Chronic pain treatment programs in North America are based predominantly on a behavioral science model of contingency management, whereby the focus of treatment is directed toward the psychological aspects of pain. Treatment objectives are designed to eliminate reinforcing environmental contingencies, thus changing pain behavior and reestablishing well behavior. The purpose of this article is to displace the contingency management model with deconstruction and thus present an alternative conceptualization based on the experiences of chronic pain sufferers. Social work's value base of self-determination and empowerment upholds these challenges to the predominant treatment model. Alternative social work interventions are explored.
Chronic pain has captured growing attention in the medical and health care professions during the past 25 years, becoming a complex problem of major medical, social, economic, and personal proportion. Chronic pain has been estimated to cost between 60 billion and 65 billion dollars and 700 million workdays annually in the United States (Blackwell, 1989; Sieppert, 1996). Health care costs, lost work hours, and compensation have been cited as key areas of concern throughout the research literature. The personal costs of chronic pain need to be recognized and validated, because chronic pain sufferers cannot elude pain characterized as "evasive:' "overwhelming' "isolating:' "horrendous," and "unbearable" (Rose, 1994; Seers & Friedli, 1996).
Chronic pain treatment has been conceptualized predominantly in a medical model, with growing emphasis on the psychological behavioral components (Bonica, 1990). Causation has been defined in three classifications: malignant, non-malignant, and idiopathic. In the first two classifications, identifiable pathology can be specified, whereas in the third no sign of tissue damage is apparent or the pain appears disproportionate to the physical cause (Bendelow & Williams, 1995). The diagnostic and treatment processes applied to patients classified with idiopathic pain is the presented concern and focus of this article. With the diagnosis of idiopathic pain, an emphasis emerges on "chronic pain behavior resulting primarily from reinforcing environmental influences or so-called operant mechanisms" (Bonica, p. 201), leading to a behavioral science model of contingency management. Contingency is defined as "the consequences that are expected to follow behaviors," whereby "the consequences of a given behavior largely i nfluence the future occurrence of that behavior" (Barker, 1997, p. 78). Chronic pain treatment thus focuses on the management of patients' behaviors, distinguishing pain behaviors through the withdrawal of reinforcing influences; for example, expressions of pain would be ignored by the health care team. Once environmental contingencies that reinforce sick (pain) behavior are eliminated, well behavior is re-established (Bonica; Fordyce, 1990; Loeser, Seres, & Newman, 1990).
From a social work perspective, this article challenges the premises on which this behaviorist approach to chronic pain is founded, follows contingency assessment through to its implications for chronic sufferers, and makes space for an alternative approach guided by the "voices of sufferers." Researchers and practitioners repeatedly highlight the necessity of trust, empathy, respect, and empowerment in service delivery to chronic pain patients (Lipkin, 1989; Marcus, 1986; Murray, 1997; Pilowsky & Barrow, 1990; Vrancken, 1989). Yet, the voices of sufferers reflect powerlessness and the fundamental need to have their pain believed (Howell, 1994; Miles, 1992; Seers & Friedli, 1996). This article uncovers the contradictions inherent in the contingency management model through the process of deconstruction. Deconstruction has been defined as an "analysis that takes apart socially constructed categories as a way of seeing how a particular world view is constructed" (Ristock & Pennell, 1996, p. …