Can Exposure and Acceptance Strategies Improve Functioning and Life Satisfaction in People with Chronic Pain and Whiplash‐Associated Disorders (WAD)? A Randomized Controlled Trial

Although 14% to 42% of people with whiplash injuries end up with chronic debilitating pain, there is still a paucity of empirically supported treatments for this group of patients. In chronic pain management, there is increasing consensus regarding the importance of a behavioural medicine approach to symptoms and disability. Cognitive behaviour therapy has proven to be beneficial in the treatment of chronic pain. An approach that promotes acceptance of, or willingness to experience, pain and other associated negative private events (e.g. fear, anxiety, and fatigue) instead of reducing or controlling symptoms has received increasing attention. Although the empirical support for treatments emphasizing exposure and acceptance (such as acceptance and commitment therapy) is growing, there is clearly a need for more outcome studies, especially randomized controlled trials. In this study, participants (N = 21) with chronic pain and whiplash‐associated disorders were recruited from a patient organization and randomized to either a treatment or a wait‐list control condition. Both groups continued to receive treatment as usual. In the experimental condition, a learning theory framework was applied to the analysis and treatment. The intervention consisted of a 10‐session protocol emphasizing values‐based exposure and acceptance strategies to improve functioning and life satisfaction by increasing the participants' abilities to behave in accordance with values in the presence of interfering pain and distress (psychological flexibility). After treatment, significant differences in favor of the treatment group were seen in pain disability, life satisfaction, fear of movements, depression, and psychological inflexibility. No change for any of the groups was seen in pain intensity. Improvements in the treatment group were maintained at 7‐month follow‐up. The authors discuss implications of these findings and offer suggestions for further research in this area.     

“Feeling” the pain of those who are different from us: Modulation of EEG in the mu/alpha range

We explored how apparently painful stimuli and the ability to identify with the person on whom the pain is inflicted modulate EEG suppression in the mu/alpha range (8–12 Hz). In a 2 × 2 design, we presented pictures of hands either experiencing needle pricks or being touched by a Q-tip. In the dissimilar-other condition, the hand was assigned to a patient suffering from a neurological disease in which Q-tips inflicted pain, whereas needle pricks did not. In the similar-other condition, the hand was assigned to a patient who responded to stimulation in the same way as the healthy participant. Participants were instructed to imagine the feeling of the person whose hand was shown and to evaluate his or her affective state. Pain conditions elicited greater EEG suppression than did nonpain conditions, particularly over frontocentral regions. Moreover, an interaction between pain and similarity revealed that for similar others, the pain effect was significant, whereas in the dissimilar-other group, suppression was equally large in the pain and no-pain conditions. We conclude that mu/alpha suppression is elicited both automatically, by observing a situation that is potentially painful for the observer, and by empathy for pain, even if the other person is different from oneself.     

Autonomy,Experience, and Reflection. On a Neglected Aspect of Personal Autonomy

The aim of this paper is to suggest that a necessary condition of autonomy has not been sufficiently recognized in the literature: the capacity to critically reflect on one’s practical attitudes (desires, preferences, values, etc.) in the light of new experiences. It will be argued that most prominent accounts of autonomy—ahistorical as well as history-sensitive—have either altogether failed to recognize this condition or at least failed to give an explicit account of it.     

Educating pain

Abstract

In times in which we ask ourselves how political cruelty and torments can be forgotten, Nietzsche’s pleadoyer for pain to serve the purpose of education, surprises. What might sound like a mere provocation, rather lies at the heart of the Nietzschean philosophy. As is pointed out, Nietzsche’s contention that pain is the most powerful aid to mnemonics, originates from his philosophy of pain as the main condition of all forms of creation. The title “educating (bilden) pain” expresses Nietzsche’s advocacy of an education towards pain as the dynamo of creation. In this paper I explore how Nietzsche’s notion of pain is linked to two concepts of Bildung. In the first part I investigate the relation between pain and “Bildung” in the sense of “creation”, and in the second part I link this to the relation between pain and “Bildung” in the sense of “education”. By these means, I try to answer the question: how far can pain, which is seen as the condition of creation, be linked to conditions of education.     

Animal Pain: What It is and Why It Matters

The basis of having a direct moral obligation to an entity is that what we do to that entity matters to it. The ability to experience pain is a sufficient condition for a being to be morally considerable. But the ability to feel pain is not a necessary condition for moral considerability. Organisms could have possibly evolved so as to be motivated to flee danger or injury or to eat or drink not by pain, but by “pangs of pleasure” that increase as one fills the relevant need or escapes the harm. In such a world, “mattering” would be positive, not negative, but would still be based in sentience and awareness. In our world, however, the “mattering” necessary to survival is negative—injuries and unfulfilled needs ramify in pain. But physical pain is by no means the only morally relevant mattering—fear, anxiety, loneliness, grief, certainly do not equate to varieties of physical pain, but are surely forms of “mattering.” An adequate morality towards animals would include a full range of possible matterings unique to each kind of animal, what I, following Aristotle, call “telos”. Sometimes not meeting other aspects of animal nature matter more to the animal than does physical pain. “Negative mattering” means all actions or events that harm animals—from frightening an animal to removing its young unnaturally early, to keeping it so it is unable to move or socialize. Physical pain is perhaps the paradigmatic case of “negative mattering”, but only constitutes a small part of what the concept covers. “Positive mattering” would of course encompass all states that are positive for the animal. An adequate ethic for animals takes cognizance of both kinds. The question arises as to how animals value death as compared with pain. Human cognition is such that it can value long-term future goals and endure short-run negative experiences for the sake of achieving them. In the case of animals, however, there is no evidence, either empirical or conceptual, that they have the capability to weigh future benefits or possibilities against current misery. We have no reason to believe that an animal can grasp the notion of extended life, let alone choose to trade current suffering for it. Pain may well be worse for animals than for humans, as they cannot rationalize its acceptance by appeal to future life without pain. How can we know that animals experience all or any of the negative or positive states we have enumerated above? The notion that we needed to be agnostic or downright atheistic about animal mentation, including pain, because we could not verify it through experience, became a mainstay of what I have called “scientific ideology”, the uncriticized dogma taught to young scientists through most of the 20th century despite its patent ignoring of Darwinian phylogenetic continuity. Together with the equally pernicious notion that science is “value-free”, and thus has no truck with ethics, this provided the complete justification for hurting animals in science without providing any pain control. This ideology could only be overthrown by federal law. Ordinary common sense throughout history, in contradistinction to scientific ideology, never denied that animals felt pain. Where, then, does the denial of pain and other forms of mattering come from if it is inimical to common sense? It came from the creation of philosophical systems hostile to common sense and salubrious to a scientific, non-commonsensical world view. Reasons for rejecting this philosophical position are detailed. In the end, then, there are no sound reasons for rejecting knowledge of animal pain and other forms of both negative and positive mattering in animals. Once that hurdle is cleared, science must work assiduously to classify, understand, and mitigate all instances of negative mattering occasioned in animals by human use, as well as to understand and maximize all modes of positive mattering.     

When more is not merrier: shared stressful experiences amplify

ABSTRACT

Sharing experiences with others, even without communication, can amplify those experiences. We investigated whether shared stressful experiences amplify. Participants completed the Cold Pressor Task at the same time as a confederate, or while the confederate completed another task. Importantly, participants in the shared (vs. unshared) condition experienced more sensory pain characteristics and reported more stress over time in relation to the task. Importantly, they reported thinking more about the confederate’s thoughts and feelings. This mentalizing sometimes mediated effects, suggesting the task amplified when participants constructed mental representations of others’ CPT experience (e.g. that it hurts) and incorporated it into their own responses.     

Evaluating the evidence for multiple realization

Consider what the brain-state theorist has to do to make good his claims. He has to specify a physical–chemical state such that any organism (not just a mammal) is in pain if and only if (a) it possesses a brain of suitable physical–chemical structure; and (b) its brain is in that physical–chemical state. This means that the physical–chemical state in question must be a possible state of a mammalian brain, a reptilian brain, a mollusc’s brain (octopuses are mollusca, and certainly feel pain), etc. At the same time, it must not be a possible (physically possible) state of the brain of any physically possible creature that cannot feel pain. Even if such a state can be found, it must be nomologically certain that it will also be a state of the brain of any extraterrestrial life that may be found that will be capable of feeling pain before we can even entertain the supposition that it may be pain. It is not altogether impossible that such a state will be found... . But this is certainly an ambitious hypothesis. (Putnam 1967/1975, p. 436)

The belief that mental states are multiply realized is now nearly universal among philosophers, as is the belief that this fact decisively refutes the identity theory. I argue that the empirical support for multiple realization does not justify the confidence that has been placed in it. In order for multiple realization of mental states to be an objection to the identity theory, the neurological differences among pains, for example, must be such as to guarantee that they are of distinct neurological kinds. But the phenomena traditionally cited do not provide evidence of that sort of variation. In particular, examples of neural plasticity do not provide such evidence.     

Explanatory Consolidation: From ‘Best’ to ‘Good Enough’

In science and everyday life, we often infer that something is true because it would explain some set of facts better than any other hypothesis we can think of. But what if we have reason to believe that there is a better way to explain these facts that we just haven’t thought of? Wouldn’t that undermine our warrant for believing the best available explanation? Many philosophers have assumed that we can solve such underconsideration problems by stipulating that a hypothesis should not only be ‘the best’ explanation available; rather, it should also be ‘good enough’. Unfortunately, however, the only current suggestion for what it might mean to say that an explanation is ‘good enough’ is, well, not good enough. This paper aims to provide a better account of what is required for an explanatory hypothesis to be considered ‘good enough’. In brief, the account holds that a ‘good enough’ hypothesis is one that has gone through a process that I call explanatory consolidation, in which accumulating evidence and failed attempts to formulate better alternatives gradually make it more plausible that the explanation we currently have is better than any other that could be formulated.     

Apocalyptic relevance

In their book, Relevance, Sperber and Wilson make an important contribution towards constructing a credible theory of this unforthcoming notion. All is not clear sailing, however. If it is accepted as a condition on the adequacy of any account of relevance that it not be derivable either that nothing is relevant to anything or that everything is relevant to everything, it can be shown that Sperber and Wilson come close to violating the condition.     

The interplay between counterfactual reasoning and feedback dynamics in producing inferences about the self

Counterfactual reasoning research typically demonstrates contrast effects—nearly winning evokes frustration, whereas nearly losing evokes exhilaration. The present work, however, describes conditions under which assimilative responses (i.e., when judgements are pulled towards a comparison standard) also occur. Participants solved analogies and learned that they had either nearly attained a target score or nearly failed to attain it. Participants in the no trajectory condition received this feedback in the absence of any prior feedback, whereas those in the trajectory condition received feedback after having received prior feedback conforming to either an ascending or descending pattern. Participants then provided perceptions of their verbal intelligence. Assimilation effects were observed in the trajectory conditions but attenuated in the no trajectory conditions. Discussion focuses on the role of feedback dynamics in determining responses to close-call counterfactuals.     

Form C of the MHLC Scales: A Condition-Specific Measure of Locus of Control

Form C of the Multidimensional Health Locus of Control (MHLC) scales is an 18 item, general purposes condition-specific locus of control scale that could easily be adapted for use with any medical or health-related condition. Data from 588 patients with one of four conditions—rheumatoid arthritis, chronic pain, diabetes, or cancer—were utilized to establish the factor stucture of Form C and to establish the reliability and validity of the resultant four subscales: Internality; Chance; Doctors; and Other (powerful) People. The alpha reliabilities of the subscales are adequate for research purposes. Data from the arthritis and chronic pain subjects established that the Form C subscales were moderately stable over time and possessed considerable concurrent and construct validity. Some discriminant validity of Form C with Form B of the MHLC was also demonstrated.     

Husserl and externalism

It is argued that Husserl was an “externalist” in at least one sense. For it is argued that Husserl held that genuinely perceptual experiences—that is to say, experiences that are of some real object in the world—differ intrinsically, essentially and as a kind from any hallucinatory experiences. There is, therefore, no neutral “content” that such perceptual experiences share with hallucinations, differing from them only over whether some additional non-psychological condition holds or not. In short, it is argued that Husserl was a “disjunctivist”. In addition, it is argued that Husserl held that the individual object of any experience, perceptual or hallucinatory, is essential to and partly constitutive of that experience. The argument focuses on three aspects of Husserl’s thought: his account of intentional objects, his notion of horizon, and his account of reality.     

Human Dignity and the Ethics and Aesthetics of Pain and Suffering

Inasmuch as unmitigated pain and suffering areoften thought to rob human beings of theirdignity, physicians and other care providersincur a special duty to relieve pain andsuffering when they encounter it. When pain andsuffering cannot be controlled it is sometimesthought that human dignity is compromised.Death, it is sometimes argued, would bepreferred to a life without dignity.Reasoning such as this trades on certainpreconceptions of the nature of pain andsuffering, and of their relationships todignity. The purpose of this paper is to laybare these preconceptions. The duties torelieve pain and suffering are clearly mattersof moral obligation, as is the duty to respondappropriately to the dignity of other persons.However, it is argued that our understanding ofthe phenomena of pain and suffering and theirrelationships to human dignity will be expandedwhen we explore the aesthetic dimensions ofthese various concepts. On the view presentedhere the life worth living is both morally goodand aesthetically beautiful. Appropriate``suffering with' another can help to maintainand restore the dignity of the relationshipsinvolved, even as it preserves and enhances thedignity of patient and caregiver alike.     

Foundational beliefs and the structure of justification

I argue that our justification for beliefs about the external physical world need not be constituted by any justified beliefs about perceptual experiences. In this way our justification for beliefs about the physical world may be nondoxastic and this differentiates my proposal from traditional foundationalist theories such as those defended by Laurence BonJour, Richard Fumerton, and Timothy McGrew. On the other hand, it differs from certain non-traditional foundationalist theories such as that defended by James Pryor according to which perceptual experience is sufficient to justify beliefs about the external world. I propose that justification for propositions describing our perceptual experiences partially constitutes any justification we may possess for beliefs concerning the external world. In this way, our justification for beliefs about the physical world may only be inferential since it is grounded in any justification we have for at least one other proposition. This theory occupies an intermediate position between the two aforementioned foundationalist accounts, which allows it to sidestep problems that confront each of them.     

Chronic pain as a posture towards the world

This article discusses what chronic pain is “about”, what the intentional object is of pain, and what is the intentional relation like? My approach is based on Maurice Merleau‐Ponty’s phenomenology, with an aim is to understand a two‐way relationship: how the sufferers bestow meaning on chronic pain, and how pain, on the other hand, signifies peoples’ life. In contrast to biomedical and cognitive‐behavioral theories, chronic pain is not only meaningful, but as an intentional emotion as well; it does not simply “happen” in the nervous system. I analyzed meanings assigned to pain through the narratives of three patients with chronic pain. Pain is described as creating a discontinuity in the patient’s Lebenswelt at the narrative level. When attempting to find meaning to their pain, patients point both to everyday life and biomedical referents. The structure of bestowing meaning is, metaphorically, like a necklace with everyday world and biomedical interpretations strung like beads, one after the other. The intentional object of pain, on the contrary, is constituted of the patients’ world in its wholeness. My results don’t confirm Drew Leder’s idea of disrupted intentionality, but underline directness as the basic relation of human experience also in case of pain and disease. Pain in itself is an e‐movere, an intense passionate movement, an intentional relation with and a bodily posture taken towards the world.     

Reactivity and response to pain

Male and female volunteers (N = 144) answered the Reactivity Scale (RS) and underwent testing for their perceived intensity and tolerance for finger-pressure pain. Half the Ss were randomly assigned to a low-intensity treatment (1150 g) and half to a high-intensity treatment (2300 g). Pain was rated at 30 and 60 sec., and Ss were asked to endure it as long as possible up to 5 min. The major findings were as follows: (1) women outscored men on reactivity; (2) the three pain measures intercorrelated highly; (3) high-intensity stimulation produced higher pain ratings and shorter tolerance than did low-intensity stimulation; (4) men gave lower intensity ratings than women and tolerated the pain longer; (5) reactivity related positively to judged pain at 30 and 60 sec, and negatively to pain tolerance; (6) there were no significant interaction effects among stimulus intensity, sex and reactivity for any pain measure; (7) the variance in the pain measures accounted for by stimulus intensity, sex and reactivity ranged from 26 to 32%. The implications were briefly discussed for the validity of the RS and factors explaining responses to experimentally-induced pain.     

Understanding and Treating Pain in Ethnically Diverse Patients

A revolution has taken place during the past 25 years in the understanding and treatment of chronic pain. Psychologists have contributed tremendously to this revolution. However, the primary psychological models of pain treatment have failed to adequately integrate the empirical findings and theoretical understanding of the role of ethnic factors. The goal of this paper is to address this problem by demonstrating the importance of understanding ethnic factors in treating pain, providing an overview of ethnic factors in pain, and proposing guidelines for Clinical Psychologists who treat pain patients from ethnically diverse backgrounds.     

Metaphysics of Pain; Semantics of ‘Pain’

Functionalism is often used to identify mental states with physical states. A particularly powerful case is Lewis's analytical functionalism. Kripke's view seriously challenges any such identification. The dispute between Kripke and Lewis's views boils down to whether the term ‘pain’ is rigid or nonrigid. It is a strong intuition of ours that if it feels like pain it is pain, and vice versa, so that ‘pain’ should designate, with respect to every possible world, all and only states felt as pain. Hence, in order to settle the dispute, we need to check which of the two – Kripke's use of ‘pain’ as rigid, or Lewis's use of ‘pain’ as nonrigid – better meets this intuition. I show that, despite crucial differences in both their semantic and metaphysical assumptions, surprisingly, both views meet this intuition equally well. Thus it appears that this question of rigidity cannot, in principle, be solved, and so, at least with respect to this particular dispute, the jury is still out on whether mental states are identical to physical states. 1     

The ends of medicine and the crisis of chronic pain

Pellegrino and Thomasma have proposed a normative medical ethics founded on a conception of the end of medicine detached from any broader notion of the telos of human life. In this essay, I question whether such a narrow teleological account of medicine can be sustained, taking as a starting point Pellegrino and Thomasma’s own contention that the end of medicine projects itself onto the intermediate acts that aim at that end. In order to show how the final end of human life similarly alters intermediate ends, such as the end of medicine, I describe Thomas Aquinas’s concept of pain and explain how his remedies for pain derive from his account of the telos of human life. In turn, this account has implications for the way in which physicians who accept such a telos would manage their patients’ pain. If a comprehensive telos for human life is necessary to make sense of even such a routine aspect of medical care, then medical ethicists may not be able to sidestep questions about the good life for human beings.