Inexplicable pain and suffering have long been of interest to clinical psychologists. The goal of Freud and the psychoanalytic pioneers was to reduce phenomenological experience and constructs to their underlying biological mechanisms and processes. In the 1930's, active efforts were undertaken to correlate physical and emotional experience. This led to the development of psychosomatic approaches. An understanding of the historical significance of the psychosomatic approach is helpful in evaluating current psychological approaches to the treatment and evaluation of pain.
The search to meaningfully link physical and psychological experience had to first overcome a 200-year scientific paradigm that separated mind and body, i.e. Cartesian Dualism. The separation of the body from the mind (and soul) had allowed early medical practitioners to investigate the workings of the human organism in both its diseased (and less often) healthy state. The pioneers of psychosomatic research shifted their emphasis to the psyche. Early theories hypothesized that specific intrapsychic conflicts were reflected in pathological physical processes. The longstanding psychoanalytic interest in conversion disorders served as a foundation for this thinking. Treatment strategies to treat so-called psychosomatic disorders (ulcers, low back pain, asthma) were postulated on the need to discover unconscious conflicts that would be physiologically expressed via specific symptom paths. As an example, oral dependent conflicts would be the cause of asthma, anal expressive conflicts led to low back pain. These formulations were abandoned by all but the most orthodox psychoanalytic practitioners by the early 1960's. Analogous thinking, however, continues to inform the more psychodynamically-oriented practitioners of psychotherapy. Treatment strategies based on these formulations have never demonstrated significant success in the treatment of pain related conditions and chronic pain syndrome. Psychodynamic approaches have been supplanted by behavior orientations which are discussed next.
At the same time that psychoanalytic pioneers were developing their psychosomatic approaches, academic psychologists in the United States were following in the footsteps of John Watson to develop a psychology based on scientific principles derived from the higher sciences, particularly physics. This led to the development of behaviorism and a study of the mechanisms of human and animal learning. Foremost among the practitioners of behaviorism was the Harvard psychologist B.F. Skinner. By the 1940's and early 1950's, psychologists began to utilize principles derived from Skinner's theory to change human behavior. It is important to note that the conceptualization involved in these efforts were to "change behavior" rather than to "cure disease." Such approaches laid the genesis for behavioral medicine, health psychology, and the psychotherapy now termed cognitive therapy. This paradigm and the practices based upon it form the foundation for the modern evaluation and treatment of pain experiences and pain behavior by psychologists. Operating independently or as part of a team, psychologists strive to examine pain behavior and the experience of pain from a biopsychosocial perspective. Such an approach departs from the longstanding disease model, which focuses on a search for fixed physical causes of pain and mechanical or chemical palliatives. Recognizing that the medical/mechanical model is useful in the diagnosis and treatment of the narrow spectrum of acute pain, psychologists have attended in a more systematic fashion to the broad spectrum of chronic pain. The remainder of this paper will examine the psychological, biological, and social factors frequently addressed by psychologists in the management of chronic pain conditions.
The so-called locus of control dimension has been systematically investigated by research health psychologists. It is assumed that persons who believe that they cannot control circumstances in their environment are more prone to pain behaviors and less likely to follow treatment recommendations because they believe that their pain is caused exclusively or predominantly by factors beyond their control. Experimental evidence (Smith, et al., 1994) supports this point of view. Smith's work also underscores the confounding effects of depression on pain (see below). Jensen and Karoly (1991) investigated the effects of control beliefs and coping efforts in the adjustment to chronic pain. Their findings indicated that the employment of positive coping self-statements, adoption of an internal locus of control, ignoring pain or diverting attention from pain could positively affect activity levels for low and moderately severe pain. This effect, however, was not noted with severe pain. This is a second confounding variable that must be taken into consideration when treating pain patients. Although the level of reported pain may be subjective, actual levels of pain may have differential effects on high pain level patients when they are compared to patients whose pain level is less severe. The subjective nature of this appraisal is regrettably most obvious and particularly vexing in forensic contexts. Secondary evidence that severe levels of pain may be less amenable to cognitive intervention stems from the work of Christensen, et al. (1991) who researched the health and locus of control beliefs of 96 hemodialysis patients. Patients with internal locus of control orientation more often hold the belief that health is a controllable experience and report less depression than persons with an external locus of control. This, however, was not true following receipt of information that a renal transplant had failed. Again, the nature of the pain context will affect psychological buffers.
Cause and effect dilemmas which bewitched early psychosomatic researchers are revisited when we examine the question of chronic pain and depression. Many theorists have long held that chronic pain syndrome (particularly low back pain) is simply a depressive equivalent. This question has been researched with mixed outcomes. Katon, et al. (1985) identified a sub-set of patients whose chronic pain syndromes were preceded by significant histories of depression and/or substance abuse. These subjects could be viewed as suffering from a chronic psychological pain syndrome which may be related to a somataform disorder (see the appendix). For these patients, chronic pain syndrome is most likely a depressive equivalent. In evaluating pain patients to determine the role played by depression, it is essential to differentiate between so-called endogenous and reactive depressions. Pain, be it acute or chronic, is invariably accompanied by some degree of depression. Persons who have a biological propensity to depression (so-called endogenous depression) will more likely be difficult to treat. A detailed history (see below) is essential for addressing this issue.
A complete and relevant history is essential for the treatment and forensic evaluation of pain patients. Every patient's experience of pain reflects that person's developmental history. Pain is often developmentally linked with themes of solace, punishment, aggression, loss, and sexuality (Blackwell, 1989). Appraisals and beliefs play an important role in the coping process. The patient's beliefs about the control, management and meaning of pain are essential in understanding so-called pain behaviors. Pain is a communicating experience, it is a symbol and it is a metaphor. No matter how rigorous the behavioral orientation, an appreciation of these dynamic factors is essential if the therapist is to make a successful and meaningful therapeutic intervention. Pain history will determine the relationship of stress to pain onset, pain maintenance and pain intensity. A pain history (including the responses of the patient's family of origin to sickness, trauma and pain) is vital. An adequate history will help the psychologist determine the role of state and trait factors as they influence pain. A skilled history taking, combined with adequate psychological testing (see below) will assist the clinician in differentiating the effects and outcomes of pain on personality from the pre-existing traits of character that influence the form of pain behavior expressed by the patient. It is essential to make this differentiation so as not to confuse cause with consequence.
Psychologists frequently employ tests and survey instruments in order to understand pain behavior and to facilitate the design of intervention plans. Perhaps the most frequently employed is the MMPI-2. The revision of the MMPI has come into common service since 1989. I prefer to employ computer-generated scoring and analysis of the instrument so to cross-check my clinical work and to develop alternative hypothesis. Occasionally, there is an over-reliance on the results of the MMPI, and this is particularly the case in forensic contexts. Utilization of an outside laboratory analysis of test results is of particular importance in the forensic context given the possibility of confirmatory bias. The Beck Depression Inventory is frequently employed in an effort to assay the role depression plays in chronic pain. The Millon Clinical Inventory is also useful as an adjunct to understand personality organization and coping styles. There exist various pain questionnaires and pain inventories that are useful in generating quantified results to compare pain experience pre- and post-intervention.
When interpreting test results, caution about cause and consequence is particularly in order. Nowhere is this more important than interpreting the so-called "V" seen on the MMPI 2. This obtains when the scores on Scale 1 and Scale 3 are higher than the score on Scale 2 (depression) and the conclusion is made that the reported somatic experience has a purely or predominantly psychological origin. Careful analysis of test results and integration with detailed history are essential when analyzing the meaning of the so-called "V."
The MMPI-2 can be useful in evaluating the possible presence of malingering - conscious efforts to exaggerate symptomology for financial gain. A variety of indices are employed to address this possibility. Again, given the possibility of unconscious bias, the computer-scored and analyzed assessment of the MMPI-2 is preferred. The so-called REY test can also be employed when conscious efforts to deceive are suspected. A thorough and detailed life history are essential in addressing the issue of possible malingering or significant exaggeration. The combination of psychological testing and a detailed history will also maximize the possibility for the appropriate diagnosis of somataform disorder as well as factitious disorder.
A discussion of the particular techniques employed by psychologists to treat the psychological aspects of pain behavior is beyond the scope of this paper. An excellent overview of the orientation to the psychological treatment of pain is afforded by Fordyce in his 1988 AMERICAN PSYCHOLOGIST article. The journals PAIN and JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY are excellent sources for descriptions of ongoing research and techniques in the field.
Pain behaviors can also be negatively reinforced. NEGATIVE REINFORCEMENT is frequently confused with PUNISHMENT (the application of aversive stimuli). Negative reinforcement obtains when an aversive stimulus is removed. The removal of an aversive stimulus can then reinforce (increase the likelihood of elicitation) of the behavior that precedes it. Chronic pain patients who complain often are able to avoid the performance of tasks. The removal of the task demand then reinforces the likelihood that significant others of the pain patient will not demand adaptive behavior. The cycle is then mutually reinforcing and pain behaviors increase, and coping behaviors decrease. Alienation and marital discord then tend to increase, followed by depression with concomitant further increases in pain behavior. The role of family education is important here in that family members often must be made aware that "hurt" and "harm" are not the same.
The sick role is quite powerful and often socially supported. Our disability system, including workers' compensation system, often offers significant incentives not only to the pain patient but to the pain patient's family for maintenance of the sick role. The solution to these problems are as much political as psychological and/or medical. (Matranga, 1992).
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