Publications
APS Bulletin • Volume 9, Number 4, July/August 1999
Special Interest Groups
David A. Williams, PhD, Department Editor
Psychosocial Research Special Interest Group: History, Advances, and Challenges
Robert D. Kerns, PhD; Robert H. Dworkin, PhD; Joan M. Romano, PhD; Beverly E. Thorn, PhD; David A. Williams, PhD
About the Psychosocial Research SIG
Introduction
The Psychosocial Research Special Interest Group (PSR-SIG) was recently constituted by APS members who share a common interest in the design and implementation of psychosocial research related to pain, and in the application of those findings to the clinical assessment and treatment of painful conditions. The PSR-SIG is open to all APS members. At the 1998 APS Annual Scientific Meeting, the following mission statement was adopted by SIG members to guide the activities of the PSR-SIG:
The proposed goals of the PSR-SIG are to foster communication among psychosocial researchers, to encourage innovative and collaborative biopsychosocial research, to explore implications of biopsychosocial research for clinical pain management, and to foster development of pain care delivery systems that incorporate evidence-based biobehavioral methods.
The founding members of the PSR-SIG had met informally at the annual APS meetings since 1994 to discuss new developments in psychosocial research. In 1998, the APS Executive Board formally recognized this group by granting SIG status. The membership of the group has grown from 40 members in 1997 to more than 130 current members. At the APS meeting in San Diego in November 1998, the PSR-SIG held two functions: a formal symposium, and its first annual business meeting. This article for the SIG column in APS Bulletin presents an overview of the presentations and discussion from both functions.
The symposium presentations on psychosocial research issues included
- a brief history of the evolution of the biopsychosocial model for pain, including recent advances and challenges
- changes in the healthcare marketplace and their implications for psychosocial pain research and treatment
- strengths and limitations of psychosocial pain research
- new directions in psychosocial pain research
Development and current status of the biopsychosocial model of chronic pain
Thirty years ago, a curative model of medicine dominated health care (i.e., medical treatment was expected to cure the presenting complaint). Chronic pain did not and does not fit neatly into this traditional medical model. Thus, patients who did not benefit from biological treatment were referred to mental-health professionals for psychosocial treatment of the mental illness that was supposedly causing the pain complaint. While such referrals opened the door for psychosocial clinicians to participate in clinical pain treatment, the inference that incurable chronic pain was a mental illness was both incorrect and unfortunate. An alternative to the traditional curative model of health care, one that emphasized rehabilitation rather than cure, was needed. Psychosocial researchers should be applauded for their sustained efforts in advancing this rehabilitation model, which has paved the way for the integration of psychosocial interventions into multidisciplinary pain practices.
Various cognitive and behavioral constructs have advanced the psychosocial or rehabilitative perspective of pain management. These include behavioral concepts such as functional status, pain behavior, and reinforcement, as well as behavioral approaches as seemingly simple as relaxation skills training. Cognitive concepts such as pain appraisal, coping, and catastrophizing have received much research attention and have also advanced the field through treatment approaches such as cognitive restructuring and cognitive strategies aimed at stress inoculation. (See Bibliography A for some of the more widely cited texts on biopsychosocial research in pain and references to the psychosocial constructs mentioned above, as well as others.) These cognitive and behavioral constructs have also been used to develop a myriad of pain assessment tools that have helped clinicians better understand the patient’s experience of pain—something that escapes reliable and valid measurement when only physiological assessments are made. (Bibliography B contains a sample listing of some of the more widely used psychosocial assessment tools in both research and clinical practice.)
Changes in the healthcare marketplace: Implications for psychosocial pain research and treatment
Today we are facing an industrialization of the healthcare delivery system. This industrialization is posing severe challenges to the psychosocial perspective. An immediate threat to the rehabilitative approach to pain management is that psychosocial treatments are being increasingly cut out of third-party healthcare coverage. One reason for the change is that psychosocial treatments, which used to be bundled along with the more traditional medical treatments as one service within one health management company, now are commonly separated from traditional medical treatments. The unbundled biomedical and mental health services are often managed (and paid for) by different companies. Although psychosocial treatments have been shown to reduce medical utilization (as described later in this article), the company that reaps the benefits (i.e., the company managing the traditionally accepted medical treatments) may not be the same company paying for the treatment (i.e., the company managing the psychosocial treatments). Moreover, psychosocial pain management approaches often are covered only if the patient is diagnosed with a mental illness that is concomitant with their pain. The available research would argue that psychosocial pain treatment, as part of a multidisciplinary pain management program, is a valid and necessary part of comprehensive medical treatment for painful conditions, regardless of whether these conditions are related to mental illness.
The industrialization of health care has resulted in a market-driven move from multidisciplinary treatment to unidimensional treatment and, with it, a rejection of the rehabilitation model in favor of the curative model of 30 years ago. With this curative model comes a preference for the “magic bullets” that will cure pain and whose allure includes being simple, understandable, efficient, quantifiable, and attractive to consumers. Cognitive and behavioral change techniques lack many of the favored attributes of the “magic bullets,” and thus practitioners of this approach face an uphill battle to remain in the mainstream of multidisciplinary pain practice. The industrialization of health care has created the business of health care, and therefore practitioners of all types, including psychosocial practitioners, have to be able to sell the therapy as well as do the therapy. One approach to selling the therapy is to effectively argue the efficacy of psychosocial treatments. Practitioners are again turning to psychosocial researchers to present the empirical support for multidimensional pain treatment.
Strengths and limitations of psychosocial pain research in the current marketplace
Research based on a biopsychosocial conceptual model has provided an empirical basis for psychosocial pain treatment as that model has evolved over the last 25 years. Recent reviews of the literature and meta-analyses have provided empirical support for the efficacy of psychosocial treatments in improving patient functioning, decreasing their self- reported pain and psychological distress, and increasing their return to work.
An NIH technology assessment panel in 1995 concluded that there was evidence of strong efficacy for relaxation and moderate efficacy for cognitive-behavioral therapy and biofeedback in reducing chronic pain (NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches, 1996). The panel also reported that multidisciplinary pain treatment programs effectively treated a number of chronic pain conditions. More recently, an issue of the Journal of Consulting and Clinical Psychology was devoted to the topic of empirically supported psychological treatments, and included an article by Compas, Haaga, Keefe, Leitenberg, and Williams (1998) that reviewed empirical findings regarding psychosocial treatment of chronic pain. Based on defined criteria for evaluating the results of outcomes studies, these authors found that cognitive behavioral therapy and operant behavioral therapy could be classified as efficacious treatments for a number of painful conditions and that thermal biofeedback was efficacious for the treatment of migraine headache. A meta-analysis of multidisciplinary pain treatment by Flor, Fydrich and Turk (1992) found that compared with no treatment and with waiting list- and single-treatment conditions, patients receiving multidisciplinary pain treatment showed greater improvements in physical and psychosocial functioning. One of the investigators’ most striking findings was that patients treated in a multidisciplinary pain center were nearly twice as likely to return to work as those who were untreated or treated with unimodal treatments. The previously cited NIH panel estimated that multidisciplinary, as compared with unidimensional, treatment could save approximately $227,000 per patient in disability benefits alone, based on the likelihood of those patients returning to work. The NIH panel concluded that the evidence was strong enough to recommend that psychosocial interventions for pain should be reimbursed as part of comprehensive medical services at rates comparable to those for other care.
Despite these positive findings, there are methodological limitations in this literature that need to be addressed to strengthen the evidence base for psychosocial treatments. The NIH Technology Asessment Panel (1996) noted that one of the limiting factors in interpreting this literature was that in some studies, control groups were either lacking or not sufficiently comparable to treated patients. For example, patients who are denied insurance coverage or who elected not to begin treatment may not be comparable with patients who do begin treatment. Another concern was that sample sizes are often small: Random assignment to different treatments is extremely difficult to achieve in clinical effectiveness studies, yet waiting-list control groups preclude the possibility of long-term follow-ups. Outcomes measures may vary from study to study, and different outcome domains can be confusing to third-party payers attempting to evaluate the psychosocial literature.
Finally, although this is not a limitation of research, many psychosocial treatments are perceived to be more costly, even though evidence is emerging that shows these treatments can result in significant cost offsets over time. In addition, treatments often are not well described or standardized and, thus, difficult to replicate. This is problematic because of the bias within the healthcare market that places value on interventions that can be highly standardized. Highly standardized interventions allow for quality control across delivery sites, enable uniformity of pricing, and permit a set of objective evaluation criteria to be developed in order to control who is and who is not qualified to deliver the service. Even when standardized treatment manuals are used, psychosocial interventions often must be individualized and will thus vary in duration and content. All of these factors can limit the attractiveness of these approaches to third-party payers whose primary focus may be on short-term cost containment.
One of the main foci of the November 1998 PSR-SIG symposium was to address ways that the field of psychosocial research can better address these limitations to increase the relevance and applicability of findings in the clinical marketplace. Probably the single most important recommendation for change was to build in outcomes measures that will be relevant to payers. Treatment trials should address clinical significance and cost-effectiveness issues as well as statistical significance in demonstrating efficacy. This means including measures of cost offset (i.e., which costs are reduced in healthcare utilization, disability payments, or lost work productivity as a result of treatment). Very few studies have attempted to measure cost offset, but this will become an increasingly important criterion in determining the utility of clinical treatments.
Other recommendations offered at the PSR-SIG symposium included clearly defining the components of care and the types of patients for whom they are applicable. Poorly described patient characteristics and treatment methods may limit the usefulness of the data and cause payers to dismiss findings as not relevant to their patient population. Patient and treatment characteristics that can help predict outcomes should be developed to provide data on which treatments for which patients with which problems are most likely to provide significant benefit. In addition, both randomized controlled-treatment efficacy studies and clinical effectiveness studies are needed to demonstrate that treatments are efficacious in rigorous, internally valid studies, and that the results can be generalized to the world of clinical practice in which they will be applied. Outcomes studies may not provide information about the active ingredients of therapy; as a result, process studies are needed to identify components of treatment that are responsible for change in specific outcomes. This may help to make treatments more streamlined, cost-efficient, and targeted for specific problems. A final recommendation of the PSR-SIG symposium was to develop and evaluate models of care that are cost- and time-effective and that can be integrated into primary care settings.
Dissemination of information regarding psychosocial treatments for pain remains a major challenge for the field. This involves not only publishing relevant findings in research journals, but also increasing the access to information for consumers (who are defined broadly as patients, employers, payers, clinicians, and the public) about evidence-based health and behavior research relevant to pain. All consumers are potential allies of the psychosocial perspective if the benefits of such research can be adequately disseminated. Many creative, effective new strategies are being explored in the fields of behavioral medicine and psychosocial pain research. Researchers are placing empirically supported clinical materials on Web sites for clinicians to use. Fact sheets are being developed for the public as well as clinicians. Peer-reviewed journals are beginning to include standardized treatment manuals along with studies that support a specific treatment’s efficacy or effectiveness. Psychosocial researchers are forging partnerships with large HMOs so as to more effectively assess the cost offset of behavioral interventions. Advocates of behavioral science are seeking to develop treatment codes that include behavioral and psychosocial services for medical conditions, to influence regulatory boards to include psychosocial perspectives, and to continue to emphasize the importance of behavioral and cognitive approaches with students and trainees. Training programs for pain clinicians also have to incorporate training in empirically supported treatments and in outcomes evaluation that is attuned to the current healthcare market.
New research directions: The transition from acute to chronic pain
Some of the models used in studying the etiology of psychopathology might well be applied in studies of how acute pain evolves over time into chronic pain. For example, Kendler, Kessler, Neale, Heath, and Eaves (1993) and Kendler et al. (1995) have studied risk factors for depression, and their work suggests that four domains of variables are likely to be important: genetics, traumatic life experiences (childhood as well as recent), interpersonal support, and temperament. In a study of twins, he found that of these four domains, traumatic life events made the greatest contribution to predicting an episode of major depression. Models such as this can help provide a foundation for generating testable models of the development of chronic pain. In addition, given that depression is a common comorbid disorder in chronic pain, such models may also help illuminate the sources of chronicity in pain patients.
Examples of research that explore the development of chronic pain include the work of Gatchel, Polatin, and Mayer (1995), who examined factors that predict the transition from acute to chronic low-back pain and disability, as well as Jensen, Krebs, Nielsen, and Rasmussen (1985) and Katz (1992), who explored factors leading to the development of phantom limb pain and conducted ongoing studies investigating the onset of chronic whiplash following motor-vehicle accidents and the onset and maintenance of reflex sympathetic dystrophy after orthopedic interventions. Similarly, Dworkin and Banks (1999) examined models of the pathogenesis of postherpetic neuralgia, and Kwilosz, Leeming, Levy, and Strauss (1998) explored factors that predict chronic pain after surgery for breast cancer.
Untapped data: Psychosocial researchers working with the pharmaceutical industry
The pharmaceutical industry is well positioned and very capable of advancing, marketing, and promoting the use of medications for the treatment of chronic pain. Such capacity may be of benefit to psychosocial researchers. The Food and Drug Administration requires the measurement of pain intensity when a new drug is being tested for marketing as a pain reliever. Frequently, however, other secondary measures of a psychosocial nature such as pain relief, pain quality, pain unpleasantness, distress, affect, quality of life, activities of daily living, and disability are also collected. As is obvious, all of these secondary measures assess factors that have been prominent domains of psychosocial research for decades and for which the psychosocial field has developed numerous assessment tools. Such data sets may be beneficial in cross-validation studies, generalization studies, and pilot studies for item-reduction analyses. Moreover, the psychosocial pain researchers are particularly well suited to provide the types of careful empirical design, application, and analyses to maximize the utility of the data already gathered and data to be gathered in the future.
Summary
Psychosocial pain research has pioneered the design, application, and evaluations of multidimensional pain research for several decades. The efficacy of behavioral and cognitive-behavioral treatments for painful conditions has been empirically supported. Innovative advances in research on treatment efficacy now require inclusion of cost-offset outcome data, standardization of treatment protocols, and component analyses of effective aspects of treatment as well as appropriate patient characteristics. We have to be able to more clearly define which treatments are appropriate for which patients, for which problems, and at what cost savings. The application of models already in place in other psychosocial literature (e.g., the etiology of psychopathology) may prove to be useful in furthering our research agenda.
References
Compas, B.E., Haaga, D.A., Keefe, F.J., Leitenberg, H., & Williams, D.A. (1998). Sampling of empirically supported psychological treatments from health psychology: Smoking, chronic pain, cancer, and bulimia nervosa. Journal Of Consulting and Clinical Psychology, 66(1), 89-112.
Dworkin, R.H., & Banks, S.M. (1999). A vulnerability-diathesis-stress model of chronic pain: Herpes zoster and the development of postherpetic neuralgia. In R.J. Gatchel & D.C. Turk (Eds.), Psychosocial factors in pain: Critical perspectives (pp. 247-269). New York: The Guilford Press.
Flor, H., Fydrich, T., & Turk, D.C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, 221–230.
Gatchel, R.J., Polatin, P.B., & Mayer, T.G. (1995). The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine, 20, 2702-2709.
Jensen, T.S., Krebs, B., Nielsen, J., & Rasmussen, P. (1985). Immediate and long-term phantom limb pain in amputees: Incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain, 21, 267-278.
Katz, J. (1992). Psychophysiological contributions to phantom limbs. Canadian Journal of Psychiatry, 37, 282-298.
Kendler, K.S., Kessler, R.C., Neale, M.C., Heath, A.C., & Eaves, L.J. (1993). The prediction of major depression in women: Toward an integrated etiologic model. American Journal of Psychiatry, 150, 1139-1148.
Kendler, K.S., Kessler, R.C., Walters, E.E., MacLean, C., Neale, M.C., Heath, A.C., & Eaves, L.J. (1995). Stressful life events, genetic liability, and onset of an episode of major depression in women. American Journal of Psychiatry, 152, 833-842.
Kwilosz, D.M., Leeming, R., Levy, L., & Strauss, M.E. (1998, November). Factors affecting post-lumpectomy pain. Paper presented at the annual meeting of the American Pain Society, San Diego.
NIH Technology Assessment Panel on Integration of Behavioral and Relaxation Approaches. (1996, July 24/31). Integration of behavioral and relaxation approaches into the treatment of chronic pain and insomnia. Journal of the American Medical Association, 276(4), 313-318.
Bibliography A: A Sampling of Seminal Texts That Have Assisted the Transition of Psychosocial Research from Academia into Clinical Practice
Blanchard, E.B., & Andrasik, F. (1985). Management of chronic headaches. New York: Pergamon Press.
Fordyce, W.E. (1976). Behavioral methods for chronic pain and illness. Saint Louis: C.V. Mosby.
Gatchel, R.J., & Turk, D.C. (1996). Psychological approaches to pain management: A practitioner’s handbook. New York: The Guilford Press.
Gatchel, R.J., & Turk, D.C. (1999). Psychosocial factors in pain: Critical perspectives. New York: The Guilford Press.
Karoly, P., & Jensen, M. (1987). Multimethod assessment of chronic pain. New York: Pergamon Press.
Lazarus, R.S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer Publishing Company.
Melzack, R., & Wall, P.D. (1983). The challenge of pain. New York: Basic Books.
Sternbach, R.A. (1968). Pain: A psychophysiological analysis. New York: Academic Press.
Turk, D.C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive-behavioral perspective. New York: The Guilford Press.
Bibliography B: A Sampling of Assessment Tools for Pain by Domain
Pain
McGill Pain Inventory
Melzack, R. (1983). The McGill Pain Questionnaire: Major properties and scoring methods. Pain, 1, 277-299.
Brief Pain Inventory
Cleeland, C.S. (1985). Measurement and prevalence of pain in cancer. Seminars in Oncology Nursing, 1, 87.
General Distress and Physical Functioning
SF-36
Ware, J.E., Jr., & Sherbourne, C.D. (1992). The MOS 36-Item Short-Form Health Survey (SF-36): Conceptual framework and item selection. Medical Care, 30(6), 473-483.
Oswestry
Fairbank, J.C.T., Couper, J., Davies, J., & O’Brien, J.P. (1980). The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy, 66, 271-273.
SCL90R
Derogatis, L.R. (1983). SCL-90-R administration, scoring and procedures manual-II (2nd ed.). Towson, MD: Clinical Psychometric Research.
Pain-Specific Functioning and Distress
WHYMPI
Kerns, R.D., Turk, D.C., & Rudy, T.E. (1985). The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain, 23(4), 345-356.
Sickness Impact Profile
Follick, M.J., Smith, T.W., & Ahern, D.K. (1985). The Sickness Impact Profile: A global measure of disability in chronic low back pain. Pain, 21(1), 67-76.
Illness Behavior Questionnaire
Pilowski, I. (1978). A general classification of abnormal illness behavior. British Journal of Medical Psychology, 51, 131-137.
Environmental Factors
WES & FES
Moos, R.H. (1981). Work Environment Scale: Manual. Palo Alto, CA: Consulting Psychologist Press.
Moos, R.H., & Moos, B.S. (1981). Family Environment Scale: Manual. Palo Alto, CA: Consulting Psychologist Press.
Pain Behavior
Pain Behavioral Observation Systems
Keefe, F.J., & Block, A.R. (1982). Development of an observation method for assessing pain behavior in low back pain patients. Behavior Therapy, 13, 363-375.
Follick, M.J., Ahern, D.K., & Aberger, E.W. (1985). Development of an audiovisual taxonomy of pain behavior: reliability and discriminant validity. Health Psychology 4(6), 555-568.
Richards, R., Nepomuceno, C., Riles, M., & Suer, A. (1982). Assessing pain behavior: The UAB Pain Behavior Scale. Pain, 14, 393-398.
Coping and Beliefs
Coping Strategies Questionnaire
Rosenstiel, A.K., & Keefe, F.J. (1983). The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain, 17(1), 33-44.
Vanderbilt Pain Management Inventory
Brown, G.K., & Nicassio, P.M. (1987). Development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients. Pain, 31(1), 53-64.
Pain Beliefs and Perceptions Inventory
Williams, D.A., Robinson, M.E., & Geisser, M.E. (1994). Pain beliefs: Assessment and utility. Pain, 59(1), 71-78.
Survey of Pain Attitudes
Jensen, M.P., Karoly, P., & Huger, R. (1987). The development and preliminary validation of an instrument to assess patients’ attitudes toward pain. Journal of Psychosomatic Research, 31(3), 393-400.
Affective Responses and Comorbid Psychiatric Symptoms
POMS-LASA
Sutherland, H.J., Lockwood, G.A., & Cunningham, A.J. (1989). A simple, rapid method for assessing psychological distress in cancer patients: Evidence for linear analog scales. Journal of Psychosocial Oncology, 7, 31-43.
MMPI
Graham, J.R. (1993). MMPI-2: Assessing personality and psychopathology (2nd ed.). New York: Oxford University Press.
Beck Depression Inventory
Beck, A.T., Rush, A.J., Shaw, B.F., & Emery, G. (1979). Cognitive therapy and depression. New York: The Guilford Press.
Beck Anxiety Inventory
Beck, A.T., & Steer, R.A. (1990). Beck Anxiety Inventory: Manual (2nd ed.). New York: The Psychological Corporation, Harcourt Brace Jovanovich, Inc.
Hamilton Depression Rating Scale
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23, 56-62.
Robert D. Kerns is chief of the psychololgy service at the West Haven Veterans Administration; Robert H. Dworkin is a professor of anesthesiology at the University of Rochester in Rochester, NY; Joan M. Romano is an associate professor of psychiatry and behavioral science at the University of Washington in Seattle; Beverly E. Thorn is a professor of psychology at the University of Alabama at Tuscaloosa; and David A. Williams is an associate professor of psychiatry at Georgetown University Medical Center in Washington, DC.