This is the fifth in a series of interviews with PRF science advisors.
Christopher Eccleston, PhD, strives to advance evidence-based treatments and new therapeutic approaches for people with chronic pain. A professor of psychology and director of the Centre for Pain Research at the University of Bath, UK, he is also the coordinating editor of the Pain, Palliative and Supportive Care Review Group of the Cochrane Collaboration. Eccleston was founding director of the Bath Pain Management Unit at the Royal National Hospital for Rheumatic Diseases in the UK, and established the first interdisciplinary residential rehabilitation program for teenagers with chronic pain. In his research, he works to elucidate the attentional and motivational mechanisms of chronic pain. He discourages the viewpoint that patients’ responses to chronic pain can best be explained as psychopathology within models of abnormal psychology, advocating instead for a “normal” psychology of pain. Eccleston spoke by phone with Megan Talkington, and explained the rewards of doing research that advances patient care, the challenges in translating knowledge from the lab into the clinic, and the advances he sees on the horizon. The following is an edited transcript of their conversation.
In your areas of research, what trends excite you?
Within evidence-based medicine, I'm excited about the stage we've now reached where we have a fairly comprehensive understanding of analgesic efficacy [see McQuay et al., 2012]. I'm also excited by what might seem like a negative message—which is that one should expect analgesic failure. What we mean by that is that one should embark upon the treatment of acute and chronic pain expecting treatment to be ineffective for the majority of patients. That sounds like a nihilistic message, but it’s actually a very positive message because it means we are getting away from the simplistic understanding that all pain is going to react in the same way and that there is one solution for all. Clinicians need options.
The interventions I am especially interested in are those with a prominent psychological component. Psychological treatments are maturing. We are working to develop methods for establishing the effectiveness of treatments and guiding new treatment development. The challenge is to better understand, classify, and control the heterogeneity inherent in the unhelpful term “chronic pain patient” and the heterogeneity inherent in the term “psychological intervention.”
Evidence-based medicine is not about answering, “Does it work?” It's about capturing the quality and the maturity of the field, and giving guidance to the next generation about how to improve new treatment design and delivery. Evidence-based medicine (EBM) should communicate clearly the uncertainties around the treatment choices clinicians have to make. Done badly, EBM can be disabling. Done well, it is active and enabling.
As a psychologist, I am particularly interested in human bias. Much of our systematic review work in the Cochrane Collaboration involves understanding the biases that people introduce when they undertake science and the effect those biases have on the conclusions they draw from the their investigations. The classic example is randomization. Why do we randomize? Because we are managing human biases. We are now understanding how to manage other prevalent biases in research, including biases from design choices such as a randomization and allocation, biases in analysis such as the choice of imputation method, biases in the reporting of studies, such as measurement selection and partial reporting, and biases inherent in the publication process such as duplication, serial publication, and the shocking lack of replication studies.
People are interested in the work of the Cochrane Collaboration. The challenge is to manage an active library of current evidence, make it useful, and improve the quality of the evidence as our standards of undertaking both primary trials and the secondary analysis of data improves. How to understand evidence is a positive conversation people are willing to have rather than feeling they are being criticized, and that is good news, I think.
What other areas are you focusing on?
We’ve been trying to encourage people, for a number of years now, to think about pain as an attentional and motivational phenomenon. We’re interested in how pain interrupts normal cognitive function and resets a person’s priorities by introducing a threat stimulus that literally stops you, refocuses your attention, and imposes a higher-order priority of escape or avoidance. That attentional mechanism is what chronic pain patients talk about: They say often that what they find difficult is what pain stops them doing and who it stops them from being. If you think about pain in that way, it becomes an attentional problem.
One of the corollaries of this revolutionary way of thinking about pain as an attentional problem is that we next need to change how we measure the effectiveness of analgesics, and look for new targets of analgesic action, and new analgesic endpoints.
If you really think about it, it's quite an odd situation we have cornered ourselves into. We take people to a lab, put them in pain, and then tell them to stop what they’re thinking about, attend to their pain and tell us how bad that pain is. This is what we use as a measure of the effectiveness of an analgesic. But a really effective analgesic is one that stops the pain from interrupting in the first place, or one that reduces the frequency of the interruption, or one that makes the interruption less disabling. What we're trying to do is to measure that attentional grab aspect of pain. I'm not saying that intensity is unimportant; once pain has impinged upon your awareness or dragged your attention away from everything else and you attend towards it, then it's better that it was low intensity rather that high intensity. But if pain never grabs your attention in the first place—that for me is a good analgesic outcome. We don’t currently measure this.
Many researchers are familiar with measuring pain intensity on a scale of 0 to 10. How do you measure whether pain is grabbing a person’s attention?
We have developed cognitive tasks that we explore within what Geert Crombez [Ghent University, Belgium] and I have called primary task paradigms. Crudely, we say to participants: “Your job is to complete this particular cognitive task regardless of the pain.” This allows us to measure objectively the impact pain has on their performance.
Let’s pick a task like doing a crossword, which involves all sorts of micro-cognitive processes (various aspects of attention and memory function) and draws on different higher-order cognitive abilities (lexical problem solving, etc.). What we do is break such complex tasks down and look at them individually. We've discovered that pain doesn't affect all forms of attention—some people seem to be able to maintain certain attentional tasks regardless of being interrupted by pain, but there are other attentional tasks that are destroyed, and we are trying to focus on those [see Moore et al., 2011]. If we can standardize and measure those particular forms of attentional disruption, then we have novel ways—ways that are meaningful to patients—to measure the effectiveness of an analgesic.
That’s only part of the attentional story. The other part we’re interested in is the cascade flowing from repeated attentional interruption that we see in chronic pain patients. If you spend your life being interrupted by a threatening, painful stimulus 20-30 times an hour, or more, then what effect does that have on your life—your ability to plan, your memory, your relationships, your mood? That's how we understand chronic pain, and the bulk of our work is about how to help people with this complex, disassembling condition.
Helping children with chronic pain is also a big part of your clinical efforts. Can you tell me about that?
Our interest in young people started when more and more young people were referred to our adult services. We had no options. Sending people away with nothing was heartbreaking to the team. Clinicians need options.
So we decided to establish an adolescent service, which is still running. It was an interesting and privileged experience, which I got to write about once [see Eccleston et al., 2006]. We had (and still have) tremendous support from the international pediatric pain community, who are well organized and well coordinated through the IASP Special Interest Group on Pain in Childhood.
From a research perspective it was a relatively open field. There were no measures of the impact of chronic pain on adolescents, so we thought we’d better create them. There was no focus on parents, so we investigated the impact of child pain on parents. It grew in that way, as we filled in the gaps. We needed to establish and improve the effectiveness of the Bath treatment. And, of course, we undertook and still maintain the Cochrane Systematic Review on psychological treatments for chronic pain. There are still very few treatments in place, although there are some very good examples now in Germany, Sweden, Australia, and across the US. More treatments are needed, as are replications.
For me, this is now historical. More recently, we have been interested in two things. Ellen Henderson in my lab is looking at how young people use the Internet to make sense of their experience and seek help. I like that because we are asking sensible questions. These kids—Western kids, at least—are digital natives. They grow up with the Internet, they play on the Internet, they do their homework on the Internet, and they go there for their entertainment and social relationships. And then they go to the hospital and we give them paper and pencil!
We asked a very simple question: If your kids have pain, and they go on the Internet, what advice are they going to find? Then we ask how we can use the technology for social good and improve the quality of their experience [see Henderson et al., 2012].
Second, we are interested in developing treatments targeted at parents to help them be coaches for their kids with pain, because parents are critically important. We are working to support Tonya Palermo and colleagues in Seattle who are developing what will be the first parent-only treatment program ever trialed in pain. That is exciting.
Are there places in pain research where you and your colleagues are getting stuck?
I don't wish to be too provocative, but if you look at the history of experimental psychology, it has been hugely influenced by methods and technologies. Right from the very beginning, when Wilhelm Wundt introduced the use of chronometry into multisensory experiments, everybody started measuring perception by time to recognition. The stopwatch (if a rather large one) was king. Kurt Danziger reminds us that psychology has been too methodolatrous—an admixture of idolatry and method.
I see shades of that with neuroimaging. It concerns me greatly that we have become a little distracted by what is currently called neuroscience. This is not a popular message. But it surprises me how quickly we have redefined biological psychology and experimental psychology into neuroscience, which at the moment is driven by the methods, not the questions. Now, I’m not anti-technology, and there are some really interesting examples of neuroimaging. But as a whole, I think it presents a challenge to the field to make sure we don't rely too much on the methods, and that we think about the questions more.
You have commented in the past that applied pain psychology is too open to fashion, as in the current interest in acceptance and commitment therapy. You have published extensively on acceptance therapy. What do you see as the problem?
Well, actually, I have written and presented more on the concept of acceptance, which is open to many interpretations, and causes quite a bit of confusion. Personally, I am interested in moving methodically toward a better understanding of how acceptance as a target of some psychological treatments can be achieved [see Risdon et al., 2003]. That is the privilege of being a researcher and not a clinician—you can point out all the many and varied things that can be interesting. But if you're a clinician, you need to know what to do. And that is where people are rushing ahead and delivering new forms of therapy, and I argue that it's too soon.
It’s too early to move these therapies into clinical practice?
Yes, they’re not ready. And we shouldn't throw away what was working because we see something merely new.
Sometimes it happens in pharmacology as well: Everybody chases the same molecule, and then everyone chases in a different direction. But there are all sorts of regulations that stop people from turning those molecules into human medicines too quickly. That doesn’t really exist in psychology, because there’s an incorrect view that “You can’t cause harm, so it’s worth trying.”
I recognize that you need advocates—clever people who are really keen to push certain areas ahead. That’s how progress happens. But I’m just sounding a warning, so that we don’t throw away what’s useful and effective just because it's not fashionable.
Perhaps the most important thing to say about this debate is that we need to ask the right questions. Psychologists too often design studies and trials with a "horse race" design. We too often ask which is a better treatment: psychology treatment type A or psychology treatment type B, and pitch them against each other. This is often the wrong question. The right question is for whom and in what circumstances might treatment A be effective and for whom and in what circumstances might treatment B be effective. Clinicians need options. Have I said that before?
You advocate for looking at people’s psychological responses to chronic pain as normal adaptive responses to a difficult situation, rather than as abnormal psychology. Why does that distinction matter? How would such a change in perspective reshape research?
If you try to understand a person with chronic pain as displaying behavior that can be understood as psychopathological, then your job becomes identifying, categorizing, and understanding the illness. What you really need to understand is people’s behavior in context—how they’re responding to an unusual situation. What’s abnormal is not the people in pain, but the fact that a fundamental assumption of our culture has been violated, that they have unceasing pain. Their struggle—to understand, make sense of, react to, fix, mitigate, banish, escape, or accept that pain—is a wholly normal human reaction. What would you do?
If you accept this point of view, you start asking different questions. You don’t pathologize people and push them into a situation where they have to defend themselves against an unwelcome psychiatric-sounding diagnosis, when they could instead be looking at how they might cope. Scientifically, it pushes you to think about the wealth of models and theories that we have about normal behavior, theories you wouldn’t necessarily look at if you were spending your time trying to identify abnormal patterns. Now, don’t get me wrong: Having pain doesn’t inoculate you from having other psychological problems. You’re allowed to have more than one problem. But those other psychological problems are, in the vast majority of cases, unlikely to explain your pain behavior [see Eccleston, 2011].
The normal psychology of pain is more than a philosophical argument. It does lead us to do different empirical research. Recently, for example, we took a critical look at our own work on catastrophic thinking in young people, and by applying a normal psychological view, we analyzed our data differently, and this gave us a new understanding and new ways to think about treatment [see Eccleston et al., 2012].
Coming from a psychology background, do you have any favorite papers or books that you recommend all pain researchers read?
Well, there are too many papers to list. There are some terrifically good psychologists in pain research today. For books:
David Morris’ The Culture of Pain (1993). David is an English Literature professor first, and a social scientist second, so it’s well written, and he takes a thoroughgoing look at analgesic beliefs and practices in Western societies, and how they shape our expectations and behavior.
Bill Fordyce’s Behavioral Methods for Pain and Chronic Illness (1976) is a small book. It’s short on data, but conceptually it’s very clean. There are lots of people now who probably haven’t read it, just because they think it’s an old book, but what’s nice is that it’s a comprehensive system that really tries to translate why people behave the way they do. You can see the roots of what I’m calling normal psychology of pain in that behavioral analysis. There’s a lot in there that people have forgotten, and that’s why I think it’s worth revisiting.
Another book is Bandolier’s Little Book of Pain (2003). This book is all about evidence and how to ask questions, and what to do with the answers. It tries to demystify evidence-based medicine and make it relevant to pain. It’s a very neat contribution.
Is there a question you wish I had asked but didn’t?
I sometimes spend my time thinking about what is rather unglamorously called “workforce planning.” So I wonder: Are we doing enough as a pain community to ensure the future of pain scientists? And I’d say probably not. Recruiting the best people into pain, enabling a community that they can train within, ensuring that there’s a career path for them. That’s our challenge.
There are pockets of very good practice. Patrick McGrath [at Dalhousie University, Halifax, Canada] and his colleagues have done a remarkable thing in the last few years. They’ve set up the Pain in Child Health training initiative. Pediatric pain is a very small community of people, from bench scientists to psychological behavioral scientists. The PICH principal investigators have gathered them together—a lot of them seem to be in Canada—and have won grants to train people and create a community. It’s been very popular and very successful. This model should be learned from in other areas of pain training. Good scientists have choices: We need to turn them on to a career in pain.
Do you have a dream project? If you were magically given all the resources and time to do any project you’d like, what would you do that you’re not doing already?
First, I’d see if we could, from a policy and practice point of view, overcome barriers to delivering effective medicines to people who need them. That would be a knowledge transfer endeavor: an international knowledge transfer project. It sounds rather grand perhaps. This is not just about focusing on poorly resourced parts of the world. There are quite varied practices in the highest resourced areas, like in the US. There is an unacceptable variation worldwide in analgesic practice that is not explained by analgesic efficacy, but driven more by unchecked human biases.
Second, we are very interested in new treatment development. In psychology, most of our methods are based on a very small number of highly disabled people. I’m interested in mass treatment: How could we develop low-intensity, high-impact, highly effective treatments for the 40 percent of people who report a severe episode of pain every year? We’ve got some novel ideas about how to do that. It’s going to take 10 years, probably, to get to that.
Third, I’d really like to accelerate the work we’re doing on alternative targets—attention and motivation targets—for analgesics.
We’ll end on that ambitious note. Many thanks for talking with the PRF.
PRF Related Content:
News: Lancet Review: Most Chronic Pain Treatments Don’t Work (7 July 2011)
View Christopher Eccleston’s profile on Pain Research Forum (requires member log in)
Andrew Moore, Jayne Edwards, Jodie Barden and Henry McQuay. Bandolier’s Little Book of Pain. Oxford: Oxford University Press, 2003.
Morris, David. The Culture of Pain. Berkeley: University of California Press, 1993.
Fordyce, Wilbert. Behavioral Methods for Chronic Pain and Illness. St. Louis: Mosby, 1976.
Other Forum Interviews:
Pain and Its Control: A Conversation with Allan Basbaum (6 June 2012)