Mark Jensen, PhD, is a professor and the vice chair for research in the Department of Rehabilitation Medicine at the University of Washington Medical Center, US. Mark has contributed to the development and evaluation of measures of pain, and pain-related beliefs and coping strategies, as well as to the development and assessment of psychosocial pain interventions that include cognitive behavioral, hypnotic, and motivational approaches.
Here, Mark chats with Rodrigo Rizzo, a PhD candidate at the University of New South Wales, Sydney, Australia, and PRF correspondent, about his journey through the world of pain science over the past decades, and the future of research in the field of psychosocial interventions for chronic pain. Below is an edited transcript of their conversation.
Can you tell me about your training and why you got into pain science in the first place?
I got into pain science because of Monty Python. I went to graduate school with a plan to study depression and strategies for helping people learn how to self-manage depression, but the professor working in that area was too busy to take on a new graduate student. So I had to interview other faculty members to find out who I might work with. When I met who turned out to be my primary mentor, Paul Karoly, I said a line out of a Monty Python sketch early on in our interview. He immediately said the next line, and we ended up going through the sketch. We clearly had a similar sense of humor. I thought to myself, "I want to work with this guy," even before I found out much about what he did.
So I asked him. He said that he worked in the area of “health psychology.” This was around 1982, and I didn't have any idea what “health psychology” meant. [Paul] invited me to read up on it, and I immediately became fascinated, especially about the role that psychology plays in a person’s experience and response to pain. So I started working with Paul, focusing on pain. I was told multiple times throughout my graduate school training, "You're too focused. You're too focused. You should learn about and research topics other than just pain." I just wasn't that interested in other topics. In fact, I think focusing that way is actually a good idea. I think that being very focused allows one to ultimately have a greater impact on the field.
At that time, what were the challenges and opportunities in the pain research field?
I wanted to understand pain and how psychological factors contributed to pain. Of course, to study pain, you have to be able to measure it. At the time, the gold standard measure for pain intensity was the Visual Analog Scale (VAS). I started using it in my studies, but it turned out that many of my study participants were unable to use it. Not only were the marks they sometimes put on the VAS line difficult to interpret, but they would sometimes write on the line itself rather than make a mark on the line. For example, I remember one participate wrote on the VAS line, “It hurts a lot!” I thought, "How can this be the gold standard? There's got to be something easier for people to use." I looked at alternatives, and I noticed that we really didn't know much about how the different pain intensity measures compared to each other in terms of validity, reliability, and ease of use. Out of necessity, I started to conduct a series of studies to compare pain intensity measures, with a goal of identifying the ones that are easy to use, while still being both valid and reliable. Over time, I've become even more interested in measuring pain, but at the time, I was mostly interested in understanding psychological factors and just needed a useful measure of pain intensity to help with that.
Similarly, in the early 1980s, there were a lot of untested theories about the psychological factors that contribute to pain and its impact, such as beliefs and self-efficacy. I wanted to test those theories, and I looked for measures of the constructs hypothesized to be important, but they didn't exist yet. Again, out of necessity, I had to learn how to develop measures and how to test their validity.
Can you elaborate a bit more on the scales you developed, their importance, and how they have been used in research and clinical practice?
If we have a hypothesis that there are personal factors that are related to and impact someone’s response to pain, and those factors are targeted for change with treatment, we must have measures of those factors to test our theories. [These measures] need to be precise, reliable, and valid. At the time, cognitive behavioral therapy was emerging as a major player, but valid measures of the cognitive “piece” did not exist.
We had a measure of [pain] catastrophizing, which includes items that measure very negative beliefs. But catastrophizing was not the only personal factor we were targeting in treatment. Therefore, I developed the Survey of Pain Attitudes (SOPA) in 1987. The SOPA assessed the variety of beliefs we thought were most important at the time. This included the beliefs, "I can control my pain,” “hurt equals harm,” and that, “pain is a signal of damage.” In treatment, we were working to teach people to have more confidence about their ability to control pain and its impact, and to understand that the experience of pain does not necessarily mean that the body is being damaged.
I had a sense that the SOPA assessed the majority of beliefs that needed to be examined in research, so I then went on to develop a measure of how people cope with pain. At the time, I was working as an attending psychologist at Multidisciplinary Pain Treatment at the University of Washington, and we were teaching strategies such as, “Keep with a task that you know is safe, even when you hurt.” We called this coping responsetask persistence. We taught strategies for ignoring pain and other coping responses that we had no measures for at the time. That was the inspiration for the Chronic Pain Coping Inventory, first published in 1995.
In recent years, there's been an interest not only in what people think about and how they cope with pain, but also in what they do with their thoughts – cognitive processes like mindfulness, pushing away thoughts, and accepting thoughts. There have been treatments, like acceptance and commitment therapy, that have argued that how people manage their thoughts is perhaps even more important, or as important, as what those thoughts are. With my colleague Melissa Day at the University of Queensland – she was the lead author on the development of this scale, which was published in 2018 – we developed a measure of cognitive processes called the Pain-Related Cognitive Process Questionnaire. Using this measure – as well as our legacy measures assessing cognitive content or beliefs and coping responses – we are working to discover the beliefs, coping responses, and cognitive processes most easily changed by what treatments, and when you change these beliefs, what happens to important outcomes like pain intensity, pain interference, and psychological function?
Can you give us an example of how you can differentiate content from processes?
There’s a metaphor I like to use to differentiate cognitive content from cognitive processes. Let's say you want to diet to lose weight; you want to control your diet. What's more important to losing weight? Is it the content of what's in the refrigerator, or is it what you do with the content in the refrigerator? People might argue that one is more important than the other. On the surface, it might be reasonable to argue that what you do with the food is more important than the food that is available. But in fact, if there is only unhealthy food available, since you have to eat to live, you are kind of stuck with eating unhealthy food. I think it is most reasonable to argue that both are important, but the role that each plays in weight loss or gain depends on context.
Thoughts are like that. You can sit back and ask, "What are the thoughts that are going through my head?" For most people, there are some that are useful, like, "I'm a good person. I'm strong. I'm competent. I'm compassionate." Sometimes, people have heard messages when they were growing up that have stuck with them and are less useful, such as, "I have some doubts. Maybe I'm not as smart as I should be. Maybe I'm not a good person.” When working with someone with pain, it is critical in my view to understand the thoughts that are present – what is the food that they have available to them? Then we can determine if (and when) to focus on content, process, or both. By understanding the thoughts going through a person’s head, we are in a better position to teach them what they can do to nurture the adaptive thoughts, and perhaps not try and suppress the less helpful thoughts. We now understand that thought suppression is not effective; however, teaching people how to morph less useful thoughts into ones that are more useful and adaptive is effective. It's a matter of teaching people these skills, to both change the content of the refrigerator, and then what you do with that content.
Is that the future of self-reported measures for pain?
That's certainly my future. In the next 5-10 years, I hope to refine the measures that we've developed, and then ask the questions, “Which treatments alter which domains?” and “What cognitive content, coping, and cognitive process domains are most closely associated with outcome?”
You have published several papers and books about clinical hypnosis. Can you tell us why you became interested in hypnosis for pain management?
I was curious about hypnosis in graduate school because it kept coming up as a potential pain treatment, mostly in case study reports. So I asked my mentors, "Should we be looking into hypnosis as an option for chronic pain management?" They said, "No. Maybe for labor pain, but certainly not for chronic pain. Who can be in a trance all the time?"
I had this initial curiosity but did not follow through with it for many years. Then, I think in the mid-1990s, I read a book called A Whole New Life by Reynolds Price. He's a person who had cancer in the spine and the severe pain associated with that. He described a turning point in his life when he learned self-hypnosis and was able to take his “9 out of 10” pain and just put it aside, so he could get on with his life. He noted that, "When I looked at [the pain], it was still a 9 out of 10, but I was able to use hypnosis to put it aside." I thought that sounded interesting. At the same time, I was working with many patients with pain from a spinal cord injury who were telling me after cognitive therapy treatment, "I'm thinking better, I have better thoughts, but I really hurt. Do you have anything to help with the pain? Drugs aren't helping. Nothing is helping. I just hurt." I thought, "You know, this thing that Reynolds Price described looks pretty interesting. I should look into that."
You've had an incredible impact on pain research. What makes you so productive?
I got two bits of advice early on that I think have been very helpful, one from Paul Karoly, and one from another mentor, Judy Turner. Paul said that to be productive, he finds it useful to have a project at every stage. You should be collecting data. You should be analyzing data for one project and writing the paper for another. You should have a paper that's under review, papers that are accepted or “in press,” and then papers that have been recently published. If you don't have something in any one of those bins, do something to fill that bin. At the same time, if you have too much in one bin, then stop working in that bin. If you are always collecting data, you will not have time to analyze the data or write it up for publication. If you are not collecting data for a project while you are writing up another one, you won’t have data on hand to analyze and write up when you submit the paper you’re working on.
Judy Turner advised that if you're lucky, and you’re an academician, in the morning you will have a day in front of you to decide what you are going to do. With this flexibility, her advice was to always work on the project that's closest to publication. If you have a paper almost ready to submit for publication, finish and submit it as a top priority. Even then, if you are working on a paper and you get a notice that a paper has been accepted pending revision, stop everything else, revise the paper, and resubmit it. Then get back to the paper that is almost ready to be submitted.
There’s a third thing that many people already know but has taken me more time to learn, and that is the ability to say, “No.” As you're more successful, you will be asked to do more and more things, so you have to figure out a way to politely decline. Every time you say “yes” to something, you have to say “no” to something else, such as a paper that then won't ultimately get written. So I have learned to say, "I'm sorry. I can't. I have too many other commitments." Early on, I struggled with that, and I ended up feeling overwhelmed with too many commitments and not enough time to get my own work done. So I had to start a behavioral program, where I would reinforce myself with a reinforcer. Every time I said no to something, I gave myself a treat, and learned to say, “No, thank you.”
Is there anything else that you would suggest for younger researchers?
Everything is a team approach, so who you choose to work with is very, very critical. I've found myself working only with people who are responsive. You send them an email, they write back. You send them a paper to review, a couple of days later it's back with edits. If I start working with a new colleague, and I send them work that just sits on their desk for weeks, I will of course follow through with my commitment for that project, but I do not usually choose to work on future projects. So my advice: Do not work alone. Find colleagues and collaborators. Be highly responsive to their requests for feedback and edits on collaborative projects. Stick with and by those colleagues who are most timely in their responses.
Rodrigo Rizzo is a physiotherapist and PhD candidate at the University of New South Wales and Neuroscience Research Australia in Sydney, Australia. Twitter: @rodrizzo_pain