBT-CP (Hayes, 2004). Hayes proposed a novel theoretical model, termed relational frame theory, predicated on the idea that human language and cognition are learned and therefore modifiable through the application of operant-behavioral principles (Hayes et al., 2001). At its most fundamental level, Hayes’s approach is the antithesis of virtually all other pain-management approaches, which emphasize pain as “bad” and seek to reduce its intensity. By contrast, acceptance- and mindfulness-based approaches encourage the acceptance of pain and focus on identifying and reinforcing behaviors consistent with valued social roles and desired behavioral goals. At their core, these approaches move away from CBT-CP’s emphasis on logic and the role of “helpful” thinking as a precursor to optimal physical functioning and emotional well-being. Instead, acceptance- and mindfulness-based approaches normalize suffering as an inherent part of the human condition and acknowledge that psychological suffering is highly correlated with physical pain. They encourage persons with pain to pursue valued activities by accepting, rather than challenging, pain and associated thoughts or emotions.”
Excerpt: “As psychological interventions for chronic pain such as supportive psychotherapy, biofeedback, CBT-CP, and acceptance- and mindfulness-based interventions have garnered support for their effectiveness across a variety of painful conditions and populations, they have become more mainstream and acceptable to patients and providers alike. Efforts are currently under way to investigate which interventions work best and for whom. Emotional-awareness and expression therapy (EAET) is a more recent therapeutic intervention that seeks to address this question. At its core, EAET targets the hypothesized connection between physical and emotional pain first postulated by Sarno (1998). Psychological processes such as mood, appraisals, and thoughts are critical contributors to pain. However, some researchers have argued that psychosocial and emotional processes may be particularly salient for many people with chronic pain (Lumley & Schubiner, 2019a, 2019b). Indeed, the literature seems to support this assertion; early-life traumas, posttraumatic stress disorders (PTSDs), and life stress have demonstrated strong associations with many chronic painful disorders (Seng et al., 2006). Notably, research has suggested that certain patients, including those classified as interpersonally distressed and those with comorbid trauma, may evidence suboptimal responses to evidence-based psychological interventions for pain (Turk, 2005). Perhaps this is because existing psychological interventions for pain do not directly target disrupted emotional or relational processes. Because emotional and physical pain share overlapping neurobiological substrates, disrupted emotional or relational processes may maintain or exacerbate the physical experience of pain (MacDonald & Leary, 2005).”
Excerpt: “Racial and ethnic disparities in pain care may be driven in part by false beliefs about people of color (Meints et al., 2019). In a primary-care setting, Black and Hispanic patients were monitored more closely for potential drug abuse than White patients were (Becker et al., 2011), which suggests that providers believed non-White patients were more likely to misuse and abuse opioid prescriptions. Hoffman and colleagues also found that nearly half of a sample of medical students endorsed false beliefs about biological differences between Black and White individuals, and those who did so reported lower pain ratings for Black patients compared with White patients (Hoffman et al., 2016). A recent meta-analysis of studies using the implicit association task (IAT), a test of unconscious bias in attitudes and beliefs, revealed that of the dozens of studies that have used the IAT to evaluate provider bias in relation to health disparities, over 80% found evidence for biases in favor of Whites or against people of color across levels of training and disciplines (Maina et al., 2018).”
Here’s how the article ends: “Embracing the biopsychosocial model of pain and its management, psychological interventions for chronic pain have emerged as critical components of effective multidisciplinary pain care. Indeed, the NPS strongly encourages the widespread dissemination of psychological interventions to improve functioning and quality of life among individuals with chronic pain while simultaneously reducing practitioners’ overreliance on strategies (e.g., opioids, surgical interventions) that may convey more risk than benefit. Despite overwhelming evidence for the effectiveness of psychological interventions in the management of chronic pain, gaps in knowledge and barriers to uptake remain. In particular, efforts to optimize the effectiveness of such interventions, to educate persons with pain and their providers about their utility, to broaden their reach, and to tailor them for unique populations remain important avenues for continued research.”
TO OBTAIN A COPY OF THE ARTICLE: Mary A. Driscoll, Department of Psychiatry, Yale School of Medicine Email email@example.com
Ken Pope, Melba J.T. Vasquez, Nayeli Y. Chavez-Dueñas, & Hector Y. Adames:
Ethics in Psychotherapy & Counseling: A Practical Guide, 6th Edition (Wiley, 2021)
“No, no, you’re not thinking, you’re just being logical.”—Niels Bohr, Nobel Prize in Physics (1885-1962)