310 Pain Management
suggestions that these treatments can result in changes of be-
liefs about pain, coping style, and reported pain severity, as
well as direct behavior changes. Further, treatment that re-
sults in increases in perceived control over pain and de-
creased catastrophizing also results in decreases in pain
severity and functional disability. When successful rehabilita-
tion occurs, there is a major cognitive shift from beliefs about
helplessness and passivity to resourcefulness and ability to
function regardless of pain, and from an illness conviction to
a rehabilitation conviction (M. P. Jensen, Turner, & Romano,
1994; Tota-Faucette, Gil, Williams, Keefe, & Goli, 1993).
The complexity of chronic pain that we have described
suggests that no single health care professional or discipline
is likely to prove effective for a large number of patients by
itself. Over the past 30 years, this observation has resulted in
the development of multidisciplinary pain rehabilitation pro-
grams (MPRP) designed to deal with the complexities.
PATIENT-UNIFORMITY MYTH
There are a number of chronic pain syndromes (e.g., low back
pain, “bromyalgia syndrome, temporomandibular disorders,
migraine, pelvic pain). These disorders do not have known
pathology and commonly they are de“ned by vague and often
exclusionary criteria. Despite unknown pathology, these pain
syndromes create a great deal of suffering and disability. The
lack of understanding of the underlying mechanisms of the
chronic pain syndromes has not inhibited attempts to treat pa-
tients with quite diverse modalities. Yet, to date, these syn-
dromes remain largely recalcitrant to all treatments.
What is quite evident is the fact that the treatment of many
chronic pain syndromes has been based on the traditional
model where the intervention is matched to symptoms and
medical diagnoses even when crudely de“ned. Prescribing
treatment based on medical diagnoses is logical when there is
a known etiology, but this approach has no basis when the
causes are unknown. When there is no consensus regarding
what treatment should be prescribed, the choice becomes
empirical, delivered on a trial-and-error basis and at times
motivated by pecuniary interests. This may explain why so
many treatments have been applied to patients with identical
diagnoses. Chronic pain patients have tended to be treated as
a homogeneous group for whom a common treatment is
deemed appropriate.
Few attempts have been made to individualize treatments
matched to unique patient characteristics. It is common to
see patients with a wide range of diagnoses and locations
of pain, not to mention demographics, and psychosocial
differences treated with the identical treatments (e.g., pain
rehabilitation). In short, we have adopted the patient unifor-
mity mythwhere all patients with the same diagnosis, no
matter how vague, are treated in a similar fashion.
We need to develop a broader conceptualization of
chronic pain patients in order to develop a more effective
approach to treating them. It has become apparent that simply
identifying physical factors and arriving at a diagnosis, and
subsequently prescribing somatic treatments, will not ame-
liorate symptoms for a signi“cant number of patients with
prevalent pain syndromes. Variability in treatment outcome is
understandable when we consider that pain is a personal
experience in”uenced by attention, anxiety, prior learning
history, meaning of the situation, reinforcement contingen-
cies, and other psychosocial variables. The wisdom of treat-
ing the person with the symptom or disease and not just the
symptom or disease seems particularly apt.
There is a great deal of published data suggesting that at-
tention needs to be given to identifying the characteristics of
patients who improve and those who fail to improve (Turk,
1990). Treatment should be prescribed only for those patients
who are likely to derive signi“cant bene“t. The ability to
identify characteristics of patients who do notbene“t from a
speci“c treatment should facilitate the development of inno-
vative treatment approaches tailored to the needs of those
patients.
Identifying responses to treatment by groups of patients
with different characteristics (e.g., demographics and per-
sonality) has a long tradition in pain treatment outcome
research. Many individual difference and demographic vari-
ables have been examined to determine who bene“ts from
treatment. The results have not consistently identi“ed spe-
ci“c demographic, disease status, pain history, prior treat-
ments, litigation/compensation, or psychological features
that consistently predict successful treatment outcome.
Attempts to identify subgroups of chronic pain patients
have tended to focus on single factors such as signs and
symptoms, demographics, psychopathology, idiosyncratic
thinking patterns, and behavioral expression. Rehabilitative
outcomes, however, are likely to be determined by the inter-
active effects of multiple factors; single factors may not be
adequate to account for a statistically signi“cant or clinically
meaningful proportion of the variance in outcome. The delin-
eation of homogeneous subgroups among pain patients
would provide a framework for the development of speci“c,
optimal treatment regimens for speci“c pain-patient sub-
groups when treatment can be matched to assessment or rele-
vant variables areas: (a) that are reasonably distinct and not
highly correlated, (b) when valid measures of these response
classes are available, and (c) when treatments that affect
these response classes are available. Although patient