I just recently finished working through Fordyce’s Behavioral Methods for Chronic Pain and Illness that was republished by IASP with invited commentaries. Francie J. Keefe was one of the editors and commentary contributors in the book along with Steven J. Linton providing another one of the commentaries, both of who will be speaking at the upcoming ISPI Clinical Conference. This seminal work was originally published back in 1976 and is still relevant in many ways today. At the time of its publishing most chronic pain patients sent to a psychologist for examination were accompanied by the question, “Is this patient’s pain real or psychogenic?” Unfortunately, some people still are asking this question today as they evaluate their chronic pain patients, is it real or just all in the patient’s head. Dr. Fordyce over forty years ago started the process of trying to reframe this type of question into ones looking instead into social and environmental influences on a person’s pain behaviors. Dr. Fordyce found that it was not the health care provider’s job to serve as the lie detector to determine: is this pain real or not. Instead our role is to establish a warm, empathetic therapeutic alliance with patients to assist them through their pain behaviors toward more “well behaviors.”
This book is full of significant nuggets on treating people in pain even though Dr. Fordyce wrote it over forty years ago. I thought I would share one that was on the second page of chapter one.
“Pain is not simply a neurophysiological event. To hold that it is, is to fail to come to grips with what happens to patients. It is equally true that pain is not simply what a patient says it is. There are at least two reasons why this statement is true. One is that the patient’s knowledge and perceptions will limit his ability to discriminate well enough what is going on. Patient reports about pain will be subject to influence and distortion by a host of factors deriving from ongoing cortical activities, from the immediate stimulus situation, and from prior experience. There is a most important second reason why the patient’s pain is not necessarily what he or she says it is, which relates to the first reason but which should be viewed from a different perspective. For the problem to be identified, the person must in some fashion communicate to the surrounding environment that he or she is experience pain. The report of pain particularly chronic pain, may be verbal or by some other form of audible or visible action; some behavior. What the patient says the pain is (the verbal report) is not to be considered the final, definitive answer of what it is, even for him or her. That is of course true because of inherent patient limitations to observe the total system or to have the knowledge properly to interpret the data gained from experiencing current bodily states. But it is also true because there is no inherent reason why what patients say and what they do will correlate highly or be the same. This is a discussion of chronic pain, but the same point could be made about virtually any other human activity. The point is that verbal statements about pain are one kind of behavior, and the other visible and audible methods by which the problem is communicated to the environment are another. For the moment they will be distinguished as verbal and nonverbal pain behaviors. The latter group includes non-language sounds (such as moans and gasps), body posturing and gesturing (limping, rubbing a painful area, grimacing), and displaying functional limitations or impairments (reclining excessive to rest or staying home from work because it hurts too much.) Each of these sets of behaviors meets different contingencies or consequences in the environment. As a result, verbal and nonverbal behaviors are not only somewhat free to vary from each other; they in fact do vary from each other far more than we often are ready to accept. The discrepancy between what people say and what they do is not simply a question of honesty or candor. Verbal and nonverbal behaviors each meet consequences. These consequences are often not the same. Since consequences influence behavior, it follows that verbal and nonverbal behaviors – even when focused around a single conceptual theme or topic – can be expected to vary from each other. The variation is an inevitable result of learning or conditioning.”
Reading this I can see the influence Fordyce had on Johan Vlaeyen (another editor of the republished work), when Vlaeyen stated last year at a conference I was at: “Pain is about behavior.” Bill Fordyce was one of the early pioneers to see pain beyond a biomedical approach. He points out in this text that pain even extends beyond the neurophysiology of the brain also. It is seeing pain in the broadest context of a biopsychosocial approach and behavior. He points out the importance of biology and neurophysiological aspects, but potentially even more important the social components. While this was his point over forty years ago, I would argue we still struggle in the medical community to see the importance of these social behaviors within the pain experience of individuals as they come to us each day in pain. In addition, the research into these social behaviors is woefully lacking. Pick up any medical journal and look for articles that are looking into pain and you will see the discrepancy of what we are looking at in trying to understand pain. How many articles are directed toward the biological end of pain, how many at the psychological end compared to how many toward the social aspects of pain behaviors. We see the variations in our patients daily and Fordyce points out these variations can be attributed to the inevitable result of learning and conditioning.
Okay your turn: Are we looking into the learned and conditioned behaviors of our patients? How do you do that? Do you need to or is that someone else’s job? – What say you?
Via Kory Zimney
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!
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