Pain, 3 (1977) ‘L91-292 29%

a Else~ier/Nort~~-Holiand Biomedical Press

Book Review
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Behavioral Methods for Chronic Pain and Illness, W.E. Fordyce, C.V. Mosby Company,
St. Louis, MO., 1676, ix + 236 pp.

Psychological methods have been developed in recent years in the attempt

to control pain in patients who have not been helped by the traditional
medical approaches. Back pain, for example, may persist after successive
disc operations, rhizotomies, cordotomies, and so forth. The patient often
becomes dependent on drugs, tends to diminish normal physical activities
of a91 kinds, slips slowly into depression and lethargy, and thus becomes
a problem to the family, to the physician, and to society (who often pays a
substantial portion of the medical bill).
It is the treatment of this kind of patient that is th.e topic of Fordyce’s
book. Mthough the title of the book is broad, the book rapidly focuses onto
the method of operant conditioning to control pain. Fordyce developed this
method and has achieved recognition as a pioneer in the field of behavioral
methodollogy for pain control.
T?e book comprises 3 sections: fl) . conceptual background, (2) evaluation
and (3) treatment. The first section provides an excellent overview of the
field of ope:rant conditioning as wel? as a detailed description of the teeh-
niques that are employed in the “acquisition of operant pain”. What
Fordyce says, in essence, is that people are often reinforced for having pain.
They get attention and sympathy, they don’t have t.o do jobs they don’t
like, they get medicines with impressive-sounding names, and they are often
treated with a degree of respect they never had when they were lwell. In this
way, the pain and other behavior patterns associated with it [such as an
abnormal gait) are reinforced. The task of the behavior therapist, then is
to remove the reinforcements, to try to stop the patient from complaining
of pain, and to induce the patient to resume nonnal behavior patterns
ranging from gait to general day-to-day activities.
Fordyce provides a thorough description of his procedures to re-tr:3in the
patient who suffers chronic pain. The exposition is clear, and the reader
learns exactly what is done, how it is done, the time-course of treatment,
how to collect data, what kinds of problems are encountered, and SC on.
Every aspect of the method is exemplified -fii.& a@prc;priate case h.is1,o2%%
and detailed tables and graphs. The ca:ii;espresented are impressitie. M&r the
operant procedure, the patients are more active, complain less, t&t? fess
drugs, work, and generally lead more normal lives. The Teader.! ~EOVJ~~~S is
left with 3 vital questions that still need to be answered.
First, does the patient actudly feel less pain as a result of ,the trf3ining?
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That is, the patient is conditioned to diminish the frequency of certain "pain
behaviors"; but does that mean that the patient feels less pain or simply
learns to complain less or walk more in spite of the pain? Unfortuna!:e!y,
Fordyce dismisses the whole question in a single paragraph, in which h e
implies that the problem is basically philosophical and not one that an
operant conditioning psychologist need be concerned with. However, t h e
problem is too important to be ignored; the failure to come to grips with it
weakens the i~npact of the book.
Second, how does the operant technique compare with other methods,? Is
i~ any better' than social modelling, biofeedback, relaxation training, trans-
cendental meditation, or the simpler "contractual" procedure developed
by Sternbach and his colleagues? Or, for that matter, is it any better than a
"placebo" effect? It is hard to imagine a more powerful "placebo" than the
constant, ma~c;sive attention, sympathy, encouragement, praise, ~md all the
other psychological rewards that are an integr~d part of the complex operant
procedure to diminish "pain behaviors".
Finally, it is evident that the technique is lengthy, expensive, ~ad requires
a large amount of hospital space, time, and equipment. If this were the best
of all possible worlds, this kind of treatment should be available to everyone.
In fact, it is feasible for only a small number of patients, and well..to-do ones
at that. Because of these limitations, it becomes important to determine the
place of a technique such as this in societies that have limited funds for
medical care.
However, when all else fails, as Fordyce points out, the operant condition-
ing technique remains as a hopeiul possibility for the desperate patient. Cer-
tainly, this is a book that should be read ant| critically evaluated by every
psychologist and psychiatrist interested in treai;ing people in pain.

Ronald Melzack