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10 Articles in Volume 7, Issue #7
Burning Mouth Syndrome
Chronic Pain Program in a Primary Care Setting
Chronic Persistent Pain Can Kill
Education and Exercise Program for Chronic Pain Patients
Managing Pain in Intensive Care Units
Oxycodone to Oxymorphone Metabolism
Patulous Eustachian Tube: Part 1
Rational, Emotive, Ethical Approaches to Bio-psychosocial Pain Care
Smoking and Aberrant Behavior in Chronic Pain Patients
Structuring Opioid Therapy

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

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

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

Ellis’ maintained that these impulses were intrinsic to the human condition, and that expectations and beliefs arise from, and give rise to, cognitive patterns (that develop via biological and environmental interactions). In this way, expectation and belief could also be influenced, if not frankly controlled by cognitive processes. Despite the psychological community’s initial antipathy toward Ellis’ cognitive emphasis, this approach, which by the 1960s had come to be called rational emotive behavioral therapy (REBT), represented an important step in the paradigmatic revision of contemporary psychological practice, and spawned both person-centered counseling and, ultimately, other forms of cognitive-behavioral therapy. 22

According to Ellis, individuals’ patterns of cognitive and emotional reactivity to events – and not simply the circumstances themselves—determine the valence and extent of psychological stability or distress (i.e., rational mental health vs. irrationality in mental disorder). Ellis maintained that people attend to basic biological needs (e.g., freedom from pain and suffering, satisfying physiological drives) and primary life goals and values (e.g., vocational and familial interests, lifestyle, etc) on many levels. When certain activating events (A) disrupt or impact these needs, goals and values, prior and extant expectations and beliefs (B) shape the cognitive constructs and meanings of how activating events are interpreted and dictate the resultant emotional and behavioral consequences (C). Beliefs can be consciously or unconsciously rational and healthy (rB), or irrational (iB). The latter evoking fear, sadness, anger, and self-reproach. Initially, individuals respond to desires, and while preferring to get their goals, may learn (or be forced) to rationally suppress purely goal-oriented behaviors and emotional reactivity.23

Co-author Dr. Leonor I. Lega pictured with Dr. Albert Ellis in the 1980’s.

But biological pre-dispositions and experience may also prompt another cognitive trajectory in which people may superimpose irrational demands that their desires, needs, and goals must or should be fulfilled, and/or that circumstances should or must be as construed by their particular beliefs and expectations.24 Obviously, the distinctions between such expectation and reality can create significant cognitive dissonance and psychological disturbance(s) that can be manifested as both emotional features and physical signs and symptoms (including exacerbation of pain and its effects).

Rational emotive behavioral therapy holds that patients have a choice of either succumbing to the negative manifestations and effects of their irrational beliefs, or adopting a more logical, constructive, and non-self-defeating appreciation of events and the circumstances that are part of the human condition.25 In other words, Ellis posited that the underlying self-referent premises that individuals cognitively attach to events dictate the conclusions that they tend to construct about a situation’s implications and ramifications upon their life and interactions with the world.

The role of the (rational emotive behavioral) therapist, is to 1) illustrate the A-B-Cs of cognitive susceptibility and emotional reactivity, 2) help the patient to dispute (D) errant A-B associations through either philosophical (i.e., querying the logic of certain premises) or empirical (i.e., questioning the objective validity of the A-B linkage and premises) discourse and refutation, and 3) develop a new practical, rational philosophy (E).26 According to Ellis “…when people keep challenging and questioning their self-disturbing core philosophies, after a while they tend…to bring new, rational, self-helping attitudes to their life problems.”27

REBT in Chronic Pain Management

“I started to call myself a rational therapist in 1955; later I used the term rational emotive. Now I call myself a rational emotive behavior therapist.”

“…cognitive behavior therapy and rational emotive therapy are much more popular…than they ever were...”—Albert Ellis 28,29

Ellis has been called the “grandfather of cognitive behavioral therapies.” As such, the influence of REBT on CBT, and the role of cognitively-based psychotherapeutic approaches in pain management establish Ellis’ work as a foundation of modern multi-disciplinary pain care. While there are a number of studies that specifically address REBT in pain management, much of this work is contained within the larger volume of literature that has examined the outcomes, mechanisms, and utility of cognitive therapy in pain treatment contexts.30 According to Lebovits, the cognitive-behavioral therapies are the most commonly used psychological techniques in the treatment of chronic pain patients.31 To a large extent, the widespread use of these approaches is based upon the success, and strongly validating experience of the patient actively partnering with the clinician to:

  • identify potentially harmful cognitive premises and catastrophizing beliefs (e.g., “What did I do to deserve this?” “My pain is the worst thing that could happen to me.” “I will never be able to provide income/enjoy hobbies, etc. again.”),
  • dispute and refute these beliefs, and
  • acquire less self-defeating expectations and thoughts (e.g., “My pain can be pretty bad, but it is not the worst thing that could happen to me.” “There are times when I really hurt, but I also have good days when I can fully enjoy my life.”)32

This active participation in the therapeutic process serves to internalize patients’ locus of control, enhance patients’ capacity to generalize positive cognitions to current and future events (of pain and pain-related circumstances), avoid the slippery-slope of negative cognitions, emotions and effects, and ultimately become less dependent upon the therapist or therapeutic milieu to implement and sustain healthier coping skills. Meta-analyses and systematic reviews support the efficacy and utility of cognitive therapies (including REBT) in diminishing overall pain levels in a number of chronic pain conditions, facilitating response to other pain interventions, and reducing pain-related illness and illness-behaviors.33-35

REBT as Bio-psychosocially-oriented, Patient-centered Care

Yet despite these positive outcomes, several criticisms have been levied against CBT in general, and REBT more specifically. On the whole, these contend that REBT is somewhat uni-dimensional in its philosophical focus (and as such fails to accommodate cultural diversity and human inter-dependence), is anachronistic, dogmatic, and overtly paternalistic.36,37 While we acknowledge that all therapeutic approaches have inherent limitations, and none are without flaw, we reject these criticisms and offer the following arguments in opposition.

First, REBT recognizes that cognition reflects a variety of constituent processes that are expressed as a final common pathway of genetic, physiological and environmental effect(s). Thus, REBT is a multi-dimensional, emphatically bio-psychosocial approach, and does not limit an account of psychological health or distress to consideration of only a single factor.

Second, REBT acknowledges that these interactions can occur on a variety of levels, from genome to culture and, rather than ascribing a patient’s condition to wholly biological or cultural variables, focuses upon the individuality of the person as a complex network of systems. In this way, it is inherently cognizant of the roles of context and culture, and intent upon revealing the (A-B-C) effects that such interactions evoke and sustain in a specific patient.

Third, we contend that through this epistemic breadth, REBT is both what Hobson calls modernly “neurodynamic” and consistently-patient centered.38 Fourth, by acknowledging that activating event(s) (e.g., intractable pain) frequently cannot be changed,39 but that the underlying “cause” (e.g., irrational beliefs and absolutistic thinking) can be altered through the therapeutic process, REBT attempts to cure as capable, heal as possible, while maintaining immutable focus upon the primacy of the good of, and for, the patient. In this way, it can manifest both an Asclepian (i.e., curative) and Hygieian (i.e., healing) approach and, in doing so, remains inherently flexible to the needs of the patient, non-dogmatic, and complementary to other forms of treatment.40

Ellis was aware that the needs that drive a patient to seek therapy differ widely, and the philosophical orientation of REBT seeks a therapeutic approach that is relevant to these needs. The therapeutic process examines the beliefs, values, and goals of each patient. This discourse is dependent upon the needs of the patient and her capacity for rational re-address of self-defeating beliefs and expectations. In this way, it reflects and supports the values-based approach of Fulford,41 and the goal-directed approach of Waters and Sierpina (as used in chronic pain management).42 We argue that REBT seeks to work with the needs, goals, and dimensions of the individual patient, rather than in spite of these, to restore the patient to a relative level of improved health. This focus upon the patient upholds beneficence in the four-fold sense of striving to provide:

  1. the technical good of therapeutic skill and technique
  2. the good for the patient as a person
  3. the good of the choices that the patient could make
  4. the good for the patient as an embodied “self” that exists as a “being-in-an-environment”43-45

Finally, it is axiomatic to REBT that many patients require therapy because of a compromised capacity for rational perspective and decision-making, and that the role of the therapist is to empower the patient toward healing. To do this, the therapist can execute a variety of roles, but the condition and needs of each patient dictate which role(s) should or must be enacted, as well as the tenor and nature of this articulation. Based upon the patient’s presentation and capacities, the therapist may engage in:

  • a co-deliberative therapeutic process as an intellectual partner
  • a mildly paternalistic, directed process of philosophical discourse and disputation
  • a more strongly paternalistic approach that is based upon the (communicated) fact that the patient manifests profoundly irrational beliefs that mandate a regrounding of rationality and emotional responsivity to serve the patient’s best interest

The therapist’s decision of what role to assume is at once therapeutic and moral. It requires insight to the patient’s condition and rational capacity, and the responsibility to act as steward of expert knowledge and healer.

Conclusion

Pain is a complex phenomenon that involves cognitions, emotions, and behaviors. Almost half a century ago, Albert Ellis recognized the power of cognitions and emotions to affect health. The application of his rational emotive approach to pain management, both directly and more broadly within the context of the cognitive behavioral therapies, provides proof-of-concept for Ellis’ forethought and visionary ideas. Ellis described himself as a scientist, clinician, and humanist. As a scientist, he was committed to being self-critical and revising his theories, hypotheses and work; as a clinician he saw and addressed the need for effective, broadly available, affordable, and evidence-based clinical care. Most of all, as a humanitarian, Dr. Ellis was wholly dedicated to healing. The recent, consilient efforts of the sciences and the humanities have shown us how body, brain, and mind exist as a unity in both health and disease. Practical pain management must employ such knowledge in the development and implementation of safe, effective, and ethically sound therapeutics. A tribute to Ellis’ legacy is that the cognitive therapies he developed have become a durable staple of this field

A formal service will be held for Dr. Ellis on Friday, September 28, 2007 at St. Paul’s Chapel at his alma mater, Columbia University, New York. Our hope is that this essay, and the message it conveys, contributes in some small way to his memorial.

Last updated on: February 26, 2013
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