analgesics (Holroyd et al., 1991). Moreover, an influential recent review or reviews
found that, for chronic pain, the strongest evidence for effectiveness across all psycho -
logical interventions was for cognitive behavioural therapy with a focus on cognitive
coping strategies and behavioural rehearsal (Eccleston, Morley and Williams, 2013).
Change techniques can also focus directly on pain-related behaviour with a view
to enhancing activity and quality of life rather than pain reduction. Application
of change techniques based on the principles of operant conditioning such as extinction
and reinforcement were pioneered by Fordyce (1976). Central to this approach is
the assumption that pain behaviours (e.g. withdrawal, lying down, crying, limping,
reliance on medication) are learned responses that become conditioned through
reinforcement (e.g. receiving attention, sympathy and care in response to pain behav -
iour and avoiding anticipated pain by taking analgesic medication). Therefore, this
approach seeks to:
1 reinforce adaptive ‘well’ behaviours such as walking without limping after a minor
operation;
2 encourage family and friends not to attend to or reward pain behaviours; and
3 provide analgesic medication on a fixed schedule (e.g. every 4 hours) and not when
the patient requests it or is in pain.
Each of these change techniques has been found to successfully reinforce new
adaptive behaviour patterns and to extinguish previous maladaptive behaviour (Horn
and Munafo, 1998). For example, patients’ reliance on medication can be reduced over
a short period of time. By providing the medication on a fixed schedule, receiving it
becomes independent of requests for it and as a result, reinforcing effects are eliminated.
Over a couple of weeks, the dosage of medication can be reduced by mixing it with
a flavoured syrup to mask the taste and then gradually reducing the amount of the
analgesic in the mixture.
Pain experiences such as headache pain and chronic back pain are caused by changes
in physiological processes, which are frequently triggered by stress. Consequently,
relaxation and biofeedback techniques are used to help patients manage stress. Typically
progressive muscle relaxation is used in which patients learn to relax and tighten different
muscle groups in a quiet, comfortable environment for approximately 20 to 40 minutes
in weekly sessions over a number of months. Once trained, patients are encouraged to
use this technique whenever they feel a painful or stressful episode is developing.
Biofeedback is a technique in which a patient learns to exert control over basic
autonomic bodily processes such as blood pressure, heart rate and blood flow as well
as learning to gain increased control over voluntary processes such as muscle tension.
Feedback is achieved by placing electrodes and transducers on the skin that can detect
and convert bodily signals such as temperature, galvanic skin response and blood flow
into electrical signals, which are then typically transmitted as a tone. Through training
and hearing the tone change when a specific muscle group is relaxed, patients can learn
to exert control over muscles previously not under their voluntary control. Progressive
muscle relaxation and biofeedback have both been found to be effective (e.g. Andrasik
and Schwartz, 2006). However, these techniques may have limited impact in patients
suffering from severe chronic pain and therefore are often used in combination with
other techniques (e.g. Holroyd et al., 2001).
RELATING TO PATIENTS 251