More Than Biology: A Psychosocial Approach to Chronic Pain

Francis KeefeFrancis Keefe, PhD, is a professor in the Department of Psychiatry and Behavioral Sciences; the Department of Psychology and Neuroscience; the Department of Anesthesiology; and the Department of Medicine at Duke University in Durham, North Carolina, US. Keefe is a pain researcher whose work focuses on understanding psychosocial aspects of chronic pain and developing and testing treatment protocols, such as cognitive behavioral therapy, mindfulness meditation, partner-assisted pain coping skills training, tai chi, and yoga. He spoke recently by phone with freelance writer Laura Kiesel to discuss his path to pain research, why chronic pain is best understood as a complex, multifaceted experience involving much more than biology alone, and the studies he is working on now. Below is an edited transcript of their conversation.  

How did you become involved in pain research?

I came to Duke in 1978 to run its biofeedback lab. Because I had experienced pain myself, I began seeing patients with pain in the lab. Within two or three months of coming here, my own pain got much worse because I had a herniated disc. I ended up having lumbar back surgery, and it took me almost a year to fully recover to where I was before the surgery. Over the course of that year, I started to take a more in-depth look at the experience of the patients we were treating in our lab. One thing led to the other and I developed a series of research projects trying to develop better ways to understand and treat persistent pain, from a behavioral and psychosocial perspective.

Are you fully recovered now?

Yes, but I learned a tremendous amount from having pain—from seeing how much it affected me, my daily life, and my family. It really gave me insights into the experience. If you talk to a number of pain researchers, you’ll find that many of them have either had a pain experience of their own that really affected them or they had a loved one who had a similar experience.

You’ve worked with people in different fields of science. How has that experience served your pain research?

I’ve collaborated very closely with people, especially in immunology and rheumatology, which has had a profound effect on my research. It got me very interested in pain that was disease-related, and it broadened my interests in terms of extending biopsychosocial models and approaches to disorders such as arthritis and cancer where traditionally they had not been considered that much.

Why are studies of psychosocial aspects of pain important to pain research and treatment?

Despite the advances in pain that have occurred over the last 25 to 30 years, pain is still typically treated as a biological or sensory event. What we now know is that pain is a multidimensional experience. There is a sensory component, but there is also an emotional component to pain. We now know that because pain is so complex, particularly when it persists, integrating the psychosocial perspective along with the biological perspective is very important, both for better understanding a person’s pain and for developing an effective treatment approach.

Let’s look at one very important psychosocial aspect of pain—pain catastrophizing. What is it, and what role does it play in the experience of pain?

Pain catastrophizing is the tendency to focus on the pain itself, to ruminate about it, and to feel helpless about our own ability to deal with it. It is important not only in understanding how people with chronic pain adjust to pain, but also how people respond to acute pain. In laboratory settings, healthy people who are more prone to pain catastrophizing react differently [to painful stimuli]. According to some brain imaging studies, they process pain differently. Many studies have found that, even after controlling for pain level, the tendency to catastrophize explains outcomes such as medication intake and how disabled, depressed or anxious people with pain might be. It’s a very powerful factor, and there is a lot of interest in it right now across the spectrum of pain research.

Are certain people more predisposed to pain catastrophizing than others?

People who have had catastrophic experiences in their past, such as an auto accident resulting in tragic loss of multiple family members or exposure to other severe trauma, are subsequently more likely to catastrophize about pain when they experience it.

Your work has highlighted social isolation as a factor in people who experience more persistent and intense pain. Yet this research has also shown that those who catastrophize seem to have stronger social support. Can you explain the contradiction?

People with pain who catastrophize a lot perceive the people around them as being socially supportive. Their view is that, though they are having trouble dealing with pain, they are getting good social support from others when their pain is severe. On the other hand, if you look at people who are in a position to provide support, they are feeling strained as a caregiver.

If a person has a pain condition that goes on for a long time, that individual often has problems letting others know about the pain. For example, the person might not want to burden others with his or her pain, and so holds back on talking about the pain. Significant others, in turn, might not want to upset the person by asking about the pain and so tend to leave the person alone. As a result, the person with pain gradually may become more isolated. When the pain becomes severe enough, however, pain communication does occur and what is communicated at this point often is that the pain is overwhelming and can’t be controlled.

One of the ways to help with this problem is to develop programs to train people how to better communicate about pain.

Why do individuals with lower socioeconomic status (SES) tend to experience more chronic pain symptoms and have a greater risk for developing disabling pain? And since SES can’t easily be modified, what can someone in a low SES group do to mitigate his or her risk for developing pain, or once it does develop, to deal or cope with it?

There is an interesting study by Leigh Callahan and her colleagues that looked at the association between formal education level and mortality in patients with rheumatoid arthritis. They found that people with low education were much more likely to die early from that disease. They also looked at helplessness, which is a component of pain catastrophizing, and found that when they controlled for helplessness, the relationship between education and mortality was no longer significant. This suggests that the effect of low education—which is a marker of low SES—on mortality was actually explained by feeling helplessness in the face of disease.

We know that helplessness, as well as pain catastrophizing, are potentially modifiable. One of the things this finding might do is stimulate interest in ways of helping people who have fewer resources learn how to reduce their sense of helplessness. Along those lines, there’s been some really nice work done by Kate Lorig and her colleagues on the benefits of training people in self-management of pain and other symptoms. She has conducted studies in low-income populations suggesting that trained lay leaders can teach individuals with varied socioeconomic backgrounds and pain conditions self-management skills that can enhance their self-efficacy—their confidence in their ability to actually decrease their pain when they need to—and reduce pain and disability.

Have studies taken into account whether low-income people have had access to treatment?

That’s a real concern. We know that people with chronic pain are stigmatized, and people in minority groups are stigmatized with regard to their pain, its assessment and treatment. Our medical system does a good job of certain things— for example, delivering medications—but it’s not set up to address these broader social issues. These findings should spur all of us to work towards improving access to pain treatments for all, regardless of their socioeconomic circumstances.

Cognitive behavior therapy (CBT) has shown very positive results in decreasing pain among patients in clinical studies. What is CBT, and what are the most effective and useful CBT methods for coping with or decreasing pain?

CBT is probably the most well-researched psychosocial approach for pain treatment. In CBT, people are first educated about pain, so they begin to see their pain in a different light. The idea is to help them understand that pain is not simply a biological event, but a multidimensional phenomenon that can be influenced by emotions, thoughts, and motivation. Next, CBT uses a variety of techniques to teach people skills for managing pain. Many cognitive behavioral programs involve an activation component—walking, aerobic exercise, yoga, or stretching. Many of them also involve some approach to relaxation like meditation, imagery training, or relaxation training. A key goal of training in these strategies is to increase the person’s self-efficacy. The increases in self-efficacy that occur over the course of CBT are very important in explaining short- and long-term outcomes.

People trained in these techniques are encouraged to put them together in different combinations to deal with pain. One thing we do know from epidemiological studies is that a more active coping approach is more effective than a more passive approach. Programs that encourage patients to recline, or to have massage, or to simply take medications as the only methods for dealing with chronic pain are usually not as effective as methods that are more active, such as encouraging those patients to increase the level and range of activity and exercise.

Can you describe some of the research you are doing on complementary/alternative medicine approaches to pain?

Over the years, I’ve worked with researchers looking at a variety of interventions that would be grouped in this category. First, I’ve worked with Pao-Feng Tsai studying the effects of tai chi on pain in older adults (60 years and older). That study found that tai chi produced significant reductions in pain and stiffness.

I’ve also worked closely with James Carson, a former yoga monk, who developed and tested a yoga intervention for pain and symptom management. While at Duke he carried out a series of studies. Among them was a study showing that women having metastatic cancer who were trained in yoga and practiced regularly had lower levels of pain, fatigue and higher levels of relaxation and invigoration, and a study showing that yoga reduced joint pain hot flashes and fatigue in breast cancer survivors with menopausal symptoms. We are currently involved in a randomized study comparing mindfulness meditation to behavioral therapy and cognitive therapy for pain.

Do positive results over the long term depend on staying with a certain method or treatment for an extended period, or can a person eventually stop?

There are some things that people learn over the course of these treatments that become part of daily habits so that keeping up with them is not onerous. There are other things that people use when they need them, such as when they are having a particularly hard time. A lot of the skills they learn either become part of a life pattern, or are used in a judicious fashion to, for example, prevent a minor flare from becoming a major relapse.

What other research are you focusing on now?

A lot of our research now is focused on novel ways to disseminate the interventions that we’ve developed so that people who need them can access them much more readily. We’re working on web-based platforms to deliver pain coping skills training. Working with Chris Rini at the University of North Carolina, we developed and tested PainCOACH, an internet-based program, and found that it helped reduce pain in patients with osteoarthritis. That study found that women who received the program had significant reductions in arthritis pain and that both men and women reported improvements in self-efficacy for controlling their pain and reductions in pain-related anxiety and pain interference.

Researchers in our group are also involved in developing and/or testing the efficacy of voice-over-internet-based approaches and a YouTube video to teach couples how to work together around pain management. We are also pilot testing a virtual reality intervention that can be delivered via smartphone so that people who are housebound and having a lot of pain could have access to a virtual world that might serve as a distraction from their pain.