Chapter 19: Counseling and Behavior Modification Techniques for Functional Loss and Chronic Pain

Objectives

On completion of this chapter, the student/practitioner will be able to:

• Discuss the relationship between chronic pain and depression.

• Compare and contrast the various behavioral theories and their indication for use in a clinical setting.

• Discuss the term “positive psychology” as it relates to the treatment of chronic pain.

• Define the various methods of behavioral modification that may be applicable to the practicing therapist.

Key Terms

• Behavior therapy

• Depression

• Operant therapy

• Positive psychology

Introduction

Chronic pain and its concomitant functional loss requires a multimodal approach in management. Medical management seeks to resolve or decrease pain with medication, surgery, or a combination of both. Therapeutic management entails a variety of disciplines working together with the patient to help the patient better cope and function with chronic pain. “Counseling” and “behavior management” are umbrella terms used to describe strategies used by psychotherapy professionals working with patients with chronic pain.

It is well documented that pain is more than just a physiological response to a stimulus—pain is an experience. Included in this experience are psychological, emotional, sociological, financial, and environmental factors that influence an individual's perception of pain. This mulifaceted concept of pain is so well regarded that the Commission on Accreditation of Rehabilitation Facilities will accredit pain management facilities only if they have a mental health specialist on staff.¹ To complicate the matter further, individuals with chronic pain are often more likely to experience other psychological disturbances, such as depression.

Researchers have spent much money and time investigating the relationship (specifically the temporal relationship) between depression and chronic pain. To date, however, theorists have been able only to posit models relating the two. These models enlighten the psychology behind chronic pain and include the cognitive distortion model, in which individuals experiencing chronic pain have a “cognitive vulnerability” to depression, and the model of learned helplessness, in which individuals with chronic pain feel as though they cannot control their own outcomes (related to pain) and they develop an attitude of helplessness. The behavioral model, which embraces operant therapies as an intervention, presupposes that depression as a function of chronic pain occurs because of one or a combination of three reasons: (1) There are fewer positive reinforcers, (2) positive reinforcers that do exist no longer have an impact, or (3) the individual is incapable of gaining positive reinforcement. As a means to encompass components of each of these models, the chronic pain experience has evolved to capture the individual nature of each person's chronic pain experience.²

As is the case with any form of intervention, psychotherapeutic approaches to chronic pain and functional loss require a skilled professional. The counseling involved with this type of intervention strategy is derived from a ...