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 Contributors

Rachel V. Aaron, PhD, Seattle Children’s Hospital Research Institute, Seattle, Washington
John G. Arena, PhD, Charlie Norwood VA Medical Center and Department of Psychiatry
and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
Benjamin H. Balderson, PhD, Kaiser Permanente Washington Health
Research Institute, Seattle, Washington
Pat M. Beaupre, PhD, private practice, Redlands, California
Sophie Bergeron, PhD, Department of Psychology, University of Montreal, Montreal,
Quebec, Canada
Dawn C. Buse, PhD, Department of Neurology, Montefiore Medical Center, Bronx, New York
Annmarie Cano, PhD, Department of Psychology, Wayne State University, Detroit, Michigan
Leanne R. Cianfrini, PhD, The Doleys Clinic, Birmingham, Alabama
Howard Cohen, MD, Progressive Pain and Psychiatry Clinic, Dallas, Texas
Serena Corsini‑Munt, PhD, Department of Psychology and Neuroscience, University of Halifax,
Halifax, Nova Scotia, Canada
Beth D. Darnall, PhD, Department of Anesthesiology, Perioperative and Pain Medicine,
Stanford University School of Medicine, Palo Alto, California
Jeroen de Jong, PhD, Department of Rehabilitation, Maastricht University Medical Centre,
Maastricht, The Netherlands
Marlies den Hollander, MSc, Department of Rehabilitation, Maastricht University
Medical Centre, Maastricht, The Netherlands
Jeffrey Dersh, PhD, South Texas Veterans Health Care System, San Antonio, Texas
Daniel M. Doleys, PhD, The Doleys Clinic, Birmingham, Alabama

vii
viii Contributors

Angela Liegey Dougall, PhD, Department of Psychology, University of Texas at Arlington,

Arlington, Texas
Christopher Eccleston, PhD, Department for Health, University of Bath, Bath, United Kingdom;
Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
Emma Fisher, PhD, Seattle Children’s Hospital Research Institute, Seattle, Washington
Noor M. Gajraj, MD, North Texas Center for Pain Management, Plano, Texas
Robert J. Gatchel, PhD, ABPP, Department of Psychology, University of Texas at Arlington,
Arlington, Texas
Thomas Hadjistavropoulos, PhD, ABPP, Department of Psychology and Centre on Aging
and Health, University of Regina, Regina, Saskatchewan, Canada
Ryan Hulla, BA, BS, Department of Psychology, University of Texas at Arlington, Arlington, Texas
Mark A. Ilgen, PhD, VA Center for Clinical Management Research, VA Ann Arbor
Healthcare System, and Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
Mark P. Jensen, PhD, Department of Rehabilitation Medicine, University of Washington,
Seattle, Washington
Francis J. Keefe, PhD, Department of Psychiatry and Behavioral Sciences, Duke University,
Durham, North Carolina
Sarah A. Kelleher, PhD, Department of Psychiatry and Behavioral Sciences, Duke University,
Durham, North Carolina
Edmund Keogh, PhD, Department for Health, University of Bath, Bath, United Kingdom
Robert D. Kerns, PhD, Departments of Psychiatry, Neurology, and Psychology,
Yale University, New Haven, Connecticut; Pain Research, Informatics, Multimorbidities,
and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
Nancy Kishino, OTR/L, West Coast Spine Rehabilitation Center, Riverside, California
Alexander J. Kuka, MA, Department of Psychology, University of Mississippi, Oxford, Mississippi
Steven James Linton, PhD, Center for Health and Medical Psychology, Örebro University,
Örebro, Sweden
Travis I. Lovejoy, PhD, MPH, Center to Improve Veteran Involvement in Care,
VA Portland Health Care System, and Department of Psychiatry, Oregon Health & Science University,
Portland, Oregon
Cindy McGeary, PhD, ABPP, Department of Psychiatry, University of Texas Health Science Center,
San Antonio, Texas
Don McGeary, PhD, ABPP, Department of Psychiatry, University of Texas Health Science Center,
San Antonio, Texas
Lindsey C. McKernan, PhD, Department of Psychiatry and Behavioral Sciences,
Vanderbilt University Medical Center, Nashville, Tennessee
Elena S. Monarch, PhD, Lyme and PANS Treatment Center, Cohasset, Massachusetts
Benjamin J. Morasco, PhD, Center to Improve Veteran Involvement in Care,
VA Portland Health Care System, and Department of Psychiatry, Oregon Health & Science University,
Portland, Oregon
Stephen Morley, PhD (deceased), Leeds Institute of Health Sciences, University of Leeds,
Leeds, United Kingdom
 Contributors ix

Paul Nabity, PhD, Department of Psychiatry, University of Texas Health Science Center,
San Antonio, Texas
Michael R. Nash, PhD, ABPP, Department of Psychology, University of Tennessee,
Knoxville, Tennessee
Diane Novy, PhD, Department of Pain Medicine, University of Texas MD Anderson Cancer Center,
Houston, Texas
John D. Otis, PhD, Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Tonya M. Palermo, PhD, Seattle Children’s Hospital Research Institute, Seattle, Washington
David R. Patterson, PhD, ABPP, Department of Rehabilitation Medicine, University of Washington,
Seattle, Washington
Donald B. Penzien, PhD, Departments of Anesthesiology, Neurology, and Psychiatry,
Wake Forest School of Medicine, Winston‑Salem, North Carolina
Peter B. Polatin, MD, private practice, Dallas, Texas
Sheri D. Pruitt, PhD, private practice, Sacramento, California
Chelsea Ratcliff, PhD, Department of Psychology and Philosophy, Sam Houston State University,
Huntsville, Texas
Christopher T. Ray, PhD, College of Nursing and Health Innovations, University of Texas
at Arlington, Arlington, Texas
Natalie O. Rosen, PhD, Department of Psychology and Neuroscience, Dalhousie University,
Halifax, Nova Scotia, Canada
Meredith E. Rumble, PhD, Department of Psychiatry and Psychology,
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Eric Salas, MA, Department of Psychology, University of Texas at Arlington, Arlington, Texas
Steven H. Sanders, PhD, Chronic Headache Management Program, James A. Haley VA Hospital,
Tampa, Florida
Laura Simons, PhD, Department of Anesthesiology, Perioperative, and Pain Medicine,
Stanford University School of Medicine, Palo Alto, California
Todd A. Smitherman, PhD, Departments of Anesthesiology, Neurology, and Psychiatry,
University of Mississippi, Oxford, Mississippi
Michele Sterling, PhD, Recovery Injury Research Centre, University of Queensland,
Herston, Australia
Anna Wright Stowell, PhD, private practice, Dallas, Texas
John A. Sturgeon, PhD, Department of Anesthesiology and Pain Medicine, University
of Washington, Seattle, Washington
Abby Tabor, PhD, Department for Health, University of Bath, Bath, United Kingdom
James D. Tankersley, MS, Charlie Norwood VA Medical Center, Augusta, Georgia
Hallie Tankha, MEd, Department of Psychology, Wayne State University, Detroit, Michigan
Dennis C. Turk, PhD, Department of Anesthesiology and Pain Medicine,
University of Washington School of Medicine, Seattle, Washington
Alyssa N. Van Denburg, MA, Department of Psychology and Neuroscience, Duke University,
Durham, North Carolina
x Contributors

Miranda A. L. van Tilburg, PhD, Department of Medicine, Division of Gastroenterology

and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Johan W. S. Vlaeyen, PhD, Department of Health Psychology, KU Leuven University,
Leuven, Belgium
Michael Von Korff, ScD, Kaiser Permanente Washington Health Research Institute,
Seattle, Washington
Lynette Watts, BS, Department of Psychology, University of Texas at Arlington, Arlington, Texas
William E. Whitehead, PhD, Center for Functional Gastroenterological and Motility Disorders,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Amanda C. de C. Williams, PhD, Research Department of Clinical, Educational
and Health Psychology, University College London, London, United Kingdom
Laurie D. Wolf, PhD, Orlando VA Medical Center, Orlando, Florida
 Preface
Advances in Psychosocial Approaches
to Treating Patients with Chronic Pain

In the Preface to the first two editions of this volume, we observed that attempts to
treat individuals experiencing persistent pain were closely aligned with how pain was
conceptualized and evaluated. Traditionally, the focus in health care has been on the
cause of the symptoms reported, with the assumption that there is a physical basis for
each of these and, once identified, the source can be eliminated or blocked by medical,
surgical, or other physical interventions (e.g., physical therapy exercises, transcuta-
neous electric nerve stimulation [TENS], and ultrasound). Consequently, assessment
was focused on identifying the physical mechanisms—the “putative cause(s)”—for the
symptoms. In the absence of specific physical pathology to validate the patient’s self-
report, psychological causation is invoked as an explanation; hence the terms “psycho-
genic,” “psychosomatic,” “secondary gain” (i.e., symptom reports that are assumed
to be consciously or nonconsciously motivated to achieve desired outcomes—such as
attention, disability compensation, to obtain positively reinforcing drugs). In the case
of many of the most prevalent chronic pain conditions (e.g., chronic low back pain,
fibromyalgia, headache, whiplash-associated disorders), there is frequently no, or very
limited, objective evidence substantiating the report of pain and its severity. Hence,
the traditional view of persistent pain complaints has been characterized by a simple
dichotomy: The pain report is either somatogenic or psychogenic.
The dichotomous view of pain has been shown in numerous studies to be in-
complete, inadequate, and, in some situations, simply wrong. There is no question
that physical perturbations contribute to symptoms of pain; nor is there any reason-
able argument that psychological factors do not play a part in the symptom reporting.
Moreover, research has convincingly demonstrated that socioeconomic, familial, and
contextual variables play important roles in patients’ acceptance of recommendations
and response to the treatments prescribed, the development of symptom chronicity,
and the maintenance of disability. The balance among physical, psychosocial, and
xi
xii Preface

contextual contributors may vary across individuals, as well as over time within the
same individual. The limitations of the traditional biomedical model may explain why,
despite advances in knowledge and understanding of the neurophysiological mecha-
nisms involved with nociception and pain, there are still no treatments available that
consistently and permanently alleviate pain for all those afflicted (Turk, Wilson, &
Cahana, 2011).
Predictors of chronicity continue to be a major focus of research, and evidence
has consistently revealed that psychosocial variables are better predictors of disability
and response to treatment than physical ones (e.g., Benyon, Hill, Zadurian, & Mallen,
2010; Carragee, Allamin, Miller, & Carragee, 2005; Jarvik et al., 2005). Identifica-
tion of psychosocial predictors holds promise for prevention and early intervention
in order to prevent chronicity and disability. Comprehensive psychosocial assessment
has become accepted as essential prior to surgery and implementation of spinal cord
stimulators and implantable drug-delivery systems.
Exciting developments that have appeared in the literature demonstrate the di-
rect effects of psychological variables on physiological parameters associated with
pain (e.g., Baranto, Hellstrom, Cederlund, Nyman, & Sward, 2009; Jensen et al., 2012;
Kucyi et al., 2014). Psychosocial factors are no longer secondary phenomena; they play
a mechanistic role in the anatomy and physiology of pain. Moreover, the role of psy-
chosocial factors in predicting pain onset, remission, and disability (e.g., Carragee et
al., 2005; Jarvik et al., 2005; Severeijns, Vlaeyen, Kester, & Knottnerus, 2001), and re-
sponse to treatment (e.g., Benyon et al., 2010; Smeets, Vlaeyen, Kester, & Knottnerus,
2006; Thomee et al., 2008), along with concerns about medication coupled with in-
creasing evidence to support the positive outcomes reported for many psychological
interventions (e.g., Eccleston, Palermo, Williams, Lewandowski, & Morley, 2009;
Henschke et al., 2010; Hoffman, Papas, Chatkoff, & Kerns, 2007; Williams, Eccleston,
& Morley, 2012), all support the importance and timeliness of this current volume.
The results of these research studies have contributed to the growing number of calls
for the use of nonpharmacological treatments as alternatives, if not adjuncts, to drugs
(e.g., Buckhardt et al., 2005; Chou et al., 2007; Institute of Medicine, 2011).
More cost-effective and not just clinically effective interventions are being driven
by changes in health care, with concerns about cost containment. The emphasis in
all treatments is on “streamlining” and efficiency, with cost being a critical driver
and outcome consideration. Greater attention is being devoted to the development and
evaluation of advanced technologies (e.g., Web-based, smartphone-delivered applica-
tions), not only to be efficient and to reduce costs, but also potentially to increase
access and to enhance adherence to treatment recommendations and maintenance of
benefits.
Despite the advances noted here and throughout this volume, the traditional medi-
cal model has not, in general, relinquished its firm grasp on the thinking of medical
providers, the health care system, and payers. We would be remiss if we did not ac-
knowledge what we have labeled the “evidence-based paradox.” Despite the growing
calls for evidence, even though there is more clinical and cost evidence for the effec-
tiveness of psychological treatments, relative to any of the alternatives (e.g., Gatchel
& Okifuji, 2006; Hoffman et al., 2007; McCracken & Turk, 2002; Turk & Theodore,
2011), health care providers tend to be resistant to considering psychosocial interven-
 Preface xiii

tions, and payers demonstrate a significant lack of willingness to cover these treat-
ments. We believe this is likely to change given the concerns about the inadequacy, if
not outright pernicious effects, of more traditional medical treatments. Mental health
providers need to keep abreast of the growing literature and to use it as supporting evi-
dence for the services they offer. It will be incumbent on them to demonstrate that they
follow the guidelines described throughout this volume as to the standards of care, and
also cite evidence for the clinical effectiveness and cost-effectiveness of the treatments
they provide, because payers may not be familiar with such evidence.
The state of pain management has not changed significantly in the 15 years since
the publication of the previous edition of this volume. Concerns about misuse and
abuse of medications, however, are leading to a call for better assessment to predict
misuse, and for alternatives to drugs with abuse potential. Also, psychosocial treat-
ments are gaining renewed and growing interest as more than just adjuncts of phar-
macological interventions. Even when medications are indicated, the interrelationship
between somatic and psychosocial factors supports more integrated approaches to
treatment. Indeed, although individuals with diverse chronic pain syndromes have
much in common, there are unique characteristics that require attention specific to the
problem associated with the disease or condition. For example, patients with occupa-
tional injuries have concerns about their ability to return to work; those with amputa-
tions must deal with particular limitations associated with the physical impairments
posed by limb loss; individuals with chronic pelvic pain must deal with problems
associated with sexuality and sexual function; individuals with cancer have to cope
with fears of dying, disfigurement, and dependence; and people who have sustained
injuries in automobile collisions must face their fears of driving, reinjury, and legal
ramifications, all in addition to problems created by the presence of persistent pain.
Thus, despite the fact that the psychosocial treatments described have been used for
some time now, they need to be customized to the unique patient populations and, as
always, to each unique patient.
We have presented many workshops and have given numerous lectures describ-
ing psychological approaches to pain management. We have also received many com-
ments on the two previous editions of this volume. What we have learned is that most
providers are interested in going beyond overviews and academic discussions of the-
ory and general principles. They seek specific and practical strategies and methods
as to how to address their specific patients, and the common problems they confront
in treating the patients in their practices. Whereas some spend the majority of their
time providing services to pain patients, others are increasingly receiving referrals
of patients who have diverse chronic pain disorders, especially given the growing
concerns about medication misuse and abuse by those patients. These providers raise
questions about how to motivate patients; how to most effectively and efficiently
evaluate these patients; how to select the most appropriate treatment options among
the variety of available psychosocial treatment approaches; when and how to involve
their patients’ significant others; what are successful strategies to increase adherence
to treatment recommendations; how to design appropriate homework assignments;
how best to address problems of relapse and flare-ups; and what are good strategies
regarding follow-up; among many others. Essentially, they are seeking not only what
to do but also how to do it. Thus, in planning this edition, as well as the previous
xiv Preface

editions, we had had two driving considerations: (1) to bring together experts and
masterful clinicians who have direct clinical experience with the most common and
difficult chronic pain diagnoses; and (2) to instruct all contributors about the need
to provide specific and practical information and guidance to practitioners who will
be treating patients with these various conditions, regardless of these practitioners’
levels of experience.
In order to facilitate the second consideration and to provide unique value to
readers of this edition, we requested that contributors include in each chapter a text
box that presents practical “Clinical Highlights” of the material covered in a succinct
fashion. Specifically, these boxes address what a provider should keep in mind when
treating patients with the diagnosis covered in the chapter, and when applying any of
the psychosocial treatments described. We directed authors to write these “Clinical
Highlights” boxes to provide a quick review for practitioners, assuming that the chap-
ter may have been read some time prior to actually treating their patients. We hope this
addition will prove to be a particular benefit to readers, and we welcome your com-
ments to improve our future efforts.
Since the publication of the second edition of this volume, there have been as-
tronomical advances in many important areas, such as better understanding of the
genetics and neurophysiology of pain and the experience of living with persistent pain;
the roles and nature of a range of psychosocial, behavioral, and contextual factors in
the onset, maintenance, and exacerbation of pain; responses to, and acceptance of,
treatment; adherence to treatment recommendations; and retention of benefits of treat-
ment over time. Moreover, there is mounting evidence of the clinical effectiveness and
cost-effectiveness of various nonpharmacological treatments as monotherapies and
when combined with more traditional medical interventions. Inertia continues to be
a constraint, and significant challenges remain despite the advances to which we al-
lude here. Few patients are “cured” by the available treatments, and the majority of
patients, regardless of the treatment sophistication, continue to experience some level
of pain and related symptoms with which they will have to learn to live, and to better
“manage.” Thus, we need to move away from an overly simplistic “curative” model of
treatment, toward a more realistic “management” model. This requires courage, self-
control, and a considerable degree of resilience. Psychological approaches may help in
this process of working with patients to enhance their ability to better manage their
lives as effectively as possible, despite the residual symptoms. We focus in this volume
on how to help patients achieve such management outcomes.
Health care is evolving at a dizzying pace. There is greater and greater reliance on
empirically based outcomes that focus not only on cost but also on patient satisfaction
and efficiency, as well as clinical effectiveness. As a consequence, it is no longer pos-
sible to justify treatment based solely on beliefs and assertions. The plural of anecdote
is not accepted as data or evidence anymore. We hope the information presented in this
volume may serve as “antidotes” to these limited and non-data-based anecdotes. But,
as noted earlier, even evidence may not be sufficient without taking into consideration
cost and availability of providers of treatments with demonstrated efficacy.
We have attempted to cover the topics outlined in this edition, with an emphasis
on innovations, expanded knowledge, and opportunities created, all with an eye to-
ward practical clinical utility and efficiency. In an effort to balance “what to do” and
 Preface xv

“how to do it” of various treatment approaches with different painful conditions, and
the need for a rational conceptual basis and demonstrated evidentiary base, we have
organized the volume into three sections.
Part I, Conceptual, Diagnostic, and Methodological Issues (Chapters 1–3), sets
the foundation for the various treatment approaches described. Chapter 1 presents an
integrated biopsychosocial perspective that is critical to understanding chronic pain,
individuals experiencing pain, and the impact of pain, regardless of the specific condi-
tion or treatment. The second chapter establishes the interrelationship among psycho-
logical disorders and chronic pain, considering the causal connections between physi-
cal and mental health. Chapter 3 provides important insights into outcomes research
and offers suggestions for how to conduct, critically evaluate, and interpret published
reports of treatment outcome studies and communicate these results to policy and
payer decision makers.
Part II, Treatment Approaches and Methods (Chapters 4–14), focuses on impor-
tant topics and models that transcend specific pain conditions. There is no question
that patient motivation is essential, regardless of the treatment approach adopted.
Chapter 4 describes a model for facilitating patient motivation. Chapters 5 and 6 de-
scribe the rationale and detailed methods of two of the most common psychologi-
cal perspectives and approaches, namely, behavioral (e.g., operant conditioning) and
cognitive-­behavioral, to treating individuals with chronic pain. Chapters 7–9 describe
several specific psychological techniques—biofeedback, hypnosis, exposure-based
desensitization—that can be adapted for use in patients with any number of different
pain conditions described in Part III. Chapters 10 and 11 address particular modes of
treatment delivery—­group and family involvement. There are unique benefits to treat-
ing patients in groups, both in terms of efficiency and the power of group dynamics.
But there are logistical trade-offs that need to be overcome in organizing groups. Indi-
viduals with chronic pain, like most people, do not live in isolation but in a social con-
text. Moreover, the vast majority of chronic pain patients—by definition, people with
conditions that extend over long periods of time—will continue to experience pain
long after the conclusion of formal treatment. Consequently, significant others play
important roles in maintaining the benefits derived during treatment, and in generaliz-
ing the positive outcomes beyond the clinical setting. Involvement of significant others
can enhance long-term maintenance; however, one cannot forget that significant oth-
ers can also be potential impediments and undermine treatment. Thus, it is important
to educate them about their potential impact. Greater attention is being given to the
additive, if not synergistic, potential of such combinations. Chapter 12, a new chapter
in this volume, addresses a concept that has been neglected but has aroused growing
interest, “resilience”—an individual’s ability to function and even thrive despite the
presence of circumstances (i.e., chronic pain) that unquestionably create significant
problems in all domains of life (physical, emotional, behavioral, and social). Facilita-
tion and enhancement of a patient’s sense of resilience can result from psychosocial
treatments that, in general, can transcend any specific modality. Recently, two particu-
lar treatment approaches have centered on the concept of resilience—mindfulness-
based stress reduction (MBSR) and acceptance and commitment therapy (ACT). Both
of these approaches, variants of cognitive-behavioral therapy (CBT), are described in
this new chapter. There is growing evidence that monotherapies, whether pharmaco-
xvi Preface

logical, interventional, or psychological, do not eliminate the problem of pain for many
patients and that combinations of treatment with different emphases may be necessary.
Chapter 13 describes an approach to integrating pharmacological and psychological
treatment.
As noted previously, there are rapid technological developments in forms of com-
munication with the advent of the Internet and smartphones. These technologies are
providing tremendous clinical opportunities, and they will unquestionably escalate in
the coming years. Closing out this section, another new chapter in this edition, Chapter
14, describes some of the advances made possible by technologies in treating patients
directly, facilitating adherence, and enhancing maintenance.
Part III, Specific Pain Conditions and Populations (Chapters 15–30), covers sec-
ondary assessment, prevention, and treatment of populations at the extremes of the
lifespan (i.e., children and the growing number of elderly adults), and with many of
the most common pain syndromes and comorbidities. Awareness of, and methods to
address, the complexities involved in treating the diversity of chronic patients are cov-
ered in depth throughout Part III. The authors of the chapters provide insights and
make suggestions to increase the likelihood of achieving the best outcomes with these
unique groups.
There is growing evidence demonstrating the importance of patient selection
when implementing interventional modalities (i.e., surgery, spinal cord stimulators,
implantable drug delivery systems). Chapter 15 describes the expanding role that men-
tal health professionals may play, and the methods they may use in assessing chronic
pain patients for whom these interventions are being considered. Chapters 16–26 pro-
vide detailed discussion and case examples describing the treatment of patients with
specific and prevalent chronic pain syndromes (i.e., back pain, headaches, fibromyal-
gia, whiplash-associated disorders, temporomanidbular disorders, pelvic pain, func-
tional gastrointestinal disorders, cancer, and unexplained somatic symptoms). As we
noted earlier, there are commonalities among patients with different pain conditions,
yet there are unique problems that must be addressed for each specific syndrome.
These chapters address both the commonalities and the specific features that must be
targeted to successfully treat patients with each particular pain condition.
Chapters 27 and 28, also new to this volume, cover the treatment of patients with
comorbid psychological disorders and chronic pain (i.e., posttraumatic stress disor-
der and substance use disorders). There is a growing number and awareness of these
comorbid and challenging patients. Treatment of these groups requires particular sen-
sitivities and approaches. Concluding this section, Chapters 29 and 30 describe the
treatment needs of children and elderly adults. Although the same psychological prin-
ciples apply across the span of life, the methods used to treat elderly adults and very
young patients create unique challenges, and require special skills and sensitivity for
presentation and delivery.
It is our intention that this volume bridge the gap between clinical research and di-
rect application to the clinical environment. In addition to completely updating topics
and treatment approaches described in the previous editions, as previously noted, we
have added a new chapter regarding the potential of advanced technologies to improve
efficiency, treatment outcomes, and associated costs, as well as chapters covering
emerging problems related to comorbidity among patients with chronic pain. These
 Preface xvii

topic areas adhere to the National Institutes of Health’s emphasis on the importance
of the “transfer of technology” from basic research to clinical populations in the “real
world.” In a complementary way, the Institute of Medicine’s (2011) report on reliev-
ing pain in America has called for a “cultural transformation” that addresses societal,
educational, and patient needs related to pain and its treatment. We hope this volume
will contribute to these cultural and clinical transformation themes regarding pain
treatment.
Each of the contributors to this volume is a seasoned clinician who is widely
regarded as an expert in his or her field. Chapter authors were carefully selected in
an effort to assist in the dissemination of information for use in the “real world” of
the management of patients with chronic pain, and the health care environment more
broadly. We believe this handbook will be of particular relevance and value to clini-
cians, whether they treat only a small number of pain patients or the majority of their
practices are centered on this population. The specificity of this shared clinical wis-
dom should also make the text valuable to students and those new to the field of chron-
ic pain. Each chapter also provides evocative and practical guidelines. We believe the
content will help practitioners, regardless of their experience or training, to better un-
derstand the most appropriate and heuristic ways of thinking about, and working with,
their patients, and interfacing with the health care and payer environment. Careful
attention to the insights provided should facilitate clinical interactions and contribute
to better outcomes. Moreover, the specific elements of treatments presented should
inform clinical investigators, and also potentially suggest avenues of future clinical
research to ultimately improve treatment options, and, thereby, the lives of the millions
of individuals who experience chronic pain.
As always, we welcome your comments and suggestions for improving our ef-
forts.

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 Contents

PART I. CONCEPTUAL, DIAGNOSTIC, AND METHODOLOGICAL ISSUES

1. Biopsychosocial Perspective on Chronic Pain 3

Dennis C. Turk and Elena S. Monarch

2. Psychological Disorders and Chronic Pain: 25

Are There Cause-and-Effect Relationships?
Eric Salas, Nancy Kishino, Jeffrey Dersh, and Robert J. Gatchel

3. Conducting and Evaluating Treatment Outcome Studies 51

Amanda C. de C. Williams and Stephen Morley

PART II. TREATMENT APPROACHES AND METHODS

4. Enhancing Motivation to Change in Pain Treatment 71

Mark P. Jensen

5. Operant and Related Conditioning with Chronic Pain: Back to Basics 96

Steven H. Sanders

6. A Cognitive-Behavioral Perspective on the Treatment 115

of Individuals Experiencing Chronic Pain
Dennis C. Turk

7. Introduction to Biofeedback Training for Chronic Pain Disorders 138

John G. Arena and James D. Tankersley

xix
xx Contents

8. Clinical Hypnosis in the Treatment of Chronic and Acute Pain 160

Lindsey C. McKernan, Michael R. Nash, and David R. Patterson

9. Exposure In Vivo for Pain-Related Fear 177

Johan W. S. Vlaeyen, Marlies den Hollander, Jeroen de Jong,
and Laura Simons

10. Group Therapy for Patients with Chronic Pain 205

Francis J. Keefe, Pat M. Beaupre, Meredith E. Rumble,
Sarah A. Kelleher, and Alyssa N. Van Denburg

11. Treating Adults with Chronic Pain and Their Families: 230
Application of an Enhanced Cognitive-Behavioral Transactional Model
Hallie Tankha, Robert D. Kerns, and Annmarie Cano

12. Facilitating Patient Resilience: Mindfulness-Based Stress Reduction, 250

Acceptance, and Positive Social and Emotional Interventions
John A. Sturgeon and Beth D. Darnall

13. Integration of Pharmacotherapy with Psychological Treatment 264

of Chronic Pain
Peter B. Polatin, Noor M. Gajraj, and Howard Cohen

14. Using Advanced Technologies to Improve Access to Treatment, 289

to Improve Treatment, and to Directly Alter Experience
Christopher Eccleston, Abby Tabor, and Edmund Keogh

PART III. SPECIFIC SYNDROMES AND POPULATIONS

15. Evaluating Patients for Neuromodulation Procedures 303

Daniel M. Doleys and Leanne R. Cianfrini

16. Strengthening Self-Management of Low Back Pain in Primary Care: 319

An Evolving Paradigm
Benjamin H. Balderson, Sheri D. Pruitt, and Michael Von Korff

17. A Cognitive-Behavioral Approach to Early Interventions 340

to Prevent Chronic Pain-Related Disability
Steven James Linton

18. Occupational Musculoskeletal Pain and Disability 357

Christopher T. Ray, Robert J. Gatchel, Ryan Hulla, and Anna Wright Stowell

19. Recurrent Headache Disorders 377

Todd A. Smitherman, Alexander J. Kuka, Dawn C. Buse,
and Donald B. Penzien
 Contents xxi

20. Treatment of Patients with Fibromyalgia 398

Dennis C. Turk

21. Treatment of Patients with Whiplash-Associated Disorders 425

Michele Sterling

22. Treatment of Patients with Temporomandibular Disorders 439

Angela Liegey Dougall, Lynette Watts, and Robert J. Gatchel

23. Treating the Patient with Genito-Pelvic Pain 458

Sophie Bergeron, Natalie O. Rosen, and Serena Corsini-Munt

24. Treating Patients with Functional Gastrointestinal Pain Disorders 473

Miranda A. L. van Tilburg and William E. Whitehead

25. Treating Cancer Patients with Persistent Pain 485

Chelsea Ratcliff and Diane Novy

26. Treating Patients with Somatic Symptom and Related Disorders 499
Don McGeary, Cindy McGeary, and Paul Nabity

27. Treating Patients with Posttraumatic Stress Disorder and Chronic Pain 515
Laurie D. Wolf and John D. Otis

28. Management of Chronic Pain in Patients with a Comorbid 530

Substance Use Disorder
Benjamin J. Morasco, Travis I. Lovejoy, and Mark A. Ilgen

29. Treating Children and Adolescents with Chronic Pain 541

Emma Fisher, Rachel V. Aaron, and Tonya M. Palermo

30. Treating Older Patients with Persistent Pain 556

Thomas Hadjistavropoulos

Index 569
 PA RT I

CONCEPTUAL, DIAGNOSTIC,
AND METHODOLOGICAL ISSUES
 CHAPTER 1
Biopsychosocial Perspective on Chronic Pain
DENNIS C. TURK
ELENA S. MONARCH
The past several decades have given rise to ad-
vances in knowledge of the neurophysiologi-
cal mechanisms involved with nociception and
pain, advances in sophisticated diagnostic imag-
ing procedures, and the development of innova-
tive treatments. Yet there are still no treatments
available that consistently and permanently al-
leviate pain for all those afflicted (Turk, Wil-
son, & Cahana, 2011). In this chapter we review
the biomedical model and several alternative
biopsychosocial models that incorporate psy-
chological and social factors. When these fac-
tors are integrated with neurophysiological fac-
tors, a broader biopsychosocial framework can
be used to help us better understand individuals
with chronic pain and their disability, as well as
guide treatment planning. We review research
focusing specifically on psychological, behav-
ioral, and social factors, how these may directly
interact with neurophysiological and hormonal
factors, and we also discuss the implications of
these contributors for treatment and rehabilita-
tion. The set of factors discussed here underlie
many of the treatment approaches described in
other chapters in this volume.
The Need for an Alternative to the Disease Model
The conventional biomedical model of pain,
which dates back to the ancient Greeks and was
inculcated into medical thinking by Descartes in
the 17th century, assumes that people’s reports
3
of pain result from a specific disease state or pa-
thology associated with disordered anatomy or
physiology. From this model, efforts are made to
confirm the diagnosis from data obtained from
objective tests (e.g., imaging, laboratory assays
of fluids) validating physical damage or disease,
and impairment. Based on these data, medical
interventions are specifically directed toward
eliminating either the source of pathology or re-
mediating the identified organic dysfunction—
the putative causes of the symptoms described.
From the perspective of the biomedical
model, accompanying features of chronic
conditions, such as sleep disturbance, depres-
sion, psychosocial disability, and pain, are not
viewed as pathognomonic of a particular dis-
ease or syndrome. Rather, they are viewed as
mere reactions to the malady, and are thus of
secondary importance. It is assumed that once
the disease is “cured,” or pathology resolves
or is corrected, these secondary reactions will
abate. If the symptoms persist, speculations
arise as to possible psychological causation for
their maintenance. Thus, traditional medicine
has adopted a dichotomous, Cartesian mind–
body dualistic view in which symptoms are
either somatogenic or psychogenic. Although
evidence to support this dichotomy is lacking
and often contrary, the view remains pervasive
in health care, in patients and patients’ signifi-
cant others, and the general population.
Decidedly diverse responses to objectively
similar physical perturbations and identical
4 C onceptual , D iagnostic , and M ethodological I ssues
treatments have been noted clinically and docu-
mented in numerous empirical investigations.
For example, although they are related, the as-
sociations between physical impairments on the
one hand, and pain report and disability on the
other, are modest at best (see, e.g., Brinjikji et
al., 2015; Finan et al., 2013). Identified physical
pathology by itself is not highly predictive of
the severity of pain or level of disability. More-
over, pain severity does not adequately explain
emotional distress or extent of disability ob-
served. Many of the most prevalent chronic pain
conditions (e.g., back pain, fibromyalgia [FM],
migraine) do not reveal any definitive pathol-
ogy that would adequately explain the presence,
extent, and persistence of pain and associated
disability (e.g., Baranto, Hellstrom, Cederlund,
Nyman, & Sward, 2009; Blankenbaker et al.,
2008; Jarvik et al., 2005).
Several prospective longitudinal studies in-
dicated that the evolution of persistent pain is
unrelated to the number of pathological discs
revealed in magnetic resonance imaging (MRI)
findings. For example, Jarvik and colleagues
(2005) reported that psychological factors were
significantly better predictors of back pain 3
years after initial assessment than were MRI
scans. In an even longer duration follow-up, Ba-
ranto and colleagues (2009) tracked groups of
elite male athletes and nonathletes for 15 years,
and found that the evolution of persistent pain
was unrelated to the number of pathological
discs the MRI revealed. These authors found
that the presence of pain failed to predict pa-
thology; moreover, the presence of pathology
did not predict pain. These data do not obviate
the important contribution of physical pathol-
ogy to the experience of pain; rather, they sug-
gest that other variables, as well as biomedical
ones, are important and worthy of attention. The
question that remains to be answered, then, is:
What set of factors account for the highly var-
ied experience of, and behavioral responses to,
pain observed? This question has led to a search
for broader models that can account for the lack
of any isomorphic relationship between defined
pathology and pain reports.
It is apparent that chronic pain involves much
more than a physical symptom. Its continuous
presence creates widespread manifestations of
distress, including preoccupation with pain;
limitation of personal, social, and work activi-
ties; demoralization and affective disturbance;
and increased use of medications and of health
care services for those affected. It comes to
consume the entire life of the individual, and it
evolves overtime. Although the importance of
such factors has been acknowledged for some
time (e.g., Engel, 1977), only within the past
half-century have there been systematic at-
tempts to incorporate these factors within com-
prehensive models of pain (e.g., Flor & Turk,
2011; Gatchel, Peng, Peters, Fuchs, & Turk,
2007). Dissatisfaction with the inadequacies of
the biomedical model of pain led to a seminal
event, the postulation of the Gate Control Theo-
ry of pain by Melzack and his colleagues (Mel-
zack & Casey, 1968; Melzack & Wall, 1965).
The Gate Control Theory of Pain
The first attempt to amalgamate physiological
and psychological factors, and to develop an
integrative model of chronic pain that circum-
vents shortcomings of unidimensional models,
was the gate control theory (GCT; Melzack &
Casey, 1968; Melzack & Wall, 1965), which had
to account for a number of facts: (1) the variable
relationship between injury and pain noted; (2)
non-noxious stimuli sometimes produce pain;
(3) the location of pain and tissue damage is
sometimes different; (4) pain can persist long
after tissue healing; (5) the nature of the pain
and sometimes the location can change over
time; (6) pain as a multidimensional experience;
and (7) lack of adequate pain treatments. It was
precisely these facts that no theory at the time
could explain.
Melzack and Casey (1968) differentiated
three systems related to the processing of no-
ciceptive stimulation: sensory–discriminative,
motivational–affective, and cognitive–evalu-
ative, all of which contribute to the subjective
experience of pain. In this way, the GCT spe-
cifically includes psychological factors as inte-
gral aspects of the pain experience. In addition,
by emphasizing central nervous system (CNS)
mechanisms, this theory provides a physiologi-
cal basis for the role of psychological factors in
chronic pain.
According to the GCT, peripheral stimuli in-
teract with cortical variables, such as mood and
anxiety, in the perception of pain. Pain, then,
is not considered either somatic or psychogenic;
instead, both factors have either potentiating or
moderating effects. From the GCT perspective,
the experience of pain is an ongoing sequence
of activities, largely reflexive in nature at the
outset, but modifiable even in the earliest stages
 Biopsychosocial Perspective on Chronic Pain
by a variety of excitatory and inhibitory influ-
ences, as well as the integration of ascending
and descending CNS activity. The process re-
sults in overt expressions communicating pain,
and strategies by the person to terminate the
pain. Because the GCT invokes the continuous
interaction of multiple systems (sensory–physi-
ological, affect, cognition, and behavior) con-
siderable potential for shaping of the pain expe-
rience is implied.
Whereas prior to the GCT formulation psy-
chological factors were largely dismissed as
solely reactions to pain, this new model sug-
gested that cutting or blocking neurological
pathways is inadequate because psychological
processes are capable of influencing (i.e., am-
plifying or diminishing) perception of the pe-
ripheral input. Emphasis on the modulation of
inputs in the spinal cord and the dynamic role of
the brain in pain processes, and ultimately per-
ception, resulted in more serious consideration
of psychological variables (e.g., past experience,
attention, and other cognitive activities) to ad-
equately understand pain. Perhaps the major
contribution of the GCT has been its highlight-
ing of the CNS and, particularly, the brain as
an essential component in pain processes and
perception.
The physiological details of the GCT have
been challenged almost since its initial incep-
tion (e.g., Nathan, 1976; Price, 1987). As addi-
tional knowledge has been gathered since the
original formulation in 1965, specific mecha-
nisms have been disputed and have required re-
vision and reformulation (Melzack, 2001, 2005;
Wall, 1989). Overall, however, the GCT has
proved remarkably resilient and flexible in the
face of accumulating scientific data and chal-
lenges to these data. It still provides a “powerful
summary of the phenomena observed in the spi-
nal cord and brain, and has the capacity to ex-
plain many of the most mysterious and puzzling
problems encountered in the clinic” (Melzack
& Wall, 1982, p. 261).
The GCT has had enormous heuristic value
in stimulating further research in the basic
science of pain mechanisms. It has also given
rise to new clinical treatments, including neu-
romodulatory-based procedures (e.g., neural
stimulation techniques, neurofeedback, phar-
macological advances, behavioral treatments,
and interventions targeting modification of at-
tentional and perceptual processes involved in
the pain experience; e.g., Flor & Turk, 2011;
M. Jensen, Day, & Miro, 2014; M. Jensen &
5
Turk, 2014). After the GCT was proposed, no
one could continue trying to explain pain exclu-
sively in terms of peripheral factors and resort
to the traditional biomedical model.
The Neuromatrix Theory
Melzack (1999) extended the GCT and inte-
grated it with Selye’s (1950) theory of stress.
The Neuromatrix Theory (NT) makes a num-
ber of assumptions about pain. The central con-
cept proposed by Melzack was that the multi-
dimensional experience of pain is produced
by patterns of nerve impulses generated by a
widely distributed neural network comprising
a “body–self neuromatrix.” The neuromatrix is
to some extent genetically determined, but it is
modifiable by sensory experience and learning.
Another important hypothesis of the NT is that
the patterns of nerve impulses can be triggered
either by sensory inputs or centrally, indepen-
dent of any peripheral stimulation. Further-
more, the NT proposes that the output patterns
of the neuromatrix engage perceptual, behav-
ioral, and homeostatic systems in response to
injury and chronic stress.
According to Melzack (1999, 2001, 2005), a
person’s unique body–self-neuromatrix is the
primary determinant of whether the organ-
ism experiences pain, and is the basis for the
individual differences observed because the
neuromatrix is plastic. A critical component of
the NT is the recognition that pain is the conse-
quence of the output of the widely distributed
brain neural network rather than a direct re-
sponse to sensory input following tissue injury,
inflammation, and other pathologies (Melzack,
2001). There is a growing body of research con-
firming Melzack’s proposed distributed brain
neural network in the perception and response
to noxious stimulation (e.g., Apkarian, Bush-
nell, & Schweinhardt, 2013; Apkarian, Hashmi,
& Baliki, 2011; Tracey & Bushnell, 2009).
Another important feature of the NT is that
when an organism is injured, it proposes that
there is an alteration and disruption of the ho-
meostatic regulation. This deviation from the
body’s normal state is stressful and initiates a
complex of neural, hormonal, and behavioral
mechanisms designed to restore homeostasis
(Selye, 1950). The negative effects of stress in-
clude atrophy of muscle tissue, impairment of
growth and tissue repair, immune system sup-
pression, and morphological alterations of brain
6 C onceptual , D iagnostic , and M ethodological I ssues
structures that, together, might create conditions
for the development and maintenance of various
chronic illnesses associated with increased al-
lostatic load (e.g., Chrousos & Gold, 1992; Mc-
Beth et al., 2005; McEwen, 2001; McLean et al.,
2005). The concept of allostatic load, and the
factors that contribute to physiological burden,
is becoming increasingly recognized as an im-
portant component across diseases and disabili-
ties (Seng, Graham-Bermann, Clark, McCar-
thy, & Ronis, 2005; Singer, Friedman, Seeman,
Fava, & Ryff, 2005; Tucker, 2005).
Building on the GCT, pain suppression can
be produced by sensory and evaluative process-
es, as well as activation of the endogenous opi-
oid system. Furthermore, Melzack (1999, 2005)
hypothesized that prolonged stress and ongoing
efforts to restore homeostasis can suppress the
immune system and activate the limbic system.
The limbic system has an important role in
emotion, motivation, and cognitive processes.
Moreover, emerging research also suggests that
inflammatory responses in the body are capable
of crossing the blood–brain barrier (Simnaz et
al., 2015) via two possible routes. One proposed
route of the inflammatory trigger is from the
olfactory bulb into the limbic system (Cut-
forth, DeMille, Agalliu, & Agalliu, 2016), an
area known to be heavily involved in the stress
response. Another potential route of bodily in-
flammation into the CNS may be through the
newly discovered lymphatic vessels lining the
dural sinuses of the brain (Louveau et al., 2015).
These lines of research question the imperme-
ability of the blood–brain barrier, and offer pain
researchers and clinicians greater cause to con-
sider the direct impacts of bodily injuries, pain,
and inflammatory processes on the brain, and
nicely integrate within the NT.
The cumulative effects of stresses that pre-
ceded or are concomitant with the current stress
may account for the large variation in individ-
ual responses to what objectively might appear
to be the same degree of physical pathology. In
this way, the NT incorporates the prior learn-
ing history of the individual with pain to shape
the neuromatrix by influencing interpretive
processes and individual physiological and be-
havioral response patterns. A new stressor may
amplify baseline stress and related efforts of
homeostatic regulation. Prolonged stress aug-
ments tissue breakdown as the body contin-
ues to attempt to return to its “normal” state.
Once pain is established, however, it becomes
a stressor in and of itself, as the body continues
to attempt return to homeostasis. The presence
of pain is a continual threat that initiates and
maintains attention, and creates physical de-
mands on the body. Fear, worry about the fu-
ture, ruminations regarding the meaning of the
nociceptive stimulation, and implications for
the future contribute to the ongoing stress, pro-
ducing additional deviations from homeostasis
(e.g., Chrousos & Gold, 1992; McEwen, 2001).
Nociception involves activation of energy
impinging on specialized nerve endings. The
nerve(s) involved conveys information about
tissue damage to the CNS. Animal research
suggests that repetitive or ongoing nocicep-
tive input can lead to structural and functional
changes that may cause altered perceptual pro-
cessing and contribute to pain chronicity (e.g.,
Apkarian et al., 2011, 2013; Hashmi et al., 2013).
These structural and functional changes dem-
onstrate plasticity in the nervous system and
may explain why a person experiences a gradu-
al increase in the perceived magnitude of pain,
referred to as “neural (peripheral and central)
sensitization.” Moreover, once these changes
have occurred, they may contribute to nocicep-
tion even after the initial cause has resolved.
These changes in the CNS offer an explanation
for the reports of pain in many chronic pain
syndromes (e.g., back pain, migraine FM, whip-
lash-associated disorders) even when no physi-
cal pathology is identified (e.g., Yunus, 2015).
According to Melzack, these CNS changes can
be accounted for by modification of the body–
self-neuromatrix. Thus, Melzack’s (2001, 2005)
NT poses intriguing hypotheses and integrates
a great deal of physiological and psychological
knowledge. However, components of the theo-
ry, and the theory itself, await more systematic
investigation. As was the case with the GCT,
the NT offers a heuristic way of thinking that
should stimulate research.
The Biopsychosocial Perspective:
A Basic Description
It is well known that people differ markedly in
how frequently they report physical symptoms,
in their propensity to visit physicians when ex-
periencing identical symptoms and, as noted, in
their response to identical treatments. Therefore,
the distinction between disease and illness is
crucial to understanding chronic pain. Disease
is generally defined as an objective biological
event that involves disruption of specific body
 Biopsychosocial Perspective on Chronic Pain
structures or organ systems caused by patho-
logical, anatomical, or physiological changes.
In contrast to this customary view of physical
disease, illness is defined as a subjective experi-
ence or self-attribution that a disease is present;
it yields physical discomfort, emotional distress,
behavioral limitations, and psychosocial disrup-
tion. In other words, illness refers to how the
sick person and members of his or her family
and wider social network perceive, live with,
and respond to symptoms and disability.
The distinction between disease and illness
is analogous to the distinction between pain and
nociception. Nociception entails stimulation of
nerves that convey information about tissue
damage occurring at the periphery, projecting
to the spinal cord and, ultimately, to the brain
(Melzack & Wall, 1965). Pain is a subjective
perception that results from the transduction,
transmission, and modulation of sensory input,
filtered through a person’s genetic composition
and prior learning history, and modulated fur-
ther by the person’s current physiological sta-
tus, idiosyncratic appraisals, expectations, cur-
rent mood state, and sociocultural environment
(e.g., Diatchenko et al., 2005; Flor & Turk, 2011;
Gatchel et al., 2007). This is why we emphasize
assessment of the person because we cannot as-
sess pain removed from the person exposed to
the nociception.
Socioeconomic context
Premorbid Age at pain
characteristics onset
• Genes • Pathology
• Learning history
• Personality
37
FIGURE 1.1. Longitudinal versus cross-sectional perspective. From Okifuji and Turk (2014, p. 228). Copyright
© Springer Verlag France. Reprinted with permission of Springer.
7
In contrast to the biomedical model’s em-
phasis on disease, the biopsychosocial model
focuses on both disease and illness, a complex
interaction of biological, psychological, and so-
cial variables. From this perspective, diversity
in illness expression, which includes its sever-
ity, duration, and consequences for the individ-
ual, is accounted for by the interrelationships
among biological changes, psychological status,
and the social and cultural contexts. Moreover,
prior to the development of an injury or disease,
each person has a unique genotype and prior
learning history. All these variables shape the
person’s perception and initial and ongoing re-
sponse to illness (Gatchel et al., 2007; Okifuji &
Turk, 2015).
The biopsychosocial way of thinking about
the differing responses of people to symptoms
and the presence of chronic conditions is based
on an understanding of the dynamic nature of
these conditions. That is, by definition, chronic
syndromes extend over time. Therefore, these
conditions need to be viewed longitudinally
as ongoing, multifactorial processes in which
there is a vibrant reciprocal interplay among
biological, psychological, and social factors that
shape the experience and responses of patients
(see Figure 1.1). Biological factors may initiate,
maintain, and modulate physical perturbations,
whereas psychological variables influence
Current age Expectancy
• Change in • Change in
pathology pathology
44 76+
Resources
• Interpersonal support
• Economic
8 C onceptual , D iagnostic , and M ethodological I ssues
perception of internal physiological signs, and
social factors continually shape patients’ be-
havioral responses to the perceptions of their
physical perturbations. Conversely, psychologi-
cal factors may influence biology by directly
affecting hormone production (see, e.g., Mc-
Beth et al., 2007; McEwen & Kalia, 2010), brain
structure and processes (see, e.g., Goffaux,
Redmond, Rainville, & Marchand, 2007; Hash-
mi et al., 2013; Kucyi et al., 2014; Salomons,
Johnstone, Backonja, Shackman, & Davidson,
2007), and the autonomic nervous system (see,
e.g., Colloca, Benedetti, & Pollo, 2006; Mc-
Beth et al., 2005, 2007). Behavioral responses
may also affect biological contributors, such
as when a person avoids engaging in certain
activities in order to reduce his or her symp-
toms (e.g., Crombez, Eccleston, van Damme,
Vlaeyen, & Karoly, 2012; Vlaeyen & Linton,
2000). Although avoidance may initially reduce
symptoms, in the long run, it will lead to fur-
ther physical deconditioning (i.e., loss of muscle
mass and strength, endurance, and flexibility),
which can exacerbate nociceptive stimulation.
The picture is not complete unless we consid-
er the direct effects of disease factors and treat-
ment on a range of cognitive and behavioral
factors. Biological influences and medications
(e.g., steroids, opioids) may affect the ability to
concentrate, induce fatigue, and modulate peo-
ple’s interpretation of their state, as well as their
ability to engage in certain activities.
At different points during the evolution of a
disease or impairment, the relative weighting of
physical, psychological, and social factors may
shift. For example, during the acute phase of a
disease, biological factors may predominate,
but, over time, as initial physical pathology
resolves, psychological and social factors may
assume a disproportionate role in accounting
for symptoms and disability (Okifuji & Turk,
2015; Skinner, Wilson, & Turk, 2012). More-
over, there is considerable variability in behav-
ioral and psychological manifestations of dys-
function, both across persons with comparable
symptoms and within the same person over
time (e.g., Arnow et al., 2011).
To understand the variable responses of
people to chronic conditions, it is essential that
biological, psychological, and social factors
each be considered. Moreover, a longitudinal
perspective is essential. A cross-sectional ap-
proach will only permit consideration of these
factors at a specific point in time, and chronic
conditions continually evolve (see Figure 1.1).
What is observed at any one time is a person’s
adaptation to interacting biological, personal,
and environmental factors. In summary, the
hallmarks of the biopsychosocial perspective
are (1) integrated action, (2) reciprocal deter-
minism, and (3) development and evolution
(Flor & Turk, 2011; Okifuji & Turk, 2015). This
perspective can be contrasted with the tradi-
tional biomedical model, whose emphasis on
the somatogenic–psychogenic dichotomy is too
narrow in scope to accommodate the complex-
ity of chronic pain.
Support for the Importance
of Nonphysiological Factors
As noted, many studies have revealed rather
weak associations between objective indicator
reports of both pain and disability (e.g., Brin-
jikji et al., 2015; Finan et al., 2013), and the
predictive role of both cognitive and emotional
factors accounting for significantly greater por-
tions of the variance than objective signs in
chronic pain (e.g., Carragee, Alamin, Miller, &,
Carragee, 2005) and disability (e.g., Severeijns,
Vlaeyen, van den Hout, & Weber, 2001). More-
over, psychological factors have consistently
been demonstrated to predict pain severity and
time to discharge following diverse types of
surgery during the postoperative period (e.g.,
Ip, Abrishami, Peng, Wong, & Chung, 2009;
Khan et al., 2011; Pavlin, Sullivan, Freund, &
Roesen, 2005), and at 6- and 12-month follow-
up (e.g., Peters, Sommer, van Kleef, & Mar-
cus, 2010; Thomee et al., 2008). Psychological
variables have also been shown to be important
predictors of response to both pharmacological
and nonpharmacological treatments for various
painful conditions (e.g., Benyon, Hill, Zadu-
rian, & Mallen, 2010), and to duration of dis-
ability (e.g., Busch, Goransson, & Melin, 2007).
The history of medicine is replete with de-
scriptions of interventions believed to be appro-
priate for alleviating pain, many of which are
now known to have little therapeutic merit, and
some of which may actually have been harm-
ful to patients (Turk, Meichenbaum, & Genest,
1983). Prior to the second half of the 19th centu-
ry and the advent of research on sensory physi-
ology, much of the pain treatment arsenal con-
sisted of interventions that had no direct mode
of action on organic mechanisms associated
with the source of the pain. Despite the absence
of an adequate physiological basis, these treat-
 Biopsychosocial Perspective on Chronic Pain
ments proved to have some therapeutic merit, at
least for some patients.
Personality Factors
Prior to the onset of a pain problem, individu-
als have a range of genetic factors and learning
experiences that help shape their personalities.
Within the biopsychosocial perspective, these
individual-difference variables are viewed as
important to the experience, response to, and
impact of symptoms (Figure 1.1). The search
for specific personality factors that predispose
people to develop chronic pain has been a major
emphasis of psychosomatic medicine. Studies
had attempted to identify a specific “migraine
personality,” a “rheumatoid arthritis personal-
ity,” and a more general “pain-prone person-
ality” (Blumer & Heilbronn, 1982). However,
on the basis of their prior experiences, people
develop idiosyncratic ways of interpreting in-
formation and coping with stress. Avoidance,
and the resulting failure to experience discon-
firmation, prevent the extinction or modifica-
tion of these interpretations and expectations.
There is no question that these unique patterns
will have an effect on their perceptions of, and
responses to, the presence of pain (Weisberg &
Keefe, 1999; see also Salas, Kishino, Dersh, &
Gatchel, Chapter 2, this volume).
Anxiety sensitivity refers to the fear of anxi-
ety symptoms, based on the belief that they will
have harmful consequence (Reiss & McNally,
1985). Anxiety sensitivity appears to be a vul-
nerability factor (i.e., diathesis) that may condi-
tion specific fears that contribute to the develop-
ment and maintenance of distress (Asmundson,
Coons, Taylor, & Katz, 2002). Coupled with the
fact that pain is essential for survival, attention
may be “primed” to process painful stimuli
ahead of other attentional demands. People with
high levels of anxiety sensitivity may be espe-
cially hypervigilant to pain, as well as to other
noxious sensations. Selective attention directed
toward threatening information, such as bodily
sensations, leads to greater arousal. Because of
this attentional process, those with high anxi-
ety sensitivity may be “primed,” such that even
minor painful stimuli may be amplified.
Preliminary studies that demonstrate the
importance of anxiety sensitivity as a predis-
positional factor in chronic pain have been re-
ported. For example, Asmundson and Norton
(1995) found a positive association between
9
anxiety sensitivity and pain-related anxiety,
escape/avoidant behaviors, fear of negative
consequences of pain, and negative affect. Not
only were patients with high anxiety sensitivity
more likely to experience greater cognitive dis-
turbance as a result of their pain, but they were
also likely to use greater amounts of analgesic
medication to control equal amounts of pain
compared to those with low or medium anxiety
sensitivity. Furthermore, Asmundson and Nor-
ton (1995) demonstrated that anxiety sensitivity
directly exacerbates fear of pain and, indirectly,
exacerbates pain-specific avoidance behavior
even after they controlled for the direct influ-
ences of pain severity on these variables (for a
more extensive review, see Asmundson et al.,
2002).
General fearful appraisals of bodily sensa-
tions may sensitize predisposed people and
cause high awareness of bodily sensations.
Thus, anxiety sensitivity is only one individu-
al-difference characteristic that might predis-
pose people to develop and maintain chronic
pain and disability. For example, somatization,
negative affectivity, bodily preoccupation, and
catastrophic thinking also may be involved (see
McGeary, McGeary, & Nabity, Chapter 26, this
volume).
Sociocultural Factors
People are social beings, functioning within a
cultural context that begins at birth and colors
experiences throughout their lives. Attempt-
ing to understand people’s experience of pain
without consideration of their historical and
current context will be inadequate (Okifuji &
Turk 2012, 2015). Commonsense beliefs about
illness and health care providers are acquired
from both prior learning experiences and so-
cial and cultural transmission of meaning and
expectations. Ethnic group membership influ-
ences how one perceives, labels, responds to,
and communicates various symptoms, as well
as from whom one elects to obtain care when it
is sought, and the types of treatments received.
Sociocultural factors influence how families
and local groups respond to and interact with
patients (see discussion of operant learning
mechanisms later). Furthermore, ethnic and ra-
cial expectations and sex and age stereotypes
may influence the practitioner–patient relation-
ship (e.g., Anderson, Green, & Payne, 2009;
Cook & Chastain, 2001; Lazakani et al., 2015;
10 C onceptual , D iagnostic , and M ethodological I ssues
McGuire, Nicholas, Asghari, Wood, & Main,
2014).
Social Learning Mechanisms
The role of social learning has received some at-
tention in the development and maintenance of
chronic pain states. From this perspective, pain
behaviors (i.e., overt expressions of pain, dis-
tress, and suffering) may be acquired through
observational learning and modeling processes;
that is, people can learn responses that were not
previously in their behavioral repertoire by ob-
serving others who respond in these ways (e.g.,
Goubert, Vlaeyen, Crombez, & Craig, 2011;
Levy, 2011). Children acquire attitudes about
health and health care, perceptions and interpre-
tations of symptoms, and appropriate responses
to injury and disease from their parents, cultur-
al stereotypes, and the social environment (see,
e.g., Fisher, Aaron, & Palermo, Chapter 29, this
volume). Based on their experiences, children
develop strategies to help them avoid pain and
learn “appropriate” (acceptable) ways to react.
Children are exposed to numerous minor inju-
ries throughout the day, and how adults address
these experiences provides ample learning op-
portunities (Levy, 2011). Children’s learning
influences whether they will ignore symptoms
or respond or overrespond to symptoms. The
observation of others in pain is an event that
captivates attention. A large amount of experi-
mental evidence, going back several decades,
demonstrates the role of social learning in con-
trolled studies in the laboratory (Craig, 1986;
1988), and observations of patients’ behavior in
clinical settings (e.g., Levy, 2011). For example,
in an early study, Richard (1988) found that
children whose parents had chronic pain chose
more pain-related responses to scenarios pre-
sented to them and were more external in their
health locus of control than were children with
healthy or diabetic parents. Moreover, teachers
rated the pain patients’ children as displaying
more illness behaviors (e.g., complaining, days
absent, and visits to school nurse) than the chil-
dren of the diabetics and healthy controls.
Operant Learning Mechanisms
Early in the 1900s, Collie (1913) discussed the
effects of environmental factors in shaping
the experience of people with persistent pain.
However, a new era in thinking about pain was
initiated with Fordyce’s (1976; for a historical
reflection and extension, see Main, Keefe, Jen-
sen, Vlaeyen, & Vowles, 2015; see also Sanders,
Chapter 5, this volume) description of the role
of operant factors in chronic pain. The operant
approach stands in marked contrast to the bio-
medical model of pain described earlier. Oper-
ant theory hypothesizes that all behavior is sen-
sitive to the effects of environmental responses
to that behavior. Fordyce noted that “pain be-
haviors”—the things that people do that com-
municate pain to others (i.e., overt expressions
of pain and suffering such as limping and gri-
macing)—are no different than any other be-
havior with respect to their sensitivity to envi-
ronmental influences. Overt behaviors, by their
very nature, are observable and hence capable
of eliciting responses. Pain behaviors followed
by reinforcing events, such as affection or sanc-
tioned time out from social responsibilities, will
increase in frequency. However, if pain behav-
iors are systematically ignored, and behaviors
incompatible with them—so-called “well-
behaviors” such as exercise and maintaining
an active lifestyle including employment—are
encouraged or positively reinforced, then over
time these well-behaviors will increase and
pain behaviors will decrease.
Fordyce (1976) argued that pain behaviors,
which can be protective in the short run fol-
lowing acute injury, are no longer useful in
the context of chronic pain. In fact, once heal-
ing has occurred, pain behaviors often become
maladaptive—they can contribute to disability
(e.g., ongoing resting and guarding behaviors
cause muscle atrophy) and maintain pain. Also,
these behaviors may continue beyond any ex-
pected healing time because of the presence of
not only significant pain but also reinforcers of
pain behaviors, as well as the absence of rein-
forcers for well behaviors.
In the operant formulation, behavioral mani-
festations of pain, rather than pain per se, are
central. When people are exposed to a stimu-
lus that causes tissue damage, their immediate
response is withdrawal or an attempt to escape
from the noxious sensations. Their behaviors
are observable and, consequently, are subject to
the principles of reinforcement. Behaviors that
are positively reinforced increase and persist,
whereas behaviors that receive no positive re-
sponse decrease and become diminished. Those
behaviors that permit avoidance of aversive
events (negatively reinforced) will also increase.
The operant view proposes that through exter-
nal contingencies of reinforcement, acute pain
 Biopsychosocial Perspective on Chronic Pain
behaviors, such as limping to protect a wound-
ed limb from producing additional nociceptive
input, may evolve into chronic pain problems.
Pain behaviors may be positively reinforced di-
rectly (e.g., by attention from a spouse or health
care provider). They may also be maintained by
the escape from noxious stimulation through
the use of drugs or rest, or avoidance of unde-
sirable activities such as work.
In addition, “well behaviors” (e.g., activity
and working) may not be sufficiently positively
reinforced and will be extinguished. Pain be-
haviors originally elicited by organic factors
may therefore occur totally, or in part, in re-
sponse to reinforcing environmental events.
Because of the consequences of specific be-
havioral responses, Fordyce (1976) proposed
that pain behaviors might persist long after the
initial cause of the pain is resolved or greatly
reduced. The operant conditioning model does
not concern itself with the initial cause of pain.
Rather, it considers pain an internal subjective
experience that may be maintained even after
its initial physical basis is resolved. A number
of studies have provided evidence that supports
the underlying assumptions of the operant con-
ditioning model (e.g., Eck, Richter, Straube,
Miltner, & Weiss, 2011; Jolliffee & Nicholas,
2004).
Treatment from the operant perspective fo-
cuses on extinction of pain behaviors and in-
creasing well behaviors by positive reinforce-
ment. This treatment has proven to be effective
for select samples of patients with chronic pain
(see, e.g., Henschke et al., 2010; Thieme, Turk,
& Flor, 2007; see also Sanders, Chapter 5, this
volume). Although operant factors undoubtedly
play a role in the maintenance of pain and dis-
ability, the operant conditioning model of pain
has been criticized for its exclusive focus on
motor pain behaviors, failure to consider the
emotional and cognitive aspects of pain, and
failure to treat the subjective experience of pain
(e.g., Okifuji & Turk, 2015; Skinner et al., 2012).
Respondent Learning Mechanisms
Factors contributing to chronicity that have pre-
viously been conceptualized in terms of operant
learning may also be initiated and maintained
by respondent conditioning. In an early study,
Fordyce, Shelton, and Dundore (1982) hypoth-
esized that intermittent sensory stimulation
from the site of bodily damage, environmental
reinforcement, or successful avoidance of aver-
11
sive social activity are not necessarily required
to account for the maintenance of avoidance
behavior or protective movements; anticipation
of pain may be sufficient to maintain avoid-
ance behavior. Vlaeyen and colleagues (e.g.,
Asmundson, Norton, & Vlaeyen, 2004; Crom-
bez et al., 2012; Vlaeyen & Linton, 2000) have
reviewed a wealth of studies confirming that
avoidance of activities is related more to anxi-
ety about pain than to actual pain.
Once an acute pain problem is established,
fear of motor activities that the patient expects
to result in pain may develop and motivate
avoidance of activity (Crombez et al., 2012;
Vlaeyen & Linton, 2000). Nonoccurrence of
pain is a powerful reinforcer for future reduc-
tion of activity. In this way, the original respon-
dent conditioning may be followed by an oper-
ant learning process, whereby the nociceptive
stimuli and the associated responses need no
longer be present for the avoidance behavior to
occur.
In acute pain states, it may be useful to re-
duce movement and, consequently, to avoid
pain, in order to accelerate the healing process.
Over time, however, anticipatory anxiety re-
lated to activity may develop and act as a con-
ditioned stimulus for sympathetic activation
(the conditioned response), which may be main-
tained after the original unconditioned stimu-
lus (injury) and unconditioned response (pain
and sympathetic activation) have subsided (e.g.,
Philips, 1987). Indeed, sympathetic activation
and increases in muscle tension may be viewed
as unconditioned responses that can elicit more
pain. Even when no injury is present, pain relat-
ed to sustained muscle contractions may also be
conceptualized as an unconditioned stimulus,
and conditioning may proceed in the same fash-
ion as outlined previously. Although an origi-
nal association between pain and pain-related
stimuli may result in anxiety regarding these
stimuli, with time, the expectation of pain relat-
ed to activity may lead to avoidance of adaptive
behaviors, even if the nociceptive stimuli and
the related sympathetic activation are no longer
present. Even in acute pain, many activities that
are otherwise neutral or pleasurable may elicit
or exacerbate pain, and are therefore experi-
enced as aversive and avoided. Over time, more
and more activities may be seen as eliciting or
exacerbating pain, and are therefore feared and
avoided (i.e., stimulus generalization).
Avoided activities may involve simple motor
behaviors, as well as work, leisure, and sexual
12 C onceptual , D iagnostic , and M ethodological I ssues
activity. In addition to the avoidance learn-
ing, pain may be exacerbated and maintained
in an expanding number of situations because
anxiety-related sympathetic activation and ac-
companying muscle tension may occur both in
anticipation and as a consequence of pain (cf.
Flor & Turk, 2011; Main et al., 2015). Thus, psy-
chological factors may directly affect nocicep-
tive stimulation and need not be viewed merely
as reactions to pain. We return to this point later
in this chapter.
Persistent avoidance of specific activities
prevents disconfirmations that are followed
by corrected predictions (Rachman & Arntz,
1991). Early studies have shown that predic-
tion of pain promotes pain avoidance behavior,
and overprediction of pain promotes excessive
avoidance behavior (Schmidt, 1985a, 1985b).
Insofar as pain avoidance succeeds in preserv-
ing the overpredictions from repeated discon-
firmation, they will continue unchanged. By
contrast, people who repeatedly engage in be-
havior that produces significantly less pain than
they predicted will likely make adjustments in
subsequent expectations, which will eventually
become more accurate. Increasingly accurate
predictions will be followed by reduction of
avoidance behavior (Vlaeyen, de Jong, Geilen,
Heuts, & van Breukelen, 2001). These observa-
tions support the importance of physical ther-
apy and exercise quota, with patients progres-
sively increasing their activity levels despite
their fears of injury and discomfort associated
with renewed use of deconditioned muscles.
From the respondent conditioning perspec-
tive, individuals with chronic pain may have
learned to associate increases in pain with all
kinds of stimuli that were originally associ-
ated with nociceptive stimulation (i.e., stimulus
generalization). As the pain symptoms persist,
more and more situations may elicit anxiety and
anticipatory pain and depression because of the
low rate of reinforcement obtained when behav-
ior is greatly reduced. Sitting, walking, cogni-
tively demanding work or social interaction,
sexual activity, or even thoughts about these
activities, may increase anticipatory anxiety
and concomitant physiological and biochemi-
cal changes (Flor & Turk, 2011). Subsequently,
patients may respond inappropriately to many
stimuli, reducing the frequency of numerous
activities, in addition to those that initially in-
duced nociception. Physical abnormalities often
observed in patients with chronic pain (e.g.,
distorted gait, decreased range of motion, and
muscular fatigue) may actually result from sec-
ondary changes initiated in behavior through
learning rather than continuing nociception. In
short, the anticipation of suffering or prevention
of suffering may be sufficient for the long-term
maintenance of avoidance behaviors.
Cognitive Factors
People are not passive responders to physical
sensation. Rather, they actively seek to make
sense of their experience. They appraise their
conditions by matching sensations to some pre-
existing implicit model, and they determine
whether a particular sensation is a symptom of
a particular physical disorder that requires at-
tention or can be ignored. In this way, to some
extent, each person functions with a uniquely
constructed reality (i.e., a body–self neuroma-
trix). When information is ambiguous, people
rely on general attitudes and beliefs based on
experience and prior learning history. These
beliefs determine the meaning and significance
of the problems, as well as the perceptions of
appropriate treatment. If we accept the premise
that pain is a complex, subjective phenomenon
that is uniquely experienced by each person,
then knowledge about idiosyncratic beliefs, ap-
praisals, and coping repertoires becomes criti-
cal for optimal treatment planning and for ac-
curately evaluating treatment outcome (Flor &
Turk, 2011; Okifuji & Turk 2014; Skinner et al.,
2012).
Research investigating the impact of poor
emotional coping, maladaptive thought pro-
cesses, and appraisals of pain have consistently
demonstrated that patients’ attitudes, beliefs,
and expectancies about their plight, them-
selves, their coping resources, and the health
care system affect their reports of pain, activ-
ity, disability, and response to treatment (e.g.,
Okifuji & Turk, 2012; Smeets, Vlaeyen, Kester,
& Knottnerus, 2006). For example, a belief that
pain is “damaging” and “dangerous” in patients
with chronic pain has been shown to be asso-
ciated with greater pain and disability (Turner,
Jensen, & Romano, 2000). Conversely, modifi-
cation in maladaptive beliefs about their pain
can directly affect brain processing of nocicep-
tive stimulation (e.g., K. Jensen et al., 2012) and
seems to predict changes in pain and disability
following treatment (e.g., Burns, Glenn, Bruehl,
Harden & Lofland, 2003; Robinson, Theodore,
Dansie, Wilson, & Turk, 2013).
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 DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI

Newala, too, suffers from the distance of its water-supply—at least

the Newala of to-day does; there was once another Newala in a lovely
valley at the foot of the plateau. I visited it and found scarcely a trace
of houses, only a Christian cemetery, with the graves of several
missionaries and their converts, remaining as a monument of its
former glories. But the surroundings are wonderfully beautiful. A
thick grove of splendid mango-trees closes in the weather-worn
crosses and headstones; behind them, combining the useful and the
agreeable, is a whole plantation of lemon-trees covered with ripe
fruit; not the small African kind, but a much larger and also juicier
imported variety, which drops into the hands of the passing traveller,
without calling for any exertion on his part. Old Newala is now under
the jurisdiction of the native pastor, Daudi, at Chingulungulu, who,
as I am on very friendly terms with him, allows me, as a matter of
course, the use of this lemon-grove during my stay at Newala.
 FEET MUTILATED BY THE RAVAGES OF THE “JIGGER”
(Sarcopsylla penetrans)

The water-supply of New Newala is in the bottom of the valley,

some 1,600 feet lower down. The way is not only long and fatiguing,
but the water, when we get it, is thoroughly bad. We are suffering not
only from this, but from the fact that the arrangements at Newala are
nothing short of luxurious. We have a separate kitchen—a hut built
against the boma palisade on the right of the baraza, the interior of
which is not visible from our usual position. Our two cooks were not
long in finding this out, and they consequently do—or rather neglect
to do—what they please. In any case they do not seem to be very
particular about the boiling of our drinking-water—at least I can
attribute to no other cause certain attacks of a dysenteric nature,
from which both Knudsen and I have suffered for some time. If a
man like Omari has to be left unwatched for a moment, he is capable
of anything. Besides this complaint, we are inconvenienced by the
state of our nails, which have become as hard as glass, and crack on
the slightest provocation, and I have the additional infliction of
pimples all over me. As if all this were not enough, we have also, for
the last week been waging war against the jigger, who has found his
Eldorado in the hot sand of the Makonde plateau. Our men are seen
all day long—whenever their chronic colds and the dysentery likewise
raging among them permit—occupied in removing this scourge of
Africa from their feet and trying to prevent the disastrous
consequences of its presence. It is quite common to see natives of
this place with one or two toes missing; many have lost all their toes,
or even the whole front part of the foot, so that a well-formed leg
ends in a shapeless stump. These ravages are caused by the female of
Sarcopsylla penetrans, which bores its way under the skin and there
develops an egg-sac the size of a pea. In all books on the subject, it is
stated that one’s attention is called to the presence of this parasite by
an intolerable itching. This agrees very well with my experience, so
far as the softer parts of the sole, the spaces between and under the
toes, and the side of the foot are concerned, but if the creature
penetrates through the harder parts of the heel or ball of the foot, it
may escape even the most careful search till it has reached maturity.
Then there is no time to be lost, if the horrible ulceration, of which
we see cases by the dozen every day, is to be prevented. It is much
easier, by the way, to discover the insect on the white skin of a
European than on that of a native, on which the dark speck scarcely
shows. The four or five jiggers which, in spite of the fact that I
constantly wore high laced boots, chose my feet to settle in, were
taken out for me by the all-accomplished Knudsen, after which I
thought it advisable to wash out the cavities with corrosive
sublimate. The natives have a different sort of disinfectant—they fill
the hole with scraped roots. In a tiny Makua village on the slope of
the plateau south of Newala, we saw an old woman who had filled all
the spaces under her toe-nails with powdered roots by way of
prophylactic treatment. What will be the result, if any, who can say?
The rest of the many trifling ills which trouble our existence are
really more comic than serious. In the absence of anything else to
smoke, Knudsen and I at last opened a box of cigars procured from
the Indian store-keeper at Lindi, and tried them, with the most
distressing results. Whether they contain opium or some other
narcotic, neither of us can say, but after the tenth puff we were both
“off,” three-quarters stupefied and unspeakably wretched. Slowly we
recovered—and what happened next? Half-an-hour later we were
once more smoking these poisonous concoctions—so insatiable is the
craving for tobacco in the tropics.
Even my present attacks of fever scarcely deserve to be taken
seriously. I have had no less than three here at Newala, all of which
have run their course in an incredibly short time. In the early
afternoon, I am busy with my old natives, asking questions and
making notes. The strong midday coffee has stimulated my spirits to
an extraordinary degree, the brain is active and vigorous, and work
progresses rapidly, while a pleasant warmth pervades the whole
body. Suddenly this gives place to a violent chill, forcing me to put on
my overcoat, though it is only half-past three and the afternoon sun
is at its hottest. Now the brain no longer works with such acuteness
and logical precision; more especially does it fail me in trying to
establish the syntax of the difficult Makua language on which I have
ventured, as if I had not enough to do without it. Under the
circumstances it seems advisable to take my temperature, and I do
so, to save trouble, without leaving my seat, and while going on with
my work. On examination, I find it to be 101·48°. My tutors are
abruptly dismissed and my bed set up in the baraza; a few minutes
later I am in it and treating myself internally with hot water and
lemon-juice.
Three hours later, the thermometer marks nearly 104°, and I make
them carry me back into the tent, bed and all, as I am now perspiring
heavily, and exposure to the cold wind just beginning to blow might
mean a fatal chill. I lie still for a little while, and then find, to my
great relief, that the temperature is not rising, but rather falling. This
is about 7.30 p.m. At 8 p.m. I find, to my unbounded astonishment,
that it has fallen below 98·6°, and I feel perfectly well. I read for an
hour or two, and could very well enjoy a smoke, if I had the
wherewithal—Indian cigars being out of the question.
Having no medical training, I am at a loss to account for this state
of things. It is impossible that these transitory attacks of high fever
should be malarial; it seems more probable that they are due to a
kind of sunstroke. On consulting my note-book, I become more and
more inclined to think this is the case, for these attacks regularly
follow extreme fatigue and long exposure to strong sunshine. They at
least have the advantage of being only short interruptions to my
work, as on the following morning I am always quite fresh and fit.
My treasure of a cook is suffering from an enormous hydrocele which
makes it difficult for him to get up, and Moritz is obliged to keep in
the dark on account of his inflamed eyes. Knudsen’s cook, a raw boy
from somewhere in the bush, knows still less of cooking than Omari;
consequently Nils Knudsen himself has been promoted to the vacant
post. Finding that we had come to the end of our supplies, he began
by sending to Chingulungulu for the four sucking-pigs which we had
bought from Matola and temporarily left in his charge; and when
they came up, neatly packed in a large crate, he callously slaughtered
the biggest of them. The first joint we were thoughtless enough to
entrust for roasting to Knudsen’s mshenzi cook, and it was
consequently uneatable; but we made the rest of the animal into a
jelly which we ate with great relish after weeks of underfeeding,
consuming incredible helpings of it at both midday and evening
meals. The only drawback is a certain want of variety in the tinned
vegetables. Dr. Jäger, to whom the Geographical Commission
entrusted the provisioning of the expeditions—mine as well as his
own—because he had more time on his hands than the rest of us,
seems to have laid in a huge stock of Teltow turnips,[46] an article of
food which is all very well for occasional use, but which quickly palls
when set before one every day; and we seem to have no other tins
left. There is no help for it—we must put up with the turnips; but I
am certain that, once I am home again, I shall not touch them for ten
years to come.
Amid all these minor evils, which, after all, go to make up the
genuine flavour of Africa, there is at least one cheering touch:
Knudsen has, with the dexterity of a skilled mechanic, repaired my 9
× 12 cm. camera, at least so far that I can use it with a little care.
How, in the absence of finger-nails, he was able to accomplish such a
ticklish piece of work, having no tool but a clumsy screw-driver for
taking to pieces and putting together again the complicated
mechanism of the instantaneous shutter, is still a mystery to me; but
he did it successfully. The loss of his finger-nails shows him in a light
contrasting curiously enough with the intelligence evinced by the
above operation; though, after all, it is scarcely surprising after his
ten years’ residence in the bush. One day, at Lindi, he had occasion
to wash a dog, which must have been in need of very thorough
cleansing, for the bottle handed to our friend for the purpose had an
extremely strong smell. Having performed his task in the most
conscientious manner, he perceived with some surprise that the dog
did not appear much the better for it, and was further surprised by
finding his own nails ulcerating away in the course of the next few
days. “How was I to know that carbolic acid has to be diluted?” he
mutters indignantly, from time to time, with a troubled gaze at his
mutilated finger-tips.
 Since we came to Newala we have been making excursions in all
directions through the surrounding country, in accordance with old
habit, and also because the akida Sefu did not get together the tribal
elders from whom I wanted information so speedily as he had
promised. There is, however, no harm done, as, even if seen only
from the outside, the country and people are interesting enough.
The Makonde plateau is like a large rectangular table rounded off
at the corners. Measured from the Indian Ocean to Newala, it is
about seventy-five miles long, and between the Rovuma and the
Lukuledi it averages fifty miles in breadth, so that its superficial area
is about two-thirds of that of the kingdom of Saxony. The surface,
however, is not level, but uniformly inclined from its south-western
edge to the ocean. From the upper edge, on which Newala lies, the
eye ranges for many miles east and north-east, without encountering
any obstacle, over the Makonde bush. It is a green sea, from which
here and there thick clouds of smoke rise, to show that it, too, is
inhabited by men who carry on their tillage like so many other
primitive peoples, by cutting down and burning the bush, and
manuring with the ashes. Even in the radiant light of a tropical day
such a fire is a grand sight.
Much less effective is the impression produced just now by the
great western plain as seen from the edge of the plateau. As often as
time permits, I stroll along this edge, sometimes in one direction,
sometimes in another, in the hope of finding the air clear enough to
let me enjoy the view; but I have always been disappointed.
Wherever one looks, clouds of smoke rise from the burning bush,
and the air is full of smoke and vapour. It is a pity, for under more
favourable circumstances the panorama of the whole country up to
the distant Majeje hills must be truly magnificent. It is of little use
taking photographs now, and an outline sketch gives a very poor idea
of the scenery. In one of these excursions I went out of my way to
make a personal attempt on the Makonde bush. The present edge of
the plateau is the result of a far-reaching process of destruction
through erosion and denudation. The Makonde strata are
everywhere cut into by ravines, which, though short, are hundreds of
yards in depth. In consequence of the loose stratification of these
beds, not only are the walls of these ravines nearly vertical, but their
upper end is closed by an equally steep escarpment, so that the
western edge of the Makonde plateau is hemmed in by a series of
deep, basin-like valleys. In order to get from one side of such a ravine
to the other, I cut my way through the bush with a dozen of my men.
It was a very open part, with more grass than scrub, but even so the
short stretch of less than two hundred yards was very hard work; at
the end of it the men’s calicoes were in rags and they themselves
bleeding from hundreds of scratches, while even our strong khaki
suits had not escaped scatheless.

NATIVE PATH THROUGH THE MAKONDE BUSH, NEAR

MAHUTA

I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
 The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.

MAKONDE LOCK AND KEY AT JUMBE CHAURO

 This is the general way of closing a house. The Makonde at Jumbe
Chauro, however, have a much more complicated, solid and original
one. Here, too, the door is as already described, except that there is
only one post on the inside, standing by itself about six inches from
one side of the doorway. Opposite this post is a hole in the wall just
large enough to admit a man’s arm. The door is closed inside by a
large wooden bolt passing through a hole in this post and pressing
with its free end against the door. The other end has three holes into
which fit three pegs running in vertical grooves inside the post. The
door is opened with a wooden key about a foot long, somewhat
curved and sloped off at the butt; the other end has three pegs
corresponding to the holes, in the bolt, so that, when it is thrust
through the hole in the wall and inserted into the rectangular
opening in the post, the pegs can be lifted and the bolt drawn out.[50]

MODE OF INSERTING THE KEY

With no small pride first one householder and then a second

showed me on the spot the action of this greatest invention of the
Makonde Highlands. To both with an admiring exclamation of
“Vizuri sana!” (“Very fine!”). I expressed the wish to take back these
marvels with me to Ulaya, to show the Wazungu what clever fellows
the Makonde are. Scarcely five minutes after my return to camp at
Newala, the two men came up sweating under the weight of two
heavy logs which they laid down at my feet, handing over at the same
time the keys of the fallen fortress. Arguing, logically enough, that if
the key was wanted, the lock would be wanted with it, they had taken
their axes and chopped down the posts—as it never occurred to them
to dig them out of the ground and so bring them intact. Thus I have
two badly damaged specimens, and the owners, instead of praise,
come in for a blowing-up.
The Makua huts in the environs of Newala are especially
miserable; their more than slovenly construction reminds one of the
temporary erections of the Makua at Hatia’s, though the people here
have not been concerned in a war. It must therefore be due to
congenital idleness, or else to the absence of a powerful chief. Even
the baraza at Mlipa’s, a short hour’s walk south-east of Newala,
shares in this general neglect. While public buildings in this country
are usually looked after more or less carefully, this is in evident
danger of being blown over by the first strong easterly gale. The only
attractive object in this whole district is the grave of the late chief
Mlipa. I visited it in the morning, while the sun was still trying with
partial success to break through the rolling mists, and the circular
grove of tall euphorbias, which, with a broken pot, is all that marks
the old king’s resting-place, impressed one with a touch of pathos.
Even my very materially-minded carriers seemed to feel something
of the sort, for instead of their usual ribald songs, they chanted
solemnly, as we marched on through the dense green of the Makonde
bush:—
 “We shall arrive with the great master; we stand in a row and have
no fear about getting our food and our money from the Serkali (the
Government). We are not afraid; we are going along with the great
master, the lion; we are going down to the coast and back.”
With regard to the characteristic features of the various tribes here
on the western edge of the plateau, I can arrive at no other
conclusion than the one already come to in the plain, viz., that it is
impossible for anyone but a trained anthropologist to assign any
given individual at once to his proper tribe. In fact, I think that even
an anthropological specialist, after the most careful examination,
might find it a difficult task to decide. The whole congeries of peoples
collected in the region bounded on the west by the great Central
African rift, Tanganyika and Nyasa, and on the east by the Indian
Ocean, are closely related to each other—some of their languages are
only distinguished from one another as dialects of the same speech,
and no doubt all the tribes present the same shape of skull and
structure of skeleton. Thus, surely, there can be no very striking
differences in outward appearance.
 Even did such exist, I should have no time
to concern myself with them, for day after day,
I have to see or hear, as the case may be—in
any case to grasp and record—an
extraordinary number of ethnographic
phenomena. I am almost disposed to think it
fortunate that some departments of inquiry, at
least, are barred by external circumstances.
Chief among these is the subject of iron-
working. We are apt to think of Africa as a
country where iron ore is everywhere, so to
speak, to be picked up by the roadside, and
where it would be quite surprising if the
inhabitants had not learnt to smelt the
material ready to their hand. In fact, the
knowledge of this art ranges all over the
continent, from the Kabyles in the north to the
Kafirs in the south. Here between the Rovuma
and the Lukuledi the conditions are not so
favourable. According to the statements of the
Makonde, neither ironstone nor any other
form of iron ore is known to them. They have
not therefore advanced to the art of smelting
the metal, but have hitherto bought all their
THE ANCESTRESS OF
THE MAKONDE
iron implements from neighbouring tribes.
Even in the plain the inhabitants are not much
better off. Only one man now living is said to
understand the art of smelting iron. This old fundi lives close to
Huwe, that isolated, steep-sided block of granite which rises out of
the green solitude between Masasi and Chingulungulu, and whose
jagged and splintered top meets the traveller’s eye everywhere. While
still at Masasi I wished to see this man at work, but was told that,
frightened by the rising, he had retired across the Rovuma, though
he would soon return. All subsequent inquiries as to whether the
fundi had come back met with the genuine African answer, “Bado”
(“Not yet”).
 BRAZIER

Some consolation was afforded me by a brassfounder, whom I

came across in the bush near Akundonde’s. This man is the favourite
of women, and therefore no doubt of the gods; he welds the glittering
brass rods purchased at the coast into those massive, heavy rings
which, on the wrists and ankles of the local fair ones, continually give
me fresh food for admiration. Like every decent master-craftsman he
had all his tools with him, consisting of a pair of bellows, three
crucibles and a hammer—nothing more, apparently. He was quite
willing to show his skill, and in a twinkling had fixed his bellows on
the ground. They are simply two goat-skins, taken off whole, the four
legs being closed by knots, while the upper opening, intended to
admit the air, is kept stretched by two pieces of wood. At the lower
end of the skin a smaller opening is left into which a wooden tube is
stuck. The fundi has quickly borrowed a heap of wood-embers from
the nearest hut; he then fixes the free ends of the two tubes into an
earthen pipe, and clamps them to the ground by means of a bent
piece of wood. Now he fills one of his small clay crucibles, the dross
on which shows that they have been long in use, with the yellow
material, places it in the midst of the embers, which, at present are
only faintly glimmering, and begins his work. In quick alternation
the smith’s two hands move up and down with the open ends of the
bellows; as he raises his hand he holds the slit wide open, so as to let
the air enter the skin bag unhindered. In pressing it down he closes
the bag, and the air puffs through the bamboo tube and clay pipe into
the fire, which quickly burns up. The smith, however, does not keep
on with this work, but beckons to another man, who relieves him at
the bellows, while he takes some more tools out of a large skin pouch
carried on his back. I look on in wonder as, with a smooth round
stick about the thickness of a finger, he bores a few vertical holes into
the clean sand of the soil. This should not be difficult, yet the man
seems to be taking great pains over it. Then he fastens down to the
ground, with a couple of wooden clamps, a neat little trough made by
splitting a joint of bamboo in half, so that the ends are closed by the
two knots. At last the yellow metal has attained the right consistency,
and the fundi lifts the crucible from the fire by means of two sticks
split at the end to serve as tongs. A short swift turn to the left—a
tilting of the crucible—and the molten brass, hissing and giving forth
clouds of smoke, flows first into the bamboo mould and then into the
holes in the ground.
The technique of this backwoods craftsman may not be very far
advanced, but it cannot be denied that he knows how to obtain an
adequate result by the simplest means. The ladies of highest rank in
this country—that is to say, those who can afford it, wear two kinds
of these massive brass rings, one cylindrical, the other semicircular
in section. The latter are cast in the most ingenious way in the
bamboo mould, the former in the circular hole in the sand. It is quite
a simple matter for the fundi to fit these bars to the limbs of his fair
customers; with a few light strokes of his hammer he bends the
pliable brass round arm or ankle without further inconvenience to
the wearer.
SHAPING THE POT

SMOOTHING WITH MAIZE-COB

CUTTING THE EDGE

 FINISHING THE BOTTOM

LAST SMOOTHING BEFORE

BURNING

FIRING THE BRUSH-PILE

 LIGHTING THE FARTHER SIDE OF
THE PILE

TURNING THE RED-HOT VESSEL

NYASA WOMAN MAKING POTS AT MASASI

Pottery is an art which must always and everywhere excite the
interest of the student, just because it is so intimately connected with
the development of human culture, and because its relics are one of
the principal factors in the reconstruction of our own condition in
prehistoric times. I shall always remember with pleasure the two or
three afternoons at Masasi when Salim Matola’s mother, a slightly-
built, graceful, pleasant-looking woman, explained to me with
touching patience, by means of concrete illustrations, the ceramic art
of her people. The only implements for this primitive process were a
lump of clay in her left hand, and in the right a calabash containing
the following valuables: the fragment of a maize-cob stripped of all
its grains, a smooth, oval pebble, about the size of a pigeon’s egg, a
few chips of gourd-shell, a bamboo splinter about the length of one’s
hand, a small shell, and a bunch of some herb resembling spinach.
 Nothing more. The woman scraped with the
shell a round, shallow hole in the soft, fine
sand of the soil, and, when an active young
girl had filled the calabash with water for her,
she began to knead the clay. As if by magic it
gradually assumed the shape of a rough but
already well-shaped vessel, which only wanted
a little touching up with the instruments
before mentioned. I looked out with the
MAKUA WOMAN closest attention for any indication of the use
MAKING A POT. of the potter’s wheel, in however rudimentary
SHOWS THE a form, but no—hapana (there is none). The
BEGINNINGS OF THE embryo pot stood firmly in its little
POTTER’S WHEEL
depression, and the woman walked round it in
a stooping posture, whether she was removing
small stones or similar foreign bodies with the maize-cob, smoothing
the inner or outer surface with the splinter of bamboo, or later, after
letting it dry for a day, pricking in the ornamentation with a pointed
bit of gourd-shell, or working out the bottom, or cutting the edge
with a sharp bamboo knife, or giving the last touches to the finished
vessel. This occupation of the women is infinitely toilsome, but it is
without doubt an accurate reproduction of the process in use among
our ancestors of the Neolithic and Bronze ages.
There is no doubt that the invention of pottery, an item in human
progress whose importance cannot be over-estimated, is due to
women. Rough, coarse and unfeeling, the men of the horde range
over the countryside. When the united cunning of the hunters has
succeeded in killing the game; not one of them thinks of carrying
home the spoil. A bright fire, kindled by a vigorous wielding of the
drill, is crackling beside them; the animal has been cleaned and cut
up secundum artem, and, after a slight singeing, will soon disappear
under their sharp teeth; no one all this time giving a single thought
to wife or child.
To what shifts, on the other hand, the primitive wife, and still more
the primitive mother, was put! Not even prehistoric stomachs could
endure an unvarying diet of raw food. Something or other suggested
the beneficial effect of hot water on the majority of approved but
indigestible dishes. Perhaps a neighbour had tried holding the hard
roots or tubers over the fire in a calabash filled with water—or maybe
an ostrich-egg-shell, or a hastily improvised vessel of bark. They
became much softer and more palatable than they had previously
been; but, unfortunately, the vessel could not stand the fire and got
charred on the outside. That can be remedied, thought our
ancestress, and plastered a layer of wet clay round a similar vessel.
This is an improvement; the cooking utensil remains uninjured, but
the heat of the fire has shrunk it, so that it is loose in its shell. The
next step is to detach it, so, with a firm grip and a jerk, shell and
kernel are separated, and pottery is invented. Perhaps, however, the
discovery which led to an intelligent use of the burnt-clay shell, was
made in a slightly different way. Ostrich-eggs and calabashes are not
to be found in every part of the world, but everywhere mankind has
arrived at the art of making baskets out of pliant materials, such as
bark, bast, strips of palm-leaf, supple twigs, etc. Our inventor has no
water-tight vessel provided by nature. “Never mind, let us line the
basket with clay.” This answers the purpose, but alas! the basket gets
burnt over the blazing fire, the woman watches the process of
cooking with increasing uneasiness, fearing a leak, but no leak
appears. The food, done to a turn, is eaten with peculiar relish; and
the cooking-vessel is examined, half in curiosity, half in satisfaction
at the result. The plastic clay is now hard as stone, and at the same
time looks exceedingly well, for the neat plaiting of the burnt basket
is traced all over it in a pretty pattern. Thus, simultaneously with
pottery, its ornamentation was invented.
Primitive woman has another claim to respect. It was the man,
roving abroad, who invented the art of producing fire at will, but the
woman, unable to imitate him in this, has been a Vestal from the
earliest times. Nothing gives so much trouble as the keeping alight of
the smouldering brand, and, above all, when all the men are absent
from the camp. Heavy rain-clouds gather, already the first large
drops are falling, the first gusts of the storm rage over the plain. The
little flame, a greater anxiety to the woman than her own children,
flickers unsteadily in the blast. What is to be done? A sudden thought
occurs to her, and in an instant she has constructed a primitive hut
out of strips of bark, to protect the flame against rain and wind.
This, or something very like it, was the way in which the principle
of the house was discovered; and even the most hardened misogynist
cannot fairly refuse a woman the credit of it. The protection of the
hearth-fire from the weather is the germ from which the human
dwelling was evolved. Men had little, if any share, in this forward
step, and that only at a late stage. Even at the present day, the
plastering of the housewall with clay and the manufacture of pottery
are exclusively the women’s business. These are two very significant
survivals. Our European kitchen-garden, too, is originally a woman’s
invention, and the hoe, the primitive instrument of agriculture, is,
characteristically enough, still used in this department. But the
noblest achievement which we owe to the other sex is unquestionably
the art of cookery. Roasting alone—the oldest process—is one for
which men took the hint (a very obvious one) from nature. It must
have been suggested by the scorched carcase of some animal
overtaken by the destructive forest-fires. But boiling—the process of
improving organic substances by the help of water heated to boiling-
point—is a much later discovery. It is so recent that it has not even
yet penetrated to all parts of the world. The Polynesians understand
how to steam food, that is, to cook it, neatly wrapped in leaves, in a
hole in the earth between hot stones, the air being excluded, and
(sometimes) a few drops of water sprinkled on the stones; but they
do not understand boiling.
To come back from this digression, we find that the slender Nyasa
woman has, after once more carefully examining the finished pot,
put it aside in the shade to dry. On the following day she sends me
word by her son, Salim Matola, who is always on hand, that she is
going to do the burning, and, on coming out of my house, I find her
already hard at work. She has spread on the ground a layer of very
dry sticks, about as thick as one’s thumb, has laid the pot (now of a
yellowish-grey colour) on them, and is piling brushwood round it.
My faithful Pesa mbili, the mnyampara, who has been standing by,
most obligingly, with a lighted stick, now hands it to her. Both of
them, blowing steadily, light the pile on the lee side, and, when the
flame begins to catch, on the weather side also. Soon the whole is in a
blaze, but the dry fuel is quickly consumed and the fire dies down, so
that we see the red-hot vessel rising from the ashes. The woman
turns it continually with a long stick, sometimes one way and
sometimes another, so that it may be evenly heated all over. In
twenty minutes she rolls it out of the ash-heap, takes up the bundle
of spinach, which has been lying for two days in a jar of water, and
sprinkles the red-hot clay with it. The places where the drops fall are
marked by black spots on the uniform reddish-brown surface. With a
sigh of relief, and with visible satisfaction, the woman rises to an
erect position; she is standing just in a line between me and the fire,
from which a cloud of smoke is just rising: I press the ball of my
camera, the shutter clicks—the apotheosis is achieved! Like a
priestess, representative of her inventive sex, the graceful woman
stands: at her feet the hearth-fire she has given us beside her the
invention she has devised for us, in the background the home she has
built for us.
At Newala, also, I have had the manufacture of pottery carried on
in my presence. Technically the process is better than that already
described, for here we find the beginnings of the potter’s wheel,
which does not seem to exist in the plains; at least I have seen
nothing of the sort. The artist, a frightfully stupid Makua woman, did
not make a depression in the ground to receive the pot she was about
to shape, but used instead a large potsherd. Otherwise, she went to
work in much the same way as Salim’s mother, except that she saved
herself the trouble of walking round and round her work by squatting
at her ease and letting the pot and potsherd rotate round her; this is
surely the first step towards a machine. But it does not follow that
the pot was improved by the process. It is true that it was beautifully
rounded and presented a very creditable appearance when finished,
but the numerous large and small vessels which I have seen, and, in
part, collected, in the “less advanced” districts, are no less so. We
moderns imagine that instruments of precision are necessary to
produce excellent results. Go to the prehistoric collections of our
museums and look at the pots, urns and bowls of our ancestors in the
dim ages of the past, and you will at once perceive your error.
MAKING LONGITUDINAL CUT IN
BARK

DRAWING THE BARK OFF THE LOG

REMOVING THE OUTER BARK

 BEATING THE BARK

WORKING THE BARK-CLOTH AFTER BEATING, TO MAKE IT

SOFT

MANUFACTURE OF BARK-CLOTH AT NEWALA

To-day, nearly the whole population of German East Africa is
clothed in imported calico. This was not always the case; even now in
some parts of the north dressed skins are still the prevailing wear,
and in the north-western districts—east and north of Lake
Tanganyika—lies a zone where bark-cloth has not yet been
superseded. Probably not many generations have passed since such
bark fabrics and kilts of skins were the only clothing even in the
south. Even to-day, large quantities of this bright-red or drab
material are still to be found; but if we wish to see it, we must look in
the granaries and on the drying stages inside the native huts, where
it serves less ambitious uses as wrappings for those seeds and fruits
which require to be packed with special care. The salt produced at
Masasi, too, is packed for transport to a distance in large sheets of
bark-cloth. Wherever I found it in any degree possible, I studied the
process of making this cloth. The native requisitioned for the
purpose arrived, carrying a log between two and three yards long and
as thick as his thigh, and nothing else except a curiously-shaped
mallet and the usual long, sharp and pointed knife which all men and
boys wear in a belt at their backs without a sheath—horribile dictu!
[51]
Silently he squats down before me, and with two rapid cuts has
drawn a couple of circles round the log some two yards apart, and
slits the bark lengthwise between them with the point of his knife.
With evident care, he then scrapes off the outer rind all round the
log, so that in a quarter of an hour the inner red layer of the bark
shows up brightly-coloured between the two untouched ends. With
some trouble and much caution, he now loosens the bark at one end,
and opens the cylinder. He then stands up, takes hold of the free
edge with both hands, and turning it inside out, slowly but steadily
pulls it off in one piece. Now comes the troublesome work of
scraping all superfluous particles of outer bark from the outside of
the long, narrow piece of material, while the inner side is carefully
scrutinised for defective spots. At last it is ready for beating. Having
signalled to a friend, who immediately places a bowl of water beside
him, the artificer damps his sheet of bark all over, seizes his mallet,
lays one end of the stuff on the smoothest spot of the log, and
hammers away slowly but continuously. “Very simple!” I think to
myself. “Why, I could do that, too!”—but I am forced to change my
opinions a little later on; for the beating is quite an art, if the fabric is
not to be beaten to pieces. To prevent the breaking of the fibres, the
stuff is several times folded across, so as to interpose several
thicknesses between the mallet and the block. At last the required
state is reached, and the fundi seizes the sheet, still folded, by both
ends, and wrings it out, or calls an assistant to take one end while he
holds the other. The cloth produced in this way is not nearly so fine
and uniform in texture as the famous Uganda bark-cloth, but it is
quite soft, and, above all, cheap.
Now, too, I examine the mallet. My craftsman has been using the
simpler but better form of this implement, a conical block of some
hard wood, its base—the striking surface—being scored across and
across with more or less deeply-cut grooves, and the handle stuck
into a hole in the middle. The other and earlier form of mallet is
shaped in the same way, but the head is fastened by an ingenious
network of bark strips into the split bamboo serving as a handle. The
observation so often made, that ancient customs persist longest in
connection with religious ceremonies and in the life of children, here
finds confirmation. As we shall soon see, bark-cloth is still worn
during the unyago,[52] having been prepared with special solemn
ceremonies; and many a mother, if she has no other garment handy,
will still put her little one into a kilt of bark-cloth, which, after all,
looks better, besides being more in keeping with its African
surroundings, than the ridiculous bit of print from Ulaya.
MAKUA WOMEN