308 Pain Management
Use of the health care system and analgesic medication are
other ways to assess pain behaviors. Patients can record the
times when they take medication over a speci“ed interval
such as a week. Diaries not only provide information about
the frequency and quantity of medication but may also permit
identi“cation of the antecedent and consequent events of
medication use. For example, a patient might note that he took
medication after an argument with his wife and that when she
saw him taking the medication she expressed sympathy.
Antecedent events might include stress, boredom, or activity.
Examination of antecedent is useful in identifying patterns of
medication use that may be associated with factors other than
pain per se. Similarly, patterns of response to the use of anal-
gesics may be identi“ed. Does the patient receive attention
and sympathy whenever he or she is observed by signi“cant
others taking medication? That is, do signi“cant others pro-
vide positive reinforcement for the taking of analgesic med-
ication and thereby unwittingly increase medication use?
COGNITIVE-BEHAVIORAL MODEL FOR
THE TREATMENT OF CHRONIC PAIN
The cognitive-behavioral model (CBM) has become the most
commonly accepted psychological treatment choice of
chronic pain patients (Morley, Eccleston, & Williams, 1999).
The CBM perspective suggests that behaviors and emotions
are in”uenced by interpretations of events, rather than solely
by the objective characteristics of an event itself. Rather than
focusing on the contribution of cognitive and emotional fac-
tors to the perception of a set of symptoms in a static fashion,
emphasis is placed on the reciprocal relationships among
physical, cognitive, affective, and behavioral factors.
CBM incorporates many of the psychological variables
described, namely, anticipation, avoidance, and contingen-
cies of reinforcement, but suggests that cognitive factors, in
particular, expectations rather than conditioning factors are
central. The CBM approach suggests that conditioned re-
actions are largely self-activated on the basis of learned
expectations rather than automatically evoked. The critical
factor for CBM, therefore, is not that events occur together in
time but that people learn to predict them and to summon
appropriate reactions. It is the person•s processing of infor-
mation that results in anticipatory anxiety and avoidance.
According to the CBM approach, it is peoples• idiosyn-
cratic attitudes, beliefs, and unique representations that “lter
and interact reciprocally with emotional factors, social in”u-
ences, behavioral responses, and sensory phenomena. More-
over, peoples• behaviors elicit responses from signi“cant
others that can reinforce both adaptive and maladaptive
modes of thinking, feeling, and behaving. Thus, a reciprocal
and synergistic model is proposed. One effective CB inter-
viewing and intervention technique is the introduction of
self-monitoring records of symptoms, feelings, thoughts, and
actions. Such daily diaries are useful diagnostically and clin-
ically. They have the potential of demonstrating to the clini-
cian and the patients the patterns of maladaptive thinking and
pain behaviors that may be contributing to their pain experi-
ence. Self-monitoring records can be used for many pur-
poses, such as allowing the therapist to know when ”are-ups
occur; identifying the precedents and antecedents of painful
episodes; and determining target behaviors, thoughts, and
feelings that should be addressed during therapy sessions.
There are “ve central assumptions that characterize the
CB approach (summarized in Table 13.2). The “rst assump-
tion is that all people are active processors of information
rather than passive reactors to environmental contingencies.
People attempt to make sense of the stimuli from the external
environment by “ltering information through or ganizing at-
titudes derived from their prior learning histories and by
general strategies that guide the processing of information.
People•s responses (overt as well as covert) are based on
these appraisals and subsequent expectations and are not to-
tally dependent on the actual consequences of their behaviors
(i.e., positive and negative reinforcements and punishments).
From this perspective, anticipated consequences are as im-
portant in guiding behavior as are the actual consequences.
A second assumption of the CB approach is that one•s
thoughts (e.g., appraisals, attributions, and expectations) can
elicit or modulate affect and physiological arousal, both of
which may serve as impetuses for behavior. Conversely, af-
fect, physiology, and behavior can instigate or in”uence think-
ing processes. Thus, the causal priority depends on where in
the cycle the person chooses to begin. Causal priority may beTABLE 13.2 Assumptions of Cognitive-Behavioral Perspective- People are active processors of information rather than passive reactors
to environmental contingencies. - Thoughts (for example, appraisals, attributions, expectancies) can elicit
or modulate affect and physiological arousal, both of which may serve
as impetuses for behavior. Conversely, affect, physiology, and behavior
can instigate or in”uence a person•s thinking processes. - Behavior is reciprocally determined by both the environment and the
individual. - If people have learned maladaptive ways of thinking, feeling, and
responding, then successful interventions designed to alter behavior
should focus on each of these maladaptive thoughts, feelings,
physiology, as well as behaviors and not one to the exclusion of the
others. - In the same way as people are instrumental in the development and
maintenance of maladaptive thoughts, feelings, and behaviors, they
can, are, and should be considered active agents of change of their
maladaptive modes of responding.