Beverly Thorn, PhD, ABPP, is Professor Emerita of Psychology at the University of Alabama. Thorn obtained her PhD in Bioclinical Psychology from Southern Illinois University in 1980 and worked at the Ohio State University before spending much of her career the University of Alabama. Since her retirement in 2016, Thorn has continued to plan an active role in the dissemination and implementation of CBT for chronic pain in low-income and disadvantaged populations. In the lead up to the 42nd Annual Scientific Meeting of the Australian Pain Society, to be held in Hobart from April 10-13, 2022, Thorn spoke with Lincoln Tracy, a research fellow from Monash University, Australia about her path to pain research, her passion for information dissemination, and more. Below is an edited transcript of their conversation.
How did you get started in research?
When I was young, growing up in the suburbs of Washington, I had a neighbour who was a social worker who I looked up to. She got me a summer job where she worked, and I loved getting to work closely with people. So, I started out as an undergraduate sociology major at Emory University in Atlanta, but it was all theory. It drove me crazy!
Then I took my first psychology class as a sophomore, and I was hooked. After that I worked with a faculty member in psychology, which was a great opportunity for me. It was non-human animal research, looking at brain mechanisms of eating and drinking. I did my Honours project there, before being accepted into an early version of a health psychology program at Southern Illinois.
Once again, I gravitated towards the neuroscience end of things, probably because that was what I was used to. I had a mentor who was interested in opiate dependence and withdrawal research. It wasn’t until later, after I became a faculty member, that I started doing human research as well as animal research. I did that for 15 years and then I moved completely to human research.
How did you make the transition from working with both humans and animals to focusing on the components of cognitive behavioural therapy for chronic pain conditions?
That was a multi-year transition. I first started doing human research when I was at Ohio State University. We were using the cold pressor test and other ischemic pain techniques, and I became very interested in observing what people were telling themselves about the experience. Some of the early studies looked at time distortion. I found it interesting that if you gave somebody a goal to, for example, last three minutes in the cold pressor, they generally lasted three minutes, even if you didn’t show them how long they were lasting. But if you told somebody to last as long as they could, they lasted about half as long.
Having a goal also led to more accurate time estimations than not having a goal, which was also very interesting to me. During this research, I talked to a lot of people. The kinds of things they were thinking was amazing, like, “I am absolutely going to die, I’m going to die, I’m just going to die”—just from having their hand in ice water. I found what people told themselves interesting, as it made a huge difference in their ability to cope.
That’s how I started looking at cognitive behavioural therapy more closely. I found most of the good clinical research was more behavioural in orientation. Bill Fordyce—the father of behavioural pain psychology—used operant theory to talk about pain and coping. He talked about positive reinforcers, negative reinforcers, punishment, and using these to improve people’s function.
There was a lot out there on behavioural aspect, but I didn’t see a whole lot out there on the cognitive aspect, especially in pain. So, one of the things I was really interested in was expanding that awareness. There was a text by Dennis Turk and his colleagues on cognitive behavioural therapy for chronic pain, but the cognitive component wasn’t fleshed out in detail. It was somewhat more theoretical than clinical or practical. I thought, I want to make this clinical and practical. So, when I published my first book in 2004, Cognitive Therapy for Chronic Pain, I focused on applying the cognitive model to chronic pain. I’m not claiming I’m the only one who did that, but I fleshed it out for practitioners who could use this model.
What was the process behind writing that first book?
It felt like I was pulling bits and pieces from a lot of different places. As I said before, it’s not like I invented this concept by any means. For example, I looked at Aaron Beck’s work on cognitive therapy in depression and applied it to chronic pain. I thought there was a missing link in pain and that Beck’s tripartite model of automatic thoughts, intermediate beliefs, and core beliefs could be applied to chronic pain. In addition, we knew from the literature that the way people judged a pain stimulus or stressor makes a difference in the first place.
We all walk around with this running stream of automatic thoughts about our experiences. They can often get quite judgemental, especially about ourselves. A lot of the time we don’t realise they’re occurring, but they influence our emotions and coping behaviour. Like what Beck did and taught in depression, I wanted to help patients become aware of these thoughts and to question their validity. And if they aren’t valid, can we change the thought to something a bit truer?
Everybody has a set of rules and expectations about themselves, how the way the world is supposed to be, and how they’re supposed to be. For example, if someone with chronic pain believes, “To be a good person, I must financially provide for my family,” then how will they cope when they are debilitated by their pain? This is when we need to hold onto our core beliefs about our worthiness. I believed this could be a perfect template for a cognitive therapy intervention for chronic pain. Ultimately, I tried to put the book together in a format that would be useful to practitioners.
What has been the most interesting research study or clinical initiative you’ve been involved in during your career?
In the decade or so after I published my first book, I was surprised to get so many emails from practitioners who had bought and read it. People enjoyed the book and found it useful, but they wondered whether the cognitive therapy approach—which requires written records, reading, and doing homework—was appropriate for people who don’t necessarily do a lot of reading and writing?
My initial response was, of course it is. But after thinking about it for a while, I just had to find out if what they were saying was true. So, my graduate students and postdocs embarked on a 15-year journey to make sure the therapy detailed in the book was appropriate for the general population. We started by determining at what level the patient materials in the book were written. I’m ashamed to say they were written at a 10th grade level, and current guidelines are that our written materials for patients should be at a fifth-grade level. But that was the olden days when I hadn’t paid attention to those sorts of things.
We essentially rewrote the patient materials at a fifth-grade level. To do that, we used available guidelines to adapt the materials, increase the font size, reduce the number of syllables in words, and reduce jargon. We added illustrations, and we held focus groups with patients in the right demographic to make sure the new materials would be acceptable.
We went through a multi-year adaptation phase and ran a randomised controlled trial with patients at federally funded pain clinics called community health centres, many of whom don’t have insurance. We wanted to show the materials were appropriate and acceptable to these people and people, and that they would show up stay in the groups. But we also wanted to see if it the treatment was effective. And while it was effective in decreasing pain and depression, we had a higher drop out rate in our cognitive behavioural therapy group than in a simpler pain education comparison group.
The dropout rate told me that the cognitive-behavioural treatment was still too complicated and that we needed to keep adapting. And we did until we had the right kind of treatment. After that, we ran another large trial and showed both cognitive behavioural therapy and pain education did a better job than medical treatment as usual in terms of reducing pain, reducing depression, and increasing function. And we didn’t have as many dropouts. That’s been the most rewarding and most interesting aspect of my career.
What were some of the challenges in adapting and refining the cognitive behavioural therapy program?
People with limited literacy skills or from other kinds of disadvantaged backgrounds have often been cut out of research for one reason or another. But they’re a big part of our society, are differentially affected by chronic pain, and have a lot of real-world barriers to accessing healthcare. One thing we really found was transportation. In many cases one family uses one car, and they juggle people’s needs and appointments so the car can be well utilized. And sometimes they don’t have a car, so just getting them there was a problem.
But I think the most interesting thing to me is how the patients judge you based on whether they feel like you are a real person. They don’t judge you on your degrees or your intellect. They judge you on whether you’re genuine. If you are genuine, if they think you are genuine, they will do anything for you. But if they think you are not genuine or you are acting all high and mighty, they’ll never show up again. This was fascinating to me because my experience with well-educated people was the opposite. They cared about my degrees and the fancy words I was using, but they weren’t really looking at my personhood. It was challenging to break the habit of using all our fancy words, and being more real, but when you do break the habit, it’s so rewarding.
What’s the best piece of advice you’ve received?
One thing I still talk to my students about is that collaboration is really, really, important, but not everyone is going to be the ideal collaborator. The most important thing about collaboration is to do what you say you’re going to do. And then do it when you say you’re going to do it. You only need to drop the ball a few times before people start talking and you find yourself being shut out of collaboration opportunities. A key part of it is something as simple as closing the loop. When I send you an email, you send an email back saying, “Got it. Will do it” or “Got it. Can’t do it for a week but I got it.” A small message is better than nothing and sitting there wondering whether they got the email or not. And some really good advice that is often not heeded is finishing a project before the deadline. Why? Because chances are, something unavoidable will come up right around that deadline, and now you have no insurance policy. Do it early. You won’t regret it.
Finally, if you could have a dinner party with anyone from history—dead or alive—who would you want at your table and why?
This was the hardest question by far [laughs]. I thought about inviting the Dalai Lama, but he has a very early dinner because he gets up at 3.30 in the morning. So, I would have to say van Gogh’s sister-in-law, Johanna van Gogh-Bonger. van Gogh’s brother—Theo—was an art dealer, historian, and promoter, who really tried to help him as an artist. But mainly, he had to help him a lot with getting by day to day because van Gogh had serious mental illness. His brother went to a lot of trouble to sort of keep him propped up and painting to the point where he was such a caretaker. Theo probably shortened his own life by all the caregiving he gave Vincent, as he died prematurely.
When Theo died, Jo took up the call. She was really the one responsible for putting van Gogh’s artwork into the light. She was the one who said, “This is important stuff, and we are going to promote it.” I would love to hear her thinking process behind all of that. Was it just a matter of I had no choice, I had to provide for my family? I don’t think so, because it took a whole lot more than just providing for your family to do what she did. I’d love to hear about how she mastered all that while being a woman in the late 1800s, which was a really difficult time for professional women.
Lincoln Tracy is a postdoctoral research fellow in the School of Public Health and Preventive Medicine at Monash University and freelance writer from Melbourne, Australia. He is a member of the Australian Pain Society and enthusiastic conference attendee. You can follow him on Twitter (@lincolntracy) or check out some of his other writing on his website.