Cognitive-Behavioral Model for the Treatment of Chronic Pain 309less of a concern than the view of an interactive process that
extends over time with the interaction of thoughts, feelings,
physiological activity, and behavior.
The CB perspectives is unique in that it emphasizes the
reciprocal effects of the person on the environment and the
in”uence of environment on the person and his or her behav-
ior. The third assumption of the CB perspective, therefore,
is that behavior is reciprocally determined by both the envi-
ronment and the person. People not only passively respond to
their environment but also elicit environmental responses by
their behavior. In a very real sense, people create their envi-
ronments. The person who becomes aware of a physical
event (symptoms) and decides the symptom requires atten-
tion from a health care provider initiates a differing set of
circumstances than a person with the same symptom who
chooses to self-medicate or to ignore the symptoms.
A fourth assumption is that if people have learned mal-
adaptive ways of thinking, feeling, and responding, then suc-
cessful interventions designed to alter behavior should focus
on these maladaptive thoughts, feelings, physiology, as well
as behaviors and not on one to the exclusion of the others.
There is no expectancy that changing only thoughts, or feel-
ings, or behaviors will necessarily result in changes in the
other two areas.
The “nal assumption is that in the same way as people are
instrumental in the development and maintenance of mal-
adaptive thoughts, feelings, and behaviors; they can, are, and
should be considered active agents of change of their mal-
adaptive modes of responding. Chronic pain sufferers, no
matter how severe, despite common beliefs to the contrary,
are not helpless pawns of fate. They can and should become
instrumental in learning and carrying out more effective
modes of responding to their environment and their plight.
From the CB perspective, people with pain are viewed as
having negative expectations about their own ability to
control certain motor skills without pain. Moreover, pain
patients tend to believe they have limited ability to exert any
control over their pain. Such negative, maladaptive appraisals
about the situation and personal ef“cacy may reinforce the
experience of demoralization, inactivity, and overreaction to
nociceptive stimulation. These cognitive appraisals and ex-
pectations are postulated as having an effect on behavior
leading to reduced efforts and activity, which may contribute
to increased psychological distress (helplessness) and subse-
quent physical limitations. If we accept that pain is a com-
plex, subjective phenomenon that is uniquely experienced by
each person, then knowledge about idiosyncratic beliefs, ap-
praisals, and coping repertoires becomes critical for optimal
treatment planning and for accurately evaluating treatment
outcome.
Pain sufferers• beliefs, appraisals, and expectations about
pain, their ability to cope, social supports, their disorder, the
medicolegal system, the health care system, and their em-
ployers are all important because they may facilitate or disrupt
the sufferer•s sense of control. These factors also in”uence pa-
tients• investment in treatment, acceptance of responsibility,
perceptions of disability, adherence to treatment recommen-
dations, support they seek from signi“cant others, expectan-
cies for treatment, and acceptance of treatment rationale.
Cognitive interpretations also affect how patients present
symptoms to others, including health care providers. Overt
communication of pain, suffering, and distress will enlist re-
sponses that may reinforce pain behaviors and impressions
about the seriousness, severity, and uncontrollability of pain.
That is, complaints of pain may induce physicians to pre-
scribe more potent medications, order additional diagnostic
tests, and, in some cases perform invasive procedures
(Turk & Okifuji, 1997). Signi“cant others may express sym-
pathy, excuse the patient from responsibilities, and encourage
passivity, thereby fostering further physical deconditioning.
The CB perspective integrates the operant conditioning em-
phasis on external reinforcement and respondent view of
conditioned avoidance within the framework of information
processing.
People with persistent pain often have negative expecta-
tions about their own ability and responsibility to exert any
control over their pain. Moreover, they often view themselves
as helpless. Such negative, maladaptive appraisals about their
condition, situation, and their personal ef“cacy in controlling
their pain and problems associated with pain reinforce their
experience of demoralization, inactivity, and overreaction
to nociceptive stimulation. These cognitive appraisals are
posited as having an effect on behavior, leading to reduced ef-
fort, reduce perseverance in the face of dif“culty, and reduced
activity and increased psychological distress.
The CB perspective on pain management focuses on pro-
viding the patients with techniques to help them gain a sense
of control over the effects of pain on their life as well as ac-
tually modifying the affective, behavioral, cognitive, and
sensory facets of the experience. Behavioral experiences help
to show pain sufferers• that they are capable of more than
they assumed, increasing their sense of personal competence.
Cognitive techniques (for example, self-monitoring to iden-
tify relationship among thoughts, mood, and behavior,
distraction using imagery, and problem solving) help to place
affective, behavioral, cognitive, and sensory responses under
the person•s control.
The assumption is that long-term maintenance of be-
havioral changes will occur only if the pain sufferer has
learned to attribute success to his or her own efforts. There are