Psychotherapy with Chronic Pain Patients

Abstract

It is increasingly accepted among medical and mental health care providers that cognitions and emotions play a significant role in the perception of chronic pain and resulting disability. Though this seems an obvious point, it is a major leap considering that, as recently as 40 years ago, the primary thought was that all pain perception is directly related to the severity of injury (i.e., the worse it looks the worse it must be), as pain was believed to exist only in the presence of identifiable, causal, pathophysiology. This archaic, dualistic Cartesian style of thinking has since evolved considerably (Turk, 1996). In the 1950s, both (Bonica, 1953) and Engel (1959) described psychological factors as important contributors to the pain experience. Melzack, a leader in the exploration of the etiology behind the perception and experience of pain, made an important early contribution to its understanding. In 1965, Melzack and Wall (1965) proposed the gate control theory of pain, which solidified the involvement of the central nervous system (CNS) as an essential component in the perception and processing of pain. The gate control theory of pain served to provide a scientific understanding of how brain-generated experiences, such as emotion, affected pain perception. This theory effectively narrowed the gap between the mental and physical health fields by tying together nociception and emotional experience. Following this, a proliferation of research arose aimed at identification of specific psychological and social factors believed to play a key role in the development, maintenance and perception of pain. Specifically, Gatchel and Epker (1999) and Turk (1996) discussed at length the various contributions of behavioral, affective, and cognitive factors, as well as psychosocial risk factors for pain. In sum, their research has served to further refute the previous dualistic view of pain—that pain patients were either legitimate medical patients with “real” physical etiology or that they were psychiatric patients whose pain experience was “all in their head.” Despite the incorrect assumption that chronic pain is an inherently psychological problem, chronic pain patients do have a higher prevalence of psychiatric disorders, such as depression and personality disorders, relative to the general population (Gatchel, Polatin, Mayer, & Garcy, 1994; Kinney, Gatchel, Polatin, Fogarty, & Mayer, 1993; Polatin, Kinney, Gatchel, Lillo, & Mayer, 1993). Specifically, Kinney et al. (1993) found that, among 200 chronic low back pain patients who were assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders-III-Revised, 70% met lifetime diagnostic criteria for Axis I disorders and 51% met criteria for Axis II diagnoses. In addition to significant psychiatric distress, patients with chronic pain often have a number of additional risk factors for increased difficulty in obtaining maximal treatment gains. Specific factors identified in the literature include: a patient’s reliance on passive coping strategies (e.g., catastrophizing, hoping and praying, M. J. L. Sullivan et al., 2001)