Freud regarded pain as a common conversion symptom, although he thought that the pains encountered in hysteria were originally somatic in origin. Although the specific pains were not created by the symbolization process of conversion, the “pain that was symbolically appropriate” was picked out by the patient. Psychodynamic formulations of pain problems have been made since the time of Freud. These formulations have been supported by case studies and a few controlled studies suggesting suppression of anger and dependency needs in chronic pain patients (Pilowsky 1986). But psychodynamic models of treatment have not been favored in modern pain treatment programs, for several possible reasons: 1) chronic pain patients resist psychogenic models of pain causation because they feel blamed by them for their suffering; 2) chronic pain patients are often entrenched in a regressed “sick role” position, and therapies that promote regression can reinforce this position; and 3) a “here and now” perspective suits the workers’ compensation programs that fund much of chronic pain treatment.

The modern era in pain psychology began in 1976 with Wilbert Fordyce’s (1976) application of operant learning theory to chronic pain treatment. According to operant learning theory, pain behaviors can be controlled by external reinforcers as well as internal sensations. Help or affection from others, time off from onerous tasks, and greater distance from conflictual relationships are all examples of potential reinforcers for pain behavior. A rehabilitation program for chronic pain based on these ideas was developed at the University of Washington, which has become a model for many similar programs around the world. In 1996, the American Pain Society listed 352 such multidisciplinary pain programs in the United States. These provide treatment for more than 175,000 patients each year.

The pure operant model of pain treatment has been criticized for its focus on motor pain behaviors, its neglect of the emotional and cognitive aspects of pain, and its failure to treat the subjective experience of pain. In recent years, the operant model of pain treatment has been largely subsumed under the cognitive-behavioral model (Turk and Okifuji 1999b). In cognitive-behavioral therapy (CBT), the therapist uses environmental manipulations, as do the behavioral (operant) therapists. However, in CBT, these are conceptualized as informational feedback to the patient, prompting him or her to question maladaptive thoughts, feelings, and behaviors. Common factors in CBT approaches are 1) interest in monitoring and modifying the patient’s thoughts, feelings, and beliefs as well as behaviors and 2) use of behavior therapy procedures to promote these changes. A recent meta-analysis of randomized controlled trials of CBT for pain verified its effectiveness.

Cognitive-behavioral theory is consistent with the modern understanding of pain neurophysiology as represented by the gate control theory of pain. This theory provides a role for affective and cognitive, as well as sensory, processes in pain processing and perception. Multidisciplinary pain treatment programs often use the cognitive-behavioral perspective, not simply as a way to address the psychological dimensions of pain but also to structure the overall rehabilitation effort. Physical therapy, medication management, and vocational planning can all be directed according to the principles of CBT. Physical therapy is focused on active exercise according to quota so that patients’ self-efficacy and their physical capacities are increased. Medications are administered by schedule rather than “as needed,” so that patients do not worry about whether they need or deserve more pain medication. Alternative strategies to resolve work disability problems are proposed and tested. CBT is not intended to cure or eradicate the patient’s pain. It is intended to lessen the effect of the pain on function and quality of life. In some cases, pain intensity may diminish. It is important to agree on these goals of treatment with the patient if CBT is to be successful.

CBT typically takes place in five phases that often overlap. In the first assessment phase, psychosocial and behavioral factors that affect disability are evaluated. Barriers to successful rehabilitation are identified. The second phase is reconceptualization of the pain problem. The clinician attempts to recast the pain problem as a discrete and manageable problem rather than as an overwhelming impediment to the patient’s overall life. It is important to teach the patient the roles played by affective and cognitive processes in the pain experience. In this way, a purely biomedical and sensory model of pain can be replaced by one that provides a role for rehabilitation. The patient must turn away from the quest for cure and “no pain” and come to accept “less pain” and “better function” as goals of treatment. The therapist makes clear that the patient must be an active partner in the treatment process. Automatic negative thoughts, such as catastrophizing about the pain, are identified and examined for truthfulness.

After goals for treatment have been agreed on, the acquisition and consolidation of adaptive coping skills can proceed. The specific skills taught are adapted to the patient’s needs and goals. Skills focus not only on pain reduction but also on the disability and suffering associated with the pain. The easiest skills and situations are dealt with first, followed by a graded sequence toward the most difficult. The pain problem is broken up into smaller, more manageable problems. The patient is then provided problem-solving skill training involving alternatives appropriate to different situations. The patient tries these alternatives out in their natural environment and reports back to the therapist on barriers and accomplishments. Relaxation training and distraction techniques are often taught in this phase.

The fourth phase involves rehearsal of the treatment program. Role-playing in the therapist’s office, sometimes with reversed roles, is often used. This can be followed by homework to consolidate skills in the home environment. The fifth phase addresses generalization and maintenance of these skills. Relapses are anticipated and planned for. The patient is given clear credit for advances that have been made. The treatment follow-up phase helps ensure that reinforcement can occur before failure occurs. The patient’s new view of himself or herself as capable is reinforced. Beliefs about pain are a powerful determinant of chronic pain adaptation.

Spouse and family are essential partners in the chronic pain rehabilitation effort. Many families respond to chronic pain in a member as they would to an acutely ill family member by urging rest, medication use, and time away from responsibilities. But this model can reinforce disability and therefore suffering associated with chronic pain. Families should be educated to encourage the patient to do all that he or she can. A critical belief that must be addressed is that chronic pain signals damage and danger. Patients and families must be shown that “hurt does not equal harm” in most cases of chronic pain. In this way, the path to successful rehabilitation can be opened.

Multidisciplinary programs based on a biopsychosocial approach are often considered to be the ideal model for the provision of integrated services to patients with chronic pain. Flor et al. (1992), in their meta-analysis of 65 studies examining the efficacy of multidisciplinary treatment centers for chronic back pain, found that these programs were beneficial in improving pain and mood, facilitating a return to work, and decreasing patient use of the health care system. Furthermore, the benefits appeared to be maintained over an extended period.

The role of psychiatry in such multidisciplinary programs varies from psychiatrists whose primary clinical activities are in pain treatment centers to those who provide consultations only on referral. The role of the psychiatrist is often in the assessment of psychiatric comorbidity (e.g., concurrent depression), determination of personality and family systems variables that influence the patient’s pain, and in-depth assessment of behavioral and possible psychodynamic factors that may be of relevance to the patient’s pain (e.g., history of physical or sexual abuse). The psychiatrist also may serve as the primary psychopharmacologist, in terms of both treating comorbid psychiatric disorders (e.g., major depression) and detecting patients for whom the use of analgesic medications may be problematic (e.g., patients with a history of drug dependency). Psychologists have historically been more involved with multidisciplinary pain treatment than have psychiatrists. But psychiatrists can be uniquely helpful in developing the multimodal medical, behavioral, psychotherapeutic, and psychotropic treatment plans needed in the chronic pain setting.

Although postoperative and other acute pain problems generally have been handled almost solely by anesthesiologists and surgeons, a multidisciplinary approach appears to provide better evaluation and management. Whether for acute or chronic pain, a coordinated multidisciplinary treatment plan involving a combination of therapeutic modalities is usually more beneficial than a sequential approach in which only one form of treatment is provided at a time. Integrated treatment models are often essential for acceptance of psychological treatment modalities by patient and family.

Many different therapeutic modalities have been used for pain in addition to those already discussed. Because many patients with chronic pain are deconditioned, which can result in the exacerbation and perpetuation of the pain, physical therapy is a vital part of chronic pain treatment programs (Protas 1996). Physical therapy can not only improve patients’ physical fitness but also provide instruction on proper body mechanics that may lead to a reduction in pain. Occupational therapy may assist patients in performing activities of daily living that may be restricted because of pain.

Among the most frequently used biomedical techniques are surgery (including implantable spinal cord stimulators and pumps), nerve blocks, trigger point injections, acupuncture, physical therapy, and transcutaneous electrical nerve stimulation (TENS). As with the psychologically based modalities, support in the literature for the efficacy of each of these therapies varies. Very few techniques that involve further damage to the nervous system provide good long-term pain relief. On the whole, conservative therapies (e.g., TENS, physical therapy, acupuncture) should be tried before proceeding to more invasive ones (e.g., nerve blocks, surgery). Interventions such as acupuncture, TENS, and the psychotherapies have the additional benefit of a minimal risk of causing side effects or exacerbating the patient’s pain.

There is increasing recognition that surgery for the purpose of pain relief may be done too readily. Too many patients with low-back pain, for example, have been undergoing surgical procedures (Deyo and Phillips 1996). Clinicians still approach chronic pain looking for a diagnosis via a clinicopathological correlation. But this paradigm, which is very helpful for acute pain and other acute health problems, may apply to a minority of chronic pain problems (Sullivan 1998). A common misconception is that the response to a treatment modality enables the physician to determine the etiology of the pain. For example, it is sometimes thought that if a patient responds to physical interventions, there must be a physical basis for the pain, and similarly, if the patient responds to a psychologically based treatment, there must be a psychological basis for the pain. However, little evidence supports this view. Patients with pain with clear physical pathology (e.g., patients with cancer) can receive relief from psychotherapeutic interventions, including supportive psychotherapy, relaxation techniques, and hypnosis, and patients whose pain is clearly associated with psychological factors (e.g., a woman with pelvic pain who has a history of childhood abuse and posttraumatic stress disorder) may receive benefit from nerve blocks or trigger point injections.