Developments In Psychological Models Of Chronic Pain Over Time

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There is a 40-year history of development in the behavioral and cognitive approaches to chronic pain, beginning with the operant approach,1 including the cognitive-behavioral approaches,2 up to the present day. As this history continues, any description of the psychological effects of chronic pain will be a snapshot in time and in a process of change. It is fortunate for this purpose, however, that interest in the contributory causes of chronic pain has been more changeable over time than interest in the effects of chronic pain, which has tended to yield greater consensus. In other words, psychologists and other professionals have considered an ever wider range of variables in the search for where suffering, disability, and life disruption come from, as opposed to what they are made of or how significant they are. If there is doubt about these trends, notice our changing interest in conversion disorders, pain behavior, reinforcement, social support, and responses from significant others, depression, neuroticism, locus of control, self-efficacy, coping, catastrophizing, stages of change, attention and hyper-vigilance, fear and avoidance, attachment style, and, more recently, acceptance and mindfulness, among others.

Greater attention to the influences on the experience of chronic pain is perhaps appropriate, as it is the processes by which patients suffer that should dictate how to help. In any case, the distinction between the causes and effects of chronic pain is probably best considered flexibly. The variables we define as causes and effects ought to serve practical purposes and not be regarded as absolutes. The lines we draw between initiating causes, maintaining or exacerbating causes, and effects, obviously do not exist in nature as such, but are analytic tools only. While we sometimes can take our variables too seriously, as if they are real or true entities, and not simply ways of speaking and writing, their truth or falsity will, perhaps, most usefully depend on how well they serve the purpose of the analysis at hand. It is, arguably, the whole person acting within a context of complex historical and situational events, both inside and outside their body, that is of primary clinical interest. With these caveats in mind, it is the effects of chronic pain that are the primary focus of this chapter.

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