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QME Evaluation and Treatment Models in Chronic Pain

by William W. Deardorff, Ph.D, ABPP.

4 Credit Hours - $129
Last revised: 12/02/2014

Course content © Copyright 2014 - 2023 by William W. Deardorff, Ph.D, ABPP. All rights reserved.


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IMPORTANT NOTE:  This course is approved for California Qualified Medical Evaluator (QME) continuing education credits as well as other accreditations held by  If you do not need California QME continuing education credits, you should take the Chronic Pain Management Series of courses instead.  This course addresses chronic pain management issues as well as information specific to practicing as a QME in the State of California.  In My Account, be sure to add QME to your Degree list and your QME Provider Number to your Licenses.  All Degrees and Licenses will be printed on the CE certificate.



Introduction and Course Overview

Learning Objectives

Assessment of Chronic Pain

     Targets of Assessment

          Patient Targets

          Biological Targets

          Affective Targets

          Cognitive Targets

          Behavioral Targets

          Environmental Targets

     Integrating Assessment Information

          Methods of Assessment

                The Clinical Interview



                Psychological Testing


                Archival Data

Achieving the Goals of Assessment

Reporting the Results of the Evaluation

Psychological Treatment of Chronic Pain

      Cognitive Behavioral Treatment

           Preparing the Patient for Cognitive Behavioral Treatment

               Introducing the Patient for Cognitive Behavioral Treatment

               The Three- and Five- Column Technique

               Styles of Negative or Distorted Thinking

               Changing Negative Automatic Thoughts

Relaxation Techniques

     The “Relaxation Response”: More Than Just Relaxing

              Different Type of Breathing

              Chest Breathing

              Abdominal or Diaphragmatic Breathing

              Teaching Patients Deep Relaxation Exercises

              Cue-controlled Relaxation

Guidelines for Practicing Deep Relaxation

Obstacles to Practicing






The previous course (Chronic Pain Management I: Concepts) reviewed current theories of pain, the chronic pain syndrome, and factors that influence a patient’s perception of pain and suffering.  This course will review the “targets” of evaluation such as the patient and various environments (family, the healthcare system, sociocultural).  These targets are evaluated across domains of biologic, affective, cognitive and behavioral.  The course will also review methods of assessment such as the clinical interview, pain and psychological testing, and observational data.  After the multifactorial evaluation is completed, a treatment plan is developed and implemented.  The course will review cognitive behavioral techniques and deep relaxation approaches for chronic pain management.   


This course assumes knowledge of the information presented in the first course in the series: Chronic Pain Management I: Concepts.  The third course in the series, Chronic Pain Management III: Special Issues discusses medications for pain, long term opioid maintenance, aggressive conservative treatment, and spinal cord stimulation.




·         List the targets of assessment in chronic pain

·         Describe the integration of assessment information

·         Discuss the methods of assessment including the clinical interview and testing

·         List six types of negative automatic thoughts

·         Describe a deep relaxation technique for chronic pain


As discussed by Turk and Monarch (2002) chronic pain should be assessed from a biopsychosocial perspective. This is consistent with the gate control model of pain and the pain system model discussed in Course I. The biopsychosocial perspective takes into account biologic, affective, cognitive, behavioral, and sociocultural influences on pain.  The clinical health psychology assessment model developed by Belar and Deardorff (1995, 2008) is useful in completing a biopsychosocial assessment of chronic pain. The following is adapted from Belar and Deardorff, Clinical Health Psychology in Medical Settings, Second Edition (APA Books, Washington D.C., 2008).




In biopsychosocial assessment of chronic pain, there are various “targets” of assessment that should be addressed. The target groups form a 4 X 4 assessment grid (domain of information by unit of assessment). The domains of information include biologic or physical, affective, cognitive, or behavioral. The units of assessment include patient, family, health care system, and sociocultural context. The following table shows some examples of the kinds of information that might be collected. For a more detailed example, see Belar and Deardorff (1995, 2008).





Healthcare System



age, race, sex, physical appearance, symptoms, health, vital signs, lab data, medications, genetics

home setting, economics, family size, family illness

Treatment setting, medical procedures, prosthetics

Social services, financial issues, social networks, occupational, health hazards


mood, affect, feelings about treatment and other aspects of chronic pain, history of affective disorder

family feelings about patient, illness, and treatment

providers’ feelings about patient, illness, and treatment

sentiment of the culture about patient, illness, and treatment


cognitive style, thought content, intelligence, education

knowledge about illness, attitudes and expectations

provider knowledge, provider attitudes

current state of knowledge, cultural attitude


activity level, interactions with others

involvement in care

provider skills, education, and training

employer, laws, customs


Each block also has an associated developmental or historical perspective that could be critical to a full understanding of the patient’s present condition. In each area, the clinician should attempt to understand the patient's (a) current status, (b) changes since onset of the pain, and (c) past history. The focus of the assessment should not be based solely on identification of problems but also on delineation of assets, resources, and strengths of the patient and his or her environment.


Patient Targets


The patient targets of assessment include biological, affective, cognitive, and behavioral. In many ways, these targets of assessment coincide with the “layers” of the pain system model (e.g., nociceptive input, pain sensation, cognitive, affective, pain behaviors, psychosocial environment, etc).


Biological Targets


The most obvious biological targets are the patient's age, race, sex, and physical appearance. In addition, the clinician needs to gain a thorough understanding of the patient's current pain and other physiological symptoms and how they are similar or different from past symptoms. Recent changes in the pain condition or treatment are particularly salient to the assessment, because they are often the precipitating events that elicit the referral (e.g., increased pain, decreased function, contemplation of surgery, etc.). The clinician will want to obtain information on the specifics of the pain problem: nature, location, and frequency of symptoms; current treatment regimen; and general health status or other medical problems. Other sources of biological information include the physical exam, current and past vital signs, results from relevant laboratory tests, medications, and use of illicit drugs. Furthermore, a history of the patient's constitution and general health including previous illnesses, relevant genetic information, injuries, and surgeries should be obtained.


Depending on the type of pain problem, biological targets might also include variables associated with the autonomic nervous system or musculoskeletal activity (e.g., electromyographic [EMG] recordings or peripheral temperature readings) obtained in both resting and stress related conditions. For example, a psychophysiological profile involving lumbar paraspinal EMG activity under relaxed and stressed conditions, in addition to various postures, could be obtained on a patient suffering from chronic low back pain.


As will be discussed subsequently, the use of a pain questionnaire and pain diary can be very helpful in assessing the biological and other targets.


Affective Targets


The assessment of affective targets involves understanding the patient's current mood and affect, including their contextual elements and historical features. In addition, an assessment would be incomplete without having obtained information about the patient's feelings about his or her pain problems, treatment, health care providers, future, social support network, and, of course, self. Again, it is helpful to obtain data that allow for comparison between current affective states and those of the past, in that it is often the contrast that has prompted the referral.


Cognitive Targets


Assessment of the patient's cognitive functioning involves gathering information about the patient's knowledge, perceptions, and attitudes, as well as the content and pattern of thinking. It is imperative that the clinician be aware of cognitive abilities and limitations of the patient, from both current and developmental perspectives. Cognitive targets include the following: general intelligence; educational level; specific knowledge concerning the pain problem and treatment; attitudes toward health, illness, and health care providers; perceived threat of illness; perceived control over psychological and physical symptoms; perception of costs and benefits of possible treatment regimens; and expectations about future outcome. Another important target is the perceived meaning of the chronic pain problem (and resulting loss of function) to the patient. The clinician should be aware of the patient's general cognitive style and philosophy of life, including religious beliefs. Assessment of the patient’s religious and spiritual beliefs is an area of assessment and intervention that is very often neglected. Research indicates this one of the most important areas to patients but the least often addressed by health care providers (See Deardorff and Reeves 1997 for a review).


Behavioral Targets


Behavioral targets include what the patient is doing (the action) and the manner in which he or she does it (the style). In assessing pain behaviors, the following actions are often evaluated:


·         talking or complaining about the pain

·         grimacing, moaning, crying, limping, moving slowly

·         taking pain medicine, rubbing a painful area

·         using assistive devices such as a cane, walking, brace, etc

·         moving more slowly, asking for help, lying down

·         avoidance of certain activities, seeking further treatment


The style of behavior can also be evaluated such as flamboyant, hesitant, age appropriate, hostile, restless, and passive. The pain management clinician will want to understand the patient's overall level, pattern, and style of activity in areas of self-care and interpersonal, occupational, and recreational functioning, as well as specific behavioral targets related to the reason for referral. Other important behavioral targets in chronic pain include medication seeking, exercise, activities of daily living (ADL’s), sexual functioning, compliance with treatment regimens, etc.


Of special interest is the patterning and nature of the physician-patient relationship, as well as whether the patient senses any type of control over the pain problem. Once again, a historical perspective is important, because past behavior is often the best predictor of future behavior.


Extremely important in pain psychology is the assessment of current and previous health habits (e.g., smoking, exercise, eating patterns, and alcohol usage) and health care utilization. The clinician should be able to answer the following questions about the patient: (a) What are the nature, frequency, and pattern of past contacts with health service providers, and (b) what have been the antecedent stimuli and consequences of these contacts (i.e., history of previous help-seeking and treatments)?


Finally, an assessment would be incomplete without information concerning the patient's current and past history of compliance or adherence to treatment regimens, with specific reasons noted for noncompliance whenever it has occurred. Areas of assessment here include medication usage as prescribed, history of keeping appointments, and follow-through on previous recommendations.


Environmental Targets


The pain management clinician also needs to assess aspects of the various environments within which the chronic pain patient interacts. These include the following: (a) the family unit, (b) the health care system with its various settings and providers, and (c) the sociocultural environment, including social network, occupational setting, and aspects related to ethnicity and cultural background. As with assessment of the individual patient, environmental targets of assessment include physical, affective, cognitive, and behavioral domains, with a focus on relevant demands, limitations, and supports.


Family environment. In assessing the physical domain of the family environment, it is important to know about available economic resources and perhaps even physical characteristics of the home setting, depending on the problem being assessed (e.g., chronic low back pain). The family's developmental history, size, and experience of recent changes are all important aspects to consider. The clinician should also be aware of other illnesses and pain problems in family members and familial models for various symptoms (e.g., a parent who has been disabled due to chronic pain, etc).


In the affective domain, it is important to understand family members' feelings about the patient, the patient's pain problem, and the treatments rendered. Assessment of past or present affective disorders in the family is essential.


In the cognitive domain, the clinician must assess the family's attitudes, perceptions, and expectations about the patient, the patient's pain problem and treatment, and the future. Family members' intellectual resources, as well as knowledge that they possess about health and the pain problem, should be understood.


In the behavioral domain, the clinician will want to know whether there have been any changes within the family since the onset of the chronic pain problem. An example might include a shift in roles and responsibilities of family members due to the chronic pain patient’s lack of ability to function (e.g., at home and at work). It is also important to find out to what degree family members participate in the patient's care. As discussed under the pain system model in Course I, reinforcement contingencies can have a powerful effect on pain behavior. The clinician should investigate how the patient’s pain and illness behaviors are being reinforced by the family members to the exclusion of wellness behaviors. Pain behaviors might be positively reinforced (e.g., nurturing and “supportive” help for the patient) and negatively reinforced (e.g., removing the patient from stressful responsibility demands, family members taking over the household chores and ADL’s, etc). Consider the following example based on an actual case referred for psychological pain assessment:



Case Example



Mr. Smith had been disabled from his job for one year after a low back work injury. The patient had undergone a variety of diagnostic tests and these had not identified likely pain generators. Although the patient complained of extreme pain, the physical findings simply did not explain his level of suffering and disability. Prior to his injury, he had been working two jobs to support the family, neither of which he enjoyed. After the injury, he was receiving disability payments and his wife had returned to work to help support the family. Mr. Smith spent virtually all of his time at home, in bed. Mr. Smith was on a significant amount of pain medicine and his doctor was able to get the insurance company to buy Mr. Smith a hospital bed for his home. The family put the bed in the living room so that Mr. Smith could interact more with his children, who were very helpful in taking care of him. So far, a myriad of physical treatments had provided no relief.



As can be seen, assessment of behaviors of family members that could influence the patient's pain behavior or physical adaptation is crucial. For example, families might model chronic pain behavior, punish patient attempts at self-help, or be secretive in a manner that increases patient anxiety.


Health care system. The health care system should also be assessed across physical, affective, cognitive, and behavioral domains. For example, in the first domain the clinician needs to know the physical characteristics of the setting in which the patient is being assessed or treated (e.g., chronic pain program, surgeon’s practice, multiple doctors). In addition, the pain management clinician must understand the physical characteristics of the diagnostic procedures and the treatment regimen to which the patient has been, is being, or will be exposed. This is why it is important for the clinician to be familiar with the type of chronic pain problem that is being treated. As an example, anyone who works with spinal disorders and resulting pain problems should be familiar with the common diagnostic tests (e.g., MRI, CT, CT-myleogram, discogram, bone scan, EMG, NCS, etc.) and common medical treatments (e.g., physical therapy, medications, epidural and nerve root blocks, and the various spine surgeries).


In the affective domain, one must be aware of how health care providers feel about the patient and about the patient's chronic pain problem. Also, the attitudes of providers themselves toward the health care system within which they work can enhance or detract from overall health care. Chronic pain patients who are on disability and not showing any significant response to various medical treatments can become frustrating to healthcare providers who are continuing with a strictly medical model approach (e.g., medications, surgery, physical modalities). After awhile, one might see a certain passive-aggressiveness by the healthcare providers towards the patient as frustration mounts. Of course, the symptoms of the chronic pain patient will often worsen due to attempts to “prove” the severity of their ongoing symptoms and need for treatment.


In the cognitive domain, the clinician needs to have some understanding of how knowledgeable health care providers are about the patient's pain problem and treatment. As discussed in Course I, in the medical community one often observes that all pain problems are treated as if they are “acute”. Of course, this is not the appropriate intervention for chronic pain problems. One needs to assess healthcare providers’ attitudes and expectations about these issues as well as about the patient's future. Furthermore, it is helpful to be aware of the community standard of care for the problem. When assessing the "behavior" of the overall health care system, the clinician needs to be aware of policies, rules, and regulations that will affect the patient and his or her treatment (e.g., staffing patterns at the treatment center, appointment schedules, medication refill policies). It is also important to understand which specific behaviors health care providers might be displaying that could influence patient behavior. An example of such behaviors might be transmitting information about the pain problem. I have heard countless stories of chronic back pain patients being told by their physician that, “you have the spine of an 80 year old”. Of course, this type of information significantly impacts the patient’s belief system and expectations regarding future recovery (or lack thereof).


Sociocultural environment. Physical aspects of the patient's sociocultural environment include both (a) the physical requirements and flexibilities of the patient's occupational and work setting and (b) the social and financial resources-services available to the patient. In addition, the clinician should be aware of the nature of the patient's social network (including size, density, and proximity) and the frequency of the patient's contact with it. This is an extremely important area of assessment in chronic pain. It is not uncommon for a chronic pain patient to be referred for psychological pain management near the end of the treatment cycle. By that time the patient has often been on disability from work for quite some time, is in financial trouble, and is almost completely isolated from previous social support networks outside of the home. All of these factors act as significant barriers to recovery.


In the affective and cognitive domains the clinician should understand cultural sentiments, attitudes and expectations as impacted by the patient's race, gender, ethnicity, lifestyle, religion, pain problem, and treatment (e.g., sentiments about a chronic pain problem and disability in a person who was previously the primary breadwinner of the household). The clinician should be able to answer the following questions: What are the cultural attitudes towards the pain problem and disability? What is the health belief model of the culture itself? Are there prevalent religious beliefs that could impact the patient's willingness to obtain treatment?


In terms of the behavior of large sociocultural systems the clinician might need to know specific employment policies related to the pain problem being assessed (e.g., regulations regarding return to work for patients with back problems). In addition, legislation regulating health care provision and health habits is relevant (e.g., The Americans with Disability Act, state Workers Compensation Laws, etc.) Finally, the clinician should be aware of ethnic customs that could be related to symptom reporting (or underreporting) and health care use.




It becomes clear from a review of the targets for assessment that these "blocks" are interrelated and that the nature or relative importance of information obtained in one block is often affected by information found in another. For example, type and location of the pain problem can affect perceived meanings of the physical symptoms because of the special psychological significance of certain body parts (face, back, pelvic, extremity pain may carry different meaning for the patient).



Purpose of the Assessment: Treating versus Forensic Evaluation



A QME, AME or IME evaluation is different from that of a treating healthcare provider.  A treating practitioner appropriately trusts his or her patient and there is no reason to do otherwise.  However, in the forensic arena, the purpose and method of evaluation is quite different.  The following are some of the primary differences between a treatment and forensic evaluations (adapted from Greenburg and Shuman, 1997)





Treating Evaluation



Forensic Evaluation


Who is the client?





Attorney and/or court


What are the goals of assessment?




Provide treatment and support


Objectively evaluate the applicant


What is the primary source of data?




Accept what the patient says


Corroborate or refute examinee’s statements with collateral information and objective data


What is the emphasis?




Treating and “helping”


Assessment of medical-legal issues at stake


What are the trust issues?



Assume basic honesty of the patient


Do not blindly trust any souce


What are accountability issues?




Anticipate little challenge to conclusion, diagnosis


Anticipate cross-examination, consider alternative hypotheses, explanations


Who holds the privilege?






Information available to attorneys and defendants


What knowledge of legal issues is required?




May be aware of legal standards, rules of evidence


Familiar with labor laws and WC guidelines governing issues to be addressed


What is the attitude towards interacting with the legal system?



Avoid depositions and court appearances


Accept legal proceedings including depositions as part of the work


Integrating assessment information is critical in the evaluation of a chronic pain patient. It is also critical to gather accurate information across as many “blocks” of assessment information as possible. This is due to the fact that a chronic pain patient is often being treated by more than one provider. It is not uncommon to have a patient who is being treated by a pain management physician, physical therapist, internist, pain management clinician, surgeon and others. Patient self-report and questionnaires are only two data sources and the information may or may not be entirely accurate. For instance, patients often do not know the medical diagnosis for their pain problem, do not remember or know the details of their medication regimen, do not understand the surgeries they are facing (or have undergone), etc. In addition, a patient may be reluctant to discuss a past history of medication abuse but this information would likely be available elsewhere. Of course, the results of any psychological testing would be impacted by such things as medication use, level of concentration, substance abuse, and the ability to tolerate the pain and maintain focus while taking a lengthy test such as the MMPI-2. As can be seen, information gathered across assessment blocks should be compared and contrasted to determine consistencies and inconsistencies.


In conducting an assessment, it is important to understand that the data obtained could be influenced by the type of setting in which the assessment occurs. For example, low-back-pain patients often walk with greater or lesser flexibility depending on who is watching them and in what setting they are being observed. The pain management clinician should be collecting all observational data that is available (examples might include: the patient walking from the parking lot to the office, the patient sitting in the waiting room, the patient interacting with staff, etc). Consider the following example:



Case Example



A low-back-pain patient in an inpatient, chronic pain program was repeatedly observed ambulating with a walker by program personnel. However, on one occasion, when the patient was unaware that he was being observed, he was seen casually carrying his walker over his shoulder while ambulating with appropriate body posture and gait.



Patient expectations about the purpose of the assessment clearly impact the data obtained. As example, the demand characteristics for patients seeking a spine surgery that he or she believes will “cure” the pain will clearly impact how the pain evaluation is approached. When evaluating a chronic pain patient it is imperative to take into account the reason for the evaluation. Various evaluation purposes might include:


·         To determine appropriateness for psychological pain management treatment

·         As part of a psychological screening for surgery

·         To determine disability status related to the chronic pain

·         To determine pain issues related to some type of litigation


The patient who is undergoing a psychological pain evaluation in pursuit of treatment will likely respond very differently from the one that is being assessed for disability or litigation issues. The purpose of the evaluation should be clearly discussed with the patient at the beginning as part of the informed consent process.


The presence of other people, their roles, and their behavior can also affect responses during assessment. For instance, one might witness the emotional breakdown of a chronic pain patient only a few moments after the patient assured his physician that he was doing “fine” or felt ready for some type of proposed treatment or surgery. Or, one might see the reluctance of patients to reveal even significant physical symptoms because of the perception of their physician as being too rushed. The pain management clinician working with chronic pain patients will often be able to obtain much more information than the treating physicians. This underscores the importance of communication amongst treating professionals.


The following are more examples of relationships that influence the interpretation of information obtained during assessment:



Interpretation of Assessment Information



Medication effects on psychological testing results and psychophysiological recordings (e.g., diazepam on EMG level)


Fund of knowledge of the physician on accuracy of medical diagnosis (often specialists need to be consulted to evaluate medical record data, as the referral may come from a general practitioner who had not completely evaluated the presenting problem)


Family understanding, emotional support, and involvement in treatment on compliance with medical regimen


Family members' behavior relative to self-care activities (e.g., overprotectiveness often impedes the pain patient’s attempts at self-management and, consequently, hinders the development of a sense of mastery)


Legislation on sick-role behavior (e.g., disability payments could reinforce chronic pain behavior)


Religious beliefs on the perceived meaning of symptoms and acceptance of medical regimens (e.g., pain as guilt for past sins)


Providers' attitudes about the effect of the chronic pain on the patient’s affective responses


Family attitudes towards the chronic pain (e.g., support, solicitousness, punishment) and its effect on the patients' affective and behavioral responses


Characteristics of the environment on patient activity level (e.g., chronic pain patients who use a cane, walker, wheelchair, etc)


Occupational requirements on self-esteem (e.g., loss of breadwinning capacity due to chronic pain after an industrial injury)


Providers' attitudes toward treatments on patient suffering (e.g., negative attitudes about use of narcotics resulting in under-medication of pain)

Cognitive factors related to chronic pain, depression and anxiety, and medications (e.g., memory, concentration, etc)


Cognitive factors on physical symptoms (e.g., perceived control of pain results in increased tolerance for pain)





In performing the chronic pain evaluation, there are numerous methods that can be used. Many of these give information about one or more targets in the assessment model. The choice of methods depends on the target being assessed, the purpose of the assessment, and the skill of the clinician.


There are probably as many different approaches to the evaluation of chronic pain as there are clinicians involved in this field. It is not so much the individual methods used as long as the important targets of assessments are addressed in a valid manner. The issue of validity will be discussed in great detail subsequently. The critical issue is that any psychological testing results, mental status examination, or other data must be interpreted within the context of the chronic pain problem and symptoms.


One should not be wedded to any one particular technique, as each has its strengths and weaknesses. However, it is safe to say that a good clinical interview is the core assessment method. Belar and Deardorff (1995, 2008) endorse a multiple-measurement model and a convergent-divergent, hypothesis-testing approach to clinical assessment. A detailed description of all the specific methods available to assess the chronic pain patient is beyond the scope of this presentation. The following is an approach that I have found useful and is similar to what other clinicians in the field might do. The Suggested Resources at the end of the online course provides excellent references for further study in this area. The methods of assessment discussed are interview, questionnaires, diaries, psychometrics, observation, and archival data.




The clinical interview is perhaps the most common method of gathering information. It has the capacity to elicit current and historical data across all domains (i.e., physical, affective, cognitive, and behavioral information regarding the patient and his or her family, health care, and sociocultural environments). The interview is also a means of developing a supportive working relationship with the patient. It permits the acquisition of self-report and observational data from the patient, family members, significant others, employers, and health care providers. Understanding one's own stimulus value is crucial to the interpretation of interview data.


Content and style of individual interviews vary depending on the assessment question and purpose. The formality of the interview process (unstructured, semistructured, or structured) often depends on the personal preference of the clinician as well as the setting and time constraints. Specific intervention programs (e.g., a chronic pain rehabilitation program) commonly use structured interviews. Probably the best approach is a combination of the structured and unstructured interview approaches. This helps to avoid interviewer bias and to remain open to exploring areas not immediately recognized as important.


In most situations, it is most useful to develop one's own structured/semi-structured interview for a specific pain patient population (especially if you are specializing in one chronic pain group over another). For instance, if you find yourself working with mostly spinal pain problems you might develop an interview specific to that patient population. Although there will be a great deal of overlap, structured interviews for other pain problems (e.g., complex regional pain syndrome, craniofacial pain, neuropathies, pelvic pain, etc) might be slightly different.


Preparing the Patient 


The first few minutes of contact with the patient can be critical in completing a valid and comprehensive chronic pain evaluation. Prior to being referred to the pain management clinician, chronic pain patients have often been very involved in medical evaluations and treatments. Thus, the referral to a pain management clinician can be threatening and misunderstood. At the beginning of the interview, it can be useful to ask the patient the name of the referring physician and the patient’s understanding of why he or she was referred (the response will often be, “I don’t know”). Initially, a very brief explanation of the role of pain psychology can be helpful. After that, explain to the patient that you are going to gather a lot of information about their pain problem (and other aspects of their lives) to determine if pain management techniques might be helpful. Hopefully, at that point, some rapport has already been established. After the introductory comments, the next segment of the interview should be very focused on the pain and medical issues. It is useful to start with gathering more “medical” information initially since the patient will be comfortable with this interaction and not be place on the defensive. Later, the interview can focus on “psychological” data gathering after more rapport and credibility with the patient is established. After gathering the medical information one can usually move into the other areas without much resistance (e.g., psychosocial, work, psychiatric histories and mental status examination).


Elements of the Clinical Interview


Later in this section is an example of a pain evaluation report template that illustrates the important elements of information gathering from all available sources (e.g., the clinical interview, psychological testing, medical records review, and discussions with family and healthcare providers). Elements of the clinical interview often include the pain and medical history, psychosocial histories (family, work, educational), current psychosocial status, and the mental status examination (MSE).


Not every clinical interview will assess all categories outlined previously but there should be certain common components to every clinical interview. For instance, every clinical interview should include some elements of the Mental Status Examination (MSE). The extensiveness of the MSE will depend on the presenting symptoms and preliminary findings. Elements of the MSE should include at least the following sections:


(1) Appearance, Attitude, and Activity

(2) Mood and Affect

(3) Speech and Language

(4) Thought Process, Thought Content, and Perception

(5) Cognition

(6) Insight and Judgment


The MSE commonly yields information that has not been previously assessed by another health care professional. Many of the areas of assessment (e.g., sexual functioning, drug- and medication-use history, and suicidality) are uncomfortable areas for other providers to explore, but they are of great concern to the patient. For instance, in asking about the impact of a pain problem on sexual functioning, the following response is not uncommon, "I am glad someone finally asked me about that! I've been very concerned. . . ."


An excellent mental status exam resource is, The Psychiatric Mental Status Examination (Trzepacz & Baker, 1993). There are also many MSE structured formats available.




Clinician developed, problem focused, information gathering questionnaires are very useful in the assessment of a chronic pain problem. Depending upon the purpose of the interview, the questionnaire may be mailed to the patient before the first visit and reviewed at the time of interview. This method is a considerable time-saver in the evaluation of chronic pain patients since the amount of information that needs to be gathered from the patient tends to be quite extensive. Chronic pain patients also appreciate the ability to fill these questionnaires out at home since sitting tolerance and endurance is often an issue (precluding having the patient complete the forms in the waiting room at the time of the interview). Of course, if the purpose of the evaluation is related to disability or is medical-legal, the questionnaires and psychological testing must be completed in a controlled environment.


The interviewer may review questionnaire data with the patient but can focus more time on areas needing further clarification and on more general psychological issues. Reviewing some questionnaire information with the patient is important since it demonstrates the value of the data to the clinician and helps to establish rapport. Questionnaires are also a mechanism for the systematic recording of data that can facilitate clinical research and subsequent program evaluation.


An example intake questionnaire for use with chronic pain patients is as follows:






The following questionnaires are designed to provide you with the most comprehensive evaluation possible. The questionnaires will give us valuable information about the impact your medical problem has had on your life.


Depending on which questionnaires are included, the assessment will take between 20 minutes and 2 1/2 hours to complete. Questionnaires might include any combination of the following depending on the purpose of the assessment:


Pain Patient Questionnaire

Minnesota Multiphasic Personality Inventory (MMPI-2)

Battery for Health Improvement (BHI-2)

The Multidimensional Pain Inventory (MPI)

Beck Depression Inventory (BDI-2)


These Questionnaires are commonly used in pain clinics throughout the world. Please read the following instructions carefully.


1. It is very important to fill out the questionnaires alone and not to discuss your answers with anyone. If, for some reason, you cannot complete the questionnaires without assistance please let us know.


2. It is important to answer ALL of the questions. Please do not leave any blank. Answer all of the questions as accurately and honestly as possible. Please read the instructions for each questionnaire carefully.


It is important to understand that all patients being evaluated get the same questionnaires. Many of the questions will apply to your situation and many will not. In fact, you may not understand why some of the questions are even being asked. Answering all of the questions is essential as we evaluate a wide variety of complex pain problems. Therefore, we have everyone answer all of the same questions. Thank you for your cooperation. We will go over the results of the evaluation at its completion.




Today’s Date:___________________________________________

Name: ____________________________________ Age:________

Address: _______________________________________________

City State Zip: __________________________________________

Phone: ________________________________________________

Briefly describe your pain problem:____________________________________




Choose a number between 0 (no pain) and 10 (the most intense pain imaginable) which describes the level of your pain at its:


Highest intensity   ______________

Usual intensity   ______________

Lowest intensity   ______________

Your pain level at this very moment   ______________


Choose a number between 0 (no interference) and 10 (continuous interference) which describes how much your pain interferes with the following activities:


Work   ______________

Family chores   ______________

Play, recreation   ______________

Sex   ______________


What is the percentage of time that you are in pain (0 to 100): _________



What makes your pain worse?



What eases or reduces your pain?



Use the figures below to indicate (1) Where the pain is located, (2) How much area is involved, and (3) Whether there is more than one location.



Do your sensations spread? If so, show where they spread by writing an “X” at the main area of pain and draw arrow to show how the symptoms spread.






Please complete the table below for any surgeries you have had:

Date of Surgery

Type of Surgery


Complications (if any)


























List all of your current medications. Continue on the back if necessary.

Current Medications


# of pills per day

Times of day taken

Side Effects?
































List all of the doctors involved in your medical care:

Doctor’s Name


Type of Treatment

Dates of Treatment


























Do you have any history of drug/alcohol abuse problems? YES NO


How much of the following do you take in a day?

coffee ________ cups/day

tobacco ________ cigarettes/day

cola _________ glasses/day

beer _________ 12 oz. cans/day

wine _________ glasses/day

liquor _________ ounces/day


Please list any psychiatric or psychological care you have had in the past or now:





On the lines below and on the back of this page if necessary, please list any questions or other information about your pain problem that you think is important for us to know as part of your evaluation.  



In the thousands of patients who have been asked to complete various versions of this questionnaire, refusal has been almost nonexistent. However, given the initial defensiveness of many patients to seeing a pain management clinician, it is important to limit questionnaire items to variables related to sociodemographic features and the chief complaint, leaving broader psychological exploration to the interview.


Questionnaires can also be developed for significant others and health care providers. The form and content of the questionnaire will depend, of course, on the theoretical orientation of the clinician. Questions can be forced choice, open ended, simple ratings, checklists, or pictorial in nature (e.g., pain maps). Clarity and ease of response are important features. However, the clinician must take care not to use questionnaire techniques in a fashion that would substitute for the development of a quality professional relationship with either the patient or the referral source.


Pain Ratings and Drawing


Some aspects of the pain questionnaire merit further discussion.  For instance, if a patient rates his or her pain as a 10 at its lowest, usual and highest intensity, he or she is either making a cry for help or cannot distinguish between variations in pain intensity.  This is also true for someone who rates his or her pain at an 8 at its lowest intensity.  All pain perception is variable over time and it important that patients be able to make subtle distinctions in intensity.  This is often one of the treatment goals of chronic pain management.


The pain drawing can also be a very significant source of information that can be assessed very rapidly.  As discussed by Block et al. (2003), “The pain drawing allows the clinical not only to rapidly visualize the areas in which the patient is experiencing, but also to assess certain aspects of the patient’s perception of pain” (p. 49).  A number of scoring systems have been developed for pain drawings (See Block et al., 2003) and these are designed to identify drawings that are “abnormal” or indicative of pain not due to physical factors or nociceptive input.  Penalty points paindrawing1(indicating more abnormality of the drawing) are scored in three domains: poor anatomic localization, pain expansion or magnification, and explanatory notes or other features added to the drawing not requested in the instructions.  Pain drawing scoring systems are more often used in research and are not typically used in clinical practice.  However, when a drawing is grossly abnormal, a scoring system is not necessary (as can be seen in the examples).  Pain drawings are simple to use and can provide a wealth of information.  Repeat pain drawings can also be used to track response to treatment.


Pain drawing #1.  The first pain drawing is considered abnormal since the symptoms do not follow anatomic distribution and the pattern is vague and diffuse.  This drawing would meet two of the penalty point domains: poor anatomic localization and pain expansion.  In this patient, after extensive objective testing, there were no factors identified that would explain this pattern paindrawing2of pain.  The possibility of a conversion disorder was considered.


Pain drawing #2.  The second pain drawing was considered abnormal since it met three of the penalty point domains: poor anatomic localization, pain expansion, and adding features or explanatory notes.  The drawing also shows pain outside the body.  Again, there were no objective findings that would explain these pain and symptom distributions.


Pain drawing #3.  This pain drawing is probably the most fascinating I have come across in practice.  This was a 23 year old male who was referred for a pre-surgical screening prior to a proposed spinal fusion.  The pre-surgical screening was completed and the patient was not cleared due to biopsychosocial factors.  It was also clear during the clinical interview that the patient was showing insidious onset of psychotic features (delusions, paranoia, disorganized speech, etc.) that would wax and wane.  The patient had no history of psychiatric treatment or reported symptoms and his surgeons had paindrawing3simply referred him for routine screening.  The patient was ultimately hospitalized on a psychiatric basis and began appropriate treatment after receiving a diagnosis of schizophrenia.  Although he did have some objective findings relative to the pain symptoms, there was symptom amplification due to the psychological issues and spine surgery was determined not to be indicated.  I think this case also underscores that, although the pain practitioner will primarily be involved with more behavioral health related issues, it is important for the clinician to be able to assess and appropriately manage these types of unusual psychiatric situations.




Patient diaries are commonly used to record behaviors, both overt (e.g., activities, pain medication use, “down time”, etc) and covert (e.g., thoughts, feelings, and pain intensity). They are used as baseline measures and as an intervention to foster learning about antecedents, consequences, and the relationships among internal and external behaviors (i.e., to promote psychological and physiological insights). Diaries are also used to measure the effectiveness of treatment programs. Although there are controversies about the reliability and validity of diary data, these methods continue to be an excellent source of clinically useful data.


To improve compliance (and the validity of the data collected), diaries should be easy to use, brief, and non-intrusive. Training patients in how to use a diary is important. The use of cues as reminders to record information can increase compliance.


There are many examples patient diaries used in the evaluation and treatment of chronic pain. The diary should be custom made to collect the type of information that is important to the treatment of the specific pain problem.  






In general, two kinds of psychometric techniques are used in the assessment of chronic pain problems: general tests that are adapted for use in this population (e.g., MMPI-2, BDI-2) and tests constructed specifically for use with medical/pain patients (e.g., BHI-2, MPI). To get even more specific, there are also tests developed just for specific pain problems. For this overview discussion, tests designed for specific pain disorders will not be reviewed.



Purpose of Forensic Assessment: Establishing Credibility



Forensic evaluation of the chronic pain patient is not uncommon given the fact that the pain often starts with an injury.  As discussed in the AMA Impairment Guides, “It is considerably more difficult to provide a method for assessing chronic, persistent pain than acute pain.  In chronic pain states, there is often no demonstrable active disease or unhealed injury, and the autonomic changes that accompany acute pain, even in the anesthetized individual, are typically absent” (p. 566).  The Guides go on to state that, “Pain is subjective.  Its presence cannot be readily validated or objectively measured” (p. 566). As such, the evaluation of the chronic pain patient relies primarily on self-report data.  The rating of impairment due to chronic pain “differs significantly from the conventional rating system, which relies primarily on objective indices of organ dysfunction or failure” (p. 573). According to the AMA Guides (p. 573), pain-related impairment is considered unratable if:


·         His or her behavior during the evaluation raises significant issues of credibility


·         He or she has clinical findings atypical of a well-accepted medical condition


·         He or she is diagnosed with a condition that is vague or controversial


This reliance on subjective, self-report data underscores the absolute necessity for establishing patient credibility.  Establishing credibility of the patient self-report should include any or all of the following:


·         Standardized tests to rule out malingering and deception


·         Assessing consistency or inconsistency of symptom reporting over time (through medical record review)


·         Evaluation other physicians analysis of possible symptom embellishment


·         Assessing behavioral reliability



It is beyond the scope of this presentation to review all of the psychological tests that are used with pain patients (for that purpose the reader is referred to such volumes as Gatchel, Andersson, Deardorff, et al., 2001; Gatchel, Deardorff et al., 2006; Gatchel and Weisberg, 2000; Turk and Gatchel, 2002; and Turk and Melzack, 1992). The following reviews examples of commonly used tests and these are of both the “adapted-for-use” type and the specifically-designed type:


The Minnesota Multiphasic Personality Inventory (MMPI-2)


The original MMPI was the most commonly used standardized personality test with chronic pain patients. The original MMPI was revised and released as the MMPI-2. Similar to its predecessor, it is likely that the MMPI-2 will also be the most commonly used personality test with chronic pain patients. Some of the strengths in using the MMPI-2 with chronic pain patients are follows:


The identification of psychopathology and personality disorders.  There is a high prevalence of psychiatric and personality disorders among chronic pain patients. Identifying these psychopathological disorders is extremely important in the management of a chronic pain problem.


The identification of personality and behavioral characteristics.  The identification of personality and behavioral characteristics of chronic pain patients differs from the identification of psychopathology. Examples of pain patient personality characteristics that might be identified by the MMPI -2 include such things as dependent personality trends, passive aggressiveness, and obsessive-compulsive behavior. Identification of these characteristics by the MMPI-2 can help in treatment planning with chronic pain patients.


The MMPI-2 yields standardized scores.  Another strength of the MMPI-2 is that the scores are standardized. The experienced MMPI-2 user will compare a chronic pain patient's profile not only with the normative reference group but also with other chronic pain patient profiles and subgroups developed though statistical means.


The MMPI-2, treatment planning and prediction of outcome.  Many users of the MMPI-2 use it to make predictions regarding patient behavior, including response to treatment and treatment outcome. Many studies have shown that MMPI-2 profiles of chronic pain patients can be reliably classified into three or four major subgroups. The subgroups have been found to differ reliably from one another on such variables as pain intensity, medication use, functional disability, and employment status, and surgery outcome.


The MMPI-2 is not face valid and allows for detection of response bias.  The MMPI-2 is one of the only instruments that has several sophisticated mechanisms to check for response bias by the patient. In addition, the vast majority of the items are not face valid. Therefore, the clinician can generally tell if the patient answered the questions with a response bias (for whatever reason) that might affect the final profile results.


Anyone using the MMPI-2 to assess the personality characteristics of chronic pain patients must also be aware of its weaknesses and avoid inappropriate use of the instrument. Critical areas to be aware of include the following:


Length of the test and item content.  The MMPI-2 contains 567 true-false questions. For the chronic pain patient to complete the test it can take several hours and may have to be completed over several sessions. Some clinicians believe that, although the MMPI-2 might yield useful information, the amount of time required to complete the test does not make it cost effective. Another common complaint of pain patients taking the MMPI-2 is its item content. Pain patients are particularly sensitive to psychological assessment since they believe the clinician may be implying the pain is "imaginary." This issue always has to be managed carefully by the referring physician and the pain psychologist doing the assessment. The method in which the MMPI-2 is introduced to the patient is critical.


Standardization sample is not appropriate for pain patients. It has been argued that the results of the MMPI-2 profiles are invalid when used with chronic pain patients due to the inclusion of items that reflect features of both a psychiatric disturbance and a chronic illness such as long term pain. Scales 1 (Hypochondriasis) and 3 (Hysteria) contain a number of items reflecting a general medical or physical condition. Research has shown that elevations on Scales 1 and 3 can be reflective of disease rather than psychological status. This must be taken into account when interpreting MMPI-2 results.


Incorrect interpretation of test results. For a clinician who is not extremely familiar with the use of the MMPI-2 with pain patients, there is a high risk of misinterpretation of the results. The risk of misinterpretation is due to several factors including the standardization sample, the contamination of certain scale items with physical symptoms, and the "outdated" scale names that purport to measure something they do not. A test interpreter who is not aware of these issues is likely to make a serious mistake in the MMPI-2 interpretation.


Battery for Health Improvement-2


The Battery for Health Improvement-2 (BHI-2) is a 217-item, self-report, multiple-choice instrument designed for the psychological assessment of medical patients. The purpose of the test is to provide relevant information and treatment recommendations to professionals who treat injured patients in a variety of settings, including physical rehabilitation, vocational rehabilitation, and general medicine. The BHI-2 has 18 scales organized into five domains: Validity scales, Physical Symptoms scales, Affective scales, Character scales, and Psychosocial scales. The BHI-2 was designed for patients 18-65 years old who are being evaluated or treated for an injury. The test was designed for patients with at least a 6th grade education and takes approximately 35 to 40 minutes to complete.


Unlike many psychological tests that have been adapted for use with medical patients, the BHI-2 was designed specifically for this clinical population. As discussed in The Manual (Disorbio and Bruns, 2003), self-report psychological tests tend to “overpathologize” what might actually be normal or expected for the average medical or rehabilitation patient. Thus, traditional psychological tests must be used with caution and interpreted accordingly by a qualified individual.

As documented in The Manual, research relative to the development of the test has been extensive. This has included establishing normative values, demonstrating reasonable reliability (internal, test-retest), and assessing validity by correlating BHI-2 scales with scales from other established instruments (e.g., MMPI-2, MCMI-III, etc.). One potential problem with the BHI-2 that the user should be aware of is that there does not seem to be much clinical research yet available outside of that done by the authors during test development.


Millon Behavioral Medicine Diagnostic (MBMD)


According to the test publisher, The Millon Behavioral Medicine Diagnostic (MBMD) is designed to assess psychosocial factors that may support or interfere with a chronically ill patient’s course of medical treatment.  The MBMD consists of 165 True-False items and take between 20-25 minutes to complete.  The test result yield 29 Content Scales grouped into five domains (Psychiatric Indicators, Coping Styles, Stress Moderators, Treatment Prognostics, Management Guide), three Response Patterns (Disclosure, Desirability, Debasesment) and six Negative Health Habits (Alcohol, Drugs, Eating, Caffeine, Inactivity, Smoking).  The MBMD provides two sets of normative data: general medical and bariatric.  The MBMD is an update and expanded version of the Millon Behavioral Health Inventory (MBHI). 


As with other instruments (except for the MMPI/MMPI2) research on the use of the MBMD with chronic pain patients is limited and the test was designed for general medical use.  There are no scales or norms specific to pain patients.  There is also a high level of item of overlap on scales.  As part of a comprehensive evaluation, it can help in the understanding risk factors and personality factors in chronic pain treatment. 


Symptom Checklist-90-Revised (SCL9-R)


The SCL-90R consists of only 90 items that are rated on the five-point scale (0 to 4). The instructions and questions are very straightforward and most patients can complete the test within 15 to 30 minutes. The results yield nine scale scores: Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety Paranoid Ideation, and Psychoticism. There are also three global measures of psychological distress: Global Severity Index, Positive Symptom Distress Index, Positive Symptom Total. The SCL 9O-R has become one of the most commonly used measures of psychological distress among chronic pain patients.


Similar to the MMPI, one of the important uses of the SCL 90- R is the identification of psychopathology. The SCL 9O-R has been used extensively in medical settings as a screening tool and outcome measure. The SCL 90-R is a good instrument for screening for global psychological distress in medical patients. It is brief, easy to score, and generally well-tolerated by patients.


Also similar to the MMPI, the SCL 9O-R yields standardized scores. This allows the clinician to compare the individual profile of the pain patient against the normative sample and other groups. The test has been standardized using non-psychiatric and psychiatric normative samples. Although the SCL 9O-R measures various psychological problems the item wording on the SCL 90-R seems to be less objectionable to most patients as compared to the MMPI.


The SCL 90-R has shown reasonable convergent validity with MMPI scales and subscales. Thus, an argument can be made for the use of the SCL 9O-R in place of the MMPI when one wants a measure that is brief, as well as being simple to administer and score. Alternatively, some pain centers will first use the SCL 9O-R as a screening tool and then administer the MMPI only to those patients who show elevated scores on the SCL 90- R.


The problems with the SCL 9O-R are somewhat similar to those leveled at the MMPI. First, the SCL 9O-R was originally designed to be used on psychiatric patients. Critics contend that using the SCL 9O-R with pain patients causes significant problems due to unsuitability of norms, questionable relevance of clinical signs and the misinterpretation of results. Thus, any interpretation of results much take into account the effect of the patient’s report of physical symptoms in elevating certain scales.


Another criticism is that, like most of the other instruments except the MMPI2, the items on the SCL90-R are very face valid. In addition, there is no scale or means of checking for response bias or conscious manipulation of test results by the patient.


Beck Depression Inventory (BDI/BDI-2)


The original Beck Depression Inventory (BDI) is a 21 multiple-choice item test reflecting specific behavioral signs of depression that are weighted in severity from 0 to 3. The total score is obtained by adding the weighted values for each response endorsed by the patient. Scores of 0-9 are considered normal, 10-15 range is seen as mild depression, 16 to 19 represents mild to moderate severity, 20-29 is judged as moderate to severe, and 30 represents severe depression. The instrument was originally standardized using psychiatric patient populations.


The BDI is very easy to administer and score. It takes a patient between 5 and 10 minutes to complete the questionnaire and the questions are very straightforward. The BDI has been shown to be a reliable and valid index of severity of depressive symptoms in chronic pain patients.


The BDI has been slightly revised to the BDI-2. The BDI-2 has essentially the same questions as the original BDI except it has been divided into two subscales: physical and cognitive (or mood). This allows the clinician to see which factors are responsible for an elevated score. This can help minimize false positives in a pain patient population in which a patient has an elevated score due to physical symptoms but is not depressed.


The BDI is a very face valid instrument. Thus, if a patient desires to present an inaccurate clinical picture of his or her emotional status, the BDI is easily manipulated. This generally does not occur and, if suspected, the BDI results can be correlated against other clinical data such as the initial interview, history, and other test measures.


Brief Battery for Health Improvement-2


The Brief Battery for Health Improvement-2 (BBHI-2) was developed to serve as a tool for assessing medical patients who may be experiencing problems with pain, functioning, somatization, depression, anxiety or other factors relevant to rehabilitation and recovery (Disorbio and Bruns, 2002). The test is 63-item, self-report, multiple-choice instrument designed for the psychological assessment of medical patients. The BBHI-2 is a shortened version of the BHI-2. The purpose of the test is to provide relevant information and treatment recommendations to professionals who treat injured patients in a variety of settings, including physical rehabilitation, vocational rehabilitation, and general medicine. The BBHI-2 has 6 scales that cover three content areas: validity (defensiveness), physical symptoms (somatic complaints, pain complaints, functional complaints), and affective symptoms (depression and anxiety). The BBHI-2 was designed for patients 18-65 years old who are being evaluated or treated for an injury. The test was designed for patients with at least a 6th grade education and takes approximately 7 to 10 minutes to complete. The test is especially useful for tracking patient progress and response to treatment.


The problem with the BBHI-2 is the same as the BHI-2 in that there is not much research outside of the development studies. The brevity of the BBHI-2 makes it most useful as: (1) a screening tool to identify patients in need of further assessment, (2) a test-retest measure of progress and response to treatment, and (3) a test to be used in conjunction with more comprehensive psychological testing.


A number of more specific measures have been developed for use with chronic pain patients specifically. These can be very useful depending on the targets of assessment chosen.


Multidimensional Pain Inventory (MPI)


The MPI is a 56-item measure comprised of three sections. The first section includes items assessing: (1) pain severity and suffering; (2) interference of functioning due to pain; (3) perceived life control (4) affective distress; (5) support from spouse or significant other. The second section assesses the patient's perception of how much the spouse or significant other is displaying solicitous, distracting, or punishing responses to pain or suffering behavior. The third section assesses the patient's level of activity in areas of household chores, outdoor work, activities away from home, social activity and general activity level. The length of the MPI is well tolerated by patients, taking only about 15 to 20 minutes to complete.


The computer scoring generates a scaled T-score and classifies the case into one of three empirically derived prototypic profiles: "Dysfunctional" (high pain severity, affective distress, and life interference with low life control and activity levels); "Interpersonally Distressed" (low levels of support from significant others); and, "Adaptive Coper" (the opposite of Dysfunctional: low levels of pain severity, affective distress, and life interference with higher levels of life control and activity).


The MPI was specifically developed for pain patient assessment. The standardization and normative data are all derived from populations of pain patients. The MPI is theoretically linked to a cognitive- behavioral perspective of chronic pain and health assessment. Because the MPI was developed for use with pain patients, the item is relevant to the experience of the person with chronic pain. Therefore, patients generally do not question why the questionnaire is being used to assess their problem.


The MPI was designed to be a brief measure of specific characteristics of pain patients. As such, it does not yield any detailed information about such things as depression, anxiety or somatization (the affective distress scale has questions and its content is related). It also is not designed to screen for psychopathology that might impact chronic pain treatment. Therefore, the MPI might be best used in conjunction with another instrument such as the SCL 9O-R or MMPI-2.


Coping Strategies Questionnaire (CSQ)


The CSQ is a 50-item self-report instrument originally designed to assess six cognitive (diverting attention; reinterpreting pain sensation; coping self-statements; ignoring pain sensation; praying or hoping; catastrophizing) and two behavioral (increasing activity level; increasing pain behaviors) coping strategies. This instrument also includes two items that ask patients to report their perceived control over pain and their ability to decrease pain.


The psychometric properties of the CSQ are good, and it has received a great deal of clinical research attention in terms of comparing reported use of coping strategies to indices of patient functioning and treatment outcome. For example, one major association between the CSQ factors and adjustment to chronic pain is that patients who report catastrophizing thinking styles and who view themselves as ineffective at controlling their pain appear to be more disabled and depressed at initial assessment as well as follow-up assessment. Results such as these speak highly of the clinical utility of the CSQ with pain patients.


Factor analytic studies of the CSQ have failed to reveal a reliable factor structure, thus indicating the empirical difficulty of identifying distinct dimensions of coping. This suggests the need for additional research evaluating the "active ingredients" of patients' self-reported coping responses. Although this suggests a theoretical shortcoming with regard to the structure of coping strategies, it does not distract from its clinical utility.


Chronic Pain Coping Inventory (CPCI)


The CPCI is a recently developed instrument comprised of 64 items that yields scores on 8 main subscales measuring coping strategies that are frequently the target of treatment in multidisciplinary programs: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising, Stretching, Coping Self- Statements, and Seeking Social Support.


The CPCI was developed specifically for use with chronic pain patients and attempts to overcome shortcomings of other coping measures. Most coping measures assess primarily cognitive coping strategies (e.g., the Coping Strategies Questionnaire) to the exclusion of behavioral strategies. The CPCI was designed to assess behavioral coping strategies. Because the CPCI is so new, there is a limited amount of research available; thus, it is unknown how the CPCI results related to such issues as treatment planning and prediction of outcome.


Obviously this listing is not exhaustive. We cannot over emphasize the need for the practitioner to be aware of the reliability and validity issues specific to each measure for each usage. Failure to recognize limits of interpretation of test results is contrary not only to good clinical practice but also to ethical standards.




Observation of the chronic pain patient is one of the most fundamental methods of assessment and can provide the clinician with information applicable to many of the target areas described in the model. Observation can be unstructured or highly structured and can be made directly by the clinician, by family members, or by health care providers. Furthermore, these observations can be audiotape or videotape recorded.



Assessing Behavioral Reliability



Assessing behavioral reliability related to chronic pain is an essential element in forensic assessment (QME, AME, IME).  According to the AMA Guides, assessing behavioral reliability involves the following (p.582):


Congruence with established condition.  If a patient’s pain behavior are consistent with a known medical condition, then credibility is supported.  If the behavior is not consistent, then credibility is suspect.  For instance, in a complex regional pain syndrome of the upper extremity one might expect extreme sensitivity to “light touch of a health-appearing extremity following a trivial injury” (referred to as allodynia, AMA, p. 582).  Similar symptoms in the low back region due to a musculoskeletal condition would suggest symptom embellishment.


Consistency over time and situation.  Pain behaviors should be reasonably consistent regardless of situation and other external factors.  For example, a chronic pain patient who presents for evaluation using a walker and exhibits a shuffling gait would not be expected to be seen ambulating effortless over several hours on video surveillance.


Consistency with anatomy and physiology.  Chronic pain symptoms that are not consistent with anatomy and physiology are suggestive of possible symptom embellishment. For instance, a herniated disc at L5-S1 to the right compressing a nerve root should result in a predictable radicular pain pattern in the right lower extremity.  Diffuse pain throughout the entire right lower extremity or predominately in the left lower extremity might suggest a problem with consistency. 


Observer agreement.  As discussed in the AMA Guides (p. 582), it is important to gather collateral information from relative, friends, employers, and other professionals, as available.  This information can help to confirm or dispute the patient’s observed pain behaviors.



In most instances, the source of observational data will be during the clinical interview, as well as in the office setting or outpatient clinic (e.g., waiting room, walking to and from the office, etc). If the patient is being assessed on an inpatient basis, observation can be made on the unit, etc. Another important source of observational data is the interaction between the patient and significant others. It can be very helpful to have family members available to be interviewed as part of the evaluation. This can give the clinician a sense of how family members are reacting to pain behaviors of the patient.


Observations can be quantified through rating methods, content analyses (e.g., somatic focus) or frequency scores (e.g., pill counts to determine compliance) among other methods. The clinician can also collect impressions in an effort to generate hypotheses for more precise testing. It is especially useful to compare direct observation of behavior to others, perceptions of the behavior, or to the patient’s own perception of his or her behavior (e.g., the "demanding patient”). Reasons for the lack of correlation could be clinically very meaningful and thus help target areas for intervention.




Archival data might include the patient’s medical chart, literature reviews relating to the pain condition, employment records, etc. Literature reviews of the chronic pain condition including cause, symptoms, course, prevention, treatment, and psychological components can provide archival data that is useful in the assessment process. Having a familiarity with the pain problem before assessing the patient can be very useful in helping the clinician obtain the more relevant information as efficiently and effectively as possible. It also helps to establish the credibility of the clinician with the patient. If you are referred a pain patient who has a condition with which you are not familiar, a quick Internet search of a reputable medical website (e.g., medscape or webMD) can provide useful information prior to the initial evaluation.


Reviews of previous medical and psychiatric charts are very valuable sources of information in the assessment of the chronic pain patient. The data from these archival sources can be compared and contrasted with that collected elsewhere (e.g., patient self-report, psychological testing, etc). Although these records are not always easily obtained, the clinician will find the information contained within them most useful in providing a historical perspective of the patient, his or her problem, and aspects of help-seeking behavior.


It might also be necessary to consult archival data when assessing the potential impact of various environmental variables on the problem, such as the health care system and the sociocultural environment. Hospital policies, insurance coverages, legislation relating to disability, laws regulating the practice of health care provision, and employers' policies need to be understood to develop an adequate conceptualization for intervention. This is especially true when working with chronic pain patients who are part of a workers’ compensation or other disability system (e.g., Social Security).




According to Belar and Deardorff (1995, 2008), at the end of the assessment process, the clinician should have an understanding of:


(a) the patient in his or her physical and social environment

(b) the patient's relevant strengths and weaknesses

(c) the evidence for psychopathology

(d) the nature of the disease and treatment regimen

(e) the coping skills being used by the patient


After integrating relevant information, the clinician should be able to answer the seven questions listed below. These questions were derived by Belar and Deardorff (1995, 2008) from Moos (1977) who delineated these areas as the major adaptive tasks for any patient with a medical illness (including chronic pain). The relative importance of answers to each question in determining the overall status of the patient will vary, dependent on the understandings developed through assessment of the previously mentioned targets.



Goals of Assessment: Getting Answers to Important Questions



How is the patient dealing with pain, incapacitation, and other symptoms?


How is the patient dealing with the hospital environment and the special treatment procedures?


Is the patient developing and maintaining adequate relationships with the health care system?


Is the patient preserving a reasonable emotional balance?


Is the patient preserving a satisfactory self-image and maintaining a sense of competence and mastery?


Is the patient preserving relationships with family and friends?


How is the patient preparing for an uncertain future?



In conclusion, the purpose of the psychological pain evaluation is to understand the patient and his or her problem in order to arrive at a treatment strategy or a management decision. One need not be wedded to a particular theory or assessment strategy; rather, flexibility in this regard is an asset. However, the biopsychosocial conceptual framework should form the foundation of any chronic pain evaluation or treatment strategy.




Once the pain management clinician has an “understanding” of the chronic pain patient this information is usually recorded in an evaluation report. The following represents a template for the pain management evaluation report. Depending upon the setting and other issues, the report template can certainly be modified. For instance, very few physicians (and no surgeons) will take the time to read a lengthy evaluation report (the kind that psychologists are very good at producing). In many cases, it is appropriate to send only a very brief summary of important points to the other health care providers. The more lengthy report is often necessary when the patient is part of a comprehensive pain program, med-legal evaluation or disability assessment.



Pain Management Evaluation


Identifying Information


Presenting Problem and Review of Available Medical Records


Work History


Educational History


Legal History


Military History


Other Medical Problems


History of Work/Other Injuries


Interviewer Observations and Mental Status Examination

The following is a summary of interviewer observation and a mini-mental status examination. A formal mental status examination was not necessary.


     Pain Behaviors:


     Crying Spells:


     Appetite and weight changes:

     Energy level:

     Memory and concentration abilities:

     Suicidal ideation, plan, previous attempts:

     Sexual functioning:

     Symptoms of generalized anxiety or panic:

     Thought Process:



Psychosocial Situation


Psychiatric Treatment History


Substance Use




Pain and Psychological Assessments


Pain and Functional Ratings

The numerical pain ratings assess the patient’s pain intensity and fluctuations. The functional ratings assess the patient’s self-perception of how the pain is impacting physical abilities across a number of domains.


Pain Drawing

The pain drawing assesses the patient’s report of sensory distribution of pain and other symptoms


Battery for Health Improvement-2

The BHI-2 is a comprehensive self-report instrument designed for the psychosocial assessment of medical patients (Bruns and Disorbio, 2003). The purpose of the test is to provide assessment information and treatment recommendations for injured patients in a variety of settings.


Multi-Dimensional Pain Inventory

This is a comprehensive self-report instrument that evaluates the impact of diverse chronic pain syndromes on multiple dimensions of a patient’s life (Turk and Melzak, 1992).


Beck Depression Inventory-2

The BDI-2 is a self-report measure of depression. It is not used to diagnose depression in a patient; rather, it is designed to provide a measure of the intensity of depression in a patient who is found likely to be “depressed” by other measures (e.g., clinical interview). The BDI-2 helps to assess the chronic pain syndrome.




     Symptoms of a Chronic Pain and Disability Syndrome:

     Contribution of Operant/Cognitive/Affective Factors:

     Strengths and Assets:


     Suicidal Risk:

     Substance Abuse Potential:

     Potential Problems Related to Compliance with Treatment Recommendations:

     Propensity towards Side-effects to Medications or Treatment:

     Appropriateness for Antidepressant Medication Evaluation and Treatment:

     Psychosocial Barriers to Recovery:

     Appropriateness for Multidisciplinary Treatment:


Conclusions and Recommendations




The two most common types of direct psychological treatment of chronic pain include cognitive behavioral interventions and relaxation training. These approaches are often used together to provide simultaneous interventions at cognitive and physical levels.


Cognitive Behavioral Treatment (CBT)


The cognitive behavioral model is excellent for treating many aspects of a chronic pain problem. It is beyond the scope of this discussion to review all of intricacies of the cognitive behavioral model. For that discussion, the reader is referred elsewhere (See Bradley, 1996; Gatchel, 2004; Turk, 2002). This section will present an overview of the cognitive behavioral approach with a special emphasis on using it in treating chronic pain.


Turk (2002) provides an excellent overview of cognitive-behavioral treatment of chronic pain patients. Much of that detailed discussion will be reviewed subsequently along with information from other sources. As discussed by Turk (2002), “According to the C-B model, then, it is the pain sufferer’s perspective, based on his or her idiosyncratic beliefs, appraisals, and unique schemas, that filter and interact reciprocally with emotional factors, social influences, and behavioral responses, as well as sensory phenomena. Moreover, patient’s behaviors elicit responses from significant others (including health care professionals) that can reinforce both adaptive and maladaptive modes of thinking, feeling, and behaving” (page 140). Turk (2002) goes on to summarize the five assumptions that characterize the cognitive behavioral treatment approach and these are discussed relative to chronic pain:



Five Assumptions of Cognitive Behavioral Treatment



1.   People are active processors of information rather than passive reactors to environmental contingencies.


In the pain system model, an individual is seen as an active processor of the pain sensation including attaching meaning to it (e.g., threatening or non-threatening) and interpreting it based upon past experience and cultural influences. This active processing influence on pain becomes more and more significant as the pain goes on.


2.   A person’s thoughts can impact affective and physiological arousal, both of which may serve as impetus for behavior. In addition, affect, physiological arousal and behavior can influence one’s thoughts.


In the pain system model a person’s thoughts about the pain will directly influence such things as affective state, pain behavior, and physiological arousal. For instance, chronic pain is often associated with depression and this is characteristically preceded by “depressionogenic” thoughts (“I’ll never get better”, “I have no control”, etc). In addition, pain behaviors such as limiting activities are clearly related to one’s thoughts about the pain (if I am active I will injure myself). Lastly, physiological arousal will follow such thoughts as “I won’t be able to stand this pain much longer” and “What if the surgery doesn’t work?”


3.   Behavior is reciprocally determined by both the environment and the individual.


In the pain system model, a patient’s pain behavior will be influenced by the individual’s beliefs (thoughts) about the pain and the reaction of the psychosocial environment (positive and negative reinforcement of the pain behavior).


4.   If an individual has learned maladaptive cognitive, affective, and behavioral patterns, then treatment should be focused on changing these patterns with intervention across all dimensions (cognitive, affective, physiological, and behavioral).


As pain becomes more and more chronic, maladaptive patterns become more firmly entrenched. These patterns often include becoming more and more ensconced in the sick role with concomitant maladaptive changes in thoughts (how the patient views herself), affective status (depression) and behavioral patterns (pain and disability behaviors).


5.   Just as a person is instrumental in developing and maintaining maladaptive pattern, the individual must take an active role in changing these responses.



The gate control theory of pain posits that individuals can employ various pain management techniques to change the level of pain sensation and suffering. As can be seen, the cognitive behavioral assumptions fit nicely within the conceptualization of the pain system discussed previously.




The steps for preparing the chronic pain patient for the cognitive behavioral approach, and psychological pain management in general include the following:


1.   Dispel the myth that the patient has been referred to a pain management clinician because the pain is “in your head”.

2.   Explain and discuss the gate control theory of pain. Also, present the pain system model along with examples.

3.   Discuss that psychological pain management techniques (such as learning new ways to think about the pain and relaxation training) require the patient to be active. A good example is that of learning to ride a bike. At first one falls a lot, but with more and more practice, the skill becomes automatic.

4.   Discuss the rationale behind the various interventions (e.g., cognitive behavioral, relaxation training, etc).


Introducing the cognitive behavioral model into treatment requires some preparation of the patient. In working with chronic pain patients, the pain management clinician must always be careful not to imply that “the pain is all in your head” or not believable. It can be helpful to present the psychological pain management techniques as methods to help the person manage the pain more effectively, improve the quality of life, and improve one’s mood even though the pain will still be there.


The next step is to carefully go over the gate control theory of pain and the “pain system” model as discussed in Course I. These concepts form the foundation upon which the multifaceted intervention will be justified to the patient. It is important for the patient to be actively involved in the psychological pain management treatment or it is doomed to fail. Part of preparing the patient includes explaining that psychological pain management techniques differ from the many medical treatments the patient has likely undergone. In contrast to medical treatments, the patient must be actively involved in any type self-management and rehabilitation approach. He or she cannot simply be the passive recipient of a treatment (e.g., injections, massage, medication, surgery).


After explaining the gate control theory of pain to the patient, and the need for active patient involvement in the treatment, the cognitive behavioral approach can be discussed as one component of the chronic pain management treatment.


Introducing the Patient to Cognitive Behavioral Techniques


The patient can be told that the cognitive behavioral model (and the method for changing one’s thoughts) has been termed the “ABCDE” model and it can be a very useful tool in dealing with chronic pain. The specifics of the ABCDE model will be discussed shortly, but it is important for the patient to have an understanding of how thoughts and emotions operate. This was reviewed previously in more technical terms and the following presents a manner in which these concepts can be presented to patients.



Script for Presenting CBT to the Patient



We would all agree that we constantly have thoughts and images going through our head related to evaluating the world around us. In addition we are constantly evaluating the sensations that are going on inside of us as well. These thoughts have been termed “automatic” thoughts because they often occur automatically, almost out of our awareness. Automatic thoughts have the characteristics of being very fast, virtually out of awareness or unconscious, and highly believable. As we shall see shortly, automatic thoughts have great power over our emotions and behaviors. At first, the nature of the automatic thoughts may not be readily apparent even though it is influencing your emotions and your body's health.


Many of the cognitive researchers have observed that individuals under stress have a tendency to engage in negative automatic thoughts. Negative automatic thoughts, or

“self-talk”, have the following characteristics:


·         Self-talk occurs as specific, discrete messages that often are expressed in shorthand.

·         Self-talk is highly believable to the person no matter how unhealthy or irrational it is.

·         Self-talk is experienced as highly spontaneous and difficult to "turn off".

·         Unhealthy self-talk is often expressed in terms of "should, ought, never, always and must".

·         Self-talk is unique to you as an individual.


Chronic pain can be a particularly stressful event, easily resulting in a cascade of negative automatic thoughts. Based on these findings, the ABCDE model was developed for chronic pain management. The ABCDE stands for the following:


A is the Activating Event or Antecedent Event, which is simply the event to which you are responding. This could be an outside event, such as sitting in a traffic jam, or an internal event, such as a severe back spasm.


B is your automatic thought or Belief about the activating event. For instance your belief about being in the traffic jam might be "Oh no, this is awful. I will never make the meeting in time. I should have left earlier." Alternatively your belief might be "There's nothing I can do about this traffic jam. I'll take this time to listen to the radio and be as relaxed as possible. I'll leave earlier in the future." In the back-pain example your automatic thoughts might be "I'll never get better. My back is getting worse and worse. I'll end up a cripple." On the other hand your thoughts about the back pain might be "This pain doesn't mean I'm getting worse. This is usually a temporary thing. I am getting better overall. This pain is nothing to be frightened of."

In each of the above examples the first set of thoughts are negative automatic thoughts and the second set of thoughts are coping or rational thoughts, The difference in the makeup of these thoughts can certainly be seen and will be discussed more fully in a later section.


C is the Consequent Emotion that results from the automatic thoughts. Most people think that A causes C, but in reality, C is caused by B. A person's emotional response to a situation is caused by his or her beliefs about the situation and not by the situation itself


D is the Disputing Thoughts that are used to change automatic negative thoughts. These are used to help change the way a person thinks about stressful situations (such as back pain) from a negative standpoint to a coping standpoint. In working with patients on doing this exercise, we like to term this process the power of realistic thinking.


E is the Evaluation part of using the disputing thoughts to challenge the negative automatic thoughts. This process will be discussed further.



The following examples will help the patient understand just how the ABCDE model operates.




Activating Event: You experience a mild increase in your heart rate and feel "uncomfortable and jittery."


Belief: I'm having a heart attack!!!


Consequent Emotion: Fear, anxiety, panic.


Resulting Behavior: Call doctor or go to emergency room.


In this situation the symptoms are being interpreted as a possible heart attack. The subsequent emotions and behavior follow from this belief. Suppose an alternative belief was that "I just drank four cups of coffee and the caffeine is causing the symptoms." With this explanation the emotions and resulting behavior would be entirely different.




Activating Event: You hear a noise at the bedroom window in the middle of the night.


Belief: There is an intruder trying to get in.


Consequent Emotion: Fear, panic.


Resulting Behavior: Call police, hide, and grab a weapon.


Again, in this example, the emotions and behavior follow from the belief that there is danger. Alternatively if the belief was that the noise was caused by the wind blowing a tree branch against the window, the emotional response and behaviors would be entirely different. It should be noted that in each of these examples the situations prompting the beliefs are exactly the same. The only difference is how the information is interpreted by the person in terms of beliefs. These beliefs are what caused the emotional response and behavior, not the situation itself!


We often see a similar occurrence in back pain cases. Take, for instance, the following example:




Activating Event: Back or neck pain



   "There is something seriously wrong with my spine."

   "My spine is weak and fragile."

   "My pain is going to get worse and worse"

   "I can't cope with this pain."

   "I will never get better."

   "I will always have pain."

   "I should be better by now."

   "I should never have let this happen."

   "My back pain is all their fault." "Nobody really understands my pain."

   "If I move the wrong way, I'll do myself in."


Consequent Emotion: Hopelessness, Helplessness, Anxiety, fear, Depression, Anger


Resulting Behavior: Bed rest, Social isolation, Irritability, Physical deconditioning, Decreased sex drive, Disability from work, Use of pain medicines, Groaning, moaning, and grimacing, Slow, robotic movements


These examples illustrate how our thoughts influence our emotions and behavior. But how can we use this information to help with chronic pain? This is done through the use of the "three-column" and the "five-column" techniques. The power in using this approach comes from changing the negative automatic thoughts to "realistic, coping, and nurturing" thoughts. By changing the thoughts about the chronic pain the patient can change his or her emotional responses and behaviors.




The ABC and ABCDE models can be utilized in a three- and five-column technique. A three-column worksheet can be seen in following table.


The Three-Column Technique



Activating Event




Consequent Emotions

Sitting at work. Supervisor gave me too much to do. I’m noticing worse pain in my back and neck.

“There is something seriously wrong with my back.”
“My spine is weak and fragile.”
“If I move the wrong way, I’ll do myself in.”


“I’ll never lead a normal life.”
“I can’t cope with this pain.”



“There is nothing I can do about this pain.”


“My back pain is all their fault.”
“My boss doesn’t understand my pain.”
“My boss expects too much of me.”

Anger and Entitlement

“I should be better by now.”
“I should never have let myself get injured in the first place.”
“This pain is ruining my life.”




The three columns represent the A, B, and C events discussed previously. It is useful to make several copies of a blank ABC worksheet in order to practice identifying activating events, beliefs, and consequent emotions. The three-column technique is a tool that enables the patient to run the automatic negative thoughts in slow motion. The patient can use the three-column technique to analyze thoughts and feelings whenever a stressful situation presents itself. An activating event can be any stressor, such as pain, a situation, a memory, or an interaction with another person. At first it can be difficult for the patient to "flesh out" the beliefs or automatic negative thoughts about a situation. Automatic negative thoughts often contain such words as “should, ought, must, never, and always”. As can be seen in the previous examples, phrases with these words are common in negative thinking. It is best to have the patient practice just the three-column technique for a week. In the follow up session the chart should be reviewed to ensure that the patient understands the concepts and is being compliant with the charting. Any problems can then be resolved early on.




Negative thinking often takes on certain styles or patterns and these are important to identify and discuss with the patient. Briefly, these styles can be summarized as follows:




This type of negative thinking is characterized by imagining the worst possible scenario and then acting as if that will actually happen. It will often include a series of “What if’s” such as:


·         What if I never get better?

·         What if I get worse?

·         What if I become a cripple?

·         What if . . . ?


In catastrophic thinking, the dire predictions are not based on facts but rather on pessimistic beliefs.




This negative thinking style involves focusing on only the negative aspects of a situation to the exclusion of any positive elements or options. This style will commonly include searching for evidence of "how bad things really are" and discounting any positive or coping focus. Examples include:


·         There is nothing that will help my back pain.

·         Everything in my life is rotten due to this pain. Nobody really cares.

·         The doctors have nothing to offer.

·         I've tried everything, and nothing has helped at all.


This style of negative thinking is often characterized by discounting and "yes-butting." No matter what positive option or coping method is suggested, the chronic pain sufferer will discount it with a "yes-but." For instance a person with back pain has been able to stop the pain medicines and start on a mild exercise program. When this is discussed as being a very positive change, the person retorts "Yes, but I still have pain, I haven't returned to work, and I'll bet this pain doesn't go away." This type of thinking continues to foster helplessness, hopelessness, and depression.


Black-and- White Thinking


This type of thinking is seeing things either one way or the other. There is no middle ground or shades of gray. This type of thinking is typified by:


·         Either I'm cured or I'm not.

·         I either have pain or I don't.

·         The treatment either works or it doesn't. This doctor is either good or bad.


This type of thinking undermines any small steps toward improvement, severely limits one's options, and filters out any positive aspects of the back-pain situation.




This is the process of taking one aspect of a situation and applying it to all other situations. It involves generalizing reactions to situations in which such reactions are not appropriate. For instance:


·         With this back pain there's no way I could handle going to a movie.

·         People don't want to be around me with this back pain.

·         My wife told me to try to do something about the pain. She must be ready to leave the marriage.


As can be seen, this style of irrational thinking will take one incident and make it apply to many other situations.


Mind Reading


This negative thinking trap involves making assumptions about what other people are thinking without actually knowing. The person will then act on these assumptions, which are usually erroneous. Examples of this might include the following:


·         I know my wife thinks I'm less of a man due to this pain. I know my husband thinks I'm exaggerating.

·         My doctor doesn't really think I'll get better even though she tells me I will.

·         They're not telling me everything about my pain problem.


If a person accepts these assumptions as facts, then the behavior will follow accordingly, and a possible self-fulfilling prophecy will be created. For example, a patient’s spouse might ask, "How does your back feel today?" Instead of taking his or her comment at face value, the patient believes he or she really means "Are you still letting that little back pain bother you?" So the patient responds, "How do think it feels today! The same as always, that's how." One can easily guess how this scenario would be completed.


Should Statements


Should statements are key elements in negative automatic thinking. Examples of such thinking include:


·         I should be getting better.

·         I should never have allowed this to happen.

·         I should not have had that spine surgery. My employer should have protected my back better.

·         I should be tougher.

·         My family should be more helpful.


Should thinking also include terms such as ought, must, always, and never. Should thinking is very judgmental and often involves measuring your performance against some irrational perfect standard. It has the effect of making you feel worthless, useless, and inadequate. When directed at others, it will have the effect of making the patient feel angry and resentful in those relationships.




In blaming, the person makes something or someone else responsible for the chronic pain. This type of negative thinking is very often seen in cases of industrial injury, automobile accidents, or other such trauma. Examples include:


·         My boss is to blame for my pain.

·         They should have swept up that water I slipped on. It's all their fault.

·         That guy who hit me owes me everything for the pain I'm suffering.

·         I'm to blame for this lousy back-pain problem.


Blaming as a form of negative automatic thoughts can be focused either externally or internally. Blaming can be very destructive in keeping the patient from focusing on what he or she needs to do to get better.




To help the patient become proficient at the three-column technique, exploring some common possible antecedent events can be helpful (e.g., pain flare-up, negative relationship interactions, other stressor, etc). Once several antecedent situations are identified as examples, the patient’s beliefs and emotional responses can then be discussed. In some cases, it is easier for patients to identify emotional reactions first and then work backwards to identify the negative automatic thoughts or beliefs.


When the patient has become skilled at identifying the ABC components of stress and pain, the three-column technique can be expanded to a five-column technique. This expansion is done by adding the columns for Disputing Thoughts and Evaluation. The disputing thoughts are constructed to directly "attack" and counter the negative automatic thoughts that are generated in column B. Challenging the negative automatic thoughts can be done using six questions that follow and these will help the patient develop the “coping” thoughts to be recorded in column D:


·         What is the evidence for that conclusion?

·         Is this statement always true?

·         What is the evidence for that conclusion being false?

·         Among all possibilities is this belief the healthiest one to adopt?

·         Am I looking at the entire picture?

·         Am I being fully objective?


Having the patient subject his or her self-talk to these questions will help identify negative versus positive (or coping) messages. After helping the pain patient to identify and challenge any negative self-talk, it is important to facilitate the process of substituting positive, realistic, or coping self-talk. The patient writes these coping thoughts in the thoughts and feelings diary and then practices them through rehearsal. Bourne (1995) has developed the following rules to help patients write positive coping self-talk statements.



Rules for Developing Coping Thoughts



Avoid negatives


When having patients write positive coping statements teach them to avoid using negatives. For instance, instead of saying, “I can’t be nervous about the pain increasing” a patient can say, “I will be confident and calm about completing this activity”. The first type of statement can be anxiety producing in and of itself which will defeat the purpose of the coping thought.


Keep coping thoughts in the present tense


Since most negative self-talk occurs in the here and now, it should be countered by coping thoughts that are in the present tense. Instead of a patient saying, “I will be happy when this pain is gone” he or she might say, “I am happy about ____ right now”. Teaching pain patients to begin self-statements with, “I am learning to ____” and “I can ____” is very beneficial for cognitive restructuring.


Keep coping thoughts in the first person


Whenever possible, have patients keep their thoughts in the first person. This can be done by having patients begin coping thoughts with “I” or by being sure that “I” occurs somewhere in the sentence.


Make coping thoughts believable


Coping thoughts should be based in reality. This will insure that the patient will have some belief in his or her own coping self-talk. As a patient practices the positive self-talk, it becomes more and more believable. A person’s coping thoughts should not be broadly positive, Pollyannaish, and unrealistic; otherwise the patient will completely discount them as untrue. For instance, the coping thought of “I can’t wait to have the surgery. I’m sure it will completely take away my pain” is unrealistic and not believable. Rather, the thought, “I will do my best to make sure the surgery is as successful as possible and I look forward to beginning the recovery process” is much more tenable.



Coping self-talk can challenge each of the negative styles. The clinician can review the following examples with the patients to help them understand how the disputing or challenging thoughts are generated:




For catastrophizing, the patient should be reminded that no one can predict the future. Tell the patient that it is probably in his or her best interest to predict a realistic or positive outcome rather than a catastrophic and “What if....” outcome. Explain to the patient that acting “as if” things will turn out OK is usually the best course of action.


·         No one can predict the future.

·         If I’m going to engage in “What if’s” I might as well choose healthy ones.

·         If I believe in myself, I’ll be able to handle any situation including this chronic pain.




If a patient is filtering out everything except the most negative aspects of a situation, he or she needs to learn to shift focus. First, teach the patient to redirect his or her attention onto active strategies that can be used to make the situation more manageable. Help the patient look at the situation realistically rather than magnifying the negative aspects. Then, have the patient focus on the positive aspects of the situation. Patients should be encouraged to avoid the negative thought, “I can’t stand it”.


·         I can handle this situation.

·         I’ve developed a number of resources to manage this pain.

·         I am doing this activity for the positive reasons of ____ even though my pain may flare.

·         I’m looking forward to getting better through continued ____.

·         I’ve had the procedure and now I can focus on getting better.


Black and White Thinking


Thinking in Black and White will always set the patient up for disappointment, because there will be no allowance for gradual improvement. The first step in changing this thinking is to help the patient identify when he or she is using absolute words like “all, every, always, never, and none”. The second step is to have the patient focus on how the situation may be changing in gradual steps. Lastly, remind the patient there are always different options, not just the two extremes of black and white.


·         I am making progress in the following areas ____.

·         My ultimate goal is ____, and I’m moving towards it in the following ways ____.




In overgeneralizing the patient is taking one element of a situation and applying it to everything else. A patient can stop overgeneralizing by being reminded to evaluate each aspect of a situation realistically and independently.


·         I’ve been able to get through a lot of situations and I’ll get through this one

·         Just because the last time I tried this activity caused increased pain, it doesn’t mean this time will be the same.


Mind Reading


Nobody can read another person’s mind although individuals often have the tendency to act as if it is possible. This causes a person to act and feel towards others based upon inaccurate conclusions. For instance, a patient might think, “I know my doctor doesn’t like me” based simply on “mind reading”. Remind patients that nobody can read another person’s mind and it is important to “check it out”.


·         I can’t be sure about what he/she thinks unless I check it out.

·         I need to act based on the facts, not on what I assume.


Should Statements


If a patient has a propensity towards using the words “should, ought, must”, then he or she is either self-discounting or is judging others by standards that are unrealistic. These types of statements seek to lower a patient’s self-confidence and self-esteem. To help patients evaluate when this is happening, teach them to ask themselves, “Is this standard realistic?” “Is this standard flexible?” and “Does this standard make my life and situation better?”


·         I do not have to be perfect.

·         Forget the should’s, ought’s, and must’s.

·         I will not “should” on myself anymore.

·         I am doing the best I can.

·         I am doing what I can to get better and I will reward myself for that.




If patients are tending towards self-blame, they should be reminded that they tried to make the best choice at the time and can continue to make healthy choices from now on. If they are blaming others, have them assess realistically how they went about making their choices and remind them of what aspects of the situation are in their control and realm of responsibility.


·         They are doing the best they can.

·         I did the best I could.

·         From now on, I will ____.


The result of these exercises is the five-column technique as illustrated in the following table. Give the patient several blank five-column tables


The Five Column Technique


Activating Event


Consequent Emotions

Disputing Thoughts


Sitting at work. Supervisor gave me too much to do. I’m noticing worse pain in my back and neck.

“There is something seriously wrong with my back.”
“My spine is weak and fragile.”
“If I move the wrong way, I’ll do myself in.”


“Hurt does not equal harm! This pain does mean injury.”
“The spine is a strong structure.”
“I am not at risk for injury.”

Much less fear

“There is nothing I can do about this pain.”


“No one can predict the future.”
“I’m learning ways to cope. I’ve made it through before.”

More feeling of control

“There is nothing I can do about this pain.”


“There are things I can do. They are _____.”

Somewhat better

“My back pain is all their fault.”
“My boss doesn’t understand my pain.”
“My boss expects too much of me.”

Anger and Entitlement

“Blaming does not help me get better.”
“My boss acts that way toward everyone.”
“I can get a lot done if I work steadily and pace myself.”

Decreased anger

“I should be better by now.”
“I should never have let myself get injured in the first place.”
“This pain is ruining my life.”


“I am trying to get better and am working hard at it.”
“It was not my fault.”
“There are things I can do to lead a quality life regardless of the pain.”

Guilt improved




Excess anxiety and tension can cause such things as heightened emotional upset (anxiety, depression, anger), increased pain, slower healing times, and increased side-effects to medications, among other things. A sustained stress response causes multiple negative problems such as increasing muscle tension and pain while decreasing the activity of the immune system and blood flow to the extremities.


What is Stress?


It is important for the patient to have a good understanding of what stress is, what it can do to the body and mind, and its impact on chronic pain. A detailed discussion with this patient regarding these issues will provide a solid rationale for the benefits of relaxation training.


Stress can be generally defined as a “demand” that is made upon the body, either physical or mental. Certainly, chronic pain and associated “losses” (both physical and mental) fall within the boundaries of a significant demand on the body and mind. The body’s stress response includes such things as:


·         Increased blood pressure

·         Increased heart rate

·         Rapid breathing

·         Release of stress hormones

·         Muscles tension

·         Reduced blood flow to the head, gut, skin, hands and feet


Having the chronic pain patient learn the “relaxation response” is the key to overcoming these symptoms. It should be explained to the patient that the stress response and the relaxation response are completely incompatible. If the patient can learn to elicit the relaxation response, the stress response can be effectively blocked and the pain (or suffering) can be diminished. The relaxation response also provides many benefits beyond simply blocking the stress response and helping with pain.


The “Relaxation Response”: More than Just Relaxing


It is important to distinguish from the "relaxation response" versus simply "relaxing." When discussing relaxation training as part of chronic pain management, patients often ask if they can simply do something they enjoy such as listening to music or sitting out in the backyard. It should be explained that although these types of activities are certainly “relaxing” they do not elicit the “relaxation response”.


The type of relaxation that is important in chronic pain management is some form of deep relaxation. Deep relaxation, or the relaxation response, refers to a specific physiological state that is the exact opposite of the way the body reacts when it is under stress. The relaxation response was first described by Dr. Herbert Benson and his colleagues at Harvard Medical School in the early 1970's. The relaxation response involves a number of physical changes, including:


·         Decrease in heart rate.

·         Decrease in respiration rate.

·         Decrease in blood pressure.

·         Decrease in skeletal muscle tension.

·         Decrease in the rate of your metabolism and oxygen consumption.

·         Decrease in analytical thinking.

·         Increase in alpha wave activity of the brain.


This type of deep relaxation or relaxation response can only be achieved with regular practice of a relaxation technique. Once the patient learns to elicit the relaxation response, he or she will notice feeling more relaxed even when not directly practicing the relaxation technique. A direct comparison of the physiologic effects of the stress response versus the relaxation response is as follows:


Physiologic State

Stress Response

Relaxation Response




Blood Pressure



Heart Rate



Blood Flowing to the Muscles of the Arms and Legs



Muscle Tension



Slow Brain Waves




Learning how to achieve a relaxation response produces many benefits, both directly associated with managing the symptoms of chronic pain, as well as other aspects of the patient’s life. These have been summarized as follows:



Benefits of the Relaxation Response



A reduction of generalized anxiety.


Preventing stress from building up over time.


Practicing deep relaxation on a regular basis can help prevent the build-up of cumulative stress.


Increased energy level and productivity.


Improved concentration and memory.


Practicing deep relaxation on a regular basis seems to increase your ability to focus.


A reduction of insomnia and fatigue.


The relaxation response helps prevent insomnia and generally leads to sleep that is deeper and more restorative.


It can prevent or reduce physical disorders, which are impacted by stress and often tend to worsen with chronic pain.


An increased awareness of your actual emotional state and feelings.  



The deep relaxation response also directly impacts the physical stressors associated with chronic pain. These include the following:


·         Pain Reduction

·         Control of side-effects to medications such as nausea

·         Enhanced immune response which may keep the patient healthier

·         Improved respiratory function


There are many techniques and exercises for bringing about deep relaxation or the relaxation response. These include such things as breathing techniques, progressive muscle relaxation, visualizing a peaceful image, meditation, imagery, among others. In general, the breathing exercises seem to be the easiest way to learn to elicit the relaxation response and probably the most appropriate initial technique to be used with chronic pain patients. The exercises are straightforward and require a minimal amount of body movement. This makes them easily applied to most chronic pain conditions, even those in which restriction on movement or position may be part of the functional problem. Generally, there is no problem with using any of the breathing techniques which will be presented here.




At first, the patient may think it strange to discuss learning how to breathe properly. Breathing is essential for life and it is often taken for granted that we all know how to do it properly. In reality, very few people actually breathe in the healthiest fashion. The following explanation works well for patients:



Script for Explaining Healthy Breathing to Patients



Breathing allows us to take in oxygen, which is transported through the blood to the lungs. When your blood leaves your lungs through arteries, it has a high oxygen content. It is pumped by your heart to all parts of the body, delivering the essential oxygen. The oxygen in the blood cells is exchanged for waste products. The blood is then pumped back through the heart and is returned to the lungs where the waste products are expelled in the form of carbon dioxide. Once the waste products are released by the blood cells, they take in the fresh oxygen and the cycle repeats itself.


Breathing improperly can cause an insufficient amount of oxygen to reach the blood cells, causing waste products that should have been removed to be kept in circulation. Poorly oxygenated blood is one aspect of a stress response.


There are generally two types of breathing. One is called chest breathing and the other is termed abdominal or diaphragmatic breathing.


Chest Breathing


Chest breathing, which is also termed, “shallow breathing”, leads to poorly oxygenated blood, as discussed above. Chest breathing occurs when you expand your chest with each in-breath and tuck in your abdomen. The breaths tend to be shallow and short. They can also be quite irregular and rapid. When the air is inhaled, the chest expands and the shoulders rise.


Chest breathing can be associated with high anxiety states in which a person may experience holding their breath, hyperventilation, shortness of breath, constricted breathing, or feeling like you are going to pass out. People are more prone to chest breathe when they are under stress (such as increased pain), which in turn decreases their ability to cope with the stress.


In extreme cases of chest breathing, a hyperventilation syndrome can occur. This is due to exhaling excess carbon dioxide in relation to the amount of oxygen the person is taking in. This can result in a syndrome of symptoms that includes a rapid heartbeat, dizziness, tingling sensations at the fingertips and around your mouth, feeling nervous and jittery, and disorientation. Learning how to breathe abdominally will help alleviate any symptoms of stress or a hyperventilation syndrome.


Abdominal or Diaphragmatic Breathing


Abdominal or diaphragmatic breathing is how we breathe naturally. Newborn infants are abdominal breathers, as evidenced by their stomach moving with each breath. Also, adults breathe abdominally when they sleep. Unfortunately, most of us learn to be chest breathers over the years. Learning to breathe diaphragmatically can produce the positive benefits as discussed previously. Although it may seem unnatural at first, diaphragmatic or abdominal breathing is, indeed, the most natural and healthy way to breathe.


The diaphragm is a sheet-like muscle that stretches across the chest and separates the chest cavity from the abdominal cavity. The diaphragm muscle generally expands and contracts automatically, although it can be done voluntarily. When inhaling, the diaphragm contracts, causing air to be pulled into the lungs. As this is occurring, the abdominal wall moves out. When the diaphragm and the chest relax, the lungs contract and the air is forced out, which is "exhaling." As this process occurs, the abdomen once again flattens out and the cycle starts over. Breathing diaphragmatically or abdominally allows a person to take a deeper breath, as well as allowing a more complete exhale.


Learning how to breathe diaphragmatically is a key component to learning how to elicit the relaxation response.



Teaching Patients Deep Relaxation Exercises


Patient should be told that they will be taught an easy-to-learn technique for eliciting the relaxation response and that this will involve a 3-step process:


1.   Assessing how the patient breathes currently


2.   Choosing one or two of the breathing exercises to practice regularly


3.   Making time to practice


This section outlines a variety of breathing/relaxation exercises since people have different likes and dislikes in terms of techniques. It is important that the patient chooses the technique that is enjoyable and works. This will increase the likelihood of regular practice.




By regularly practicing proper breathing techniques, the patient can learn to elicit the relaxation response. In this section, several types of breathing exercises will be reviewed. Prior to teaching the relaxation exercises, have the patient assess how he or she breathes currently.


Breathing Awareness


The following is a four-step exercise to help the patient become aware of how he or she normally breathes. Have the patient complete the breathing awareness by giving the following directions:


1.   Lie down on your back in a comfortable place. If for some reason, lying on your back is not comfortable, you may want to try sitting in a chair.


2.   Place one hand on your breastbone and the other hand over your belly button. Close your eyes.


3.   Without trying to change how you normally breathe, become aware of which part of your body is moving as you inhale and exhale. The hand on your breastbone will be monitoring chest breathing and the hand over your belly button will be monitoring abdominal breathing. Which hand rises when you inhale, the one on your abdomen or the one on your chest?


If the patient’s abdomen moves up and down with each breath, then he or she is breathing diaphragmatically. If the chest moves up and down with each breath, chest breathing is more likely.


Diaphragmatic or Abdominal breathing


The following exercise will help the patient develop the skill of abdominal breathing. Have the patient practice it until he or she is able to breathe abdominally during a relaxation session of 5 to 10 minutes.


1.   Lie down in a comfortable position on your back with your legs straight and slightly apart. Allow your toes to point comfortably outward and let your arms rest at your sides without touching your body. Place your palms up and close your eyes.

2.   Allow your attention to focus on your breathing and place your hand on the spot that seems to rise and fall the most as you inhale and exhale. Notice the position of your hand. Is it on your chest, abdomen or somewhere in-between?

3.   Now, gently place both of your hands (or a book) on your abdomen and again focus on your breathing. Pay attention to how your abdomen rises as you inhale and falls as you exhale. Try and make your hands rise and fall as you inhale and exhale.

4.   Breathe through your nose during this exercise. If needed, you may need to clear your nasal passages prior to doing your breathing exercises.

5.   If you have difficulty breathing into your abdomen, press your hand down on your abdomen as you exhale and allow your abdomen to push your hand back up as you inhale deeply. The pressure from your hand will help you become more aware of the action of your abdomen during breathing.

6.   Notice if your chest is moving in harmony with your abdomen, or if it appears rigid. Take a few minutes and let your chest follow the movement of your abdomen. This is done by continuing to focus on your abdomen moving up and down as you breathe and simply allowing your chest to follow its motion naturally.

7.   If you have difficulty breathing abdominally with the above exercises, you might try the following exercise. Lie on your stomach with your head rested on your folded hands. Take deep abdominal breaths so that you can feel your abdomen pushing against the floor as you breathe.

8.   As you practice abdominal breathing for five or 10 minutes, scan your body for tension.


Deep Breathing


After the patient has mastered abdominal breathing, a deep breathing exercise can be helpful to begin to learn to elicit the deep relaxation response. The deep breathing exercise is accomplished as follows (this exercise can be practiced in a variety of positions, but the following one is recommended):


1.   Lie down on your back. Bend your knees and move your feet about eight inches apart with your toes turned slightly outward. This will help straighten your spine and keep you comfortable as you practice the breathing exercise. If you have back problems, you may want to place a pillow under your knees for extra support.

2.   Mentally scan your body for any tension.

3.   Place one hand on your abdomen and one hand on your chest.

4.   Inhale slowly and deeply through your nose into your abdomen, so that your hand rises as much as feels comfortable. Your chest should move only a little and should "follow" your abdomen.

5.   When you feel at ease with step #4, you can practice the deep breathing cycle. In the deep breathing cycle, you should practice inhaling through your nose while smiling slightly. Once you inhale deeply and diaphragmatically, exhale through your mouth. This is done by gently blowing the air out of your lungs and making a "whooshing" sound like the wind. Doing this will help relax the muscles of your mouth, tongue, and jaw.

6.   Take long slow deep breaths that raise and lower your abdomen. Focus on the sound and feeling of breathing as you become more and more relaxed.

7.   Continue this deep breathing pattern for five or 10 minutes at a time, once or twice a day. Once you have done this daily for a week, you might like to extend your deep breathing exercise period to 15 or 20 minutes.

8.   At the end of each deep breathing session, take time to once again scan your body for tension. Compare the tension you feel at the conclusion of the exercise with that you were feeling at the beginning of the exercise.

9.   As you become more proficient at deep breathing, you can practice it anytime during the day, in addition to your regularly scheduled sessions. Simply concentrate on your abdomen moving up and down and the air moving in and out of your lungs.

10.        Once you have learned to use the deep breathing technique to elicit the relaxation response, you can practice it whenever you feel the need.


Complete Natural Breathing


1.   The complete natural breathing exercise will help the patient “fine tune” the breathing technique. Practicing this exercise will make the abdominal breathing even more efficient and natural.

2.   Begin by sitting or standing straight using good posture. This can also be done while lying down on your back if necessary.

3.   Breathe through your nose.

4.   As you inhale, first fill the lower section of your lungs. As you fill the lower section of your lungs first, your diaphragm muscle will push your abdomen outward to make more room for the air. Second, fill the middle part of your lungs, as your lower ribs and chest move forward slightly to accommodate the additional air. Third, fill the upper part of your lungs as you raise your chest slightly. You can learn to accomplish these three steps in one smooth, continuous, inhalation.

5.   As you inhale completely, hold your breath for a few seconds to experience how your lungs feel when they are completely full.

6.   As you exhale slowly, pull your abdomen in slightly and slowly lift it up as your lungs empty. When you have completely exhaled, relax your abdomen and chest.

7.   At the end of the inhalation phase, raise your shoulders and collar bone slightly so that the top of your shoulders are sure to be replenished with fresh air.




Successfully teaching the chronic pain patient how to elicit the deep relaxation response is only half the battle. The next critical component to this type of intervention is generalization of the skill. This is where cue-controlled relaxation can be very effective.


Cue-controlled relaxation is a powerful technique that can be used either in conjunction with relaxed breathing or alone. In cued relaxation the patient learns to use a cue to signal the relaxation response. The cue can be anything and is best developed based on discussions with the patient. One example is to have the patient place small colored dots around his or her environment. The colored labeling dots available at most stationary stores work quite well. Have the patient get the dots in a color that is “relaxing” for him or her. Tell the patient to place the dots where they will be seen at least every 15 minutes throughout the day. Some excellent places are on the back of the phone, on the computer monitor, on the dashboard of the car, etc. Each time the patient sees a dot, he or she is reminded to “check your muscle tension level, take a relaxation breath, and go about your business”.


Other examples of cues might be a verbal signal such as a word or a muscular signal. When a word or phrase is used it is most commonly something that the patient can say quietly to him- or herself such as “relax”. This is usually done while taking a relaxation-breath. Instead of a verbal signal, a muscular signal such as gently touching the thumb and index finger together can also be used.


To use cue-controlled relaxation with a muscular signal, the patient would simply touch the thumb and forefinger together in order to elicit the deep relaxation response. This is especially useful when the patient is in a situation where actually engaging in the relaxed breathing is difficult. For example, when the patient is talking to doctors or undergoing an uncomfortable procedure.


How Does Cue-controlled Relaxation Work?


It is very helpful for patients to understand how a cue, such as a word or touching fingers together can cause relaxation. To do this, explain the process of classical conditioning as follows:


In the early 1900’s Ivan Pavlov, a Russian physiologist, did a series of experiments that demonstrated the ability of basic physiological responses to come under the control of cues which are totally unrelated to them. In his now famous experiments, which you may have heard of, he showed that the salivation response in dogs could be caused or elicited by the sound of a bell. Since bells having nothing to do with the salivation response in animals, how did they cause salivation? Pavlov found that by repeatedly associating the bell with food (which does cause salivation), the bell would begin to cause salivation even when no food was present. He did this by first ringing the bell and quickly following with the food. Dogs quickly learned to salivate to the sound of the bell.


This form of learning is called Pavlovian or Classical Conditioning and occurs daily in all avenues of our lives. For example, like the bell, even thoughts can be conditioned to elicit a physiological response. Simply think about biting in to a juicy slice of lemon and you will likely experience some salivation. The thought, or visual image of biting into a lemon has been associated with past experiences of tasting an actual lemon and has thus become conditioned to elicit salivation. Another example of classical conditioning can be seen in patients who have become nauseated following the injection of a drug. After this experience they find themselves becoming nauseated to the smell of the alcohol which was used to clean the skin prior to the injection. This occurs even though the alcohol smell itself originally had nothing to do with them becoming nauseated.


In cue-controlled relaxation, the cue is also conditioned to elicit the relaxation response using classical conditioning. The cue (the word relax, a phrase, or touching your fingers together), is analogous to the bell in Pavlov’s experiments. The cue is associated with the relaxed breathing, which elicits or causes the physiological changes associated with relaxation. Eventually, with practice, the cue becomes conditioned to elicit the relaxation response the same way the bell caused salivation. It should be noted that the cue will not typically result in the same degree of relaxation as actually doing the breathing, but in many situations you do not need to be too deeply relaxed. In these situations you may need to just stop stress, anxiety and pain, from escalating further. This use of cue-controlled relaxation for damage control can be very effective.


Learning Cue-Controlled Relaxation


The following paragraphs will step the patient through the procedures involved in learning cue-controlled relaxation. However, before the patient tries to learn cue-controlled relaxation, it is important to have a basic mastery of relaxed breathing and eliciting the deep relaxation response. Have the patient practice relaxed breathing for at least a week or two prior to learning the cue-controlled relaxation. After the deep relaxation response is established, use the following script to help the patient develop cue controlled relaxation:



Learning Cue-Controlled Relaxation



STEP# 1: Choose a cue


The cue you choose can be verbal or muscular. Verbal cues include such things as a word like relax, breath or the number one; a phrase, such as I am Calm; or, a phrase from a prayer. An example of an easy muscular cue is to gently touch your thumb and index finger of your non-dominant hand together. You can even combine several cues, though we tend to favor the simplicity of using only one. While many patients prefer a verbal cue, the use of the finger cue is easy to use and frequently you must use the cue in situations where you have to be interacting with others or engaging in thought processes, which would make the use of verbal cues very difficult.


STEP #2: Conditioning the cue


Whenever you practice the relaxed breathing exercise, use the last 20 breaths at the end of your practice sessions to learn cue-controlled relaxation. For example:


Word or Phrase Cue: If you choose to use a word cue, such as relax, stretch out the sound of the word while you are exhaling by saying reeelaax. With practice, simply saying relax to yourself will result in relaxation.


Finger Cue: If you choose the finger cue, gently squeeze your thumb and forefinger together on the inhalation, or in-breath, but not too tight, and then relax the squeeze on the out-breath. You do not need to part the thumb and forefinger when you relax the squeeze and the action should be effortless. Remember, squeeze and release very gently. The cue, then, is to simply squeeze your thumb and forefinger together and then release the squeeze when you need to signal the relaxation response. The finger cue is discrete, can be used anywhere, and does not interfere with social interactions or thought processes.  





Cue-controlled relaxation can be used in many situations where it is either difficult or impossible to actually engage in relaxed breathing, or when the patient needs to slow things down and re-direct his or her attention to relaxation. Examples of the uses for cue-controlled relaxation are as follows:


To signal the relaxation response in any situation.  The cue-controlled relaxation can be used in any situation especially if the pain patient is having difficulty actually being able to do relaxed breathing. For example if the patient is in a stressful meeting with his or her doctor discussing medical matters and wants to reduce his or her distress, doing the breathing would be conspicuous and disruptive but the cue relaxation works just fine.


To re-focus one’s concentration on breathing, relaxing and coping.  For example, the patient is in a situation where he or she is being distracted from relaxing and is beginning to feel distress. The cue can be used as a signal to relax.


Thought stopping.  Cue-controlled relaxation is a powerful technique for stopping or disrupting negative automatic thinking. For example, the cue-controlled relaxation can be used if the patient finds that he or she tends to get carried away with negative thoughts that are causing anxiety or distress. The cue can be used to disrupt or stop these thoughts and redirect thinking towards coping self-statements. This can be very useful as part of the cognitive-behavioral intervention as presented previously.


To prepare oneself for an uncomfortable medical procedure.  The cue-controlled relaxation is an excellent way to prepare for an uncomfortable medical procedure especially when doing the breathing is difficult or not possible. Employing a cue to either prepare for or cope with a painful medical procedure is one of the most effective uses of cue-controlled relaxation. For example, the pain patient can use the cue to signal relaxation to reduce the discomfort associated with such procedures as a nerve block, an injection, the placement of an IV catheter or when working through a difficult exercise.


To manage pain flare-ups.  Cue-controlled relaxation can be used to manage pain flare-ups. Virtually all chronic pain patients complain of periodic episodes of pain flare-up. The cue can be used to get the patient through these episodes by using it as soon as the increased pain is experienced. This can also help reduce to overall amount of pain medications consumption since the patient has other “tools” available to help manage the pain.


In summary, cue-controlled relaxation is a very powerful skill, which can be used in a variety of situations related to pain management as well as in everyday life. As with all skills, one must TAKE TIME TO PRACTICE! The cue will work for the patient, but only if it is practiced and given a chance to become conditioned to the deep relaxation response.




Just like learning any new skill, the deep relaxation exercises must be practiced to be effective. The following guidelines will help the patient establish a regular practice regimen. The following guidelines will also help insure that the patient gets the most out of each breathing session. The learning process will require more time initially, but after the patient masters the skill of deep relaxation, less practice time overall will be required. The following guidelines should be reviewed with the patient:


Practice once or twice a day.  It is important to have patients practice the breathing exercises once or twice per day. Practicing at least once per day is mandatory in order to learn to elicit the deep relaxation response. As patients practice regularly, they may find that the amount of time required to elicit the relaxation response decreases.


Practice in a quiet location.  It is important for patients to practice the breathing exercises in a quiet location where they will not be disturbed or distracted. For instance, patients should be told turn the ringer on the telephone off and the volume down on the answering machine. Also, they should not be able to hear outside distracting noises. It can often be useful for patients to use something like a fan or air conditioner to block out outside noise if that is a problem.


Give a five-minute warning.  It can be useful to give to have the patient give other family members a five-minute warning when he or she begins breathing exercises. This can help a patient take care of "loose ends" prior to practicing the deep breathing. For instance, if a patient tends to be worried about a number of things "to do," it can be helpful to have him or her make a short list prior to doing the relaxation exercise. This will help the patient be able to focus on the deep relaxation exercise rather than "trying to remember" what "needs" to be done after relaxing.


Practice at regular times.  It is important to have patients set up regular practice times, as this will increase the likelihood or follow through on deep relaxation exercises. These times should be when a patient is most likely to follow through on completing the exercises. The regular practice times should not be when the patient is so tired (for instance, right after a big meal or just prior to bed) that he or she is likely to fall asleep.


Practice on an empty stomach.  As discussed above, practicing deep relaxation after a big meal increases the likelihood that a patient will fall asleep in the middle of trying to relax. Also, the process of digestion after meals can disrupt deep relaxation. Therefore, it is recommended that patients try and practice on an empty stomach if possible.


Assume a comfortable position.  A patient should be in a comfortable position when practicing deep relaxation exercises. A common position is lying flat on one’s back with the legs extended out and arms comfortably at the sides. Depending upon the patient’s pain condition, assuming this posture may not be possible. In that case, some other position can be used (e.g., knees up with a pillow underneath, sitting or even standing). If a patient is tired or sleepy, relaxation exercises can be practiced sitting up, as opposed to lying down, to prevent falling asleep


Loosen clothing.  It is useful to have patients loosen any tight clothing and take off such things as shoes, watch, glasses, jewelry, and other constrictive apparel when practicing relaxation. Again, the object is to have the patient be as comfortable as possible while practicing.


Assume a passive attitude.  It is important for patients to complete the deep relaxation exercise while adopting an attitude of "allowing" the relaxation response to happen. The patient should not "try" and relax or "control" his or her body.




Almost everyone who practices the deep relaxation exercises finds the relaxed state quite enjoyable and beneficial. Certainly, the research has demonstrated how useful learning to elicit the deep relaxation response can be in helping to manage chronic pain and associated symptoms. Even so, almost everyone comes up against common obstacles to practicing the deep relaxation exercises on a regular basis. Regular practice is essential to learn to elicit the deep relaxation response so that it can be used when needed. The following are some of the most common obstacles to practicing the deep relaxation on a regular basis.


There is no time to relax.  This is one of the most common obstacles to practicing the deep relaxation procedures. What this statement really means is that the patient has not made practicing the deep relaxation exercises a priority. It may be useful to review with the patient why he or she has not found the time to practice on a regular basis. Most often, people will have made everything else a priority except for taking care of themselves by practicing the exercises. Explain that the patient must choose to practice on a regular basis, knowing that the outcome will be improved pain management skills as a whole.


It's boring.  Some people have trouble with the deep relaxation exercises because they feel it is "boring." Often, these are the types of people that must be busy all of the time and feel particularly anxious when they try to relax or close their eyes. If the patient experiences this situation, it can be important to explore why the patient may have trouble just "being still". The more common reasons include negative thoughts such as follows:


·         I only feel worthwhile when I am doing something

·         I feel others will think I am being irresponsible if I take time out for myself

·         I keep busy all of the time as a means of distracting myself from something that is stressful

·         It is difficult for me to take the time to do deep relaxation exercises

·         I don't have a place to relax


When people have trouble practicing the relaxation exercises on a regular basis, a common excuse is that they don't have a place to relax. They will often state that the house is too "noisy" or their attention to the needs of others is in constant demand (such as job responsibilities, caring for the children, etc.). Even in these situations, it is very possible to structure one’s environment to get 20 minutes per day to practice the exercises. For instance, the following suggestions for the patient might be helpful:


·         Put the phone on an answering machine and unplug the phone in your bedroom.

·         Give your family the "five-minute warning" that you will be unavailable for the next 20 minutes.

·         Close the door to the room and place a "Do Not Disturb" sign on the door knob.

·         Prior to practice, be sure the family demands are placed on-hold or managed by a household member.

·         If there is not room enough to "get away" from these distractions, you might have to practice when the other people in the household are out of the house.


Peculiar sensations when practicing deep relaxation.  A small group of people will experience either peculiar sensations when they practice deep relaxation or feeling more anxious when they relax. This can occur when a person is especially not accustomed to the feelings of deep relaxation due to being "speeded up" most of the time. In these cases, it can be useful for the patient to start out slowly and keep the practice sessions short initially. As the patient practices more, he or she can gradually work up to longer periods of practice, until a target of about 15-20 minutes is reached. Although some people try to practice longer, it is generally not recommend that pain patients practice for more than 30 minutes at a time.


Mind chatter.  At times the patient may find it difficult to keep his or her mind focused on the breathing exercises. The patient may complain of his or her mind wandering to other issues of the day or being distracted by outside noises or negative thoughts. Explain to the patient that this is a common occurrence and is nothing to worry about. Discuss with the patient that the following can be helpful to manage mind chatter:


·         Allow yourself to “notice” the distracting thought or issue and let it “pass through” your awareness knowing that you will have plenty of time to deal with it later.

·         Use the more active breathing techniques in order to keep your mind focused. An example of this is the breath counting and letting go of tension techniques. Also, the imagery exercises to be discussed later can be useful.

·         As discussed previously, write down all of your “worries” or “to do’s” during the five-minute warning. This will allow your mind to focus on the breathing exercise.


Precautions.  Using the deep breathing exercises to elicit the relaxation response is both safe and natural. Even so, there are some instances when precautions might need to be taken and are generally related to the body needing to adjust to being relaxed. These would include such things as seizure disorders, insulin-dependent diabetes, and hypertension.


In seizure disorders, some seizures are brought on by a change in the level of arousal such as going to sleep or waking up. Since the brain waves that occur during deep relaxation are similar to those of some stages of sleep, people with sleep-onset seizure disorders may experience seizures when they first start practicing the exercises. Have the patient discuss this issue with his or her doctor. Research indicates that the triggering of these types of seizures generally subsides with continued practice or choosing another type of relaxation technique.


In rare cases, patients who are on insulin may find that their insulin requirement is decreased after starting regular practice of the deep relaxation exercises. Again, this issue should be discussed with the patient’s doctor as hypoglycemic reactions need to be taken seriously.


Lastly, certain medications such as antihypertensives and antidepressants can interfere with normal blood pressure adjustments when making postural (or position) changes. For instance, the patient may feel light-headed or dizzy when rapidly going from a lying down to a standing position. Therefore, warn the patient to slowly change his or her posture after practicing the deep relaxation exercises. For instance, the patient should go slowly from a lying down to a sitting position, giving the body time to adjust. Then, move slowly to a standing upright position. This will prevent any drop in blood pressure due to rapid postural changes.





The following books are excellent resources for any who works with chronic pain patients.


Belar, C.D. and Deardorff, W.W. (2008). Clinical Health Psychology in Medical settings: A Practitioner's Guidebook, Second Edition.  Washington, D.C.: American Psychological Association.


Gatchel, R.J. (2004). Clinical Essentials of Pain Management. Washington, DC: APA Books.


Gatchel, R.J. & Turk, D.C. (1999). Psychosocial Factors in Pain: Critical Perspectives New York: Guilford Press.


Gatchel, R.J. and Weisberg, J.N. (2000). Personality Characteristics of Patients with Pain. Washington, DC: APA Books.


Turk, D.C. & Gatchel, R.J. (2002). Psychological Approaches to Pain Management: A Practitioner’s Handbook 2nd edition. New York: Guilford Press.


Turk, D.C. and Melzack, R. (1992). Handbook of Pain Assessment. New York, New York: Guilford Press.


Winterowd, C., Beck, A.T., Gruener, D. (2003). Cognitive Therapy with Chronic Pain Patients. New York: Springer Publication Company




Benson, H. (1975). The relaxation response. New York: Morrow.


Block, A., Gatchel, R.J., Deardorff, W.W. and Guyer, R. (2003). The Psychology of Spine Surgery. Washington, DC: American Psychological Association Press.


Bourne, E.J. (1995). The anxiety and phobia workbook, 2nd edition. Oakland, CA: New Harbinger Publications.


Chapman, R.C., Nakamura, Y. and Flores, L.Y. (1999). Chronic pain and consciousness: A constructivist perspective. In R.J. Gatchel and D.C. Turk (Eds). Psychosocial factors in pain: critical perspectives (pp.35-55). New York: Guilford Press.


Deardorff, W.W. and Reeves, J. (1997). Preparing for Surgery: A Mind-Body Approach to Enhance Healing and Recovery. Oakland, CA: New Harbinger Publications, Inc.


Fordyce, W.E. (1988). Pain and suffering: A reappraisal. American Psychologist, 43, 276-283.


Gatchel, R.J. (1991). Early development of physical and mental deconditioning in painful spinal disorder. In T.G. Mayer, V. Mooney, & R.J. Gatchel (Eds.), Contemporary conservative care for painful spinal disorders (pp. 278-289). Philadelphia: Lea & Febiger.


Gatchel, R.J. (1996). Psychological disorders and chronic pain: Cause and effect relationships. In R.J. Gatchel and D.C. Turk (Eds.), Psychological approaches to pain management: A practitioner’s handbook (pp. 33-52). New York: Guilford Press.


Gatchel, R.J. (2004). Clinical Essentials of Pain Management. Washington, DC: APA Books.


Gatchel, R.J., (Ed)., Andersson, G. , Deardorff, W.W. et al. (2001). A Compendium of outcome instruments for assessment & research of spinal disorders. Chicago: North American Spine Society.


Gatchel, R.J. and Weisberg, J.N. (2000). Personality Characteristics of Patients with Pain. Washington, DC: APA Books.

International Association for the Study of Pain. (1979). Pain terms: a list with definitions and notes on usage. Pain, 6, 249 – 252.


Melzack, R. and Wall, P.D. (1965). Pain mechanisms: A new theory. Science, 150, 971-979.


Melzack, R. and Wall, P.D. (1982). The Challenge of Pain. New York: Basic Books.


Merskey, H., Bogduk, N. (eds). (1994). Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, 2nd edition. Seattle, WA: IASP Press.


Morris, D.B. (2003). The challenges of pain and suffering. In T.S. Jensen, P.R. Wilson, and A. Rice (Eds.), Chronic Pain (pp. 3-14). New York: Oxford University Press.


Sinel, M.S. and Deardorff, W.W. (1999). Back Pain Remedies for Dummies. Chicago: IDG Worldwide Publications. (a health book in the “Dummies” series).


Sinel, M.S., Deardorff, W.W. & Goldstein, T.B. (1996). Win the Battle Against Back Pain: An Integrated Mind-Body Approach. New York: Bantam-Doubleday-Dell.


Sternbach, R.A. (1987). Mastering Pain. New York: Ballantine Books.


Trzepacz, P.T. and Baker, R.W. (1993). The Psychiatric Mental Status Examination. New York: Oxford University Press.


Turk, D.C. (2002). A cognitive-behavioral perspective on treatment of chronic pain patients. In D.C. Turk and R.J. Gatchel (Eds.), Psychological approaches to pain management: a practitioner’s handbook 2nd edition (pp 138-158). New York: Guilford Press.


Turk, D.C. and Flor, H. (1999). Chronic pain: A biobehavioral perspecitve. In R.J. Gatchel and D.C. Turk (Eds), Psychosocial factors in pain: critical perspectives (pp. 18-34). New York: Guilford Press.


Turk, D.C. and Melzack, R. (1992). Handbook of Pain Assessment. New York, New York: Guilford Press.


Turk, D.C. and Monarch, E.S. (2002). Biopsychosocial perspectives on chronic pain. In D.C. Turk and R.J. Gatchel (Eds.), Psychological approaches to pain management: a practitioner’s handbook 2nd edition (pp 3-29). New York: Guilford Press.


Winterowd, C., Beck, A.T., Gruener, D. (2003). Cognitive Therapy with Chronic Pain Patients. New York: Springer Publication Company


Psychological Testing




Bradley, L.A., Haile, J.M.& Jaworski, T.M. (1992). Assessment of psychological status using interviews and self-report instruments. In D.C. Turk and R. Melzack R (Eds.), Handbook of Pain Assessment. New York: The Guilford Press.


Butcher, JN. (1990). MMPI-2 in PsychologicaITreatment. New York: Oxford University Press.


Butcher, JN, Dahlstrom, WG, Graham, JR, Tellegen, A, & Kaemmer B. (1989). Manual for administration and scoring of the MMPI-2. Minneapolis, MN: University of Minnesota Press.


Deardorff, WW (2002). The MMPI-2 and chronic pain. In R.J. Gatchel and J.N. Weisberg (Eds.), Personality Characteristics of Pain Patients (pp 109-125). Recent Advances and Future Directions. Washington, DC: APA Books.


Fishbain, DA (1996). Some difficulties with the predictive validity of Minnesota Multiphasic Personality Inventory. Pain Forum, 5, 81-82.


Helmes, E. (1994). What types of useful information do the MMPI and MMPI-2 provide on patients with chronic pain? American Pain Society Bulletin, 4 (1), 1-5.


Graham, JR. (1990). MMPI-2: Assessing Personality and Psychopathology. New York: Oxford University Press.


Greene, RL (1991). The MMPI-2/MMPI: An Interpretive Manual. Boston: Allyn & Bacon.


Hathaway, SR and McKinley, JC. (1943). The Minnesota Multiphasic Personality Schedule (revised). Minneapolis, MN: University of Minnesota Press.


Keefe, FJ, Lefebvre, JC, & Beaupre PM. (1995). The Minnesota Multiphasic Personality Inventory in chronic pain: Security blanket or sound investment? Pain Forum, 4, 101-103.


Keller, LS and Butcher, JN. (1991). Assessment of Chronic Pain Patients with the MMPI-2. Minneapolis, MN: University of Minnesota Press.


Main, CJ and Spanswick, CC (1995). Personality assessment and the Minnesota Muliphasic Personality Inventory, 50 years on: do we still need our security blanket? Pain Forum, 4, 90-96.


Sanders, SH. (1995). Minnesota Multiphasic Personality Inventory and clinical pain: The baby or the bathwater? Pain Forum, 4, 108-109.


Turk, D C and Fernandez, E. (1995). Personality assessment and the Minnesota Multiphasic Personality Inventory in chronic pain: underdeveloped and overexposed. Pain Forum, 4, 104-107.


Millon Behavioral Medicine Diagnostic (MBMD)


Bockian, N., Meager, S., Millon, T.  (2000).   Assessing personality with The Millon Behavioral Health Inventory, The Millon Behavioral Medicine Diagnostic, and the Millon Clinical Multiaxial Inventory.  In Gatchel, RJ, Weisberg, JN (Eds).  Personality Charasteristics of Patients with Pain.  Washington, DC: American Psychological Association Press.


Battery for Health Improvement-2 (BHI-2)

Bruns, D. and Disorbio, JM. (2002). Battery for Health Improvement-2 Manual. Minneapolis, MN: NCS Pearson.


Symptom Checklist -90R


Derogatis, L. (1983). The SCL90-R Manual-II: Administration, Scoring and Procedures. Baltimore: Clinical Psychometric Research.


Derogatis, L. (1994). Symptom Checklist-90-R: Administration, Scoring and Procedures Manual. Minneapolis, MN: National Computer Systems, Inc.


Green, C.J. (1982). Psychological assessment in medical settings. In T. Millon, C. Green, & R. Meagher (Eds.), Handbook of Clinical Health Psychology. New York: Plenum Press.


Jamison, RN, Rock, DL, & Parris, WC. (1988). Empirically derived Symptom Checklist 90 subgroups of chronic pain patients: A cluster analysis. J Behavioral Medicine, 11, 147-158.


Shutty, MS, DeGood, DE, & Schwartz, DP. (1986). Psychological dimensions of distress in chronic pain patients: a factor analytic study of Symptom Checklist-90 responses. J Consulting and Clinical Psychology, 54, 836-842.


Williams, D A, Urban, B, Keefe, FJ, Shutty, MS, & France R. (1995). Cluster analyses of pain patients' responses to the SCL-90R. Pain, 61, 81-91.


Beck Depression Inventory


Beck, A T. (1972). Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press.


Beck, AT, Ward, CH, Mendelson, M, Mock, J, & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.


Beck, AT, Steer, RA, & Garbin MG. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Reviews, 8, 77-100.


Bishop, SR, Edgley, K, Fisher, R, & Sullivan, MJL. (1993). Screening for depression in chronic low back pain with the Beck Depression Inventory. Canadian Journal of Rehabilitation. 7, 143-148.


Brief Battery for Health Improvement (BBHI-2)


Disorbio, JM. and Bruns, D. (2002). Brief Battery for Health Improvement-2 Manual. Minneapolis, MN: NCS Pearson.


Multidimensional Pain Inventory (MPI)


Bradley, LA, Haile, JM, & Jaworski, TM. (1992). Assessment of psychological status using interviews and self-report instruments. In D.C. Turk DC and R. Melzack R (Eds.), Handbook of Pain Assessment. New York: The Guilford Press.


Kerns, RD and Jacob, MC. (1992). Assessment of the psychosocial context in the experience of pain. In DC Turk DC & R Melzack (Eds.), Handbook of Pain Assessment (pp. 235-256). New York: Guildford.


Kerns, RD, Turk, DC, & Rudy TE. (1985). The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pai, 23, 345-356.


Rudy, TE. (1987, 1989). Multiaxial Assessment of Pain: Multidimensional Pain Inventory Computer Program User's Manual, v. 2.0. Pittsburgh, PA: Pain Evaluation and Treatment Institute, University of Pittsburgh School of Medicine.


Turk, DC and Kerns, RD (1985). Assessment in health psychology: A cognitive-behavioral perspective. In P. Karoly (Ed.) Measurement strategies in health psychology (pp. 335-372). New York: Wiley.


Turk, DC and Rudy, TE. (1988). Toward an empirically derived taxonomy of chronic pain patients: Integration of psychological assessment data. Journal of Consulting and Clinical Psychology, 56, 233-238.


Turk, DC and Rudy, TE. (1990). The robustness of an empirically derived taxonomy of pain patients. Pain, 43, 27-36.


Coping Strategies Questionnaire (CSQ)


Rosenstiel, A and Keefe, F. (1983). The use of coping strategies in low back pain patients: relationship to patient characteristics and current adjustment. Pain, 17, 33-40.


Turner, JA. (1991). Coping and chronic pain. In MR Bond, JE Charlton, CJ Woolf (Eds.), Proceedings of the VI World Congress on Pain (pp. 219-227). New York: Elsevier.


Chronic Pain Coping Inventory (CPCI)


Jensen, MP, Turner, JA, Romano, JM, & Strom SE. (1995). The Chronic Pain Inventory: Development and preliminary validation. Pain, 60, 203-216.


Hadjistavropoulos, HD, MacLeod, FK, & Asmundson, GJG. (1999). Validation of the Chronic Pain Coping Inventory. Pain, 80, 471-481.





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