treating chronic-pain patients in psychotherapy

Treating Chronic-Pain Patients in PsychotherapyÄ

Timothy R. TumlinIndependent Practice

This article provides an overview of the breadth of issues a therapist mayface in treating a person with chronic pain. Questions such as the relativecontributions of biological and psychosocial influences on the patient’sreported condition must be addressed. In addition, the counselor oftenmust help the patient deal with psychopathology that occurs in reactionto the pain, which is likely to be contributing to it. Other financial, medical,and legal circumstances also may impinge on the therapeutic frameworkto limit or influence the course of treatment. Two examples of treatmentlessons are offered, and a case example illustrates the lengthy and multi-dimensional course some treatments can take. © 2001 John Wiley &Sons, Inc. J Clin Psychol/In Sess 57: 1277–1288, 2001.

Keywords: chronic pain; pain management; biopsychosocial model

Patients have called chronic pain a “slow catastrophe” that pervades almost every cornerof their lives and drains their resources. Its effect is felt not only through the pain sensa-tion itself, but also by wearing the patient down psychologically, socially, financially andmedically. Months and years of job interruption, medical bills, reduced functioning, legalbattles, surgery, mind-fogging medications, and physical deconditioning all take theirtoll. Many such persons demonstrate a pre-existing vulnerability to life stresses and,therefore, become overwhelmed. Thus, treating the person with chronic pain is often acomplicated undertaking.

The medical treatment of chronic pain often includes psychological consultation,and many mental-health professionals specialize in this area, working closely with pain-management or rehabilitation centers. Those specialists may find little new in this article,which offers an overview and treatment resources for clinicians in practice with littleexperience with this population.

The clinician treating persons with chronic pain must sort out how biological andpsychosocial variables have intertwined progressively to create and maintain the patient’s

Correspondence and requests for reprints should be sent to: Timothy R. Tumlin, Independent Practice, 100Tower Drive, Suite 120, Burr Ridge, IL 60527; e-mail: [email protected].

JCLP/In Session: Psychotherapy in Practice, Vol. 57(11), 1277–1288 (2001)© 2001 John Wiley & Sons, Inc.

perceptions of pain and disability. Additionally, chronic-pain patients as a group showlevels of psychopathology equal to that of psychiatric outpatients, but many resist psy-chotherapy as part of pain treatment. The clinician also will find a number of practicalcircumstances in the clinical setting that could limit the goals of any course of treatment.

Pain usually is distinguished as chronic when it persists for more than six months.Chronic-pain conditions most often brought to the attention of psychotherapists are thosethat have questionable origin, continue beyond typical healing periods, or that otherwisehave resisted treatment. Patients in medical treatment also often are referred when theypresent with obvious problems in emotionally adjusting to their condition; those whohave marked difficulties in their relationships with health-care providers also often arereferred.

Chronic pain affects 30% of the U.S. population (Bonica, 1990). The prevalencerates of chronic pain vary by gender, age, geographic region, and type of diagnosis(LeResche & Von Korff, 1999). However, epidemiological measures are difficult to obtainbecause many people with diagnosable symptoms do not seek treatment, and others intreatment have less or little evidence of a discernible biomedical condition. For example,Talley and colleagues (1990) found that only 14% of persons with irritable-bowel-syndrome symptoms sought medical help, while White and Gordon (1982) found that85% of patients with lower-back pain had no identifiable pathology.

Applying the Biopsychosocial Model

Chronic pain is an exemplar of the model that conceptualizes illness as resulting from acomplex interaction of biological, psychological, and social variables. This biopsycho-social model particularly is appropriate for chronic pain in light of the subjective natureof pain reports and disability assertions. In contrast to conditions such as hypertension—where the patient may feel no symptoms but objective tests show dysfunction—in painmanagement, outcomes almost wholly are dependent on the perception and report of thepatient. Psychology has demonstrated amply that people can be highly susceptible toalterations in their perceptions, attitudes, and motivations under certain meaningful influ-ences. Chronic-pain conditions offer many such influences, and there is evidence thatthese persons are more likely to adopt such alterations as ways of coping with theirstressors. The model requires that these variables be seen affecting the individual overtime, not just at any one point. Each intertwines with the others as the condition contin-ues; no single factor in isolation will explain the individual’s chronic-pain status (Turk,1996). The therapist familiar with the complexity of systems theory, in which severalparts of a system influence each other in different ways over time, will recognize much inthis model of how these conditions evolve.

Considerable research has demonstrated that patients’ attitudes, beliefs, and expec-tancies about their diagnoses, their self concepts, their coping resources, and the medicaland legal systems affect how they sense and report their pain and disability. For example,patients report more pain and dysfunction when they feel the pain is not controllable,when it signals declining health, and when they feel helpless or lack efficacy in their ownability to improve their condition. Those who do not understand the cause of their con-dition report more pain and distress than those who believe they do. Patients prone tocognitive errors, such as catastrophizing when describing their conditions, report morepain, distress, and disability than do those who use more adaptive language. Studies ofoperant conditioning have provided evidence, for example, that pain behaviors, such asinactivity, can be influenced by verbal reinforcement, and that patients with a solicitousspouse tend to report higher pain levels when the spouse is present. Historically, Melzack

1278 JCLP/In Session, November 2001

and Wall (1965) made a significant advancement in the understanding of pain in theirproposal of gate-control theory. Though revised and extended since, it offered a neuro-biological rationale for including cognition and affect as a mediating variable in theperception of pain and introduced the dimension of time as a factor in the development ofthe psychological and biological interaction.

Partialling out and understanding the mechanism of these biopsychosocial processesis hard enough for the professional. Articulating these influences to the patient in a waythat is not insulting can be a special challenge in therapy. As noted in the following caseexamples, the therapist sometimes must go to extra lengths in creating “lessons” that getthese points across to patients in ways that are palatable and understandable.

Psychopathology in Chronic Pain

A number of studies find that chronic-pain patients as a group show high levels of psy-chopathology. Studies estimate the prevalence rate of Axis-I disorders (primarily involv-ing depression, anxiety, and substance abuse) in chronic-pain patients to be as high as90%. The cause-and-effect relationship of these disorders and the pain condition is notalways clear, because some distress clearly is reactive to the burdens caused by the paincondition. However, researchers also have found that that most patients were diagnosablebefore the onset of their pain. The prevalence of personality disorders in people whoexperience chronic pain also has been found to reach the level of that found in outpatientpsychiatric populations. Studies have found that 31 to 59% of the chronic-pain popula-tion could be diagnosed with at least one personality disorder (Weisberg & Keefe, 1997).Given that those studies used DSM diagnostic categories rather than dimensional assess-ments, it is safe to assume that even more chronic pain patients show distinctive person-ality deficits.

Viewing a personality disorder as a systemic weakness in coping, and given theprogressively stressful circumstances of chronic pain, one can see the potential for dys-function at many levels for a subset of the population with long-term coping deficits. Insorting out the relationship between pain and personality, Weisberg and Keefe (1997)proposed a diathesis–stress model. The model demonstrates how personality weaknessesmay not result in a disorder premorbidly when life challenges are less difficult, but thatpain patients will become symptomatic as the stresses mount. This also accounts for thefinding that, early in the case, biological variables predominate in creating the pain con-dition, but as time goes on, psychosocial variables exert a greater influence in determin-ing the pain reports.

The issue of personality disorders among pain patients goes beyond deficits in cop-ing with the pain itself. It also has implications for how the patient manages the manyother interpersonal tasks of pain treatment. Many persons being treated medically arelikely to have difficult, and oftentimes exasperating, relationships with the health-careproviders. Patients predisposed to demanding, manipulative, exploitive, dependent, orself-involved behavior in their relationships may use their pain conditions as highly effec-tive leverage for continuing their interpersonal patterns. These patterns easily may lead toa spiraling breakdown in relationships that interrupt the patient’s treatment.

The probability of psychiatric illness often is difficult to broach with those patientswithout a history of psychological treatment. Many see themselves as only suffering amedical problem and have no intention of seeing a psychologist. Many pain patientsrecognize they are under tremendous stress and naturally feel depressed at times. Treat-ment can begin with a goal of reducing stress and increasing coping.

Treating Chronic-Pain Patients 1279

Contextual Factors

The clinician undertaking the counsel of the person with chronic pain also will encountera number of other conditions rarely addressed in clinical trials, but frequently affectingthe course of treatment. For example, patients often are resistant to treatment, sometimesangrily so, and view a referral as an insult or a sign that the physician is giving up onthem. Many patients have litigation and applications for disability benefits pending, andresearch clearly has documented that financial incentives influence pain and disabilityreports. Many have dug in their heels to the disability role after being called malingerersor catching videotape surveillance crews following them. Some say they feel they are atwar with insurance companies, claims adjusters, and opposing attorneys to prove they aredisabled and/or deserving of long-term medical care. Metaphorically speaking, patientsenter the therapist’s office with an entourage that includes claims adjusters (many havelittle medical training and yet rule on important treatment issues), nurse case managers(one asked to sit in on psychotherapy sessions), lawyers (some have advised patientsagainst counseling), multiple doctors, relatives, and employers. Many of those stakehold-ers expect or legally can demand access to case notes as the intervention is in progress,almost making the treatment a public event. Frequently, chronic-pain patients have fewfinancial resources for psychotherapy because of lost income and high medical bills.Mental-health insurance benefits typically are inferior to medical coverage, so they mustpay for a greater share of their psychotherapy than for medical services. In addition, painpatients often are prescribed a variety of medications from several physicians that affectmemory, concentration, emotions, and sleep. Drugs will numb patients so they cannotidentify feelings or think through problems, and some have fallen asleep during sessions.

In treatment, some of these issues may be confronted head-on. For example, resistantpatients can be told, “I know you don’t believe this helps, but a lot of pain patients havefound value in this work, so let’s give it a try, and if it doesn’t help, I’ll be the first toadmit it.” They also can be told outright that the therapy alliance is strictly for the patient’sgood and “let’s throw out of the room all the doctors, lawyers, and case managers for nowand look just at what’s good for you.”

Given the wide scope and varying goals of chronic-pain therapy, the clinician iswarned to be ready to either cast a wide therapeutic net or focus on very limited ends. Forone case, keeping a patient emotionally stable and engaged in medical services with afrustrated pain-clinic staff is a victory. For another case, the patient may learn conscien-tiously to employ a broad variety of personal pain-management techniques and reportmuch better coping, even discontinue pain medication in lieu of psychological methods.A third case may require long-term treatment for ongoing mood disorders and frequentmedical and personal crises. Protocols have been outlined for some specific pain syn-dromes and types of treatment, and they should be consulted when available (see SelectReferences/Recommended Readings.)

Case Illustration

Presenting Problem/Patient Description

Richard is a 56-year-old male referred by his orthopedic surgeon to the pain-managementcenter in April 1999. He injured his back while on the job as a technician in 1989 and hadtwo spine operations in 1990. He returned to work but stopped after a year when he hurthimself again; he had not worked since 1992. Richard settled his worker’s compensationclaims in 1994 and qualified for Social Security disability benefits that same year. He was


able to use the health insurance from his wife’s employer for much of his treatment. Hereported pain in his lower back and legs, accompanied by spasms and loss of functioningin one leg. His initial evaluation resulted in a medical diagnosis of post-laminectomysyndrome with radicular pain, meaning he was still having pain radiating from his spineafter corrective surgeries. He also was diagnosed with myofascial pain, a reference tomuscular pain with spasms, tender spots, or muscle knotting.

During the psychological evaluation, Richard reported that he increasingly had beendiscouraged and depressed for several years. Two months earlier, he had made a suicidalgesture, cutting himself lightly with a knife, and sought help from a psychiatrist. Theprescribed Prozac helped to elevate his mood to where he felt better, but he said he stillwas usually down and out, and outright depressed about two days a week. He said he stillhad some fleeting, but not serious, suicidal thoughts. He said his loss of functioning andhis financial problems were the chief causes of his depression. He said he had felt hisself-esteem slipping for a long time as he became a “professional pain patient.” He relatedserious problems in his relationship with his wife, to whom he had been married for manyyears. He also said he often felt moderately anxious in some social situations and has afear of heights. He reported chronic insomnia even with sleep medication. Richard saidhe frequently overexerts himself and then is “laid up” for some time to recuperate. Hereported his muscle spasms were so extreme that he sometimes lost the use of a leg and,in a couple of instances, slammed the accelerator pedal of his car involuntarily. He alsoreported that he smoked a pack and a half of cigarettes a day and drank a six-pack of softdrinks, as well as two cups of tea, a day.

Richard described a history of alcohol abuse. He quit by participating in AlcoholicsAnonymous 16 years earlier and remained deeply involved in AA. He said that he wasashamed of much of his behavior during his drinking years, explaining that he had beenverbally abusive and exploitive toward others. He also hinted at more serious acts that henever detailed and for which he felt guilty. Richard was a friendly and outgoing man inhis relations with the clinic and its staff. He enjoyed being demonstrably entertaining,telling corny jokes and doing impersonations when talking to the staff, so that the recep-tionists often were rolling their eyes to the ceiling.

Case Formulation

Richard’s case includes several of the psychosocial risk factors that can play a part inchronic pain. His alcoholism and related behaviors indicated long-term problems in cop-ing. Receiving disability benefits for eight years made it easy to adopt the role of beingdisabled. His marital difficulties not only cost him valuable social support, but also addedgreatly to his current stress. His increasing depression also reduced his motivation andability to cope with the further stresses of his pain and medical condition. His habit ofoverexerting himself indicated problems in managing his health behavior. Chronic sleepproblems contributed to his gradual demoralization.

Several circumstances of Richard’s case were promising for a good outcome, how-ever. He was open to psychosocial interventions. As an AA devotee, he was more familiarwith the language and concepts of personal growth. Richard was not seeking furtherfinancial benefits or compensation, so he was free of the pressure to “prove” his disabilityto himself and authorities. Although his financial resources were limited, he had goodhealth insurance that would contribute to the full care offered by the center. He wasmotivated to change in that he expressed a desire to return to work and felt the distress ofhis depression and anxiety.


Course of Treatment

Richard began weekly sessions in May. The frequency tapered off to biweekly sessionsby late fall, and then, by spring of the next year, only monthly meetings were held untilthat August. Earlier sessions concerned direct methods of pain control, such as activitypacing and relaxation. Then the focus broadened to his mood, relationships, and person-ality functioning. The final phase consisted of continued emotional processing and ther-apeutic support, as well as technical discussions and booster sessions about using hispain-management techniques.

An issue addressed at the outset was his problem in pacing himself such that heexacerbated his condition, a treatment area often easy to identify and confront. This hasbeen done effectively with the following lesson and accompanying illustration (see Fig-ure 1), one which pain patients generally have liked and found useful. More importantly,it serves as a platform on which to build more interventions and open the patient totherapeutic concepts. The therapist describes the model while hand-drawing the illustra-tion. People seem to find it easier to absorb the concepts this way, and they often ask totake the drawing home for reference. Like many interventions with pain patients, it cantake considerable “selling” and normalizing to convince them to accept psychologicaltreatment for what they regard only as a medical condition.

therapist: Richard, since you brought up the issue of overexerting yourself, let me drawfor you an illustration of some ideas that have helped a lot of pain patients, as well aspeople with many other types of long-term illness. And as I’ll show you, it’s really amodel that applies to all of us in one way or the other. I usually start by drawing acouple of lines, and I call this one (A), the too-much line, and this one (B), thetoo-little line. This is like a scale of activity, with the upper end meaning moreactivity (C). Now, if you or I had the flu or broke an arm, we might just “veg out” fora day or two on the sofa until we feel better, right? And that’s a good idea when youare recovering from a short-term illness or injury, and you can let your body fight itoff or heal up. That would put us down here in the activity level (putting one or two

Figure 1. Illustration accompanying the Zone Model lesson.


dots on D), and that would work for the time being. Now, let’s say you have along-term illness like chronic fatigue, fibromyalgia, or another pain problem whereyou are hurting or feeling very tired for weeks or longer. You would be tempted tojust “veg out,” but what if you did that for weeks, or even months (drawing the dotsacross D–E)? For example, what would happen to our bodies if you or I spent severalmonths on the couch watching TV?

patient: We would break down, get fat.therapist: You bet. We would decondition. And what would happen to you spiritually

and emotionally?patient: I’d probably start feeling lousy and get more depressed.therapist: Absolutely. We would start to break down physically, psychologically, and

spiritually. And by the way, physical deconditioning also makes your medical treat-ment that much harder.

therapist: And what would happen to someone’s self-esteem?patient: It would go down.therapist: Of course, and our confidence and motivation to get going and make things

happen? Our sense of control over things?patient: Worse, it would all get worse.therapist: Exactly. You’re getting the idea of the dangers of doing too little. So, when

we are inactive for a long time, we begin to break down in lots of ways. Part of thebehavioral treatment is this: On a bad day, do more (slowly drawing line from Fupward slightly). Even when you are hurting or tired, just getting out of bed, gettingmoving, taking a shower, anything like that to get above this too-little line is going tobe good for you. Have you had days where you felt like staying in bed but somehowyou got yourself going anyway?

patient: Sure. The worst time for me is in the mornings, and I have to talk myself intogetting out of bed and get moving.

therapist: Now, that’s just the half of it. Here’s the next danger, and this is the problemI heard you talking about. Everyone who has a chronic illness has good days. It maybe because your medication is working, or you just got an injection, or you just feelgood for no reason at all. And when people feel a lot better, what do they do? (draw-ing the line higher from F) They do three loads of laundry . . . (drawing the linetoward point G), mow the lawn . . . take the kids to the mall for two hours, and so on. . . they drive themselves past the too-much line . . . (peaking the line and thendramatically down to H), and . . . this is what I call “The Crash.”

patient: Yep, that’s me. I am always crashing, now that you put it that way.therapist: Right. This is the problem with people who want to do too much, like you.

Once you are feeling better, you get out there and overdo it, and then crash. Thenyou’re laid up for an hour, or an evening, or a week to recuperate. Then you takemore pain medication and you feel better, but it also dulls your body sensations andyou’re more likely to zoom up here and go past the too-much line again. This “crash”model just teaches you a lesson that every time you try to get going and do some-thing, you wind up feeling bad and hurt yourself more. It also tells you that everytime you do something, you need more pain medicine. Now, let me show you anotherway to handle this situation. As I said, on a bad day, do more. But on a good day, asyou get to this point (I), before you are overexerting yourself, pull up short and saveyourself. Even if you feel like you can do more right now. When you do that, thenyou don’t crash, but you do a little less, then a little more, and you can keep on goingall day (line to J). I call this “Staying in the Zone.” It lets you stay in the game andkeep functional all day, every day. Now . . . this point here, (I), is a very interesting


place. It represents several challenges. First, it’s an intellectual challenge. You haveto know where your too-much line is and pull up short of it. That will take somelearning on your part.

patient: I go past that almost every day. A good example is Sunday when I mowed thelawn. Once I get going, I don’t stop until the front and the back are done, even thoughI know that it was too much for me. I was on the couch for two days, and I had to takemore pain medicine.

therapist: Exactly. This spot is also a social challenge. A lot of people are pushed intogoing too far past the too-much line by others around them. Sometimes it’s that thekids won’t help with the laundry, or the other guys on the work crew think you’resandbagging them, or a wife or husband just isn’t understanding that you have topace yourself in order to be able to keep going without crashing.

patient: Yep, my wife still expects me to be able to do the things I used to, althoughmaybe I really don’t let her know how hard it is for me.

therapist: Finally, this is an emotional challenge and an issue of changing your idea ofwho you are. Many pain patients have a very hard time pulling up short when theyfeel as though they could keep going. They are people who are used to working hard,and they feel guilty if they aren’t accomplishing things. This is exactly the time totake a look at yourself and your attitudes and make some changes that will improveyour health.

patient: Yes, I’ve always been the one that everyone else turns to for help. I used towork 12-hour shifts and still had time to take care of everything at home.

therapist: When I first explain this to pain patients, they think I’m encouraging them todo less. But almost everyone who takes it seriously comes back here to say that theyare getting more done and they are controlling their pain better by staying in thezone.

This teaching tool can be used in therapy at several levels. At its most fundamental,it introduces the concept of pacing in a way that is easy to use. The illustration alsoincludes several other assumptions that can lead to further exploration by the therapist:

1. The model implies acceptance of limitations imposed by the injury or illness.Many patients resist accepting the long-term nature of the pain, therefore, over-exert themselves, feeling discouraged when they “crash,” and becoming fearfulof all activity. They contemplate acceptance resentfully, seeing it as surrender andas inviting further depression. The zone illustration suggests that realistic accep-tance of limitations enhances functioning. Many patients report that confrontingthis acceptance issue was a breakthrough in their management.

2. The change point (I) can introduce cognitive restructuring. The patient’s ideasabout self and environment are challenged in a way that suggests behavior changesfor the better.

3. Greater awareness of body sensations is encouraged. Some pain patients proudlyreport having a high threshold of pain, which is a lack of attention to the body thatinvites further injury, but the illustration shows how that can be detrimental. Italso provides reasoning for cautioning a patient that overuse of pain medicationcan dull body perception and increase the risk of overexertion.

4. The lesson provides a starting point for discussing how social resources can behelpful and how others must be educated and recruited for their support. Many


patients report success in showing their families and coworkers the zone conceptto explain their need for moderate-but-consistent behavior.

5. “Staying in the Zone” requires thinking through and planning activities. Thisintroduces problem solving as a coping tool. Patients often are told by the thera-pist, “You now have to play life smarter than before. You have to think thingsthrough a lot more than other people, but it will then bring you benefits.” Patientsoften report back the many small ways they have learned to stay within the zone.

6. This lesson assumes that pain can be regulated through behavior. This is a newconcept to many patients and opens the door to greater personal control. Thetherapist can ask, “Between people using the zone model and the crash model,which ones would feel more in control of their pain and, perhaps, other parts oftheir lives? Which ones are more likely to feel depressed and helpless? Whichwill use more pain medication? How would using more painkillers make the‘crash’ cycle even worse?”

7. More broadly, the illustration encourages the concept of moderation as adaptivein other aspects of life. This is helpful for many patients, especially those withpersonality problems that involve dysregulation of thought, emotions, and behavior.

Richard had good immediate results with the zone idea. By the second session, hesaid he found he was “crashing” less often and could see how moderating his behaviorwould help him feel better and do more in the long run. He also realized that his seriousre-injury in 1991 might have come from overextending himself. We discussed his meth-ods of working and resting and how it helped, particularly the muscle pain. The simplebehavioral model helped build a collaborative relationship and gave him hope that wecould work on changes that would improve his physical condition. This gave us a startingpoint with each session, if needed. He began to pay more attention to his body sensations.He reported slowing down on his yard work and found he still accomplished all thechores that were necessary. He became more interested in problem-solving systems as away of helping him stay “in the zone,” and general coping skills were frequently a topic.

The need for further stress and pain management led to relaxation exercises, anotherpotentially rich treatment that can be initiated at a simple behavioral level. Many authorshave published guides for inducing relaxation, including some specifically for pain patients.Relaxation is easy to introduce to most patients because they know that pain createschronic muscle tension, which causes its own pain. Relaxation can be practiced in theoffice, and the patient can take home a tape for practice. While the therapist can recordthe live session and give the patient the tape, a prerecorded tape can be very effective. Ihave used home stereo equipment to record and duplicate tapes that seem to be veryhelpful and popular among patients. Beyond reducing muscle tension, the procedure canbe extended to include greater benefits:

1. Relaxation reduces sympathetic nervous-system arousal. Some pain travels alongsympathetic pathways, so this can be touted as another form of direct pain reduction.

2. Reducing sympathetic arousal introduces stress-management concepts. Chronicpain can be characterized as a constant stressor that is frequently “yanking the firealarm in your body” and triggering the fight-or-flight response. This may lead toother stress-management techniques, such as cognitive restructuring, personal orga-nization, assertiveness, and problem solving.

3. Being able to reduce immediately some tension increases the patient’s sense ofcontrol over mental and physical events. This is another way to “stay in the zone.”


4. Relaxation and home-use tapes have been helpful in treating insomnia amongmany pain patients. Several patients who have used a therapist’s relaxation tapefor months have said they have never heard the end of it because they fall asleep.This also increases the sense of control and brings the many benefits of bettersleep.

5. The patient also can begin using relaxation in a manner more akin to self-hypnosis and meditation. By both physically relaxing and releasing their attach-ment to thoughts and feelings, the patient can learn to separate the affective/cognitive and the sensory aspects of pain. One patient aptly said, “The pain is stillthe same, but it doesn’t bother me as much.”

We did a relaxation exercise in the office and Richard took home a practice tape. Healready had been trying to relax with music and environmental-sounds tapes, but thesemihypnotic quality of the relaxation was more powerful for him.

To describe a sense of the long-term nature of such a case and the breadth of con-cerns, following is chronology of Richard’s case as it developed and resolved.

June:He reported using the zone concept to his advantage; he was able to do moreyard work without hurting himself further. He said he felt more in control. Healso grappled with continued marital problems; his wife came in for one session,but it was apparent they were on the verge of separating. Throughout the month,he said his mood had improved in terms of his pain management and that he feltbetter because of the center’s medication regimen and the behavior changes. Bythe end of the month, he knowledgeably could discuss how well he was staying“in the zone.” He began using the relaxation methods and said that they werehelping him get refreshing sleep. He also processed some of the medical deci-sions left to him by several of his doctors. His pain physician had prescribed oralmedication, and Richard received a steroid injection and nerve block. The pro-cedures gave him substantial relief from the pain, but it returned within twoweeks.

July: He continued his behavioral changes, but also began to raise more personalconcerns, such as the effects of his upbringing on his coping style, his alcohol-ism, and troubling memories. He said his depression was lessened. The painphysician performed a second nerve block. This reduced his pain somewhat, hesaid.

August:He reported his depression was continuing to lift and that he was using hisnewly learned social skills, particularly communication, to improve his friend-ships. However, late in the month he and his wife separated, and he moved to hisown home. He reported the move caused him to overexert, but this was reframednot as a failure, but as a lesson in what price he had to pay to get a necessary jobdone.

September:Treatment was focused on helping him maintain his pain-managementgains and deal with the changes and losses he had experienced. He had learnedto accept both the loss of his marriage and his pain condition and reported feel-ing greater peace with these two issues than before. His pain physician referredhim back to the surgeon for consideration of an operation.

October: Richard’s pain condition had improved a great deal. He was learning topush himself in exercising on a treadmill; he was proud of how many minutes hewas putting in without “crashing.” He was having second thoughts about further


surgery. He said he was extending his moderate-zone practice to his emotionallife, and he began to talk about going back to work. He arranged a vocationalevaluation by a state agency that could retrain him.

November:He hurt his back again, but did not know how. Richard endured thesetback without seeking extra medication. Treatment consisted in part of dis-cussing specific coping skills for pain management, as well as his relationshipsand managing his mood.

December:His relaxations were now regular, deep, and skillful meditations. Throughour sessions, he learned to attain very relaxed states and to recall troublingmemories, relieving the anxiety associated with them. He would start one ses-sion by saying “Well, doc, I took care of some more of those memories.” Hereported more control over his depressive moods and early self-interventions topull out of the episodes. He continued to express more optimism about his treat-ment, with a realistic understanding of the limits of his goals.

At the beginning of the next year, in January, Richard was reporting that his spasmswere gone, primarily due to his exercise and improved conditioning. His leg “went out”on him only once a month rather than several times a day, as before. He proudly reportedthat he was able to paint his entire apartment “20 minutes at a time.” Richard had one laststeroid injection near his spine; again, there was some pain relief, but not for more than afew days.

February:He reported that he has ruled out further surgery and began to reduce hispain medication on his own initiative. He showed greater confidence that he canmanage his pain more by his own efforts. Staying “in the zone” had become ahabit for him, and he was very aware of when he was about to exceed his limits.He began some preparations for taking classes at a local college to retrain him-self to fix computers.

March: Richard discontinued his long-acting pain medication and only took a short-acting one as needed. He also stopped taking his sleep medication, confident thathe could control his sleep through relaxation, regular health habits, and exercise.He also began looking for odd jobs in his old profession while preparing for hisretraining. Treatment sessions consisted of technical support for behavioral meth-ods, as well as processing interpersonal issues and continued work on managinghis mood, at which he was becoming adept. He was developing a personal rela-tionship with a woman.

April/May: Richard’s mood was very good, and his behavioral pain management hadbecome a series of habits that he had mastered well. He continued to reduce hispain medication and had stopped all consideration of surgery.

June/August:Monthly sessions took the form of checking in to report continuedprogress and discuss making plans for future retraining and other employment.By the end of treatment, he reported his depression and anxiety were resolved,although he continued to take Prozac, and he felt a great deal of personal controlover his pain condition. He realized and accepted the fact that his medical treat-ment would not improve his condition much more; it was up to him to manage itwith his behavior and attitude. He had re-established a new romantic relation-ship and had very satisfying relationships with friends, as well as hopes forcontinuing his education and retraining. As he once put it, “Doc, now I likemyself.”


Clinical Issues and Summary

Richard’s chronic-pain condition developed in complex ways over time, and treatmenttook more than a year of addressing many parts of his life in conjunction with medicalcare. It ranged across skill building in deep relaxation and activity pacing, helping himgrieve the loss of a marriage, understanding his personality, and learning to be appropri-ately assertive and communicative in relationships. Over treatment, Richard was helpedto ride out medical and psychological relapses, as well as manage crises. Thus, for Rich-ard and for many others, pain management becomes a metaphor for greater adaptation tolife. This includes learning moderation, broadening the coping repertoire, managing rela-tionships, improving communication, understanding the origins and function of person-ality, facing limits, and dealing with the exigencies of life while maximizing its quality.

Select References/Recommended Readings

Block, A.R., Kremer, E.F., & Fernandez, E. (Eds.). (1999). Handbook of pain syndromes. Mahwah,NJ: Erlbaum.

Bonica, J.J. (1990). The management of pain. Philadelphia: Lea & Febiger.

Gatchel, R.J., & Turk, D.C. (Eds.). (1996). Psychological approaches to pain management: A prac-titioner’s handbook. New York: Guilford.

Gatchel, R.J., & Turk, D.C. (Eds.). (1999). Psychosocial factors in pain. New York: Guilford.

Gatchel, R.J., & Weisberg, J.N. (Eds.). (2000). Personality characteristics of patients with pain.Washington, DC: American Psychological Association.

LaResche, L., & Von Korff, M. (1999). Epidemiology of chronic pain (pp. 3–22). In R.J. Gatchel &D.C. Turk, (Eds.). Handbook of pain syndromes. Mahwah, NJ: Erlbaum.

Melzack, R., & Wall, P. (1965). Pain mechanisms: A new theory. Science, 50, 971–979.

Miller, T.W. (Ed.). (1990) Chronic Pain. (Vols. 1–2). Madison, CT: International Universities.

Talley, N.J., Phillips, S.F., Melton, L.J., Mulvihill, C., Wiltgen, C., & Zinsmeister, A.R. (1990).Diagnostic value of the Manning criteria in irritable bowel syndrome. Gut, 31, 77–81.

Turk, D.C. (1996). Biopsychosocial perspective in chronic pain (pp. 3–32). In R.J. Gatchel & D.C.Turk (Eds.), Psychological approaches to pain management: A practitioner’s handbook. NewYork: Guilford.

Turk, R.C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive–behavioral perspective. New York: Guilford

Weisberg, J.N., & Keefe, F. (1999). Personality disorders in the chronic pain population: Basicconcepts, empirical findings, and clinical implications. Pain Forum, 6(1), 1–9.

White, A.A., & Gordon, S.C. (1982). Synopsis: Workshop on idiopathic low back pain. Spine, 7,141–149.


treating chronic-pain patients in psychotherapy

Documents