Motivational Issues in Pain Management

Robert D. Kerns, Mark P. Jensen, and Warren R. Nielson

Disease self-management has emerged as a dominant approach to keeping chronic illness under control, reducing its impact on physical health status and functioning, and improving coping with the psychosocial sequelae of the illness (Clark et al. 1991; Lorig et al. 1999; Newman et al. 2004). Consistent with this zeitgeist, as the field of pain medicine has matured, it has become increasingly apparent that an approach that emphasizes self-management may be key to control of acute pain and prevention of the progression to chronic pain (Damush et al. 2003) and to promoting optimal adjustment and adaptation to persistent pain conditions such as arthritis (Keefe et al. 2000), fibromyalgia (Okifuji and Hare 2011), and chronic back pain (Hoffman et al. 2007), among others. Given a growing body of research that documents important roles of psychological factors, including pain-related coping, as predictors of the development of chronic pain, it is intuitively appealing to predict that early efforts to promote use of adaptive pain coping or selfmanagement skills among persons with acute pain can play a role in resolving pain and preventing the development of chronic pain. Adoption of adaptive pain self-management coping skills is predicted to contribute to positive adjustment and accommodation to acute pain and to facilitate resolution of the experience of pain and its potential negative impacts.

Optimal self-management involves numerous behaviour changes by persons with pain, including taking medications when indicated, physical exercise, undertaking preventive action, learning stress reduction strategies, moderating or pacing activities, and changing other aspects of their lifestyles. It is in this context that psychological interventions have been developed and promoted as important alternatives to more traditional medical and rehabilitation therapies (Turk and Gatchel 2002). Dominant among the numerous psychological therapies that have been applied to chronic pain management are those that assist individuals in developing a perspective of personal control and mastery and adoption of a range of adaptive cognitive and behavioural pain coping skills (Turk et al. 1983). Significant reductions in pain severity, disability, and affective distress, as well as reductions in healthcare resource utilization have been repeatedly documented. However, high rates of treatment refusal and treatment dropout continue to be reported (Turk and Rudy 1991). Equally problematic are reports that many patients fail to adhere to therapist recommendations related to cognitive and behavioural pain management skill acquisition and practice (Heapy et al. 2005). A variety of contributors to dropout and poor adherence have been suggested including a failure to take into account important individual differences in treatment planning, the overall complexity of therapist recommendations for skill development, and patient motivation for making changes (Jensen 2002; Kerns et al. 1998). After all, because the ability of patients to manage chronic pain depends much more on what they do than on what is done to them, motivation can be viewed as a primary issue in pain self-management.

Specific attention to motivation and factors that influence motivation may serve an important role in improving engagement and participation in pain self-management interventions, including interventions for persons experiencing acute pain (Kerns et al. 2006). Motivation for engaging in pain self-management has emerged as a particularly important focus of research in the past decade. Of great heuristic importance has been the development of a sound and integrative conceptual motivational model of pain self-management (Jensen et al. 2003) and tools for measuring the core constructs of the model, especially those designed to measure persons’ ‘pain readiness to change’ (Kerns and Habib 2004; Nielson et al. 2003, 2008, 2009). In addition, Kerns (1994) has suggested that a prescriptive approach to pain treatment planning may be an important strategy for promoting engagement and participation in treatment and for improving outcomes. He calls for individual tailoring of training in new pain coping skills strategies by matching patients’ preferences for a more limited number of specific treatment components. Jensen (2002) and Kerns and his colleagues (Kerns et al. 1998) have also suggested that the incorporation of specific motivational enhancement strategies may also promote engagement of a larger proportion of otherwise appropriate patients as well as adherence to therapist recommendations for skill acquisition and practice. Frantsve and Kerns (2007) have drawn attention to issues of patient-provider interactions and shared medical decision-making in pain management and their importance in considering patient motivation for engaging in pain self-management. These theoretical, clinical, and empirical developments have contributed to increased attention to issues of motivation in the field of pain management.

In this chapter we describe a motivational model of pain self-management and discuss its potential relevance in clinical situations. Briefly, according to the model, patients’ readiness to engage in pain self-management at the time of acute injury or illness, or even in the context of the emergence of unexplained pain, is expected to influence their coping responses to pain, their efforts to acquire and use new adaptive pain coping strategies, and ultimately, the course of pain and the likelihood that pain will resolve. We also describe methods for assessing motivation and readiness to adopt a self-management approach to chronic pain, methods for promoting motivation for pain treatment and for learning and implementing adaptive pain-coping skills, and strategies for tailoring pain treatment to patient preferences, interests, and expectations for treatment. We conclude the chapter with a more explicit discussion of the implications of the motivational model and motivational issues for understanding and addressing the process of transitioning from acute to chronic pain, and for preventing this transition.

 
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