Motivating Chronic Pain Patients for Behavioral Change

Akiko Okifuji

Emily Hagn

Christina Elise Bokat

Dennis C. Turk

Motivation is a primary determinant of human behavior, influencing its initiation, direction, intensity, and persistence.¹ Historically, motivation has not been a central issue in health care as the modal approach to treat illness was believed to require very little active participation from patients beyond complying with advice. However, as our appreciation of the growing number of chronic diseases for which there are no cures, the importance of helping patients become active in a treatment has been increasingly noted. Patients have described the importance of motivation and accountability, particularly when they become discouraged or have difficulty with treatment adherence.²^,³ This realization has led to motivation and motivation enhancement being given greater attention. Self-management approaches for managing health have gained in importance as potential methods to increase motivation for self-management and to facilitate long-term health-relevant behaviors. There is a large volume of literature indicating that even relatively simple behaviors, such as taking medication in the prescribed manner, can be problematic. Studies have reported that depending on how it is defined and measured, the rates of nonadherence to medication in adults range anywhere from 8% to 62%.⁴^,⁵ In general, one-third of patients can be expected to be nonadherent.⁶ Treatment nonadherence is also a significant behavioral health problem and public health concern in pediatric populations. Approximately 50% of children⁷ and 65% to 90% of adolescents⁸^,⁹ are nonadherent across pediatric conditions.

For patients with chronic pain, rehabilitation rather than complete cure is most realistic. One of the critical requirements for successful rehabilitation is that patients adopt an active, participatory role in their treatments, coping with symptoms and life changes, and adjustment to their circumstances. Literature consistently acknowledges that multidisciplinary pain care, which includes an activating therapy, is helpful for restoring functioning and improving quality of life, without complete elimination of pain.¹⁰ However, such a treatment requires patients to make significant lifestyle changes including the incorporation of various functional activities in their daily routines. Maintaining these changes over long periods of time is often difficult even for healthy individuals. For example, two-thirds of those who sign up with gyms never use the facility,¹¹ and 50% drop out of physical activity programs within the first 6 months.¹² Thus, it is hardly surprising that patients with chronic pain find it difficult to adhere to regular physical activity regimens, use of coping skills, engaging in problem solving, and modifying communication patterns with family, friends, and coworkers as well as health care providers. In the one study that directly examined the issue of adherence to pain rehabilitation recommendations, Lutz et al.¹³ followed patients 8 months after they had been successfully treated at pain rehabilitation and found that, based on self-report, the rates of adherence with each of the specifically recommended behaviors (e.g., progressive ambulation and stretching exercises, regular application of ice and heat, relaxation) averaged about 42% and with all of the recommendations proscribed by the treatment program was only 12.2%.

Another dilemma for successful implementation of activating therapy is that it can be contrary to the very nature of pain where the motivational drive is to avoid or escape from any activities that might increase pain. Furthermore, most people including many health care providers have learned “if something hurts, don’t do it.” This approach may be appropriate for acute pain care where may pain serve a protective role. However, for chronic pain, equating hurt with harm often becomes a barrier for successful rehabilitation and even increases disability following loss of mobility, strength, and endurance from inactivity. Thus, clinicians are frequently faced with the challenge of how to motivate patients to actively engage in the treatment recommendations that may seem counter to patients’ acquired beliefs. Long-term treatment success, in particular, depends on regular adherence to recommended self-care regimens,⁶^,¹⁴^,¹⁵ although how close to the recommendations is an open question.¹⁶^,¹⁷ Historically, clinicians have invested less energy in patients who show little commitment to follow through with recommended therapies. “You can lead a horse to water, but you can’t make it drink” was a typical way of conceptualizing the issue.¹⁸ However, as noted earlier, motivation to commit to the treatment plan and adherence with regimen are essential in successful pain rehabilitation (pharmacologic as well as rehabilitative).¹⁷ Thus, motivating patients for behavioral change is essential and a critical clinical issue in successful pain management. In this chapter, we review the two approaches to optimize motivation and engagement of patients: motivation enhancement therapy (MET) and implementation intentions (IIs).

Neural Mechanisms of Motivation

Neural mechanisms of motivation are complex, involving multiple brain systems.¹⁹ Although motivation is a critical component of recovery from chronic pain, how specific neural factors underlie the motivational factors relevant to people with chronic pain is not well understood. However, we may consider how chronic pain itself as well as comorbid dysfunctions could contribute to the motivational state of chronic pain patients to adhere to specific recommendations.

Chronic pain commonly outlives peripheral tissue injury or actual neural damage; yet, long-lasting changes in the modulations of pain due to neural plasticity and central sensitization have been well documented in various chronic pain conditions.²⁰^,²¹ Neuroimaging studies in humans have demonstrated alterations in the reward, motivational, emotional, and cognitive brain centers that may play a role in establishing and/or maintaining chronic pain.²²^,²³^,²⁴ In addition, it has been hypothesized that some chronic pain syndromes may be maintained by dysregulation of homeostatic reward processes similar to those described in addiction neurobiology.²⁵ Addiction and chronic pain disorders may share central reward deficiency and motivational maladaptation patterns secondary to hypodopaminergic states in the nucleus accumbens core (NAc) and medial prefrontal cortex (mPFC) and alterations in endogenous pain transmission pathways.²⁶^,²⁷^,²⁸ Furthermore, a study in mice by Schwartz et al.²⁹ suggests that chronic pain
induces synaptic changes within the NAc, which plays a central role in the neural circuitry that modulates motivation.²⁹^,³⁰ Such pain-induced synaptic changes can have a negative impact on patients’ motivation,²⁹^,³¹^,³² which in turn could lead to difficulty in adhering to a treatment plan for their chronic pain.

In addition to the painful symptoms, individuals who have chronic pain often experience a multitude of quality of life-altering symptoms such as anxiety, depression, fatigue, sleep disturbance, elevated stress levels, activity reduction, and cognitive deficits.³¹^,³²^,³³^,³⁴ Such comorbidities can further decrease motivation to initiate and complete goal-directed and higher order mental and physical tasks.²⁹ Thus, individuals can experience a twofold impairment of motivation secondary to both chronic pain itself and its comorbidities.

Concept of Readiness to Change: Transtheoretical Model of Behavior Change

The transtheoretical model of behavior change was developed in an attempt to understand motivation to adhere to health care regimens. The model offers an integrative framework describing the process of behavior change.³⁵ It was originally developed to understand how people change their addictive behaviors. The model, however, has been extended to many medical problems including chronic pain.³⁶ The basic assumptions underlying the model are the notions that people differ in their readiness and willingness to take on behavioral change and that there are certain processes of changes that facilitate the advancement of one’s readiness. The model is organized around a major construct: stages of change.

According to the model, patients attempting to change health-related behavior move from one stage to another, often in a cyclic fashion (Fig. 88.1; description of each stage is in Table 88.1), although the movement through these stages is not necessarily linear or unidirectional. Some behaviors are easier to change than others; it is reasonable to assume that several attempts may be necessary to achieve significant behavioral change. A good example of the nonlinear change of stages may occur in smoking cessation where average smokers take seven to eight attempts to quit before succeeding.³⁷ The description of each stage as well as typical patient behavior seen at each stage point is listed in Table 88.1.

The model has been adapted to chronic pain. Kerns and colleagues³⁶ developed a self-report inventory “Pain Stages of Change Questionnaire” to assess the level of readiness to adopt self-management approach in chronic pain patients. Research has found the significant association between the stages of change and coping as well as disability of chronic pain patients.³⁸ Furthermore, improvement of the stages corresponds with better outcomes of pain rehabilitation.³⁹

FIGURE 88.1 Stages of changes.

TABLE 88.1 Stages of Change

Stages	Descriptions	Patients’ Behaviors
Precontemplation	Patient does not perceive a need to change and actively resists change.	Unwilling to discuss “Who? Me?”
Contemplation	Patient begins to see a need for change and may consider making a change in the future.	Somewhat ambivalent or fearful of change “Yes, but …”
Preparation	Patient feels ready to change and takes a first concrete (behavioral) change.	Sees more pros for change than cons “I’ll start this on Sunday!”
Action	Patient actively engages in behaviors consistent with regimen.	Feels more confident
Maintenance	Patient executes plans to sustain the changes made.	Feels comfortable with the change Identifies self as the changed entity
Relapse	Some patients fail to sustain the effort.	Variable

There are three critical parameters of the model that determines the likelihood of advancing one’s readiness.

Processes of change are one of the dimensions of the transtheoretical model that enables understanding of how shifts in behavior may be achieved. Change processes involve both covert and overt activities and experiences that patients engage in when they attempt to change their behavioral patterns. Each process is a broad category, and an eclectic collection of techniques, methods, and interventions can be recommended to facilitate the change process. Ten processes are cluster into two groups: the cognitive-experiential cluster of processes and the behavioral processes (Table 88.2). As can be seen (right-hand column of Table 88.2), there are various strategies that come from the disparate theoretical orientations to target each process.
Self-efficacy is defined as personal confidence in one’s ability to change problematic situations.⁴⁰ If people think that there is no way that they can perform the prescribed activities, it is highly unlikely that they will initiate or persist in the desired behaviors and that the treatment will be successful.
Decisional balance is defined as a personal “balance sheet” of gains (benefits) and losses (costs) for changing and not changing their behaviors.⁴¹ People are likely to advance their change stages when they (1) perceive themselves to have adequate skills to cope, (2) feel confident
in executing those skills (i.e., high efficacy belief), and (3) perceive more gains of changing and losses of not changing than more losses of changing and gains of not changing (decisional balance). We discuss the decisional balance process later in this chapter as a part of reviewing some motivational enhancement techniques.

TABLE 88.2 Processes of Change

Processes	Definition	Therapeutic Strategies That May Help Targeting the Process
*Experiential Processes*
Consciousness raising	Increasing information about self and problem	Observations, confrontations, interpretations, bibliotherapy
Self-reevaluation	Assessing how one feels and thinks about oneself with respect to a problem	Value clarification, imagery, corrective emotional experience
Dramatic relief	Experiencing and expressing feelings about one’s problem and solutions	Role playing, psychodrama, grieving losses
Environmental reevaluation	Assessing how one’s problems affect the physical environment	Empathy training, documentaries
Social liberation	Increasing alternatives for nonproblem behaviors available in society	Advocating for rights of repressed, empowering, policy interventions
*Behavioral Processes*
Counterconditioning	Substituting alternatives for problem and anxiety related behaviors	Relaxation, desensitization, assertion, positive self-statements
Helping relationships	Being open and trusting about problems with someone who cares	Therapeutic alliance, social support, self-help groups
Reinforcement management	Rewarding oneself or being rewarded by others for making changes	Contingency contracts, overt and covert reinforcement, self-reward
Stimulus control	Avoiding stimuli that elicit problem behaviors	Adding stimuli that encourage alternative behaviors, restructuring one’s environment, avoiding high-risk cues, fading techniques
Self-liberation	Choosing and committing to act or believe in ability to change	Decision-making therapy, resolution

Some of the behavioral strategies such as counterconditioning and stimulus control are generally a major part of the rehabilitation for chronic pain. The cognitive-behavioral self-management skill training that is typically a part of the pain rehabilitation also improves self-efficacy⁴²; however, baseline levels of self-efficacy vary across patients, and there is a linear relationship between the baseline level of self-efficacy and posttreatment level of self-efficacy and subsequent treatment benefit self-management skill training.⁴³ Strategies targeting experiential processes are recommended as the primary approach to help people with low level of treatment readiness and self-efficacy.⁴⁴ Thus, using the concept of the change process seems a promising way to optimize the clinical outcomes of pain rehabilitation.

MOTIVATION ENHANCEMENT THERAPY

MET, developed by Miller,⁴⁵ is one of the therapeutic methods to target motivation and patient engagement with therapy. This approach is based on the transtheoretical model that people vary in their readiness to adhere to treatment regimen and provides a problem-focused, patient-centered, cliniciandirected approach with the aim of helping patients move through the stages-of-change readiness. Although some of the techniques and approaches overlap with those of cognitivebehavioral therapy (CBT), one of the most prevalent behavioral medicine approaches in treating chronic pain patients, the two therapy approaches have some distinct characteristics. The nature of the therapy course is no doubt variable depending on the personal styles of the clinicians, and there is a danger of oversimplification of complex therapy modalities; however, for the sake of comparison and contrast, we summarize the characteristics of MET as compared to CBT in Table 88.3.

MET is nonconfrontational and patient-centered, exploring and reaching resolution of ambivalence toward behavior change. A MET clinician helps patients explore their inner phenomenology that is explored without judgment or criticism. In order to facilitate this process, MET encourages a clinician to exercise empathetic listening and to ask open-ended questions.

Asking open-ended questions helps the clinician to better understand the individualized phenomenology of the patient regarding the problem that is the target of behavior change in a nonthreatening manner. It also aids the patient to achieve a clearer view on the issue. Asking open-ended questions, however, is not time-efficient; asking questions that can be responded with a short “yes” or “no” answer can save time. As you can see in the following sections describing the MET techniques, however, asking open-ended questions is vital in successful implementation of MET. Some examples of open-ended and close-ended questions are listed in Table 88.4.

The MET offers a collection of therapeutic techniques to help patients (1) clearly recognize their problems, (2) perform decisional balance work, and (3) produce self-motivational statements and internalize those motivational statements by means of improved self-efficacy. MET also provides the guidance for how to handle resistance and setbacks. In the following section, we describe the basic MET methods, including how to deal with resistance and what not to do while engaging in MET. Although MET might be a treatment within itself, it may also serve as a complement to CBT and set the stage for patients to benefit from the skills included in CBT.

TABLE 88.3 Motivation Enhancement Therapy (MET) Versus Cognitive-Behavioral Therapy (CBT) Approaches

	MET	CBT
Orientation	Patient-centered	Goal-oriented
Therapist-patient relationship	Collaborative	Top-down
Focus	Stage change	Action
Therapist’s task	More listening	More talking
Dealing with ambivalence	Explore ambivalence	Direct persuasion
Approaches to reasons for change	Elicit reasons for change	Give reasons for change