A personal bias

Now some readers have been wondering what my background is…Sometimes I feel like being rather provocative and asking why – while other times, like now, I feel like ‘fessing up.

Here is a clue: in pain management, to me the most important thing is to see people doing things differently.

That’s right, although I’m a strong believer in working with thoughts and beliefs and values and so on – if it doesn’t mean something observable changes, it didn’t work. My aim with pain management is to help people do what they want to do, to be in control so they can achieve their potential, not just ‘feel better’. Likewise with teaching – if I haven’t stimulated you to do something differently, then I’ve failed.

My reason? Well in pain management, because pain is a quale, that is, it has sensory and emotional qualities that we can’t directly share with each other, we cannot ever know how much pain another person is feeling. The only clues we have that pain is present (or not) is what the person does about it. That is, behaviours or actions. Even when the experience is an emotion, you and I can’t share the emotion except through the medium of language or action.

So we infer that pain is present on the basis of behaviours (including speech). This is one reason that, as clinicians, we can never truly say whether someone is ‘malingering’ or ‘faking’ (that’s more likely the job of a private investigator!) – and if behaviours are the only aspect of pain that we can observe, we also need to acknowledge that behaviours are subject to all the influences of any behaviour, such as contingencies and social learning as well as cognitive aspects such as attitudes, beliefs and so on.

As a result, we can do a whole heap of work with someone’s thinking, but unless they do something differently, nothing has really changed for them. If they feel more positive, hopefully we could count smiles; if they are less distressed, hopefully they will go to the Emergency Department less; maybe even return to work! We also know that if people do more, feel better about themselves, and they’re able to do more!

This isn’t new stuff – this is pretty fundamental to the operant conditioning model of pain introduced by Wilbert Fordyce in the early 1980’s onwards. By conceptualising pain behaviour as the subject of treatment, Fordyce introduced the idea of living despite pain. By noticing that reports of pain intensity vary depending on distress, depression, reinforcement from over-supportive others and so on, psychologists recognised that if pain behaviours reduce, often reports of pain intensity reduce. And more importantly, people began to live lives again. Now that’s what I’m about!

For more from the man himself, here are a couple of the original articles – plus a couple of others that are important to explain the biopsychosocial model.

Did the clue help? Do you know what ‘flavour’ health professional I started off as? Do you know what flavour health professional I am now? Does it really matter?

Fordyce, W. E. (1984). Behavioural science and chronic pain. Postgraduate Medical Journal, 60(710), 865-868.

Fordyce, W. E., Roberts, A. H., & Sternbach, R. A. (1985). The behavioral management of chronic pain: a response to critics. Pain, 22(2), 113-125.

Fordyce, W. E., Shelton, J. L., & Dundore, D. E. (1982). The modification of avoidance learning pain behaviors (Journal of Behavioral Medicine. 5(4):405-14, 1982 Dec.).

Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.

Turk, D. C., & Monarch, E. S. (2002). Biopsychosocial perspective on chronic pain. In D. C. Turk & R. J. Gatchel (Eds.), Psychological approaches to pain management (2 ed., pp. 3 – 29). New York: The Guilford Press.

Oh, here are some other on-line bits and pieces on the biopsychosocial model. Firstly, a review of a video by Bob Gatchel on Pain Management using the Biopsychosocial Model…

For those who don’t think a full-on postgraduate course is possible, this on-line CME course may be helpful:
UCLA CME course

And don’t forget the University of Otago, Christchurch, papers in Pain and Pain Management – see the link to your right…


  1. It’s not hard to pick up the bias – an occupational therapist strongly warped by exposure to psychologists! But the point I wanted to make is that we can get hung up on ‘who does what’ and forget that the evidence is what we need to base our clinical decisions on, and also who ‘fits’ with the client/patient the best.

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