Page 108 Guide to Pain Management in Low-Resource Settings

96 Claudia Schulz-Gibbins

pain. In ancient sophisticated cultures, magical beliefs respect. Within the theoretical understanding of pain,
were connected directly to punishment as a result of in- classical conditioning according to Pavlov, based on
sulting the gods. Th e perception of pain as “punishment stimulus and reaction, builds the foundation for fur-
by God” within the framework of religious structures is ther considerations. Th e feeling of pain is primarily a
still widespread today; for example, pain patients feel reaction to a pain stimulus and thus has a response. In
“less desire to reduce pain and feel more abandoned by this regard, a primarily neutral stimulus, for example,
God” [14]. Lovering [7] investigated cultural beliefs with a rotation of the body with evidence of relevant mus-
regard to causes of pain in various cultures and reports cular malfunction, is connected to feeling an unpleas-
of references by the patients to “the evil eye” (Filipino, ant psychophysiological reaction such as increased
Saudi, and Asian cultures) or the power of the ancestors heart rate or a painful increase of tension in muscles.
(Tswana culture). Th e handling of pain is infl uenced Th e consequence is to avoid this type of rotation of
not only by the patient’s attitude toward pain, but also the body, which can make sense when the pain is felt
by the attitude of the health professional. In an explana- for the fi rst time. However, if this behavior is main-
tory model, “Patients and health professionals bring tained, an increase in the muscular malfunction leads
their own cultural attitudes to the communication and to a strengthening of the mechanism. If both stimuli
interpretation of the patient’s pain experience.” In this are often experienced together, then the body reacts to
interaction, it is the health professional’s knowledge and the original neutral stimulus. Receptiveness for a given
attitudes that dominate the response to the patient’s stimulus is determined by the individual’s life and ill-
experience of pain [7]. Th e consideration of subjective ness history. For example, stress stimuli, which are of-
assumptions with regard to the development of pain— ten accompanied by pain, can be the cause of subse-
such as belief in magical, biomedical, or biopsychosocial quent pain.
approaches to pain—make it possible to develop rel-
evant therapy concepts by incorporating the wishes and Does operant conditioning also play an
important role?
targets of patients. Understanding the personal experi-
ence narrative means understanding the outcome. Operant conditioning has been explored in the work of
B.F. Skinner in the 1930s and 1940s. In this paradigm,
Consequently, what are the functions it is hypothesized that behavior increases in frequency
of psychological assessment? if reinforced. A decrease follows if this behavior is not
Th e chief purpose of psychological assessment is to get rewarded or punished. In the late 1960s, Fordyce fi rst
a complete picture of the pain syndrome with all af- explored the principles of operant-behavioral therapy
fected dimensions: somatic, aff ective, cognitive, behav- (OBT) as a treatment for patients with chronic pain.
ioral, and above all, the individual consequences for the The operant model assumes that one’s reac-
patient. Th e complete information and the analysis of tion to pain is not determined by somatic factors but
conditions of pain maintenance enable us to fi x targets as a result of psychosocial consequences. The lon-
for treatment. For example, a patient with a diagnosis of ger pain persists, the greater the likelihood that the
back pain and avoidance behavior needs education to pain experience is primarily influenced by reactions
understand why it makes sense to minimize such behav- to the environment. Behavioral attitudes will more
ior. A patient with back pain, avoidance behavior, and than likely emerge when they are directly positively
depressive reactions needs a good explanation of the strengthened or when negative effects can be avoid-
biopsychosocial model. For example, what are the con- ed. The awareness of pain can thus be affected by
sequences of depression in the context of pain? A better positive strengthening, for example, by increased care
understanding can enable the patient to develop better and attention by third parties. A negative strengthen-
strategies of coping and minimize helplessness. ing of pain awareness can be caused by the absence of
unpleasant activities or by avoidance of conflicts as a
What are psychological models for result of expressing pain. This behavior can be sus-
explaining conditions of pain development tained even after alleviation of pain and thereby lead
and maintenance? to a renewed sustainment of the vicious cycle, for ex-
Cognitive and behavioral factors, as well as classical ample, by sustained avoidance of beneficial behavior
conditioning, are factors we have to think about in this such as activity.