Behind the Book
We asked authors Herta Flor, PhD, of the Central Institute of Mental Health, University of Heidelberg, Germany, and Dennis C. Turk, PhD, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA, to give us a glimpse inside the book:
Q: The book describes how cognitive and behavioral factors play a major role in chronic pain. Can you give an example (from your own clinical experience, perhaps) that shows how powerful memories or expectations of pain can be?
A: There are many, many clinical instances that illustrate the important roles of cognitive and behavioral factors in the perception of pain, adjustment to the presence of long-standing noxious sensation, disability, and response to treatment. We can provide a few brief examples.
One of our patients, a 48-year-old woman, came to an assessment interview with her husband. As she slowly walked into the room, her husband was carrying her purse. He helped her to sit down, which was accomplished with some difficulty and posturing. The husband was extremely solicitous, encouraging her to move carefully and not "overdo it." He explained that he was carrying her purse because the weight added to her pain. The husband's behavior demonstrated the role of reinforcement contingencies on the patient's behaviors and became an important target of treatment because we did not want him to undermine his wife's plan to increase her activity, which would most likely be accompanied by some behaviors that conveyed distress.
Another example was a 68-year-old man who had received orthopedic surgery that involved the implantation of steel rods along his lumbar spine. This patient was extremely resistant to engage in active physical therapy. When we asked why he was not performing the prescribed exercises, he said he was afraid the recommended activities would increase his pain too much, might cause physical damage, and worst of all, might "break the rods." Obviously, this set of beliefs was serving as an impediment to improved physical functioning, and it became a target for intervention.
An especially powerful example of the effects of a pain memory is a simple assessment task we often use where we ask the patient to merely remember or imagine a pain episode. This request invariably leads to an increase in muscle tension or skin conductance level, measures of negative affect and arousal. This exercise shows the patient how memory traces can be directly translated into bodily reactions. An even more impressive example is the fact that the same magnitude of nociceptive painful stimulation is processed in a completely different manner depending on an individual's pain history. Thus, if a person has experienced unpredictable pain for several days, other brain regions are activated in a functional imaging study than if the pain was predictable, even though the physical stimulus that was applied was the same.
Q: You provide a lot of practical information on the assessment and treatment of patients with chronic pain. Can you describe how the protocols you provide in this book and on the accompanying CD can be directly applied to clinical practice?
A: Our impression from reading many journal articles and book chapters that mention different assessment methods and treatments is that they tend to be rather general and do not provide a great deal of information about important details of treatment that would make these methods applicable for practical use by clinicians. In this volume, in addition to providing the rationale for our approach, we describe different assessments and treatments in as much detail as possible, providing practical suggestions and clinical insights that will help clinicians to apply these methods in their practices.
Q: Is this book intended to be a handbook for clinical psychologists? Will other clinicians—physicians or nurses, for example—be able to use the assessment and treatment protocols you provide?
A: The biobehavioral perspective and many of the assessment methods and treatment principles that we describe can be used by the entire range of health care providers, not just clinical psychologists. Some of the treatment techniques can be used by most clinicians. Specific treatments such as biofeedback or cognitive restructuring, however, do require specialized knowledge and training and would best be provided by clinicians with appropriate behavioral health care training.
Q: Why is it that patients with low back pain, for example, are coming to psychological treatment only after a series of medical treatments have failed?
A: Several factors contribute to such excessive delays. Health care providers as well as patients tend to believe in what we call an acute illness model, in which the presence of symptoms is an indication of underlying physical pathology. The assumption is that once the cause of the symptoms is identified, it should be removed, or if that is not possible, then treatments should be provided—whether pharmacological or surgical—that cut or block the "pain signals." If pain persists, then a quest begins to find THE treatment that will resolve the problem. Unfortunately, there may not be any treatment that can eliminate all of the pain, yet the futile search drags on and may contribute to even greater disability. This process can delay appropriate rehabilitation, with an emphasis on self-management, for excessive periods, often years, with greater deconditioning as the unintended consequence. For example, in an early meta-analysis that we conducted, we found that the average duration of pain at the time patients were referred to interdisciplinary pain centers was 7 years. Another negative consequence of the prolonged search for a cure or an optimal treatment is that it creates a "yo-yo" effect, where each new provider or new treatment is presented with some expectation of benefit. Patients may have faith that the new treatment will eradicate their problems, and a failure to obtain the anticipated effect may contribute to an increased sense of frustration and depressed mood.
Q: According to the evidence base, would it be better to apply treatments such as relaxation training or operant group therapy earlier on, rather than as a last resort?
A: Absolutely! The longer the patient continues to seek treatment, going from provider to provider and from treatment to treatment, the greater the chance for excessive disability and depressed mood. In an early study, the pioneer of behavioral pain treatment, Bill Fordyce, and his colleagues once showed that a simple limitation of bedrest, along with taking medication not "as needed" but on a fixed schedule, greatly reduces the chronicity of acute back pain.
Q: What's your philosophy on tailoring a treatment to the individual patient? How can you tell whether behavioral (operant) therapy, cognitive-behavioral therapy, biofeedback, or relaxation training will be most effective?
A: We strongly advocate customizing treatments to individual patient needs and characteristics. Having said that, we are only just beginning to learn about how to match treatments to individual patients. This is an important area of future research. Most clinical trials present group data. Even when a treatment is demonstrated to produce a statistically significant effect, we have little information about what sets apart the patients who derive a substantial benefit from those who achieve a modest effect, or those who receive little benefit or may even get worse. We describe several studies in the book that have directly investigated the potential of treatment matching. At present, however, the best approach we can suggest is to conduct a careful and thorough assessment of patients and understand the targets of the different treatments, using these targets as the basis for treatment decisions. It is also important to monitor progress and modify treatments depending on how well the patient is accomplishing the goals of pain reduction, functional improvement, and improvement in overall health-related quality of life.
Q: What are the most promising new treatment methods based on new insights about learning-related maladaptive plastic reorganization of the brain?
A: Recent treatment methods that focus on the reversal of brain changes related to chronic pain attempt to eliminate pain memory traces from the brain. This can be accomplished by a number of methods, including pain extinction training, which focuses on reducing pain-related behaviors and increasing positive pain-incompatible behaviors. Other promising methods include cognitive interventions that divert attention from the pain and treatments such as mirror therapy or virtual reality training that provide feedback of an intact body to the brain. Various types of biofeedback may achieve similar results. They all have the goal of altering maladaptive brain changes by providing "normal feedback" to the brain, which helps to target maladaptive changes and replace them with non-pain-related positive associations.
Q: Herta, can you talk about your personal experience with some of these exciting cutting-edge approaches in your own patients?
A: We have made some unexpected discoveries in chronic pain patients using these methods. For example, just showing patients their painful back in a mirror or on video reduces the pain they feel in that body region. This may be related to the fact that seeing another person in pain evokes adaptive responses that transfer what one sees into altered perception. Seeing one's own back may elicit similar potentially adaptive mechanisms. Phantom limb pain patients can enhance the sense of control they have over their phantom limb when they receive mirror feedback. They also report that an enhanced sense of control helps them to reduce the pain they experience in the phantom limb. We also found unexpected positive evidence for our request that patients should refrain from talking about pain in our group extinction sessions because their comments might focus their attention on the pain. In an attention control group where we asked patients and social workers to freely discuss any pain-related problems, we found an increase of pain and pain-related interference that persisted up to several months after the treatment. Needless to say, we offered the standard treatment to these patients when we discovered this negative effect!
Q: And Dennis, what are the most successful psychological therapies in use at your clinic?
A: There is no one particular psychological treatment that is superior. What is more important than treatment techniques is your perspective about your patients. Different treatment techniques can produce comparable improvements because they share some underlying principles—mainly an emphasis on self-efficacy and self-management. Regardless of the cognitive, behavioral, or physical techniques that are included in treatment, patients need to learn specific skills they can use to manage their pain and their lives, to whatever extent possible. Not only must they learn self-management strategies, they also have to develop a sense of confidence and competence in their own abilities to live meaningful lives despite the presence of some level of pain. In the volume we note and paraphrase the Serenity Prayer: "Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference." In addition to learning what they can do on their own, patients need to take the initiative to actually make appropriate changes and to adopt a self-management perspective that extends for long periods of time, because we do not have a cure, and at least some level of pain may persist for extensive periods of time. It is important for patient to generalize what they learn within treatment to their natural environments and to maintain their efforts over time, despite flare-ups and setbacks.
Q: Are psychological therapies appropriate or feasible in the low-resource setting? What about in war-torn parts of the world?
A: Not only are they feasible, psychological methods may be the best alternatives for use when sophisticated and expensive interventions are not available. We do need to develop more efficient ways to deliver these treatments, or at least components of these treatments, more efficiently and effectively. Developing technologies from the Internet and smart phones with lower costs are making these approaches more reasonable. A number of studies are beginning to demonstrate potential creative and innovative uses of these technological advances. We expect to see them used much more in the next few years.
Q: Can you give an example of a psychological therapy that has proven very successful with children?
A: Cognitive-behavioral therapies, biofeedback, and relaxation have all been studied in children and adolescents. There is a wealth of evidence demonstrating that these treatments are at least as effective, if not more so, in young populations compared to adults. Children and adolescents seem to be particularly responsive because they may not hold some of the same stereotypes that adults may have about the use of psychological modalities.
Q: What about older adults—will clinicians working with this population need to use different treatment options? Is age taken into account in group therapy?
A: As in the case of children and adolescents, research has demonstrated that psychological therapies can be effective regardless of the patients' age. Obviously, some modifications might be necessary to take into account physical limitations that accompany the aging process. For example, written materials may need to be modified to make sure the presentation is appropriate for those with a visual impairment. Audio materials will need to be customized to any limitation in hearing, and so forth. Of course, for both children and older adults, some customization of content and presentation will need to be considered for those with limited education, verbal skills, and cognitive abilities. It is up to the clinician to know his or her patients and to adapt the methods to meet specific requirements and limitations.
In addition, the myth that the brain is plastic only in children and "hard wired" in adults, with especially little flexibility in old age, has been dispelled in the last 20 years. Research in animals and humans has shown that the aging brain does not lose its capacity for plastic changes and that stimulation and training can have amazing effects, even including the production of new nerve cells. This is exciting news for everyone, but especially for older people.
Q: The book emphasizes multidisciplinary care—for example, a psychologist working in collaboration with a referring physician. Dr. Turk—based on your years of experience in the setting of a multidisciplinary pain clinic—is that model of care the ideal way forward for treatment of chronic pain?
A: Absolutely! Recently a report was published in the United States by the Institute of Medicine, a branch of the National Academy of Science, that emphasized the importance of interdisciplinary pain management. However, interdisciplinary care does not have to take place in a specialized pain clinic. Given the complexity of chronic pain and the impact on all elements of patients' lives, it is naive to assume that one more pill, one more procedure, or one single clinician will be able to address the myriad of problems that these patients experience—physical, psychosocial, and behavioral. Availability and costs may limit the model of care being conducted in a special clinic, but in primary care there is a growing awareness of the importance of having teams of physicians, behavioral health specialists, and physical therapists that provide care for the entire patient and not just his or her individual body parts.
Q: This book promises to be very accessible and useful for psychologists as well as pain clinicians. Any final comments?
A: We have provided a detailed and comprehensive rationale for the biobehavioral approach to the management of patients with chronic pain. We show how assessment should follow this model and guide treatment. We believe this integrated approach will lead to the best outcomes for the majority of patients. We provide detailed clinical protocols for assessment and treatment, and we also include our clinical insights from over 60 (combined) years of experience working in the field of pain management. We present the empirical and evidence-based background for this approach. Of course, we also acknowledge the limitations in our current knowledge. We realize that additional research will surely lead to refinements in assessment methods and treatment methods; however, we believe the perspective on patients that we have presented will continue to guide the evolution of successful outcomes in the future.