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Rational, Emotive, Ethical Approaches to Bio-psychosocial Pain Care

The influence of Albert Ellis and rational emotive behavioral therapy on clinical bioethics.
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The Passing of an Icon

On July 24, 2007, the healthcare community lost one of its most influential figures in the passing of Dr. Albert Ellis at age 93. Although not instantly affiliated with the field of pain management, Ellis’ lifelong work in cognitive behavioral therapies had made him a veritable icon in the American and international psychology communities. Keenly insightful and possessing a sardonic wit, Albert Ellis could easily be described as elder statesman of contemporary psychology, radical reformer, controversial, quintessential mentor and educator, occasionally ribald, and humanitarian clinician. Indeed, to those who had the pleasure of knowing him and honor of working with him, he could be any or all of these things at a given time.

Ellis’ contribution to the field of pain management has become increasingly apparent in light of our expanding knowledge of the interrelation of body-brain-mind and pain, and the demonstrated success of cognitive-behavioral therapies in treating patients suffering from chronic pain. In this essay, we describe how this progress in brain science has re-validated Ellis’ perspective on psychological distress, and fortified the importance of the therapeutic approaches that he pioneered. Unapologetically, it is homage to the person of Albert Ellis, but it is also an elucidation of how his work has become well-established in the field of pain management. We address past and recent criticisms of his work, and defend against these critiques by arguing for the effectiveness, modernity, and ethical integrity of rational emotive behavioral therapy (REBT).

Body, Brain, and Mind: Pain as Physiological and Psychological Event

The inseparability of pain from psychological process and mental processing fortifies the importance of consciousness, cognitive, and emotional substrates to both the perception of, and reaction to, pain (as sensation and construct). These events are subserved by interacting neural systems that function to evoke activities at various levels of consciousness. These actions may sustain positive adaptational benefit by producing and conditioning avoidance and/or escape responses against stimuli and circumstances that can incur acute pain, and facilitating rest and recuperative responses following tissue damage that evokes chronic pain.1,2 But cognitive, emotional, and behavioral dimensions can also contribute to, and be heightened by durable pain; contributing both to the progression of pain as illness (maldynia)3, and the co-morbidity of clinically relevant psychological conditions that can heighten negative responses to pain, and denigrate the overall clinical picture.4,5 Melzack’s neuromatrix model of pain describes a neural network that integrates 1) noxious (and non-noxious co-terminal) sensory input, 2) tonic and phasic cognitive-emotional states, and 3) stimulatory and inhibitory modulation from peripheral and central neuraxes.6 These networks allow for the pairing of noxious and non-noxious stimuli so as to ‘construct’ a cognitive ‘map’ of pain-related expectations, perceptions, emotions, and behavioral responses. The Vlaeyen-Linton fear-avoidance model, and the fear-anxiety-avoidance model of chronic pain proposed by Asmundsen and colleagues provide working depictions of how existing neural sensitivities and cognitive expectations can engage various neural networks to produce and sustain maladaptive emotions and behaviors.7,8 In this way, physiological responses (e.g., autonomic arousal) can be yoked to circumstance to evoke Damasio’s “feeling of what happens,”9 and can be linked to:

  • memories and expectations
  • manifest reasoning about co-terminality
  • a construct of “why it happens”
  • behaviors based upon an anticipation that “it will happen again”
  • reaction to a belief that “it should not happen to me” (i.e., failed avoidance responses)10,11

We have posited that pre-depositions and susceptibilities to pain, and the co-morbidity of certain psychological disorders (including dysthymia-depression, generalized and specific object anxiety, stress sensitivity, somatization, and opioid and cannabinoid insensitivity) may reflect a form of spectrum disorder, in which genotypically-determined phenotypes are differentially expressed as a consequence of interaction(s) with the internal and external environment(s) throughout life.12 In this model, the function and structures of neurological networks develop to sustain susceptibilities and sensitivities to both environmental input, and neural response patterns that are ultimately expressed as perceptions, cognitions, emotions and behaviors. These patterns of neurological activity can:

  • be influenced by and, in turn, influence environmental circumstances
  • result from complex, dynamical systems’ interactions at various levels in the bio-psychosocial hierarchy
  • manifest both ‘bottom-up’ (i.e., sub-cellular to the systemic and whole organism) and ‘top-down” (i.e., whole organism to the sub-cellular ) effects13

In other words, the internal milieu of body, brain, and “mind,”14 and the external environment are reciprocally interactive and influential. A complex systems’ approach enables an account of the putative material (i.e., substance), and formal (i.e., process) causes for these relationships and effects; and how these causes contribute to pain (and the co-morbidities of mood, anxiety, and perhaps opioid insensitivity and abuse) as part of a neuropsychological spectrum disorder. This description encourages appreciation for the mutuality of psychological and physiological events, and such an understanding of the interdependence of pain and psychological processes sustains (if not obligates) the need for psychological co-management of chronic, and maldynic pain.15,16

Albert Ellis and Rational Emotive Behavioral Therapy

The growing acceptance of the Gate Theory of pain strengthened the notion that pain could be modulated by higher cognitive factors (i.e., “gates”), and that in certain individuals and circumstances, severe and/or durable pain could affect cognition.17 Yet, almost a decade prior to Melzack and Wall’s groundbreaking theory, the interactive role of cognitions and emotions in determining behaviors (and their consequences) had been the primary focus of Albert Ellis’ work during the 1950s, and was the epistemic basis from which he developed the rational cognitive therapeutic approach.18

Much of the early work of his career was grounded in the writings of the stoic philosopher Epictetus, and Ellis’ views on the therapeutic process were influenced, at least partly, by the philosophical psychology espoused by Korzybski.19,20 Employing a definably classical perspective, Ellis argued that the stoic notion of apatheia – the tranquility that arises from the acceptance of things as they are, without being burdened by excessive emotionality derived from expectation of gain or failure – represents the balance of rationality (intellectual measure) and impulses of irrationality (spontaneity and reactivity).21

Last updated on: February 26, 2013
First published on: September 1, 2007