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INTERVIEW | COVINGTON
The sine qua non of good
pain treatment is reconditioning.
I can’t say enough
good things about helping
people to get fit.
The concept of learned helplessness builds on the same
theme. Those taught by bitter experience that they are powerless
to change their plight are likely to give up and risk becoming
depressed, resigned, and passive. The bottom line is that
those who see themselves as capable are likely to do a lot to try
to cope with pain.
Q. In terms of getting better, how do people with an
external locus of control fare compared to those with
an internal locus of control?
DR. COVINGTON ‘Fault and blame’ are potentially very toxic to
patients in pain. Doug DeGood reported a nice study of this
subject (4). Patients were asked to respond to a number of questions
about their pain, several of which dealt with the issue of
who was to blame for the pain. It was found that patients who
blamed their pain on others were more likely to be depressed,
more behaviorally aberrant, more likely to have failed treatment,
and more pessimistic about the benefit of future treatment.
Those who did not blame others, who said ‘things happen,’
seemed to do better.
This concept suggests a slogan from Alcoholics Anonymous:
‘Holding onto resentments is like drinking poison and
waiting for your enemy to get sick.’ Clinically, we see people
who are absolutely stuck and destroyed by the grudges they’re
holding. Although doing so is a challenge, at some point, they
must relinquish the focus on the person who ‘did them dirty,’
and start focusing on the question, ‘How can I have a good life?’
OPERANT CONDITIONING
Q. What role does operant conditioning play in people
with CRPS?
DR. COVINGTON All animals tend to repeat behaviors that are
rewarded, and to reduce behaviors that are not. Imagine a world
in which that was not true. Animals would fail to return to the
place where they found water and food, and would fail to avoid
the place where they’d been attacked. Survival is contingent on
being programmed to repeat behaviors that are rewarded.
Unfortunately, behavior is often influenced more powerfully
by what is immediate than by what is important. Thus, we
are all at risk of behaving self-destructively in response to
reinforcers. This is why ‘buy now, pay later’ is so seductive.
Many behaviors that would promote recovery are unpleasant at
first. Conversely, many things that are very pleasant at first can
make you sick. For example, almost every back patient would
feel better if he simply went to bed. But after a few weeks of
this, some ‘strenuous’ activity such as tying shoelaces will cause
pain and send the person back to bed. Thus the rest, which
causes initial relief, leads ultimately to more pain and less function.
Therefore it is essential for people in chronic pain to
consider the long term effects of their choices, as opposed to
focusing only on what helps immediately.
Q. For people with CRPS and other chronic diseases
there are sometimes secondary gains. Would you talk
about these?
DR. COVINGTON ‘Secondary gains’ are the good things that
happen when one is sick—security, increased attention, nurture,
medications that relieve pain. But there are tremendous
‘secondary losses’ associated with chronic pain as well. You can
lose the pride of being the bread winner, the camaraderie of
co-workers, and a sense of identity. Financial compensation is
often thought of when the term secondary gain is used, and in
fact, many chronic pain patients do receive money as a result of
becoming disabled; however, most remain poor. They have a
steady but meager source of income, and little hope of more in
the future, because there won’t be any raises. Nevertheless, the
‘gains’ of illness can certainly reduce patients’ efforts to recover,
especially if there are few gains to be had for being well.
PSYCHOLOGICAL TREATMENTS
Q. What are some proven psychological treatments
for CRPS?
DR. COVINGTON There are several. Probably the most important
“psychological treatment” is physical therapy. I list it as a
“psychological” treatment because it not only helps patients
become strong enough to resume activities that used to give
them pleasure, it also changes the way they see themselves. It
helps them feel powerful and less fragile, and it reduces depression
and anxiety. The sine qua non of good pain treatment is
reconditioning. I can’t say enough good things about helping
people to get fit.
Cognitive therapies, helping people reinterpret their situations
and their pain in ways that facilitate coping, have been
shown to improve pain and function in a number of painful
conditions.
Another treatment is psychophysiologic training. Often
this involves biofeedback equipment, which measures muscle
tension, hand temperature, palmar sweating, and so on. It
teaches people to relax muscles and reduce sympathetic arousal.
It helps people feel they have some power over their bodies,
instead of their bodies having power over them, and it helps
them understand the effects of emotions on pain.
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