Feature

Bob Gatchel, PhD, has spent much of his academic career developing strategies for treating chronic pain associated with jaw disorders and back injuries: the kind of debilitating pain that takes people away from their jobs, their hobbies, their families--their lives. But beyond saving individuals from a life of physical agony, his work has helped foster the evidence-based trend toward interdisciplinary care--blending traditional medical practices, mental health treatment, physical therapy and social work--for treatment of the range of chronic diseases.

"It's rare to have the opportunity to really be involved in a major paradigm shift in medical science," says Gatchel, professor and chair of psychology at the University of Texas at Arlington. "My background in psychophysiology has allowed me to be in the right place at the right time--to be one of the people pushing this movement to where it is now."

A whole-person approach

Gatchel has focused much of his work on chronic pain in the lower back and related to jaw misalignment, called temporomandibular disorder. He sees psychological issues as a factor in such pain.

For example, Gatchel says a person with a stressful, hated job might use pain from a back injury as a way to escape it. Worse, he says, if they see pain as a way out, they may not do everything they can for a successful recovery. Identifying and treating a social influence like that, and its hidden psychological consequences, he says, can speed a patient's recovery.

"One group particularly susceptible to social factors are single moms," Gatchel says. "Single working moms are under the greatest stress, and the reason for that is they have two jobs: taking care of a family and putting food on the table. Being injured and in pain creates that much more stress for a working mom, making finding a reason to stay home attractive."

Beyond that, stress itself can lower a person's pain threshold.

"Stress creates a cycle that can rev up pain," he says. "The more stressed we are, the less stimulus we need to feel pain. It's a vicious feedback loop and another clear reason for an interdisciplinary approach to treatment."

Pain resulting from severe injury to other parts of the body also requires multidisciplinary intervention, notes Gatchel. Even after the original injury has healed, patients may still be in pain or very susceptible because their muscles have atrophied and there's nothing protecting them from sprains and strains. With that low activity level, they are likely to lose muscle tone throughout their body.

"If someone in the health-care team picks up behavioral problems like that, we can do something about them," Gatchel says. "We can get them into physical therapy for reconditioning, we can get them a cortisone injection to reduce inflammation, we can help them sleep, we can teach them to relax and we can get them medication if they're oversensitized to pain. But it all depends on catching the behavioral problem, and that means treating the whole person."

Proving the point

Through research published in 1995 in Spine (Vol. 20, No. 24), Gatchel showed that future chronic pain could be predicted. He and his research team evaluated 421 patients with workplace injuries resulting in acute lower back pain--pain complaints of less than six weeks--for psychosocial problems like mental illness, poor coping skills and stressful lifestyle, to determine who had a "psychosocial disability factor." The study showed a significant correlation between that factor and some workers' development of chronic lower back pain one year later.

Subsequently, he developed a treatment model that incorporates traditional medical practices, psychotherapy, physical therapy and social work into a personalized early-intervention system. For example, an at-risk patient in Gatchel's clinic is monitored closely and taught emotional coping skills by a psychologist, encouraged by a physical therapist to keep up mobility and counseled about work and living conditions by a social worker--all while continuing work with a physician.

A 2003 article in the Journal of Occupational Rehabilitation (Vol. 13, No. 1) spelled out the success of this approach: Patients who received early intervention displayed significantly greater improvements in psychosocial functioning, pain levels, medication use, health-care needs and occupational outcomes. In addition, overall treatment costs dropped.

Contributing to a larger trend

Through his chronic pain research, Gatchel is opening eyes to the effectiveness and efficiency of interdisciplinary approaches in all areas of chronic disease, says University of Washington psychologist Dennis Turk, PhD, who co-wrote with Gatchel the book "Psychological Approaches to Pain Management: A Practitioner's Handbook," (2002, Guildford Publications).

"He has truly epitomized the biopsychosocial perspective to which so many give lip service but so few actually practice," says Turk.

In addition to his academic, research and ideological achievements, Gatchel, who received this year's APA Award for Distinguished Professional Contributions to Applied Research, is illustrating the cost-effectiveness of interdisciplinary pain treatments to insurance companies and the medical establishment in general--important to the field becoming an integral part of health-care delivery, says Turk.

And his main assistant in doing that, says Gatchel, is strong science.

"Our major task as behavioral scientists will be to ensure that the biopsychosocial approach's continued evolution occurs in a scientifically rigorous manner," Gatchel says. "With great opportunity comes equally great responsibility for progress in this exciting new era for psychologists."

Further Reading

Learn Gatchel's approach

More information on how to treat patients with chronic pain is available in an APA-produced video, "Pain Management with Robert J. Gatchel," and the new APA book "Clinical Essentials of Pain Management," by Gatchel. The video explains the interaction between psychosocial factors and pain and demonstrates how psychologists can work with patients to control pain. For more information on the video, go to www.apa.org/videos/4310589.html, and for information on the book, go to APA Books 4317053.