contextual behavioral science

Pain behaviour: what is it and what do we do about it?


I’m re-reading Fordyce’s classic Behavioral Methods for Chronic Pain and Illness and once again I’m struck by how many of the concepts he introduced and systematically investigated are either mis-interpreted and ignored in our current approaches to helping people with persistent pain. Today I’ll explore just a tiny portion of what Fordyce described.

Pain behaviour refers to all the observable actions we do in relation to experiencing pain (NB some people include thoughts as well, but for today I’ll just focus on observable actions). There are roughly two groups of actions: those involuntary ones that we can call nocifensive responses that include reflex withdrawal underpinned by spinal reflexes but including brainstem circuits (see Barik, Hunter Thompson, Seltzer, Ghitani & Chesler, 2018); and those that are developed and shaped by learning (operant conditioning as well as social learning).

When I write about learning, I often have comments about this suggesting people have a choice about what they do, and that this learning must involve conscious awareness – the upshot of these comments is the idea that if we just tell someone that they’re doing something, information alone will be sufficient to change how often they’re doing it. Well, I don’t know about you, but if you’ve ever chewed your nails, changed your diet, decided to go on a social media diet, or do more exercise, you’ll know that there’s an enormous gap between knowing about and being able to follow through. So let me review some of the processes involved in learning and pain behaviour.

Pain behaviour probably has evolutionary significance. What we do when we’re sore acts as a signal to others, whether those actions are voluntary or involuntary. For example, while limping off-loads weight from the sore limb, it can also function to let other people know there’s something wrong. Groaning or sighing also lets people around us know that we’re not OK. Remembering that we’re a social species, being able to let others know that we need help – or not to do what we just did – means we’re more likely to receive attention, and also to warn others about potential danger. Of course, by eliciting help, we’re kinda obligated to help others when they do the same, which may be why when we see someone demonstrating prolonged pain behaviours we tend to feel annoyed: we might be asking ourselves “If they’re not going to reciprocate, why would I help? Dem’s the rules”

Now pain behaviour is also subject to learning principles. In other words, the specific behaviours we do develop in form and frequency depending on context. The underlying analysis goes like this: an antecedent is present (maybe it’s a particular person, location, or occasion), the behaviour occurs, then something in the environment/context occurs – and it’s this “something in the environment/context” that influences whether the behaviour is repeated, and/or the frequency of that behaviour. The easiest example of this is when you watch a three-year-old playing just a little distance from Mum and Dad. When she trips and falls, she’ll probably get up and brush herself down – and then you’ll see her look for Mum or Dad, and if they’re close enough, she’ll probably let out a bit of wail. In the context of Mum and Dad and her falling over, she’s learned that if she cries she’s likely to get a cuddle or some attention, and this is nice. In the absence of Mum and Dad, if she trips she’s less likely to cry because she’s not likely to get that cuddle. Clever huh?

So if that kind of learning occurs from the time we’re little, it’s easy to see how rapidly this pattern of behaving can become habitual, and when it’s habitual it’s unlikely to be something the child is aware she’s doing. Crying, or seeking attention, when we’re sore is something we’ve learned to do from an early age and while the form of that attention likely differs as we mature, the underlying mechanisms still apply (please don’t scream the place down when you go get your Covid vaccination! It’s OK for babies to cry, but not quite so socially appropriate for grown-ups to cry!).

How does the form of that behaviour change? It’s called “shaping” and it is something that occurs naturally through social learning, and it can also occur in a planned way. Take the example of the three-year-old falling and crying: crying is probably OK outdoors where there’s plenty of room and not too much attention being paid to the interactions between parents and child. Take that same behaviour indoors, perhaps in a supermarket or worse – a quiet waiting room – and it’s likely the parents will shush the child more quickly, and be a little more firm about any ongoing wailing. The context is different, the parents respond differently, and the child learns that it’s not OK to cry loudly where there are other people who might not approve. Over time children learn that in different contexts, different ways to attract attention are required. Clearly there’s more technical language we can use to describe this process, but for our purposes this is enough.

Why do we care about this?

Pain behaviour is normal. It’s something we all do. Mostly it functions in a positive way. We signal to others that we need help, we protect the sore body part, and gradually we recover and resume normal life. In some contexts, though, the tendency to continue doing pain behaviours outlives its welcome. In persistent pain it’s particularly problematic, but it’s also problematic in acute pain situations.

Let’s take the example of the dreaded pain rating scale. The 0 = no pain to 10 = most severe pain I can imagine scale. In the context of an emergency room, being asked to rate pain is a quick and very practical way for clinicians to decide how severe the presumed injury/tissue damage is, whether the person needs analgesia, and whether they’re responding to it. Give a number less than 3 or 4 and you’re probably not going to get a lot of pain relief. Give a number closer to 10, and you’ll get something. Give a number greater than 10 and you may get raised eyebrows. In an experiment by Herta Flor (Flor, Knost & Birbaumer, 2002), participants were given an electric shock and asked to rate their pain intensity (also nociceptive detection threshold (aka pain threshold) and pain tolerance). After they’d rated their pain over several trials, they were given one of two conditions: one in which they were given smiley faces and money when their rating was higher than their average rating for the previous trials, and one in which they were given a sad smiley when their rating was lower than their average. Flor and colleagues found that those people who had been given positive smiley faces for higher pain ratings rated their pain intensity significantly higher than those who had been given neutral or negative smileys.

This experiment doesn’t reflect changes in pain intensity. And this is a critical point to note! The stimuli were the same across both groups. What changed was the response offered to participants after they rated their pain. In other words, behaviour associated with experiencing pain and the resultant rewards given for higher ratings was reinforced.

This experiment, along with a large number of others, is one reason why I don’t like pain intensity measures being taken at every treatment session. Pain intensity ratings are behaviours subject to the contingencies that all behaviour is subject to – people learn what to do, and they do it. And they’re unaware of this process.

We often rely on pain intensity ratings in both experimental studies and clinical practice. Unfortunately, while a numeric rating scale or visual analogue scale are quick and dirty, they’re not like a pain thermometer. We just don’t have an objective measure of pain intensity. And we forget this.

Where am I going with this?

A couple of points. I don’t think we can always influence a person’s experience of their pain. This means that we’re often needing to influence what they do about it – because prolonged distress and disability is not good for anyone. Given the social nature of our species, and the involuntary nature of our response to another person’s distress, we’re inclined to try to reduce distress by offering comfort. Nothing wrong with that except where it gets in the way of the person beginning to do things for themselves. As clinicians we need to reinforce actions a person does to increase their capabilities. We also need to limit our reinforcement of illness behaviour, and we need to do this with the consent of the person – being open about why we’re doing this. Remember people learn this stuff without knowing they’re learning it! This means that as clinicians we must stop judging people and what they do in response to pain. Pain behaviour is learned over a loooong time, and it’s reinforced in so many places. People don’t do pain behaviour on purpose. So we can’t judge people as being “non-copers” or having “exaggerated illness behaviour” – we can just gently show the person what happens, why it happens, and what the effect of that pattern of behaving is having on their life.

The second point is that we can’t treat pain ratings as Truth with a T, and think that we’re getting a pure measure of pain intensity – because rating pain on a scale is a behaviour, and it’s influenced in exactly the same way as all behaviours are. This doesn’t mean ignoring someone’s pain intensity – it just means we need to listen to what the person is trying to communicate.

Barik, A., Thompson, J. H., Seltzer, M., Ghitani, N., & Chesler, A. T. (2018). A Brainstem-Spinal Circuit Controlling Nocifensive Behavior. Neuron, 100(6), 1491-1503 e1493. doi: 10.1016/j.neuron.2018.10.037

Flor, Herta, Knost, Bärbel, & Birbaumer, Niels. (2002). The role of operant conditioning in chronic pain: an experimental investigation. Pain, 95(1), 111-118. doi: https://doi.org/10.1016/S0304-3959(01)00385-2

Musings on new learning


Over the past week I’ve been reading a book on embodied cognition, Intelligence in the Flesh: Why your mind needs your body, written by Guy Claxton. In this book, Claxton argues that we place far too much emphasis on abstract ideas of language and intelligence, and fail to recognise how intertwined our body and brain systems really are. It’s fascinating and raises many ideas and questions for me when I think of our pain experience.

To add to my musing, I had the great pleasure of attending the Australia and New Zealand Association for Contextual Behavioural Science conference in Wellington where I had the opportunity to have my mind blown by Steven Hayes and colleagues talking about a way of viewing language and behaviour from a functional contextual perspective (lots of links in this post because I can’t hope to do justice to the topics and I hope you’ll take the opportunity to click through to read more).

The truly weird thing is the links between these two aspects of being human: the one in which language is viewed in the context of whole body systems, and the one in which language (and thought) is viewed as a behaviour that develops as we grow and make connections between what is “out there” and what is “in here” – and all the abstract things in between.

I have no idea where this post will lead to, but here goes!

Let’s begin by thinking about how a baby experiences pain. Not that long ago it was believed that because babies can’t remember early life experiences and don’t have language to represent their experience, they didn’t feel pain. This, despite all of us knowing that when a baby is surprised by something external to them, when they want or need something, and times when they respond dramatically to an injection or being bumped, they react! And they react loud and clear.

Babies grow up into toddlers, and as they do we notice they develop associations between symbols and objects and experiences they interact with. Kids without hearing, in an environment where they’re surrounded by people using sign language, quickly develop the capability to represent experiences and objects with movements that mean something both to them and to those around them. Embodied cognition approach argues that the network of physiological responses flows in cycles between body and multiple parts of the brain to stamp “expected” patterns that begin to represent the world around us, and inside us. And we develop associations between internal and external objects that ultimately loop around many bits of the brain to ultimately be represented by symbols – words either spoken or gestured. Actually, according to Guy Claxton, these initial representations unfurl like ferns as a welling-up of associations and actions with multiple potential associations and actions that are either dampened down by past experience or allowed to develop dependent on intentions.

So, for example, a baby has a bunch of signals from his or her belly that flow and cycle around to various parts of the brain and endocrine system that represent what we know as “hunger”. Maybe initially it’s an urge to recapture that warm, safe, satisfied experience of having a full belly, but over time these signals develop more complex associations, with some representing “hunger”, others “milk”, “food”, “mummy”, “give me”, “want” and so on. As the baby develops, the associations between experiences and representations become far more complex and largely out of our “conscious” awareness, and these representations begin to develop a life of their own, so that as a two-year old, around dinner time, all those associations of “hungry”, “milk”, “food”, “mummy”, “give me”, “want” clamour for attention and the toddler has a melt-down! Seriously, perhaps for a toddler, being given a carrot which doesn’t fit with all those associations of  “hungry”, “milk”, “food”, “mummy”, “give me”, “want” actually doesn’t fit with the representations the toddler is trying to achieve at dinner time.

Let’s think about pain then. When a baby experiences the “yukkiness” of an empty belly – or the absence of “warm”, “mummy”, “food”, “safety” – he or she responds by crying. A baby’s whole body gets in on the act (you go watch one cry!) – and we respond. We use a bunch of words to talk to a baby when they fall down or get hurt – and they quickly learn that falling down or getting hurt isn’t nice – and that someone will come get them when they cry. Over time these experiences accumulate and the words we use for pain become associated with lots of unpleasant experiences like – cold, hungry, sad, tired, afraid, ouch, scratch, sore, comfort, abandonment, worry and so on. Soon enough any time we hear the word “ouch” or “pain”, or see a scratch or someone falling or ourselves falling, this constellation of associations are all activated, some more than others! Given how long we’ve been pairing all these associations together, it’s no wonder that pain, any pain, holds a whole bunch of meaning for us, many of which are deeply physical but also psychosocial.

At the same time as we make these connections, we’re also beginning to view “me” or “I” as somehow separate from what happens to us, and we’re all familiar with our internal narrative. This narrative contains not only the words we use to describe or narrate what’s happening, but also all those experiences and associations that go along with them. In contextual behavioural science, the representations of words, concepts, and all the associations between where, when, and how we connect these things are viewed as just as important as the words themselves.  This matters when we begin to believe that the representations (words, language) actually ARE what they “stand in for”. So, for example, if the word “pain” links with a whole bunch of experiences body processes, including perhaps not being helped to feel secure, or of fearing the worst, or of bad things happening to others around us (in life or TV even), it’s likely we’ll be experiencing those things as if they were happening in real life now. Pair that word with body experience which brings the whole to life again (in ways we can’t always express in language), and it’s no wonder many people are truly afraid of what’s going on – and act accordingly, perhaps without not really realising that this is happening. It’s like the unfurling of associations and actions occur independently of what we call “conscious thought”.

I know this is a fairly simplistic account of what I’ve been reading and learning about – and I have much more to learn and explore! But it strikes me that if our bodies are so comprehensively intertwined with the “what it is like” to be living in our world, it’s no wonder that only providing education about pain may not always be as powerful as we’d like. It helps me understand why experiencing our bodies doing things in different contexts while feeling safe/secure is so necessary. It also gives me more confidence that using metaphors (which represent our world or situations in symbols that straight words may not elicit) helps draw on these embodied representations and may elicit change more quickly than trying to “convince” or “tell” someone what’s going on.

I’d love to hear your thoughts – join in the conversation and let’s help each other make sense of this very groovy neuroscientific approach that integrates the social into our biopsychosocial framework.