Treatment for pain can include counseling, relaxation training, meditation, hypnosis, biofeedback, or behavior modification. The philosophy common to all of these approaches is the belief that patients can do something on their own to manage their pain. That something may mean changing attitudes, feelings, or behaviors associated with pain.

Psychotherapy. Some patients may benefit from individual or group counseling. Trained professionals can help the chronic pain sufferer learn valuable coping skills. They also provide the patient with much needed support-both psychological and emotional-for dealing with pain.

Relaxation and meditation therapies. These methods enable people to relax tense muscles, reduce anxiety, and alter mental states. Both physical and mental tension can make pain worse, and in conditions such as headache or back pain, tension may be at the root of the problem. Meditation, which aims at producing a state of relaxed but alert awareness, is sometimes combined with therapies that encourage people to think of pain as something remote and apart from them. The methods promote a sense of detachment so that the patient thinks of the pain as confined to a particular body part over which he or she has control. The approach may be particularly helpful when pain is associated with fear, as in cancer.

Hypnosis. No longer considered magic, hypnosis is a technique in which an individual's susceptibility to suggestion is heightened. Normal volunteers who prove to be excellent subjects for hypnosis often report a marked reduction or obliteration of experimentally induced pain, such as that produced by a mild electric shock. The hypnotic state does not lower the volunteer's heart rate, respiration, or other autonomic responses. These physical reactions show the expected increases normally associated with painful stimulation.

The role of hypnosis in treating chronic pain patients is uncertain. Some studies have shown that 15 to 20 percent of hypnotizable patients with moderate to severe pain can achieve total relief with hypnosis. Other studies report that hypnosis reduces anxiety and depression. By lowering the burden of emotional suffering, pain may become more bearable.

Biofeedback. Some individuals can learn voluntary control over certain body activities if they are provided with information about how the system is working-how fast their heart is beating, how tense their head or neck muscles are, how cold their hands are. The information is usually supplied through visual or auditory cues that code the body activity in some obvious way-a louder sound meaning an increase in muscle tension, for example. How people use this biofeedback to learn control is not understood, but some practitioners of the art report that imagery helps: they may think of a warm tropical beach, for example, when they want to raise the temperature of their hands. Biofeedback may be a logical approach in pain conditions that involve tense muscles, like tension headache or low back pain. But results are mixed.

Behavior modification. This psychological technique (sometimes called operant conditioning) is aimed at changing habits, behaviors, and attitudes that can develop in chronic pain patients. Some patients become dependent, anxious, and homebound-if not bedridden. For some, too, chronic pain may be a welcome friend, relieving them of the boredom of a dull job or the burden of family responsibilities. These psychological rewards-sometimes combined with financial gains from compensation payments or insurance-work against improvements in the patient's condition, and can encourage increased drug dependency, repeated surgery, and multiple doctor and clinic visits.

There is no question that the patient feels pain. The hope of behavior modification is that pain relief can be obtained from a program aimed at changing the individual's lifestyle. The program begins with a complete assessment of the painful condition and a thorough explanation of how the program works. It is essential to enlist the full cooperation of both the patient and family members. The treatment is aimed at reducing pain medication and increasing mobility and independence through a graduated program of exercise, diet, and other activities. The patient is rewarded for positive efforts with praise and attention. Rewards are withheld when the patient retreats into negative attitudes or demanding and dependent behavior.

How effective are any of these treatment methods? Are some superior to others? Who is most likely to benefit? Do the benefits last? The answers are not yet in hand. Patient selection and patient cooperation are all-important. Analysis of individuals who have improved dramatically with one or another of these approaches is helping to pinpoint what factors are likely to lead to successful treatment.