Pain and Pain Control - Illness Experience and Health Care

Health Psychology: Theory, Research and Practice - David F. Marks 2010

Pain and Pain Control
Illness Experience and Health Care

’[M]edicine has overlooked the fact that the activity of this (pain) apparatus is subject to a constantly changing influence of the mind.’

Bonica (1990: 12)


In this chapter, we discuss the complex and multifactorial nature of pain, starting with the direct line of transmission, pattern and multi-dimensional gate control theories. Psychological and social processes that mediate and moderate pain behaviour and experience are considered. We summarize the pros and cons of different pain assessment methods. The fear-avoidance model and relevant empirical evidence are reviewed. Finally, we explore psychological techniques used in pain management and the evidence for their effectiveness. The postscript discusses recent uses of torture and interrogation.

What is Pain?

According to the Institute of Medicine (2011), chronic pain affects approximately 100 million Americans. This is higher than the number of diabetes, heart disease and cancer sufferers combined. The cost to the US economy of chronic pain, including health care and lost productivity costs, was estimated to be between US$560 billion and $635 billion annually. In Europe, one study found that 19% of adults suffered from chronic pain of moderate-to-severe intensity and nearly half received inadequate pain management (Breivik et al., 2006). One in five Australians will expect to suffer chronic pain in their lifetime, and it is estimated to cost the economy AU$34 billion per annum (Pain Australia, 2010). One scientific problem is that pain is subjective.

Artists have often referenced pain and suffering in their work, none more emotively and extraordinarily than Pablo Picasso’s mural ’Guernica’ (see Figure 20.1), completed in June 1937 following the foreign fascist blitz of the Basque country village in Northern Spain at the request of the Nationalist government in the Spanish Civil War. Picasso’s brilliant mural of the suffering and pain of animals and humans under the aeriel attack of bombs has a timeless, crushing impact upon the viewer.

Figure 20.1 Guernica by Pablo Picasso, 1937


We know that pain is a highly adaptive but complex and multifaceted phenomenon that is poorly understood by many health care practitioners, especially physicians. As a consequence, many of those afflicted by pain suffer prolonged periods without understanding, care and support. This can cause conflict, irritability and even anger. It has been wisely asserted by two leading experts that:pain is not a monolithic entity. Pain is, rather, a concept used to focus and label a group of behaviours, thoughts and emotions. Pain has many dimensions, including sensory and affective components, location, intensity, time course, and the memories, meaning, and anticipated consequences that it elicits … no isomorphic relationship exists among tissue damage, nociception, and pain report. (Turk and Wilson, 2013: 314)

The pain experience is also difficult to disentangle from the language we use to describe it. The socio-cultural context, consisting of beliefs and explanations, may be implicit in the description. A physician is unlikely to be able to allocate the time necessary to analyse all of the variables that influence the waxing and waning of chronic pain reported by an individual sufferer. The physician may simply ask ’Is it painful? and/or ’Where is the pain?’.

An account of the initiation, exacerbation and maintenance of pain is a compelling and engaging task for the patient and her/his carers. If they are lucky, they will have access to a health professional with training in chronic pain management. However, such expertise is rare, and millions of patients globally receive inadequate care and are left to their own devices. Bring out the paracetamol!

It is frequently asserted that pain is a biological safety alarm to warn us when something is physically wrong, allowing us to act to alleviate the problem. Pain serves an essentially homeostatic function. Its importance can be seen when cases of congenital universal insensitivity to pain (CUIP) are considered. Most cases of CUIP involve premature death. A different concept, ’psychological pain’, is used to refer to mental anguish or suffering. Pain expression is a performance of affliction of a person in a social situation, suggesting that pain can influence any aspect of existence, not only the physical body. In this chapter we discuss only physical pain, not mental anguish, although the first may lead to the other.

Pain experience is uniquely personal. It can be described in many ways, including:

· An aversive, personal, subjective experience, influenced by cultural learning, the meaning of the situation, attention and other psychological variables, which disrupts ongoing behaviour and motivates the individual to attempt to stop the pain (Melzack and Wall, 1982/1988).

· Whatever the person experiencing it says it is, existing whenever the experiencing person says it does (McCaffery and Thorpe, 1988).

· An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (Merskey, 1996).

Such definitions highlight the subjective, emotional and multi-dimensional nature of pain experience. Pain is further classified as either acute or chronic, differentiated only by a duration of six months (acute being under six months and chronic over six months). The six-month cut-off is highly arbitrary; other suggested cut-off points are 30 days, three months or 12 months.

The International Association for the Study of Pain (IASP) published pain terminology in 1994 and in revised form in 2007 (Jensen et al., 2011). Changes were made to definitions of central pain: ’pain initiated or caused by a primary lesion or dysfunction in the central nervous system’; and hyperpathia: ’a painful syndrome characterized by an abnormally painful reaction to a stimulus, especially a repetitive stimulus, as well as an increased threshold’.

Acute pain is a useful biological response provoked by injury or disease (e.g., broken leg, appendicitis), which is of limited duration (IASP, 2010). It tends to be amenable to pharmacological treatment. Chronic pain is described as pain persisting for six months or more and tends not to respond to pharmacological treatment. The time continuum is imperfect because there are many cases of acute recurrent pain, e.g., migraine headaches, and also pain from progressive illnesses such as metastatic cancer.

Further useful distinctions include:

· malignant (associated with progressive illness, e.g., cancer);

· benign (not associated with progressive illness, e.g., lower back pain, LBP);

· progressive (becomes worse over time, e.g., arthritis);

· intractable (resistant to treatment, e.g., LBP);

· intermittent (pain that fluctuates over time and in intensity, e.g., fibromyalgia);

· recurrent (acute pain occurring periodically, e.g., migraine);

· organic (involving observable tissue damage, e.g., arthritis);

· psychogenic (absence of demonstrable pathology, e.g., fibromyalgia);

· referred (pain originating in one body area which is perceived as originating from another, e.g., perceiving an ’earache’ that originates from a bad tooth).

Pain can affect anyone at any time and can be highly disabling, often involving all aspects of a person’s life, including physical, psychological and emotional states, disrupting daily activities, work, finances, social, marital and family life and relationships (e.g., Marcus, 2000). In addition to its association with many chronic illnesses (e.g., cancer, HIV/AIDS, sickle-cell anaemia), particular groups appear more likely to experience chronic pain, especially the elderly and many disabled people, even in the absence of illness (e.g., pain from braces or harnesses).

Pain is simply suffering for the person with it, but it is an extremely interesting phenomenon for physicians, physiologists and psychologists alike: pain is perceived in the body, produced by the central nervous system, and processed by the mind. To the pain sufferer, however, pain can be the primary determining influence on quality of life and well-being. Talking about pain is always a tricky problem. Discussing it with the sufferer in simple terms or using tired clichés should always be avoided. It is lamentable to ’psychologize’ pain; little else can be more infuriating to a pain sufferer.

One response to pain is to misinterpret it as a catastrophe, a sign of serious injury or pathology over which one has little or no control. This can lead to an excessive fear of pain that gradually extends to a fear of physical movements such that people will avoid physical activities that they presume will worsen their problem, and as their inactivity is reinforced, their disablement worsens as a consequence. We review in a later section the fear-avoidance model (FAM) (Asmundson et al., 1999; Vlaeyen and Linton, 2000; Crombez et al., 2012).

Pain Assessment

Pain assessment is not a simple process. The inherent difficulty is trying to interpret a uniquely individual experience related by another person. Assessment is crucial to the understanding and treatment of pain, including its underlying mechanisms and mediating factors, as well as the development of effective treatment programmes.

Assessments are mostly undertaken for medical, research or compensation claim purposes and the purpose will influence the type of assessment used. Assessment measures may include intensity, psychological and functional effects and pain behaviours. Assessment methods can generally be grouped under one of four categories: physiological measures, pain questionnaires, mood assessment questionnaires and observations (direct observations or self-observations).

Table 20.1 summarizes some of the common measures that have been described in the literature. Medical examinations form the backbone of clinical pain assessments and include joint mobility and heart rate. Physiological measures attempt to objectively measure responses to pain. Psychological measures assess pain using psychometric instruments of different kinds.

Pain questionnaires present commonly used descriptive words that the individual uses to communicate their current experience. The words may be presented in rating scales or descriptive lists. The McGill Pain Questionnaire (MPQ; Melzack, 1975; Melzack and Katz, 2013) is the most frequently used questionnaire. In this, descriptive terms are clustered in groups of two to five. Participants circle the words that describe their pain, one word from each group. Then they must go back and circle the three words in groups 1—10 that most convey their pain response, two words in groups 11—15 that do the same thing, and one word in group 16. Finally, they are asked to pick one word in groups 17—20. At the end, they should have seven words that they can take to their doctor that will help describe the nature and intensity of the pain. Examples are as follows: Group 1 — Flickering, Pulsing, Quivering, Throbbing, Beating, Pounding; Group 2 — Jumping, Flashing, Shooting; Group 3 — Pricking, Boring, Drilling, Stabbing; Group 19 — Cool, Cold, Freezing; Group 20 — Nagging, Nauseating, Agonizing, Dreadful, Torturing (Melzack, 1975).


Fear of pain has been implicated in chronic pain behaviour. McCracken et al. (1992) developed an instrument to measure fear of pain across cognitive, behavioural and physiological domains — the Pain Anxiety Symptoms Scale (PASS). Related to fear of pain is acceptance of chronic pain, which occurs when an individual reduces avoidance or control and tries to focus on carrying out activities in the pursuit of personal goals. McCracken et al. (2004b) investigated the psychometric properties of the Chronic Pain Acceptance Questionnaire (CPAQ). They found that factors assessing (a) the degree to which one engaged in life activities regardless of the pain and (b) the willingness to experience pain were both positively related to patient functioning.

Other methods include verbal rating scales, visual analogue scales and a pain diagram that shows front and back outlines of a body on which patients can mark areas where pain is felt. Visual analogue scales may be most appropriate with diverse cultural groups, children, the elderly and people with communication difficulties. They are easy to use and therefore frequent ratings can be made then averaged, or peak times and triggers identified. Most pain questionnaires attempt to assess sensory, affective and evaluative dimensions of pain. They can be completed by the individual or as part of an interview. Specific types of pain seem to be described using similar words, and questionnaires have been found to discriminate between different pain populations.

Observations of individual pain behaviours and functional levels are also used in assessments, either direct observations by another person (e.g., a nurse on a hospital ward), or self-observations (e.g., in diaries or logs). However, direct and self-observations have drawbacks. Direct observations can never elicit unbiased data, being influenced by the setting in which they occur (e.g., clinical setting, home), the purpose of the assessment (e.g., benefit claim versus treatment assessment) and assessor characteristics (e.g., gender, ethnicity). Similarly, self-observations (e.g., pain diaries) may be inaccurate or overly subjective. Scales exist for patients and carers to rate their ability, on a 0—10 scale, to carry out everyday tasks such as sitting, car riding, dressing, sleeping, having sex, walking, housework, getting up from a chair or bed, shopping and carrying out light work, e.g., the Activities of Daily Living Scale (Linton, 1990).

An alternative approach is to use interviews to assess all aspects of the pain experience, including a full pain history, emotional adjustment and pre- and post-pain lifestyle. However, interviews need to be structured or they tend to tail off in different directions as sufferers need to talk about their pain and disrupted life experience at length, often because they don’t feel listened to by doctors. In the vast majority of cases, physicians and surgeons care only about one thing: reducing pain using medication. They don’t get paid for, or care too much about, discussing the finer distinctions about where pain is, what it feels like, or even what is causing it; they just want it gone. Hence, there is a niche for the more empathic health psychologist.

Issues in Pain Assessment

Many assessment instruments are insensitive to age, disability and culture. For groups who have communication difficulties, due to age, language problems, or sensory or cognitive deficits, assessment may require extended assessment time to enable rapport building. Herr et al. (2006) found that there is no standardized tool based on non-verbal/behavioural pain indicators in English that can be recommended for clinical practice. It is necessary to rely on the reports of significant others (e.g., a carer or interpreter), which has additional challenges of perception, interpretation and motivation. More work is required to address issues around the impact of the situational context and assessor characteristics on the assessment process. Further investigation is needed of the influence of assessment, including the impact of compensation claim assessments and of the need to prove the existence of pain and how it restricts the sufferer’s daily activities.

Mechanisms, Mediators and Moderators of Pain

A useful framework for conceptualizing pain includes attention, expectations, beliefs, knowledge, emotions, coping strategies, along with cultural and family influences, which can all play a role in mediating and moderating pain experience (Linton and Shaw, 2011). The diagram in Figure 20.2 is self-explanatory. All of the processes are familiar ones. However, moving from a framework to a scientific model and then to a theory are massive steps that have yet to be convincingly taken. A few faltering steps have been made, but there is thin ice afoot for the unwary. We are not even going to begin to discuss here the philosophical complexities, but they are substantial.

The biopsychosocial model (see Chapter 1) encapsulates the contemporary view that chronic pain and disability have multiple causes: biological, psychological and social. Psychosocial factors are important predictors of chronic pain and disability early in acute and sub-acute stages of pain (Boersma et al., 2014). The transition from acute to chronic pain and to disability is moderated by depression, anxiety, pain beliefs, catastrophizing and coping behaviours. All of the factors shown in Figure 20.2 are embodied in a single nervous system to produce the pain experience. An external observer can only guess at the resulting experience from the subject’s verbal and non-verbal behaviour.

Figure 20.2 Psychosocial mechanisms involved in the perception and performance of pain


Source: Linton and Shaw (2011)

Theories about pain production are few in number, and none to date is able to explain all of the known facts. The specific mechanisms for the transmission and perception of pain are not well understood, although knowledge in the form of empirical data is expanding. Three main theories have been proposed: specificity theory, pattern theory and gate control theory.

Specificity Theory

Specificity theory was suggested by René Descartes in 1664 (Figure 20.3) and taken up by von Frey in 1894. This theory describes a direct causal relationship between pain stimulus and pain experience. Stimulation of specific pain receptors (nociceptors) throughout the body sends impulses along specific pain pathways (A delta fibres and C fibres) through the spinal cord to specific areas of the sensory cortex of the brain. Stimulus intensity correlates with pain intensity, with higher stimulus intensity and pain pathway activation resulting in a more intense pain experience. Failure to identify a specific cortical location for pain, realization that pain fibres do not respond exclusively to pain but also to pressure and temperature, and the disproportional relationship between stimulus intensity and reported pain intensity (e.g., injured soldiers reporting little pain while similarly injured civilians requiring substantial medication) led to specificity theory losing favour. To put it bluntly, the theory is simply wrong.

Figure 20.3 The pain pathway in René Descartes’ Traité de l’homme (1664). The specificity view of pain has been replaced with more complex theories


Pattern Theory

Pattern theorists proposed that stimulation of nociceptors produces a pattern of impulses that are summated in the dorsal horn of the spinal cord. Only if the level of the summated output exceeds a certain threshold is pain information transmitted onwards to the cortex, resulting in pain perception. Evidence of deferred pain perception (e.g., soldiers not perceiving pain until the battle is over), intact pain transmission systems where pain is perceived without injury (e.g., phantom limb) and injury without pain perception (e.g., CUIP) raised questions about pattern theories. In addition, there was growing evidence for a mediating role for psychosocial factors in the experience of pain, including cross-cultural differences in pain perception and expression. The theory was inadequate.

Gate Control Theory

Conscious experience, whether pain or otherwise, is derived from a multiplexed array of afferent information arriving via sensory transducers allied with cognitive and emotional information about the context, history and future implications of the stimulus environment. The growing body of evidence contradicting the direct line of transmission and pattern theories culminated in the development of the gate control theory by Melzack and Wall (1982/1988). In the gate control theory, pain is viewed as a multi-dimensional, subjective experience in which ascending physiological inputs and descending psychological inputs are equally involved. The gate control theory posits that there is a gating mechanism in the dorsal horn of the spinal cord that permits or inhibits the transmission of pain impulses (see Figure 20.4).

The dorsal horn receives inputs from nociceptors that it projects to the brain via a neural gate. The dorsal horn also receives information from the brain about the psychological and emotional state of the individual. This information can act as an inhibitory control that closes the neural gate preventing the transmission of the nociceptive impulses and thus modifying the perception of pain. The mechanism operates based on the relative activity of the peripheral nociceptor fibres and the descending cortical fibres. Pain impulses must reach conscious awareness before pain is experienced. If awareness can be prevented, the experience of pain is decreased, eliminated or deferred.

The gate control theory has been an influential theory that continues to inform theoretical and empirical work. Gate control theory offers substantial explanatory power by acknowledging a role for descending control and psychological, social and behavioural factors. However, the absence of any direct evidence of a ’gate’ in the spinal cord is a problem. Also, gate control theory is unable to explain several chronic pain problems, such as phantom limb pain.

Melzack (1999; see also Melzack and Katz, 2014) updated gate control theory by describing a ’body-self neuromatrix’, in place of the gate. The body-self neuromatrix is a proposal that pain is a multi-dimensional experience produced by characteristic ’neurosignature’ patterns of nerve impulses generated by a widely distributed neural network in the brain. These neurosignatures may be triggered by sensory inputs or generated independently of them. Pain is produced by a ’widely distributed neural network in the brain rather than directly by sensory input evoked by injury, inflammation or other pathology’ (Melzack, 1999: 880).

Figure 20.4 The Melzack—Wall gate control theory of pain


Source: Melzack and Wall (1967: 975), Figure 4

Box 20.1 Key Study: How can We Know When Another Person Really Experiences Pain?

First-person introspection is necessary for communicating the pain experience to a third-person observer. Therefore, can we ever be sure they are not fabricating? This study by Coghill et al. (2003) identified the neural correlates of an individual’s subjective experience of pain. Seventeen healthy volunteers (eight women and nine men of mean age 26) participated in a psychophysical and fMRI study of individual differences in pain sensitivity. Thermal stimuli were delivered and assessed with a ten-unit mechanical VAS for pain intensity. Thirty-two stimuli (35°C, 43—49°C, 5-second duration) were applied to their non-dominant ventral forearm. Each participant underwent functional imaging during thermal stimulation of the skin of the right lower leg. For painful stimulation, five 30-second duration epochs of 49°C stimulation were interleaved with six 30-second duration epochs of 35°C stimulation. At the end of each 330-second series, participants provided a rating of pain intensity. Participants were assigned to a high- (mean VAS rating = 7.43), moderate- (mean VAS rating = 4.44) or low-sensitivity (mean VAS rating = 2.43) sub-group. To identify brain regions that were activated more frequently in the high-sensitivity individuals, the frequency map of the low-sensitivity group was subtracted from that of the high-sensitivity group.

Cortical regions involved in sensation, attention and affect were activated more frequently in pain-sensitive individuals than in those who were insensitive. The most robust difference between high-sensitivity and low-sensitivity sub-groups was located within a portion of the anterior cingulate cortex, where six out of six of the highly sensitive volunteers, but none of the insensitive volunteers, displayed statistically significant activation. This study shows that individuals with similar subjective reports of pain evoke similar patterns of activation magnitude, suggesting that people can accurately represent their conscious experience via introspection.

Source: Coghill et al. (2003)

Pain is the output of this neural network determined by sensory, cognitive, affective, experiential and genetic influences, as indicated in Figure 20.2. Melzack (1999) claims that the new ’theory’ of a ’neuromatrix’ provides an explanation for phantom limb pain and pain experience more generally. However, the ’theory’ consists of the familiar black box type model of overlapping circles with some arrows pointing at them, which seems incredibly vague, and, one might ask, what exactly is the ’theory’ saying and which predictions does it make? It is a truism that pain experience must be coded in the nervous system. Using the definitions and terminology of Chapter 1, the ’neuromatrix’ is not a theory but a framework summarizing one knowledgeable scientist’s ideas about pain. A ’work in progress’ is a phrase that springs to mind. There appear to be no definite predictions that can be based upon it, which means that the search for the neural networks of pain will go on, but without any specific guidance from this particular approach.

Neural Correlates of Pain

What kind of neural networks exist in the brain that may help to explain how pain is coded? Are differences in self-reported pain associated with measurable neural differences? Coghill et al. (2003) used psychophysical ratings to define pain sensitivity, and functional magnetic resonance imaging (fMRI) to assess brain activity. They found positive evidence that individuals who were more sensitive to pain stimuli exhibited more frequent and more robust pain-induced activation of the primary somatosensory cortex, anterior cingulate cortex and prefrontal cortex than did insensitive individuals. Coghill et al. identified objective neural correlates of subjective differences, validating the use of self-reported pain from introspection as a method of communicating a first-person experience.

On the other hand, Mouraux et al. (2011) found that the largest part of the fMRI responses elicited by phasic nociceptive stimuli reflected non-nociceptive-specific cognitive processes, i.e., nociceptive and non-nociceptive stimuli triggered overlapping sets of brain activity. The search for nociceptive-specific brain activities continues. Meanwhile, millions of chronic pain patients deserve better health care and support. Enter the health psychologists.

Psychological Factors in Clinical Practice

Many psychosocial factors have been investigated in relation to pain and these appear to exert independent effects on the experience of pain. The most significant determinant of pain chronicity appears to be the level of impact on activities of daily living, the functional disability associated with the pain. While the role of psychological factors in the experience of pain is now generally accepted, discussion of psychological inputs to pain is likely to provoke passionate responses and/or denials from sufferers, who fear invalidation of their very real experiences as ’all in the mind’. Health professionals need to be sensitive to this fear and present psychological issues skilfully, in ways that cannot be interpreted as invalidating the experience of the individual. Eccleston (2001) provided a helpful set of guidelines for the clinical care of patients with pain (Table 20.2).

Cognition and Emotion

Cognition influences emotion to produce pain-related behaviour. An individual’s cognitions influence the experience of pain, particularly the appraisal of situations for their significance and meaning (e.g., association of pain and sexual pleasure for masochists). Three aspects of cognition that have received attention in relation to pain are attention, interpretation, with or without dysfunctional thinking, and coping style.


Source: Eccleston (2001). Reproduced by permission

Increased attention to pain has been associated with increased pain perception. Pain demands or draws attention to itself, reducing the ability to focus on other competing activities, and therefore increasing pain perception. This may explain why distraction techniques are useful in combating pain. However, the role of attention may differ for acute and chronic pain. In acute pain, taking attention away from pain (e.g., via distraction) appears to be associated with reduced anxiety and depression, whereas it has an opposite effect for chronic pain patients, for whom attending to rather than avoiding the pain may be more adaptive.

Dysfunctional thoughts, attitudes and beliefs about pain are automatic patterns of thinking that block the attainment of an individual’s goals (e.g., participating in work or social activity). A major form of dysfunctional thinking that influences the pain experience is catastrophizing (e.g., ’It’s hopeless, pain has ruined my life, I can’t cope, it will never get better’). Catastrophic thinking has been found to increase the likelihood of chronicity, level of perceived intensity and disability, and even to have a small association with pain onset (e.g., Crombez et al., 2003). Other dysfunctional thoughts include negative mental bias, discounting the positive, fortune telling and magnification.

Cognitive coping styles are strategies that an individual uses in an attempt to deal with their pain. They can be divided into active and passive coping. Both can be functional or dysfunctional. Active coping might include keeping oneself busy or taking recreational drugs, which could easily become dysfunctional. Passive coping might include resting, which would be useful in the early stages of pain but could become dysfunctional if continued for too long. In general, active coping styles have been found to be associated with improved coping, reduced pain intensity and improved recovery rates. However, McCracken and Eccleston (2003) suggest that acceptance of pain and its incorporation into one’s sense of self appears to be an adaptive cognitive technique for chronic pain. Specific coping techniques are detailed below under pain management.

Learning: Previous Experience and Conditioning

Previous experience of pain is a significant factor in current pain experience. Both classical and operant conditioning have been implicated in the aetiology of chronic pain via the association of behaviour and pain. In classical conditioning theory, a particular situation or environment may become associated with pain (e.g., the dentist) and therefore provoke increased anxiety and pain perception. Jamner and Tursky (1987) reported that even the words used by migraine sufferers to describe their pain appear to reinforce the experience by provoking stronger physiological responses than non-pain words. In operant conditioning theory, pain stimuli are perceived as sensations and unpleasant effects that generally evoke responses like grimacing or limping, demonstrating that the person is in pain. Pain behaviours become conditioned responses through positive (e.g., attention, medication, time off work) and negative reinforcements (e.g., disapproval of others, loss of earnings). Pain behaviours may be functional and appropriate (e.g., removing a hand from a burning source of heat), or they may be less functional and therefore pain maintaining (e.g., avoidance, alcohol).

Secondary Gains

The role of secondary gains in the development and maintenance of pain and illness behaviours has been described. Secondary gain relates to social rewards accruing from the demonstration of pain behaviours (e.g., receiving attention, financial benefits, time off work). These secondary gains are thought to reinforce pain behaviours and thus maintain the condition. For example, receipt of financial disability compensations has been associated with slower return to work and increased pain. However, this may actually reflect that those in receipt of compensation can allow themselves appropriate time to recover and says nothing about the quality of life of those who returned to work earlier. For many individuals, pain results in the loss of jobs, social contact, leisure activities, valued identities, reduced incomes and concomitant reduced standard of living. Such losses are very real and distressing and are often associated with substantial hardships, lowered mood and loss of self-esteem, which are unlikely to be outweighed by incidental benefits.


The most common moods that have been associated with pain are anxiety and depression. Where these moods are present, pain appears to be increased. It has been reported that acute pain increases anxiety but once pain is decreased through treatment the anxiety also decreases, which can cause further decreases in the pain — a cycle of pain reduction. Alternatively, chronic pain remains unalleviated by treatment and therefore anxiety increases, which can further increase the pain, creating a cycle of pain increase. Research has shown that anxiety increases pain perception in children with migraine and people with back pain and pelvic pain (McGowan et al., 1998).

Anxiety is normally a result of fear. Pain-related fear can be specific or general (e.g., ’The pain is going to get worse’ or ’What will the future be like?’). The fear-avoidance model of pain suggests that fear of pain amplifies perception and leads to pain avoidance behaviours in some people, especially those with a propensity to catastrophic thinking (Vlaeyen and Linton, 2000). This cycle results in pain experience and behaviours becoming separated from pain sensation through exaggerated pain perception. A prospective study by Klenerman et al. (1995) found fear-avoidance variables correctly predicted future outcome in 66% of patients. A more recent prospective study (Linton et al., 2000) also found that higher baseline scores for fear-avoidance in a non-pain population were associated with double the likelihood of reporting back pain in the following year and a significantly increased risk of reduced physical functioning.

While correlations between mood states and pain have been found, the causal direction and the nature of the relationships remain unclear. Most recent work appears to indicate that negative mood states are an outcome of chronic pain rather than a cause.

Fear-Avoidance Model

The fear-avoidance model (FAM) explains how individuals develop chronic musculo-skeletal pain as a result of avoidance of activities based on their fear of pain (Lethem et al., 1983). This model helps to explain how individuals experience pain despite the absence of pathology. If an individual experiences acute pain and manages the situation by using avoidant behaviour, a lack of pain increase reinforces this behaviour. However, this avoidant behaviour causes the individual to decrease exercise, which may in turn lead to increased disability (Figure 20.5).

Vlaeyen and Linton (2000) explained how and why some individuals with musculo-skeletal pain develop a chronic pain syndrome using the FAM of exaggerated pain perceptions. ’Confrontation’ and ’avoidance’ are postulated as the two extreme responses to the fear of pain. While the former leads to the reduction of fear over time, avoidance leads to the maintenance or even exacerbation of fear. Possible precursors of pain-related fear include negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity. Subsequently, a number of fear-related processes ensue, including escape and avoidance behaviours resulting in poor behavioural performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. Vlaeyen and Linton (2000: 317) concluded that ’Pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculo-skeletal pain’. A substantial body of evidence to date supports the FAM of chronic pain. Waddell et al. (1993) developed the ’Fear-Avoidance Beliefs Questionnaire’ (FABQ) to investigate the role of fear-avoidance beliefs in chronic LBP and disability.

Figure 20.5 The fear-avoidance model


If pain, from an injury or other cause, is interpreted as threatening (pain catastrophizing), fear evolves — which leads to avoidance behaviours and hypervigilance to bodily sensations. This may lead to disability, disuse and depression. The latter will maintain the pain experience, fuelling a vicious circle of increasing fear and avoidance. In non-catastrophizing patients, no pain-related fear and rapid confrontation with daily activities is likely to occur, leading to fast recovery. Pain catastrophizing is assumed also to be influenced by negative affectivity and threatening illness information

Source: Vlaeyen and Linton (2000)

Chronic musculo-skeletal pain relates to impaired health-related quality of life, disability indices and health risk behaviours. Patients with chronic pain report lower scores on several factors related to quality of life compared to controls and other patient groups. In a study of over 1,000 participants, patients with back pain and patients with multiple pain localizations reported the lowest quality of life, pain catastrophizing showing the strongest association with decreased quality of life, even stronger than pain intensity (Lamé et al., 2005). Beliefs about pain — pain catastrophizing — were the biggest single factor in the quality of life scores. Across all eight domains, from physical to mental, those who catastrophized pain more (i.e., those who tended to have exaggerated negative reactions) scored significantly lower. This effect was even stronger than the actual intensity of pain itself. These results emphasize the important role that a person’s psychological reaction to pain can play. How people respond to pain is an important factor in the transition from an acute painful episode to a chronic experience.

Wertli et al. (2014) carried out a systematic review of RCTs that suggested that fear-avoidance beliefs are associated with poor treatment outcome in patients with LBP of less than six months. Patients with strong fear-avoidance beliefs are more likely to improve when fear-avoidance beliefs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if fear-avoidance beliefs are present. The findings of Wertli et al. (2014) support the FAM in suggesting that early treatment, including interventions to reduce fear-avoidance beliefs, may avoid delayed recovery and chronicity.

Box 20.2 Clinical Case Study: Chronic Pain Response and Reduced Quality of Life Following an Accidental Injury

A woman, Miss D, aged 75, was a spectator at a yacht race where she was struck at close quarters with a piece of fast-moving shrapnel from a starting cannon. Fortunately, the physical injury itself was slight, leaving a small red mark in close proximity to a scar from a cancer operation on her right breast. However, the trauma would bring profound changes to Miss D’s quality of life.

A health psychologist at a multidisciplinary pain clinic diagnosed Miss D as suffering from chronic pain syndrome as a direct consequence of the accident. This syndrome was triggered initially by an intense fear that she would suffer a recurrence of breast cancer. While this fear may seem irrational, for Miss D it was a very palpable consequence of being struck with some force.

The mechanism for the development of the chronic pain syndrome can be explained by the FAM. Since the accident, Miss D progressively decreased her activity levels to avoid the pain that was mysteriously appearing in different parts of her body. This complex of unexplained pain led to a vicious circle of pain—fear—avoidance of activity—more pain.

Miss D gave up many of her normal daily physical activities, which included walking, cycling, yoga and dancing. Starting with the trauma, triggering her fear of cancer recurrence, her consequent avoidance of activity to prevent pain, hyper-vigilance to internal and external illness information, sleeplessness, disuse of her body, depression and finally progressive disability. The quality of life for Miss D had been significantly lowered by the incident and her suffering seemed likely to continue until a suitable treatment could be identified. Cognitive behavioural therapy and graded exercise were offered and these led to a partial recovery. However, following legal compensation and treatment, Miss D believes that she will never make a full recovery from what was an unlucky ’wrong place at the wrong time’ chance event.

Social interaction has a critical influence on experience and expression of pain, particularly during early development. Children’s and adolescents’ cognitions and beliefs about pain, including fear-avoidance beliefs, develop within the family context. Asmundson et al. (2011) amended the FAM for paediatric populations. The paediatric model recognizes distinct fear/escape and anxiety/avoidance pathways and increases the possible influences of predispositional and current psychological factors. The paediatric FAM emphasizes the two-way relationship between parental pain management behaviour (e.g., protectiveness, solicitousness), parent psychological responses (e.g., parent catastrophizing, anxiety sensitivity, general distress) and child/adolescent psychological responses (e.g., catastrophizing, acceptance, anxiety sensitivity) in influencing child/adolescent escape and avoidance behaviours. In this paediatric model, both child/adolescent and parent psychological responses encompass the individual’s overt expression of pain and/or fear. The child/adolescent escape and avoidance behaviours can directly impact parent psychological responses and, indirectly, through parent psychological responses, impact parent pain management behaviours. Furthermore, the model includes the likely effect that parent pain management behaviours (e.g., removing children and adolescents from pain-inducing activities) would have on child/adolescent escape and avoidance behaviours.

Crombez et al. (2012) argue that the FAM needs to be extended by adopting a motivational perspective on chronic pain and disability. They propose that the next generation of the FAM needs to adopt an explicit motivational perspective built around goals and self-regulatory processes. This might yield a better understanding of how the disruptiveness of pain to an individual’s life goals can be overcome by successful problem solving, moving away from efforts to remove pain to fostering acceptance and palliation.


Before the complex and multi-dimensional nature of pain had been accepted, pain was treated through the administration of analgesic drugs, surgery and rest. Today pain management programmes seek to address the pain experience utilizing psychological and physical interventions, with considerable emphasis on psychology and weaning patients off opiates. The historical aim of pain management was to eliminate pain. More recently, the aims have shifted towards acceptance of pain, reducing pain perception, improving coping ability, increasing functional ability, and decreasing drug reliance and distress. Many commonly used pain management strategies are listed in Table 20.3.

Whether prescribed by health professionals or independently adopted by the individual, any pain management strategy has the potential to improve the situation (e.g., numbing pain sensations with drugs or improving mood with aromatherapy). Equally, any strategy can worsen the situation, as with medication side effects or lowered mood induced by substance abuse. It is important that an individual’s own attempts at self-management are respected and that health professionals work in partnership with the individual to identify the optimum programme for that person.

Behavioural Strategies

Most behavioural strategies are based upon operant learning processes, like using operant conditioning in which pain behaviours are ignored (negative reinforcement) and improved activity is praised (positive reinforcement). Conditioning is integral to contingency management. Typically, this is a two- to six-week inpatient programme, during which nursing staff would ignore medication requests, reinforce targeted ’well’ behaviours, introduce increasing exercise quotas and employ a fixed-schedule ’pain cocktail’. The pain cocktail delivers medication within a strong-tasting masking fluid that allows medication dosages to be reduced without the patient noticing. While such programmes have had good (even dramatic) short-term results, they have been less successful in maintaining such gains, possibly due to non-generalization outside the hospital environment. It is rare for programmes today to focus solely on conditioning methods.


Graded exercise strategies involve setting a starting level of activity that the person can manage and then developing a schedule to gradually increase the length of time and intensity of the exercise. The schedule allows the person to gain the confidence to handle each new level before the next increment.

Cognitive Strategies, Cognitive Behavioural Therapy and Mindfulness

Cognitive strategies work on the principle that cognitions (thoughts and beliefs) are responsible for the consequences of events, not the event itself, and if these cognitions can be changed, the consequence(s) will also change. In relation to pain management, cognitive strategies aim to help the individual identify and understand their cognitions and their connection with their experience of pain and then change negative cognitions to improve it. This includes teaching individuals to identify and challenge distorted thinking (e.g., catastrophizing) — a process known as cognitive restructuring, an active coping technique that promotes the internal attribution of positive changes.

While coping strategies can be helpful, there is growing evidence that pain control efforts directed at uncontrollable pain can come to dominate an individual’s life and distance them from important and valued aspects of their lives, such as family, friends and work.

Cognitive behavioural therapy (CBT) utilizes the full range of cognitive and behavioural techniques already described in individualized programmes that emphasize relapse prevention strategies. The literature on CBT and pain suggests considerable promise as an effective treatment for pain in adults (Eccleston et al., 2002). It forms the major component of most current pain management programmes. Improved mood, affect, function and coping have been associated with CBT in up to 85% of pain patients. While there is some support for the efficacy of CBT for the control of headache pain in children, there is a paucity of research relating to other pain conditions in children, as well as CBT for pain in the elderly and people with intellectual or communication difficulties, probably as it may be assumed not to be an appropriate treatment option for these groups. Acceptance and Commitment Therapy (ACT) and mindfulness-based approaches, which can be seen as sub-types of CBT, may hold more potential for future progress (McCracken and Vowles, 2014).

Morley et al. (1999) carried out a meta-analysis of 25 randomized controlled trials of CBT and behaviour therapy for chronic pain in adults, excluding headache. CBT showed significant and fairly large effect sizes on pain measures greater than alternative active treatments for pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Tatrow and Montgomery (2006) reviewed cognitive behavioural therapy techniques for distress and pain in a meta-analysis of CBT techniques with breast cancer patients. The results showed that CBT techniques have significant impact on distress and pain, with 62% and 69% of breast cancer patients in the CBT groups reporting less distress and less pain respectively, relative to the control groups.

Another approach is based on mindfulness meditation. The concept follows the Buddhist tradition of living in the present. Mindfulness is the practice of ’observing’ physical symptoms, emotions or thoughts. The goal is to change how pain is experienced and the influences it exerts on behaviour. Brown and Ryan (2003) developed a Mindful Attention Awareness Scale (MAAS) containing items such as: ’I find it difficult to stay focused on what is happening in the present’, ’I rush through activities without being really attentive to them’, ’I find myself preoccupied with the future or the past.’ In a study of chronic pain, McCracken et al. (2007) found that mindfulness was associated with measures of depression, pain-related anxiety, as well as physical, psychosocial and ’other’ disability. In each instance greater mindfulness was associated with better functioning. However, the results from systematic reviews are mixed. For example, Rajguru et al. (2014) found that mindfulness meditation has minimal effects on chronic pain. Hilton et al. (2016) reviewed 38 randomized controlled trials and found low-quality evidence that a small decrease in pain is associated with mindfulness meditation compared with controls. Small but statistically significant effects were also found for depression symptoms and quality of life.

Box 20.3 The Acceptance Commitment Model

… the overarching goal of ACT … is to increase successful engagement in activities that bring meaning, vitality, and importance to the lives of individuals experiencing persistent pain, discomfort, or distress. This goal is particularly relevant when these aversive experiences cannot be effectively avoided or when avoidance efforts risk their exacerbation, as is often the case with persistent pain. … Its pragmatic goal is ’effective action,’ meaning it aims to facilitate the effectiveness of behavior in achieving adaptive and functional goals over the longer term. At the level of actual clinical interaction, this goal is described in terms of greater engagement in valued actions. The functional contextual orientation of ACT allows one to define two primary aims: (1) accurate prediction and (2) useful influence on behavior. The pursuit of these aims requires one to attend to the relevant contextual events in any analysis of behavior, including historical events giving rise to the behavior as well as relevant ongoing events in the person’s environment. Practically, ACT seeks to undermine the influence of key current and historical stimuli that contribute to ineffective responses to pain, such as persistent avoidance, and bolster the influence of those that contribute to more effective responses, such as the specification and pursuit of desired valued outcomes. These aims of ’accurate prediction’ and ’useful influence on behavior’ are concordant with the operant behavioral roots of both ACT and Cognitive‐Behavioral Therapy. Much discussion has occurred regarding the similarities and differences amongst ACT and other forms of psychotherapy, principally Cognitive Behavioral Therapy (CBT). … We suggest that there are two key differences between these approaches. The first is the central focus on the facilitation of values‐based actions in ACT. While such a focus is both fully compatible and at times apparent within CBT, its centrality in ACT is distinctive. The second key difference pertains to working with human language and cognition. In brief, ACT seeks not to directly alter the occurrence of certain instances of human cognition (e.g., catastrophic thinking) and sensation (e.g., pain intensity), but to increase the repertoire of responses to these cognitions and sensations, as well as the flexible use of them, to facilitate actions more in line with valued activities over the longer term.

Source: Pielech et al. (2017: 3)


Imagery involves forming and maintaining a pleasant, calming or coping image in the mind. In guided imagery attention is guided away from an undesirable sensation or mood (e.g., pain) by another person, who verbally describes the image while the patient relaxes. Most imagery involves relaxation and employs images of a peaceful, safe, pain-free place, which the individual focuses upon while relaxing. The person may also be guided to visualize energy flowing into their body and pain flowing out. The benefits derived from this type of imagery are probably due to relaxation and distraction effects. Alternatively, confrontational imagery may be employed, for example visualizing white blood cells as an army attacking the source of pain (e.g., a tumour). Imagery has been found to be effective for the treatment of pain. The benefits of imagery may relate to relaxation, distraction effects and an active stance, increasing feelings of self-efficacy. As imagery generally involves elements of relaxation, it is unclear what unique and independent effects it has. Syrjala et al. (1995) compared relaxation and imagery with cognitive behavioural training to reduce pain during cancer treatment in a controlled clinical trial. Results confirmed that patients who received either relaxation and imagery alone or patients who received the package of cognitive behavioural coping skills reported less pain than control patients. Adding cognitive behavioural skills to the relaxation with imagery did not further improve pain relief.

Meditation also frequently forms part of relaxation training and involves the individuals focusing their attention on a simple stimulus, such as a meaningless monosyllable or disyllabic sound repeated slowly and continuously (aloud or in their head) to the exclusion of all other stimuli. Prayer is another common coping strategy that patients have reported to be helpful in response to pain, including headaches, neck pain and back pain (McCaffery et al., 2004). Both meditation and prayer inherently involve some distraction and possibly aspects of relaxation, although this is far from consistent.

Information provision has been shown to reduce pain reports and intensity, possibly by alleviating the fear and anxiety of not knowing what to expect for acute and postoperative pain (Williams et al., 2004). The widespread interest in self-help literature, internet information and support groups may be indicative of the desire of people in pain to understand their experience, what to expect and potential treatment options.

Pharmacological Strategies

Various analgesics and anaesthetics are prescribed for the treatment of pain. Anaesthetics (local or central) are used to numb the sensation of pain. The identification of endogenous opioid mechanisms has confirmed the status of opioid analgesics as an effective pain treatment. However, the associated perceived high risk of addiction has resulted in their use being restricted to severe pain cases, such as cancer, a perception challenged by the findings from studies of patient-controlled analgesia and low-dose opioid treatment that suggest the risk of addiction may not be very high (e.g., Urban et al., 1986). Non-opioid analgesics, NSAIDs (non-steroidal anti-inflammatory drugs) and drugs that control pain indirectly (e.g., antidepressants, sedatives) are commonly used. Drugs with indirect effects may be beneficial due to their action on higher brain regions, modulating the downward transmission of pain, or due to their modulating effects on negative mood states.

Another aspect relating to drugs is the placebo effect. It has been shown that substantial pain relief occurs in about 50% of patients when they are treated with an inert compound rather than the drug they are expecting, often equalling the relief felt by those receiving the actual medication (Melzack and Wall, 1982/1988). The effect is strongest with high doses, when it is injected, and depends upon the individual believing they are receiving a pain-relieving substance. Unsurprisingly, the effect rapidly declines with repeated use: you cannot fool all of the people all of the time!

In addition to prescribed drug treatments, many individuals self-medicate with recreational drugs like alcohol and cannabis to alleviate their pain. However, there is considerable anecdotal evidence for cannabis as an effective pain control treatment, and an endogenous cannabinoid pain control system has now been identified. This system functions as a parallel but distinct mechanism from the opioid system in modulating pain (Notcutt, 2004). Cannabinoids have been authorized for the treatment of pain and other conditions in a number of countries and states, including the Netherlands, many states in the USA and the UK. While current research may result in new cannabinoid-based NSAID-like treatments in the future, problems with the restricted range of dosages that allow pain control before producing psychotropic effects, and concerns about the incidental condoning of recreational cannabis use, mean this is far from being certain. The informal use of cannabis for pain control and its interaction with other pain control strategies warrants further investigation (Eisenberg et al., 2014).

Physical Strategies

Surgical control of pain mainly involved cutting the pain fibres to stop pain signal transmission. However, it provided only short-term results and the risks associated with surgery mean it is no longer viewed as a viable treatment option (Melzack and Wall, 1982/1988).

Physiotherapy may be used to increase mobility and correct maladjusted posture, encourage exercise and movement (often despite pain), and education. In addition, individuals may be taught safe ways to function (e.g., stand up, sit down, lift objects). Physiotherapy is about maintaining mobility, increasing function and helping the individual manage their life (e.g., Eccleston and Eccleston, 2004).

An additional strategy is the promotion of mobility-enhancing exercise to help retain and improve physical function and prevent lack of mobility from exacerbating pain problems. General practitioners can refer pain patients to specialist rehabilitation classes at local fitness centres, which has shown some success for older people with musculo-skeletal disorders (Avlund et al., 2000).

Interdisciplinary Pain Rehabilitation Programme

Originally run as inpatient programmes, pain management programmes tend to be run in specialist pain management or rehabilitation centres. Interdisciplinary teams may include doctors, nurses, physiotherapists, psychologists, psychiatrists, occupational therapists and counsellors, and provide a range of management techniques usually underpinned by CBT. An interdisciplinary chronic pain rehabilitation programme (IPRP) is a partial-hospitalization programme in which patients with chronic non-cancer pain who are resistant to opiate management, steroid injections and surgery receive a tailored combination of interventions. Programmes aim to improve quality of life by reducing pain as far as possible, increasing activity and coping, restoring function, and promoting self-efficacy and self-management. The patient receives a full history-taking assessment, education, skills training, exercise schedules, relapse prevention and family work. Multidisciplinary rehabilitation programmes represent the most comprehensive approach to date, by targeting the individual’s specific pain experience and tailoring appropriate treatment combinations.

Pain treatment facilities are both scarce and in high demand according to a review by Fashler et al. (2016). Access varies by country, with one per 310,000 people in Australia, one per 258,000 people in Canada, and one per 200,000—370,370 people in the UK. With an estimated 37% of the world population suffering from chronic pain, this indicates poor availability of services for pain sufferers. The high demand for multidisciplinary pain treatment facilities is reflected in the wait times, which have a median of 100—150 days in several countries (Fashler et al., 2016)

Bosy et al. (2010) described a private, intensive eight-week IPRP with a CBT emphasis and the results obtained with a cohort of 338 consecutive patients who completed the programme over a three-year period. Improvements in vocational status occurred in 75% of patients with chronic pain; pain levels were reduced by 16%; levels of anxiety and depression were reduced by 13% and 17%, respectively; and 61% of patients were able to reduce or eliminate their pain medications.

Vowles et al. (2014) studied Acceptance and Commitment Therapy in 117 completers of an interdisciplinary programme. A significant change in at least one measure of functioning (depression, pain anxiety and disability) was achieved by 46.2% of patients. Changes in psychological flexibility were found to mediate changes in disability, depression, pain-related anxiety, number of medical visits and the number of classes of prescribed analgesics.

Such programmes are economically unaffordable on a mass scale; a health economist noted that ’there is still a long way to go to understand the economic implications of interdisciplinary rehabilitation from the perspectives of society, the health insurers, and the patients’ (Becker, 2012: 127). Demand far outstrips supply.

Treatment Issues

Pain management can be a particularly controversial issue. Evidence suggests that in many circumstances pain is under-treated. Some of the reasons for this include inadequate services, lack of assessment, focus on underlying pathologies, negative stereotypes and erroneous assumptions about certain population groups, addiction fears, the inappropriateness of non-pharmacological treatments and patients’ inability to verbalize pain information or requests for medication (e.g., Greenwald et al., 1999). Many medical professionals have their own benchmarks concerning acceptable pain behaviour and medication levels for different conditions. It has also been shown that many prejudices and misconceptions operate in the treatment of pain patients, with various populations (e.g., children, people with communication difficulties and the elderly) being under-treated for pain (Todd et al., 2000). For example, sickle-cell patients are often assumed to be drug addicts and their pain outcries to be drug-seeking behaviour, resulting in inadequate medication being administered. Similarly, pain has only recently been recognized as part of the symptom repertoire of people with HIV infection or AIDS, and therefore up to 85% of people with HIV infection or AIDS receive inadequate pain management (Marcus et al., 2000).

Karus et al. (2005) investigated patients’ reports of symptoms and their treatment at three palliative care projects servicing individuals with HIV infection or AIDS in Alabama, Baltimore and New York City. Pain, lack of energy and worry were reported by a majority of patients at all sites, often with a high level of associated distress. However, only four symptoms (pain, nausea, difficulty swallowing and mouth sores) were being treated in half or more of patients at all sites.

Pain is sometimes deemed to be psychogenic, resulting from emotional, motivational or personality problems. The distinction between ’organic’ and ’psychogenic’ pain has little practical value and can be highly stigmatizing and alienate patients. A number of diseases where pain was not thought historically to be a valid symptom have subsequently had a physiological basis for pain identified, including multiple sclerosis and HIV/AIDS (e.g., Marcus et al., 2000). Pain designated as ’psychogenic’ may relate to as-yet-undetected or unidentified organic pathology. Health psychologists must endeavour to promote the sensitive and respectful treatment of individuals reporting pain in terms of research, intervention development and treatment.

Postscript: The Use of Pain in Torture and Interrogation

It is a reasonable expectation of psychologists that they engage in activities concerned with the care and well-being of patients and the reduction of pain, not in its deliberate use for torture. Take a deep breath as we are about to enter the ’Dark Side’ of health psychology …

Astonishing as it may seem, health and positive psychologists have been extensively involved in developing programmes of interrogation and torture (see the Independent Review conducted by Hoffman, 2015). This includes waterboarding, sleep deprivation and sensory deprivation, which were all used at Guantanamo Bay and elsewhere during the Bush administration. Some prominent psychology professors have assisted and advised the Department of Defense (DoD) and Central Intelligence Agency (CIA) in designing this torture. Joseph Matarazzo, the person who gave Health Psychology its definition, has owned shares in a company which advises the CIA on interrogation and torture. The Hoffman report states that Joseph Matarazzo was asked by the CIA to provide an opinion about whether sleep deprivation constituted torture. The advice from Matarazzo was that it did not. [Wow! Now that is a shocker!] Martin Seligman, one of the founders of Positive Psychology, and developer of the theory of learned helplessness, was involved in DoD and CIA programmes at the time that torture was being administered and in training soldiers to resist torture. Seligman (2016) has denied any such involvement in or knowledge of the CIA torture employed at Guantanamo Bay detention camp and other locations. Amnesty International has referred to Guantanamo as ’the gulag our times, entrenching the notion that people can be detained without any recourse to the law’ (Kahn, 2005).

The Hoffman (2015: 44) report states that: Hubbard, Mitchell and other CIA psychologists met with former APA President Martin Seligman at his home to fully understand the psychological theory of “learned helplessness,” a theory that Mitchell and others at the CIA were clearly incorporating into the CIA interrogation program. Seligman and Matarazzo also spoke at the SERE training academies where Mitchell and Jessen had been instructors, with Seligman doing so at Hubbard and Mitchell’s request. … Mitchell and Jessen, who were alternating between (a) interrogating and waterboarding detainees in secret CIA sites abroad and (b) having meetings and conferences in the U.S. on topics that might assist them in attempting to extract information through torture and other abusive interrogation techniques.

The report also states that Seligman and Matarazzo may have tried to help Hubbard recruit Philip Zimbardo, American Psychological Association President in 2002, to assist the CIA, including with its interrogation efforts. Also, they wanted to ensure that the Ethics Code provisions governing informed consent in research were changed. The 2003 APA President, Robert Sternberg, was also involved as he made a presentation at the CIA in December 2002 on the development of psychological assessment tools. The Science Directorate publicized this visit in its newsletter under the headline, ’APA President Sternberg Visits the CIA’, and posted his PowerPoint presentation on the APA website.

The report states: ’The evidence supports the conclusion that APA officials colluded with DoD officials to, at the least, adopt and maintain APA ethics policies that were not more restrictive than the guidelines that key DoD officials wanted. … APA chose its ethics policy based on its goals of helping DoD, managing its PR, and maximizing the growth of the profession’ (Hoffman, 2015: 11). The ethical code requires psychologists to do no harm. If superior orders require harm, then a psychologist may be forced to use the ’Nuremberg defence’: ’I was ordered to do it.’ The report’s conclusion states: DoD is like a rich, powerful uncle to APA, helping it in important ways throughout APA’s life. Acting independently of a benefactor like this is difficult. But APA’s bylaws demand that the Association not only ’advance psychology as a … profession’ but also ’advance psychology … by the establishment and maintenance of the highest standards of professional ethics and conduct.’ One question that arises from this investigation is whether APA has taken sufficient steps to ensure that, as an organization, its commitment to the highest standards of ethical integrity is sufficiently strong and independent of powerful government benefactors. (Hoffman, 2015: 72)

On 24 July 2015, the APA wrote a letter of apology to all members which stated: Dear Members,

As is true for us, we know the contents of the Independent Review (IR) report are extremely troubling and painful to our members. We have heard from many that you feel the profession you love and respect has been tarnished and, for some, your identity as a psychologist and integrity as a person are called into question even though you personally have done nothing wrong. On behalf of our organization, we apologize for what has emerged in the Hoffman report, including the secret coordination between several APA leaders and the Department of Defense that resulted in the lack of a clear and consistent anti-torture stance, limited guidance for military psychologists in the field, a failure to uphold an appropriate conflict-of-interest policy with regard to the PENS Task Force on military interrogation, and a lack of appropriate checks and balances that could have revealed these significant problems. In addition, we deeply regret the fact that some APA members and other critics were privately and publicly discounted for raising concerns. What happened never should have.

Discussion Topic: A Grey Area

We began this chapter with Picasso’s chilling mural on the horrors of warfare — Guernica. Sadly, it has been necessary to end on a similar note. We live in a far-from-ideal world that is fearful, dangerous and threatening. Terrorism is everywhere a real and imminent danger. World War III is the ’War on Terror’. Our military forces, police and intelligence authorities have a responsibility to protect citizens and to keep us safe. As the ’Leader of the Free World’, President Donald J. Trump has vowed to keep Guantanamo open and to use it to detain ’bad dudes’, including American ISIS supporters. President Trump has stated: ’I would bring back waterboarding, and I’d bring back a hell of a lot worse than waterboarding. … Don’t tell me it doesn’t work — torture works … if it doesn’t work, they deserve it anyway, for what they’re doing to us’ (Bruck, 2016).

Psychologists are employed by governmental organizations, including defence and intelligence, for their knowledge of human behaviour. If a military psychologist is given a direct superior order, then he/she must follow it. If that order would be to interrogate a suspected terrorist using torture, then what should the psychologist do? Hold up the ethics code and risk court-martial for disobedience, or administer the torture? What would you do?

Future Research

1. A testable theory of the neural coding of pain needs to be developed.

2. Long-term, prospective studies are required to understand the relationships between psychosocial factors and pain, particularly in diverse sub-groups within the chronic pain population.

3. Additional research is needed regarding the pain experience of under-represented groups, especially those who are verbally challenged (e.g., babies, older people, people with disabilities, people with a diagnosis of dementia), including the development of improved measurement instruments and assessing the efficacy of CBT in these groups.

4. The FAM requires refinement and extension to provide a better understanding of unexplained sources of pain.


1. Pain is a complex and multi-dimensional phenomenon that includes biological, psychological and social components.

2. Early pain theories proposed that pain was a sensation that involved a direct line of transmission from the pain stimulus to the brain. This theory is unsupported by evidence of psychological elements to pain.

3. The growing evidence on the psychological mediation of pain has seen the development of the gate control theory. However, the absence of any direct evidence of a ’gate’ in the spinal cord is a problem. Also, gate control theory is unable to explain several chronic pain problems, such as phantom limb pain.

4. Many psychological variables that influence the pain experience have been examined, including cognitions, prior experience, conditioning, secondary gains, personality and mood.

5. Particular groups appear to be under-represented in the pain literature, including ethnic minorities, children, the elderly, some disabled people and people with certain medical conditions (e.g., dementia, HIV and chronic fatigue syndrome (CFS)).

6. Assessment of pain is difficult and various techniques are used singly or in combination, such as medical examinations, observations, questionnaires, diaries and logs, and interviews.

7. A wide variety of pain management strategies exist. Currently, the most successful approach appears to be tailored programmes that use cognitive behavioural therapies fostering acceptance and the reduction of fear. There is no panacea, including medications.

8. Demand for services far outstrips supply. More resources need to be put into health care provisions internationally for patients suffering from unexplained pain.

9. The use of torture and interrogation techniques, such as waterboarding, raises ethical issues that require strong leadership from national psychological associations. Secret coordination between APA leaders and the Department of Defense was a shameful episode in the history of the discipline.

10. Health psychologists can make a genuine, significant contribution in promoting sensitive and respectful research and treatment for people experiencing long-standing painful conditions.