Robert J. Gatchel1 and Don McGeary2
1Clinical Health Psychology Research, Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, TX, USA
2Department of Psychiatry, Department of Family and Community Medicine, The University of Texas Health Science Center San Antonio, San Antonio, TX, USA
The first non‐edited and comprehensive textbook in health psychology was published by Gatchel and Baum (1983). At that time, the field of health psychology was simply an array of basic and sometimes fragmented different areas (e.g., clinical psychology, cognitive psychology, experimental psychology, neuropsychology, physiological psychology, social psychology, etc.). These areas, though, began to touch upon important biobehavioral and medical content topics new to the field, such as adherence to medical regimens, promoting healthy lifestyles, rehabilitation approaches to disability, and the prevention and treatment of chronic pain, just to name a few. At about this time, when the term health psychology was still a relatively new one, a series of five edited volumes were published under the title, Handbook of Psychology and Health (Baum & Singer, 1982, 1987; Baum, Taylor, & Singer, 1984; Gatchel, Baum, & Singer, 1982; Krantz, Baum, & Singer, 1983). The books in this series focused on specific topic areas including pain. As subsequently noted by Baum, Revenson, and Singer (2001) in their handbook, this earlier series was published over several years just as health psychology became firmly established in its own right. There have been numerous other such handbooks published since then. Moreover, the quite diverse areas of how health psychology and medical illnesses are interrelated were perfectly aligned with the very important and influential Institute of Medicine's (IOM) report on Living Well and Chronic Illness: A Call for Public Health Action (Institute of Medicine, Committee on Living Well with Chronic Disease: Public Action to Reduce Disability, Improve Functioning and Quality of Life, 2012). This major IOM report was written as “… a guide for immediate and precise action to reduce the burden of all forms of chronic illnesses through the development and implementation of cross‐cutting and coordinated strategies to help Americans live well…” (A‐1). One such illness category was chronic pain. Indeed, one of the most frequently cited reasons for patients in the United States to seek medical care is due to pain. Recent estimates reveal that 25.3 million American adults (11.2%) suffer from daily (chronic) pain and 23.4 million (10.3%) report “a lot of pain” (Nahin, 2015). Moreover, according to earlier statistics from the National Academy of Sciences (Gaskin & Richard, 2011), the societal costs of chronic pain and related disability in the United States alone is $560–$635 billion each year. Unfortunately, many chronic pain conditions cannot yet be successfully treated. More clinical research is still needed to develop better treatment methods. Thus, social, economic, and biobehavioral research have become increasingly important in medicine and in the general related area of health psychology.
The above subsequently led to another very influential IOM report, “Relieving Pain in America” (Institute of Medicine of the National Academy of Science, 2011), which highlighted the urgent need for the development of better methods for pain management because the ever‐increasing costs associated with current treatment approaches cannot be sustained. This important focus has been further reinforced by National Institutes of Health's (NIH's) recent “National Pain Strategy: A Comprehensive Population Health‐Level Strategy for Pain” (https://www.federalregister.gov/articles/2015/04/02/2015‐07626/solicitation‐of‐written‐comments‐on‐draft‐national‐pain‐strategy). The mission of the strategy is to “Enhance pain research efforts and promote collaboration across the government, with the ultimate goals of advancing fundamental understanding of pain and improving pain‐related treatment strategies.” It was also charged to develop “a comprehensive population level health strategy for pain prevention, treatment, management, education, reimbursement, and research that includes specific goals, actions, time frames, and resources” as recommended in the IOM report on “Relieving Pain in America.” The proposed strategy also emphasizes the use of the biopsychosocial model of pain, which is the underpinning of interdisciplinary pain assessment and treatment.
The result of the new area of health psychology led to the replacement of the outdated biomedical reductionism, or a “dualistic” perspective that the mind and body function separately and independently, to a more heuristic biopsychosocial approach to medicine, initially introduced by Engel (1977) and that further emerged in the 1980s. In the context of pain, the biopsychosocial model views it as the result of a dynamic interaction among biological, psychological, and social factors that perpetuate and may even worsen the clinical presentation. Gatchel and others (Gatchel, 2004, 2005; Gatchel, McGeary, McGeary, & Lippe, 2014; Gatchel & Okifuji, 2006; Gatchel, Peng, Peters, Fuchs, & Turk, 2007; Gatchel & Turk, 1999; Turk & Monarch, 2002), for example, have further advanced this health psychology/biopsychosocial perspective of pain.
As earlier reviewed by Gatchel and Okifuji (2006), traditional interventions for chronic pain had predominantly involved monotherapies, such as surgery, injections, and a wide array of pharmacotherapeutic approaches. However, as Turk and Gatchel (2002) began to highlight, a more comprehensive interdisciplinary approach was needed to address both the physical and psychosocial factors involved in chronic pain. A major outgrowth, in turn, was the development of the biopsychosocial model. As briefly discussed earlier, this model views pain as the result of a dynamic interaction among biological, psychological, and social factors that perpetuate and may even worsen the clinical presentation. Each patient experiences pain uniquely, and a range of psychological and socioeconomic factors can interact with physical pathology to modulate that patient's report of symptoms and subsequent pain‐related disability. This model has been very influential in the area of pain, especially with the resultant development of treatment‐ and cost‐effective interdisciplinary pain management programs (Gatchel et al., 2007; Gatchel & Okifuji, 2006), to be reviewed later. Such programs, based upon the biopsychosocial model, have been found to be the most heuristic approach to understanding and assessing chronic pain (Gatchel et al., 2007). Indeed, the influential IOM report (Institute of Medicine of the National Academy of Science, 2011, p. 35) states that “Today, most researchers and clinicians who specialize in pain issues use the ‘biopsychosocial model’ [denoting the combination of biological, psychological and social/family/cultural contexts of pain to understand and treat chronic pain (Gatchel et al., 2007)].”
The biopsychosocial model focuses on both disease and illness, with illness being viewed as the complex interaction among biological, psychological, and social factors (Gatchel, 2005). As succinctly summarized by Turk and Monarch (2002), disease is usually viewed as a pathophysiological event that results in a disruption of some anatomical/physiological structure or organ system functioning. Illness, on the other hand, is usually viewed as a more subjective experience that a specific disease is present. Illness, therefore, basically refers to how a “sick” individual and possibly members of his/her family accommodate and react to the resultant symptoms of possible disability and limited activities of daily living. As Turk and Monarch (2002) further point out, the distinction between disease and illness can basically be viewed as similar to the difference one can make between nociception and pain. Essentially, nociception refers to the stimulation of nerves that transmit signals to the brain about potential tissue damage. In contrast, pain is the subjective perception that results from the sensory input to the brain. Moreover, such input is usually “filtered” through a number of layers (e.g., past learning experiences, psychosocial influences, genetic predispositions, etc.). Therefore, because the biopsychosocial model of chronic pain views each individual as experiencing pain uniquely, it is important to evaluate the different dimensions of this interactive process (Gatchel, 2004). Other comprehensive reviews of the biopsychosocial model of pain can also be found elsewhere (Gatchel, 2004; Gatchel et al., 2007, 2014; Turk & Monarch, 2002).
The biopsychosocial model of chronic pain was one of the first models designed to accommodate the complexity of the chronic pain experience. As the model began to permeate academic and clinical medicine, so, too, did multicomponent models of pain management care. To date, the interdisciplinary pain management approach stands as one of the best and most efficacious examples of comprehensive pain management (Gatchel et al., 2014). Before exploring interdisciplinary care in greater detail, one must first be able to draw a distinction between interdisciplinary and multidisciplinary care. In an excellent review of interdisciplinary pain management models, Turk et al. (2010) carefully explained how interdisciplinary and multidisciplinary models differ. They appropriately highlight that, although the two models may both include components that match the dimensions of the biopsychosocial pain conceptualization, a truly interdisciplinary pain management program is more integrated and all treatment components are administered “under one roof” at the same pain management facility. In contrast, multidisciplinary care may be delivered by different providers at different facilities, thus decreasing integrative care and constant communication among providers “under one roof.” Integration of pain management services is essential and can manifest in multiple ways, although most agree that coordination of care through daily team‐based communication “under one roof” and common treatment goals is the key to effective integrative pain management (Gatchel et al., 2014). Interdisciplinary pain management teams will often include pain medicine physicians, nursing staff, clinical health psychology, and physical/occupational therapy providers who synthesize their care through effective leadership and commonly developed goals to create a comprehensive treatment program, with the resultant effectiveness greater than the sum of its parts (Okifuji, 2003).
A number of published studies describe the effectiveness of interdisciplinary pain management models in multiple pain populations (Gagnon, Stanos, van der Ende, Rader, & Harden, 2013; Gatchel et al., 2014). Indeed, a PubMed search for “interdisciplinary pain management” returned 50 published studies between 1995 and 2015, most of which demonstrate significant benefit of interdisciplinary pain management programs for pain of various etiologies. Despite a wealth of supportive research outcomes, interdisciplinary pain management programs are widely unavailable to many pain patients. Numerous barriers prohibit both the implementation of comprehensive pain management programs and the long‐term follow‐up needed to ensure that gains are maintained. First, some have noted that third‐party payer reimbursement policies have played an important role in limiting the availability of more comprehensive pain management options (Gagnon et al., 2013). This is quite surprising in light of the staggering cost of chronic pain over time and the substantial socioeconomic gains that are possible through interdisciplinary care (Lippe & Polatin, 2014). Others have noted that interdisciplinary programs may not be utilized as well as they could be because many pain treatment providers prioritize simple palliative pain management (e.g., medications) over interdisciplinary options. Breivik, Eisenberg, O'Brien, and OPENMinds (2013) have noted that palliative pain relief options may be preferred because chronic pain patients and their most oft‐seen medical providers (e.g., non‐specialty physicians) are either not aware of more effective treatment options or are not familiar with the data supporting interdisciplinary pain management. There is some hope that increased US congressional attention to the pain management crisis, and federal policy calling more interdisciplinary healthcare options, will alleviate these concerns in the future (Gatchel et al., 2014).
In order to truly improve the availability of interdisciplinary pain programs, there needs to be some agreement on the necessary components. In a “Letter to the Editor” in the journal, Pain, Kaiser, Deckert, Kopkow, Schmitt, and Sabatowski (2014) pointed out that there is no broadly accepted definition of multidisciplinary or interdisciplinary pain programs (including the level of emphasis required for psychosocial intervention). This has resulted in heterogeneity in interdisciplinary pain programs under study, making it difficult to examine the state of the research meta‐analytically with much refinement. Some have stressed a need to establish common outcomes across pain programs that can be used to uniformly examine the important components of pain management (i.e., key ingredients) for translation (Deckert et al., 2015). In fact, the NIH have developed the Patient‐Reported Outcomes Measurement Information System (PROMIS) (http://www.nihpromis.org/) in order to encourage all pain practitioners to use the set of outcome measures. Regardless, most who study interdisciplinary pain management seem to agree that psychosocial intervention is vital if a pain management program wants to holistically address the biopsychosocial model (Gatchel et al., 2014). Numerous studies have uncovered psychosocial constructs of pain (e.g., pain catastrophizing, pain acceptance, fear avoidance, etc.) that contribute to the pain management process (Vowles, McCracken, & Eccleston, 2007), and subsequent studies have found that these concepts may mediate the relationship between pain experience and mood (Weiss et al., 2013). In light of these findings, interdisciplinary pain programs must appreciate the value added by the clinical health psychologist in order for the treatment team to be successful.
Despite the heterogeneity of interdisciplinary pain programs, there are a few models under study with more definite composition and a more definite role of clinical health psychology. Of these, functional restoration (FR) programs represent some of the most well researched, with a strong emphasis on return to function and the pursuit of long‐term socioeconomic goals (e.g., reduced medical visits for pain management, increased employment, increased retention of employment). The mechanics of FR pain and disability management typically include an emphasis on both physical capacity and psychosocial functioning (Mayer, McGeary, & Gatchel, 2004). Health psychology is a prominent component of FR. In fact, the recommended FR treatment team should always include a psychologist, along with a pain management physician, nurse, and physical or occupational therapist. These providers must work in an interdisciplinary fashion to quantify function across all relevant rehabilitation domains (e.g., functional capacity, mood, pain coping) and to develop an integrated treatment program that targets these domains synergistically (Gatchel & Okifuji, 2006). Treatment begins with a comprehensive assessment battery (i.e., quantify function), and the resulting data are used to identify treatment targets. As an interdisciplinary program, FR's goals are determined collaboratively across all providers and are agreed upon by patients who are given regular feedback about their assessment and shown evidence of physical and psychosocial progress over the course of the intensive FR program. Again, the clinical health psychologist plays a key role in the FR treatment process. For example, the psychologist helps mitigate emotional disruption (e.g., depression) that may affect physical function and/or engagement in rehabilitation with other FR team members (Heiskanen, Roine, & Kalso, 2012) and helps the patient learn how to effectively track goals and communicate with other healthcare providers to ensure that their clinical needs are met and that they are progressing toward their goals. They also teach the patient effective pain management strategies that can be used to overcome self‐limiting functional activity, which helps maximize the benefits of physical rehabilitation (Gatchel et al., 2014).
Over the past 30 years, numerous studies have confirmed the efficacy and effectiveness of FR pain management models, often showing significant gains beyond those demonstrated in one‐dimensional programs of physical/physiotherapy or biomedical care (Mayer et al., 1987; Steiner et al., 2013). As studies of FR have progressed, research surrounding these interdisciplinary programs has started to expand, with increasing emphasis on the effectiveness of FR in managing orthopedic/musculoskeletal pain and common comorbidities (including sleep, non‐orthopedic pain conditions, and psychiatric disorders) that typically present with chronic pain. For example, Hartzell et al. (2014) found that patients with chronic musculoskeletal pain and comorbid fibromyalgia show a significant improvement in fibromyalgia symptoms after completing an FR program (e.g., 41% of completers no longer met criteria for fibromyalgia after completing treatment). Asih, Neblett, Mayer, and Gatchel (2014) found a significant improvement in insomnia among FR program completers, although the presence of insomnia was a predictor of program completion, and more severe insomnia symptoms persisted beyond treatment. As noted above, interdisciplinary pain management programs (including FR) can contribute to significant reductions in some emotional distress conditions (e.g., depression), but there are fewer data supporting the application of FR to more complex psychosocial presentations like posttraumatic stress disorder (PTSD) (McGeary, Moore, Vriend, Peterson, & Gatchel, 2011). This is particularly relevant because of the increasing attention paid to PTSD and pain‐related comorbidity among military members and veterans who served as part of the post‐9/11 war effort.
Chronic pain and PTSD have been found to co‐occur quite frequently in some military populations. Specifically, Lew et al. (2009) report that over 58% of veterans assessed for trauma and pain in a VA Polytrauma Network Site presented with comorbid pain and PTSD and the presence of PTSD in the context of pain can have significant and deleterious effects on response to pain management intervention (McGeary et al., 2011). Little has been done to examine treatments for pain and PTSD comorbidity, but there is solid evidence suggesting that FR programs are generally effective for military service members with chronic pain (Gatchel et al., 2009), and some psychosocial interventions work quite well for military PTSD (McLean & Foa, 2014). Thus, it stands to reason that a comprehensive interdisciplinary pain management program (like FR) could incorporate effective psychosocial treatment components for PTSD to develop an efficacious treatment option for this significant problem. Large‐scale studies of interdisciplinary pain and PTSD management are underway, but some smaller studies have already started to show the benefits of combined treatments for this comorbidity (Plagge, Lu, Lovejoy, Karl, & Dobscha, 2013).
The field of health psychology has grown significantly over the past several decades, and few subspecialty fields have benefitted more from this growth than chronic pain. As the field of healthcare providers who work with chronic pain increasingly adopts and expands the biopsychosocial model, greater integration of treatment will likely follow. Indeed, recent changes in legislation and the growing body of evidence supporting integrated treatment for pain bode well for the growth of interdisciplinary models. Research on psychosocial variables in the pain experience and pain management has rapidly expanded over the past 30 years, and health psychology is now widely acknowledged as a vital component of interdisciplinary pain management teams. This growth is likely to continue as pain management intervention and research start to apply the biopsychosocial model to even more complex chronic pain presentations (e.g., comorbid pain and PTSD).
Dr. Robert J. Gatchel, PhD, ABPP, is the Nancy P. & John G. Penson endowed professor of clinical health psychology at the University of Texas at Arlington. He is internationally known for his research on biopsychosocial pain management, and his scientific contributions have resulted in numerous awards including an NIH Senior Scientist Award and the Gold Medal Award for Life Achievement in the Application of Psychology from the American Psychological Association.
Dr. Don McGeary, PhD, ABPP, is an associate professor in the Department of Psychiatry and a ReACH scholar at the University of Texas Health Science Center at San Antonio. He is the principle investigator of several federally funded studies of chronic pain and psychiatric comorbidities with a particular emphasis on managing pain‐related polymorbidities in military service members and veterans.