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A deconstructive turn in chronic pain treatment: a redefined role for social work. (eng; includes abstract) By MacDonald JE, Health & Social Work [Health Soc Work], ISSN: 0360-7283, 2000 Feb; Vol. 25 (1), pp. 51-8; PMID: 10689603
Chronic pain has captured growing attention in the medical and health care professions during the past 25 years, becoming a complex problem of major medical, social, economic, and personal proportion. Chronic pain has been estimated to cost between 60 billion and 65 billion dollars and 700 million workdays annually in the United States (Blackwell, 1989; Sieppert, 1996). Health care costs, lost work hours, and compensation have been cited as key areas of concern throughout the research literature. The personal costs of chronic pain need to be recognized and validated, because chronic pain sufferers cannot elude pain characterized as "evasive," "overwhelming," "isolating," "horrendous" and "unbearable" (Rose, 1994; Seers & Friedli, 1996).
Chronic pain treatment has been conceptualized predominantly in a medical model, with growing emphasis on the psychological behavioral components (Bonica, 1990). Causation has been defined in three classifications: malignant, non-malignant, and idiopathic. In the first two classifications, identifiable pathology can be specified, whereas in the third no sign of tissue damage is apparent or the pain appears disproportionate to the physical cause (Bendelow & Williams, 1995). The diagnostic and treatment processes applied to patients classified with idiopathic pain is the presented concern and focus of this article. With the diagnosis of idiopathic pain, an emphasis emerges on "chronic pain behavior resulting primarily from reinforcing environmental influences or so-called operant mechanisms" (Bonica, p. 201), leading to a behavioral science model of contingency management. Contingency is defined as "the consequences that are expected to follow behaviors," whereby "the consequences of a given behavior largely influence the future occurrence of that behavior" (Barker, 1997, p. 78). Chronic pain treatment thus focuses on the management of patients' behaviors, distinguishing pain behaviors through the withdrawal of reinforcing influences; for example, expressions of pain would be ignored by the health care team. Once environmental contingencies that reinforce sick (pain) behavior are eliminated, well behavior is re-established (Bonica; Fordyce, 1990; Loeser, Seres, & Newman, 1990).
From a social work perspective, this article challenges the premises on which this behaviorist approach to chronic pain is founded, follows contingency assessment through to its implications for chronic sufferers, and makes space for an alternative approach guided by the "voices of sufferers." Researchers and practitioners repeatedly highlight the necessity of trust, empathy, respect, and empowerment in service delivery to chronic pain patients (Lipkin, 1989; Marcus, 1986; Murray, 1997; Pilowsky & Barrow, 1990; Vrancken, 1989). Yet, the voices of sufferers reflect powerlessness and the fundamental need to have their pain believed (Howell, 1994; Miles, 1992; Seers & Friedli, 1996). This article uncovers the contradictions inherent in the contingency management model through the process of deconstruction. Deconstruction has been defined as an "analysis that takes apart socially constructed categories as a way of seeing how a particular world view is constructed" (Ristock & Pennell, 1996, p. 114). This process will reveal the governing principles of the contingency management model, exposing the underlying structures of program delivery. Social work and health care professionals will be challenged to consider an alternative way of working with chronic pain sufferers, based on the recognition and validation of sufferers' experiences. The word "sufferer" is chosen intentionally to depict the population referred to in this article, for it identifies chronic pain "patients'" existence--their physical, emotional, and spiritual struggle.
I write this article as a social worker, educator, and chronic pain sufferer. I worked for six years as a medical social worker with sufferers of chronic pain and have lived with chronic pain for 14 years. I also have been a "patient" in a chronic pain treatment program that was based on the contingency management model. I eventually obtained substantial relief from radical surgery and consider myself to be one of the more fortunate.
DECONSTRUCTION OF THE CONTINGENCY MANAGEMENT MODEL
The contingency management model has been used since the 1960s as a multidisciplinary intervention in the treatment of chronic pain, primarily delivered on an inpatient basis by teams consisting of varied combinations of physicians (psychiatrist, anesthesiologist, neurologist), nurses, psychologists, physiotherapists, occupational therapists, and social workers (Bonica, 1990; Melzack & Wall, 1988; Roy, 1992). "The multi-disciplinary pain centre...is the dominant type of facility in the United States" (Loeser et al., 1990, p. 2107). The University of Washington was the founding site of this treatment modality under the direction of Dr. John Bonica, in collaboration with psychologist Wilbert E. Fordyce. The text identified for the deconstructive process is taken from Fordyce's writings on "contingency management," found in Bonica's (1990) The Management of Pain. According to Loeser et al. (1990), "most comprehensive pain centers have a strong component of behavioral medicine and owe their intellectual heritage to the work of Fordyce" (p. 2107). Throughout the literature on chronic pain, Fordyce is cited and occasionally challenged for his attention to pain behaviors (Blackwell, 1989; Bond, 1987; Craig, 1989; France, Krishnan, Houpt, & Maltbie, 1988; Kelly, 1996; Melzack & Wall, 1988), which occupy a founding presence in chronic pain intervention.
Patients admitted to chronic pain programs that use this model are assessed as having complex chronic pain problems that have "failed" to respond to conventional medical treatment. Either no obvious organic pathology is evident or the noxious stimulus does not fit with the degree of pain exhibited. Typically the patient has been through numerous medical interventions, with little to no relief. The patient is frustrated, worn down, and depressed because of the pain and the diminished prospect of recovery. Health care providers feel frustrated, powerless, and hopeless with their inability to ease the patient's suffering (Clements & Cummings, 1991). Causation becomes aligned with psychological pathology, whereby the patient is experiencing "real" pain, defined within the parameters of psychological dysfunction. The patient is believed to have adopted a "sick role" exhibited through various pain behaviors (Bond, 1987; Fordyce, 1990; France et al., 1988). Symptomatology and expressions of pain are not viewed as correlative with the physical findings. Treatment is focused on modifying environmental contingencies that reinforce the pain behavior, ultimately eliminating the sick role behavior and returning patients to healthier lifestyles. The central assumption of the contingency management perspective is that "chronic pain is psychological in nature"; the beginning cell of the deconstructive inquiry of displacing logics has been established, within the process of "affirming the incoherence of discourses and thus opening them to alternative viewpoints" (Ristock & Pennell, 1996, p. 93).
The second cell, the contrary, defined in opposition to cell one, is founded on the assumption that "chronic pain is biological in nature." Located in the medical model, this cell represents the dominant position for patients with clear biological origins of their pain but becomes the subordinate position for patients with unclear biological causation. Organic pathology defined in terms of tissue damage constitutes the construction of pain. Chronic cancer pain and neurological pain have been traditionally classified in this category, because there is obvious and observable organic damage to explain the pain. The symptomatology specifically fits with the signs of scientifically classified disease processes and therefore is deemed a legitimate concern that elicits medical intervention. Pain treatment options may involve a variety of interventions, including nerve blocks, surgeries, transcutaneous electrical nerve stimulation, localized injections of steroids, saline or analgesics, and opioid therapy or other appropriate medications.
The third cell, the contradiction, is defined as "both.... and" whereby "chronic pain has both psychological and biological features." Representative of a biopsychosocial model, chronic pain is considered a biological impairment complicated by psychological effects. People are complex beings, consisting of emotional, physical, social, and spiritual elements. Living with chronic pain, year after year, can take an incredible toll on all aspects of a patient's life (Howell, 1994; Seers & Friedli, 1996; Unruh, 1996). As one patient expressed, "pain takes your personality away" (Seers & Friedli, p. 1164). A multilevel treatment regimen from a holistic perspective would best meet the needs of this special population. Difficulty surfaces, however, when physical cause cannot be located in a medical diagnosis, and there is a subsequent reversion to the logic of position number one, the psychological explanation of chronic pain. Wall (1994) considered it "unwise arrogance" on the part of physicians who believe their judgments to be infallible, subsequently placing the onus of responsibility on the patient's psychological profile. Treatment is diverted from physical intervention toward personal pathology, offsetting the balance of the biopsychosocial model.
The deconstructed assumption displaces the power of the central position of psychological causation, pushing the logics to their outer boundaries and therein producing a new construct. The final cell, upholding the original assumption, is defined as a "neither/nor" position, for "chronic pains are sufferers' experiences." Linguistically two changes should be noted: first, given the displacement of power, "patients" has been changed to "sufferers" in recognition of their pain and suffering; and second, "chronic pain" has been pluralized to emphasize the uniqueness of each sufferer's experience. Pain is a uniquely personal experience that has evaded standardized measurement and puzzled researchers, practitioners, and philosophers for centuries. For the person living with chronic pain, frustration, anxiety, and hopelessness can emerge in trying to explain one's experience. "No one can feel, know, or experience someone else's pain, that no one really knows the character of pain except each individual sufferer" (Hilbert, 1984, p. 373). Sufferers know their bodies, their sense of self, and the effects of their pain. Having their experience of pain validated and believed is fundamental to their coping strategies, yet health care professionals have a tendency not to listen to or believe sufferers' accounts of their pain (Klafehn, 1992; Reid, Ewan, & Lowy, 1991; Rose, 1994; Seer & Friedli, 1996). The sufferer's knowledge is lost, leading potentially to ineffective treatments and the possibility of misuse. This has far-reaching implications for all sufferers, their families, the health care system, and society in general. Sufferer-centered treatment options are needed, focusing on empowerment through the proclamation of voices. In keeping with this vision, a critical analysis of the contingency management model becomes a vital element in the application of deconstruction.
Applying the Deconstruction
The deconstruction challenges the contingency management model in a number of areas. The first area of challenge emerges with the criteria for application of the contingency management model. According to Fordyce (1990) the assessment for application of the model is based on the following criteria, with respect to the sufferer: ingestion of excessive amounts of pain medication, too deactivated, exhibition of too many pain behaviors, overly concerned about their pain, and overuse of the health care system. Professional judgment is the basis for this assessment, gauging the unmeasurable pain experience against operationally defined behavior. Given the magnitude of suffering, the measure of these activities might be proportional.
Another substantial challenge lies with the supposition that chronic pain sufferers experience "gains" through their sick-role behavior (Fordyce, 1990). Gains have been identified in the form of special attention or supportive action by friends, family, and colleagues; decreased responsibilities at home or work; financial compensation through disability pensions, workers compensation, or pending liability; and physical and psychological dependency on drugs (Finn, 1988; Fordyce, 1990; Loeser & Egan, 1989). The theoretical and practical assumption is that sufferers experience primary or secondary gains through their experience of chronic pains, whereas sufferers themselves speak of multiple "losses": loss of identity--through decreased or eliminated roles; loss of employment--through disability or employer's intolerance of special needs; loss of relationships--partners withdraw as they struggle to understand; loss of dignity and respect--as a member of a disadvantaged group; loss of ability--accessibility complicates social interaction; loss of normalcy--feeling labeled, judged, and ultimately different; loss of voice--silenced by the pain, the medical experts, and society in general; and loss of control--feeling betrayed by one's own body and trying to find ways to control the pain as desperation builds with each unsuccessful attempt (Brown & Williams, 1995; Kelley & Clifford, 1997; Miller, 1995; Reid et al., 1991; Rose, 1994; Seers & Friedli, 1996). By attending to the voices of sufferers, social workers and health care providers can recognize their losses, validate their struggles for survival, and form a plan of action that will begin by sufferers rebuilding a sense of control over their pain, their relationships, and their lives. Worden's (1991) tasks of mourning follow a similar process of accepting the losses, working with the pain, and adjusting to an environment that is more conductive to the situation.
The contingency management model focuses on the withdrawal of reinforcement to behavior as a method of extinguishing sick-role behaviors and elicits the involvement of the sufferer's spouse in ignoring their partner's unhealthy behavior (Fordyce, 1990). To withdraw that support and to involve the sufferer's family in the extinguishing or reinforcement of behaviors potentially could alienate family members from one another and tamper with a critical link to the sufferer's survival. Feeling isolated, chronic pain sufferers might opt to give up; however, through the love and support of friends and family, they may find strength. As expressed best in the words of a sufferer, "I only keep going because of the family. If I was single... I can understand people doing themselves in" (Seers & Friedli, 1996, p. 1164). The contingency management model contradicts the social work practice of supporting and building families.
According to Fordyce (1990), "contingency management methods are not a substitute for a treatment relationship. The treatment relationship, including full informed consent and consensus as to objectives, is a prerequisite of all behavior change methods" (p. 1704). The contingency management model appears to contradict the idea of a relationship built on mutual respect, cooperation, and the active involvement of sufferers in their treatment. Trust and confidence are not reciprocal, for the sufferer must agree to the program, follow the rules and procedures of the service delivery, and comply with the therapist's instructions. For example, the Johns Hopkins University Hospital's (1996) inpatient program description for the chronic pain treatment service states, "you must comply with our plans to try to help you and you must try to help yourself" (p. 1). The program description reflects the mistrust of the sufferer and devaluation of the sufferer's contribution to treatment. Brown and Williams (1995) claimed "people who experience illness can then make an active contribution to shaping how their problems are both conceived and resolved" (p. 700). Social work has an opportunity to work within the system, to advocate for the inclusion of sufferers' participation in treatment plans, and to empower sufferers to proclaim their rights as a member of the multidisciplinary team.
The voice of the sufferer may be jeopardized, and respectability of the sufferer may be threatened when the staff is directed to look continually for discrepancies and evaluative markers within the sufferer's behavioral repertoire. For example, if sufferers are able to engage in a relatively "normal" sex life, then their pain is believed to have operant factors present and therefore is unlikely to be organic in nature (Fordyce, 1990). On clarification with the sufferer, maybe sexual activity was consciously continued to maintain a healthy relationship, to embrace an element of normalcy, or to have an orgasmic response that temporally relieved the pain. Risk of a double standard emerges, whereby sufferers might be labeled and classified regardless of their behavior. This is avoidable only through the involvement of sufferers in the interpretation of their own behavior. Members of the multidisciplinary team must return to basic social work skills of active listening and participatory intervention. As one sufferer explained, "I was overjoyed to find a doctor who listened. What a rare commodity" (Miles, 1992, p. 98).
Finally, according to Fordyce (1990), "persons who have been 'sick' a long time may not know how to be well; they may have had major defects in their well behavior repertoire for an extended period" (p. 1709). One must exercise caution to not pathologize the sufferer's behavior, as this may lead to unwarranted treatment. Social work's challenge to individual pathology needs to be applied whereby alternative interventions for chronic pain sufferers are explored.
Alternative Interventions for Social Work Practice
Social work is a multifaceted profession with a value base in emancipatory practice (Levine, 1982). Central to the analysis of the profession is the social, political, and economic distribution of resources and power. Social work is rooted in an ethical philosophy that promotes the dignity and worth of all people and stresses the right to self-determination (CASW, 1994; NASW, 1994). Within this framework, social work has an opportunity to challenge traditional services delivery to chronic pain sufferers.
Traditionally, social work intervention with chronic pain sufferers has focused on biopsychosocial assessments, coping interventions, family therapy, and group work under the structure of cognitive-behavioral treatment (Marcus, 1986; Roy, 1992; Sieppert, 1996). Practice that opposes oppression focuses on the empowerment of service users and challenges social workers to redefine their interventions. Practice would consist of five nonhierarchical modalities: (1) individual and family empowerment counseling, (2) advocacy, (3) organization of sufferers, (4) research, and (5) policy and program construction.
With regard to individual and family counseling, the counselor would be engaged actively in listening to sufferers and their families, deriving assessment insight through sufferers' sharing of their knowledge. Validation would be given to the experiences and self-knowledge of the group. Expert status would belong with the sufferers. The counselor would recognize the survival skills necessary to live with chronic pain and its cumulative toll on the sufferer and their relationships. The sufferer would give direction as to the goals and objectives of the helping process. The re-establishment of control, trust, and acceptance for the sufferer is fundamental, for once this has been achieved, focused interventions can begin. Coping strategies, financial concerns, resource allocation, support, and relationship strengthening are potential areas of service aimed at reducing the environmental stressors of living with chronic pain. Specific treatment strategies used under the cognitive-behavioral regime might still be used; for example, biofeedback, imagery, and relaxation training, with the focus directed away from behavioral change toward empowerment and pain reduction. Notes, files, or documents would be produced by the social worker and the sufferer. This creates a forum for the voice of the sufferer to be heard, which strengthens the sufferer's emotional ability to engage in various treatment modalities.
Consciousness raising, focused on challenging the stereotypes commonly held about sufferers, would be a central component of advocacy. Sufferers, their families, members of the multidisciplinary team, and employers may all believe myths or hold traditional views of chronic pain sufferers and their pain that need to be questioned. For example, research has pointed to the pharmaceutical under treatment of chronic pain, sanctioned by views of narcotic addiction. (Melzack & Wall, 1988). Social work also can use consciousness raising to facilitate the involvement of chronic pain sufferers in their own treatment plans, advocating for open communication during service delivery. Advocacy in the form of resource provision, with respect to financial compensation, home services, employment, or education options, is another crucial area of service. Keeping in mind the goal of self-determination, the critical feature of advocacy is that it is done only under the direction of the sufferer and ultimately by the sufferer with the social worker's support and encouragement.
Recognition of each sufferer's experience is important, but within the collective strength of an organized body, power can be found. The intent is not to homogenize the perspective of sufferers but rather to establish links among them so that their voices are attended to with respect. Social work can play a key role in linking sufferers, providing facilitation and initial support to the group until they can become self-sufficient. A person living with chronic pain can be very lonely, as energies are consumed in trying to cope with the pain, social participation is usually strained, communication is challenged, and withdrawal is common. Validation and normalcy can be created through discerning likenesses. Chronic pain sufferers together in an organized forum could advocate on behalf of the group's needs. Networking with other chronic pain groups that are sufferer centered would increase their collective power and potentially accelerate change.
From a research perspective gender distributions need to be examined watchfully. Women have traditionally been labeled with more histrionic disorders, depression, and somatization disorders than men (Burstow, 1992; Caplan, 1995; Levine, 1982). A gender analysis needs to be applied to admittance to chronic pain treatment programs with a contingency management model, to determine whether this pattern continues. According to Bendelow and Williams' (1996) study, a higher ratio of women admitted to pain treatment programs was not unusual. Likewise, class, race, and age distribution of sufferers attending such programs should be examined. Such research initiatives are warranted, given the inherent power structures in society, whereby people on the margins have little or no voice. Sufferers are silenced already by the nature of their disability, by adding another disadvantaged voice, be it women, elderly people, or a member of an ethnic or racial minority group, an added layer of oppression is experienced.
The final service delivery element is program and policy development. Too often at this stage, sufferers are forgotten, although they are the best informed about the effects of chronic pain. Through the empowerment and organization of this group, input needs to be encouraged. Social workers can be an information resource with respect to program directives, along with coaching sufferers on lobbying and social action. Social work can take the initiative in the delivery of proactive services, promoting alternative programming designed with the full participation of this group.
The deconstruction of the contingency management model in the treatment of chronic pain displaces the hierarchy of assumptions contained in the scientific application of the model's principles. Three key positions identified in chronic pain treatment were explored. First, the central assumption of the contingency management model--"chronic pain is psychological in nature" where treatment initiatives are directed at eliminating sick-role behavior. Second, its contrary "chronic pain is biological in nature," for which treatment is directed at physiological pathology through medical interventions. Third, its further contrary "chronic pain has both psychological and biological features," where consideration is given to holistic treatment regimes that address both the physical and emotional elements of pain. When physical causation evades medical diagnosis, however, the psychological explanation of chronic pain is re-established. To avoid this, the fourth position displaces the power of the central assumption as it overturns the logical sequence and pushes the boundaries of reason, to challenge beyond what is evident: "chronic pains are sufferers' experiences." This position directs treatment initiatives away from cause and effect variables and toward the central involvement of the sufferers in the diagnosis and treatment of their chronic pains.
Chronic pain can be a life-defeating experience, where powerlessness, loss of control, emotional grief, and physical anguish are daily difficulties. Social workers struggle with the complexity of people's emotional pain, yet physical pain, particularly of a chronic nature, is relatively unfamiliar territory, as "medical social workers have had very limited exposure to the chronic pain concepts and issues identified by the literature" (Sieppert, 1996, p. 128). Social work as a profession has a chance to influence this area of service delivery through empowerment-based practice, as difficulties have been highlighted with respect to sufferers' rights and accessibility to participatory treatment. Chronic pain sufferers have many stories to be shared and voices to be heard, directing service delivery and health care initiatives with respect to this troubling disability. More research must be conducted on the specifics of these interventions and their effectiveness, with full participation of the sufferers of chronic pain. This perspective holds hope and new possibilities for the chronic pain sufferer, the medical community, multidisciplinary health providers, and the health care system in general.
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