Chronic Pain PDF

Journal of Consulting and Clinical Psychology Copyright 2002 by the American Psychological Association, Inc.
2002, Vol. 70, No. 3, 678 – 690 0022-006X/02/$5.00 DOI: 10.1037//0022-006X.70.3.678
Psychological Factors in Chronic Pain: Evolution and Revolution
Dennis C. Turk Akiko Okifuji

University of Washington School of Medicine University of Utah School of Medicine
Research has demonstrated the importance of psychological factors in coping, quality of life, and
disability in chronic pain. Furthermore, the contributions of psychology in the effectiveness of treatment
of chronic pain patients have received empirical support. The authors describe a biopsychosocial model
of chronic pain and provide an update on research implicating the importance of people’s appraisals of
their symptoms, their ability to self-manage pain and related problems, and their fears about pain and
injury that motivate efforts to avoid exacerbation of symptoms and further injury or reinjury. They
provide a selected review to illustrate treatment outcome research, methodological issues, practical, and
clinical issues to identify promising directions. Although there remain obstacles, there are also oppor-
tunities for psychologists to contribute to improved understanding of pain and treatment of people who
suffer from chronic pain. The authors conclude by noting that pain has received a tremendous amount of
attention culminating in the passage of a law by the U.S. Congress designating the period 2001–2011 as
the “The Decade of Pain Control and Research.”
During the past decade there has been an explosion of knowl- on pain associated with cancer (e.g., Chochinov & Breitbart, 2000)
edge regarding the underlying neuroanatomical pathways and the and developmental issues in pain (Berde & Masek, 1999; Walco &
neurophysiological mechanisms involved in the complex experi- Harkins, 1999). We encourage the interested reader to examine
ence of pain and the contributions of psychosocial factors to the these.
pain experience, patients’ responses to nociceptive stimulation, Furthermore, we have narrowed our focus to several areas that
and treatment. As a consequence, there have been significant we feel are representative of the developments over the past
advances in the development of pharmacological, surgical, neuro- decade and that we believe have promise for the future evolution
augmentative, and psychological treatment modalities. Indeed, it is of understanding of pain, pain sufferers, and treatment. In partic-
reasonable to characterize the research over this period as not only ular, we provide a status report on research implicating the impor-
evolutionary but revolutionary. Wide-ranging compendiums, often tance of people’s appraisals of their symptoms, their ability to
in excess of 1,000 pages, have been published in an attempt to self-manage pain and related problems, and their fears about pain
cover the expansive field of pain (e.g., Loeser, Butler, Chapman, & and injury that motivate efforts to avoid exacerbation of symptoms
Turk, 2001; Wall & Melzack, 1999). Many additional volumes and further injury or reinjury. We provide a selected review of
more narrowly focusing on the contributions of psychological recent treatment outcome research, methodological issues, practi-
factors to understanding pain and treating people with pain have cal issues (e.g., concerns about both clinical and cost-
appeared (cf. Gatchel & Turk, 1996, 1999; Price, 1999; Turk & effectiveness, efficiency of treatment delivery), and clinical issues
Melzack, 2001). (e.g., treatment matching, readiness for change, motivation en-
It would be impossible to provide detailed coverage of the hancement) to identify promising directions. Issues related to
wealth of exciting developments that have occurred in the under- subject attrition, noncompliance, and individual differences in
standing of pain and pain sufferers or to predict the future with
treatment response should be addressed in future studies. We
confidence. Because of space limitations, we focus on chronic
conclude by suggesting future areas of research that we believe
noncancer pain in adults. There are excellent volumes and articles
will advance the evolutionary process. Even with our targeted
focus, we are not able to discuss the topics selected in depth.
Moreover, we acknowledge that there are many areas of interest
Dennis C. Turk, Department of Anesthesiology, University of Wash- that we are unable to cover. We hope, however, that our discussion
ington School of Medicine; Akiko Okifuji, Department of Anesthesiology, will stimulate the reader to explore further the area of pain, as
University of Utah School of Medicine. psychologists have made significant contributions.
Preparation of this article was supported in part by National Institute of There has been a growing recognition that pain is a complex
Arthritis and Musculoskeletal and Skin Disorders (NIAMSD) Grants AR/ perceptual experience influenced by a wide range of psychosocial
AI44724 and AR47298 and National Institute of Child Health and Human factors, including emotions, social and environmental context,
Development Grant HD33989, awarded to Dennis C. Turk, and NIAMSD
sociocultural background, the meaning of pain to the person, and
Grants AR44230 and AR46303, awarded to Akiko Okifuji.
Correspondence concerning this article should be addressed to Dennis beliefs, attitudes, and expectations, as well as biological factors.
C. Turk, Department of Anesthesiology, University of Washington Pain that persists for months and years, chronic pain, will influence
School of Medicine, Box 356540, Seattle, Washington 98195. E-mail: all aspects of a person’s functioning: emotional, interpersonal,
[email protected] avocational, and physical. Consequently, successfully treating
678
SPECIAL ISSUE: PSYCHOLOGICAL FACTORS IN CHRONIC PAIN 679
chronic pain patients requires attention not only to the organic case of chronic pain is often maladaptive. For example, the belief
basis of the symptoms but also to the range of factors that mod- that activity might aggravate the initial injury and thus must be
ulate nociception and moderate the pain experience and related harmful often results in fear of engaging in rehabilitative efforts,
disability. leading to preoccupation with bodily symptoms and to physical
deconditioning, which can exacerbate pain and maintain disability.
Biopsychosocial Model Such hypervigilance may predispose patients to attend selectively
to somatic perturbations that might otherwise be ignored and to
Unlike the unidimensional biomedical perspective, which fo- avoid more and more activities that they believe will contribute to
cuses on etiological and pathophysiological explanations for further problems (i.e., fear avoidance). This process seems to be
chronic pain, or the psychogenic view, which suggests pain as particularly problematic for patients whose pain began following
physical manifestations of psychological difficulties, a biopsycho- an accident. Moreover, a physical trauma may alter the interpre-
social view provides an integrated model that incorporates purely tation of physical sensations. People who attribute their symptoms
mechanical and physiological processes as well as psychological to an injury appear more likely to view any physical sensation as
and social– contextual variables that may cause and perpetuate harmful and noxious, thereby increasing anxiety. These changes
chronic pain. In contrast to the biomedical model’s emphasis on may, consequently, lower pain thresholds and tolerance, further
the disease process, a biopsychosocial model views illness as a increase activity avoidance and functional limitations, and facili-
dynamic and reciprocal interaction between biological, psycholog- tate general deconditioning (Turk & Okifuji, 1996).
ical, and sociocultural variables that shapes the person’s response The importance of attribution of symptom onset can be illus-
to pain (Turk & Flor, 1999). The biological substrate of a disease trated with samples of patients diagnosed with fibromyalgia syn-
is known to affect psychological factors (e.g., mood) and the social drome (FMS; generalized musculoskeletal pain). Several studies
context within which the person exists (e.g., interpersonal have demonstrated that traumatic onset is associated with greater
relationships). perceived severity of symptoms (Greenfield, Fitzcharles, & Es-
Our biopsychosocial model presumes some form of physical daile, 1992) even when there is no difference in physical pathology
pathology or at least physical changes in the muscles, joints, or between those who attribute symptom onset to a traumatic event
nerves that generate nociceptive input to the brain. Perception and those who perceive their symptoms has having an insidious
involves the interpretation of nociceptive input and identifies the onset (Turk, Okifuji, Starz, & Sinclair 1996). Moreover, patients
type of pain (i.e., sharp, burning, punishing). Appraisal involves whose painful symptoms follow an accident have been shown to
the meaning that is attributed to the pain and influences subsequent be more refractory to treatment than patients with nontraumatic
behaviors. These appraisals will be influenced by the beliefs each onset (DeGood & Kiernan, 1996).
person develops over his or her lifetime. On the basis of these It is important to note that the putative cause of pain onset also
beliefs and the appraisal process, the person may choose to ignore influences the mindset of clinicians. Patients who describe their
the pain and continue working, walking, socializing, and engaging pain as a consequence of accidental injury are significantly more
in previous levels of activity or may choose to leave work, refrain likely to be prescribed physical and pharmacological modalities
from all activity, and assume the sick role. In turn, this interper- for symptomatic relief, including nerve blocks, physical therapy,
sonal role is shaped by responses from significant others that may transcutaneous electrical nerve stimulation, and opioid medication
promote either the healthy and active response or the sick role. The (Turk & Okifuji, 1996). Patients who reported symptoms follow-
biopsychosocial model has been instrumental in the development ing a trauma were five times more likely to be prescribed opioid
of cognitive– behavioral treatment approaches for chronic pain. medication even though they did not reveal greater physical find-
ings. Thus, health care providers treat patients who report trau-
Patient Beliefs matic onset of their symptoms differently, despite the fact that they
do not necessarily differ in the extent of detectable physical
There is a growing body of evidence supporting the importance pathology.
of patients’ beliefs in chronic pain. Beliefs about the meaning of
symptoms, the patient’s ability to control pain and the impact of Fear and Harm Avoidance
pain on his or her life, and worry about the future are just some that
have been shown to play a central role in chronic pain. Such beliefs Because fear is a natural consequence of pain, avoidance of a
have been found to be associated with psychological functioning fear-provoking event is reasonable for acute pain but may serve as
(e.g., Jensen, Romano, Turner, Good, & Wald, 1999; Stroud, an impediment to recovery from chronic pain. In chronic pain,
Thorn, Jensen, & Boothby, 2000), physical functioning (Stroud et pain-related anxiety and fear may actually accentuate the pain
al., 2000; Turner, Jensen, & Romano, 2000), coping efforts experience (e.g., Crombez, Vlaeyen, Heuts, & Lysens, 1999).
(Anderson, Dowds, Pelletz, Edwards, & Peeters-Asdourian, 1995), Chronic pain patients with elevated pain-related anxiety tend to
behavioral responses (e.g., Jensen et al., 1999), and response to anticipate higher levels of pain than those with low anxiety, and
treatment (e.g., Tota-Faucette, Gil, Williams, Keefe, & Goli, anticipation of pain often results in poorer behavioral performance
1993). (McCracken, Gross, Sorg, & Edmands, 1993).
When people with pain symptoms are exposed to a feared
Patients’ Attribution of Pain Onset situation (e.g., walking up a flight of stairs), some experience a
cascade of avoidance responses, including a cognitive response,
Resting and protecting a painful area following an acute injury worry (McCracken & Gross, 1993); effort to escape and avoid
is adaptive. However, reliance on the acute model of coping in the increased pain and exacerbation of injury (Crombez, Vervaet,
680 TURK AND OKIFUJI
Lysens, Eelen, & Baeyerns, 1998; Crombez, Vlaeyen, & Heuts, inability to extinguish fear by some patients include differences in
1999; Crombez, Vlaeyen, Heuts, & Lysens, 1999; Vlaeyen, Haa- prior learning history and the normal distribution of sensitivity to
zen, Schuerman, Kole-Snijders, & van Eck, 1995); and self-reported noxious stimulation. These explanations are not mutually exclu-
disability (Crombez, Vlaeyen, Heuts, & Lysens, 1999). Fearful sive. The results of future studies may help us to understand better
patients appear to attend more to signals of threat and appear to be the individual variability observed.
less able to ignore pain-related information (Crombez et al., 1998).
Waddell and colleagues (1993) reported that fear avoidance of Self-Efficacy
physical activities and work tasks is more strongly associated with
disability and work loss during the previous year than are biomed- The construct of self-efficacy (SE) has gained a great deal of
ical variables and characteristics of pain. They concluded that “fear attention in the pain literature (e.g., Dolce, Doleys, et al., 1986).
of pain and what we do about it is more disabling than the pain An SE expectation is defined as a personal conviction that one can
itself” (Waddell et al., 1993, p. 164). Several authors (Hildebrandt, successfully perform certain required behaviors in a given situa-
Pfingsten, Saur, & Jansen, 1997; Mayer & Gatchel, 1988) have tion. Bandura (1977) proposed that given sufficient motivation to
argued that patients with chronic back pain often demonstrate engage in a behavior, it is a person’s SE beliefs that determine
prolonged iatrogenically abetted protectiveness and passivity, whether that behavior will be initiated, how much effort will be
largely induced by fear. The result is likely to be a decrease in expended, and how long effort will be sustained in the face of
spinal mobility, muscle strength, and cardiovascular fitness, and obstacles and aversive experiences. From this perspective, coping
ultimately an increase in disability. Klenerman et al. (1995) dem- behaviors are conceptualized as being mediated by people’s effi-
onstrated that fear avoidance was one of the most powerful pre- cacy beliefs that situational demands do not exceed their coping
dictors of chronic disability in back pain patients. In fact, Vlaeyen, resources. People with weak efficacy expectancies are less likely
Kole-Snijders, Boeren, & van Eck (1995) observed that fear of to emit coping responses or persist in the presence of obstacles and
reinjury by activity was a better predictor of self-reported disabil- aversive consequences than those with positive efficacy
ity than were biomedical signs and symptoms or pain severity. expectations.
Furthermore, Vlaeyen and colleagues (Vlaeyen, Haazen, et al., Mastery experiences gained through performance accomplish-
1995; Vlaeyen, Kole-Snijders, et al., 1995) found a strong associ- ments are hypothesized to have the greatest impact on establishing
ation between pain-related fear and increased physiological and strengthening perceived SE. Thus, techniques that enhance
arousal. Physiological arousal might contribute to maintenance and mastery experiences (e.g., graded task accomplishments with both
increase in pain severity (Flor & Turk, 1989). Burns, Wiegner, physical and verbal feedback) should be powerful tools for bring-
Derleth, Kiselica, and Pawl (1997) and Vlaeyen et al. (1999) ing about behavior change. Moreover, the patient’s self-attribution
demonstrated that fear-induced increases in lower paraspinal mus- of success should facilitate maintenance of improvements. If pa-
cle reactivity predicted greater pain during subsequent physical tients feel that there is little they can do to control their symptoms,
performance tests. they will expend minimal effort in trying to use self-control
Counterconditioning by means of graded exposure to a feared techniques; conversely, they may become more emotionally dis-
stimulus is an effective treatment for people suffering from exces- tressed, which may amplify symptom perception.
sive fear (Davey, 1997). Several investigators have demonstrated Converging lines of evidence indicate that SE is important in the
the effectiveness of exposure-based counterconditioning treat- control of pain (e.g., Lorig, Chastain, Ung, Shoor, & Holman,
ments for secondary prevention of chronicity for people with 1989), adaptive psychological functioning (e.g., Spinhoven, Ter
subacute, work-related back pain (Linton, Bradley, Jensen, Spang- Kuile, Linssen, & Gazendam, 1989), disability (e.g., Lorig et al.,
fort, & Sundell, 1989). Furthermore, there is preliminary evidence 1989), impairment (e.g., Lorig et al., 1989), and treatment outcome
that exposure-based counterconditioning treatment focusing on (e.g., O’Leary, Shoor, Lorig, & Holman, 1988). For example, SE
fear of movement can be effective for patients with chronic back seems to have some predictive value for the level of performance
pain (Vlaeyen, Haazen, et al., 1995) and FMS (Vlaeyen et al., of physical tasks in back pain patients (Council, Ahern, Follick, &
1997). Kline, 1988). Similarly, SE expectancies were found to closely
Finally, McCracken and Gross (1998) reported that reduction in parallel increases in actual exercise levels during treatment (Dolce,
pain-related anxiety predicted improvement in functioning, affec- Crocker, Moletteire, & Doleys, 1986). Furthermore, posttreatment
tive distress, pain, and interference with activity. It appears that SE ratings were correlated significantly with reduction in medica-
fears, pain-related anxiety, and concerns about harm avoidance all tion use and return to work at follow-up periods ranging from 6
play an important role in chronic pain. Thus, it is appropriate to to 12 months (Dolce, Crocker, et al., 1986).
address these factors when treating chronic pain patients. Additionally, patients’ anticipation of pain during and following
It is not clear why fear during the acute phase is extinguished for physical tasks seems to interact with SE, collaboratively determin-
some but becomes a chronic factor for others. One plausible ing the level of performance. The influence of SE extends to pain
hypothesis is that premorbid individual differences may modulate reports, depression, and disability in chronic pain patients (Lorig et
this process. A good deal of attention has been given to the al., 1989). Furthermore, improvement in SE has been associated
potential predisposition of negative affectivity and anxiety sensi- with improvement in pain, disability, and mood (Keefe et al.,
tivity in fear related to pain symptoms (Asmundson, 1999). Neg- 1997; Smarr et al., 1997).
ative affectivity, the general tendency to experience subjective In short, SE appears to play a particularly important role in
distress and dissatisfaction, has been demonstrated to be associated perception of and adjustment to pain and subsequent disability.
with elevated symptom reporting by chronic pain patients (e.g., Cioffi (1991) suggested that at least four psychological mecha-
Vassend, Krogstad, & Dahl, 1995). Other explanations for the nisms could account for the association between SE and behavioral
outcome: (a) Because perceived SE decreases anxiety and its sponses on the Linton and Hallden “yellow flags” questionnaire
concomitant physiological arousal, the patient may approach the significantly predicted return to work, pain, and functional disabil-
task with less potentially distressing physical information to begin ity for low back pain patients following active physical therapy.
with; (b) the efficacious person is able to willfully distract atten- However, despite these general conclusions about psychosocial
tion from potentially threatening physiological sensations; (c) the predictors of disability, the results must be interpreted cautiously,
efficacious person perceives and is distressed by physical sensa- as there are methodological problems inherent in each study that
tions but simply persists in the face of them (i.e., displays sto- make generalizations based on the body of research problematic
icism); and (d) physical sensations are neither ignored nor neces- (cf. Turner, Franklin, & Turk, 2000). Particular problems that limit
sarily distressing but rather are relatively free to take on a broad conclusions include reliance on retrospective study, small and
distribution of meanings (i.e., change interpretations). unrepresentative samples, use of univariate models, inadequate
There are several ways in which perceived coping efficacy can description of predictor variables and outcomes, and failure to
contribute to relief from pain. People who believe they can alle- examine important variables.
viate suffering will likely mobilize whatever ameliorative skills
they have learned and will persevere in their efforts. Those who Clinical Outcomes
doubt their controlling efficacy are likely to give up readily in the
absence of rapid results. A sense of coping efficacy also reduces Psychological modalities have been used in the treatment of
distressing anticipations that create aversive physiological arousal chronic pain patients either on their own or, more typically, as an
and bodily tension, which only exacerbate pain sensation and essential component of comprehensive, multidisciplinary rehabil-
discomfort. Bandura (1977) suggested further that those tech- itation. A large volume of research exists demonstrating the effi-
niques that enhance mastery experiences the most will be the most cacy of the psychological treatments for low back pain (e.g.,
powerful tools for bringing about behavior change. He proposed Goossens et al., 1998; Hildebrandt et al., 1997), FMS (Turk,
that cognitive variables are the primary determinants of behavior Okifuji, Sinclair, & Starz, 1998; Turk, Okifuji, Sinclair, & Starz,
but that these variables are most influenced by performance ac- 1998), noncardiac chest pain (Mayou et al., 1997), arthritis (Lorig,
complishments. Thus, SE may play a role in fear avoidance. Mazonson, & Holman, 1993), headaches (Holroyd & Lipchik,
Exposure to feared activities without the negative consequences 1999), temporomandibular disorders (TMD; S. F. Dworkin et al.,
anticipated may reduce that fear while at the same time increasing 1994), and whiplash-associated disorders (Vendrig, Van Ak-
perceived SE. Pain sufferers who avoid activity because of fear of kerveeken, & McWhorter, 2000), to name a few examples. Fur-
pain, injury, or reinjury will never receive corrective feedback or thermore, cognitive– behavioral approaches appear to prevent the
information that can enhance their sense of SE—that is, the knowl- development of chronic disability due to pain (e.g., Hasenbring,
edge that they can successfully confront the feared activity without Ulrich, Hartmann, & Soyka, 1999).
the dire consequences they anticipate. In general, psychological treatments for chronic pain are most
effective when incorporated with other treatment components or
Psychological Factors Predict Long-Term Disability modalities (e.g., physical therapy, education; see, e.g., Bendix,
Bendix, Lund, Kirkbak, & Ostenfeld, 1997; Flor, Fydrich, & Turk,
Psychological factors have been reported to be predictive of 1992). We review several illustrative studies to raise a number of
long-term disability for many pain syndromes as well as for pain issues that will need to be resolved in future studies (for more
severity, emotional distress, and treatment seeking (e.g., Boothby, extensive discussion, see Morley, Eccleston, & Williams, 1999).
Thorn, Stroud, & Jensen, 1999; Johansson & Lindberg, 2000; Coverage of other pain-related disorders, for example, arthritis and
Pfingsten, Hildebrandt, Leibing, Franz, & Saur, 1997). For exam- noncardiac chest pain, is included in other articles in this special
ple, in one study, psychosocial variables accounted for 59% of the issue.
variance in disability associated with chronic pain (Burton, Tillot-
son, Main, & Hollis, 1995). When we review studies of predictors FMS
of recovery versus continued disability, maladaptive attitudes and
beliefs, lack of social support, heightened emotional reactivity, job Diffuse pain and hypersensitivity to palpation, accompanied by
dissatisfaction, substance abuse, compensation status, and the various functional, physical, and psychological dysfunctions, char-
prevalence of pain behaviors (e.g., Turk, 1997) and psychiatric acterize FMS (Wolfe et al., 1990). Nicassio et al. (1997) compared
diagnosis (Gatchel & Epker, 1999) appear to be among the best weekly behavior therapy sessions with patient education. Behavior
predictors of the transition from acute injury to chronic disability. therapy sessions included education, relaxation, problem solving,
It is interesting to note that physical factors, including severity of and goal setting. Although both groups showed reduction in pain
injury and physical demands of the job, do not appear to contribute sensitivity, distress, and pain behaviors, the patients in the behav-
as much to the prediction of chronicity. ior therapy group achieved significantly greater improvements.
Linton and Hallden (1997) developed a screening questionnaire Nielsen, Harth, and Bell (1997) examined the effectiveness of
that was based on the observations regarding the importance of an outpatient program for FMS that included family education
psychosocial factors as predictors of disability. This instrument has along with physical and psychological components. Patients dem-
subsequently been adopted as a set of “yellow flags” to be used in onstrated significant improvements on measures of pain, interfer-
conjunction with physical pathology to identify people who have ence of symptoms with life, emotional distress, and activity levels
acute, work-related musculoskeletal injuries who might be at risk following treatment. All but the improvements in activity levels
for long-term disability in New Zealand (Kendall, Linton, & Main, were maintained at 1-year follow-up. No changes, however, were
1997). Recently, Hurley and colleagues (2000) found that re- recorded on any objective measure of functional activities. The
discrepancy between results on objective and self-report measures some of which may be unnecessary, and (b) patients with different
continues to be a concern in the treatment of chronic pain patients characteristics may benefit from different treatments, and not all of
that needs to be investigated further (Morley et al., 1999). the components included may be necessary for all patients (Kole-
Snijders et al., 1999; Turk, 1990).
Chronic Back Pain Goossens et al. (1998) evaluated the additive effects of the
cognitive and relaxation components to a rehabilitation program
Despite technological advances in medical and surgical treat- for chronic pain patients based on operant principles. The usual
ment, the incidence of low back pain disability continues to esca- cost for the operant-alone program averaged $8,795. This cost was
late (Waddell, 1998). Several recent studies support the efficacy of compared with the combined operant and cognitive-relaxation
rehabilitation programs that incorporate psychological interven- treatment, which cost $9,196. Thus, the additional cognitive and
tions for chronic back pain (e.g., Haldorsen, Kronholm, Skouen, & relaxation components contributed a cost of $401 for each patient.
Ursin, 1998; Hasenbring et al., 1999). For example, in a study This additional expenditure did not significantly improve the al-
designed to evaluate psychological treatments in the prevention of ready very positive outcome of the operant treatment. We must be
chronicity in patients with sciatica, Hasenbring et al. (1999) com- cautious in this interpretation, however, because 43% of the
pared two psychological treatments (biofeedback vs. cognitive– operant-alone group was unavailable at follow-up. Moreover, the
behavioral therapy) for patients at risk for chronicity with usual authors noted that only a small number of patients in the cognitive-
care and treatment refusers. One of the best predictors of disability relaxation group complied with the assignments for home practice,
was refusal of treatment. Treatment refusers did not differ on any and thus, the treatment may not have been given an appropriate
demographic or physical factors from those who entered treatment. trial (Turk, Rudy, & Sorkin, 1993).
These results lend support to the recommendations of many au- The studies included in the meta-analyses published by Flor et
thors (e.g., Waddell, 1998) who believe that efficacy will be al. (1992) and Morley et al. (1999) support the effectiveness of
enhanced if cognitive– behavioral treatments are initiated earlier in including a psychological component within a rehabilitation pro-
the course of treatment and are scheduled in accordance with gram. The cost figures from a study reported by Bendix et al.
individual psychological patterns of coping and readiness for ac- (1997) illustrate the importance of going beyond statistical signif-
ceptance of self-management (Kerns, Rosenberg, Jamison, Caud- icance to examine the cost-effectiveness, as this may lead to
ill, & Haythornthwaite, 1997; Turk, 1990). different interpretation of the comparative outcomes. Because their
study shows that the efficacy of the program including a psycho-
Multidisciplinary Pain Rehabilitation Programs logical intervention did not differ from the efficacy of the exercise-
alone program, one could conclude that the psychological module
The large body of evidence demonstrating the importance of did not add therapeutic benefit significantly. This conclusion,
psychosocial and behavioral factors in the study and treatment of however, needs to be tempered by the fact that there was a 20%
pain has led to the proliferation of multidisciplinary pain rehabil- attrition from the program with no psychological component com-
itation programs (MPRPs) internationally. These MPRPs typically pared with an 8% patient dropout from the program with psycho-
include psychological components with comprehensive treatment logical components. Because the costs of the two shorter treatment
plans. programs were equivalent, the better patient acceptance, as evident
Flor et al. (1992) concluded that MPRPs were more effective by the lower attrition rate, favors the inclusion of the psychological
than no treatment, a waiting-list control, and monodisciplinary treatment. Additional research is needed to examine the interaction
treatments on reduction of health care use and medication, in- of inclusion of a psychological component and continuation within
creased activity and return to work, closure of disability claims, rehabilitation treatment programs.
and reductions of affective distress. More recently, Morley and Systematic examination of outcomes related to cost-
colleagues (1999) drew similar conclusions on the basis of their effectiveness of MPRPs that include psychological components as
systematic review and meta-analysis of randomized controlled core ingredients indicates that these interventions are more effi-
trials, comparing the effectiveness of cognitive– behavioral ther- cient than alternatives such as surgery, implantable devices, and
apy to waiting-list controls and alternative-treatment control con- long-term opioid therapy. We (Turk & Okifuji, 1998) demon-
ditions. They found that cognitive– behavioral therapy produced strated the cost-effectiveness of MPRPs by calculating differences
significantly greater changes in pain experience and cognitive in pain medication, health care use, and disability payments. We
coping and that it reduced behavioral expressions of pain. Signif- then compared the outcomes of these financial parameters with the
icant differences were not found, however, for dysphoric mood, most frequently used alternative treatments. Overall, we deter-
negative appraisals, and social role functioning. The failure to find mined that MPRPs were up to 21 times more cost-effective than
significant improvement in affective distress by Morley et al. alternatives such as surgery.
is at variance with the report of Flor et al. The explanation for
this inconsistency is unclear, and the issue warrants further What Works for Whom?
investigation. Although psychological treatments appear to be important com-
MPRPs are often referred to as being based on operant, behav- ponents of rehabilitation treatments for chronic pain patients, not
ioral, or cognitive– behavioral principles. The actual treatments are all patients benefit equally. Focusing solely on group effects may
broadly defined and often include diverse ingredients. It is difficult mask important issues related to the characteristics of patients who
to determine what the active components of the treatment packages successfully respond to a treatment. Chronic pain syndromes are
actually are. This is important because (a) it is not cost-effective to made up of heterogeneous groups of people even if they have the
provide comprehensive treatments with multiple components, identical medical diagnosis. A common pitfall in clinical research
and practice is the assumption of patient homogeneity. Inclusion of Kerns et al. (1997) developed the Pain Stages of Change Ques-
a diverse group of patients into the same category simply because tionnaire (PSOCQ) to assess patients’ readiness to adopt a self-
they present a common set of symptoms may result in inconsistent management approach to chronic pain. On the basis of their
research results, as commonly observed in the pain literature. response to the PSOCQ, patients’ readiness can be classified as
Several efforts have been made to identify groups of patients who one of the following stages: precontemplation, contemplation,
differ on important variables and to evaluate differential treatment action, or maintenance. Several investigators (Biller, Arnstein,
responses. Caudill, Federman, & Guberman, 2000; Kerns & Rosenberg,
A significant problem with rehabilitation-oriented treatments is 2000) demonstrated that specific stage of change of patients was
that (a) a large number of patients refuse treatment offered, (b) a associated with completion of a self-management treatment pro-
large number of patients drop out of treatment, and (c) the rates of gram, suggesting that the concept of readiness for treatment may
relapse are relatively high (Richmond & Carmody, 1999; Turk & identify patients at risk of prematurely terminating their treatment.
Rudy, 1990a). One of the problems is the prevalent assumption Discussion continues, however, on whether the transtheoretical
regarding delivery of medical care. Conventionally, patients model (Prochaska & DiClemente, 1998), originally developed for
present problems, and health care providers evaluate and apply a conceptualizing stages of readiness to stop smoking (on which the
solution (treatment). In this model, patients are passive recipients PSOCQ is based), is appropriate for chronic pain patients (e.g.,
of the intervention. However, rehabilitation approaches generally Jensen, Nielson, Romano, Hill, & Turner, 2000; Keefe et al.,
require patients to do things; active engagement and performance 2000). Jensen and colleagues found that patients in the action and
of tasks and exercises are critical in this approach. Despite pa- maintenance phases did not differ and that none of the groups
tients’ active participation, these programs may not necessarily differed from the others significantly on the precontemplation
eliminate pain. scale, leaving some question as to the ability of the PSOCQ to
The main objective of rehabilitation programs is to help patients classify patients into distinct groups. Although readiness for
assume responsibility for self-management of their condition. The change makes intuitive sense, there may be some limitation to the
programs do this by directing treatment toward fostering self- measure being used to classify patients into discrete stages. Sim-
management and self-efficacy, including both physical (e.g., ex- ilarly, Biller et al. (2000) cautioned against using scores on the
ercises, pacing, and body mechanics) and psychological ap- PSOCQ as a basis for withholding treatment. Rather, clinicians
proaches. Rehabilitation programs require patients to make a might develop methods to match preparatory information to pa-
number of lifestyle changes including regular performance of tients’ readiness to adopt a self-management approach (Jensen,
physical exercises, practice and use of various coping strategies, 1996; Keefe et al., 2000).
and communicating differently. Research on programs for other It is interesting to note that the stages of change did not predict
lifestyle changes, such as weight loss, smoking cessation, and treatment outcome in one study (Kerns & Rosenberg, 2000). This
substance abuse, has shown that patients experience significant may be because the cognitive– behavioral components of treatment
relapse following initially successful outcomes. Thus, it is not were designed to help patients reconceptualize their views of their
surprising that the relapse rates are high for those pain patients problems and their ability to exert control. Thus, modification of
who complete rehabilitation. Efforts to identify those prone to patients’ readiness to adopt greater responsibility for pain man-
treatment rejection, dropout, and relapse would be useful as they agement is a target in these programs. These findings suggest that
could guide attempts to prepare patients for treatment and to increased commitment to a self-management approach may serve
structure treatments to meet important characteristics of patients as a mediator or moderator of successful treatment.
that may promote positive outcomes.
Identification of Patient Subgroups
Readiness to Change
A number of studies have identified subgroups of patients
Patients’ own beliefs and expectations concerning how their according to psychosocial and behavioral characteristics (e.g.,
pain should be treated appear to have an important influence on Johansson & Lindberg, 2000; Mikail, Henderson, & Tasca, 1994;
treatment outcome. Patients who did not initially agree with the Turk & Rudy, 1988, 1990b; Turk, Sist, et al., 1998). Several
self-management approach reported greater pain and tended to be studies (Dahlstrom, Widmark, & Carlsson, 1997; Epker &
less satisfied with the treatment (Shutty, DeGood, & Tuttle, 1990). Gatchel, 2000; Rudy, Turk, Kubinski, & Zaki, 1995) found that
Identification of the pretreatment beliefs that may interfere with patients classified into different subgroups on the basis of their
treatment would permit targeting of information to modify these psychosocial and behavioral responses responded differentially to
beliefs prior to formal treatment to increase acceptance and within identical treatments. Subgroups of chronic pain patients character-
the treatment to facilitate remaining in treatment and adherence to ized by a number of psychosocial and behavioral characteristics
the self-management exercises. seem to be fairly consistently observed across different pain syn-
Kerns and colleagues (1997) proposed that people experiencing dromes (e.g., cancer, FMS, TMD, headaches, low back pain; Turk
chronic pain vary in readiness to accept and adopt a self-management & Rudy, 1990b; Turk, Sist, et al., 1998), suggesting the indepen-
approach to mange their pain and associated problems. According to dence of psychosocial factors from the physical pathology. A
this readiness-for-change model, some people who believe strongly number of investigators (e.g., S. F. Dworkin & LeResche, 1992;
that their pain is “medical,” requiring physical treatment, are not likely Turk, 1990) recommend the use of a dual-diagnostic system: a
to accept a self-management approach. Others may acknowledge that biomedical diagnosis and a psychosocial diagnosis. Distinctive-
medical interventions are limited and may be more willing to accept ness of the psychosocial profiling implies that patients in different
a self-management treatment. subgroups may exhibit differential responses to a treatment. In-
deed, this has been demonstrated in several outcome studies. For Compliance and Adherence
example, one of the most frequently used pain inventories, the
Multidimensional Pain Inventory (MPI; Kerns, Turk, & Rudy, For a treatment to be effective, the patient must comply with the
1985; Piotrowski, 1998), yields a three-subgroup solution. The treatment recommendation (Turk et al., 1993). Unfortunately, the
extent to which patient compliance influences treatment outcomes
MPI subgroups were initially developed using the cluster-analytic
is not well understood because treatment outcome studies rarely
approach. Turk and Rudy (1988) labeled one subgroup character-
assess patients’ compliance with recommendations (Epstein,
ized by severe pain, compromised life activities and enjoyment,
1984). This is a particular problem, because failure to assess
reduced sense of control, and high level of emotional distress as
patient compliance may lead to a conclusion that a treatment is not
“dysfunctional.” Another subgroup, also marked with relatively effective when the treatment may not have been given an adequate
high degrees of pain and affective distress but further characterized trial. To understand this point, consider a study conducted by
by low levels of perceived support from significant others, was Basler and Rehfisch (1991) in which they evaluated the effective-
labeled “interpersonally distressed.” The third subgroup consisted ness of a cognitive– behavioral therapy for patients with rheumatic
of chronic pain patients who appeared to be coping relatively well pain. The initial results of this study suggested that the treatment
despite their long-standing pain. This group, which experienced did not produce a significant benefit. When patients were divided
low levels of pain, functional limitations, and emotional distress, into those who had complied with the recommendations and those
was labeled “adaptive copers.” The subgroups have been repli- who had not, however, the compliant patients demonstrated sig-
cated and validated in numerous studies (e.g., Jamison, Rudy, nificant improvements whereas the noncompliant patients did not.
Penzien, & Mosley, 1994). Thus, because lack of compliance tends to severely undermine the
overall effects of the therapy, failure to attend to the issue of
compliance may lead to an erroneous conclusion about the efficacy
Potential for Treatment Matching of the intervention. One must be cautious in interpreting treatment
outcome differences between compliant and noncompliant pa-
Studies comparing the MPI subgroups have yielded evidence tients, however, as these groups may not be comparable and may
supporting differential response to the same intervention (e.g., differ on other important variables that might be associated with
Dahlstrom et al., 1997; Epker & Gatchel, 2000; Rudy et al., 1995). better outcomes (e.g., good social support). Nevertheless, there is
For example, when a treatment consisting of an intraoral appli- no question that compliance and adherence will continue to be
ance, biofeedback, and stress management for TMD patients was important areas to be studied if the maintenance of treatment
tested, the dysfunctional group showed significantly greater im- outcome is to improve.
provements on measures of pain intensity, perceived impact of
symptoms on their lives, and depression relative to the interper-
Future Directions
sonally distressed and adaptive coper groups (Rudy et al., 1995).
Comparable results were reported with a rehabilitation pain We have attempted to provide an overview of areas that con-
management program for FMS patients (Turk, Okifuji, Sinclair, & tribute to our understanding of the person with chronic pain and
Starz, 1998). In this study, the patients in the dysfunctional group psychological variables that have implications for improvements
improved in most areas, whereas the interpersonally distressed in treatment. We noted that clinical outcomes tend to support
patients, who reported levels of pain and disability comparable to addressing cognitive, affective, and behavioral contributors to the
the dysfunctional group, failed to respond to the treatment. There experience of and response to chronic pain. We now consider
was little change in the adaptive coper patients, owing possibly to future directions beyond what we have already suggested.
a floor effect. The results further support the need for different
treatments targeting characteristics of subgroups and suggest that Integration of Physical, Psychosocial, and Behavioral
psychosocial characteristics of FMS patients are important predic- Parameters
tors of treatment responses and may be used to customize treat-
ment. For example, whereas the interpersonally distressed patients One of the major emphases of psychological research on pain is
may require additional treatment components addressing clinical delineation of the relationship between psychological and physio-
logical parameters. A number of investigators have described
needs specific to this group (e.g., interpersonal skills), some com-
models that attempt to integrate physiological, psychophysiologi-
ponents of the standard interdisciplinary treatment may not be
cal, psychological, and behavioral factors to explain symptoms,
essential for the adaptive coper patients.
perception of pain, disability, and response to treatment (e.g.,
The results described implicate the importance of matching
Price, 1999; Turk & Flor, 1999). Technological advancements in
patients’ characteristics to treatment. It is unfortunately all too the recent decades in medicine, such as functional magnetic reso-
common to treat chronic pain patients with a “one-size-fits-all” nance imaging and positron emission tomography, permit re-
intervention. By specifically addressing patients’ psychological searchers to examine brain activity noninvasively (e.g., Rainville,
needs, clinicians are likely to be able to enhance both the cost- Duncan, Price, Carrier, & Bushnell, 1997). Psychological research
effectiveness and the clinical effectiveness of interventions. More- needs to take advantage of such technology to better understand
over, early identification of patients’ modes of adapting to sub- the effects of psychological factors on brain structures. Greater
acute pain may lead to the development of interventions that can understanding of the reciprocal interactions among neurological,
prevent chronicity and long-term disability (Gatchel & Epker, hormonal, endocrine, and psychological factors should advance
1999; Johansson & Lindberg, 2000). our understanding and ability to treat pain more effectively.
Investigators need to address such questions as the following: velopment of strategies for improving outcome. To paraphrase the
How are the anatomy of the nervous system and physiological old behavioral adage, “Insight without changing behavior is a
processes altered by psychological interventions? How do physi- waste of time.”
ological processes and physical status affect mood, thoughts, and Prevention and earlier interventions hold promise for reduction
behavior? What is the role of genetic predispositions on pain in the extent of disability. The average person treated at a multi-
perception and response? How are memories organized, stored, disciplinary pain center averages over 85 months of pain (Flor et
and retrieved so that they influence the pain experience? Devel- al., 1992). By this time, patients have become so disabled that
opment of a truly revolutionary, unified model awaits the answers rehabilitation becomes a Herculean task; the outcomes, although
to these and numerous other questions. reasonably good, could have been improved if implemented at an
earlier stage. Von Korff and colleagues (Moore, Von Korff, Cher-
Overgeneralization Based on Pain Clinic Samples kin, Saunders, & Lorig, 2000; Von Korff et al., 1998) described an
early intervention program that was implemented in primary care.
Minimal attention has been given to those people who recover This program focuses on patient education and efforts to enhance
spontaneously or who make adequate and often exceptional ac- patients’ SE. Linton and Bradley (1996) have reviewed a number
commodations to their conditions regardless of physical impair- of efforts that may be viewed as secondary prevention, that is,
ments and limitations. Much of what is known about chronic pain treatments used with those who have already had a first pain
syndromes is based on people who seek treatment. These individ- episode and designed to prevent long-term disability.
uals are not a representative group (cf. Bradley et al., 1994). It is Given the natural history of many musculoskeletal pain disor-
likely that people will seek treatment when they have an exacer- ders, it is important that early interventions be reasonably inex-
bation of their symptoms. As a result, almost any treatment will pensive. For example, experience with back pain suggests that a
appear reasonably successful. Thus, one must be cognizant of the significant percentage of people will recover in only a few weeks.
potential impact of regression to the mean when evaluating out- Providing expensive interventions for groups with high rates of
come studies based on treatment seekers. It is essential that re- natural recovery is inefficient and costly. Von Korff (1999) re-
search extend beyond the clinical population to community sam- minded us that for a number of patients, pain will persist or recur,
ples that are not seeking care. although they are able to return to work in a short time. Efforts to
People with different pain syndromes have prior learning histo- prevent, or at least minimize, the consequences of exacerbations
ries that preceded the onset of their symptoms. One must consider and relapse may be particularly cost-effective. The effects of early
the relevance of antecedent factors and not focus exclusively on interventions are mixed, but the costs of chronicity are so extreme
patients at one point in time, the point of symptom onset or at that research in this area is definitely warranted.
which they seek treatment. On the flip side, however, one should
keep in mind that when patients who have had symptoms for many
Prospective and Process Research
years are asked to recall features of their lives prior to symptom
onset, they may produce invalid information (i.e., demonstrate a The majority of the research in the field of pain has been
retrospective bias). People seek post hoc rationales and causal cross-sectional. Little is known about the evolution and changes
factors to explain their current situation. Thus, patients’ recollec- that accompany pain conditions over time, as well as throughout
tions may lack complete veracity, not because of conscious decep- the process of treatment. Prospective studies with high-risk popu-
tion but because of the cognitive heuristics used (Turk & Salovey, lations, such as those preparing for amputation and herpes zoster
1986) and the influences of memory. One must resist the tempta- patients who are at risk for development of postherpetic neuralgia
tion to make inferences about causality from correlational data and (R. H. Dworkin et al., 1992), may be able to tell us a great deal
retrospective interpretations. about the changing pain experience, adaptation, and disability.
These disorders offer the opportunity to study the evolution of the
The Transition From Acute to Chronic Pain: Secondary adaptive processes.
Prevention Process research is important not only for observing the evolu-
tion of chronic pain syndromes but also for learning about the
The vast majority of people who are injured recover in a co-occurrence of physical and psychological factors over time.
reasonable amount of time and do not develop chronic disorders. That is to say, rather than relying on retrospective reports, it will
Similarly, a significant number of people who develop chronic be useful to investigate the co-occurrences of thoughts, feelings,
diseases associated with pain do not become physically and emo- and behaviors over time. This process approach can also provide
tionally disabled. As noted, a number of efforts have been made to useful information about the manner in which changes occur
identify the predictors of disability among these groups (e.g., during treatment. For example, what are the relationships between
Gatchel & Epker, 1999; Johansson & Lindberg, 2000; Linton & physical and psychological changes during the course of a treat-
Hallden, 1997). There are, however, few longitudinal studies, and ment such as biofeedback? Do autonomic parameters change first,
replications are the exception rather than the rule (Turner, Frank- influencing symptoms, mood, thoughts, and behavior, or does
lin, & Turk, 2000). mood change first, leading to a different interpretation of symp-
As we noted, a number of studies have begun to identify toms and a subsequent alteration of physiological responses?
predictors of disability for injured workers with acute pain states Advances in computer and telecommunication technology have
and also predictors of response to treatment. But identifying pre- led to interesting innovations for process research. Studies have
dictors is insufficient. The next step is to determine whether begun to identify the relationships among thoughts, feelings, and
knowledge of predictors can guide treatment design and the de- behavior in “real time” and permit careful assessment of the lagged
effects of cognition, mood, activity, and so forth on subsequent be addressed more systematically in clinical trials and to become
symptoms (e.g., Affleck et al., 1999; Stone, Broderick, Porter, & targets of research (Turk & Rudy, 1991). Not all patients are
Kaell, 1997). The applications of these technologies should permit equally ready for treatment (Kerns et al., 1997). Assessment meth-
greater understanding of the interactive effects among these im- ods need to be refined to help identify impediments to treatment
portant variables while eliminating the potential problems and responsiveness. Intervention strategies that can be used to enhance
biases inherent in retrospective recall. motivation and receptiveness should be investigated (Jensen,
1996). Finally, the emphasis or components of treatment need to
Patient Differences and Treatment Matching be individualized to address specific maladaptive beliefs or to
reinforce more appropriate ones.
There seems no question that psychological and behavioral The many areas of behavior change indicate that the risk of
factors play a central role in pain perception, experience, and relapse is high. Treatment for people with recurrent pain and
response. Many avenues of research still need to be pursued to chronic pain often makes major demands for lifestyle changes:
reveal the mechanisms by which these factors produce their effects relaxing, pacing activities, communicating more effectively, per-
on physiological processes and behavior. As we noted, preliminary forming exercises, and so forth. If one knows that relapse is high
studies have demonstrated that groups of patients may differ in for such behavior changes as reduction or elimination of substance
psychosocial and behavioral characteristics and may respond dif- use and weight reduction, why would one be surprised that relapse
ferentially to the same treatment, even when the medical diagnosis would be high for people with persistent and recurrent pain?
is identical (Turk, Okifuji, Sinclair, & Starz, 1998; Turk & Rudy, Almost all psychological interventions for persistent pain have
1990b). been shown to be effective, at least for some people, but the
Blanchard (1979) pointed out six important dimensions that duration of the benefits varies. Strategies need to be investigated to
should be considered in evaluating clinical applications. These enhance maintenance of therapeutic gains.
dimensions would similarly hold true for the evaluation of pain Indeed, Marlatt and Gordon (1981) developed a relapse-
management procedures and for the issues that we raised above. prevention model to address the problem of long-term mainte-
They include (a) the proportion of the treated patient sample that nance of new health behaviors. It was created to aid patients to
demonstrated significant therapeutic improvement, (b) the clinical acquire new coping skills that would reduce the risks of an initial
meaningfulness of the therapeutic changes that were obtained, (c) relapse or recurrence and to prevent minor lapses from escalating
the degree of transfer of changes that were obtained in the clinical into total relapse. The major element of the model is that the
setting to the patient’s natural environment, (d) the degree of problem of possible lapses and relapses is neither ignored nor
change in the biopsychosocial response for which the treatment attributed to failures of the treatment management program or the
was prescribed, (e) the replicability of the results by different patient. Such lapses and relapses are viewed as an important part
clinicians and clinical sites, and (f) the extent and thoroughness of of the learning required for long-term successful behavioral
the follow-up data obtained. Each of these is an important factor change and thus should be included in pain rehabilitation programs
that should be considered when evaluating the therapeutic efficacy (cf. Keefe & Van Horn, 1993).
of any pain management intervention. As clinicians, we also need to go beyond the assumption that
As we noted, similar patterns of psychosocial disability are people who have problems coping with their pain suffer from a
associated with common diseases and syndromes in which chronic skills deficiency and that simply teaching them appropriate skills
pain is an important clinical feature. Careful reading of discussions will alleviate their problems. Beyond consideration of the skills
of treatment of patients with different pain syndromes reveals that deficiency, we need to consider production deficiency. That is,
all share features from the psychosocial domain— depression, lim- what are the impediments to the use of the skills in the natural
itations in activities, and increased health care use—while each environment and what can we do to help patients overcome these
retains those unique physical features from the biological or phys- obstacles?
ical domain related to the specific body site (e.g., head, jaw, back) Closely aligned with maintenance is compliance. All too often,
or pathophysiological processes (e.g., postherpetic neuralgia, can- we seem to be concerned about the details of the treatment but less
cer). Research that includes multiple pain disorders may be useful. about whether our patients adhere to the demands of the treatment.
Researchers should be less parochial in focusing their investiga- Clinicians make recommendations for significant changes in be-
tions on only one preferred syndrome (e.g., FMS, back pain, TMD) haviors and expect that their patients will continue to engage in the
with the assumption that it is uniquely different from others. behaviors prescribed. We have been rather naive in this expecta-
Actually, those who suffer from different conditions may have tion (hope, wish, or prayer); in fact, the long-term rate of adher-
more in common with each other than those with the same diag- ence by chronic pain patients has been reported to be quite low in
noses (Turk, 1990). some studies (Lutz, Silbret, & Olshan, 1983). Greater attention
needs to be given to adherence enhancement methods (Turk &
Research on Motivation for and Adherence to Treatment Rudy, 1991). We must make sure that we assess adherence in our
outcome studies.
Patients’ beliefs about their pain appear to play an important Clinicians may view a treatment as ineffective when it may, in
role in adjustment to chronic pain. Moreover these beliefs have fact, have been very effective but only for those who complied
been associated with compliance with treatment recommendations, with the prescriptive behaviors. If people do not practice the
improvement in depressive symptoms, and increases in physical exercises included within the treatment, why would we be sur-
functioning and health care use (Flor & Turk, 1988; Jensen, prised if they do not show positive outcomes? Here the poor results
Turner, Romano, & Lawler, 1994). Thus, patients’ beliefs need to are due not to an inefficacious treatment but rather to the failure of
patients to adhere to the treatment recommendations. Again, we strated to play important roles in the transition from acute to chronic
see the importance of looking not just at the effectiveness of the pain, disability, adaptation, and response to treatments. The impor-
treatment for a group but at the characteristics of patients who tance of psychologists in the assessment and treatment of chronic pain
improve as opposed to the characteristics of those who do not. has been accepted by a number of agencies and governmental bodies
in the United States, Canada, and England (e.g., U.S. Veterans Ad-
Chronic Pain Should Be Treated Like Other Chronic ministration, U.S. Social Security Administration, Ontario Workplace
Diseases Safety and Insurance Board). The Commission on the Accreditation
of Rehabilitation Facilities (CARF) requires involvement of psychol-
We noted earlier that patients with chronic pain seeking treatment ogists in treatment for a program to be certified. The National Insti-
at MPRPs have had symptoms for an average of 7 years (Flor et al., tutes of Health Technology Assessment Panel (1996) and the Amer-
1992). Even when successful, pain rehabilitation does not cure pain ican Psychological Association Division of Clinical Psychology’s
but emphasizes self-control and self-management of symptoms. This Task Force on the Promotion and Dissemination of Psychological
observation is not unique to MPRPs; the majority of people who have Procedures have endorsed cognitive– behavioral therapy as a “well-
surgery or have spinal cord stimulators or drug delivery systems established” treatment approach for several pain problems (e.g., rheu-
implanted continue to report substantial pain (Turk & Okifuji, 1998). matoid arthritis; Chambless et al., 1998).
Examination of the results of long-term opioid therapy also reveals We have described some of the representative literature and
significant residual pain. If we view chronic pain as a chronic disease pointed out a number of areas in which research is likely to evolve
like diabetes or hypertension, then our approach to treatment may be over the next decade, designated by the U.S. Congress as the “The
misguided. Why would we expect that people with long-term prob- Decade of Pain Control and Research.” There are many exciting
lems, for whom there is no cure and who have a continuation of topics that, because of space limitations, we could not discuss. We
symptoms, would be able to return to normal function following were able to give only cursory attention even to research we
treatment? Even successful treatment requires people with chronic selected for examination. We cannot predict the future; however,
pain to continue to make significant lifestyle changes and engage in the prospects for the better understanding and treatment of people
self-management techniques. Because these pain sufferers are not with chronic pain are inevitable. We are confident that the evolu-
cured, they require regular care and follow-up. Would we expect a tion and, indeed, the revolution will continue.
diabetic to come for time-limited treatment and then be sent off on his
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Journal of Consulting and Clinical Psychology Copyright 2002 by the American Psychological Association, Inc.

2002, Vol. 70, No. 3, 678 – 690 0022-006X/02/$5.00 DOI: 10.1037//0022-006X.70.3.678

Psychological Factors in Chronic Pain: Evolution and Revolution

Dennis C. Turk Akiko Okifuji

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