2011 Psychological Treatment of Chronic Pain

CP07CH16-Kerns ARI 24 February 2011 16:38
ANNUAL
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Annu. Rev. Clin. Psychol. 2011.7:411-434. Downloaded from www.annualreviews.org
• Our comprehensive search and Burel R. Goodin1

1
VA Connecticut Healthcare System, West Haven, Connecticut 06516, and 2 Department of
Psychiatry, Yale University, New Haven, Connecticut 06520; email: Robert.kerns@va.gov
Annu. Rev. Clin. Psychol. 2011. 7:411–34 Keywords

First published online as a Review in Advance on self-regulatory treatments, behavioral treatments,
December 3, 2010
cognitive-behavioral therapy, acceptance and commitment therapy,
The Annual Review of Clinical Psychology is online pediatric pain, pain in older adults
at clinpsy.annualreviews.org
This article’s doi: Abstract

10.1146/annurev-clinpsy-090310-120430
Psychological treatment has emerged as a common component of a
Copyright c 2011 by Annual Reviews. multidimensional and interdisciplinary plan of pain care for many per-
All rights reserved
sons with persistent pain. Treatments are informed by a biopsychosocial
1548-5943/11/0427-0411$20.00 model of pain and a long history of psychological research that has iden-
tified the central role of behavioral, cognitive, and emotional factors that
are believed to contribute to the perpetuation, if not the development, of
chronic pain and pain-related disability and emotional distress. Empir-
ically supported self-regulatory, behavioral, cognitive-behavioral, and
acceptance and commitment interventions are reviewed, and current
and future interventions are highlighted. Important issues related to
individual differences and disparities in the experience of pain and pain
treatment are discussed. In particular, race and ethnicity are considered,
and special considerations for the management of pain in children and
older adults are discussed.
411
may suffer from persistent pain at some point

Contents in their lives, and some have suggested that
chronic pain be considered a public health cri-
CHRONIC PAIN EXPERIENCE . . . . 412
sis. On average, reports estimate that the global
SELF-REGULATORY
prevalence of chronic pain is currently at 20%
APPROACHES . . . . . . . . . . . . . . . . . . . 414
(Boris-Karpel 2010). Recent evidence suggests
Biofeedback . . . . . . . . . . . . . . . . . . . . . . . 415
that the prevalence of chronic low back pain,
Relaxation Training . . . . . . . . . . . . . . . . 415
the most common pain condition, is increas-
Hypnotherapy . . . . . . . . . . . . . . . . . . . . . 416
ing at alarming rates (Sinnott & Wagner 2009).
Mindfulness . . . . . . . . . . . . . . . . . . . . . . . 416
For many, chronic pain contributes to declines
BEHAVIORAL APPROACHES . . . . . . 417
in physical and social role functioning and to
Operant Behavioral Therapy . . . . . . . 417
untold emotional suffering. Beyond its human
Fear Avoidance . . . . . . . . . . . . . . . . . . . . 417
costs are the estimated billions of dollars associ-

COGNITIVE-BEHAVIORAL
ated with persons’ interactions with the health-
THERAPY . . . . . . . . . . . . . . . . . . . . . . . . 418
care system in efforts to find relief and costs as-
ACCEPTANCE AND
sociated with lost work productivity, including
COMMITMENT THERAPY . . . . . 420
unemployment and disability benefits. In 2003,
SPECIAL TOPICS . . . . . . . . . . . . . . . . . . . 422
the American Productivity Audit reported that
Disparities and Inequalities in Pain
lost productive time from common chronic pain
Experience, Assessment,
conditions such as headache, back pain, arthri-
and Treatment . . . . . . . . . . . . . . . . . . 422
tis, and other musculoskeletal problems alone
Ethnicity and Race . . . . . . . . . . . . . . . . . 423
cost $61.2 billion (Stewart et al. 2003).
Age-Related Issues . . . . . . . . . . . . . . . . . 425
On a more positive note, numerous impor-
CONCLUSION . . . . . . . . . . . . . . . . . . . . . 428
tant advocacy, legislative, and policy efforts can
be cited as direct efforts to address the apparent
crisis, at least in the United States. Over the past
several decades, the field of pain medicine and
CHRONIC PAIN EXPERIENCE science has rapidly developed, as demonstrated
The experience of pain is among the most by the increased volume of pain-related content
ubiquitous of humankind and is commonly un- in the scientific literature, pain curricula devel-
derstood to be a signal of harm to the integrity opment, and the availability of clinical practice
of the body. Pain is an expected consequence guidelines (Am. Pain Soc. Quality Care Comm.
of acute illness, injury, and surgery, and it 1995, Gordon et al. 2005, Jacox et al. 1994).
most often resolves with healing. The expe- The U.S. Congress designated the period from
rience of chronic pain is an entirely different 2001–2010 as the Decade of Pain Control and
matter. Pain that persists beyond the expected Research, and in 2001, the Joint Commission,
period of healing or resolution of the source of the major healthcare accreditation organiza-
pain serves little or no useful purpose and can tion in the United States, promulgated stan-
emerge as a devastating blow to one’s sense of dards for pain assessment and management
well-being. Despite widespread beliefs to the (Berry & Dahl 2000). In the past decade, nu-
contrary, even in the case of arthritis and other merous legislative initiatives made their way
degenerative musculoskeletal disorders, pain through Congress, and most recently, bills sup-
is unreliably associated with disease severity porting improvements in pain care in Depart-
and does not apparently serve an instrumental ment of Veterans Affairs and Department of
role in protecting the sufferer or in otherwise Defense healthcare facilities were signed into
promoting adaptation and adjustment. law. In 1998, the Veterans Health Adminis-
Unfortunately, evidence suggests that a ma- tration, the largest integrated healthcare sys-
jority of persons living in Western societies tem in the United States, launched its National
412 Kerns · Sellinger · Goodin

Pain Management Strategy, which has helped Perhaps not surprisingly, the role of negative
to build capacity for pain care and pain relevant emotions, especially anxiety, depression, and
research for veterans (Kerns et al. 2006). anger, has served as the primary focus of inves-
In the past half century, an integrative and tigation (Fernandez & Kerns 2008). Fordyce’s
multidimensional biopsychosocial theoretical (1976) operant behavioral model has served
framework has largely replaced more restric- an important heuristic role that continues to
tive unidimensional and biomedical models as yield important discoveries and a sophisticated
the predominant contemporary model of pain understanding of the social learning context.
(Gatchel et al. 2007). The biopsychosocial The model continues to inform research that
model of pain builds on Melzack & Wall’s has identified the role of social contingencies
(1965) groundbreaking “gate control theory of (e.g., expressions of sympathy from family
pain” that described pain as a central nervous members and friends, disability payments, and
system phenomenon in which ascending, prescription medications) for overt expressions

sensory neural inputs from the periphery were of pain, termed “pain behaviors” (e.g., verbal
hypothesized to be modulated by downward and paraverbal expressions of pain, visits
motivational-affective and cognitive-evaluative to doctors, and avoidance of work-related
influences. More recently, Melzack and others activities and social responsibilities). The
extended this earlier view and described a cognitive-behavioral perspective of Turk et al.
“neuromatrix theory of pain” that highlights (1983) remains a dominant model in the field
a more complex, widely distributed, and and continues to encourage research that has
characteristic neural signature in the brain led to the identification of cognitive and other
(Melzack 2005). The original articulation psychological factors that appear to be strongly
of the gate control theory and more recent and reliably positively associated with pain
elaborations of the biopsychosocial model have severity and disability. Among factors that have
been associated with a virtual explosion of the strongest empirical support are such con-
scientific investigation that cuts across the basic structs as pain catastrophizing (Turner & Aaron
sciences, translational research, and specifically 2001), fear avoidance (Vlaeyen & Linton 2000),
relevant to the current review, a broad array of low self-efficacy and lack of perceived control
clinical psychological research. (Arnstein et al. 1999, Litt 1988), and passive
A large, broad, and growing empirical pain coping (McCracken & Eccleston 2003).
literature continues to inform increasingly so- Significant advances have continued on
phisticated understanding of key psychological the clinical front as well. Pain continues to
and behavioral factors that reliably influence be viewed as a private, covert, and subjective
the perpetuation, if not the development, of experience, so perhaps it is not surprising that
pain and pain-related disability. Early work clinical psychologists continue to play central
focused on the identification of personality roles in the development of psychometrically
factors hypothesized to be causally related sound and sophisticated measures of pain and
to the development of chronic pain, such as the broader multidimensional experience of
a predisposition toward denying emotional chronic pain. In the clinical setting, psycho-
and/or interpersonal distress, a somatic focus logical measures of pain severity or intensity,
of attention, or displaying features associated pain-related disability or interference, and
with a “depression-prone” personality such as emotional impact have taken their place as the
pessimism (Blumer & Heilbronn 1982, Gentry most widely employed measures of pain treat-
et al. 1974). A major focus of both laboratory ment effectiveness. Psychological measures are
analogue and clinical research is on articulating widely recommended to be used in the context
both the affective properties of the experience of a comprehensive pain assessment in order to
of pain and the central role that emotions play in better characterize, if not explain, an individ-
determining pain severity, quality, and impact. ual’s experience of pain and to inform treatment
www.annualreviews.org • Psychological Treatment of Chronic Pain 413

decision-making and planning. These measures of interdisciplinary pain care that included psy-
are also employed for determining an indi- chological interventions, published by Flor and
vidual’s appropriateness for specialized pain her colleagues, documented the benefits of such
interventions such as implantable pain medi- programs on pain and functioning, including
cation delivery systems and neural modulation return to work (Flor et al. 1992). Clinical in-
therapies. Over the past ten years, an impor- vestigators have specified roles for psycholo-
tant consensus process, called the Initiative for gists and other mental health professionals in
Methods, Measurement, and Pain Assessment interdisciplinary pain rehabilitation programs
in Clinical Trials (which includes pain experts (Townsend et al. 2006). A recent line of inves-
from academia, industry, government agencies, tigation has begun to focus on identification of
and patient advocacy groups), has endorsed predictors of change during pain treatment, the
several psychological measures of core domains process of change, and the potential to improve
for use in pain clinical trials (Dworkin et al. outcomes through a process of matching indi-
2005). Most recently, the National Institutes vidual characteristics with different treatments
of Health has launched a broadly conceived (Asenlof et al. 2005). Particularly exciting are
and novel initiative called Patient-Reported reports on the cost-effectiveness of population-
Outcome Measurement Information System, based dissemination of psychological interven-
which blends classical test theory and modern tions for persistent pain (Kroenke et al. 2010,
measurement theory methods, including item Lamb et al. 2010).
response theory and computer adaptive testing, The primary purpose of this article is to
for the efficient assessment of core constructs provide a focused and critical review of the
related to chronic disease. The majority of the broad domain of psychological interventions
proposed measures use items from existing for chronic pain. Using a framework offered by
psychological instruments, such as one of the our group in a recently published meta-analysis
first published measures designed to assess of psychological interventions for chronic low
pain behavior frequency (Revecki et al. 2009). back pain (Hoffman et al. 2007), four cate-
Most experts in the field of pain manage- gories of psychological interventions are con-
ment appreciate the importance of a com- sidered: self-regulatory, behavioral, cognitive-
prehensive, multidimensional, multimodal, and behavioral, and acceptance and commitment
interdisciplinary approach to management of therapies. Future directions, including the need
chronic pain. In this context, psychological to address pain treatment disparities, age-
and behavioral interventions are widely ac- related differences in pain care, and the inno-
cepted as important, if not critical, com- vative use of technologies to promote access
ponents of effective pain care. As early as to psychological interventions for chronic pain
the late 1960s, data began to emerge that management, are also discussed.
supported the effectiveness of psychological
interventions for persistent pain, either in the
context of interdisciplinary pain programs or in SELF-REGULATORY
isolation of other interventions. Research has APPROACHES
documented the benefits of various psycholog- The development of the gate control theory of
ical interventions for a broad array of common pain in the 1960s by Melzack and Wall marked
pain conditions such as headache, low back, a significant shift in thinking about the pain
and arthritis, among many others. A growing experience. Moving beyond the purely biolog-
number of systematic and meta-analytic reviews ical conceptualizations of pain that shaped the
document the efficacy, effectiveness, and even zeitgeist of their time, Melzack & Wall (1965)
cost-effectiveness of psychological interven- utilized the gate control theory to delineate the
tions (Hoffman et al. 2007). One particularly in- importance of psychological and social variables
fluential meta-analysis of the cost-effectiveness in the etiology and maintenance of chronic

physical pain. From this growing recognition headache pain. Recent meta-analyses have
of the important role that factors such as affect, demonstrated empirical support for a variety
cognition, behavior, and socialization play in of biofeedback methods for chronic headache,
the experience of pain, psychologists began including blood volume pulse feedback,
to develop treatments designed to manipulate electromyographic feedback, temperature
these factors in an effort to alter the perception feedback, galvanic skin response, and en-
and experience of chronic pain. Designed cephalography feedback. Among the outcomes
specifically to assist patients with developing assessed in these trials were frequency of
skills that would make them active participants headache, self-efficacy for self-management
in their own care, many early examples of of headache, anxiety, depression, and use of
these psychological treatments are collectively analgesic medication. On average, effect sizes
referred to as the self-regulatory approaches. in these meta-analyses were medium to large,
The theoretical underpinnings of these self- and clinical effects were shown to persist for
regulatory approaches demonstrate how bio- approximately 15–17 months post treatment
logical and psychological factors interact to infor both migraine and tension-type headaches
fluence the perception of pain. Often referred in adults, adolescents, and children (Nestoriuc
to as the mind-body connection, the applica- et al. 2008, Nestoriuc & Martin 2007).
tion of this conceptualization to chronic pain is
such that chronic emotional and psychological
unrest can contribute to the development and Relaxation Training
exacerbation of chronic physical pain, much like Relaxation training is an adjuvant method that
chronic physical pain can contribute to nega- is often used in the context of biofeedback
tive alterations in emotional, psychological, and training and also as a component part of other
physical well-being. Therefore, by seeking to treatment regimens (e.g., cognitive behavioral
alter one side of this equation, self-regulatory therapy). Relaxation training focuses on the
approaches utilize the mind-body connection identification of states of tension within the
by seeking to increase the individual’s sense of mind and body, followed by the application
personal control over physiological and emo- of systematic methods such as diaphragmatic
tional states that are commonly believed to be breathing (deep breathing), progressive muscle
out of one’s control. Examples of these ap- relaxation, or visualization to reduce tension
proaches include biofeedback, relaxation train- and to alter the perception of associated physi-
ing, hypnosis, and mindfulness. cal pain. Pain produces both physiological and
emotional stresses, which collectively feed into
a cycle that results in increased pain perception
Biofeedback and ongoing alteration of the physiology of the
Biofeedback is a systematic methodology body in ways that only exacerbate pain (muscle
through which individuals are provided with tension or spasm, constriction of blood vessels).
real-time feedback about a variety of physio- Relaxation training focuses on educating indi-
logical processes, with the goal of developing viduals about the relationship between emo-
an awareness of when these processes change tional and physiological stresses and seeks to
so that the individual can learn to voluntarily empower individuals by teaching them system-
exert control over the bodily reactions asso- atic self-control methods for altering physical
ciated with these processes. In the context of states (e.g., muscle tension) and psychological
pain management, the physiological targets states (e.g., stress). The use of relaxation
are typically factors that are directly associated training for the management of chronic pain
with pain exacerbations or those related to has been shown to be effective through studies
emotional responses to the pain. Biofeedback on a variety of conditions, including migraine
plays a prominent role in the treatment of pain (Kaushik et al. 2005), musculoskeletal

pain (Middaugh et al. 1991), and low back pain Theravada Buddhism, mindfulness meditation
(McCauley et al. 1983, Strong et al. 1989). is based on increasing intentional self-
regulation of attention to what is happening in
the moment. One of the pioneers in the field
Hypnotherapy of mindfulness meditation is Jon Kabat-Zinn,
Another self-regulatory approach that psychol- who has developed mindfulness-based stress-
ogists utilize in the management of chronic pain reduction programs that have been effectively
is hypnotherapy. Closely related to relaxation utilized in the treatment of chronic refractory
training, hypnotherapy involves an altered pain. Similar in many ways to the previously
state of awareness that is guided by suggestive described methods of relaxation training and
statements made by the hypnotherapist that hypnotherapy, the goals of mindfulness medi-
are designed to focus participants’ attention tation include the attainment of both relaxation
in such a way that they come to change their and greater focus of attention. However, mind-
own subjective experience of pain. As with fulness meditation emphasizes the attainment
relaxation training, participants are taught of stress reduction through increased focus on
methods for reconnecting with this state of phenomenon that are occurring in the moment,
hypnotic relaxation at any time by using behav- without the natural tendency to interpret such
ioral cues, such as deep breathing. Although events or form associations between events and
the methods used to deliver hypnotherapy for our thoughts about them. Instead, the focus is
chronic pain vary widely ( Jensen & Patterson on fully experiencing the phenomenon in rare
2006), defining guidelines for the practice form in the moment, without reference to the
of hypnotherapy have been published by the past or future. In using this approach for pain
American Psychological Association’s Society management, one of the goals is to separate the
of Psychological Hypnosis (Division 30) sensation of pain from the thoughts that often
(Green et al. 2005). However, despite the vari- occur in response to such sensations. These
ations in methodology utilized, a growing body thoughts are typically rooted in the past and
of literature provides empirical support for the project to the future, thus triggering emotional
use of hypnotherapy for pain management. responses that are based on associations. By
A recent meta-analysis of 13 controlled trials focusing only on the phenomenon of pain, as
of hypnotherapy for a variety of chronic pain if one is a detached observer, an individual can
conditions, including cancer pain, low back learn to separate the experience of pain from
pain, arthritis, pain from sickle cell disease, these thoughts. In so doing, the individual
temporomandibular pain, fibromyalgia, and can begin to accept the pain as it is without
mixed pain conditions, found good empirical the cognitive and emotional connections that
support for the use of this methodology. These are typically alarming to the patient and that
findings were based on comparisons to either serve to make the experience of pain worse.
control conditions or other baseline interven- The early works of Kabat-Zinn in applying the
tions such as education and physical therapy mindfulness meditation approach to chronic
(Elkins et al. 2007). These authors do highlight pain management demonstrated the effective-
the relatively low number of controlled studies ness of this approach in reducing current pain
that have been conducted on hypnotherapy, intensity, improving body image, increasing
but these reported findings are promising. physical activity, and improving mood and
anxiety (Kabat-Zinn 1982, Kabat-Zinn et al.
1985). A more recent meta-analysis found that
Mindfulness mindfulness-based stress reduction was an
One final and closely related self-regulatory ap- effective intervention for helping individuals
proach for chronic pain management is mind- to cope with a variety of health conditions,
fulness meditation. Rooted in the principles of including chronic pain (Grossman et al. 2004).

BEHAVIORAL APPROACHES members and friends who frequently are re-

The use of behavioral methods in the treatment sponsible for unknowingly contributing to the
of chronic pain is based largely on the operant reinforcement of pain behaviors. Considerable
conditioning model of learning that was delin- empirical investigation has been conducted
eated by B.F. Skinner. The underlying premise on the effectiveness of operant behavioral
of this model is that behaviors that are rein- therapy for chronic pain, and strong empirical
forced tend to increase in frequency, whereas support for this method has come from both
behaviors that are punished or not reinforced laboratory-based and clinically based studies
tend to decrease in frequency. In the context of this treatment approach. A review of the
of chronic pain, the behaviors that are targeted evidence supporting the use of operant behav-
through behavioral strategies are often referred ioral therapy can be found in two systematic
to as pain behaviors, which can include response reviews conducted by van Tulder et al. (2000)
patterns such as excessive verbalization of pain and Morley et al. (1999). Elements of operant
(grunting, sighing), frequent discussion about behavioral therapy have been incorporated into
pain, facial expressions, guarded movements, the broader treatment approach of cognitive-
or restriction of movement. These behaviors behavioral therapy (CBT) for pain, where
are commonly reinforced through social con- cognitive elements are also addressed. Given
tingencies, such as responses from other peo- the rise in popularity of CBT for chronic pain
ple. These responses can include expressions of management, there are few examples in the
sympathy, relieving the individual of respon- recent literature in which operant behavioral
sibility for even basic activities of daily living therapy is evaluated in its pure form (Molton
(solicitousness), or verbal reinforcement of the et al. 2007). However, a relatively recent clini-
individual’s pain symptoms. The reinforcement cal trial compared the use of operant behavioral
provided by such responses serves to increase therapy alone with its use in combination with
the pain behaviors and thus contribute to what an active physical treatment (Smeets et al.
has been referred to as the disuse syndrome. 2009). Assessed outcomes included both
The disuse syndrome is marked by excessive clinical measures (disability, quality of life)
pain behaviors that are in the service of de- and cost-effectiveness. Results showed that
creasing physical activity, which leads to phys- the use of operant behavioral therapy alone
ical deconditioning and increased risk for the to incrementally increase activity level yielded
development of worsening pain and other med- improvements in disability and quality of life
ical comorbidities (e.g., obesity) (Verbunt et al. that were equal to those of the more costly
2003). combined treatment. Using cost-effectiveness
ratios as a metric, operant behavioral therapy
was shown to be a cost-effective method for
Operant Behavioral Therapy reducing disability and improving quality
of life (Smeets et al. 2009). Findings such
In an effort to reduce such behaviors and
as these provide critical data to support the
avoid the resulting negative consequences,
implementation of operant behavioral therapy
psychologists have applied operant behavioral
approaches in these times of rising healthcare
therapy to the treatment of chronic pain.
costs and growing calls for cost-effective and
These efforts were spearheaded by the work
empirically supported treatments.
of Fordyce (1976), who emphasized the need
to reduce disability through the alteration of
pain behaviors by using methods to reduce the Fear Avoidance
reinforcing nature of the responses to such Another central concept in the field of behav-
behaviors and increasing the reinforcement of ioral pain management is fear avoidance. Based
healthy behaviors. Thus, the model of operant on behavioral principles, fear avoidance refers
behavioral therapy often involves close family to the development of avoidant behaviors that

are motivated by fear related to pain. For resolve their problems concerning maladaptive
some individuals, significant fear develops in emotions, behaviors, and cognitions through
the context of a painful condition. As a result, a goal-oriented, systematic procedure. Origi-
these individuals seek to avoid contact with the nally developed to better address the treatment
fear-provoking stimulus (pain) by engaging in needs of individuals with depression and anxiety
behaviors that allow them to avoid the onset disorders, over time CBT has been effectively
or exacerbation of pain (e.g., inactivity). This applied as a treatment for a host of psychophys-
pattern also contributes to the disuse syndrome ical disorders (e.g., insomnia, posttraumatic
described above. Lethem and colleagues (1983) stress disorder, bulimia nervosa, and chronic
first described this relationship, and since that fatigue syndrome), including chronic pain (see
time, the fear-avoidance phenomenon of pain Morley et al. 1999 for review). The develop-
has been further delineated and studied (Leeuw ment of CBT for pain management is steeped
et al. 2007, Vlaeyen & Linton 2000). At the root in the cognitive behavioral model of pain man-
of the fear-avoidance phenomenon are catas- agement, which has been developing over the
trophic thought patterns related to pain and hy- past four decades. Fordyce (1976) pioneered
pervigilance related to physical symptoms. The the behavioral model of multidisciplinary pain
pain-related fear is often tied to excessive worry management. During this time, CBT primarily
about further injuring or reinjuring oneself if focused on operant conditioning: overt motor
the choice is made to become physically active. and physiologic self-management techniques
This process has been termed kinesiophobia, such as reinforcement for participation in
implying that the efforts to avoid physical functional activities, progressive relaxation,
activity take on a phobic quality for many suf- and self-hypnosis. An individual’s behavioral
ferers. Recent advances in the treatment of fear responses to pain were modified according
avoidance have focused on the application of in to the consequences of the environment in
vivo exposure techniques to assist the individual which the behavior occurred: Behavior that
with systematically engaging in physical activ- is reinforced increases, and behavior that is
ities as a means of decreasing the fears that are ignored decreases. Over time, CBT evolved
strongly associated with such activity. A recent to include more cognitive interventions, such
clinical trial by Woods & Asmundson (2008) as the identification of negative automatic
compared in vivo exposure to a graded activity thoughts and replacement of these maladaptive
condition and a wait-list control. Results thoughts with adaptive, beneficial ones (Turk
showed significantly greater improvements et al. 1983). The cognitive aspects of CBT have
on measures of fear of pain/movement, fear been reviewed and found to contain critical
avoidance beliefs, pain-related anxiety, pain aspects of treatment that not only reduce pain
catastrophizing, anxiety, and depression when and increase functional ability, but also stabi-
compared to one or both alternative treat- lize mood and decrease disability (Kerns et al.
ments. The application of this in vivo exposure 1986). Most recently, CBT has been subsumed
method to the treatment of pain is a significant by the biopsychosocial conceptualization of
advancement and one that potentially puts the pain management (Turk & Monarch 1996).
treatment of chronic pain within reach of a The hallmark of the biopsychosocial model
broader array of psychologists who regularly of pain and its management is the notion that
utilize such treatments as part of their practice. pain is a complex experience that is influenced
not only by its underlying pathophysiology,
but also by an individual’s cognitions, affect,
COGNITIVE-BEHAVIORAL behavior, and sociocultural status.
THERAPY It has been suggested that CBT for
CBT is an empirically supported psychother- pain management has three basic compo-
apeutic treatment that aims to help individuals nents (Keefe 1996). The first is a treatment

rationale that helps individuals in pain to better there is considerable variation in the content of
understand that cognitions and behavior affect these programs, and it remains unclear which
the pain experience and emphasizes the role therapeutic mechanisms best predict patient
that individuals can play in controlling their improvement. The lack of treatment standard-
own pain. The second component of CBT ization and clarity associated with therapeutic
for pain management pertains to coping skills mechanisms of change has been highlighted as
training. Skills training may incorporate a wide one of the most important directions for future
variety of cognitive and behavioral pain-coping research related to behavioral interventions
strategies. For instance, progressive muscle for chronic pain (Vlaeyen & Morley 2005).
relaxation and cue-controlled brief relaxation In particular, because new knowledge regard-
exercises are used to decrease muscle tension, ing individual characteristics that predict or
reduce emotional distress, and divert attention moderate improvement with CBT could help
away from pain. Activity pacing and pleasant direct limited resources to those most likely
activity scheduling are used to help individuals to benefit, there is a need to match individuals
maximize their functionality and quality of with the most appropriate treatments and to
life. Training in distraction techniques such tailor interventions to patient characteristics
as pleasant imagery, counting methods, and (Heapy et al. 2006). This need has led to recent
use of a focal point helps individuals learn randomized clinical trials (RCTs) that exam-
to divert attention away from severe pain ined mediators, moderators, and predictors
episodes. Cognitive restructuring is used to of therapeutic change in CBT for chronic
help individuals identify and challenge overly pain (Turner et al. 2006, 2007). The CBT
negative pain-related thoughts and to replace intervention in these studies was designed to
these thoughts with more adaptive, coping decrease individuals’ catastrophizing, beliefs
thoughts. The third component of CBT for that they were disabled by pain and that pain
pain management involves the application and signaled harm, and maladaptive pain coping,
maintenance of learned coping skills. During and to increase individuals’ adaptive pain
this phase, individuals are encouraged to apply coping and beliefs in their ability to control
their coping skills to a progressively wider and self-manage pain. These cognitions and
range of daily situations. Individuals are taught behaviors were selected based upon previ-
problem-solving methods that enable them ous research suggesting their importance in
to analyze and develop plans for dealing with chronic pain problems and treatment ( Jensen
pain flares and other challenging situations. et al. 2001, Turner & Romano 2001). In
Self-monitoring and behavioral contracting the two RCTs completed by Turner and
methods are also used to prompt and reinforce colleagues, improvements in perceived control
frequent coping-skills practice. over pain, self-efficacy, and catastrophizing
The use of CBT for pain management has cognitions were important mediators of study
been shown to be effective for a variety of outcomes (e.g., pain-related interference,
chronic pain problems compared to wait-list disability). Further, treatment effects did not
controls and alternative active treatments appreciably vary according to patient’s baseline
(Chen et al. 2004, Eccleston et al. 2002, characteristics, suggesting that all patients
Morley et al. 1999, Weydert et al. 2003). Fur- potentially could be helped by this therapy.
thermore, with the proliferation of numerous It has become fairly well established that
interdisciplinary pain clinics all over the world, psychological input is a necessary component
the application of CBT techniques has become of multidisciplinary treatment for chronic
widespread. Although there is now consider- pain, and in particular, cognitive-behavioral
able evidence that individuals with chronic pain approaches. However, for many people suffer-
who participate in CBT programs can improve ing with chronic pain, CBT is not available,
their psychological and physical functioning, or access to this treatment modality is limited

(Turk & Okifuji 2002). One particularly salient facilities, telemental health technologies can be
reason for limited patient access to CBT is that used to connect directly to the patient’s home.
many individuals live in rural, remote locations The Department of Veterans Affairs (VA) has
away from the metropolitan areas where the been a major force in mental health innovation
vast majority of healthcare centers offering for nearly a century (Godleski et al. 2001), and
multidisciplinary treatment for chronic pain its leadership role in telemental health since
are located. The Institute of Medicine’s Com- the 1960s has established the VA as one of
mittee on the Future of Rural Healthcare has the largest telemedicine delivery systems in the
estimated that nearly one-fourth of Americans world. Accordingly, in fiscal year 2007, more
live in rural areas (Inst. Med. Comm. Future than 45,000 telemental health visits occurred,
Rural Health Care 2005), and obtaining access primarily with clinicians at 76 VA hospital facil-
to quality healthcare can be a challenge for ities, delivering care to more than 24,000 men-
these individuals. In a recent study compar- tal health patients at 242 remote community-
ing outpatient medical service utilization of based outpatient clinics. In addition, more
Medicare-enrolled rural veterans with their than 1,200 patients received home telemental
urban counterparts, veterans living in rural healthcare delivered through the use of home
settings used significantly fewer Veterans videophones and in-home messaging devices in
Health Administration and Medicare-funded approximately 5,000 encounters (Godleski et al.
primary care, specialist care, and mental health 2008). Preliminary data suggest that videocon-
care visits (Weeks et al. 2005). Further, it seems ferencing is an innovative and efficacious means
that with poor access to primary care, rural of delivering psychological treatment to rural
veterans may substitute emergency room visits patients suffering from cancer pain (Shepherd
for routine care. Such limited access and use et al. 2006). Further, a recent literature review
of healthcare by individuals living in rural lo- concluded that videoconferencing may be a fea-
cations has compelled new research examining sible and effective alternative to traditional ser-
efforts to deliver treatments such as CBT to pa- vices and may hold benefits such as high rates
tients in rural locations where they reside rather of patient satisfaction, improved access to care,
than require patients to travel to an urban improved attendance rates, and cost reductions
healthcare center. For this purpose, Internet- to the patient (Sato et al. 2009). These prelimi-
and telephone-based intervention tools are nary positive results provide a firm basis to con-
being designed to meet the goal of increased duct a randomized controlled trial of face-to-
access to healthcare for rural patients in need of face interaction versus videoconferencing for
CBT for chronic pain management (Buhrman the delivery of CBT for chronic pain manage-
et al. 2004, Naylor et al. 2008). Preliminary ment, and current efforts to do so are under way.
evidence has shown that both the Internet
and the telephone can be effective means for
the delivery of variations of CBT; however, ACCEPTANCE AND
additional research is needed comparing these COMMITMENT THERAPY
technologies with traditional face-to-face Acceptance and commitment therapy (ACT)
therapy via superiority/noninferiority trials. (Hayes et al. 1999) is an acceptance- and
Perhaps one of the most recent advance- mindfulness-based psychotherapeutic inter-
ments in treatment delivery to rural patients vention that can be applied to many clinical dis-
involves the use of videoconferencing technol- orders, including chronic pain. ACT is based on
ogy to deliver psychosocial pain care. Video- relational frame theory, a comprehensive the-
conferencing involves the delivery of care from ory of language and cognition that is framed as
a central location to a patient at a remote clin- an offshoot of behavior analysis (Hayes et al.
ical site via real-time video feeds. In addition 2001). ACT differs from traditional CBT in
to videoconferencing between two healthcare that rather than trying to teach people to better

control their thoughts, feelings, sensations, When patients find their pain unacceptable,
memories and other private events, ACT em- they are likely to attempt to avoid it at all
phasizes observing thoughts and feelings as they costs and seek readily available interventions
are, without trying to change them, and behav- to reduce or eliminate it. These efforts may
ing in ways consistent with valued goals and not be in their best interest if the consequences
life directions. The core conception of ACT include no reductions in pain and many missed
is that psychological suffering is usually caused opportunities for more satisfying and produc-
by the interface between human language and tive functioning. From this conceptualization
cognition and the control of human behavior by came much of the research examining the ac-
direct experience. Psychological inflexibility is ceptance of pain, the rationale being that some
argued to emerge from experiential avoidance, patients may achieve better overall adjustment
cognitive entanglement, attachment of a con- to chronic pain if they reduce their avoidance
ceptualized self, loss of contact with the present, and other attempts to control pain, accept
and the resulting failure to take needed be- it, and direct their efforts toward goals they
havioral steps in accordance with core values. can achieve. As a result, several studies have
Therefore, one of the primary goals of ACT now shown that greater acceptance of pain is
is to promote psychological flexibility, which associated with reports of lower pain intensity,
means contacting the present moment fully less pain-related anxiety and avoidance, less
as a conscious human being, and based upon depression, less physical and psychosocial
what the situation affords, changing or persist- disability, greater physical and social ability,
ing in behavior in the service of chosen values. and better work status (McCracken 1998,
ACT has shown promising results in several McCracken & Velleman 2010, McCracken &
recent studies examining the benefits of ACT Zhao-O’Brien 2010, Vowles & McCracken
for people suffering with chronic pain (Dahl & 2008). Also, acceptance of pain was found to
Lundgren 2006, McCracken et al. 2004, be a significant predictor of adjustment on
Robinson et al. 2004). several measures of patient function, indepen-
The basic premise of ACT as applied to dent of perceived pain intensity (McCracken
chronic pain is that while pain indeed hurts, it 1998).
is an individual’s struggle with pain that causes While developing their Chronic Pain Ac-
suffering (Dahl & Lundgren 2006). The pain ceptance Questionnaire (CPAQ), McCracken
sensation itself is an adaptive reflex serving the and colleagues (2004) showed that two primary
function of alerting us to danger, tissue damage, aspects of pain acceptance are important:
or the threat of such damage. The noxious sen- (a) willingness to experience pain and (b)
sation of pain is critical for our survival. Like- engagement in valued life activities despite
wise, the same applies to emotional pain, such as the pain experience. Of particular note, this
the sadness and despair often experienced after study showed that acceptance of pain was not
the death of a loved one or the loss of a rela- correlated with pain intensity, which suggests
tionship. It is natural and necessary to experi- it was not simply those persons with less
ence such pain in the bereavement process in pain who were more willing to accept pain.
order to heal and move on with life. In the case In addition, laboratory studies with clinical
of chronic pain, causal and maintaining factors and nonclinical populations have shown that
may be unclear, and efforts to reduce or elim- acceptance techniques used in ACT (such as
inate the pain may be unsuccessful. For these observing and accepting thoughts and feelings
reasons, continuing attempts to control pain as they are) produce greater tolerance of acute
may be maladaptive, especially if they cause un- pain and discomfort than do more traditional
wanted side effects or prevent participation in techniques of pain control, such as distraction
valued activities, such as those involving work, and cognitive restructuring (Gutierrez et al.
family, or community (McCracken et al. 2004). 2004, Levitt et al. 2004).

In ACT and other mindfulness-based eficial, and examine the factors that maintain
approaches, pain is seen as an inevitable part of avoidance of pain and prevent acceptance.
living that can be accepted, whereas struggling
to avoid inescapable pain causes more suffering.
The more an individual struggles to escape the SPECIAL TOPICS
pain, the more he or she suffers. The aim of
Disparities and Inequalities in Pain
ACT in the treatment of chronic pain is to help
the individual to develop greater psychological
Experience, Assessment,
flexibility in the presence of thoughts, feelings,
and Treatment
and behaviors associated with pain. Some of Despite increased attention, educational inter-
the most recent research examining ACT ventions, and standards aimed at optimizing
for chronic pain management has focused pain management, the literature continues
on enhancing psychological flexibility. For to report disparities and inequalities in the

instance, several studies of people with chronic treatment of pain across various patient char-
pain provide support for the role of various acteristics, including race/ethnic background
components of psychological flexibility in their (Anderson et al. 2009, Green et al. 2003a),
well-being and daily functioning, including the age (Fine 2009), and cognitive status with or
processes of acceptance of pain (Nicholas & without ability to communicate (Bachino et al.
Asghari 2006), mindfulness (McCracken et al. 2001). A brief review of the literature follows,
2007), value-based action (McCracken & Yang with the emphasis on pain treatment disparities
2006), and general psychological flexibility and the potential role psychologists can play in
itself (McCracken & Vowles 2007). Another modifying such disparities.
recent study provided evidence for the negative Psychologists are frequently involved in
impact of psychological inflexibility, including the treatment of chronic pain conditions; aside
components of avoidance and cognitive fusion, from anesthesiologists, they represent the
further providing implicit support for the adap- largest constituency of any profession in the
tive role of psychological flexibility (Wicksell American Pain Society (Am. Pain Soc. 2009).
et al. 2008). Based on data collected from pa- Accordingly, we believe there are several com-
tients in specialist and primary care treatment pelling reasons why disparities and inequalities
settings, processes of psychological flexibility in the evaluation and treatment of pain should
appear to participate in important ways in wider be of particular concern for psychologists.
processes of interaction between bodily sensa- First, psychologists often assume the unique
tion of pain, emotional experiences, thoughts, and challenging role of addressing psychosocial
social influences, and the daily life activities of factors that contribute to pain-related suffering
those with chronic pain. In doing so it appears and disability or that affect response to treat-
that they may significantly influence patient ment. Therefore, psychologists regularly face
outcomes, such as level of emotional suffering, issues thought to contribute to inequalities in
physical and social functioning, and healthcare pain treatment: socioeconomic factors that can
use. It appears that these data underlie the impact access to care, educational factors that
need to develop enhanced psychological treat- can affect a patient’s health management, and
ments that teach acceptance, mindfulness, and obstacles to patient-provider communication
willingness as alternative coping strategies that that interfere with case management. Second,
promote psychological flexibility. Additional pain-related disparities among potentially
research and ACT-based clinical applications vulnerable populations are not just limited
will be needed to further examine the role of to clinical phenomena, but can also be found
acceptance in adjustment to chronic pain, show throughout much of the research conducted by
for whom and under what circumstances the psychologists. For instance, experimental stud-
acceptance of the pain experience may be ben- ies of pain perception assessing psychosocial

and psychophysiological processes that may perspectives on disparity and inequality in pain
contribute to individuals’ responses to pain treatment as a function of ethnic background.
have demonstrated some significant differences Race and ethnicity have historically been used
across groups (e.g., ethnic, age, and cognitive interchangeably and considered by many to
status) with respect to their tolerance (i.e., mean the same thing. However, more recent
pain perception) as well as their psychological conceptualization has led to the assertion that
responses to this pain (i.e., pain coping) the terms represent distinct but overlapping
(Campbell et al. 2005, Gibson & Farrell constructs. Race is a term used to distinguish
2004). However, finding appropriate means for population groups that are related by common
translating experimental results demonstrating descent or heredity and, therefore, primarily
pain-related group differences into clinical refers to biological characteristics reflected
applications to address inequality in pain man- in generally distinct physical characteristics
agement remains a challenge for psychologists, (Edwards et al. 2001, Tait & Chibnall 2005).
and additional efforts are warranted. A final rea- By contrast, ethnicity refers to membership in
son why disparities in evaluation and treatment a group that is defined by culture, heritage, na-
should be of particular concern to psychologists tional origin, and shared beliefs (Edwards et al.
involves the highly subjective manner by which 2001). Given the considerable contributions of
individuals’ pain experience is often assessed psychosocial factors to the construct of ethnic-
(e.g., tell me about your pain). Although a ity rather than race, we use the term ethnicity
number of factors contribute to the problem of when describing how an individual’s back-
inadequate pain treatment for vulnerable pop- ground and identity can impact pain disparities.
ulations (Green et al. 2003a), pain assessment is Recently, several comprehensive reviews of
arguably the most crucial, as it is central to both the literature have examined ethnic disparities
treatment planning and to tracking treatment and inequalities in pain, and all have demon-
progress. Recent studies examining factors strated reliable differences across experimental
that influence pain assessment have reported and clinical settings (Anderson et al. 2009,
shortcomings in pain assessment as a function Green et al. 2003a, Tait & Chibnall 2005).
of ethnic background and age. For example, a Early laboratory studies of experimentally in-
multicenter study found that minority cancer duced pain have documented ethnic differences
patients were more likely to have pain under- in pain perception and responses; although
estimated than were white patients (Cleeland older studies did not exhibit the methodolog-
et al. 1997). Anderson and colleagues (2002) re- ical rigor of more recent research, their results
ported 74% and 64% of African American and are generally consistent with more modern
Hispanic patients, respectively, had their pain investigations. For example, in the mid-1940s,
underestimated by their care providers. Simi- Chapman & Jones (1944) reported lower heat
larly, pain assessment in the elderly is poor rela- pain thresholds and tolerances among African
tive to younger populations (Hadjistavropoulos American study participants compared with
et al. 2007), and elderly patients are also at non-Hispanic white participants. Similarly, a
risk of being undertreated for pain (Cavalieri, more recent study by Campbell and colleagues
2002). Disparities in pain assessment are likely (2005) examined responses to multiple pain
attributable to multiple factors, of which patient tasks, including pressure pain, heat pain,
and provider beliefs about pain and lack of stan- ischemic pain, and cold pressor pain, in African
dardized assessment instruments is foremost. Americans and non-Hispanic whites. Their re-
sults indicate significantly lower tolerances for
heat pain, ischemic pain, and cold pressor pain
Ethnicity and Race in African Americans. In addition, ratings of the
It is important to clarify the use of the terms race unpleasantness and intensity of suprathreshold
and ethnicity prior to addressing psychological heat pain stimuli were higher among African

Americans. The experimental literature shows by non-Hispanic whites, the coping strategies
reasonably consistent differences between reported by these African American individuals
African Americans and Caucasians regarding are often associated with poorer adjustment to
pain perception; however, limited data are pain (DeGood & Tait 2001).
available comparing other ethnic groups. Fu- Given previous studies that have demon-
ture research would benefit from the inclusion strated differences in pain coping strategies as
of participants from a diverse array of ethnic a function of ethnic background, the question
backgrounds in an effort to further elucidate arises, what are the factors that contribute to
whether disparities in pain perception might differences in coping? In an attempt to answer
be better attributed to certain esoteric features this question, investigators have asserted that
of individuals’ ethnic identity, majority versus stresses endemic to racism and minority status
minority status, or both. Although pain percep- contribute significantly to coping difficulties
tion differences are reasonably well established at both psychological and physiologic levels
between African Americans and non-Hispanic (Brown 2003, Clark et al. 1999, Williams
whites at this time, the implications for treat- et al. 1997). Others contend that the clinical
ment, including inequalities in treatment, are differences in adjustment may reflect a lack of
sources of ongoing debate. trust of medical professionals among African
Relative to experimental pain studies, Americans (Edwards et al. 2001) or low expec-
studies of patients with clinical pain may yield tations of benefit from treatment (Green et al.
additional and greater understanding of factors 2003b, Ibrahim et al. 2002), either of which
that mediate potential differences in response to may produce reluctance to seek or maintain
pain treatment as a function of ethnicity. Ethnic treatment. The vast majority of investigators
differences in adjustment to pain have received have noted significant methodological prob-
less attention than differences in pain percep- lems associated with the study of race and
tion, although preliminary results are generally ethnicity, including high levels of covariation
consistent. For example, African Americans with socioeconomic status (SES). Of the previ-
have demonstrated more disability associated ous studies that have examined pain coping as
with pain than have non-Hispanic whites a function of ethnicity, few have incorporated
across several clinical presentations, including indicators of SES. Notably, it has been shown
general chronic pain conditions (McCracken that when SES was controlled, some of the
et al. 2001), chronic low back pain (Selim et al. racial and ethnic differences in coping were no
2001), and arthritis (Song et al. 2006). There is longer significant ( Jordan et al. 1998).
also additional evidence that African Americans Despite the limitations of the research, the
may exhibit more affective distress in response pain adjustment literature suggests that a tar-
to pain, including anxiety and depression (Riley geted psychological assessment of the minority
et al. 2002). Differential patterns of coping have pain patient, with an emphasis on coping skills,
been suggested to be one potential mechanism may be beneficial and perhaps relevant to
explaining why African Americans may expe- reducing disparities. Patient reliance on passive
rience more emotional distress and disability strategies, for example, would lead to clinical
than their non-Hispanic white counterparts. interventions to facilitate more adaptive (i.e.,
Several existing studies have shown that active) coping tactics. Similarly, educational
African Americans make more frequent use of interventions could be used to foster realistic
passive coping strategies (e.g., catastrophizing, treatment expectations among minorities.
praying, and/or hoping) than do non-Hispanic In light of the evidence suggesting greater
whites, who are more likely to ignore pain, use difficulties with adjustment among African
active coping self-statements, and feel more in Americans, attention to the affective response
control of their pain (Edwards et al. 2005, Tan to pain in minority patients may also yield
et al. 2005). Relative to the strategies engaged benefit.

Age-Related Issues self-report tools are easy to administer, and

many developmentally appropriate pain scales
Pediatric pain. Children and adults may
are available for children 4 years of age and
experience different pain qualities from the
older. Specific assessment tools have been de-
same pain-inducing stimulus and may react
veloped to infer pain from behaviors or physical
differently depending on their personalities,
signs in very young or disabled children unable
learning, expectations, and previous pain
to report their own pain (Breau et al. 2002,
experiences. The current lack of objective
Finley & McGrath 1998, Franck et al. 2000,
knowledge about pain in children is under-
Hunt et al. 2004). If these proven methods of
standable in light of the evolution of the
asking children or observing pain signs were
scientific study of pain. Pain research efforts
used routinely, much of children’s pain could
emphasizing demographic factors such as age
be promptly recognized and effectively treated.
while incorporating a biopsychosocial model of
Over the past several decades, research

investigation are relatively modest; in addition,
into the nature, assessment, and treatment

initial studies were conducted with adults, who
of children’s pain has grown exponentially
could communicate their subjective experience
(Eccleston et al. 2002). Further, it is now
of pain, or in animals, in which nerve pathways
generally accepted that infants and children
could be directly monitored. It was implicitly
can feel pain. Pain assessment instruments with
assumed that children were either unable to
good psychometric properties are available for
communicate their experiences of pain in a re-
use in infants, toddlers, and children, including
liable manner or that they did not perceive pain
those with communication deficits and other
in the same manner as adults. Also, much infor-
impairments. Numerous drug and nondrug
mation on the development of valid methods
interventions have been developed and tested
for measuring pain, as well as the effectiveness
in a variety of clinical populations and settings.
of different techniques for pain control, has
However, inadequate prevention and relief
been obtained in studies in which controlled
of children’s pain are still widespread, an
levels of noxious stimuli were administered to
issue routinely addressed by the International
healthy adult volunteers. Since ethical concerns
Association for the Study of Pain Special
have historically limited the use of children in
Interest Group on pain in childhood. Com-
these experimental studies, there has been a
mentary from this and other similar groups
lack of basic research on pediatric pain.
has indicated that pain perception in children
In a clinical setting, children’s pain can be
reflects the complex, moment-to-moment
difficult to recognize and fully appreciate. Chil-
integration of affective, behavioral, cognitive,
dren may lack the ability or vocabulary to relate
and physiological components within a devel-
or describe their pain in a way that their care-
opmental trajectory and a sociocultural context
givers easily understand. Additionally, children
(Cohen 2007). Thus, pain management may be
often make use of coping strategies such as play
optimized when all components of the child’s
and sleep to deal with pain, which can mislead
pain experience are evaluated and addressed. A
the untrained observer to falsely conclude the
variety of psychological interventions are de-
child is not in pain. A child’s understanding
scribed in the research and clinical literatures,
and descriptions of pain naturally depend on
including distraction, play therapy, psycho-
the child’s age, cognitive level, and previous
educational approaches, hypnosis, biofeedback,
pain experience. Although clinical interviews
and guided imagery. However, it is important
are ideally suited for learning about the sen-
to note that although preliminary evidence
sory characteristics of pain and contributing
suggests possible benefits of various psycholog-
cognitive, behavioral, and emotional factors,
ical interventions for the treatment of pediatric
clinicians should also use a simple rating scale
pain, only a select few interventions qualify as
to document a child’s pain intensity. Pain
empirically validated and efficacious according

to the American Psychological Association’s importance to continue to synthesize scientific

framework for evidence-based treatments. evidence that identifies those psychological
Recent reports (Liossi et al. 2006) and meta- interventions whose widespread and consistent
analyses (Powers 1999) have suggested that use is justified. Although controlled clinical
CBT and hypnosis are effective in the manage- studies on psychological analgesia have sub-
ment of chronic pain of young patients, par- stantial room for improvement, the available
ticularly in the treatment of headaches. When evidence indicates that both CBT and hypnosis
applied to children, one of the defining com- are useful in acute and chronic pain. Recent
ponents of CBT involves helping the young investigation has produced preliminary support
person to recognize unhelpful or destructive for the use of virtual reality for helping children
patterns of thinking (with their corresponding to manage and cope with their pain (Dahlquist
ways of feeling and behaving), then modifying et al. 2009). However, innovations in pediatric
or replacing these with more realistic or pain management need not be “high-tech” in
adaptive ones. Eccleston and colleagues (2002) order to have an impact. It has been suggested
conducted a systematic review and subset meta- that children may be more adept than adults at
analysis of published randomized controlled using nondrug therapies (Brown et al. 2005),
trials of psychological therapies for children presumably because they are usually less biased
with chronic pain. A total of 18 studies—6 con- than adults about the potential efficacy of
ducted in community (school) settings—met these interventions. Healthcare providers,
criteria for inclusion in the review. Meta- particularly psychologists, can teach children a
analysis was possible for 12 headache trials and few basic attention and distraction methods to
1 trial of recurrent abdominal pain. Results reduce pain and guide families to recognize the
from these trials overwhelmingly indicate that particular circumstances that exacerbate pain
the psychological treatments examined were ef- and distress. Together, health professionals and
ficacious in reducing the pain of headache. The parents can relieve a child’s pain not only by ad-
authors found that psychological treatments, ministering analgesic drugs but also by helping
particularly relaxation and CBT, were highly children to understand the situation and allow-
effective in reducing the severity and frequency ing them to make choices and to gain whatever
of chronic pain in children and proposed that control is possible within the setting. The time
there is a strong case for these treatments to has come to give priority to bridging the gaps
be offered to patients with headache as part of between theoretical developments, evidence
routine care. Unfortunately, the authors also derived from clinical research, and current
noted that there was insufficient evidence to clinical practice in pediatric pain management.
judge the effectiveness of psychological thera-
pies in improving mood, function, or disability Pain in older adults. A major shift in the
associated with chronic pain in children and age distribution of the world’s population is
adolescents and stressed the ongoing need for currently under way. In developed countries, it
well-designed and comprehensively reported has been speculated that by the year 2050, the
randomized controlled trials of psychological percentage of the population over 65 years old
therapies for nonheadache chronic pain. will rise from 17.5% to 36.3%, and the over-80
Psychological interventions for pediatric age segment will more than triple (U.S. Bur.
pain control have garnered increasing popu- Census 2010). Older adults have some of the
larity and attention in some pediatric clinics highest rates of surgical procedures (Deyo
and children’s hospitals throughout the nation; et al. 2005) and the highest incidence of painful
however, their availability and application diseases. The prevalence of persistent pain
remains sparse and inconsistent. Pediatric pain climbs steadily with advancing age until at least
is a healthcare issue that results in significant the seventh decade of life (Thomas et al. 2004),
suffering and financial cost, so it is of the utmost often exceeding 50% in community-based

samples ( Jones & Macfarlane 2005) and up to these various systems come to influence the
80% for those individuals in residential care pain experience of older adults remains un-
(Parmelee et al. 1993). Further, pain in the clear. To address these issues, recent interest in
elderly is often unrecognized and undertreated. pain during older age has generated a steadily
Ineffective pain management can have a signifi- growing body of evidence on age differences in
cant impact on the quality of life of older adults, the phenomenology of the pain experience and
leading to depression, social isolation, and a its biopsychosocial constituents in experimental
loss of function (Cavalieri 2002). Thus, the and clinical settings. Further, age-appropriate
need for appropriate pain care in older persons pain assessment tools and controlled outcome
is urgent. Proper assessment of older adults studies of various pain management options in
requires clinicians to regularly ask about the older adults have also received greater attention
presence of pain and be skillful with strategies in recent years.
for evaluating the frequency and intensity of Experimental pain research involving older
pain. Assessment of pain in older adults with adults has shown a modest but demonstrable
dementia and communication disorders is age-related decline in pain sensitivity to mild
especially challenging; this topic is addressed in noxious stimuli (Edwards 2005). A recent meta-
greater detail below. It has been suggested that analysis of studies examining pain thresholds
effective pain management in elderly patients revealed that the pain threshold of the average
should include both pharmacologic and non- older adult would belong in the top 15% of val-
pharmacologic strategies (Ersek et al. 2003, ues seen in younger adults (Gibson 2003). The
Katz 2007). Pharmacologic strategies call for increase in pain perception threshold and the
administration of nonopioid analgesics, opioid widespread change in the structure and function
analgesics, and adjuvant medication. Polyphar- of peripheral and central nervous system noci-
macy, drug-drug and drug-disease interactions, ceptive pathways may place the older person at
age-associated changes in drug metabolism, greater risk of injury. Consistent with clinical
and the high frequency of adverse drug reac- studies of acute pain, this higher threshold may
tions need to be carefully considered when the also be associated with under-reporting of mild
decision is made to use medications in this pop- pain symptoms, which could increase the risk
ulation. Nonpharmacologic approaches such of undiagnosed disease or injury. In contrast
as cognitive-behavioral therapy, education, os- to the apparent reduced sensitivity to mildly
teopathic manipulative treatment, and exercise painful stimuli, experimental and clinical stud-
should be applied in addition to pharmacologic ies have documented an increased vulnerability
therapy. Using a team approach and incorpo- to severe or persistent pain (Gibson 2007). A
rating principles of pain management can effec- meta-analysis of pain-tolerance studies revealed
tively provide good analgesia for older adults. an age-related decline in the ability to tolerate
Current concepts of pain emphasize the im- severe pain (Gibson 2003). Similarly, the effec-
portance of the interrelations between biologi- tiveness of descending pain-inhibitory mech-
cal, psychological, and social factors in shaping anisms, particularly their endogenous opioid
the pain experience (Gatchel et al. 2007). The component, also appears to deteriorate with ad-
process of aging is associated with widespread vancing age (Edwards et al. 2003). The reduced
and pervasive changes in most biological sys- efficacy of endogenous analgesic systems, a de-
tems, including the nervous, musculoskeletal, creased tolerance of pain, and the slower reso-
immune, and neuroendocrine systems, as well lution of post-injury hyperalgesia may make it
as in psychological dimensions, such as atti- more difficult for the older adult to cope once
tudes, beliefs, coping resources, and mood, and injury has occurred. Based upon these results,
in social functioning as it relates to social roles, clinicians must be aware of the increased risk of,
employment, and spousal bereavement. How and susceptibility to, severe or persistent pain
the relations between the aging process and in older adults and make strenuous efforts to

provide adequate pain relief for this vulnerable thought to indicate pain. For instance, combi-
group. nations of behaviors such as facial grimacing or
Comprehensive clinical practice guidelines wincing, negative vocalizations, specific body
on the assessment and management of persis- languages (rubbing, guarding, or restlessness),
tent pain in older adults are now available (Am. altered breathing, or physiological signs such
Geriatr. Soc. 2002). Although these guidelines as increased heart rate or blood pressure can
acknowledge the relative lack of age-specific all be scored to provide an index of likely pain
evidence, all are tailored to the special needs intensity. These scales add to the battery of
of older adults and provide a useful and de- existing pain-assessment tools and represent a
tailed framework to help guide clinical practice. formidable step toward improving the quality of
Both assessment and treatment of pain in elder pain management for this highly dependent and
adults remain a challenge and involve complex- vulnerable group. Nonetheless, much remains
ities not encountered as frequently in younger to be done, and psychologists have the poten-
populations. Most pain-assessment instruments tial to contribute to the refinement of existing

have not been validated in an elderly popula- pain-assessment tools and develop new instru-
tion, and a higher incidence of side effects in ments that more specifically address the needs
older adults makes pharmacological interven- of patients with cognitive impairment who may
tions more difficult (Zwakhalen et al. 2006). not be able to communicate said needs.
For these reasons, psychologists may be able
to meaningfully influence pain treatment in the
elderly via research on age-appropriate evalua- CONCLUSION
tion of pain and delivery of nonpharmacological In the years following the delineation of
pain-management interventions such as those the gate control theory of pain, the field of
addressed in this review (e.g., relaxation and psychology has been at the forefront of the sci-
CBT). entific investigation of pain, the development
Further complicating the issue of pain as- of instruments to assess the multidimensional
sessment and treatment for the elderly are the nature of pain, the development and applica-
difficulties faced by the clinician attempting tion of various treatment modalities that target
to deliver services to certain older populations the complex nature of the pain experience,
such as those in residential aged care, those and the advocacy of policies and practices that
with sensory loss (impaired vision or hearing), seek to reduce disparities in the assessment and
or those with cognitive impairment. Self-report treatment of pain. There remains significant
pain-assessment tools are still a viable option work to be done on each of these fronts, and
for many older persons with mild to moderate in light of recent evidence that suggests an
dementia; however, a substantial proportion of increase in reports of common pain conditions
elderly people living in institutions are unable (Sinnott & Wagner 2009), it is crucial that the
to understand and answer even simple yes/no field continue to capitalize on the momentum
questions, and therefore cannot self-report pain that has carried us to this point. In moving for-
(Reynolds et al. 2008). In the advanced stages of ward, it is important that we remain committed
dementia, when the elderly persons are severely to solid empirical standards as we seek to
cognitively impaired, other methods of assess- develop new treatment modalities and delivery
ment, such as behavioral pain assessment meth- methods that reach groups that are currently
ods and observational tools, become more use- underserved by our existing standards of care.
ful and necessary. Over the past several years, Central to making this happen is the dissem-
new observer-rated behavioral pain-assessment ination of information about psychologically
tools have been developed for specific use in based interventions to medical providers who
those with cognitive impairment. Most instru- confront the challenges of chronic pain on
ments grade the presence of various behaviors the front lines day after day. It is only by

broadening the perspective that providers take who lives with pain. We must continue our
in their conceptualization of a patient suffering work to build upon our current knowledge base
from chronic pain that we can increase access and repertoire of psychosocial interventions,
to those patients who need our services the ensuring that what we do informs, and is
most. As a field, psychology has developed an informed by, the clinical challenges that are
impressive array of tools and techniques to help confronted by clinicians across settings, across
us understand not just pain, but also the person disciplines, and across clinical populations.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review. The views expressed in this article
are those of the authors and do not necessarily reflect the position or policy of the Department of
Veterans Affairs or the United States government.
ACKNOWLEDGMENTS
This material is based upon work supported by grants from the Department of Veterans Affairs,
Veterans Health Administration, Office of Research and Development, Health Services Research
and Development Service (REA 08-266) and Rehabilitation Research & Development (Career
Development Award B6040M).
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CP07-FrontMatter ARI 8 March 2011 4:13
Annual Review of
Clinical Psychology
Volume 7, 2011
Contents
The Origins and Current Status of Behavioral Activation Treatments

for Depression
Sona Dimidjian, Manuel Barrera Jr., Christopher Martell, Ricardo F. Muñoz,

and Peter M. Lewinsohn p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
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Open, Aware, and Active: Contextual Approaches as an Emerging
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The Economic Analysis of Prevention in Mental Health Programs
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The Nature and Significance of Memory Disturbance in Posttraumatic
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Martin E. Franklin and Edna B. Foa p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 229
Acute Stress Disorder Revisited
Etzel Cardeña and Eve Carlson p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 245
Personality and Depression: Explanatory Models and Review
of the Evidence
Daniel N. Klein, Roman Kotov, and Sara J. Bufferd p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 269
vi
CP07-FrontMatter ARI 8 March 2011 4:13
Sleep and Circadian Functioning: Critical Mechanisms

in the Mood Disorders?
Allison G. Harvey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 297
Personality Disorders in Later Life: Questions About the
Measurement, Course, and Impact of Disorders
Thomas F. Oltmanns and Steve Balsis p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 321
Efficacy Studies to Large-Scale Transport: The Development and
Validation of Multisystemic Therapy Programs
Scott W. Henggeler p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 351
Gene-Environment Interaction in Psychological Traits and Disorders
Danielle M. Dick p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 383

Psychological Treatment of Chronic Pain

Robert D. Kerns, John Sellinger, and Burel R. Goodin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 411
Understanding and Treating Insomnia
Richard R. Bootzin and Dana R. Epstein p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 435
Psychologists and Detainee Interrogations: Key Decisions,
Opportunities Lost, and Lessons Learned
Kenneth S. Pope p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 459
Disordered Gambling: Etiology, Trajectory,
and Clinical Considerations
Howard J. Shaffer and Ryan Martin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 483
Resilience to Loss and Potential Trauma
George A. Bonanno, Maren Westphal, and Anthony D. Mancini p p p p p p p p p p p p p p p p p p p p p p p 511
Indexes
Cumulative Index of Contributing Authors, Volumes 1–7 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 537

Cumulative Index of Chapter Titles, Volumes 1–7 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 540
Errata
An online log of corrections to Annual Review of Clinical Psychology articles may be

found at http://clinpsy.annualreviews.org
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The Origins and Current Status of Behavioral Activation Treatments

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Psychological Treatment of Chronic Pain

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