Applied Behavior Analysis in Pain Management

Applied behavior analysis is used in pain management protocols in hospitals and outpatient treatment to assist patients in coping with chronic pain by minimizing long-term adaptations in pain response. Additionally, behavior modification is used to help chronic pain patients cope with and reduce pain levels where part of the pain source is psychological in nature.

The intuitive perspective on pain might initially seem to indicate that applied behavior analysis would have little effect in treating or reducing such a physical sensation.

A clinical psychologist named Wilbert Fordyce was not so sure, however. A professor at the University of Washington School of Medicine since 1959, Fordyce was around for many of the groundbreaking developments at the hands of Ivar Lovaas, Montrose Wolf, Sidney Bijou, and other luminaries that helped establish the foundation of applied behavior analysis.

During the same period, researchers were looking into the wellspring of pain and finding that attributing it to purely physical sources was overly simplistic. A psychological aspect also appeared to have some bearing on the degree and intensity of pain people feel.

Fordyce, steeped in the science of operant conditioning, began to conceive of pain as simply another sort of behavior. If a physical event occurred that did not provoke a behavioral pain response (limping, favoring, recoiling, guarding etc), he theorized, then the pain, even if it had been felt, did not present a problem. And if a pain problem was a behavior, then by the tenets of operant conditioning it could be modified.

On the basis of this theory, Fordyce realized that chronic pain in many cases was in fact a vestige of the positive reinforcement of pain behaviors—a patient with a limp might have adopted the limp to avoid provoking knee pains, for example, but then found the limp persisting beyond the point where the actual painful nerve triggers were actually occurring. By applying conditioning to extinguish the pain behaviors, the perception of pain could also be reduced.

As unusual as Fordyce’s insights were, study after study into behavioral pain management has proved him right. Today, applied behavior analysts fill critical roles in pain clinics and hospitals, helping patients manage pain.

Behavioral Approaches Help Patients Function Despite Their Pain

Although purely behavioral approaches have been found to be modestly effective in reducing perceived pain in several studies, the most common application of applied behavior analysis is as part of a multidisciplinary approach to pain management. These teams commonly have professionals on them such as:

  • Neurologists
  • Internists
  • Nurses
  • Physical Therapists
  • Occupational Therapists
  • Psychologists

While neurologists and other physicians attempt to find the best ways to manage the biological sources of pain people experience, ABAs on the team look for methods to help the patient cope with pain to maintain function without adopting negative long-term adaptations.

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One example of such adaptations is called guarding. Guarding occurs when a patient finds that a certain posture or position helps reduce the physical pain that they experience. But the learned response of adopting a guarded position frequently reduces limb function—such as in the limping example, above—and creates a perception of pain that can long outlast the actual biological source of that pain.

Guarding can also lead to long-term disability by causing atrophy or reducing range of motion, ultimately degrading the patient’s quality of life long after the initial pain condition recedes.

ABAs help those patients avoid developing engrained responses to head off long-term issues before they become problems. Techniques they use include:

  • Positive verbal reinforcement of normal behaviors, even when they cause pain (for example, exercising through a full range of motion despite twinges of pain)
  • Biofeedback for contingent reinforcement of subconscious responses, such as increased blood flow or muscle response
  • Exposure and desensitization therapy to gradually improve pain tolerance

Many times, these methods become integral components of other therapies. For instance, as a physical therapist works with a patient to exercise a damaged limb, that therapist might simultaneously offer positive verbal cues at certain points as directed by the ABA on the team. The ABA might work with nurses to devise appropriate dosages of pain medications and establish conditions in which biofeedback or other techniques should be offered instead.

Psychological approaches are also combined with behavior modification in a popular technique known as cognitive behavior therapy, or CBT. This helps to address problematic behaviors using standard operant conditioning techniques while also working with the patient through psychotherapeutic talk therapy to address mental reinforcers that contribute to the problems. Depression, anxiety, and other mental issues commonly cloud the mind of patients experiencing chronic pain or with terminal diseases, such as cancer, and CBT has been proven effective in such cases.

ABAs are also finding a niche in specialty aspects of pain management, such as in working with pediatric and veterinary patients. Because verbal indications of pain are not possible with such patients, sometimes the only indicators are behavioral. An ABA can use standard functional behavior assessments in such cases to help clinicians determine the likely causes of pain.

Preparing for a Career as an Applied Behavior Analyst Working in Pain Management

As with most ABA positions, those working in pain management typically require a master’s or higher degree and certification in the field as a Board Certified Behavior Analyst (BCBA®). The Behavior Analyst Certification Board, a non-profit organization established to provide professional standards and credentialing for behavior analysts, offers the BCBA® certification.

Degrees in psychology or applied behavior analysis are good preparation for ABA careers in pain management, but having a medical background of any sort is good.

Psychotherapy is another common route into a specialization in pain management. Most practitioners are licensed psychologists, but applied behavior analysts can also provide pain management counseling.

A number of certifications are available that are useful in the field of pain management. The American Pain Association offers basic, advanced, and trainer categories of certification in pain management to therapists. The American Academy of Pain Management offered a general certification up until March of 2016, but is currently re-evaluating the requirements and levels of certification that would be most useful to members. An advanced certification is still available to medical practitioners.

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Further Reading on Applied Behavior Analysis in Pain Management

The American Chronic Pain Association – An association providing peer support and resources to sufferers of chronic pain and health care providers in the field.

American Association for Pain Management Nursing – A national non-profit offering certification and resources for pain management nurses and other practitioners.

The American Pain Association – An association supporting research, education, and improving treatment in pain management. The association offers several levels of credentialing to pain management specialists.

American Academy of Integrative Pain Management – A non-profit association promoting the integrative approach to pain management, including medical, psychological, and behavioral therapies in a multi-faceted team approach.

National Association of Cognitive Behavioral Therapists – A national associate of CBT practitioners.

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