The operant approach to chronic pain was intended to concentrate upon external pain-induced responses and the social implications of the nature of feedback.  The operant model has been particularly described by Fordyce et al (1968, 1976) based upon the work of other individuals in the behavioural field, for example Skinner.

The operant theory implies that the genesis of the pain should be distinguished from pain behaviours and the articulation of pain.External displays of pain such as wincing may be conditioned just asany other type of behaviour.  If the patient receives positive feedbackin response to pain behaviours, they may remain after the usual time of healing for that ailment.

There is a respectable body of evidence to justify the use of the operant model in response to chronic pain,yet there is a relatively miniscule level of consensus about why theywork and the validity of their theoretical foundations. The operanttheory is supported by research projects that intimate the success ofbehavioural treatments, but there are several problematic elements inthese studies which have been recently addressed. The troubling issuesinclude the antecedent belief that all pain behaviours aredysfunctional, the obstacles to continuing the learned behaviourssubsequent to treatment and the reluctance of some chronic painpatients to embrace operant modes of treatment. Essentially, the natureof the sum of the problems is dualistic, and can either be addressed ascomplications with interpreting pain behaviours or the inevitable failure rate that all treatments face.

These issues, salient though they are, are not exhaustive. The operantmodel fails to recognise the fact that the patient’s personalinterpretation of their pain and the changes they are experiencing maybe important. Acknowledging this can clear the way for cognitivetheories to add something to operant methods of treatment. Indeed,elements that influence behaviour in general and pain behaviour inparticular are complex and multi-faceted. It is seldom evident that asingle cause has led to a single effect. Although it is true thatpain-related behaviours are often modified during the course of atreatment programme, it is not necessarily true that it is for thereasons uppermost in the minds of the experts monitoring them. Inbrief, rational thought cannot condone the notion that the operantmodel of chronic pain is true because treatment programmes utilisingbehavioural methods have been shown to alter the behaviour of patients suffering from chronic pain.

A particular assertion that has come under scrutiny is the idea thatpatients modify their verbal expressions of pain in response toreactions from spouses. The methods and logic that lead to thisconclusion are questionable and so must be their perceived contributionto the validity of the operant model. Further, some studies claiming toprovide empirical support for the operant model only partially adhereto its theoretical roots. Other studies which are more methodologicallysound have suspect sample gathering procedures. The findings of thesestudies still hold merit for the cognitive model of chronic pain,though ardent followers of the operant model will inevitably bedisappointed. The fact is that the operant model of chronic pain doesnot have as strong a body of empirical evidence to back it up as itspatrons would like. As a result of the questionable reliability of theoperant theory, many researchers have begun to actively espouse thecognitive-behavioural theories of chronic pain.

Cognitive Behavioural Account of Chronic Pains

    The cognitive-behavioural approach to chronic pain purported to contain the essentials of the operant account of chronic pain,but added space for human emotions, cognitions and mental copingmechanisms.  This approach, like surgical and pharmacologicalinterventions, attempt to eliminate or reduce it. Rates of failure inachieving this have led researchers to turn from attempted painreduction to other objectives like active rehabilitation.   One studycompared and contrasted two behavioural treatments for ongoing pain.The first treatment focused on abandoning strivings to overcome painand invest more energy in achieving other aims in life. The secondtreatment was a traditional cognitive behavioural treatment stressingthe development of pain-reducing mechanisms.  The treatmentincorporating acceptance and re-focussing proved more successful thanattempts to master the pain in patients suffering from chronic pain.

Initial formulations of a cognitive behavioural approach to chronicpain were predicated upon the realisation that programmes with thebehavioural label did not contain only behavioural content. Behaviouralexperts acknowledged the necessity of addressing the cognitivefunctioning of a patient as well as his or her behavioural patterns. Atpresent, the role of cognition in reporting extremity of pain,endeavours to successfully deal with pain, emotions and level ofpain-related incapacity is solidly documented. The relationship betweencognitive functioning and pain has revealed a number of importantthemes. The way in which patients mentally interpret their pain ispredictive of their response and their level of functioning. Forexample, patients to perceive their pain as an indication of moredamage often spend more energy attempting to avoid their pain andbecome less able to function naturally as a result. Patients whocatastrophise their pain may experience augmented levels of depressioncompared with those who do not. Depression has also been linked tobehavioural functioning and both of these may be affected by thepatient’s attempts to predict or control his pain.

The sum of the implications of these findings points to the nearcertainty that cognitive functioning must be considered when attemptingto construct any comprehensive and effective model of chronic pain. Thecognitive behavioural theory does not go as far as to suggest thatcertain cognitions lead to pain; the relationship is not as simplisticas that. There is substantial evidence to suggest that cognitiveactivity related to pain can help to create coping mechanisms that areeither helpful or dysfunctional. The nature of the coping mechanismscan directly affect the degree to which chronic pain infringes oncontinued functioning.

Some behaviourists allude to the role of cognitions in their researchby referring to external or environmental factors. Strict behaviourismcontinues to be the preferred method of treatment and as such, willcontinue to concentrate on the transformation of overt behaviours.Evidence for the need to include cognitive and other factors in dealingwith chronic pain is becoming increasingly pressing, and it must beacknowledged that including one treatment session on cognitive theoryand praxis does not magically transform a behavioural programme into acognitive behavioural programme. Even the cognitive behavioural theoryitself is in need of more complete incorporation of cognitive methods.There are simple questions that can be raised in the minds of chronicpain patients that may transform the way that they think about andrespond to their pain. The claims of balanced research pale incomparison to the pressing needs of patients suffering daily who couldbenefit from cognitive interventions. Treatment for chronic pain mustbe addressed in terms of cognition and behaviour; even if behaviour isthe founding principle upon which a treatment is based, it must berecognised that behaviour acquires meaning in a cognitive sphere.

There have been propositions to reformulate the theoreticalconstruction of the cognitive behavioural approach. Modifications ofthe approach start with the conception that the issues arising from thepresence of chronic pain stem from patient reactions to their pain.Reactions are conceptualised as covering the sum of cognitive processesand not merely external actions. Dividing characteristics betweenpatients who are anxious and suffering a notable level ofincapacitation and those who are able to maintain a level offunctioning despite their pain are not found in the sensations of painexperienced by the patient but in the content of the internal cognitiveassessment the patient carries out about their own pain. Some cognitivebehavioural appraisals of pain are primarily concerned with the meaningthat the individual patient attributes to his or her pain.

The reformulated cognitive behavioural model of chronic pain proposesthat the interaction of various phenomenon such as internal appraisalsof pain, learning history, mood, avoidance behaviours and environmentalinfluences can become habitual to an extent that negative consequencesof the pain, such as level of disability, may persist despite theremoval of the sensory aspect of the pain. Motor behaviours thatattempt to evade the pain in some way may continue after the pain hassubsided or lessened and therefore the cognitions that prompted thosebeliefs continue. An acute sense of worry or anxiety may heightensafety or defence mechanisms perpetuate an autonomic arousal thatmaintains positive feedback for the notion that there is somethingwrong with the patient. Additionally, psychological dysfunction such asdepression or mild panic can augment the chances of patients makingcalculative mistakes regarding their pain including assessing the painas being worse than it actually is. This will reinforce the cycles ofavoidance that the patient has previously used.

This particular reconfiguration of the cognitive behavioural modelfurther accepts that anxiety and other maladaptive behaviours such asmisusing medication can easily invoke arousal encourage the continuanceof maladaptive behaviours. The model also takes into account the drivefor the patient to seek reassurance about their pain and they ways thatthey deal with it. They attempt to reconcile any feedback received withtheir own beliefs about their pain and its related effects. Manychronic pain patients live with the trepidation that the continuedexistence of chronic pain indicates that further damage is being doneto their bodies, which will in turn exacerbate the pain theyexperience. This may raise their levels of anxiety, which affects theirability to think rationally and calmly about their pain. They mayrequest more medical procedures—tests or treatments—to provideempirical evidence to themselves about the state of their bodies. Thereconceptualised model indicates that the response of medicalprofessionals in these situations may unknowingly encourage this kindof cognitive presumption and therefore positively reinforce incapacityor a passive response to chronic pain.

The model articulated above is extensively based upon other cognitivebehavioural models of chronic pain and can even take into accounttheories about the nature of the meta-cognitions of the patient. If,for example, the patient cognitively interprets the pain or cognitionsrelated to the pain indicate something negative about them as a person,then they may make efforts to overcome or control such thoughts inattempts to protect themselves from further negative consequences. Forexample, if the patient fears that thinking about his or her pain isgoing to make them ‘crazy’ then they may make strong efforts to altertheir thoughts about the pain in order to stop themselves fromdescending into mental illness. This may stem from a fear that sincetheir physical health has deteriorated, their mental health is underthreat as well. In addition, some patients may think that the more timethey spend thinking about their pain, the more serious and damaging itwill be. The model asserts that the more cognitive energy is spenttrying not to have pain-related thoughts, the more frequent they maybecome and the anxiety levels of the patient may continue to rise,prompting more and more pain-related cognitions. These thoughts mayincrease and the patient may feel that the more they have thesethoughts, the more damage they are doing to themselves. Patients canend up caught in a web of cognitive gymnastics about their chronicpain, which diverts energy from dealing with the pain in constructiveways and maintaining a satisfactory level of functioning.

The cognitions that a patient may develop concerning their chronic painare the product of complex and intricate synthesis of experiences,cultural forces and even childhood learning. Patients do not interprettheir pain only in terms of their immediate situation, but bring avariety of other elements to bear upon the way that they translatetheir ideas about pain and what it means into their responses to theirown pain. If they have had pain in the past, or have had closerelationships with individuals who have suffered pain, the express andnull curriculum of their experiences will provide them with a set ofbeliefs about pain, what it means and what can be done about it.Cultural ideas about how to respond to pain will also affect theirevaluations about the role of pain in the life of an individual. Spouseresponses can also be important factors in interpreting chronic pain.It can also be said that behaviour that demonstrates acceptance ofchronic pain stems from the collaboration of past and presentcircumstances, as well as the emotive and interpersonal influences ofthe present.  The way that the spouse expresses his or her beliefsabout pain can either reinforce or contradict the beliefs of thepatient. If the patient believes that his condition or experience ofchronic pain has made him incapacitated and the spouse behavessolicitously, the patient’s beliefs about his incapacitation can beconfirmed and may override any other input about the patient’s abilityto function normally.

The cognitive behavioural approach has built into its tenets thecapacity for the patient to learn new coping strategies and introducenew cognitions without an awareness of the reality of his or hersituation. This may be particularly pertinent in the area ofmedication, where any form of relief from pain, whether it is actual ofperceived, may be a response to thoughts that the pain is out ofcontrol and the patient is unable to carry on without the presence ofmedication. The cognitive behavioural approach also asserts that thesetypes of cognitions and resulting actions are cemented together andwork in partnership to perpetuate one another. If a patient thinks thatperforming a particular action will lead to further damage and pain, hewill avoid that action. Thus, he will not discover any information tothe contrary and will continue to believe that the presence of painmeans that he should not engage in such an activity. Even when patientsdo try to accomplish certain activities, if they do so utilisingprotective methods, they may only confirm the danger of the activity intheir minds and become dependent upon the protective measure instead ofachieving their full potential in functioning.    

It is becoming more and more accepted that it is prudent to explorechronic pain from a cognitive behavioural approach. There are a numberof reasons for this growing confidence. First, it has been assertedthat the reformulated cognitive model explains the breadth of evidencemore extensively than other models. Second, the hypotheses that are putforth by the model may easily be empirically tested in order todetermine whether they are statistically supported and theoreticallysound. This makes them infinitely more useful for the practical work oftreatment, as they can offer statistically supported predictions forthe type of treatment that will be most useful in various situations.Obtaining the ability to pinpoint pivotal cognitive functions shouldlead to accurate treatments in place of the relatively arbitraryapproach sometimes implemented by professionals.

    For several years, the research and treatment of chronic painconcentrated on coping mechanisms as the pre-eminent behavioural factorin adjustment. Yet when coping approaches began to be compared withother types of behavioural approaches such as acceptance of chronicpain, significant conclusions were reached regarding the potential ofthe respective approaches to predict disability and distress. It hasbeen asserted that there are fundamental problems with coping as acomprehensive adjustment mechanism. The issues with coping areconceptual and empirical in nature and stem from its reliance uponcognitive responses.  An empirical study demonstrated that acceptanceof chronic pain led to decreased intensity of symptoms and a betterquality of life. Acceptance of pain was conclusively shown to besuperior to attempting to cope with pain.

It is possible that acceptance of pain may be accomplished through avariety of methods. Some of the treatments currently in use, such asthose involving cognitive-behavioural methods can help to make painmore acceptable. This is true even for those cognitive-behaviouralmethods that focus on mastering pain. For example, it could be thatdiminished avoidance and augmented experience of pain as a result ofmore control that help patients to accept the pain in their lives. Ifpatients are exposed to more pain they may develop diminished emotionalreactions and begin to understand that pain intensity is different invarious situations. This understanding can teach them that the painthey suffer is not as intense as they first thought. In addition,teaching methods of behavioural control can result in alternations tothe patient’s internalised definition of a painful event, making iteasier to endure.

The role of values in a contextual cognitive-behavioural approach hasbeen assessed in terms of the relationships between the values ofchronic pain patients and the success of following their dailyroutines. It is often easy for chronic pain patients to expend greatamounts of effort struggling with pain rather than focusing theirenergies on living according to their values. Living according tovalues was defined in this particular study as acting according to whatthey care most about and what they want their life to stand for.  Ifpain is not then reduced, the patient may feel that not only have theirlimited amounts of energy been wasted, but they have also neglectedtheir core purposes in life, which may result in further angst andanxiety. 

In a study examining the process of living according to personal valueswhile suffering from chronic pain, 140 pain patients completed aninventory of values including categories such as family, friends,health, work and growth. The patients were also asked to recordinformation regarding their pain, anxiety and depression. The resultsshowed that the highest values for the patients were family and health,and the values of least importance overall were friends, growth andlearning.  The patients generally did not feel satisfied that they wereliving life according to their values, and this could be because oftheir level of physical and emotive functioning. The results of thestudy further demonstrated that those who achieved more success atliving according to their values reported higher levels of acceptance,although acceptance could not reliably account for the sum of thesuccess.

Although patients felt that overall they were not living according totheir values, there was a significantly higher rate of success atliving according to family values than maintaining health. In practicalterms, this means that out of the areas that patients value most, theywere able to achieve much more success in one area, family than theother, health.

  Approaches to chronic pain that are contextually based deal withcognitive issues in a different manner than normalcognitive-behavioural approaches. Approaches that are contextuallybased seek to change the operation of negative thoughts and the way inwhich they are experienced, which affects other behaviours. A largequantity of the work devoted to these types of approaches involvesreleasing maladaptive cognitive forces on behaviour and intensifyingbehavioural elasticity through cognitive de-fusion. Approaches that arefounded upon values add an aspect to this type of treatment.Articulating values during treatment for chronic pain is equivalent toadding cognitive influences to behaviour sequences.

On a practical level, the conceptualisations of the cognitivebehavioural model of chronic pain can help to explain how patients dealwith their pain, particularly the cognitive and meta-cognitiveinteractions they have with their symptoms and other factors thatinfluence their quality of life and their approach to their pain. If,for example, the patient is in the situation where the pain persistsand further tests and treatments prove unsuccessful, it may be easy forthe cognitive components of the mind of the patient to feel defeatedand to acquire a learned helplessness. The patient may subconsciouslyor even consciously feel that all of their cognitive efforts to thispoint have proved futile and therefore they may be paralysed by thenotion that whatever cognitive energy they put into dealing with theirpain will be to no avail. They may even come to believe that anyfurther medical intervention will be of no use to them. These types ofthoughts can affect the effort that patients put into their treatment.They may be less participatory and become increasingly passive even inthe face of extensive medical procedures. They may cease to beemotionally and mentally invested in working with the medicalprofessionals to achieve the best outcome possible for their situation.If patients feel that treatment will be useless and they make lesseffort, their treatment may not be as effective as it could have been.A treatment outcome that is less than optimal will only reinforce thepatient’s sense of helplessness and they may even be dismissed asunhelpful or disengaged by medical staff. If these patients are viewedfrom the perspective of the cognitive behavioural model of chronicpain, however, they will be perceived not as unmotivated but asindividuals with maladaptive cognitions. This understanding of theirbehaviour would make them prime candidates for cognitive interventions,where their chances of improvement would be quite high.

There is much empirical support for the cognitive behavioural model,and it has been found consistent with a wide scope of researchoutcomes. There is particularly strong support for the idea that whenpatients worry about their pain, they are more likely to scrutinisetheir pain, which removes effort and thought from other activities andmay make the pain worse than it is. These findings offer support forthe cognitive theory that hypervigilance and anxiety are closelyrelated. In other studies, anxiety and stress have been found topredict ambiguous ailments in patients suffering from chronic pain,which supports the theory that hypervigilance may create or exacerbatethe ill health of the patient or at least the patients perception ofthe state of their health.

In addition, pain-related trepidation was discovered to predict evadingstrategies more accurately than the intensity of the pain or thephysical ailment. Here, the researchers concluded that their findingswere not as supportive of the operant model of chronic pain as thecognitive behavioural model. Further, evidence exists that supports thenotion that striving to avert pain-related cognitions may actuallyintensify pain sensations. Though it is advisable to treat thisparticular study with some caution, there is more substantial researchto support the related notion that trying to block pain-relatedthoughts is counterproductive and will worsen anxiety. Related to thisare the theories surrounding autonomic arousal, which have alsoreceived empirical backing. It has been asserted that patientssuffering from chronic pain do not respond to pain in the same ways aspatients whose pain is not chronic. This is true despite the fact thatthey do not demonstrate significant differences from non-chronic painpatients in other areas. When the responses of chronic pain patientsare measured with regard to distressing activities, the pain levelsmeasured increased dramatically. This was not true for normalactivities.  Therefore, it seems safe to adhere to a model of chronicpain in which the state of arousal prompted by particular activitiesdirectly affects the pain experienced by the patient.

Other elements in the cognitive behavioural model have also receivedsupport. In particular the role of medication and the appropriatenessof use can affect patients’ complaints regarding symptoms and level ofincapacity. One study examined the contrasting characteristics ofchronic pain for patients whose pain could be justified by medicalexplanations and those whose pain could not be explained in medicalterminology. The authors found remarkable variations in a number ofvariables, such as excessive prescribing and internal processing in thegroup of patients whose pain could not be medically explained. Theywent on to assert that when medical professionals in this type ofsituation intimate that it could be psychosomatic, they reinforce thepatient’s self-concept of an ill person, if not physically, thenmentally. Reacting in this fashion often fails to convince the patientthat there is nothing wrong and instead, motivates their search for aplausible explanation for their pain. They may demand more tests andinterventions in search of legitimising their pain. The important pointhere is that the responses of medical professionals to patientexpressions of pain can have a significant impact on pain-relatedcognitions and thus on their responses to treatment.

The sum of this evidence provides legitimisation for approachingchronic pain in a way that is much like the way that anxiety andobsessions are approached. This suggests that if obsessions can betreated, then so can maladaptive pain-related cognitions andbehaviours. While the need for further research remains in certainareas, such as the clarification of the significance of safetybehaviours and the effectiveness of specific cognitive behaviouralintervention programmes, there is strong evidence that cognitivebehavioural treatments will overtake operant treatments as thepreferred method for addressing chronic pain. Sharp (2001) concludeshis discussion of psychological theories of chronic pain by arriving atthe destination of cognitive behavioural models akin to those used totreat anxiety. He regards the operant model as having too manyproblematic issues to be considered a reliable source of chronic paintreatment. He goes even further, to suggest that many of the cognitivebehavioural modes currently in use are hampered by the fact that theycontinue to espouse behavioural principles that have outlived theirusefulness. According to Sharp, reformulated cognitive theories areneeded in order to satisfactorily assess patient cognitions regardingtheir pain. While behavioural factors should not be completely ignored,they should nonetheless always be considered within a cognitiveframework. The concept of reformulating cognitive models is supportedby the evidence and appears to be more helpful in finding realscientific meaning therein.

Treatments involving cognitive behaviour therapy and behaviour therapyfor chronic pain in adults have been the subject of meta-analysis. Theresearchers recognised that there is persuasive data for theeffectiveness of cognitive behavioural therapy (CBT) in augmenting thefunctioning ability of patients suffering from chronic pain. There isalso conclusive evidence that CBT can enhance emotional states, reducediscomfort and minimise behaviour that stems from a sense of beingincapacitated. However, it has been noted that in a clinical treatmentcontext, CBT is not often presented as an option for individualssuffering from chronic pain. Physical, pharmacological and medicaltreatments are provided as options even though there is often lessempirical evidence for their success. This study sought to do asystematic review and meta-analysis of controlled trials in this area.The researchers indentified 25 trials that were appropriate candidatesfor meta-analysis and compared the efficacy of CBT with various othertreatments. 

In this study, the experts were concerned primarily with two issues.The first was whether or not CBT is an effective treatment for chronicpain in the sense that it is better to undergo CBT than to have notreatment at all. The second issue was whether CBT was better thanother available treatments which involve activity as part of thecurriculum.  The outcomes of the study indicated that CBT that areactive in nature are effective. CBT made marked improvements inemotional state, intensity of pain and cognitive measures of copingwith the pain. Additionally, pain-related behaviour and level offunctioning, both in an individual and a social context were improved. 

The results of this study led to the conclusion that CBT is indeed aneffective treatment for chronic pain in adults. So, too, is behaviouraltherapy. The study raised certain issues which would be best consideredin other studies, because attempting to treat chronic pain from apsychological perspective is quite a difficult endeavour. The outcomesof such treatment cannot always be broken down to determine whichvariable caused or helped to cause a particular outcome. Especiallywhere psychological methodologies and cognitive evaluations areconcerned, there is an ambiguity in proving the cause and effect ofresearch methods that is not easily overcome. The treatment of chronicpain must be recognised as an ongoing and complex process with asignificantly complicating number of variables involved. Even when thegreatest efforts are made to ensure the independent performance ofprofessionals and to shield the patients from any hint of bias, thenarrowing of treatment and research conditions is extremely difficult.

    The acceptance of chronic pain involves intentionally allowingpain, with all of its cognitive and emotional implications, to bepresent in one’s life, when the willingness results in increasedfunctioning capabilities for the patient. Acceptance means respondingto pain without attempting to avoid or control it and continuing tofunction regardless of the presence of chronic pain. Acceptance isespecially pertinent when previous attempts at control or avoidancehave limited the quality of the patient’s life.  Patients sufferingfrom chronic pain who take steps to accept it report fewer instances ofanxiety, medical intervention and depression. Two elements are neededto produce acceptance: pain willingness and activity engagement. Thedevelopment of acceptance is an ongoing process that progresses withexperience of pain and relevant social factors.  Further, acceptance ofchronic pain involves choosing not to become embroiled in fruitlessinternal struggles that may increase the intensity of the pain and itsability to disrupt active functioning. Acceptance is a newpsychological approach and conceives human suffering in new terms. Acceptance is located in the cognitive and behavioural approaches andtherefore has empirical psychological traditions to lend itcredibility. 

One study demonstrated that diminishing anxiety and augmentedacceptance of chronic pain might transfer sufferers from adysfunctional coping approach to a successful one. The studyempirically categorised patients suffering from chronic pain into threecategories: dysfunctional, interpersonally distressed or adaptivecopers.  The researchers in the study believed that identifying thecharacteristics that distinguish one group from another may help tocrystallise the behavioural mechanisms that facilitate acclimation topain. The subjects in the study were classified according to theMultidimensional Pain Inventory  and relative scores on pain acceptanceand pain-related anxiety were examined. The results demonstrated thatpatients in the dysfunctional group cited more anxiety related to theirchronic pain as well as lower acceptance of pain than those who wereinterpersonally distressed or copers. Additional analysis showed acontinued differentiation between the dysfunctional group and theothers. It was concluded that accepting pain and experiencing anxietylinked with chronic pain are individual behavioural functions ofacclimation to chronic pain, and that pain-related anxiety is a fairlyreliable predictor of adjustment.

Another study measured acceptance of chronic pain using the ChronicPain Acceptance Questionnaire (CPAQ).  The study was predicated uponthe theory that accepting chronic pain involves lessening unfruitfulendeavours to evade or regulate pain and instead to pursue individuallymeaningful activities. It has been suggested that accepting chronicpain can result in augmented functioning in patients suffering fromchronic pain, and that acceptance can even overcome depression and painseverity to a certain extent.  This study explored the mechanics of theCPAQ in a detailed fashion and found that patient participation invalued activities despite chronic pain, and willingness to feel painwere the only reliable measures of patient functioning in the CPAQ. Thestudy subsequently suggested a revision of the CPAQ.  Further, theresearchers asserted that the acceptance of chronic pain must be anintentional endeavour on the part of the patient. In order to achieveacceptance, the patient must continue personal activity and maintainsome level of functioning, even if pain is experienced while doing so.Taking an active and accepting approach to pain facilitates continuedfunctioning, and diminished functioning will follow for the patient whosuccumbs to or attempts to avoid pain. The idea of continuing tofunction even when suffering from chronic pain is somewhat foreign toWestern societies, where pain is generally a thing to be controlled andovercome before normal functioning may resume. In this respect,patients and perhaps medical professionals alike need to bere-educated. Unwanted feelings are a part of life and are often beyondthe control of the medical profession. Patients may require detailedexplanations about the causes of their pain in order to move towardacceptance.  The acceptance of chronic pain is becoming more and moresignificant in discovering the most prudent way to deal with it.

Still another project on acceptance of chronic pain analysed theresults of a treatment regime for patients suffering from complicatedchronic pain. The regime was based upon concepts of acceptance of painas a fresh approach to chronic pain and upon ways to enable patientstoward optimal functioning despite their pain. The treatment programmeconsisted of a three to four week stay in a hospital, whereparticipants engaged in behavioural and other interventions aimed ataugmenting the frequency of daily activity and willingness to live withpain. The outcomes of the treatment showed improvements in severity ofpain and daily functioning. The most remarkable improvements occurredin the areas of depression, daily pain-related hours of rest and aphysical task. There were also reductions in the amount of treatmentneeded and requested.  Engagement in activity and willingness to acceptpain are two of the most important components of acceptance of pain.Further investigations into treatment methods showed that the study wassound and the results significant.  In addition, the participants wereassessed a few months after they received treatment and most of theimprovements were still present. This study is of particular importancefor several reasons. First, it examined the effects of acceptance-basedtreatment in a long-term sense. Patients who are faced withexperiencing chronic pain indefinitely, perhaps for the remainder oftheir lives, need long-term solutions. The pain that the patients inthis study experienced was intense and ongoing. They had allexperienced many different types of treatment prior to acceptancetreatment and had found them to be unsatisfactory in improving theirquality of life. Also, the study measured improvement in a variety ofelements using data gleaned from a plethora of sources. Additionally,the outcomes of this study hold clinical as well as empiricalsignificance, and therefore show that acceptance based treatmentsshould begin to make their way out of the psychological testing arenaand into the hospitals where chronic pain patients receive treatment ona daily basis. This particular study included a scope of mental healthand health professionals, from nurses and doctors to clinicalpsychologists. The treatment discussed here, while acceptance-based,can be used in a multi-faceted treatment setting. It is adaptable andcan be altered to suit professionals from a variety of backgrounds, sothat they feel comfortable and competent administering it. Further, itbrings health professionals together and offers a holistic treatmentapproach for the patient.

Another study examining similar themes also took a long-term approachto the relationship between acceptance of chronic pain and patientfunctioning. A sample of chronic pain sufferers was assessed at twointervals. Interval average was approximately 4 months for eachpatient. The results of the study showed that acceptance and pain wereessentially not related. There was a slightly significant relationshipbetween patient functioning at Assessment 2 and pain at Assessment 2;however, there was an established relationship between acceptance atAssessment 1 and patient functioning at Assessment 2. Chronic painsufferers who cited a greater extent of acceptance at Assessment 1 alsoreported higher functioning, lower consumption of medication and higherwork status at Assessment 2. The study concluded that willingness toendure chronic pain and to remain active despite chronic pain mayresult in healthier functioning for patients. Given this, the potentialof pain management strategies founded upon acceptance of pain should befurther explored.

The acceptance of pain has also been examined in a social context, asmany of the behaviours of those with chronic pain occur in socialcircumstances, where social factors will influence their experiences.Investigations into the relationship between punishing, solicitous anddistracting responses from important people in the life of the patientand the acceptance of pain were carried out with over 200 patientsusing the Chronic Pain Acceptance Questionnaire and theMultidimensional Pain Inventory. The results revealed that responses ofpunishment and solicitation from important figures in the life of thepatient lowered the acceptance of pain. This was true regardless of theage and educational level of the patient, as well as his or her painintensity and the extent of overall support from the significant other.This study has important implications for the theory that socialinfluences can encourage or discourage activity in patients sufferingfrom chronic pain. Social factors may also influence the patient’sacceptance of chronic pain in terms of being willing for the pain to bepresent without attempting to control or evade it.

As the acceptance of chronic pain has become increasingly important inthe scientific field, empirical instruments have begun to take it intoaccount in measuring various phenomena connected with chronic pain.Vlieger at al (2006) developed the Pain Solutions Questionnaire(PaSol), which was constructed to assess efforts to change or eliminatepain (assimilative efforts) and efforts to alter life goals subsequentto the realisation that pain cannot be eliminated (accommodativeefforts). To test the instrument, 476 adult sufferers of chronic painwere asked to record data regarding the issues in their lives that areconnected with the pain. The participants were asked to comment ontheir efforts to solve pain, quality of life despite the presence ofpain, acceptance of the impossibility of eliminating pain and theirpersonal views regarding possible solutions for their pain.  Theresults of the study showed that the Meaningfulness of Life Despitepain scale was significant in commenting upon affective distress, whilethe Solving Pain scale made singular strides in the same area.  Thecumulative effects of the data point to the notion that continuedstriving toward altering or eliminating pain when the pain isindestructible can raise distress and the level of incapacitationexperienced by the patient.

The role of acceptance in dealing with chronic pain patients withsuicidal intent has not been extensively explored, nor has thefrequency of suicidal thoughts in those suffering from chronic pain.The incidence of successful suicides is believed to be higher inchronic pain sufferers in comparison with the wider population. At thetime of this study suicide was the ninth leading cause of death in theUnited States and therefore a worrying phenomenon.  Most of theliterature on the subject of suicide and chronic pain focuses onmanaging depression. One study took a step toward providing a morecomprehensive view of chronic pain and suicide by investigating thelinks between suicidal thoughts and pain intensity, pain-relatedincapacitation, and efforts to overcome pain. In a group of 200patients suffering from chronic pain, 6.5%  reported suicidal intent onthe Beck Depression Inventory.  The patients with suicidal intent anddepression were compared with a group suffering from depression butdisplaying no significant signs of suicidal intent. Both groupsreported elevated states of pain and incapacitation, and more frequentuse of passive coping mechanisms than a comparative non-depressedgroup. The two depressed groups failed to demonstrate differences intheir experiences of pain, and it was established that the presence ofdepression effected the patients’ functioning status rather than theexistence of suicidal ideation. Overall, the presence of suicidalideation was low, though it was noted that when suicidal thoughtsappear in the mental processes of chronic pain patients theirdepression should be treated immediately and aggressively.  Furtherresearch into the role that acceptance can play in treating suicidalsufferers of chronic pain is needed. The introduction of acceptancetechniques would, of course, have to be coupled with appropriatetreatment for clinical depression such as medication and therapy.

Worrying may have a significant affect upon depressed patients withchronic pain. The wider effects of living with chronic pain are oftenunpleasant and may result in financial and relationship problems aswell as the more obvious health adversities. Worry is a natural humanresponse when faced with circumstances such as these and the prospectof a very uncertain future.  One study examined the worry and relatedattempts at problem solving of chronic pain patients. The study alsoexplored whether there were significant differences between thoseindividuals actively seeking treatment for chronic pain and those whowere not seeking treatment. Refraining from actively seeking treatmentcould indicate an elevated level of acceptance and a lower amount ofworry, or it could stem from a fear to be treated and discover thecause and implications of the pain. Further, the study was interest inwhether the degree of worry and attempts to solve the pain couldpredict the level of incapacitation, pain and depression.  To assessthese components, 185 adults with chronic pain completed questionnaireswhich enquired about issues such as worry, catastrophic thinking andintensity of pain. The results indicated that regarding the predictivevalue of worrying and problem solving, worrying alone could explaindepression. The overall existence of worry was not abnormally elevatedin this group, although the extent of the worry was conclusively linkedwith lower pain tolerance, more depression, disability and catastrophicthoughts about pain.  There were also significant findings that worryis directly related to diminished confidence and self-control. Further,the intensity of pain, catastrophic thinking about pain and worry had asingular contribution in explaining depression, while problem solvingdid not contribute at all.

Related to studies about chronic pain and worry are those which addresspain-related trepidation. Within the specific context of chronic backpain, there is a growing body of evidence to suggest that pain-relatedfear is more incapacitating than the actual back pain. To examine thisclaim, three independent studies were conducted. The first studyexamined the claim that fear that is associated with pain is moredisabling than the pain itself when assessed by self-report.  Thesecond study investigated the relationship between fear of pain andbehavioural performance , and the third looked at whether pain-relatedfear and the severity of pain could predict poor behaviouralfunctioning.  The three studies showed similar results, namely thatself-reported disability and behavioural functioning were damaged bypain-related trepidation.  If the fear of pain is proved to be moredisabling than the pain itself, this could have strong implications fortreatment programmes that include a fear-reduction module. Similarmechanisms to those involved with acceptance of chronic pain could beutilised; patients could be provided with detailed information abouttheir pain and encouraged with the findings that reducing fear andbeginning to accept their pain can lead to increased functioning andtheir ability to live their lives as they want despite the presence ofchronic pain.

The manner in which pain is perceived was further examined in a studyof the pain women experience during mammography and the pain-copingstrategies the women used. Subsequent to completing questionnairesabout the pain of the procedure and how they cope with daily pain inlife, it was discovered that a vast majority (92%) of women describedthe experience as painful, but there were significant discrepancies inthe intensity of pain experienced by different individuals. Some womenreported intense pain while others reported only minor discomfort.Those women who attempted to use coping mechanisms and catastrophisingto deal with the pain experienced higher pain sensations than did womenwho ignored the pain.

As mentioned before, the breadth of studies addressing theeffectiveness of cognitive behavioural treatments is growing, but onearea that has not been extensively researched is the interactionbetween transformations in behavioural elements while treatment isbeing carried out. To help fill this gap in the research, one studyexamined the contributions made by physical activity and stress totreatment outcomes. The study concentrated on patients suffering fromlower back pain, and the treatment programme involved cognitivebehavioural therapy coupled with an exercise regiment. The resultsshowed improvements in the intensity of the pain emotional state,depression and level of activity compared with the levels the patientsdemonstrated before undergoing treatment.  Further analyses of thetests revealed that the interactions between alternations in anxietyand outcomes for treatment were completely separate from the changesthat occurred in the patients’ abilities to engage in physicalactivity. The changes that the patients experienced with regard to painanxiety could be even more significant than changes regarding physicalability, in the context of predicting behavioural changes. This hasimplications for treatment programmes that focus on augmenting physicalperformance as opposed to cognitive progress. If pain-related anxietyis more important in treating chronic pain patients than their physicalcondition, then many treatment programmes will have to be restructured.

The importance of treating things like anxiety and fear in chronic painpatients has been examined previously, specifically in a study wherethe instruments used to research fear and anxiety were tested.Instruments such as the Pain Anxiety Symptoms Scale (PASS), theFear-Avoidance Beliefs Questionnaire (FABQ), the Fear of PainQuestionnaire (FPQ) and the Spielberger State-Trait Anxiety Inventory(STAI) were examined to assess qualities about their respectivevariables. The study involved a small number (45) of patients who hadbeen referred to a pain management clinic. The various instruments wereused to compare their utility for analysing fear and anxiety in personswith chronic pain. The results showed that examining anxiety responsesto pain is more instructing than generally assessing anxiety related toa number of variables such as disability, pain and pain behaviour. TheFABQ and the PASS both produced results that showed greater variationin pain, pain behaviour and disability when compared with the resultsof the FPQ and the STAI, which measure generalised responses to chronicpain.  This study has had implications for the psychological communityin terms of which instrument is most reliable. The temptation forprofessionals would be to use the instrument that will give themresults that are closest to the ones they or the patient is lookingfor, but this study shows that professionals must exercise caution whenchoosing an instrument for use with chronic pain patients, as differentinstruments focus on differing elements. Ideally, a multi-instrumentapproach should be used to compose a holistic picture of the way thatthe chronic pain patient is affected by fear and anxiety in theirlives.

The research regarding acceptance-based treatments for persons withchronic pain also has implications for the duration that a particulartype of treatment should be attempted. Depending upon the cognitivestate of the individual, carrying on with a treatment that has run itscourse and had little or no impact may cause detriment to the cognitivestate of the patient, and in turn negatively affect his or her overallprogress. When the pain experienced by a patient is disrupting to hislife and various interventions are unsuccessful, a fresh strategy isnecessary to focus the energies of the patient in a differentdirection. New coping mechanisms need to be introduced that are basedin cognitive behavioural principles. To this end, a study was designedto explore the possibilities of a treatment programme including bothcoping and acceptance based procedures. This study asked 200 chronicpain sufferers to complete several inventories about their pain, andthe acceptance of or coping with their pain.  The results suggest that,in support of other studies of acceptance-based treatment programmes,attempting to alter pain-related cognitions and behaviours increasescontact with them and can exacerbate them in the long run. Theinstrument used established a divide between actions that are conductedfor the purpose of eliminating or avoiding pain, and those which areconducted for the purpose of greater quality of life. Possessing awillingness to live with pain and the circumstances that flow from thepain and using various management strategies to cope with the pain is apositive way to deal with chronic pain. The data resulting from thestudy of the instrument used (the BPCI) provides further support forthe basic tenets of the acceptance approach to chronic pain. One of theproblems with the study is that it records responses at a single pointin time; the physical and emotional state of chronic pain patientsinevitably varies from day to day. Further testing would be needed toestablish whether these results could be replicated over time.  TheBPCI brings the concept of acceptance of pain into a measurablecontext. By assessing avoidance and control attempts it can be helpfulfor patients dealing with chronic pain to recover a measure of theirability to function.

The acceptance versus coping battle continued to be waged in acomparison the relative merits of coping and acceptance in a sample of230 chronic pain sufferers. Here, the researchers based their ideas ofcoping on the assumption that coping allows for a relatively rigidapproach of pain control. Conversely, acceptance of pain can introduceflexibility into the patients approach and allow for increased activityand a partial return to normal functioning. This study examined thespecifically utilitarian aspects of using coping or acceptance ofchronic pain. The participants completed the Coping StrategiesQuestionnaire (CSQ) and the Chronic Pain Acceptance Questionnaire(CPAQ). The results revealed a much strong correlation between degreeof acceptance and levels of distress and disability than coping.  Inbrief, measures of acceptance account more reliably for variances inmeasures of patient functioning than can measures of coping.  Evenunder research conditions designed to augment the variance related tocoping mechanisms, measures of acceptance performed significantlybetter. The authors conclude by stating that acceptance-based modelsshould provoke professionals dealing with chronic pain patients to finda space for them in their approaches to treatment. Models of treatmentshould contain in-built flexibility to allow for the use of theeffective approach for various circumstances.

 When acceptance-based approaches for dealing with chronic pain werecompared with cognitive-control-based approaches in a small studyinvolving forty participants, the participants using theacceptance-based treatment demonstrated higher tolerance to paincompared with those using the cognitive-based approach.  Even whenexposed to a high-pain context the participants who had undergone theACT (acceptance) intervention fared much better than those whoexperienced cognitive interventions only. Those who experienced the ACTintervention were able to tolerate greater levels of pain than thecognitive participants. A further finding of this study is related tomeasuring the believability of pain. The acceptance treatment was foundto reduce the believability about pain. These marked changes in theacceptance participants are considered to be the result oftransformations enacted within private thoughts and interpretations ofpainful events. One significant problem with this study is that theparticipants were not experiencing chronic pain; another is that thesample size was relatively small (40).

Some experts have questioned whether Acceptance and Commitment Therapy(ACT) is fundamentally distinct from traditional cognitive behaviouraltherapy. When the case of a girl with chronic idiopathic pain wasexamined, those offering a critique of it concluded that it is notcertain whether ACT is answering the question of chronic painmanagement in an altogether different way, or if it is merely providingan answer similar to the one provided by Cognitive Behavioural Therapy(CBT), just providing it in a format that is easier for patients toapprehend. The authors comment that what  makes ACT distinct from CBTis the focus on acceptance versus alterations in cognitions, and anemphasis on maintaining a level of functioning despite negativefeelings and thoughts. The authors suggest that CBT also placesemphasis upon values and that the practical function of ACT is to makethe emphasis on values explicit and increase the acceptance of therapyby the patient.

In the study itself, a 14-year-old girl who had been experiencing joint painfor three years was observed to see how she would react to treatment.Her medical history included other conditions and ailments, but noneparticularly relevant to the present topic. Rigorous testing andpharmacotherapy had been of no avail to the adolescent, and theresearchers constructed an intricate profile of her depression, painintensity, propensity to attempt coping, functional ability and valuebased goals. Her functioning was extremely limited and the behavioursexhibited by family members had impeded her progress as well ashindering the functioning of the entire family.  The components of ACTwere employed and significant improvements were noted. Though this mayimmediately imply success, the authors of the critique note that moreinformation is needed regarding the complexity of the patient’scondition and medical history. Further, they propose that severalfactors could have accounted for the improvement in emotional state anddaily functioning of the patient. One of these could have been the factthat the patient entered into therapeutic treatment for the first time.What is significant could be that she was finally being treated in atherapeutic context and not particularly that she was being treatedwith ACT. In addition, the nature of the therapist-patient relationshipcould have provided extra motivation for the patient and helped toovercome the negative family dynamic that was promoting her incapacity.Further, the change in the family dynamics themselves could havefacilitated improvement in the patient. As the family learned how toreact in ways that would facilitate functioning and learned to handletheir own emotions, a healthier environment was created for all familymembers. Though the researchers who worked directly with the patientbelieve that it was the utilisation of strategies of acceptance thatenabled the patient to decrease her use of avoidance mechanisms, thescores for emotional strategies were low before and after treatment. This argument raises pertinent queries regarding the distinctiveness ofacceptance-based therapy, and whether it really is a new development orwhether it is merely dressing previously used CBT techniques in atrendier way that makes them more easily accepted by the patient.Either way, advances in making effective treatments more accessible tothe patient population are as important as conceiving new treatments.

Studies that have examined the value of accepting pain in determiningthe quality of life in patients with chronic pain have found thataccepting pain is linked to being able to engage in routine lifeactivities. In one study 120 patients suffering from chronic painwere asked to complete a series of questionnaires that assessed variousfactors related to their pain. The factors included intensity of pain,mental health and acceptance of pain. The study was divided into twophases. The first phase emphasised the unique contribution thatacceptance can make to dealing with chronic pain, and the second phasefocused on acceptance of chronic malady using the Illness CognitionQuestionnaire.  The results of the first phase demonstrate thataccepting chronic pain can go some of the way toward offering anexplanation for mental health that stretches beyond the ways thatintensity of pain affects the lives of patients. Further, acceptance ofpain can explain mental health more adequately than can catastrophisingabout pain. Accepting pain has again been proven to reduce the levelsof catastrophising in patients.   Another interesting finding of thefirst phase of this study is the effect of the belief that alteringone’s thoughts can influence pain. This should be further examined inthe context of acceptance of chronic pain. This can be explained by thefact that part of acceptance is releasing control of all of theinstances of pain and all of the consequences that stem from it.

The second phase of the study sought to examine whether or not theeffect of accepting pain was a strong one in terms of improvingphysical condition. Here, the Pain Catastrophising Scale  (PCS) wasused to measure pain catastrophising. The researchers also sought toexamine the legitimisation of acceptance in cognitive control.  In bothphases of the study, the acceptance of chronic pain played a uniquepart in the anticipation of the mental health state of patients. Theacceptance of chronic pain did lead to better mental health. Further,accepting chronic pain was found to be independent of dramatising pain.The researches concluded that they had explored the intricacies of themeaning of acceptance in the realm of chronic pain, and the twoimportant elements that were examined were found to be of importance aspredicted. The researchers reiterated that acceptance of chronic painis exemplified by normal functioning, and accepting chronic painincludes the acknowledgment that finding a cure for their condition isnot likely and that any efforts to do this only detract from wells ofenergy that could be better spent in efforts to lead a normal life.

When the meanings of ordinary conceptions of chronic painare explored, eight differing definitions were offered. Common to allof these definitions was the necessity of engaging one’s attention awayfrom chronic pain to other activities and elements of life that are notdirectly related to the pain. Part of acceptance is coming to embracethe fact that a complete cure is unlikely to materialise. Further,acceptance involves the courageous step of making intentional effortsto adapt to pain. Patients must also accept the counterintuitive notionthat acceptance of pain is not a sign of defeat. Although attempting tocontrol the pain is often viewed as being contrary to acceptance ofpain, the idea of taking control of the pain is consistent with theidea of acceptance, in the sense that it means mastering the presenceof pain in one’s daily life instead of repeating desperate and vainattempts to eliminate the pain altogether or to convince oneself thatit can be successfully corralled.  Again, accepting that pain is a partof life is counter-cultural in many modern societies, where medicaladvances and diversity of treatment often provide a false sense ofsecurity about the medical profession’s ability to treat every ailment.Yet the discussion above has repeatedly shown that attempts to controlchronic pain result in negative consequences for the patient.Acceptance as a broad concept has certainly received a substantialamount of scientific attention and is becoming increasingly establishedas a valid treatment. Whether it is materially different from all otherforms of treatment used to treat chronic pain is another question. Asthe study above demonstrated, many of the elements of ACT can be foundin other treatments, namely CBT. Whether this damages the validity ofACT as a treatment in its own right must be the subject of furtherresearch. One thing is certain: the importance of acceptance in thetreatment of patients suffering from chronic pain has been established and is not likely to be convincingly contradicted at this stage.