Chronic pain: a reformulation of the cognitive-behavioural model

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Abstract

The last few decades has seen psychological theories of chronic pain dominated by behavioural concepts and particularly, by the operant model as described by Fordyce et al. (1968: Fordyce, W., Fowler, R., & DeLateur, B. (1968) An application of behavior modification technique to a problem of chronic pain. Behaviour Research and Therapy, 6, 105–107, 1976: Fordyce, W.E. (1976) Behavioral methods for chronic pain and illness. St Louis, MO: C. V Moseby). More recently, cognitive constructs have been included, giving the impression that the operant theory of chronic pain has been replaced by a cognitive-behavioural theory (CBT). Given the fact that CBTs were introduced essentially to overcome some inherent problems with operant theory, it is notable that they are still very much based on operant theory and continue to be founded upon operant principles. Further, the extent to which CBTs (at this stage) have included contemporary cognitive research has been limited. This paper argues that it is of questionable validity to continue to include problematic concepts (e.g., operant principles) into a revised theory (e.g., CBT). Instead, consistent with research from other areas (particularly the anxiety disorders), chronic pain and the problems associated with it may be better explained by a reformulated cognitive-behavioural theory which although not ignoring the observable behaviours of pain patients and their associations with social reinforcers, interprets these phenomena from a cognitive perspective. Thus, a modified CBT is proffered, focusing more directly on patients’ thoughts about, and appraisals of, their pain. Evidence in support of such a theory is provided, as are suggestions for further research and the implications such a theory has for treatment.

Section snippets

Brief history of the presenting problem

Definitions of pain have varied considerably over the years and despite significant advances in medical technology, including the development of sophisticated scanning techniques, general agreement on what pain is and what it means continues to evade clinicians and researchers (Merskey & Bogduk, 1994). Although popular and medical opinion typically links pain and tissue damage, the evidence for this association is questionable, at best.

The link between reports of pain and identifiable pathology

Operant theory

Fordyce et al. (1968, 1976), drawing on the work of other behaviourists (e.g., Skinner, 1953) suggested a distinction be made between the original cause of pain and reports of, and displays of pain (known as pain behaviours). Although a complete review of the behavioural model is beyond the scope of this paper, its basic assumption is that pain behaviours (e.g., limping, grimacing) are subject to the same influences of conditioning as are any other behaviours (see Fordyce, 1996). As such, if

Cognitive-behavioural theories

Turk, Meichenbaum and Genest (1983) were among the first to develop a cognitive behavioural model of pain that drew on the work of Beck, 1976, Beck et al., 1979, Meichenbaum, 1977. Beginning with the observation that behavioural treatments were not exclusively behavioural, the authors noted that even Fordyce (1976) referred to the importance of reaching a ‘shared conceptualisation’ with patients. They also noted that the founders of behaviour therapy (e.g., Wolpe, 1958, Wolpe and Lazarus, 1966)

Lessons from the anxiety research

The Oxford Group (e.g., Salkovskis, Clark & Gelder, 1996) have provided empirical support for the notion that behaviours maintaining anxiety can be viewed from within a cognitive model (Salkovskis, 1991). Salkovskis describes the relationship between ‘threat cognitions’ and ‘safety seeking behaviours’, arguing that certain behaviours are understandable given a belief that danger is imminent. Avoidance, for example, is not conceptualised as a response to (conditioned) anxiety that is maintained

Towards a reformulation of the cognitive-behavioural conceptualisation

The modified cognitive-behavioural model begins with the proposition that problems associated with chronic pain originate in the way patients react to their pain. Reactions are defined as including all forms of cognition (e.g., pain-related thoughts and imagery), not simply observable behaviours. It is proposed that the difference between patients who are distressed and/or disabled, and those for whom pain is not markedly problematic, lies not necessarily in the sensory activity, but rather in

Support for the reformulated cognitive-behavioural model

There are several advantages in viewing chronic pain from within a more cognitive framework. First, it is suggested that this model better explains the existing evidence. Second, the model makes clear and testable predictions, including predictions about treatment and about what should work for individual patients. Theoretically, identifying and targeting key cognitions should lead to more effective interventions than simply using the ‘blunderbuss’ approach typically offered (Turk, 1990).

Most

Conclusions

This paper has attempted to trace the development of psychological theories of chronic pain starting with the operant model, through to a reformulated cognitive behavioural model that parallels models proffered for the anxiety disorders (Salkovskis, 1996a, Salkovskis, 1996b). In reviewing the relevant evidence, it appears that the operant model is not as well supported as has been generally thought and that even some cognitive-behavioural models suffer many of the problems their predecessors do

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