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 Contributors

Rachel V. Aaron, PhD, Seattle Children’s Hospital Research Institute, Seattle, Washington
John G. Arena, PhD, Charlie Norwood VA Medical Center and Department of Psychiatry
and Health Behavior, Medical College of Georgia, Augusta University, Augusta, Georgia
Benjamin H. Balderson, PhD, Kaiser Permanente Washington Health
Research Institute, Seattle, Washington
Pat M. Beaupre, PhD, private practice, Redlands, California
Sophie Bergeron, PhD, Department of Psychology, University of Montreal, Montreal,
Quebec, Canada
Dawn C. Buse, PhD, Department of Neurology, Montefiore Medical Center, Bronx, New York
Annmarie Cano, PhD, Department of Psychology, Wayne State University, Detroit, Michigan
Leanne R. Cianfrini, PhD, The Doleys Clinic, Birmingham, Alabama
Howard Cohen, MD, Progressive Pain and Psychiatry Clinic, Dallas, Texas
Serena Corsini‑Munt, PhD, Department of Psychology and Neuroscience, University of Halifax,
Halifax, Nova Scotia, Canada
Beth D. Darnall, PhD, Department of Anesthesiology, Perioperative and Pain Medicine,
Stanford University School of Medicine, Palo Alto, California
Jeroen de Jong, PhD, Department of Rehabilitation, Maastricht University Medical Centre,
Maastricht, The Netherlands
Marlies den Hollander, MSc, Department of Rehabilitation, Maastricht University
Medical Centre, Maastricht, The Netherlands
Jeffrey Dersh, PhD, South Texas Veterans Health Care System, San Antonio, Texas
Daniel M. Doleys, PhD, The Doleys Clinic, Birmingham, Alabama

vii
viii Contributors

Angela Liegey Dougall, PhD, Department of Psychology, University of Texas at Arlington,

Arlington, Texas
Christopher Eccleston, PhD, Department for Health, University of Bath, Bath, United Kingdom;
Department of Clinical and Health Psychology, Ghent University, Ghent, Belgium
Emma Fisher, PhD, Seattle Children’s Hospital Research Institute, Seattle, Washington
Noor M. Gajraj, MD, North Texas Center for Pain Management, Plano, Texas
Robert J. Gatchel, PhD, ABPP, Department of Psychology, University of Texas at Arlington,
Arlington, Texas
Thomas Hadjistavropoulos, PhD, ABPP, Department of Psychology and Centre on Aging
and Health, University of Regina, Regina, Saskatchewan, Canada
Ryan Hulla, BA, BS, Department of Psychology, University of Texas at Arlington, Arlington, Texas
Mark A. Ilgen, PhD, VA Center for Clinical Management Research, VA Ann Arbor
Healthcare System, and Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
Mark P. Jensen, PhD, Department of Rehabilitation Medicine, University of Washington,
Seattle, Washington
Francis J. Keefe, PhD, Department of Psychiatry and Behavioral Sciences, Duke University,
Durham, North Carolina
Sarah A. Kelleher, PhD, Department of Psychiatry and Behavioral Sciences, Duke University,
Durham, North Carolina
Edmund Keogh, PhD, Department for Health, University of Bath, Bath, United Kingdom
Robert D. Kerns, PhD, Departments of Psychiatry, Neurology, and Psychology,
Yale University, New Haven, Connecticut; Pain Research, Informatics, Multimorbidities,
and Education (PRIME) Center, VA Connecticut Healthcare System, West Haven, Connecticut
Nancy Kishino, OTR/L, West Coast Spine Rehabilitation Center, Riverside, California
Alexander J. Kuka, MA, Department of Psychology, University of Mississippi, Oxford, Mississippi
Steven James Linton, PhD, Center for Health and Medical Psychology, Örebro University,
Örebro, Sweden
Travis I. Lovejoy, PhD, MPH, Center to Improve Veteran Involvement in Care,
VA Portland Health Care System, and Department of Psychiatry, Oregon Health & Science University,
Portland, Oregon
Cindy McGeary, PhD, ABPP, Department of Psychiatry, University of Texas Health Science Center,
San Antonio, Texas
Don McGeary, PhD, ABPP, Department of Psychiatry, University of Texas Health Science Center,
San Antonio, Texas
Lindsey C. McKernan, PhD, Department of Psychiatry and Behavioral Sciences,
Vanderbilt University Medical Center, Nashville, Tennessee
Elena S. Monarch, PhD, Lyme and PANS Treatment Center, Cohasset, Massachusetts
Benjamin J. Morasco, PhD, Center to Improve Veteran Involvement in Care,
VA Portland Health Care System, and Department of Psychiatry, Oregon Health & Science University,
Portland, Oregon
Stephen Morley, PhD (deceased), Leeds Institute of Health Sciences, University of Leeds,
Leeds, United Kingdom
 Contributors ix

Paul Nabity, PhD, Department of Psychiatry, University of Texas Health Science Center,
San Antonio, Texas
Michael R. Nash, PhD, ABPP, Department of Psychology, University of Tennessee,
Knoxville, Tennessee
Diane Novy, PhD, Department of Pain Medicine, University of Texas MD Anderson Cancer Center,
Houston, Texas
John D. Otis, PhD, Department of Psychiatry, Boston University School of Medicine,
Boston, Massachusetts
Tonya M. Palermo, PhD, Seattle Children’s Hospital Research Institute, Seattle, Washington
David R. Patterson, PhD, ABPP, Department of Rehabilitation Medicine, University of Washington,
Seattle, Washington
Donald B. Penzien, PhD, Departments of Anesthesiology, Neurology, and Psychiatry,
Wake Forest School of Medicine, Winston‑Salem, North Carolina
Peter B. Polatin, MD, private practice, Dallas, Texas
Sheri D. Pruitt, PhD, private practice, Sacramento, California
Chelsea Ratcliff, PhD, Department of Psychology and Philosophy, Sam Houston State University,
Huntsville, Texas
Christopher T. Ray, PhD, College of Nursing and Health Innovations, University of Texas
at Arlington, Arlington, Texas
Natalie O. Rosen, PhD, Department of Psychology and Neuroscience, Dalhousie University,
Halifax, Nova Scotia, Canada
Meredith E. Rumble, PhD, Department of Psychiatry and Psychology,
University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
Eric Salas, MA, Department of Psychology, University of Texas at Arlington, Arlington, Texas
Steven H. Sanders, PhD, Chronic Headache Management Program, James A. Haley VA Hospital,
Tampa, Florida
Laura Simons, PhD, Department of Anesthesiology, Perioperative, and Pain Medicine,
Stanford University School of Medicine, Palo Alto, California
Todd A. Smitherman, PhD, Departments of Anesthesiology, Neurology, and Psychiatry,
University of Mississippi, Oxford, Mississippi
Michele Sterling, PhD, Recovery Injury Research Centre, University of Queensland,
Herston, Australia
Anna Wright Stowell, PhD, private practice, Dallas, Texas
John A. Sturgeon, PhD, Department of Anesthesiology and Pain Medicine, University
of Washington, Seattle, Washington
Abby Tabor, PhD, Department for Health, University of Bath, Bath, United Kingdom
James D. Tankersley, MS, Charlie Norwood VA Medical Center, Augusta, Georgia
Hallie Tankha, MEd, Department of Psychology, Wayne State University, Detroit, Michigan
Dennis C. Turk, PhD, Department of Anesthesiology and Pain Medicine,
University of Washington School of Medicine, Seattle, Washington
Alyssa N. Van Denburg, MA, Department of Psychology and Neuroscience, Duke University,
Durham, North Carolina
x Contributors

Miranda A. L. van Tilburg, PhD, Department of Medicine, Division of Gastroenterology

and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Johan W. S. Vlaeyen, PhD, Department of Health Psychology, KU Leuven University,
Leuven, Belgium
Michael Von Korff, ScD, Kaiser Permanente Washington Health Research Institute,
Seattle, Washington
Lynette Watts, BS, Department of Psychology, University of Texas at Arlington, Arlington, Texas
William E. Whitehead, PhD, Center for Functional Gastroenterological and Motility Disorders,
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Amanda C. de C. Williams, PhD, Research Department of Clinical, Educational
and Health Psychology, University College London, London, United Kingdom
Laurie D. Wolf, PhD, Orlando VA Medical Center, Orlando, Florida
 Preface
Advances in Psychosocial Approaches
to Treating Patients with Chronic Pain

In the Preface to the first two editions of this volume, we observed that attempts to
treat individuals experiencing persistent pain were closely aligned with how pain was
conceptualized and evaluated. Traditionally, the focus in health care has been on the
cause of the symptoms reported, with the assumption that there is a physical basis for
each of these and, once identified, the source can be eliminated or blocked by medical,
surgical, or other physical interventions (e.g., physical therapy exercises, transcuta-
neous electric nerve stimulation [TENS], and ultrasound). Consequently, assessment
was focused on identifying the physical mechanisms—the “putative cause(s)”—for the
symptoms. In the absence of specific physical pathology to validate the patient’s self-
report, psychological causation is invoked as an explanation; hence the terms “psycho-
genic,” “psychosomatic,” “secondary gain” (i.e., symptom reports that are assumed
to be consciously or nonconsciously motivated to achieve desired outcomes—such as
attention, disability compensation, to obtain positively reinforcing drugs). In the case
of many of the most prevalent chronic pain conditions (e.g., chronic low back pain,
fibromyalgia, headache, whiplash-associated disorders), there is frequently no, or very
limited, objective evidence substantiating the report of pain and its severity. Hence,
the traditional view of persistent pain complaints has been characterized by a simple
dichotomy: The pain report is either somatogenic or psychogenic.
The dichotomous view of pain has been shown in numerous studies to be in-
complete, inadequate, and, in some situations, simply wrong. There is no question
that physical perturbations contribute to symptoms of pain; nor is there any reason-
able argument that psychological factors do not play a part in the symptom reporting.
Moreover, research has convincingly demonstrated that socioeconomic, familial, and
contextual variables play important roles in patients’ acceptance of recommendations
and response to the treatments prescribed, the development of symptom chronicity,
and the maintenance of disability. The balance among physical, psychosocial, and
xi
xii Preface

contextual contributors may vary across individuals, as well as over time within the
same individual. The limitations of the traditional biomedical model may explain why,
despite advances in knowledge and understanding of the neurophysiological mecha-
nisms involved with nociception and pain, there are still no treatments available that
consistently and permanently alleviate pain for all those afflicted (Turk, Wilson, &
Cahana, 2011).
Predictors of chronicity continue to be a major focus of research, and evidence
has consistently revealed that psychosocial variables are better predictors of disability
and response to treatment than physical ones (e.g., Benyon, Hill, Zadurian, & Mallen,
2010; Carragee, Allamin, Miller, & Carragee, 2005; Jarvik et al., 2005). Identifica-
tion of psychosocial predictors holds promise for prevention and early intervention
in order to prevent chronicity and disability. Comprehensive psychosocial assessment
has become accepted as essential prior to surgery and implementation of spinal cord
stimulators and implantable drug-delivery systems.
Exciting developments that have appeared in the literature demonstrate the di-
rect effects of psychological variables on physiological parameters associated with
pain (e.g., Baranto, Hellstrom, Cederlund, Nyman, & Sward, 2009; Jensen et al., 2012;
Kucyi et al., 2014). Psychosocial factors are no longer secondary phenomena; they play
a mechanistic role in the anatomy and physiology of pain. Moreover, the role of psy-
chosocial factors in predicting pain onset, remission, and disability (e.g., Carragee et
al., 2005; Jarvik et al., 2005; Severeijns, Vlaeyen, Kester, & Knottnerus, 2001), and re-
sponse to treatment (e.g., Benyon et al., 2010; Smeets, Vlaeyen, Kester, & Knottnerus,
2006; Thomee et al., 2008), along with concerns about medication coupled with in-
creasing evidence to support the positive outcomes reported for many psychological
interventions (e.g., Eccleston, Palermo, Williams, Lewandowski, & Morley, 2009;
Henschke et al., 2010; Hoffman, Papas, Chatkoff, & Kerns, 2007; Williams, Eccleston,
& Morley, 2012), all support the importance and timeliness of this current volume.
The results of these research studies have contributed to the growing number of calls
for the use of nonpharmacological treatments as alternatives, if not adjuncts, to drugs
(e.g., Buckhardt et al., 2005; Chou et al., 2007; Institute of Medicine, 2011).
More cost-effective and not just clinically effective interventions are being driven
by changes in health care, with concerns about cost containment. The emphasis in
all treatments is on “streamlining” and efficiency, with cost being a critical driver
and outcome consideration. Greater attention is being devoted to the development and
evaluation of advanced technologies (e.g., Web-based, smartphone-delivered applica-
tions), not only to be efficient and to reduce costs, but also potentially to increase
access and to enhance adherence to treatment recommendations and maintenance of
benefits.
Despite the advances noted here and throughout this volume, the traditional medi-
cal model has not, in general, relinquished its firm grasp on the thinking of medical
providers, the health care system, and payers. We would be remiss if we did not ac-
knowledge what we have labeled the “evidence-based paradox.” Despite the growing
calls for evidence, even though there is more clinical and cost evidence for the effec-
tiveness of psychological treatments, relative to any of the alternatives (e.g., Gatchel
& Okifuji, 2006; Hoffman et al., 2007; McCracken & Turk, 2002; Turk & Theodore,
2011), health care providers tend to be resistant to considering psychosocial interven-
 Preface xiii

tions, and payers demonstrate a significant lack of willingness to cover these treat-
ments. We believe this is likely to change given the concerns about the inadequacy, if
not outright pernicious effects, of more traditional medical treatments. Mental health
providers need to keep abreast of the growing literature and to use it as supporting evi-
dence for the services they offer. It will be incumbent on them to demonstrate that they
follow the guidelines described throughout this volume as to the standards of care, and
also cite evidence for the clinical effectiveness and cost-effectiveness of the treatments
they provide, because payers may not be familiar with such evidence.
The state of pain management has not changed significantly in the 15 years since
the publication of the previous edition of this volume. Concerns about misuse and
abuse of medications, however, are leading to a call for better assessment to predict
misuse, and for alternatives to drugs with abuse potential. Also, psychosocial treat-
ments are gaining renewed and growing interest as more than just adjuncts of phar-
macological interventions. Even when medications are indicated, the interrelationship
between somatic and psychosocial factors supports more integrated approaches to
treatment. Indeed, although individuals with diverse chronic pain syndromes have
much in common, there are unique characteristics that require attention specific to the
problem associated with the disease or condition. For example, patients with occupa-
tional injuries have concerns about their ability to return to work; those with amputa-
tions must deal with particular limitations associated with the physical impairments
posed by limb loss; individuals with chronic pelvic pain must deal with problems
associated with sexuality and sexual function; individuals with cancer have to cope
with fears of dying, disfigurement, and dependence; and people who have sustained
injuries in automobile collisions must face their fears of driving, reinjury, and legal
ramifications, all in addition to problems created by the presence of persistent pain.
Thus, despite the fact that the psychosocial treatments described have been used for
some time now, they need to be customized to the unique patient populations and, as
always, to each unique patient.
We have presented many workshops and have given numerous lectures describ-
ing psychological approaches to pain management. We have also received many com-
ments on the two previous editions of this volume. What we have learned is that most
providers are interested in going beyond overviews and academic discussions of the-
ory and general principles. They seek specific and practical strategies and methods
as to how to address their specific patients, and the common problems they confront
in treating the patients in their practices. Whereas some spend the majority of their
time providing services to pain patients, others are increasingly receiving referrals
of patients who have diverse chronic pain disorders, especially given the growing
concerns about medication misuse and abuse by those patients. These providers raise
questions about how to motivate patients; how to most effectively and efficiently
evaluate these patients; how to select the most appropriate treatment options among
the variety of available psychosocial treatment approaches; when and how to involve
their patients’ significant others; what are successful strategies to increase adherence
to treatment recommendations; how to design appropriate homework assignments;
how best to address problems of relapse and flare-ups; and what are good strategies
regarding follow-up; among many others. Essentially, they are seeking not only what
to do but also how to do it. Thus, in planning this edition, as well as the previous
xiv Preface

editions, we had had two driving considerations: (1) to bring together experts and
masterful clinicians who have direct clinical experience with the most common and
difficult chronic pain diagnoses; and (2) to instruct all contributors about the need
to provide specific and practical information and guidance to practitioners who will
be treating patients with these various conditions, regardless of these practitioners’
levels of experience.
In order to facilitate the second consideration and to provide unique value to
readers of this edition, we requested that contributors include in each chapter a text
box that presents practical “Clinical Highlights” of the material covered in a succinct
fashion. Specifically, these boxes address what a provider should keep in mind when
treating patients with the diagnosis covered in the chapter, and when applying any of
the psychosocial treatments described. We directed authors to write these “Clinical
Highlights” boxes to provide a quick review for practitioners, assuming that the chap-
ter may have been read some time prior to actually treating their patients. We hope this
addition will prove to be a particular benefit to readers, and we welcome your com-
ments to improve our future efforts.
Since the publication of the second edition of this volume, there have been as-
tronomical advances in many important areas, such as better understanding of the
genetics and neurophysiology of pain and the experience of living with persistent pain;
the roles and nature of a range of psychosocial, behavioral, and contextual factors in
the onset, maintenance, and exacerbation of pain; responses to, and acceptance of,
treatment; adherence to treatment recommendations; and retention of benefits of treat-
ment over time. Moreover, there is mounting evidence of the clinical effectiveness and
cost-effectiveness of various nonpharmacological treatments as monotherapies and
when combined with more traditional medical interventions. Inertia continues to be
a constraint, and significant challenges remain despite the advances to which we al-
lude here. Few patients are “cured” by the available treatments, and the majority of
patients, regardless of the treatment sophistication, continue to experience some level
of pain and related symptoms with which they will have to learn to live, and to better
“manage.” Thus, we need to move away from an overly simplistic “curative” model of
treatment, toward a more realistic “management” model. This requires courage, self-
control, and a considerable degree of resilience. Psychological approaches may help in
this process of working with patients to enhance their ability to better manage their
lives as effectively as possible, despite the residual symptoms. We focus in this volume
on how to help patients achieve such management outcomes.
Health care is evolving at a dizzying pace. There is greater and greater reliance on
empirically based outcomes that focus not only on cost but also on patient satisfaction
and efficiency, as well as clinical effectiveness. As a consequence, it is no longer pos-
sible to justify treatment based solely on beliefs and assertions. The plural of anecdote
is not accepted as data or evidence anymore. We hope the information presented in this
volume may serve as “antidotes” to these limited and non-data-based anecdotes. But,
as noted earlier, even evidence may not be sufficient without taking into consideration
cost and availability of providers of treatments with demonstrated efficacy.
We have attempted to cover the topics outlined in this edition, with an emphasis
on innovations, expanded knowledge, and opportunities created, all with an eye to-
ward practical clinical utility and efficiency. In an effort to balance “what to do” and
 Preface xv

“how to do it” of various treatment approaches with different painful conditions, and
the need for a rational conceptual basis and demonstrated evidentiary base, we have
organized the volume into three sections.
Part I, Conceptual, Diagnostic, and Methodological Issues (Chapters 1–3), sets
the foundation for the various treatment approaches described. Chapter 1 presents an
integrated biopsychosocial perspective that is critical to understanding chronic pain,
individuals experiencing pain, and the impact of pain, regardless of the specific condi-
tion or treatment. The second chapter establishes the interrelationship among psycho-
logical disorders and chronic pain, considering the causal connections between physi-
cal and mental health. Chapter 3 provides important insights into outcomes research
and offers suggestions for how to conduct, critically evaluate, and interpret published
reports of treatment outcome studies and communicate these results to policy and
payer decision makers.
Part II, Treatment Approaches and Methods (Chapters 4–14), focuses on impor-
tant topics and models that transcend specific pain conditions. There is no question
that patient motivation is essential, regardless of the treatment approach adopted.
Chapter 4 describes a model for facilitating patient motivation. Chapters 5 and 6 de-
scribe the rationale and detailed methods of two of the most common psychologi-
cal perspectives and approaches, namely, behavioral (e.g., operant conditioning) and
cognitive-­behavioral, to treating individuals with chronic pain. Chapters 7–9 describe
several specific psychological techniques—biofeedback, hypnosis, exposure-based
desensitization—that can be adapted for use in patients with any number of different
pain conditions described in Part III. Chapters 10 and 11 address particular modes of
treatment delivery—­group and family involvement. There are unique benefits to treat-
ing patients in groups, both in terms of efficiency and the power of group dynamics.
But there are logistical trade-offs that need to be overcome in organizing groups. Indi-
viduals with chronic pain, like most people, do not live in isolation but in a social con-
text. Moreover, the vast majority of chronic pain patients—by definition, people with
conditions that extend over long periods of time—will continue to experience pain
long after the conclusion of formal treatment. Consequently, significant others play
important roles in maintaining the benefits derived during treatment, and in generaliz-
ing the positive outcomes beyond the clinical setting. Involvement of significant others
can enhance long-term maintenance; however, one cannot forget that significant oth-
ers can also be potential impediments and undermine treatment. Thus, it is important
to educate them about their potential impact. Greater attention is being given to the
additive, if not synergistic, potential of such combinations. Chapter 12, a new chapter
in this volume, addresses a concept that has been neglected but has aroused growing
interest, “resilience”—an individual’s ability to function and even thrive despite the
presence of circumstances (i.e., chronic pain) that unquestionably create significant
problems in all domains of life (physical, emotional, behavioral, and social). Facilita-
tion and enhancement of a patient’s sense of resilience can result from psychosocial
treatments that, in general, can transcend any specific modality. Recently, two particu-
lar treatment approaches have centered on the concept of resilience—mindfulness-
based stress reduction (MBSR) and acceptance and commitment therapy (ACT). Both
of these approaches, variants of cognitive-behavioral therapy (CBT), are described in
this new chapter. There is growing evidence that monotherapies, whether pharmaco-
xvi Preface

logical, interventional, or psychological, do not eliminate the problem of pain for many
patients and that combinations of treatment with different emphases may be necessary.
Chapter 13 describes an approach to integrating pharmacological and psychological
treatment.
As noted previously, there are rapid technological developments in forms of com-
munication with the advent of the Internet and smartphones. These technologies are
providing tremendous clinical opportunities, and they will unquestionably escalate in
the coming years. Closing out this section, another new chapter in this edition, Chapter
14, describes some of the advances made possible by technologies in treating patients
directly, facilitating adherence, and enhancing maintenance.
Part III, Specific Pain Conditions and Populations (Chapters 15–30), covers sec-
ondary assessment, prevention, and treatment of populations at the extremes of the
lifespan (i.e., children and the growing number of elderly adults), and with many of
the most common pain syndromes and comorbidities. Awareness of, and methods to
address, the complexities involved in treating the diversity of chronic patients are cov-
ered in depth throughout Part III. The authors of the chapters provide insights and
make suggestions to increase the likelihood of achieving the best outcomes with these
unique groups.
There is growing evidence demonstrating the importance of patient selection
when implementing interventional modalities (i.e., surgery, spinal cord stimulators,
implantable drug delivery systems). Chapter 15 describes the expanding role that men-
tal health professionals may play, and the methods they may use in assessing chronic
pain patients for whom these interventions are being considered. Chapters 16–26 pro-
vide detailed discussion and case examples describing the treatment of patients with
specific and prevalent chronic pain syndromes (i.e., back pain, headaches, fibromyal-
gia, whiplash-associated disorders, temporomanidbular disorders, pelvic pain, func-
tional gastrointestinal disorders, cancer, and unexplained somatic symptoms). As we
noted earlier, there are commonalities among patients with different pain conditions,
yet there are unique problems that must be addressed for each specific syndrome.
These chapters address both the commonalities and the specific features that must be
targeted to successfully treat patients with each particular pain condition.
Chapters 27 and 28, also new to this volume, cover the treatment of patients with
comorbid psychological disorders and chronic pain (i.e., posttraumatic stress disor-
der and substance use disorders). There is a growing number and awareness of these
comorbid and challenging patients. Treatment of these groups requires particular sen-
sitivities and approaches. Concluding this section, Chapters 29 and 30 describe the
treatment needs of children and elderly adults. Although the same psychological prin-
ciples apply across the span of life, the methods used to treat elderly adults and very
young patients create unique challenges, and require special skills and sensitivity for
presentation and delivery.
It is our intention that this volume bridge the gap between clinical research and di-
rect application to the clinical environment. In addition to completely updating topics
and treatment approaches described in the previous editions, as previously noted, we
have added a new chapter regarding the potential of advanced technologies to improve
efficiency, treatment outcomes, and associated costs, as well as chapters covering
emerging problems related to comorbidity among patients with chronic pain. These
 Preface xvii

topic areas adhere to the National Institutes of Health’s emphasis on the importance
of the “transfer of technology” from basic research to clinical populations in the “real
world.” In a complementary way, the Institute of Medicine’s (2011) report on reliev-
ing pain in America has called for a “cultural transformation” that addresses societal,
educational, and patient needs related to pain and its treatment. We hope this volume
will contribute to these cultural and clinical transformation themes regarding pain
treatment.
Each of the contributors to this volume is a seasoned clinician who is widely
regarded as an expert in his or her field. Chapter authors were carefully selected in
an effort to assist in the dissemination of information for use in the “real world” of
the management of patients with chronic pain, and the health care environment more
broadly. We believe this handbook will be of particular relevance and value to clini-
cians, whether they treat only a small number of pain patients or the majority of their
practices are centered on this population. The specificity of this shared clinical wis-
dom should also make the text valuable to students and those new to the field of chron-
ic pain. Each chapter also provides evocative and practical guidelines. We believe the
content will help practitioners, regardless of their experience or training, to better un-
derstand the most appropriate and heuristic ways of thinking about, and working with,
their patients, and interfacing with the health care and payer environment. Careful
attention to the insights provided should facilitate clinical interactions and contribute
to better outcomes. Moreover, the specific elements of treatments presented should
inform clinical investigators, and also potentially suggest avenues of future clinical
research to ultimately improve treatment options, and, thereby, the lives of the millions
of individuals who experience chronic pain.
As always, we welcome your comments and suggestions for improving our ef-
forts.

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 Contents

PART I. CONCEPTUAL, DIAGNOSTIC, AND METHODOLOGICAL ISSUES

1. Biopsychosocial Perspective on Chronic Pain 3

Dennis C. Turk and Elena S. Monarch

2. Psychological Disorders and Chronic Pain: 25

Are There Cause-and-Effect Relationships?
Eric Salas, Nancy Kishino, Jeffrey Dersh, and Robert J. Gatchel

3. Conducting and Evaluating Treatment Outcome Studies 51

Amanda C. de C. Williams and Stephen Morley

PART II. TREATMENT APPROACHES AND METHODS

4. Enhancing Motivation to Change in Pain Treatment 71

Mark P. Jensen

5. Operant and Related Conditioning with Chronic Pain: Back to Basics 96

Steven H. Sanders

6. A Cognitive-Behavioral Perspective on the Treatment 115

of Individuals Experiencing Chronic Pain
Dennis C. Turk

7. Introduction to Biofeedback Training for Chronic Pain Disorders 138

John G. Arena and James D. Tankersley

xix
xx Contents

8. Clinical Hypnosis in the Treatment of Chronic and Acute Pain 160

Lindsey C. McKernan, Michael R. Nash, and David R. Patterson

9. Exposure In Vivo for Pain-Related Fear 177

Johan W. S. Vlaeyen, Marlies den Hollander, Jeroen de Jong,
and Laura Simons

10. Group Therapy for Patients with Chronic Pain 205

Francis J. Keefe, Pat M. Beaupre, Meredith E. Rumble,
Sarah A. Kelleher, and Alyssa N. Van Denburg

11. Treating Adults with Chronic Pain and Their Families: 230
Application of an Enhanced Cognitive-Behavioral Transactional Model
Hallie Tankha, Robert D. Kerns, and Annmarie Cano

12. Facilitating Patient Resilience: Mindfulness-Based Stress Reduction, 250

Acceptance, and Positive Social and Emotional Interventions
John A. Sturgeon and Beth D. Darnall

13. Integration of Pharmacotherapy with Psychological Treatment 264

of Chronic Pain
Peter B. Polatin, Noor M. Gajraj, and Howard Cohen

14. Using Advanced Technologies to Improve Access to Treatment, 289

to Improve Treatment, and to Directly Alter Experience
Christopher Eccleston, Abby Tabor, and Edmund Keogh

PART III. SPECIFIC SYNDROMES AND POPULATIONS

15. Evaluating Patients for Neuromodulation Procedures 303

Daniel M. Doleys and Leanne R. Cianfrini

16. Strengthening Self-Management of Low Back Pain in Primary Care: 319

An Evolving Paradigm
Benjamin H. Balderson, Sheri D. Pruitt, and Michael Von Korff

17. A Cognitive-Behavioral Approach to Early Interventions 340

to Prevent Chronic Pain-Related Disability
Steven James Linton

18. Occupational Musculoskeletal Pain and Disability 357

Christopher T. Ray, Robert J. Gatchel, Ryan Hulla, and Anna Wright Stowell

19. Recurrent Headache Disorders 377

Todd A. Smitherman, Alexander J. Kuka, Dawn C. Buse,
and Donald B. Penzien
 Contents xxi

20. Treatment of Patients with Fibromyalgia 398

Dennis C. Turk

21. Treatment of Patients with Whiplash-Associated Disorders 425

Michele Sterling

22. Treatment of Patients with Temporomandibular Disorders 439

Angela Liegey Dougall, Lynette Watts, and Robert J. Gatchel

23. Treating the Patient with Genito-Pelvic Pain 458

Sophie Bergeron, Natalie O. Rosen, and Serena Corsini-Munt

24. Treating Patients with Functional Gastrointestinal Pain Disorders 473

Miranda A. L. van Tilburg and William E. Whitehead

25. Treating Cancer Patients with Persistent Pain 485

Chelsea Ratcliff and Diane Novy

26. Treating Patients with Somatic Symptom and Related Disorders 499
Don McGeary, Cindy McGeary, and Paul Nabity

27. Treating Patients with Posttraumatic Stress Disorder and Chronic Pain 515
Laurie D. Wolf and John D. Otis

28. Management of Chronic Pain in Patients with a Comorbid 530

Substance Use Disorder
Benjamin J. Morasco, Travis I. Lovejoy, and Mark A. Ilgen

29. Treating Children and Adolescents with Chronic Pain 541

Emma Fisher, Rachel V. Aaron, and Tonya M. Palermo

30. Treating Older Patients with Persistent Pain 556

Thomas Hadjistavropoulos

Index 569
 PA RT I

CONCEPTUAL, DIAGNOSTIC,
AND METHODOLOGICAL ISSUES
 CHAPTER 1
Biopsychosocial Perspective on Chronic Pain
DENNIS C. TURK
ELENA S. MONARCH
The past several decades have given rise to ad-
vances in knowledge of the neurophysiologi-
cal mechanisms involved with nociception and
pain, advances in sophisticated diagnostic imag-
ing procedures, and the development of innova-
tive treatments. Yet there are still no treatments
available that consistently and permanently al-
leviate pain for all those afflicted (Turk, Wil-
son, & Cahana, 2011). In this chapter we review
the biomedical model and several alternative
biopsychosocial models that incorporate psy-
chological and social factors. When these fac-
tors are integrated with neurophysiological fac-
tors, a broader biopsychosocial framework can
be used to help us better understand individuals
with chronic pain and their disability, as well as
guide treatment planning. We review research
focusing specifically on psychological, behav-
ioral, and social factors, how these may directly
interact with neurophysiological and hormonal
factors, and we also discuss the implications of
these contributors for treatment and rehabilita-
tion. The set of factors discussed here underlie
many of the treatment approaches described in
other chapters in this volume.
The Need for an Alternative to the Disease Model
The conventional biomedical model of pain,
which dates back to the ancient Greeks and was
inculcated into medical thinking by Descartes in
the 17th century, assumes that people’s reports
3
of pain result from a specific disease state or pa-
thology associated with disordered anatomy or
physiology. From this model, efforts are made to
confirm the diagnosis from data obtained from
objective tests (e.g., imaging, laboratory assays
of fluids) validating physical damage or disease,
and impairment. Based on these data, medical
interventions are specifically directed toward
eliminating either the source of pathology or re-
mediating the identified organic dysfunction—
the putative causes of the symptoms described.
From the perspective of the biomedical
model, accompanying features of chronic
conditions, such as sleep disturbance, depres-
sion, psychosocial disability, and pain, are not
viewed as pathognomonic of a particular dis-
ease or syndrome. Rather, they are viewed as
mere reactions to the malady, and are thus of
secondary importance. It is assumed that once
the disease is “cured,” or pathology resolves
or is corrected, these secondary reactions will
abate. If the symptoms persist, speculations
arise as to possible psychological causation for
their maintenance. Thus, traditional medicine
has adopted a dichotomous, Cartesian mind–
body dualistic view in which symptoms are
either somatogenic or psychogenic. Although
evidence to support this dichotomy is lacking
and often contrary, the view remains pervasive
in health care, in patients and patients’ signifi-
cant others, and the general population.
Decidedly diverse responses to objectively
similar physical perturbations and identical
4 C onceptual , D iagnostic , and M ethodological I ssues
treatments have been noted clinically and docu-
mented in numerous empirical investigations.
For example, although they are related, the as-
sociations between physical impairments on the
one hand, and pain report and disability on the
other, are modest at best (see, e.g., Brinjikji et
al., 2015; Finan et al., 2013). Identified physical
pathology by itself is not highly predictive of
the severity of pain or level of disability. More-
over, pain severity does not adequately explain
emotional distress or extent of disability ob-
served. Many of the most prevalent chronic pain
conditions (e.g., back pain, fibromyalgia [FM],
migraine) do not reveal any definitive pathol-
ogy that would adequately explain the presence,
extent, and persistence of pain and associated
disability (e.g., Baranto, Hellstrom, Cederlund,
Nyman, & Sward, 2009; Blankenbaker et al.,
2008; Jarvik et al., 2005).
Several prospective longitudinal studies in-
dicated that the evolution of persistent pain is
unrelated to the number of pathological discs
revealed in magnetic resonance imaging (MRI)
findings. For example, Jarvik and colleagues
(2005) reported that psychological factors were
significantly better predictors of back pain 3
years after initial assessment than were MRI
scans. In an even longer duration follow-up, Ba-
ranto and colleagues (2009) tracked groups of
elite male athletes and nonathletes for 15 years,
and found that the evolution of persistent pain
was unrelated to the number of pathological
discs the MRI revealed. These authors found
that the presence of pain failed to predict pa-
thology; moreover, the presence of pathology
did not predict pain. These data do not obviate
the important contribution of physical pathol-
ogy to the experience of pain; rather, they sug-
gest that other variables, as well as biomedical
ones, are important and worthy of attention. The
question that remains to be answered, then, is:
What set of factors account for the highly var-
ied experience of, and behavioral responses to,
pain observed? This question has led to a search
for broader models that can account for the lack
of any isomorphic relationship between defined
pathology and pain reports.
It is apparent that chronic pain involves much
more than a physical symptom. Its continuous
presence creates widespread manifestations of
distress, including preoccupation with pain;
limitation of personal, social, and work activi-
ties; demoralization and affective disturbance;
and increased use of medications and of health
care services for those affected. It comes to
consume the entire life of the individual, and it
evolves overtime. Although the importance of
such factors has been acknowledged for some
time (e.g., Engel, 1977), only within the past
half-century have there been systematic at-
tempts to incorporate these factors within com-
prehensive models of pain (e.g., Flor & Turk,
2011; Gatchel, Peng, Peters, Fuchs, & Turk,
2007). Dissatisfaction with the inadequacies of
the biomedical model of pain led to a seminal
event, the postulation of the Gate Control Theo-
ry of pain by Melzack and his colleagues (Mel-
zack & Casey, 1968; Melzack & Wall, 1965).
The Gate Control Theory of Pain
The first attempt to amalgamate physiological
and psychological factors, and to develop an
integrative model of chronic pain that circum-
vents shortcomings of unidimensional models,
was the gate control theory (GCT; Melzack &
Casey, 1968; Melzack & Wall, 1965), which had
to account for a number of facts: (1) the variable
relationship between injury and pain noted; (2)
non-noxious stimuli sometimes produce pain;
(3) the location of pain and tissue damage is
sometimes different; (4) pain can persist long
after tissue healing; (5) the nature of the pain
and sometimes the location can change over
time; (6) pain as a multidimensional experience;
and (7) lack of adequate pain treatments. It was
precisely these facts that no theory at the time
could explain.
Melzack and Casey (1968) differentiated
three systems related to the processing of no-
ciceptive stimulation: sensory–discriminative,
motivational–affective, and cognitive–evalu-
ative, all of which contribute to the subjective
experience of pain. In this way, the GCT spe-
cifically includes psychological factors as inte-
gral aspects of the pain experience. In addition,
by emphasizing central nervous system (CNS)
mechanisms, this theory provides a physiologi-
cal basis for the role of psychological factors in
chronic pain.
According to the GCT, peripheral stimuli in-
teract with cortical variables, such as mood and
anxiety, in the perception of pain. Pain, then,
is not considered either somatic or psychogenic;
instead, both factors have either potentiating or
moderating effects. From the GCT perspective,
the experience of pain is an ongoing sequence
of activities, largely reflexive in nature at the
outset, but modifiable even in the earliest stages
 Biopsychosocial Perspective on Chronic Pain
by a variety of excitatory and inhibitory influ-
ences, as well as the integration of ascending
and descending CNS activity. The process re-
sults in overt expressions communicating pain,
and strategies by the person to terminate the
pain. Because the GCT invokes the continuous
interaction of multiple systems (sensory–physi-
ological, affect, cognition, and behavior) con-
siderable potential for shaping of the pain expe-
rience is implied.
Whereas prior to the GCT formulation psy-
chological factors were largely dismissed as
solely reactions to pain, this new model sug-
gested that cutting or blocking neurological
pathways is inadequate because psychological
processes are capable of influencing (i.e., am-
plifying or diminishing) perception of the pe-
ripheral input. Emphasis on the modulation of
inputs in the spinal cord and the dynamic role of
the brain in pain processes, and ultimately per-
ception, resulted in more serious consideration
of psychological variables (e.g., past experience,
attention, and other cognitive activities) to ad-
equately understand pain. Perhaps the major
contribution of the GCT has been its highlight-
ing of the CNS and, particularly, the brain as
an essential component in pain processes and
perception.
The physiological details of the GCT have
been challenged almost since its initial incep-
tion (e.g., Nathan, 1976; Price, 1987). As addi-
tional knowledge has been gathered since the
original formulation in 1965, specific mecha-
nisms have been disputed and have required re-
vision and reformulation (Melzack, 2001, 2005;
Wall, 1989). Overall, however, the GCT has
proved remarkably resilient and flexible in the
face of accumulating scientific data and chal-
lenges to these data. It still provides a “powerful
summary of the phenomena observed in the spi-
nal cord and brain, and has the capacity to ex-
plain many of the most mysterious and puzzling
problems encountered in the clinic” (Melzack
& Wall, 1982, p. 261).
The GCT has had enormous heuristic value
in stimulating further research in the basic
science of pain mechanisms. It has also given
rise to new clinical treatments, including neu-
romodulatory-based procedures (e.g., neural
stimulation techniques, neurofeedback, phar-
macological advances, behavioral treatments,
and interventions targeting modification of at-
tentional and perceptual processes involved in
the pain experience; e.g., Flor & Turk, 2011;
M. Jensen, Day, & Miro, 2014; M. Jensen &
5
Turk, 2014). After the GCT was proposed, no
one could continue trying to explain pain exclu-
sively in terms of peripheral factors and resort
to the traditional biomedical model.
The Neuromatrix Theory
Melzack (1999) extended the GCT and inte-
grated it with Selye’s (1950) theory of stress.
The Neuromatrix Theory (NT) makes a num-
ber of assumptions about pain. The central con-
cept proposed by Melzack was that the multi-
dimensional experience of pain is produced
by patterns of nerve impulses generated by a
widely distributed neural network comprising
a “body–self neuromatrix.” The neuromatrix is
to some extent genetically determined, but it is
modifiable by sensory experience and learning.
Another important hypothesis of the NT is that
the patterns of nerve impulses can be triggered
either by sensory inputs or centrally, indepen-
dent of any peripheral stimulation. Further-
more, the NT proposes that the output patterns
of the neuromatrix engage perceptual, behav-
ioral, and homeostatic systems in response to
injury and chronic stress.
According to Melzack (1999, 2001, 2005), a
person’s unique body–self-neuromatrix is the
primary determinant of whether the organ-
ism experiences pain, and is the basis for the
individual differences observed because the
neuromatrix is plastic. A critical component of
the NT is the recognition that pain is the conse-
quence of the output of the widely distributed
brain neural network rather than a direct re-
sponse to sensory input following tissue injury,
inflammation, and other pathologies (Melzack,
2001). There is a growing body of research con-
firming Melzack’s proposed distributed brain
neural network in the perception and response
to noxious stimulation (e.g., Apkarian, Bush-
nell, & Schweinhardt, 2013; Apkarian, Hashmi,
& Baliki, 2011; Tracey & Bushnell, 2009).
Another important feature of the NT is that
when an organism is injured, it proposes that
there is an alteration and disruption of the ho-
meostatic regulation. This deviation from the
body’s normal state is stressful and initiates a
complex of neural, hormonal, and behavioral
mechanisms designed to restore homeostasis
(Selye, 1950). The negative effects of stress in-
clude atrophy of muscle tissue, impairment of
growth and tissue repair, immune system sup-
pression, and morphological alterations of brain
6 C onceptual , D iagnostic , and M ethodological I ssues
structures that, together, might create conditions
for the development and maintenance of various
chronic illnesses associated with increased al-
lostatic load (e.g., Chrousos & Gold, 1992; Mc-
Beth et al., 2005; McEwen, 2001; McLean et al.,
2005). The concept of allostatic load, and the
factors that contribute to physiological burden,
is becoming increasingly recognized as an im-
portant component across diseases and disabili-
ties (Seng, Graham-Bermann, Clark, McCar-
thy, & Ronis, 2005; Singer, Friedman, Seeman,
Fava, & Ryff, 2005; Tucker, 2005).
Building on the GCT, pain suppression can
be produced by sensory and evaluative process-
es, as well as activation of the endogenous opi-
oid system. Furthermore, Melzack (1999, 2005)
hypothesized that prolonged stress and ongoing
efforts to restore homeostasis can suppress the
immune system and activate the limbic system.
The limbic system has an important role in
emotion, motivation, and cognitive processes.
Moreover, emerging research also suggests that
inflammatory responses in the body are capable
of crossing the blood–brain barrier (Simnaz et
al., 2015) via two possible routes. One proposed
route of the inflammatory trigger is from the
olfactory bulb into the limbic system (Cut-
forth, DeMille, Agalliu, & Agalliu, 2016), an
area known to be heavily involved in the stress
response. Another potential route of bodily in-
flammation into the CNS may be through the
newly discovered lymphatic vessels lining the
dural sinuses of the brain (Louveau et al., 2015).
These lines of research question the imperme-
ability of the blood–brain barrier, and offer pain
researchers and clinicians greater cause to con-
sider the direct impacts of bodily injuries, pain,
and inflammatory processes on the brain, and
nicely integrate within the NT.
The cumulative effects of stresses that pre-
ceded or are concomitant with the current stress
may account for the large variation in individ-
ual responses to what objectively might appear
to be the same degree of physical pathology. In
this way, the NT incorporates the prior learn-
ing history of the individual with pain to shape
the neuromatrix by influencing interpretive
processes and individual physiological and be-
havioral response patterns. A new stressor may
amplify baseline stress and related efforts of
homeostatic regulation. Prolonged stress aug-
ments tissue breakdown as the body contin-
ues to attempt to return to its “normal” state.
Once pain is established, however, it becomes
a stressor in and of itself, as the body continues
to attempt return to homeostasis. The presence
of pain is a continual threat that initiates and
maintains attention, and creates physical de-
mands on the body. Fear, worry about the fu-
ture, ruminations regarding the meaning of the
nociceptive stimulation, and implications for
the future contribute to the ongoing stress, pro-
ducing additional deviations from homeostasis
(e.g., Chrousos & Gold, 1992; McEwen, 2001).
Nociception involves activation of energy
impinging on specialized nerve endings. The
nerve(s) involved conveys information about
tissue damage to the CNS. Animal research
suggests that repetitive or ongoing nocicep-
tive input can lead to structural and functional
changes that may cause altered perceptual pro-
cessing and contribute to pain chronicity (e.g.,
Apkarian et al., 2011, 2013; Hashmi et al., 2013).
These structural and functional changes dem-
onstrate plasticity in the nervous system and
may explain why a person experiences a gradu-
al increase in the perceived magnitude of pain,
referred to as “neural (peripheral and central)
sensitization.” Moreover, once these changes
have occurred, they may contribute to nocicep-
tion even after the initial cause has resolved.
These changes in the CNS offer an explanation
for the reports of pain in many chronic pain
syndromes (e.g., back pain, migraine FM, whip-
lash-associated disorders) even when no physi-
cal pathology is identified (e.g., Yunus, 2015).
According to Melzack, these CNS changes can
be accounted for by modification of the body–
self-neuromatrix. Thus, Melzack’s (2001, 2005)
NT poses intriguing hypotheses and integrates
a great deal of physiological and psychological
knowledge. However, components of the theo-
ry, and the theory itself, await more systematic
investigation. As was the case with the GCT,
the NT offers a heuristic way of thinking that
should stimulate research.
The Biopsychosocial Perspective:
A Basic Description
It is well known that people differ markedly in
how frequently they report physical symptoms,
in their propensity to visit physicians when ex-
periencing identical symptoms and, as noted, in
their response to identical treatments. Therefore,
the distinction between disease and illness is
crucial to understanding chronic pain. Disease
is generally defined as an objective biological
event that involves disruption of specific body
 Biopsychosocial Perspective on Chronic Pain
structures or organ systems caused by patho-
logical, anatomical, or physiological changes.
In contrast to this customary view of physical
disease, illness is defined as a subjective experi-
ence or self-attribution that a disease is present;
it yields physical discomfort, emotional distress,
behavioral limitations, and psychosocial disrup-
tion. In other words, illness refers to how the
sick person and members of his or her family
and wider social network perceive, live with,
and respond to symptoms and disability.
The distinction between disease and illness
is analogous to the distinction between pain and
nociception. Nociception entails stimulation of
nerves that convey information about tissue
damage occurring at the periphery, projecting
to the spinal cord and, ultimately, to the brain
(Melzack & Wall, 1965). Pain is a subjective
perception that results from the transduction,
transmission, and modulation of sensory input,
filtered through a person’s genetic composition
and prior learning history, and modulated fur-
ther by the person’s current physiological sta-
tus, idiosyncratic appraisals, expectations, cur-
rent mood state, and sociocultural environment
(e.g., Diatchenko et al., 2005; Flor & Turk, 2011;
Gatchel et al., 2007). This is why we emphasize
assessment of the person because we cannot as-
sess pain removed from the person exposed to
the nociception.
Socioeconomic context
Premorbid Age at pain
characteristics onset
• Genes • Pathology
• Learning history
• Personality
37
FIGURE 1.1. Longitudinal versus cross-sectional perspective. From Okifuji and Turk (2014, p. 228). Copyright
© Springer Verlag France. Reprinted with permission of Springer.
7
In contrast to the biomedical model’s em-
phasis on disease, the biopsychosocial model
focuses on both disease and illness, a complex
interaction of biological, psychological, and so-
cial variables. From this perspective, diversity
in illness expression, which includes its sever-
ity, duration, and consequences for the individ-
ual, is accounted for by the interrelationships
among biological changes, psychological status,
and the social and cultural contexts. Moreover,
prior to the development of an injury or disease,
each person has a unique genotype and prior
learning history. All these variables shape the
person’s perception and initial and ongoing re-
sponse to illness (Gatchel et al., 2007; Okifuji &
Turk, 2015).
The biopsychosocial way of thinking about
the differing responses of people to symptoms
and the presence of chronic conditions is based
on an understanding of the dynamic nature of
these conditions. That is, by definition, chronic
syndromes extend over time. Therefore, these
conditions need to be viewed longitudinally
as ongoing, multifactorial processes in which
there is a vibrant reciprocal interplay among
biological, psychological, and social factors that
shape the experience and responses of patients
(see Figure 1.1). Biological factors may initiate,
maintain, and modulate physical perturbations,
whereas psychological variables influence
Current age Expectancy
• Change in • Change in
pathology pathology
44 76+
Resources
• Interpersonal support
• Economic
8 C onceptual , D iagnostic , and M ethodological I ssues
perception of internal physiological signs, and
social factors continually shape patients’ be-
havioral responses to the perceptions of their
physical perturbations. Conversely, psychologi-
cal factors may influence biology by directly
affecting hormone production (see, e.g., Mc-
Beth et al., 2007; McEwen & Kalia, 2010), brain
structure and processes (see, e.g., Goffaux,
Redmond, Rainville, & Marchand, 2007; Hash-
mi et al., 2013; Kucyi et al., 2014; Salomons,
Johnstone, Backonja, Shackman, & Davidson,
2007), and the autonomic nervous system (see,
e.g., Colloca, Benedetti, & Pollo, 2006; Mc-
Beth et al., 2005, 2007). Behavioral responses
may also affect biological contributors, such
as when a person avoids engaging in certain
activities in order to reduce his or her symp-
toms (e.g., Crombez, Eccleston, van Damme,
Vlaeyen, & Karoly, 2012; Vlaeyen & Linton,
2000). Although avoidance may initially reduce
symptoms, in the long run, it will lead to fur-
ther physical deconditioning (i.e., loss of muscle
mass and strength, endurance, and flexibility),
which can exacerbate nociceptive stimulation.
The picture is not complete unless we consid-
er the direct effects of disease factors and treat-
ment on a range of cognitive and behavioral
factors. Biological influences and medications
(e.g., steroids, opioids) may affect the ability to
concentrate, induce fatigue, and modulate peo-
ple’s interpretation of their state, as well as their
ability to engage in certain activities.
At different points during the evolution of a
disease or impairment, the relative weighting of
physical, psychological, and social factors may
shift. For example, during the acute phase of a
disease, biological factors may predominate,
but, over time, as initial physical pathology
resolves, psychological and social factors may
assume a disproportionate role in accounting
for symptoms and disability (Okifuji & Turk,
2015; Skinner, Wilson, & Turk, 2012). More-
over, there is considerable variability in behav-
ioral and psychological manifestations of dys-
function, both across persons with comparable
symptoms and within the same person over
time (e.g., Arnow et al., 2011).
To understand the variable responses of
people to chronic conditions, it is essential that
biological, psychological, and social factors
each be considered. Moreover, a longitudinal
perspective is essential. A cross-sectional ap-
proach will only permit consideration of these
factors at a specific point in time, and chronic
conditions continually evolve (see Figure 1.1).
What is observed at any one time is a person’s
adaptation to interacting biological, personal,
and environmental factors. In summary, the
hallmarks of the biopsychosocial perspective
are (1) integrated action, (2) reciprocal deter-
minism, and (3) development and evolution
(Flor & Turk, 2011; Okifuji & Turk, 2015). This
perspective can be contrasted with the tradi-
tional biomedical model, whose emphasis on
the somatogenic–psychogenic dichotomy is too
narrow in scope to accommodate the complex-
ity of chronic pain.
Support for the Importance
of Nonphysiological Factors
As noted, many studies have revealed rather
weak associations between objective indicator
reports of both pain and disability (e.g., Brin-
jikji et al., 2015; Finan et al., 2013), and the
predictive role of both cognitive and emotional
factors accounting for significantly greater por-
tions of the variance than objective signs in
chronic pain (e.g., Carragee, Alamin, Miller, &,
Carragee, 2005) and disability (e.g., Severeijns,
Vlaeyen, van den Hout, & Weber, 2001). More-
over, psychological factors have consistently
been demonstrated to predict pain severity and
time to discharge following diverse types of
surgery during the postoperative period (e.g.,
Ip, Abrishami, Peng, Wong, & Chung, 2009;
Khan et al., 2011; Pavlin, Sullivan, Freund, &
Roesen, 2005), and at 6- and 12-month follow-
up (e.g., Peters, Sommer, van Kleef, & Mar-
cus, 2010; Thomee et al., 2008). Psychological
variables have also been shown to be important
predictors of response to both pharmacological
and nonpharmacological treatments for various
painful conditions (e.g., Benyon, Hill, Zadu-
rian, & Mallen, 2010), and to duration of dis-
ability (e.g., Busch, Goransson, & Melin, 2007).
The history of medicine is replete with de-
scriptions of interventions believed to be appro-
priate for alleviating pain, many of which are
now known to have little therapeutic merit, and
some of which may actually have been harm-
ful to patients (Turk, Meichenbaum, & Genest,
1983). Prior to the second half of the 19th centu-
ry and the advent of research on sensory physi-
ology, much of the pain treatment arsenal con-
sisted of interventions that had no direct mode
of action on organic mechanisms associated
with the source of the pain. Despite the absence
of an adequate physiological basis, these treat-
 Biopsychosocial Perspective on Chronic Pain
ments proved to have some therapeutic merit, at
least for some patients.
Personality Factors
Prior to the onset of a pain problem, individu-
als have a range of genetic factors and learning
experiences that help shape their personalities.
Within the biopsychosocial perspective, these
individual-difference variables are viewed as
important to the experience, response to, and
impact of symptoms (Figure 1.1). The search
for specific personality factors that predispose
people to develop chronic pain has been a major
emphasis of psychosomatic medicine. Studies
had attempted to identify a specific “migraine
personality,” a “rheumatoid arthritis personal-
ity,” and a more general “pain-prone person-
ality” (Blumer & Heilbronn, 1982). However,
on the basis of their prior experiences, people
develop idiosyncratic ways of interpreting in-
formation and coping with stress. Avoidance,
and the resulting failure to experience discon-
firmation, prevent the extinction or modifica-
tion of these interpretations and expectations.
There is no question that these unique patterns
will have an effect on their perceptions of, and
responses to, the presence of pain (Weisberg &
Keefe, 1999; see also Salas, Kishino, Dersh, &
Gatchel, Chapter 2, this volume).
Anxiety sensitivity refers to the fear of anxi-
ety symptoms, based on the belief that they will
have harmful consequence (Reiss & McNally,
1985). Anxiety sensitivity appears to be a vul-
nerability factor (i.e., diathesis) that may condi-
tion specific fears that contribute to the develop-
ment and maintenance of distress (Asmundson,
Coons, Taylor, & Katz, 2002). Coupled with the
fact that pain is essential for survival, attention
may be “primed” to process painful stimuli
ahead of other attentional demands. People with
high levels of anxiety sensitivity may be espe-
cially hypervigilant to pain, as well as to other
noxious sensations. Selective attention directed
toward threatening information, such as bodily
sensations, leads to greater arousal. Because of
this attentional process, those with high anxi-
ety sensitivity may be “primed,” such that even
minor painful stimuli may be amplified.
Preliminary studies that demonstrate the
importance of anxiety sensitivity as a predis-
positional factor in chronic pain have been re-
ported. For example, Asmundson and Norton
(1995) found a positive association between
9
anxiety sensitivity and pain-related anxiety,
escape/avoidant behaviors, fear of negative
consequences of pain, and negative affect. Not
only were patients with high anxiety sensitivity
more likely to experience greater cognitive dis-
turbance as a result of their pain, but they were
also likely to use greater amounts of analgesic
medication to control equal amounts of pain
compared to those with low or medium anxiety
sensitivity. Furthermore, Asmundson and Nor-
ton (1995) demonstrated that anxiety sensitivity
directly exacerbates fear of pain and, indirectly,
exacerbates pain-specific avoidance behavior
even after they controlled for the direct influ-
ences of pain severity on these variables (for a
more extensive review, see Asmundson et al.,
2002).
General fearful appraisals of bodily sensa-
tions may sensitize predisposed people and
cause high awareness of bodily sensations.
Thus, anxiety sensitivity is only one individu-
al-difference characteristic that might predis-
pose people to develop and maintain chronic
pain and disability. For example, somatization,
negative affectivity, bodily preoccupation, and
catastrophic thinking also may be involved (see
McGeary, McGeary, & Nabity, Chapter 26, this
volume).
Sociocultural Factors
People are social beings, functioning within a
cultural context that begins at birth and colors
experiences throughout their lives. Attempt-
ing to understand people’s experience of pain
without consideration of their historical and
current context will be inadequate (Okifuji &
Turk 2012, 2015). Commonsense beliefs about
illness and health care providers are acquired
from both prior learning experiences and so-
cial and cultural transmission of meaning and
expectations. Ethnic group membership influ-
ences how one perceives, labels, responds to,
and communicates various symptoms, as well
as from whom one elects to obtain care when it
is sought, and the types of treatments received.
Sociocultural factors influence how families
and local groups respond to and interact with
patients (see discussion of operant learning
mechanisms later). Furthermore, ethnic and ra-
cial expectations and sex and age stereotypes
may influence the practitioner–patient relation-
ship (e.g., Anderson, Green, & Payne, 2009;
Cook & Chastain, 2001; Lazakani et al., 2015;
10 C onceptual , D iagnostic , and M ethodological I ssues
McGuire, Nicholas, Asghari, Wood, & Main,
2014).
Social Learning Mechanisms
The role of social learning has received some at-
tention in the development and maintenance of
chronic pain states. From this perspective, pain
behaviors (i.e., overt expressions of pain, dis-
tress, and suffering) may be acquired through
observational learning and modeling processes;
that is, people can learn responses that were not
previously in their behavioral repertoire by ob-
serving others who respond in these ways (e.g.,
Goubert, Vlaeyen, Crombez, & Craig, 2011;
Levy, 2011). Children acquire attitudes about
health and health care, perceptions and interpre-
tations of symptoms, and appropriate responses
to injury and disease from their parents, cultur-
al stereotypes, and the social environment (see,
e.g., Fisher, Aaron, & Palermo, Chapter 29, this
volume). Based on their experiences, children
develop strategies to help them avoid pain and
learn “appropriate” (acceptable) ways to react.
Children are exposed to numerous minor inju-
ries throughout the day, and how adults address
these experiences provides ample learning op-
portunities (Levy, 2011). Children’s learning
influences whether they will ignore symptoms
or respond or overrespond to symptoms. The
observation of others in pain is an event that
captivates attention. A large amount of experi-
mental evidence, going back several decades,
demonstrates the role of social learning in con-
trolled studies in the laboratory (Craig, 1986;
1988), and observations of patients’ behavior in
clinical settings (e.g., Levy, 2011). For example,
in an early study, Richard (1988) found that
children whose parents had chronic pain chose
more pain-related responses to scenarios pre-
sented to them and were more external in their
health locus of control than were children with
healthy or diabetic parents. Moreover, teachers
rated the pain patients’ children as displaying
more illness behaviors (e.g., complaining, days
absent, and visits to school nurse) than the chil-
dren of the diabetics and healthy controls.
Operant Learning Mechanisms
Early in the 1900s, Collie (1913) discussed the
effects of environmental factors in shaping
the experience of people with persistent pain.
However, a new era in thinking about pain was
initiated with Fordyce’s (1976; for a historical
reflection and extension, see Main, Keefe, Jen-
sen, Vlaeyen, & Vowles, 2015; see also Sanders,
Chapter 5, this volume) description of the role
of operant factors in chronic pain. The operant
approach stands in marked contrast to the bio-
medical model of pain described earlier. Oper-
ant theory hypothesizes that all behavior is sen-
sitive to the effects of environmental responses
to that behavior. Fordyce noted that “pain be-
haviors”—the things that people do that com-
municate pain to others (i.e., overt expressions
of pain and suffering such as limping and gri-
macing)—are no different than any other be-
havior with respect to their sensitivity to envi-
ronmental influences. Overt behaviors, by their
very nature, are observable and hence capable
of eliciting responses. Pain behaviors followed
by reinforcing events, such as affection or sanc-
tioned time out from social responsibilities, will
increase in frequency. However, if pain behav-
iors are systematically ignored, and behaviors
incompatible with them—so-called “well-
behaviors” such as exercise and maintaining
an active lifestyle including employment—are
encouraged or positively reinforced, then over
time these well-behaviors will increase and
pain behaviors will decrease.
Fordyce (1976) argued that pain behaviors,
which can be protective in the short run fol-
lowing acute injury, are no longer useful in
the context of chronic pain. In fact, once heal-
ing has occurred, pain behaviors often become
maladaptive—they can contribute to disability
(e.g., ongoing resting and guarding behaviors
cause muscle atrophy) and maintain pain. Also,
these behaviors may continue beyond any ex-
pected healing time because of the presence of
not only significant pain but also reinforcers of
pain behaviors, as well as the absence of rein-
forcers for well behaviors.
In the operant formulation, behavioral mani-
festations of pain, rather than pain per se, are
central. When people are exposed to a stimu-
lus that causes tissue damage, their immediate
response is withdrawal or an attempt to escape
from the noxious sensations. Their behaviors
are observable and, consequently, are subject to
the principles of reinforcement. Behaviors that
are positively reinforced increase and persist,
whereas behaviors that receive no positive re-
sponse decrease and become diminished. Those
behaviors that permit avoidance of aversive
events (negatively reinforced) will also increase.
The operant view proposes that through exter-
nal contingencies of reinforcement, acute pain
 Biopsychosocial Perspective on Chronic Pain
behaviors, such as limping to protect a wound-
ed limb from producing additional nociceptive
input, may evolve into chronic pain problems.
Pain behaviors may be positively reinforced di-
rectly (e.g., by attention from a spouse or health
care provider). They may also be maintained by
the escape from noxious stimulation through
the use of drugs or rest, or avoidance of unde-
sirable activities such as work.
In addition, “well behaviors” (e.g., activity
and working) may not be sufficiently positively
reinforced and will be extinguished. Pain be-
haviors originally elicited by organic factors
may therefore occur totally, or in part, in re-
sponse to reinforcing environmental events.
Because of the consequences of specific be-
havioral responses, Fordyce (1976) proposed
that pain behaviors might persist long after the
initial cause of the pain is resolved or greatly
reduced. The operant conditioning model does
not concern itself with the initial cause of pain.
Rather, it considers pain an internal subjective
experience that may be maintained even after
its initial physical basis is resolved. A number
of studies have provided evidence that supports
the underlying assumptions of the operant con-
ditioning model (e.g., Eck, Richter, Straube,
Miltner, & Weiss, 2011; Jolliffee & Nicholas,
2004).
Treatment from the operant perspective fo-
cuses on extinction of pain behaviors and in-
creasing well behaviors by positive reinforce-
ment. This treatment has proven to be effective
for select samples of patients with chronic pain
(see, e.g., Henschke et al., 2010; Thieme, Turk,
& Flor, 2007; see also Sanders, Chapter 5, this
volume). Although operant factors undoubtedly
play a role in the maintenance of pain and dis-
ability, the operant conditioning model of pain
has been criticized for its exclusive focus on
motor pain behaviors, failure to consider the
emotional and cognitive aspects of pain, and
failure to treat the subjective experience of pain
(e.g., Okifuji & Turk, 2015; Skinner et al., 2012).
Respondent Learning Mechanisms
Factors contributing to chronicity that have pre-
viously been conceptualized in terms of operant
learning may also be initiated and maintained
by respondent conditioning. In an early study,
Fordyce, Shelton, and Dundore (1982) hypoth-
esized that intermittent sensory stimulation
from the site of bodily damage, environmental
reinforcement, or successful avoidance of aver-
11
sive social activity are not necessarily required
to account for the maintenance of avoidance
behavior or protective movements; anticipation
of pain may be sufficient to maintain avoid-
ance behavior. Vlaeyen and colleagues (e.g.,
Asmundson, Norton, & Vlaeyen, 2004; Crom-
bez et al., 2012; Vlaeyen & Linton, 2000) have
reviewed a wealth of studies confirming that
avoidance of activities is related more to anxi-
ety about pain than to actual pain.
Once an acute pain problem is established,
fear of motor activities that the patient expects
to result in pain may develop and motivate
avoidance of activity (Crombez et al., 2012;
Vlaeyen & Linton, 2000). Nonoccurrence of
pain is a powerful reinforcer for future reduc-
tion of activity. In this way, the original respon-
dent conditioning may be followed by an oper-
ant learning process, whereby the nociceptive
stimuli and the associated responses need no
longer be present for the avoidance behavior to
occur.
In acute pain states, it may be useful to re-
duce movement and, consequently, to avoid
pain, in order to accelerate the healing process.
Over time, however, anticipatory anxiety re-
lated to activity may develop and act as a con-
ditioned stimulus for sympathetic activation
(the conditioned response), which may be main-
tained after the original unconditioned stimu-
lus (injury) and unconditioned response (pain
and sympathetic activation) have subsided (e.g.,
Philips, 1987). Indeed, sympathetic activation
and increases in muscle tension may be viewed
as unconditioned responses that can elicit more
pain. Even when no injury is present, pain relat-
ed to sustained muscle contractions may also be
conceptualized as an unconditioned stimulus,
and conditioning may proceed in the same fash-
ion as outlined previously. Although an origi-
nal association between pain and pain-related
stimuli may result in anxiety regarding these
stimuli, with time, the expectation of pain relat-
ed to activity may lead to avoidance of adaptive
behaviors, even if the nociceptive stimuli and
the related sympathetic activation are no longer
present. Even in acute pain, many activities that
are otherwise neutral or pleasurable may elicit
or exacerbate pain, and are therefore experi-
enced as aversive and avoided. Over time, more
and more activities may be seen as eliciting or
exacerbating pain, and are therefore feared and
avoided (i.e., stimulus generalization).
Avoided activities may involve simple motor
behaviors, as well as work, leisure, and sexual
12 C onceptual , D iagnostic , and M ethodological I ssues
activity. In addition to the avoidance learn-
ing, pain may be exacerbated and maintained
in an expanding number of situations because
anxiety-related sympathetic activation and ac-
companying muscle tension may occur both in
anticipation and as a consequence of pain (cf.
Flor & Turk, 2011; Main et al., 2015). Thus, psy-
chological factors may directly affect nocicep-
tive stimulation and need not be viewed merely
as reactions to pain. We return to this point later
in this chapter.
Persistent avoidance of specific activities
prevents disconfirmations that are followed
by corrected predictions (Rachman & Arntz,
1991). Early studies have shown that predic-
tion of pain promotes pain avoidance behavior,
and overprediction of pain promotes excessive
avoidance behavior (Schmidt, 1985a, 1985b).
Insofar as pain avoidance succeeds in preserv-
ing the overpredictions from repeated discon-
firmation, they will continue unchanged. By
contrast, people who repeatedly engage in be-
havior that produces significantly less pain than
they predicted will likely make adjustments in
subsequent expectations, which will eventually
become more accurate. Increasingly accurate
predictions will be followed by reduction of
avoidance behavior (Vlaeyen, de Jong, Geilen,
Heuts, & van Breukelen, 2001). These observa-
tions support the importance of physical ther-
apy and exercise quota, with patients progres-
sively increasing their activity levels despite
their fears of injury and discomfort associated
with renewed use of deconditioned muscles.
From the respondent conditioning perspec-
tive, individuals with chronic pain may have
learned to associate increases in pain with all
kinds of stimuli that were originally associ-
ated with nociceptive stimulation (i.e., stimulus
generalization). As the pain symptoms persist,
more and more situations may elicit anxiety and
anticipatory pain and depression because of the
low rate of reinforcement obtained when behav-
ior is greatly reduced. Sitting, walking, cogni-
tively demanding work or social interaction,
sexual activity, or even thoughts about these
activities, may increase anticipatory anxiety
and concomitant physiological and biochemi-
cal changes (Flor & Turk, 2011). Subsequently,
patients may respond inappropriately to many
stimuli, reducing the frequency of numerous
activities, in addition to those that initially in-
duced nociception. Physical abnormalities often
observed in patients with chronic pain (e.g.,
distorted gait, decreased range of motion, and
muscular fatigue) may actually result from sec-
ondary changes initiated in behavior through
learning rather than continuing nociception. In
short, the anticipation of suffering or prevention
of suffering may be sufficient for the long-term
maintenance of avoidance behaviors.
Cognitive Factors
People are not passive responders to physical
sensation. Rather, they actively seek to make
sense of their experience. They appraise their
conditions by matching sensations to some pre-
existing implicit model, and they determine
whether a particular sensation is a symptom of
a particular physical disorder that requires at-
tention or can be ignored. In this way, to some
extent, each person functions with a uniquely
constructed reality (i.e., a body–self neuroma-
trix). When information is ambiguous, people
rely on general attitudes and beliefs based on
experience and prior learning history. These
beliefs determine the meaning and significance
of the problems, as well as the perceptions of
appropriate treatment. If we accept the premise
that pain is a complex, subjective phenomenon
that is uniquely experienced by each person,
then knowledge about idiosyncratic beliefs, ap-
praisals, and coping repertoires becomes criti-
cal for optimal treatment planning and for ac-
curately evaluating treatment outcome (Flor &
Turk, 2011; Okifuji & Turk 2014; Skinner et al.,
2012).
Research investigating the impact of poor
emotional coping, maladaptive thought pro-
cesses, and appraisals of pain have consistently
demonstrated that patients’ attitudes, beliefs,
and expectancies about their plight, them-
selves, their coping resources, and the health
care system affect their reports of pain, activ-
ity, disability, and response to treatment (e.g.,
Okifuji & Turk, 2012; Smeets, Vlaeyen, Kester,
& Knottnerus, 2006). For example, a belief that
pain is “damaging” and “dangerous” in patients
with chronic pain has been shown to be asso-
ciated with greater pain and disability (Turner,
Jensen, & Romano, 2000). Conversely, modifi-
cation in maladaptive beliefs about their pain
can directly affect brain processing of nocicep-
tive stimulation (e.g., K. Jensen et al., 2012) and
seems to predict changes in pain and disability
following treatment (e.g., Burns, Glenn, Bruehl,
Harden & Lofland, 2003; Robinson, Theodore,
Dansie, Wilson, & Turk, 2013).
Another random document with
no related content on Scribd:
 THE LIFE OF JEAN HENRI FABRE
[1]
CHAPTER I
 THE SÉRIGNAN JUBILEE
In a few days’ time 1 naturalists, poets, and
philosophers will repair in company to Sérignan, in
the neighbourhood of Orange. What is calling them
from every point of the intellectual horizon, from the
most distant cities and capitals, to a little Provençal
village? Moussu Fabré, they would tell you yonder, in
a tone of respectful sympathy.

But who is the Moussu Fabré thus cherished by the

simplest as well as by the most cultivated minds? He
is a sturdy old man of all but ninety years, who has
spent almost the whole of his life in the company of
Wasps, Bees, Gnats, Beetles, Spiders, and Ants, and
has described the doings of these tiny creatures in a
most wonderful fashion in ten large volumes entitled
Souvenirs Entomologiques or Etudes sur l’Instinct et
les Mœurs des Insectes. 2 [2]

One might say of this achievement what the author of

Lettres Persanes said of his book: Proles sine matre.
It is a child without a mother. It is, in short,
unprecedented. 3 It has not its fellow, either in the
Machal of Solomon, or the apologues of the old
fabulists, or the treatises on natural history written by
our modern scientists. The fabulists look to find man
in the animal, which for them is little more than a
pretext for comparisons and moral narratives, and
the scientists commonly confine their curiosity to the
dissection of the insect’s organs, the analysis of its
functions, and the classification of species. We might
even say that the insect is the least of their cares, for,
like Solomon, [3]they delight in holding forth upon all
the creatures upon the earth or in the heavens
above, and all the plants “from the cedar tree that is
in Lebanon even unto the hyssop that springeth out
of the wall” (1 Kings iv: 32–33).

Fabre, on the contrary, has eyes only for the insect.

He observes it by and for itself, in the most trivial
manifestations of its life: the living, active insect, with
its labours and its habits, is the thing that interests
him before all else, guiding his investigation of the
infinite host of these tiny lives, which claim his
attention on every hand; and in this world of insects
wealth of artifice and capacities of the mental order
seem to be in an inverse ratio to beauty of form and
brilliance of colour. For this reason Fabre learns to
disdain the magnificent Butterfly, applying himself by
preference to the modest Fly: the two-winged Flies,
which are relatives of our common House-fly, or the
four-winged Flies, the numerous and infinitely various
cousins of the Wasps and Bees; the Spiders, ugly
indeed, but such skilful spinners, and even the Dung-
beetles and Scarabæidæ of every species, those
wonderful agents of terrestrial purification.

In this singular world, which affords him [4]the society

which he prefers, he has gathered an ample harvest
of unexpected facts and highly perplexing actions on
the part of these little so-called inferior animals. No
one has excelled him in detecting their slightest
movements, and in surprising all the secrets of their
lives. Darwin declared, and many others have
repeated his words, that Fabre was “an incomparable
observer.” The verdict is all the more significant in
that the French entomologist did not scruple to
oppose his observations to the theories of the
famous English naturalist.

Not only in the certainty and the detailed nature of his

facts, but also in the colour and reality of his
descriptions is his mastery revealed. In him the
naturalist is reduplicated by a man of letters and a
poet, who “understands how to cast over the naked
truth the magic mantle of his picturesque language,” 4
making each of his humble protagonists live again
before our eyes, each with its characteristic
achievements. So striking is this power of his that
Victor Hugo described him as “the insects’ Homer,”
while one of the most accomplished of our
[5]scientists, Mr. Edmond Perrier, Director of the

Museum of Natural History, not content with saluting

him as “one of the princes of natural history,” speaks
of his literary work in the following terms:

The ten volumes of his Souvenirs Entomologiques will remain

one of the most intensely interesting works which have ever
been written concerning the habits of insects, and also one of
the most remarkable records of the psychology of a great
observer of the latter part of the nineteenth century. In them
the author depicts to the life not only the habits and the
instincts of the insects; he gives us a full-length portrait of
himself. He makes us share his busy life, amid the subjects of
observation which incessantly claim his attention. The world
of insects hums and buzzes about him, obsesses him, calling
his attention from all directions, exciting his curiosity; he does
not know which way to turn. Overwhelmed by the
innumerable winged army of the drinkers of nectar who, on
the fine summer days, invade his field of observation, he calls
to his aid his whole household: his daughters, Claire, Aglaé,
and Anna, his son Paul, his workmen, and above all his man-
servant Favier, an old countryman who has spent his life in
the barracks of the French colonies, a man of a thousand
expedients, who watches his master with an incredulous yet
admiring eye, listening to him but refusing to be convinced,
and shocking him by [6]the assertion, which nothing will
induce him to retract, that the bat is a rat which has grown
wings, the slug an old snail which has lost its shell, the night-
jar a toad with a passion for milk, which has sprouted feathers
the better to suck the goats’ udders at night, and so forth. The
cats and the dog join the company at times, and one almost
regrets that one is not within reach of the sturdy old man, so
that one might respond to his call.
 See him lying on the sand where everything is grilling in the
burning rays of the sun, watching some wasp that is digging
its burrow, noting its least movement, trying to divine its
intentions, to make it confess the secret of its actions,
following the labours of the innumerable Scarabaei that clean
the surface of the soil of all that might defile it—the droppings
of large animals, the decomposing bodies of small birds,
moles, or water-rats; putting unexpected difficulties in their
way, slily giving these tiny life-companions of his problems of
his own devising to solve. 5

That is well-expressed, and it gives us a fairly correct

idea of the vital and poetic charm of the Souvenirs.

The same writer asks, speaking of the well-defined

tasks performed by all these little creatures beloved
of the worthy biologist of [7]Sérignan: “Who has taught
each one its trade, to the exclusion of any other, and
allotted the parts which they fill, as a rule with a
completeness unequalled, save by ‘their absolute
unconsciousness of the goal at which they are
aiming?’ This is a very important problem: it is the
problem of the origin of things. Henri Fabre has no
desire to grapple with it. Living in perpetual
amazement, amid the miracles revealed by his
genius, he observes, but he does not explain.”
For the moment we can no longer subscribe to the
assertions of the learned Academician, 6 nor to his
fashion of writing history, which is decidedly too free.
The truth is that Fabre, who delights in the pageant
of the living world, does not always confine himself to
recording it; he readily passes from the smallest
details of observation to the wide purviews of reason,
and he is at times as much a philosopher as a poet
and a naturalist. The truth is that he often considers
the question of the origins of life, and he answers it
unequivocally like the believer that he is. It is enough
to cite one passage among others, a passage which
testifies to a brief uplifting of the heart that
presupposes many [8]others: “The eternal question, if
one does not rise above the doctrine of dust to dust:
how did the insect acquire so discerning an art?” And
the following lines from the close of the same
chapter: “The pill-maker’s work confronts the
reflective mind with a serious problem. It offers us
these alternatives: either we must grant the flattened
cranium of the Dung-beetle the distinguished honour
of having solved for itself the geometrical problem of
the alimentary pill, or we must refer it to a harmony
that governs all things beneath the eye of an
Intelligence which, knowing all things, has provided
for all?” 7
And indeed, when we consider closely, with the
author of the Souvenirs, all the prodigies of art, all
the marks of ingenuity displayed by these sorry
creatures, so inept in other respects, then, whatever
hypothesis we may prefer as to the formation of
species, whether with Fabre we believe them fixed
and unchanging, or whether with Gaudry 8 [9]we
believe in their evolution, we cannot refrain from
proclaiming the necessity of a sovereign Mind, the
creator and instigator of order and harmony, and we
are quite naturally led to repeat, to the glory of God
the Creator, the beautiful saying of Saint Augustine:
“Fecit in cœlis angelos et in terris vermiculos, nec
major in illis nec minor in istis.”

Now this venerable nonagenarian whom naturalists,

poets, and philosophers are so justly about to honour
in Sérignan, because his brow is radiant with the
purest rays of science, poetry, and philosophy: this
entomologist of real genius, he whom Edmond
Perrier ranks among “the princes of natural history,”
he whom Victor Hugo called “the insects’ Homer,” he
whom Darwin proclaimed “an incomparable
observer”: who is there in Aveyron, knowing that he
was born beneath our skies and that he has dwelt
upon our soil, but will rejoice to feel that he belongs
to us by his birth and the whole of his youth? [10]
1 The great entomologist’s jubilee was celebrated on the April 3, 1910.—
Author’s Note. ↑
2 Paris, Delagrave. The Souvenirs, translated by Alexander Teixeira de Mattos,
are in course of publication [2]by Messrs. Hodder and Stoughton in England and
Messrs. Dodd, Mead and Co. in the United States. The arrangement of the essays
has been altered in the English series. See also The Life and Love of the Insect,
translated by Alexander Teixeira de Mattos (A. and C. Black), Social Life in the
Insect World, translated by Bernard Miall (T. Fisher Unwin), and Wonders of
Instinct, translated by Alexander Teixeira de Mattos and Bernard Miall (T. Fisher
Unwin).—B. M. ↑
3 It must in justice be admitted that Fabre had certain precursors, among whom
mention must be made of the famous Réaumur and Léon Dufour, a physician
who lived in the Landes (died 1865), and who was the occasion and the subject of
his first entomological publication. This does not alter the fact that his great work is
not only absolutely original, but an achievement sui generis which cannot be
compared with the mere sketches of his predecessors. ↑
4 Souvenirs, Series VI., p. 65, The Life of the Fly, chap. vi., “My Schooling.” This
is Fabre’s verdict upon another naturalist, Moquin-Tandon. ↑
5 Souvenirs, VI., pp. 76–97; The Glow-worm and Other Beetles, chap, ix., “Dung-
beetles of the Pampas.” ↑
6 M. E. Perrier is a Member of the Institut de France. ↑
7 Souvenirs, VI., pp. 76, 97; The Glow-worm, chap. ix. ↑
8 M. Albert Gaudry is a sometime professor of palæontology in the Museum of
Natural History, who, by virtue of his palæontological discoveries and works,
has acquired a great authority in the scientific world. His Enchaînements du
Monde Animal dans les Temps Géologiques is especially valued and often cited.
Gaudry, who is a good Catholic as well as a scientist of the first rank, [9]very
definitely accepts the evolution of species; but for him, as for Fabre, the activity of
the animal kingdom, like that of the world in general, is inconceivable apart from a
sovereign mind which has foreseen all things and provided for all things. ↑
[Contents]
CHAPTER II
 THE URCHIN OF MALAVAL
Jean-Henri Fabre was born at Saint-Léons, the
market-town and administrative centre of the canton
of Vezins. In witness of which behold this extract
from the register of baptisms, a certified copy
transcribed by the Abbé Lafon, curé of Saint-Léons:

In the year 1823, on the 22nd September, was baptised Jean-

Henri-Casimir Fabre, of the aforesaid Saint-Léons, the
legitimate son of Antoine Fabre and Victoire Salgues,
inhabitants of the same place:—His godfather was Pierre
Ricard, primary schoolmaster. In proof of which—Fabre,
vicar. 1

Jean-Henri Casimir’s mother, by birth Victoire

Salgues, was the daughter of the bailiff of Saint-
Léons. His father, Antoine Fabre, was born in a little
mas in the parish of Lavaysse, Malaval, where his
parents were still cultivating the old family property
[11]which since then has passed to the head of the

Vaissière family.

It was thus at Malaval that the future entomologist

“passed his earliest childhood,” as he told me when
writing to me ten years ago. 2 There was no wallowing
in abundance at Saint-Léons. In order to relieve the
poor household of one mouth, he was confided to the
care of his grandmother and sent to Malaval. “There,
in solitude, amid the geese, the calves, and the
sheep, my mind first awoke to consciousness. What
went before is for me shrouded in impenetrable
darkness.”

The spot which was the scene of this first awakening

deserves description. When one follows the road
from Laissac to Vezins, a short distance after passing
Vaysse-Rodié, just as one has almost reached the
crest of the height which by reason of its rocky
helmet is called the puech del Roucas, on the line of
the watershed dividing the limestone basin of the
Aveyron from the granitic basin [12]of the Viaur, on
turning sharply to the right one sees before one the
austere Malavallis, dominated on the one hand by
the height of Lavaysse with its ancient church, and
enlivened a little on the other side by the tiny hamlet
of Malaval, which consists, to-day, of two farm-
houses; one whiter, more cheerful-looking, and on
lower ground; the other standing higher, greyer in
hue, and more difficult to discover in the shade of the
oak-trees and thickets of broom and blackthorn
which form a dense mantle of green about it. It was
there, amid these trees, in this house, three thousand
feet above the sea, in sight of the sturdy belfry of
Lavaysse, that Jean-Henri Fabre was “born into the
true life,” the life of the mind. Here, on this hillside,
which directly faces the east, he made his earliest
discoveries; here, one fine morning, as he will
presently tell us, he discovered the sun; here, he saw
not only the dawn of day, but also “that inward dawn,
so far swept clear of the clouds of unconsciousness
as to leave him a lasting memory.”

Nothing could take the place of the picturesqueness

and sincerity of the narrative in which he has related
these earliest impressions of his childhood: [13]

My grandparents 3 were people whose quarrel with

the alphabet was so great that they had never
opened a book in their lives; and they kept a lean
farm on the cold granite ridge of the Rouergue
[14]table-land. The house, standing alone amidst the

heath and broom, with no neighbour for many a mile

around and visited at intervals by the wolves, was to
them the hub of the universe. But for a [15]few
surrounding villages, whither the calves were driven
upon fair-days, the rest was only very vaguely known
by hearsay. In this wild solitude, the mossy fens, with
their quagmires oozing with iridescent pools,
supplied the cows, the principal source of wealth,
with plentiful pasture. In summer, on the short sward
of the slopes, the sheep were penned day and night,
protected from beasts of prey by a fence of hurdles
propped up with pitchforks. When the grass was
cropped close at one spot, the fold was shifted
elsewhither. In the centre was the shepherd’s rolling
hut, a straw cabin. Two watch-dogs, equipped with
spiked collars, were answerable for tranquillity if the
thieving wolf appeared in the night from out the
neighbouring woods.

Padded with a perpetual layer of cow-dung, in which

I sank to my knees, broken up shimmering puddles
of dark-brown liquid manure, the farmyard also
boasted a numerous population. Here the lambs
skipped, the geese trumpeted, the fowls scratched
the ground, and the sow grunted with her swarm of
little pigs hanging to her dugs.

The harshness of the climate did not give husbandry

the same chances. In a propitious season they would
set fire to a stretch of moorland bristling with gorse
and send the swing-plough across the ground
enriched by the cinders from the fire. This yielded a
few acres of rye, oats, and potatoes. The best
corners were kept for hemp, which furnished the
distaffs and spindles of the house with [16]the material
for cloth, and was looked upon as grandmother’s
private crop.
Grandfather, therefore, was, before all, a herdsman
versed in the love of cows and sheep, but completely
ignorant of aught else. How dumbfounded he would
have been to learn that, in the remote future, one of
his family would become enamoured of those
insignificant animals to which he had never
vouchsafed a glance in his life! Had he guessed that
that lunatic was myself, the scapegrace seated at the
table by his side, what a smack of the head I should
have caught, what a wrathful look!

“The idea of wasting one’s time with that nonsense!”

he would have thundered.

For the patriarch was not given to joking. I can still

see his serious face, his unclipped head of hair, often
brought back behind his ears with a flick of the thumb
and spreading its ancient Gallic mane over his
shoulders. I see his little three-cornered hat, his
small-clothes buckled at the knees, his wooden
shoes, stuffed with straw, that echoed as he walked.
Ah, no! Once childhood’s games were past, it would
never have done to rear the Grasshopper and
unearth the Dung-beetle from his natural
surroundings.

Grandmother, pious soul, used to wear the eccentric

headdress of the Rouergue Highlanders: a large disk
of black felt, stiff as a plank, adorned in the middle
with a crown a finger’s-breadth high and hardly wider
across than a six-franc piece. A black ribbon
fastened under the chin maintained [17]the equilibrium
of this elegant, but unstable circle. Pickles, hemp,
chickens, curds and whey, butter; washing the
clothes, minding the children, seeing to the meals of
the household: say that and you have summed up
the strenuous woman’s round of ideas. On her left
side, the distaff, with its load of tow; in her right hand,
the spindle turning under a quick twist of her thumb,
moistened at intervals with her tongue: so she went
through life, unweariedly, attending to the order and
the welfare of the house. I see her in my mind’s eye,
particularly on winter evenings, which were more
favourable to family talk. When the hour came for
meals, all of us, big and little, would take our seats
round a long table, on a couple of benches, deal
planks supported by four rickety legs. Each found his
wooden bowl and his tin spoon in front of him. At one
end of the table there always stood an enormous rye-
loaf, the size of a cartwheel, wrapped in a linen cloth
with a pleasant smell of washing, and there it
remained until nothing was left of it. With a vigorous
stroke, grandfather would cut off enough for the
needs of the moment; then he would divide the piece
among us with the one knife which he alone was
entitled to wield. It was now each one’s business to
break up his bit with his fingers and to fill his bowl as
he pleased.

Next came grandmother’s turn. A capacious pot

bubbled lustily and sang upon the flames in the
hearth, exhaling an appetising savour of bacon and
turnips. Armed with a long metal ladle, grandmother
[18]would take from it, for each of us in turn, first the

broth, wherein to soak the bread, and next the ration

of turnips and bacon, partly fat and partly lean, filling
the bowl to the top. At the other end of the table was
the pitcher, from which the thirsty were free to drink
at will. What appetites we had, and what festive
meals those were, especially when a cream-cheese,
home-made, was there to complete the banquet!

Near us blazed the huge fire-place, in which whole

tree-trunks were consumed in the extreme cold
weather. From a corner of that monumental, soot-
glazed chimney, projected, at a convenient height, a
slate shelf, which served to light the kitchen when we
sat up late. On this we burnt slips of pine-wood,
selected among the most translucent, those
containing the most resin. They shed over the room a
lurid red light, which saved the walnut-oil in the lamp.
When the bowls were emptied and the last crumb of
cheese scraped up, grandam went back to her
distaff, on a stool by the chimney-corner. We
children, boys and girls, squatting on our heels and
putting out our hands to the cheerful fire of furze,
formed a circle round her and listened to her with
eager ears. She told us stories, not greatly varied, it
is true, but still wonderful, for the wolf often played a
part in them. I should have very much liked to see
this wolf, the hero of so many tales that made our
flesh creep; but the shepherd always refused to take
me into his straw hut, in the middle of the fold, at
night. [19]When we had done talking about the horrid
wolf, the dragon, and the serpent, and when the
resinous splinters had given out their last gleams, we
went to sleep the sweet sleep that toil gives. As the
youngest of the household, I had a right to the
mattress, a sack stuffed with oat-chaff. The others
had to be content with straw.

I owe a great deal to you, dear grandmother: it was in

your lap that I found consolation for my first sorrows.
You have handed down to me, perhaps, a little of
your physical vigour, a little of your love of work; but
certainly you were no more accountable than
grandfather for my passion for insects.