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16 Articles in Volume 20, Issue #5
20/20 with Drs. Carmen R. Green and Johnathan Goree: Racial Disparities in Pain Care
A Kratom Primer: Miracle Medicine or Herb of Abuse?
A Pilot Study: Incidence and Prediction of Diversion among Opioid Therapy Patients
Analgesics of the Future: G-Protein Biased Mu-Opioid Receptor Ligands
Application Note: Decellularized Human Placenta in the Treatment of Infracalcaneal Heel Pain
Are Clinicians Effectively Counseling Patients on Safe Opioid Storage and Disposal? Survey Results
Ask the PharmD: How to Manage Pain Meds During Pregnancy?
Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors
Case Report: Spinal Cord Stimulation for the Treatment of Pain Associated with Chronic Pancreatitis
Differential Diagnoses: Inflammatory or Non-inflammatory Chronic Back Pain?
Pelvic Inflammatory Disease: Diagnosis, Education, and Treatment Options
Product Review: Non-Invasive Neuromodulation for the Treatment of the Most Difficult Pain Conditions
Provider Perspective: Carpal Tunnel's Association with Hypothyroidism
Research Insights: Opioid Use During the Peripartum Period – What to Expect
Special Report: Race, Pain Management, and the System
When Patients Become Pregnant: How to Maintain Chronic Pain Management

Behavioral Medicine: Managing Anxiety and Maladaptive Behaviors

Specific learning processes for anxiety and coping can increase patient function and reduce pain-related distress.

This column marks the fourth in a series review of the Kreitler and Kreitler system developed for the treatment of pain and focuses on the behavioral component of pain distress. The other three components in the classification system – sensory, affective, and cognitive – can be reviewed in previous issues of PPM.1

Rooted in learning theory, behavioral treatments for chronic pain predominately focus on addressing anxiety and being hypervigilant about signals of possible pain, coupled with heightened fear of possible consequences. Behavioral approaches aim to increase the patient’s daily lifestyle functioning as opposed to decreasing nociception. However, these approaches tend to work best with patients who understand this concept and, thus, accept their pain condition.2,3  For example, Kreitler and Niv found that patients desiring that their chronic pain would just vanish served as a maladaptive coping strategy and treatment barrier.4

Chronic pain can cause increased psychological and emotional distress, such as frustration, anger, stress, and feelings of helplessness. Pain-treating clinicians can use behavioral psychotherapies to ease these signs of distress. (Image: iStock)

The original Kreitler and Kreitler classification of pain psychological treatment offered three examples of behavioral therapies for the treatment of chronic pain and pain behaviors:1

  • Behavioral therapy (BT)
  • Operant behavioral therapy (OBT)
  • Environmental therapy (ET)

The following review expands on these three to include:

  • Functional analytic psychotherapy (FAP)
  • Solution-focused brief therapy (SFBT)
  • Reality therapy (RT)

We offer a broad overview of each therapy and its effectiveness for treating pain-related distress. Chronic pain can cause increased psychological and emotional distress, such as frustration, anger, stress, and feelings of helplessness. The following behavioral psychotherapies can be used to ease these signs of distress.


Models of Behaviorism: Learning Theory 

In general, behavioral therapies are informed by three theories of learning:

  • classical
  • operant
  • social

Classical conditioning is a type of learning by association, where learning takes place due to the pairing of a neutral stimulus with an unconditioned stimulus. After enough pairing, the neutral stimulus becomes a conditioned stimulus. The important characteristic of classical conditioning is that the neutral stimulus be presented before the unconditioned stimulus. An unconditioned stimulus is akin to a biological, instinctual response − it is innate, known but not learned. For example, the startle response (eg, to a loud noise) is an unlearned response shared by all humans. With consistent pairing, an organism learns to associate the precursor with the loud sound. Eventually, with enough pairings, there is a learned fear response to the precursor of the loud noise.

Whereas in classical conditioning the neutral stimulus is presented before the unconditioned stimulus, in operant conditioning the consequences that occur after the behavior result in learning. The tenets of operant conditioning offer guidance on the impact of caregiver behavior on patients’ pain behaviors.Pain behaviors are overt or subtle behaviors that serve to reinforce pain identity and inhibit treatment outcomes. Initially considered adaptive for acute pain,5 pain behaviors become maladaptive over time in that they have been found to exacerbate chronicity and decrease functioning and quality of life.6

Finally, Bandura (1977) demonstrated the importance of observational learning in his social learning theory.7 His classic Bobo doll study showed that individuals learn to link behaviors and consequences through witnessing the consequences of others’ behavior. These observed consequences, therefore, inform future behaviors for the observer. For example, a classic study found that pre-operative patients who shared a hospital room with a post-operative patient, therefore witnessing their recovery, were less anxious prior to surgery and had a shorter hospital stay compared to their pre-operative counterparts in a private room, or those who shared a room with another pre-operative patient.8 Because of the focus on observable behavior, behavioral treatments often target pain behaviors, such as facial grimacing, limping, and vocalizations like moaning.


Behavioral Therapy

In behavioral therapy (BT), pain control is attained by reinforcing adaptive behavioral strategies, such as:

  • active problem solving
  • exercising
  • returning to work
  • engaging in social activities

while avoiding non-adaptive behavioral strategies, such as:

  • excessive use of prescription drugs
  • overcautious movements
  • gradual complaining

The primary goal of BT is to enhance adequate coping by using traditional behavioral techniques such as writing in a diary, setting specific goals, reinforcement (rewards and punishments), rehearsal, and generalization of coping strategies.

Often, behavioral coping strategies are integrated into other cognitive therapies, such as cognitive-behavioral therapy (CBT) and dialectical behavior therapy (DBT), which we reviewed as part of the cognitive components of pain. BT is often practiced in a group format. There is limited literature regarding the optimal dose of behavioral interventions for pain, however, brief treatments have garnered empirical support.9

Target Patients: Behavioral therapy has been found to be effective for chronic pain across studies.10 There is reportedly little to no difference between cognitive, combined (eg, cognitive-behavioral), or operant behavioral therapy for pain relief.11


Operant Behavioral Therapy

Operant behavioral therapy (OBT) programs were originally applied to the treatment of pain by Fordyce in the 1970s, and moved beyond the closed disease model aiming instead to alter environmental contingencies to reinforce adaptive behavior.12 In OBT, patients gain awareness of maladaptive pain behaviors (eg, medication misuse and excessive use of doctor visits) and learn to differentiate them from healthy coping. They learn to recognize the maintaining factors of pain behavior related to others and personal maladaptive cognitions (eg, catastrophizing). Physical exercise is an essential part of OBT for the training of motor perception, increasing personal physical activities, and reducing avoidance behavior, intake of medication, and excessive solicitous caregiver behavior.

Partner behavior often serves as an important environmental contingency impacting a patient’s pain behavior. Specifically, solicitous partner behaviors have been found to be preceded by maladaptive, nonverbal pain behavior regardless of age, gender, and pain intensity level.13-14 As a result, OBT programs work closely with partners/caregivers in the patient’s life and aim to understand and adaptively alter solicitous and negative partner response behavior. The more that partners reinforce adaptive behaviors, the less pain behavior is displayed by the patient.15

Target Patients: In a meta-analysis, researchers found moderate qualitative evidence for operant therapy to be more effective than the waitlist control.16 Further, OBT has been found to be more effective than cognitive-behavioral therapy (CBT) at reducing pain behaviors and physical impairment.17 The same study showed OBT and CBT performed similarly at reducing pain intensity at follow-up compared to an attention placebo control condition.



Environmental Therapy

Environmental therapy (ET) is based on conditioning. In ET, pain control is achieved through changes in the patient’s environment. Removal from the environment may be actual physical removal to another geographic location, such as a clinic, recovery house, or another setting. Removal can also take the form of changing stimuli or objects in the regular environment, such as furniture, the color of walls, and other objects with which the patient has a lot of contact. Looser definitions of the term environment may include changes to wardrobe and a person’s aesthetics, such as hairdos.

Environment alterations may include changes in lighting18 or sounds,19 but may even be virtual. However, exposure to nature appears to be the most widely investigated environmental therapy for the treatment of pain. These investigations include in vivo or in vitro exposure to natural landscapes.  

Target Patients: Investigations into the impact of nature versus urban environments showed that exposure to a nature environment positively impacted both physical and psychological health in samples of chronic pain patients.20-21 Moreover, a recent review of 64 studies that investigated the impact of the Japanese practice of forest bathing on health indices found improvements in heart rate variability, blood pressure, inflammation, and endocrine functioning as a result of exposure to nature or nature scenes.22 They also concluded that the same effects can be achieved by watching videos or viewing pictures of nature scenes, making this approach far more accessible for those who are unable to travel to a different environment because of physical or geographic limitations. 

In addition, virtual reality (VR) of scenic imagery has been found to reduce pain intensity, pain unpleasantness, and pain rumination.23 VR has been found to be more effective than two-dimensional video for the treatment of pain and pain behaviors.24


Functional Analytic Psychotherapy

Functional analytic psychotherapy (FAP) was developed by Kohlenberg and Tsai as an effort to understand how radical behavioral aspects of the therapeutic alliance promoted change.25 FAP is a present-focused, process approach that requires healthcare providers to have awareness of how their own reactions may have a reinforcing effect on their patients’ maladaptive pain behaviors. Healthcare providers are encouraged to communicate the patterns they notice within the interpersonal interactions they have with their patients in order to increase the patient’s awareness of these patterns.

Target Patients: Despite limited research, one study investigated FAP group therapy for patients with chronic pain. Results indicated that FAP appears to be a promising approach for treatment-resistant chronic pain patients.26


Solution-Focused Brief Therapy

Solution-focused brief therapy (SFBT) is a strength-based, time-limited, future-focused therapy developed by de Shazer and Berg (1997) out of a desire to understand what therapists and patients do together that produce meaningful change.27 SFBTassumes that people are fully capable of change, and that the solution is not necessarily related to the problem.

With SFBT, healthcare providers assess and treat patients using techniques such as the “miracle question” to understand the patient’s vision of their goals for treatment. The miracle question asks the patient the following: What if a miracle happened in the middle of the night and the problems that brought you to treatment magically disappeared? But, because you were sleeping, you do not know that the miracle occurred. What will be different in your day to show you that the miracle happened? What will be the first thing you notice? The patient then walks the healthcare provider through their day, identifying differences that would indicate improvement from the perspective of the patient.

Target Patients: An 8-week SFBT intervention has been shown to be effective at decreasing pain interference at follow-up. The same study showed a significant increase in both self-efficacy and well-being at follow-up.28 Another study qualitatively investigated the impact of the SFBT group and identified five themes from participants’ responses to the program, including an appreciation for the opportunity to share their expertise, the comradery of the group, empowerment to push themselves to achieve tasks of daily living, and concern about maintaining their gains post group.29

While research has demonstrated support for SFBT for the treatment of chronic pain, more data are needed on the impact of SFBT on pain behaviors. Specifically, most investigations of the impact of SFBT for chronic pain have used a group format. To better understand the underlying mechanisms of SFBT, it would be important to investigate the outcome variability accounted for by individual SFBT therapy versus an SFBT group format.

Reality Therapy

Reality therapy is a present-focused, psychotherapeutic approach that emphasizes responsibility and choice in order to facilitate behavior change. This approach was developed at the Veterans Administration hospital in Los Angeles in the early 1960s by William Glasser. Guided by control theory, RT rejects the medical model and maintains that suffering is the result of an unmet need in one or more of five domains:30

  1. love and belonging
  2. power
  3. fun
  4. survival
  5. freedom

Reality therapy aims to first increase the patient’s awareness of their five domains, and second, helps them to make appropriate approximations toward changes that align with their authentic needs across domains assessed to have deficits. While this approach emphasizes responsibility, it also prioritizes the provider-patient relationship. Nonjudgmental active listening and positive affirmations are important factors in helping patients gain awareness and make authentic, adaptive life changes.

Target Patients: Research on the use of Reality Therapy with patients with specifically chronic pain has been generally scant in the existing literature. However, investigations of the impact of Reality Therapy for individuals with developmental disabilities show promise.31,32



Last updated on: September 21, 2020
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Behavioral Pain Medicine: Managing the Affective Components of Pain
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