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CHAPTER 7
Understanding and Managing Pain
Lecture Outline
I. Pain and the Nervous System
All sensory stimulation, including pain, starts with activation of sensory neurons and
proceeds with the relay of neural impulses toward the brain.
A. Somatosensory System
The somatosensory system conveys sensory information from the body through
the spinal cord to the brain.
1. Afferent Neurons
Afferent (sensory) neurons convey sensory information from sense organs to
the spinal cord and then to the brain. Efferent (motor) neurons result in the
movement of muscles. Interneurons connect afferent and efferent neurons.
Primary afferents are those neurons that have receptors in the sense organs and
that originate the neuron’s message. The vast number of neurons and their
interconnections makes neural transmission complex.
2. Involvement in Pain
Nociceptors are neurons capable of sensing pain stimuli. Three different types
of neurons are involved with transmitting pain impulses. The large A-beta fibers
and smaller A-delta fibers are covered with myelin, which speeds neural
transmission. The smaller and more common C fibers require high levels of
stimulation to fire. These different fibers with their different thresholds and
transmission speeds may relate to different types of pain sensation.
B. The Spinal Cord
Primary afferents from the skin enter the spinal cord where they synapse with
neurons in the dorsal horns of the spinal cord. The dorsal horns contain several
laminae (layers). Laminae 1 and laminae 2 form the substantia gelatinosa, a
structure that receives sensory input from the A and C fibers.
Complex interactions of sensory input occur in the laminae of the dorsal horns, and
these interactions may affect the perception of sensory input before it gets to the
brain.
C. The Brain
The thalamus receives sensory input from the different neural tracts in the spinal
cord. The skin is mapped in the somatosensory cortex in the parietal lobe of the
cerebral cortex, and the proportion of cortex devoted to an area of skin is proportional
to that skin’s sensitivity to stimulation (see Figure 7.2). Sensory information from
internal organs are not mapped as precisely as the skin, leading people to have the
ability to identify stimulation from the skin but less distinct sensory perceptions of
their internal organs. This is also the reasoning behind referred pain, when pain is
experienced in a part of the body other than the site where the pain stimulus
originates.
D. Neurotransmitters and Pain
The neurotransmitters that form the basis for neural transmission also play a role
in pain perception. The discovery of the endogenous opiates—enkephalin,
endorphin, and dynorphin—led to the discovery of neural receptors specialized for
141
Chapter 7
these neurotransmitters and the conclusion that opiate drugs produce analgesia
because of the brain’s own chemistry. The neurotransmitters glutamate and substance
P and the chemicals bradykinin and prostaglandins may exacerbate pain stimulation.
Proinflammatory cytokines produced by the immune system are also involved in pain,
possibly creating chronic pain by sensitizing neurons in the spinal cord.
E. Modulation of Pain
When the periaqueductal gray, a structure in the midbrain, is stimulated, pain
relief occurs. The neurons in the periaqueductal gray synapse with neurons in the
nucleus raphé magnus, a structure in the medulla (see Figure 7.3). These neurons
descend to the spinal cord and may constitute a descending control system for pain
perception.
II. The Meaning of Pain

The traditional view of pain focused on the physical sensations, but about 100 years
ago, C. A. Strong proposed that pain consists of not only the sensation but also person’s
reaction to that sensation.
A. Definition of Pain
Perhaps the most acceptable definition of pain is the one proposed by the
International Association Subcommittee for the Study of Pain that defined pain as an
unpleasant sensory experience accompanied by an emotional experience and actual or
potential tissue damage.
At least three stages of pain have been identified. Acute pain is ordinarily
adaptive, lasts a relatively short period of time, and includes pain from cuts, burns,
and other physical trauma. Chronic pain endures beyond the time of normal healing,
is relatively constant, is often reinforced by other people, and may become self-
perpetuating. Prechronic pain is experienced between acute and chronic pain and is
critical because during this time, the pain may either go away or evolve into chronic
pain. Another type of pain is chronic recurrent pain, or when there are alternating
episodes of intense pain and no pain.
B. The Experience of Pain
Pain is both personal and subjective, but situational and cultural factors play a role
in its experience. Beecher’s observations on wounded soldiers during World War II
highlight the variability of pain—seriously wounded soldiers reported little pain.
Individual variations exist in the experience of pain, but as Beecher suggested,
situational factors are important. Cultural expectations and stereotypes as well as
cultural sanctions against the expression of pain influence pain behaviors. Sanctions
against expressing pain may be a large part of the gender difference in pain, but some
evidence indicates that women may also be more sensitive to pain. Thus, a variety of
individual, cultural, and gender-related factors influence the experience of pain.
C. Theories of Pain
How people experience pain is the subject of a number of theories. Of the several
models of pain, two capture the divergent ways of conceptualizing pain: the
specificity theory and the gate control theory.
1. Specificity Theory
The specificity theory can be traced to Descartes, who hypothesized that the
body works by mechanistic principles. Applied to pain, this theory holds that pain
is the result of transmission of specific signals. Research has failed to find pain
142
receptors or fibers specifically devoted to pain transmission. This theory also fails
to integrate the variability of the pain experience.
2. The Gate Control Theory
Melzack and Wall formulated the gate control theory of pain as a way to
explain the variability of pain perception (see Figure 7.4). They hypothesized that
a gating mechanism exists in the spinal cord and that sensory input is modulated
in the substantia gelatinosa of the dorsal horns of the spinal cord. This modulation
can change pain perception, as can brain-level alterations from a hypothesized
central control trigger. This theory includes explanations of both physiological
and psychological modulations of the pain experience. Melzack has proposed an
extension to the gate control theory, called neuromatrix theory, which places a
stronger emphasis on the brain’s role in pain perception.
III. The Measurement of Pain

Tools for measuring pain are important in order to evaluate the various pain
therapies. A number of techniques have been used to measure laboratory and clinical
pain, and these fall into three main categories: self-reports, behavioral assessments, and
physiological measures.
A. Self-Reports
Self-reports of pain include simple rating scales, standardized pain inventories,
and standardized personality inventories.
1. Rating Scales
With self-report rating scales, patients rate the intensity of their pain on a
scale; for example, the scale may range from 1 to 100. A similar technique is the
Visual Analog in which patients check severity of pain on a continuum from no
pain to worst pain imaginable. The faces scale is a similar approach consisting of
drawings of facial expressions of pain, which is suitable for children and older
adults.
2. Pain Questionnaires
Melzack developed the McGill Pain Questionnaire (MPQ), an inventory that
categorized pain into three dimensions: sensory, affective, and evaluative. The
sensory dimension includes pain described in terms of its temporal, spatial,
pressure, and thermal properties; the affective dimension defines pain in terms of
fear, tension, and autonomic properties of the pain experience; and the evaluative
dimension includes the perceived severity of the entire pain experience. The MPQ
has adequate validity, but its vocabulary is somewhat difficult.
The Multidimensional Pain Inventory (MPI) is another questionnaire that
measures several aspects of pain: characteristics of the pain, patients’ perception
of the responses of others to their pain, and ratings of daily activities of the
patient. This inventory has allowed for the development of 13 different scales that
capture different dimensions of the lives of pain patients.
3. Standardized Psychological Tests
Standardized tests, such as the MMPI-2, have also been used to assess pain.
This instrument is useful in differentiating among types of pain patients and has
some ability to predict which patients will respond to medical treatments for pain.
Other commonly administered tests include the Beck Depression Inventory and
the Symptom Checklist-90.
B. Behavioral Assessment
Chapter 7
People in pain often behave in ways that communicate to others that they are in
pain, which can be used as an informal or standardized assessment of pain. Health
care workers tend to underestimate patients’ pain, but spouses and others close to pain
patients can provide a better assessment. This approach is especially useful for
individual who cannot provide self-reports, such as small children and some older
individuals who cannot communicate verbally.
C. Physiological Measures
Although pain produces an emotional response, research has failed to identify
specific organic states that are strongly correlated with pain. Muscle tension and
autonomic responses such as heart rate and skin temperature show some relationship
to the experience of pain, but neither type of measurement shows sufficient reliability
and validity to be a good measurement technique.
IV. Pain Syndromes

Acute pain has the advantage of signaling injury, but chronic pain has no
advantages. Such pain can be classified according to location or syndrome, symptoms
that occur together and characterize a condition. Headache and low back pain are the two
most frequently treated types of chronic pain, but health psychologists also deal with
other pain syndromes.
A. Headache Pain
Headache pain is the most common of all pains, with more than 99% of
Americans suffering from some form of headache over their lifetime. The most
common varieties are migraine, tension, and cluster headaches, although the
symptoms overlap and clear classification is often impossible. Migraine (or vascular)
headaches bring about loss of appetite, nausea, vomiting, and increased sensitivity to
light. Tension headaches are muscular in origin and are characterized by
contractions of the muscles of the neck, shoulders, scalp, and face. Cluster
headaches produce intense pain localized in one side of the head and occur
frequently over a period of days, then disappear for weeks or months.
B. Low Back Pain
The most frequent causes of low back pain are injury or stress resulting in
musculoskeletal, ligament, or neurological problems in the lower back. In addition,
stress and psychological factors may play roles in back pain. Most of the people who
experience back pain do not progress to chronic pain, but those who do tend to have
persistent pain. Only about 20% of back pain patients have an identified, physical
cause for their pain.
C. Arthritis Pain
A variety of arthritic pains exist, and many involve inflammation of the joints.
Rheumatoid arthritis, perhaps the most frequent cause of arthritic pain, is an
autoimmune disorder characterized by a dull ache within or around a joint.
Osteoarthritis is a progressive inflammation of the joints mostly affecting older
people and characterized by a dull ache in the joint area. Fibromyalgia is a chronic
pain condition characterized by tender points throughout the body, fatigue, headache,
cognitive difficulties, anxiety, and sleep disturbances. This condition leads to a
diminished quality of life that is similar to the barriers faced by those with arthritis.
D. Cancer Pain
144
Cancer pain is caused by either a malignancy or by treatment of a malignancy.

Pain is present in a majority of terminal cancer cases, and both chemotherapy and
radiation therapy produce pain. Often pain goes untreated for cancer patients.
E. Phantom Limb Pain
Phantom limb pain is the experience of chronic pain in an amputated part of the
body. People who have had arms, legs, or breasts removed nearly always continue to
feel some sensation (frequently pain) despite the removal of that body part and the
nerves that underlie sensation.
V. Managing Pain
Managing chronic pain is a challenge because this type of pain has no identifiable
cause. Thus, several approaches to treatment exist, including medical and behavioral
techniques.
A. Medical Approaches to Managing Pain
Treatment of acute pain is easier than for chronic pain, but both present
challenges.
1. Drugs
Analgesic drugs are the most common treatment for acute pain. These drugs
fall into two groups: opiates and nonnarcotic analgesics. Opiate drugs have
powerful analgesic effects but also produce tolerance and dependence. However,
the fear of drug-related problems, such as addiction, leads to under-medication
more often than to drug abuse. The recent increase in the use of prescription
analgesic drugs was due mostly for the demand for oxycodone and hydrocodone,
both of which are opiates with a potential for abuse. Low back pain patients may
receive more drug treatment than the ideal level for their condition.
Aspirin and the other nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen and naproxen sodium, as well as acetaminophen drugs, are all useful in
managing minor pain, especially pain due to injury. Antidepressant drugs and
antiseizure drugs also affect pain perception and may be useful in pain
management for some people.
2. Surgery
Surgery may be directed either to repairing damage that causes pain or to altering
the nervous system to change pain perception. Surgery is an attempt to control low
back pain more often than other pain syndromes, and specific nerves or the spinal
cord may be targets. Surgery may also be used to implant devices to stimulate the
spinal cord to decrease pain. Surgery is not always effective, either in repairing
damage or in producing pain relief, especially for people with low back pain. A
related technique is transcutaneous electrical nerve stimulation (TENS), which
uses electrical impulses to stimulate skin stimulation to block pain messages. Spinal
cord stimulation is more effective than TENS.
B. Behavioral Interventions for Managing Pain
Some people classify behavioral techniques as alternative treatment or mind-body
medicine, but psychologists focus on the behavioral aspects of these treatments and
consider them part of psychology.
1. Relaxation Training
Chapter 7
Progressive muscle relaxation involves learning to relax the entire body, one
muscle group at a time, and to breathe deeply and exhale slowly. This technique
had been used to manage a variety of pain problems, including headaches,
rheumatoid arthritis, and low back pain. A National Institutes of Health
Technology panel’s evaluation for pain treatments gave relaxation training its
highest rating.
2. Behavioral Therapy
Behavior modification techniques are based on the principles of operant
conditioning and are used by health psychologists to help people cope with stress
and pain. The goal of behavior modification is to shape behavior, not to alleviate
feelings of stress or sensations of pain. People in pain may continue their pain
behaviors because they receive positive reinforcers such as attention, sympathy,
financial compensation, relief from work, and other rewards. Positive reinforcers
may create pain traps that turn acute pain into chronic pain. The rationale behind
behavior modification is to train people in the pain patient’s environment to
discontinue reinforcement for pain behaviors, thus avoid the pain trap. Progress is
measured in terms of observable behavior, such as amount of medication,
absences from work, physical activity, and so forth. Behavior modification does
not address the cognitions that underlie behavior.
Cognitive therapy rests on the assumption that a change in the interpretation
of an event can change people's emotional and physiological reaction to that
event. Because pain is at least partially due to psychological factors, cognitive
therapy attempts to get patients to think differently about their pain experiences
and to increase their confidence that they can cope with them.
Cognitive behavioral therapy aims to develop beliefs, thoughts, and skills to
make positive changes in behavior. Dennis Turk and Donald Meichenbaum have
developed a cognitive behavioral program for pain management called pain
inoculation, which parallels stress inoculation (described in Chapter 5). These
techniques involve the cognitive stage of reconceptualization and the behavioral
stages of acquisition and rehearsal of skills and follow-through.
Research indicates that behavior modification, cognitive therapy, and
cognitive behavioral therapy are effective for a wide variety of pain conditions
(see Table 7.2).
Exploring Health on the Web

Several websites provide information about many aspects of pain, including types of
pain, theories, syndromes, and treatment options.
http://www.americanpainsociety.org
This website is the one maintained by the American Pain Society, which is a
professional society for those researching the topic of pain.
http://www.americanheadachesociety.org
The website for the American Headache Society is oriented toward professionals
but also includes information accessible to students.
http://www.theacpa.org
146
This website is maintained by the American Chronic Pain Association, an

organization devoted to raising awareness and offering support to those with chronic pain
problems.
Suggested Activities
Personal Health Profile — Charting Pain
As an activity for their Personal Health Profile, your students should begin a pain
diary, which will supplement the stress diary they began with Chapter 6. This diary should
extend for at least a week, during which time everyone will experience some type of pain.
Many of those pains will be acute, but nearly everyone suffers from headaches, at least
occasionally, and some students will have other chronic pains, such as low back pain or pain
from various injuries. As part of their pain diary, your students should rate the intensity of
their pain on perhaps a 10-point scale, record time of day when the pain is most intense, and
note environmental or psychosocial events that seem to relate to the pain's onset. They
should also describe their attempts to cope with the pain. Did they try to relax, take aspirin
or other analgesic drugs, rest in bed, or use some other means to seek pain relief? With such
a detailed diary, your students can make some predictions concerning when, where, or why
a pain will return.
Creating Chronic Pain

Many factors contribute to the development of chronic pain, and social learning
theory holds that reinforcement for pain behaviors is a major contributor. To develop a
better understanding of how people reinforce pain, arrange a role-playing activity for your
students. Choose someone to be the person in pain and work with this person so that he or
she can display a realistic variety of pain behaviors. Choose others to play the roles of
family members and friends and decide who will reinforce and who will fail to reinforce the
person’s pain. (Make sure that someone ignores the person’s pain behaviors without being
mean or unkind to this person.)
This activity should be presented as a skit in which the person in pain manifests pain
behaviors, and others react to the pain behaviors in various ways. After observing the
interactions, ask your class how they felt about those people who rewarded the pain
behaviors. Did they feel that these people were being kind and helpful? What does learning
theory say about the consequences of such “help?” How did they feel about those who failed
to reward the person’s pain? Is it acceptable to fail to be solicitous to those in pain? What
problems does this dilemma pose for people who want to be helpful but also know that
reinforcement can increase the frequency of undesirable behavior?
Understanding the Impact of Chronic Pain

The common experience of acute pain does not lead to an understanding of chronic
pain. People who do not experience chronic pain have little understanding of what life is
like with everyday pain. To better comprehend life with chronic pain, arrange for your
students to interview someone who has a chronic pain syndrome. Instruct them to ask
questions about the person’s sensations; what barriers pain has imposed on his or her life,
what treatments the person has sought, and which treatments were more effective.
Exploring a Neurological View of Pain
Chapter 7
Physicians often have views that differ from those of psychologists, and you can
allow your students to become acquainted with these differences by inviting a neurologist to
be a guest lecturer on the topic of pain. A neurologist who specializes in pain treatment
would be ideal, but any neurologist should be very familiar with the puzzles of pain and its
treatment.
Describing Pain
The textbook chapter highlights a number of different pain measures. Here are
links to some of the pain measures mentioned:
McGill Pain Questionnaire:
http://www.chcr.brown.edu/pcoc/shortmcgillquest.pdf
A sample Visual Analog Pain Scale:
http://www.partnersagainstpain.com/printouts/A7012AS1.pdf
West Haven Yale Multidimensional Pain Inventory
http://www.tac.vic.gov.au/media/upload/west_haven_yale_multidimensional_pain
_inventory.pdf
Living with No Pain

Living without pain might seem like a blessing, but it is not always. Students will
be fascinated to read about Ashlyn Blocker, the “girl who could feel no pain”, in this NY
Times article (http://www.nytimes.com/2012/11/18/magazine/ashlyn-blocker-feels-no-
pain.html). The camp mentioned in the article has the following website that has
additional links about Congenital Insensitivity to Pain:
http://www.painlessbuthopeful.org/Information_and_Media.html
Relaxation Training
One behavioral technique for managing pain is relaxation training. Below are two
sample scripts you could read aloud to students to have them gain a better understanding
of this technique works.
http:/www.amsa.org/healingthehealer/musclerelaxation.cfm
http://prtl.uhcl.edu/portal/page/portal/COS/Self_Help_and_Handouts/Files_and_
Documents/Progressive%20Muscle%20Relaxation.pdf
Video Recommendations
From Films for the Humanities & Sciences:
Pain: The Language of the Body and the Mind (2000) is a 3-part series of short videos. This
series includes "The Physiology of Pain," featuring the neurology underlying pain
perception and how the nervous system can modulate these signals, "The Psychology of
Pain," which shows how emotion and behavioral factors can increase or decrease pain, and
"The Management of Pain," which examines medical and behavioral treatments.
148
The Anatomy of Pain (2003) presents various types of pain, outlines how pain is
conveyed through the nervous system, distinguishes between acute and chronic pain, and
addresses treatment through medication and acupuncture.
Chronic Pain (2005) explores causes and treatments for pain by presenting pain experts
and patients who have used a variety of approaches to manage pain.
World of Pain: Coping and Caring (2001) combines dramatization and information to show
a hypothetical family and real case studies of pain. Both pain perception and pain
management are featured.
Headache: The Painful Truth (2001) explores tension, migraine, and cluster headaches and
those who suffer from them. In addition, this video includes prominent experts who present
research and findings about this pain syndrome.
Migraines (2007) focuses on this common and debilitating type of headache, including
diagnosis and treatment.
Low Back Pain (2005) explores this pain syndrome that as many as 80 percent of people
experience at some point in their lives. This program focuses on the physical injuries that
can result in back pain and the medical treatments.
From Fanlight Productions:
A Disease Called Pain (2003) explores chronic pain through the experience of chronic
pain patients. This program clearly distinguishes between acute and chronic pain and
presents some of the approaches to managing chronic pain.
Other Films:
127 Hours –A major motion movie about Aron Ralston (played by James Franco) who
needed to cut off his arm to save his life. Available for DVD rental.
Videos from the Web:
http://youtu.be/b3fX96OugmA –This video examines the relationship between pain and

depression, how both should be treated, and why this is difficult (1:07; “Depression and
Chronic Pain is Extremely Common”).
http://youtu.be/SPOcqXkygoQ – This video explains possible reason why pain patients

often feel as though they should “tough it out” and why this is problematic (1:53;“Pain
Patients Shouldn’t Tough It Out”).
http://youtu.be/_IUmVcwGbWE – This video explains how pain patients track their pain
(1:46).
http://www.youtube.com/watch?v=6qocxopS5fc&feature=share&list=PL9DF1AB9AE98
3C82B – This video showcases the treatment for a chronic pain patient (4:09).
Chapter 7
http://youtu.be/YL_6OMPywnQ - This video explains how mirror therapy is used to help

decrease phantom limb pain (2:32).
150
Multiple Choice Questions
1. The ______ system allows us to interpret certain sensory information as pain.

a. somatosensory
b. endocrine
c. skeletal
d. muscular
ANS: a REF: Pain and the Nervous System
2. Primary afferents convey sensory impulses to the

a. spinal cord.
b. peripheral nervous system.
c. brain.
d. motor neurons.
3. Myelinated afferent neurons are called

a. A fibers.
b. beta afferents.
c. C fibers.
d. delta afferents.
4. More than half of all sensory afferents are

a. A-beta fibers.
b. A-delta fibers.
c. C fibers.
d. myelinated.
ANS: c REF: Pain and the Nervous System
5. Sherman stubbed his toe on the sidewalk. His sensation of pain traveled first to
the
a. muscles in the foot.
b. brain.
c. spinal cord.
d. cranial nerves.
6. This system conveys sensory information from the body to the brain.
a. endocrine system
b. digestive system
c. somatosensory system
d. immune system
7. _________ neurons carry nerve impulses away from the brain and toward the
muscles.
143
Chapter 7
a. Efferent
b. Afferent
c. Beta afferents
d. Delta afferents
8. Nociception refers to the process of perceiving ________.

a. stress
b. pain
c. anger
d. oxygen
ANS: b REF: Pain and the Nervous System
9. Stimulation of the A-delta fibers, since they are myelinated, leads to a _______,
whereas the unmyelinated C fibers often result in _____________.
a. “slow pain” response; “fast pain” response
b. “no pain” response; “slow pain” response
c. “fast pain” response; “slow pain” response
d. “no pain” response; “fast pain” response
10. Afferent fibers group together after leaving the skin, forming a _____.
a. nerve
b. cell
c. cell body
d. ganglion cell
11. When pain is experienced in some other location than the site where the pain was
inflicted, this is called
a. phantom limb pain.
b. referred pain.
c. prechronic pain.
d. chronic recurrent pain.
12. Recent research gave participants __________ to reduce people’s feelings of

social pain.
a. a shock
b. a hug
c. Tylenol
d. Morphine
13. Participants who are socially excluded show more activity in the anterior
cingulate cortex, similar to people who are experiencing _____________.
a. physical pain
b. depression
144
c. anxiety
d. all of the above
14. _____ are chemicals that carry information between nerves.

a. Afferent neurons
b. Efferent neurons
c. Neurotransmitters
d. Interneurons
15. _______ are neurochemicals that help modulate, or lessen, the experience of pain.
a. Endorphins
b. Interneurons
c. Glutamates
d. Proinflammatory cytokines
16. These proteins produced by the immune system increase pain sensitivity, along
with increasing fatigue and sickness:
a. proinflammatory cytokines
b. endorphins
c. opiates
d. both a and b
17. The dorsal horns are located in the

a. brain stem.
b. kidneys.
c. midbrain.
d. spinal cord.
ANS: d REF: Pain and the Nervous System
18. The substantia gelatinosa is

a. in the dorsal horns of the spinal cord.
b. in the midbrain region, adjacent to the thalamus.
c. composed of a gelatin-like material that surrounds the lower portion of the
brain.
d. a hypothetical structure that has not yet been confirmed.
19. Which structure is most capable of modulating sensory input?

a. primary afferents
b. secondary afferents
c. substantia gelatinosa
d. spinothalamic tract
145
Chapter 7
20. Sensory input information passes through what brain structure?

a. the parietal lobe of the cerebral cortex
b. the pons
c. the cerebellum
d. the thalamus
ANS: d REF: Pain and the Nervous System
21. What brain structure contains a representation of the skin’s surface?

a. somatosensory cortex
b. parietosensory area
c. sensorimotor cortex
d. occipital cortex
22. Neurotransmitters like _____ decrease pain, but those like ________ increase the
experience of pain.
a. serotonin . . . dynorphin
b. endorphin . . . glutamate
c. substance P . . . serotonin
d. endorphin . . . enkephalin
23. Which of the body's own neurochemicals does NOT have opiate-like effects?
a. serotonin
b. dynorphin
c. endorphin
d. enkephalin
24. Pain is usually defined as

a. a sensory experience only.
b. an emotional experience only.
c. neither a sensory nor an emotional experience.
d. both a sensory and an emotional experience.
ANS: d REF: The Meaning of Pain
25. Victoria has just cut her hand with a sharp knife. The pain she feels can best be
described as
a. acute.
b. prechronic.
c. chronic intractable.
d. chronic.
ANS: a REF: The Meaning of Pain
146
26. Which of these is NOT a distinction between chronic and acute pain?
a. Acute pain is usually adaptive; chronic pain is not.
b. Acute pain is physical; chronic pain is psychological.
c. Chronic pain is frequently perpetuated by environmental reinforcers; acute
pain needs no such reinforcement.
d. Chronic pain has no biological benefit; acute warns the person to avoid
further injury.
ANS: b REF: The Meaning of Pain
27. Henry Beecher reported that soldiers wounded at the Anzio beachhead during
World War II experienced ______ pain.
a. chronic intractable
b. stress-related
c. severe, excruciating
d. very little
28. Kyle is experiencing headaches and his partner has taken over the household
chores. Research by Pence et al. (2008) would suggest that Kyle’s headaches are
likely to
a. increase in intensity.
b. decrease in intensity.
c. completely disappear.
d. disappear until his partner makes him do the chores again.
29. This personality trait has been associated with a “pain-resistant” personality.
a. Conscientiousness
b. Extraversion
c. Neuroticism
d. There is no “pain-resistant” personality.
30. Physicians are likely to underestimate the pain of

a. Asian Americans.
b. African Americans.
c. European Americans.
d. no ethnic group; doctors treat all patients equally.
31. According to the gate control theory, emotions such as ______ could increase
pain by affecting the gate to open, whereas emotions such as _____ could
decrease pain by affecting the gate to close.
a. happiness; depression
b. joy; anxiety
c. anxiety; happiness
d. depression; anxiety
ANS: c REF: The Meaning of Pain
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32. Matthew is running a marathon and trips over a pile of acorns, but finishes the
race. Afterwards, he finds out his ankle is sprained. What theory best accounts for
the fact that Matthew did not immediately stop running after tripping?
a. specificity theory of pain
b. gate control theory of pain
c. delay of gratification theory of pain
d. none of the above
33. People in pain frequently receive attention and sympathy, which may provide
____________ for these pain behaviors.
a. reinforcement
b. negative scheduling
c. punishment
d. generalization
34. In some cultures, people undergo initiation rituals that call for them to have their
body pierced, cut, tattooed, burned, or beaten. These individuals
a. feel no pain.
b. show little or no pain from an accidental injury.
c. feel pain, but their culture trains them to exhibit no pain during these
initiation rituals.
d. offer proof that pain is totally psychological.
35. What is the relationship between the experience of pain and some types of
psychopathology?
a. People with personality disorders have heightened pain perception.
b. People with pain-prone personalities tend to have borderline personality
disorder.
c. People with pain-resistant personalities tend to have bipolar disorder.
d. It is not clear whether psychopathology makes one vulnerable to pain or
whether being in pain produces psychopathology.
36. During the birth process, women in some cultures exhibit many more signs of
pain than women in other cultures. This observation shows that
a. the experience of pain varies from culture to culture.
b. cultural practices can influence the expression of pain.
c. natural childbirth produces less pain than opiate drugs.
d. women who express little pain during childbirth are undergoing self-
hypnosis.
37. With regard to gender,
148
a. women sense pain more quickly than men.

b. women are more likely to hide their pain.
c. men are more likely to be aware of their pain.
d. men are less likely to report pain.
38. Specificity theory hypothesizes that

a. a person's interpretation of pain is more important that tissue damage in
determining the intensity of pain.
b. acute pains intensify over time.
c. the experience of pain is approximately equal to the amount of tissue
damage or injury.
d. chronic pain can become acute pain over time.
39. Which of these findings cast doubt on the specificity theory of pain?
a. Researchers have failed to find specific skin receptors devoted to relaying
pain.
b. Phantom limb pain occurs in 70% of amputees.
c. Injury can occur without pain, such as that experienced by the soldiers at
Anzio beach.
d. all of these
40. The theory of pain proposed by Melzack and Wall has been called the _____
theory.
a. gate control
b. sensory decision
c. cognitive-emotional
d. tension-reduction
41. According to the gate control theory of pain, the structure that is the likely
location of the gate is
a. the substantia gelatinosa.
b. the ventral horns of the spinal cord.
c. the transverse section of the medulla.
d. supraspinal nerve endings.
42. According to the gate control theory of pain, the spinal cord
a. mechanically relays sensory input information.
b. modulates the input of sensory information.
c. does not have the physiological capacity to affect pain perception.
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Chapter 7
d. is less important in pain perception than the cerebellum.

43. The gate control theory of pain assumes

a. the physiological reality of pain.
b. the nature of motor output factors in pain perception.
c. that chronic pain is heavily influenced by both spinal cord and brain
activity.
d. that sensory input is not the only factor in pain perception.
44. Melzack proposed the _______ theory, which is an extension of the gate control
theory.
a. sensory decision
b. specificity
c. neuromatrix
d. cerebellar
45. Valid and reliable measures of pain are important to health psychologists
primarily because
a. such measurements permit accurate evaluation of various pain therapy
programs.
b. self-reports are more useful than physiological measures.
c. pain is a product of both physiological and emotional factors.
d. behavioral assessments are more reliable and valid.
ANS: a REF: The Measurement of Pain
46. Which of these methods have been used to measure pain?

a. self-reports
b. behavioral assessment
c. physiological measures
d. all of these
ANS: d REF: The Measurement of Pain
47. The Visual Analog Scale is considered to be

a. a self-report.
b. an evoked potential measure of pain.
c. a behavioral assessment of pain.
d. a pain questionnaire.
48. The most widely used pain questionnaire was developed by Ronald Melzack and
is known as the
a. Melzack and Wall Pain Questionnaire.
b. Visual Analog Scale.
c. Minnesota Multiphasic Personality Inventory.
d. McGill Pain Questionnaire.
150
ANS: d REF: The Measurement of Pain
49. A personality inventory sometimes used to assess pain is the

a. California Personality Inventory.
b. Minnesota Multiphasic Personality Inventory.
c. Edwards Personality Schedule.
d. Guilford-Zimmerman Temperament Survey.
ANS: b REF: The Measurement of Pain
50. Heart rate predicts perceptions of pain, but only for ________.
a. children
b. the elderly
c. men
d. women
ANS: c REF: The Measurement of Pain
51. Which of these techniques measures muscle tension as an index of pain?

a. electromyography
b. thermography
c. blood flow in the temporal artery
d. heart rate
52. _____ pain is the most common of all syndromes of pain with a lifetime incidence
rate of more than 99%.
a. Headache
b. Low back
c. Burn
d. Knee
ANS: a REF: Pain Syndromes
53. Rosa suffers from recurrent attacks of pain that are accompanied by exaggerated
sensitivity to light, loss of appetite, and nausea. From these characteristics you
would diagnose Rosa as having
a. migraine headaches.
b. tension headaches.
c. cancer pain.
d. phantom limb pain.
54. With regard to migraine headaches,

a. men are somewhat more likely than women to have migraines.
b. women are much more likely than men to have migraines.
c. women are slightly more likely than men to have migraines.
d. women and men are about equally susceptible to migraines.
ANS: b REF: Pain Syndromes
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55. Carlos is a 45-year-old civil engineer who has never had a migraine headache. His
chances of a first migraine are
a. very high.
b. about 50/50.
c. very low.
d. nonexistent.
ANS: c REF: Pain Syndromes
56. What type of pain has a gradual onset, sensations of tightness around the neck and
shoulders, and a steady ache on both sides of the head?
a. low back pain
b. migraine headache
c. cluster headache
d. tension headache
ANS: d REF: Pain Syndromes
57. Wendy suffers from headaches that occur nearly every day for about a month, but
then go away for about a year or more. From this description, it appears that
Wendy suffers from
a. cluster headaches.
b. migraine headaches.
c. tension headache.
d. none of the above.
58. The two most common types of pain are

a. cancer and headache.
b. arthritis and low back.
c. headache and low back.
d. cancer and low back.
59. Which of these conditions may contribute to low back pain?
a. pregnancy
b. improper lifting of heavy objects
c. aging
d. all of these
60. Low back pain has many causes. About what percent of back pain patients have
an identified, physical cause for their pain?
a. 20%
b. 50%
c. 75%
d. about 40% of men and about 60% of women
61. Unlike rheumatoid arthritis, osteoarthritis

a. frequently occurs in younger as well as older people.
152
b. affects mostly men.

c. is an autoimmune disorder.
d. affects mostly older people.
62. Chronic pain affects approximately ____ of the population in the United States.
a. 50%
b. 10%
c. 75%
d. 30%
63. The three primary kinds of headaches are:

a. migraine, cluster, chronic
b. chronic, tension, cluster
c. migraine, cluster, tension
d. tension, migraine, chronic
64. What types of headaches are more common in men than in women?
a. chronic
b. cluster
c. migraine
d. tension
65. Almost ____ of all cancer patients’ pain was untreated.

a. 10%
b. 20%
c. 50%
d. 90%
66. Jesse’s leg was amputated when he was 20. 10 years later, he still occasionally
feels pain in that missing limb. This pain is called
a. missing limb pain.
b. phantom limb pain.
c. amputation pain.
d. neuroses.
67. For phantom limb pain, the pain is more likely in the missing limb when:
a. there was much pain before the amputation.
b. there was no pain before the amputation.
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c. the amputated limb is a leg.

d. all phantom pain is the same pain intensity.
68. _______ occurs when the body needs more and more of the drug to reach the
same effect and _______ occurs when removal of the drug causes withdrawal
symptoms.
a. Withdrawal; dependence
b. Dependence; withdrawal
c. Tolerance; dependence
d. Dependence; tolerance
ANS: c REF: Managing Pain
69. The tendency to catastrophize is associated with ________.

a. magnification of pain.
b. lessening of pain.
c. no differences in perception of pain.
d. magnification of pain, but only when other people are present.
70. Cognitive behavioral therapy has been shown to be effective in relieving pain for
a. headache patients
b. fibromyalgia patients
c. patients with AIDS pain
d. all of the above
71. One variation of cognitive behavioral therapy, encourages participants to _____

their pain and focus their attention on valued activities.
a. deny
b. accept
c. enjoy
d. commit to
72. Approximately _____ % of all terminal cancer cases experience pain.

a. 15-20
b. 25-40
c. 45-65
d. 98 to 99
73. Medical procedures used in pain management have traditionally included

a. cognitive therapy.
b. drugs.
c. surgery.
d. both drugs and surgery.
154
ANS: d REF: Managing Pain
74. Opiate drugs

a. are effective analgesics.
b. produce dependence.
c. produce tolerance.
d. all of these.
75. About what percentage of people who receive opiates during a hospital stay
becomes addicted?
a. less than 1%
b. more than 5% but less than 25%
c. about 50%
d. almost 100%
ANS: a REF: Managing Pain
76. Systems of self-paced administration of analgesic drugs

a. overcome the problem of undermedication.
b. increase the probability of addiction.
c. lead to a situation in which about 45% of patients overmedicate
themselves.
d. all of these.
77. Aspirin-type analgesic drugs are most effective in

a. treating gastric disorders.
b. relieving cancer pain.
c. treating injuries that are accompanied by inflammation.
d. treating patients who are candidates for surgery.
78. Analgesic drugs are effective for pain control, but

a. most people misuse these drugs, using dangerous amounts.
b. NSAIDS are more effective than opiates.
c. anesthetic drugs are preferable for controlling chronic pain.
d. antidepressant drugs may also be useful in treating some types of pain.
79. Bailey has tried many treatments for chronic back pain. His treatment of last
resort would probably be
a. surgery.
b. TENS.
c. opium-based drugs.
d. hypnosis.
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Chapter 7
80. Researchers have found that transcutaneous electrical nerve stimulation (TENS)
a. is effective for acute but not chronic pain.
b. increases pain during stimulation, but patients report less pain after
stimulation.
c. is not very effective in relieving pain.
d. has no advantage over other medical methods.
81. The type of spinal stimulation that is most effective in controlling pain is
a. transcutaneous electrical nerve stimulation (TENS).
b. stimulation from implanted devices that stimulate the spinal cord.
c. subcutaneous chemical stimulation (SCS).
d. alternating stimulation of the peripheral nerves near the site of injury and
stimulation close to the spinal cord.
ANS: b REF: Managing Pain
82. Relaxation training has been used successfully to

a. treat rheumatoid arthritis.
b. treat low back pain.
c. reduce headache pain.
d. all of these.
83. Behavior modification techniques rely most heavily on

a. classical conditioning concepts.
b. operant conditioning principles.
c. observational learning theory.
d. cognitive learning strategies.
84. Wilbert Fordyce, along with others who advocate a behavior modification view of
pain, claimed that
a. pain itself is rewarding to the individual pain patient.
b. pain sensations can be eliminated by the use of behavior modification.
c. pain behaviors may have reinforcing consequences for the pain patient.
d. cognitive therapy is the most effective means of pain control.
85. Pain authority Frank Andrasik proposed that pain traps occur when
a. situations push people experiencing pain toward chronic pain.
b. a person with a pain-prone personality experiences pain.
c. A-delta fibers are stimulated at the same time as C fibers.
d. a person experiences pain at the same time as some positive situation.
156
86. In behavior modification programs for pain management, pain behaviors are
a. ignored.
b. punished.
c. rewarded.
d. Any of these can be a component of a behavior modification program for
pain.
87. What might be a reinforcer for pain behavior?

a. the sensory input
b. the motor output
c. the disapproval of family members
d. monetary compensation for injury
88. Cognitive therapists emphasize a change in

a. personality traits.
b. overt behavior.
c. thinking patterns.
d. philosophy of life.
89. In comparison to behavior modification techniques, cognitive therapy

a. is less effective.
b. is more solidly based in learning theory.
c. places more emphasis on the interpretation of events.
d. has a longer tradition of use for pain management.
90. According to cognitive therapists, beliefs, personal standards, and ________

strongly affect people's behavior.
a. history of reinforcement
b. “catastrophizing”
c. suggestibility
d. implicit memory
91. Of the medical and psychological interventions for managing chronic pain,
__________ is/are probably the most effective.
a. surgery
b. opiate drugs
c. biofeedback
d. cognitive behavioral therapy
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Chapter 7
True/False Questions
1. The largest organ of the body is the skin.
ANS: T
2. A recent study examined social rejection and found that the resulting emotional pain
affected brain activity similarly to physical pain.
ANS: T
3. Based on recent research by Yoshino et al. (2010) on mood and pain, if Courtney is
feeling happy, she should experience less pain than when she is feeling sad.
ANS: T
4. Efferent neurons carry nerve impulses away from the brain, whereas afferent neurons
carry nerve impulses toward the brain.
ANS: T
5. Women are more than twice as likely to develop rheumatoid arthritis as men.
ANS: T
6. Acute pain has no benefit to the person who is experiencing it.

ANS: F
7. Delmar constantly complained to his wife Merna about pain in his knee. Merna decided
to stop sympathizing with Delmar and to withhold any sort of positive reinforcement to his
pain behaviors, so we would expect Delmar to stop feeling pain in his knee.
ANS: F
8. Some people have a pain-resistant personality and are much more sensitive to pain than
other people.
ANS: F
9. In general, women are much more sensitive to pain than men.

ANS: F
10. The gate control theory assumes that pain experiences can be increased or decreased by
mechanisms in the brain and spinal cord.
ANS: T
11. Approximately 50% of people have reported severe headaches in the last 3 months.
ANS: F
12. The most common type of pain is low back pain.

ANS: F
13. People who complain about pain in an amputated limb are simply imagining the pain.
ANS: F
158
14. The dangers of opiate drugs outweigh their risks for pain control.
ANS: F
15. Medication is an important treatment for people with low back pain, and
undermedication is a serious problem for these patients.
ANS: F
16. Surgery is not a successful treatment for many people with low back pain.
ANS: T
17. According to the gate control theory, pain has only sensory components.
ANS: F
18. Low-back pain patients who use pain medications are at an increased risk for more
health problems than patients who do not use pain medications.
ANS: T
19. Providing positive feedback and assistance are the best ways to help someone with
low back pain recover.
ANS: F
20. Behavior modification attempts to change behavior without altering the environment.
ANS: F
21. Cognitive therapy and cognitive behavioral therapy both strive to alter patterns of
thinking.
ANS: T
Essay Questions
1. Jonathan has just cut his left hand while chopping onions. Trace the sensory input
from finger to brain, mentioning the important structures in the nervous system.
A. In the skin, the cut activates primary afferents.
1. The neurons that relay pain are called nociceptors.
2. Large A-beta fibers and smaller A-delta fibers are stimulated and rapidly
transmit neural impulses toward the spinal cord.
3. Although more difficult to stimulate, the cut would activate small C-fibers,
and these neural impulses would also travel to the spinal cord.
B. Sensory afferents form nerves that travel toward the spinal cord, either in sensory
nerves or mixed nerves.
C. Sensory input enters the dorsal horns of the spinal cord.
1. Many primary afferents synapse with secondary afferents in the dorsal horns,
but other primary afferents continue to the brain.
2. The arrangement and interconnections of laminae of the dorsal horns receive
sensory input, modulate it, and relay these messages toward the brain,
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Chapter 7
D. Sensory input travels to the brain by way of the spinal cord and crosses from the
left side of the body to the right side of the brain.
E. Sensory neurons synapse in the thalamus, and then go to the right somatosensory
cortex in the parietal lobe of the forebrain.
1. The primary somatosensory cortex maps those receptors in the hand,
providing a representation of the hand in the brain.
2. The somatosensory cortex is involved with interpretation of the sensory input,
most likely as pain.
2. Did Jonathan’s cut finger hurt? What experiences and psychological factors might
increase or decrease his experience of pain?
A. Jonathan’s cut finger most likely hurt.
1. If Jonathan has a congenital insensitivity to pain, then the cut did not hurt, but
this disorder is very unusual.
2. The type of pain that he experienced was acute pain.
B. Jonathan’s pain would probably be increased if
1. He was alone and had no distracting stimuli.
2. He was depressed or anxious.
3. He was looking at the cut when he cut himself.
4. He focused on his cut finger.
5. He thought about how much the cut hurt.
6. He had been rewarded previously for experiencing and complaining about
pain.
C. Jonathan’s pain would probably be decreased if
1. He was involved with some other activity in addition to chopping onions
when he cut himself; for example, if he was talking to someone, listening to
music, or watching television.
2. He was not looking at his hand when the injury occurred.
3. He did not look at his finger after the cut so that he did not see the extent of
his injury.
4. He pressed tightly on the cut finger, stimulating other neurons in addition to
the ones carrying pain messages and partially blocking the pain.
5. He experienced some other type and location of pain immediately after cutting
his finger; for example, if he dropped the cutting board on his toe.
6. He believed that men should not be bothered by minor injuries or that he was
the type of man who should not feel pain by such an injury.
160
3. Differentiate among the three stages of pain.

A. Acute pain
1. This type of pain is the most common, produced by injury from lacerations,
dental work, surgery, burns, abrasions, cuts, and other injuries.
2. This type of pain is adaptive, signaling injury to body tissue and alerting the
person to avoid further injury.
B. Prechronic pain
1. This type of pain is experienced between acute and chronic pain.
2. The experiences that occur during this period may make the critical difference
in the alleviation of pain or the onset of chronic pain.
C. Chronic pain
1. This type of pain persists after the period of healing has been completed and is
often experienced without detectable tissue damage.
2. This type of pain is often involved with situations that elicit reinforcement for
the person who is in pain such that continued pain ensures reinforcement although
it also ensures pain.
3. This type of pain never has a biological benefit but takes a substantial
psychological toll on both the sufferer and the family
4. Discuss the statement "Injury does not necessarily equal pain."

A. This statement reflects the variability of the experience of pain.
B. Some types of injuries are more likely to result in pain than other types.
1. Broken bones, sprains, and stab wounds are more likely to produce immediate
pain than cuts, scrapes, and burns.
2. Unintentional injuries are less likely to produce pain than intentional injuries;
for example, people who have been tortured all report pain, regardless of the
severity of their injuries.
C. Some people are more likely to experience pain than others.
1. Soldiers wounded during battle in World War II were less likely to experience
pain than civilians with comparable injuries.
2. Operant conditioning produces pain, and people who have prior experience
with a type of pain are more likely to experience pain in similar circumstances.
3. Individual variations in pain perception are attributable to situation and
experience.
a. Evidence does not support a pain-resistant (or pain-prone) personality
type.
b. Ethnic and gender differences in pain perception may be attributable to
cultural and gender roles than allow the display of pain behaviors and also to
sensory and perceptual differences in pain.
5. Compare the specificity and the gate control theory on their emphasis of
psychological factors in pain.
A. Specificity theory explains pain by hypothesizing that specific pain fibers and
pain pathways exist.
1. This theory views pain as mechanistic signaling of tissue damage.
2. This theory does not take individual variability or psychological factors into
account in the experience of pain.
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B. The gate control theory of pain emphasizes physiology but includes behavioral
and situational influences.
1. Pain has motivational and emotional components, which are affected by
experience and expectation.
2. Incoming stimuli are modulated in the spinal cord by the “gating” mechanism
in the substantia gelatinosa.
3. The central control trigger is a brain mechanism that activates a descending
control system that may modulate or suppress pain.
6. What are the advantages and disadvantages of physiological measures, behavioral

assessments, and self-report measures of pain?
A. Self-reports include rating scales, pain inventories, and standardized objective
tests.
1. Advantages include the ability to capture the patients’ feelings and subjective
aspects of pain, the simplicity of administration for ratings scales, and the
psychometric sophistication of standardized tests like the McGill Pain
Questionnaire and the MMPI.
2. Disadvantages include the problems in definition of some of these tests, the
high reading level of some tests, and the questionable validity of applying a
personality test such as the MMPI to diagnose pain.
B. Behavioral assessments include observation by significant others or by trained
professionals.
1. Advantages include direct observability, the opportunity to observe the person
in many settings by significant others, and the reliability of ratings that can be
achieved by trained professionals.
2. Disadvantages include the lack of observability of some aspects of pain and
the lack of strong relationship between some behaviors and pain.
C. Physiological measures include muscle tension, autonomic indices, and
temperature.
1. Advantages include objectivity of measurement and freedom from subject and
observer bias.
2. Disadvantages include the lack of a strong relationship between autonomic
indices and pain severity.
7. Evaluate the success and hazards of medical interventions for pain.

A. Medical treatments for pain have been more successful and carry less risk in
treating acute rather than chronic pain.
B. Analgesic drug treatments are common for acute pain and are sometimes used for
chronic pain.
162
1. NSAIDs such as aspirin are very common and successful in managing mild to
moderate pain, but their side effects make them unsuitable for some patients.
2. Opiate drugs are very successful in relieving severe pain, but they produce
tolerance and dependence, creating the potential for abuse and making these drugs
risky for treating chronic pain; these properties have created public fear of their
hazards, resulting in their underuse in situations of severe pain.
C. Surgery
1. Cutting the nerves that carry sensory input or lesioning the central nervous
system can bring relief from pain.
2. The hazards often outweigh the potential benefits, because any effect,
including unpleasant ones, may be permanent; surgery usually does not produce
relief from chronic pain; and the surgery itself is hazardous.
8. What are the similarities and differences of behavior modification and cognitive
therapy as used for pain management? How does cognitive behavior therapy combine
these approaches?
A. Behavior modification
1. Has the goal of shaping behavior; cognition or feelings are not a concern.
2. Has been used as a treatment for the control of pain, with the assumption that
pain can be reinforcing for some people because they receive positive
reinforcement for expressing pain.
B. Cognitive therapy
1. Employs the persons’ thoughts and feelings and assumes that behavior is
shaped by these cognitive processes.
2. Can be used for pain management to help people change their attitudes and
cognitions about the experience of pain.
C. Similarities
1. Both use a psychological approach.
2. Both share the goal of changing behavior.
3. Many cognitive therapy approaches, such as pain inoculation, combine
cognitive and behavioral techniques, making a cognitive behavioral technique.
D. Differences
1. The two approaches emphasize different routes to their similar goals of
behavior change; behavior modification through the shaping of overt behavior and
cognitive therapy through changes in cognitions.
2. Cognitive therapies work toward improving patients’ feelings of efficacy, the
feeling that they can be effective in dealing with their problems, whereas behavior
modification deals only with overt behaviors.
3. Cognitive therapies tend to emphasize self-management, whereas behavior
modification programs tend to rely on reinforcement from others to change
behavior.
E. Cognitive behavior therapy combines the techniques and goals of the cognitive
and behavioral approaches.
1. It works toward changing attitudes and thoughts.
2. It includes behavioral goals.
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Chapter 7
3. Cognitive behavioral therapy is more effective for stress and pain

management than either cognitive therapy or behavior modification.
9. Eric hurt his back two years ago when he was at work, and since that time he has
experienced periods during which he could not work because of his low back pain.
Workers’ compensation has helped financially during those times, but his wife has
been burdened by doing Eric’s chores and caring for him when he is incapacitated.
His physician is reluctant to continue his prescription of opiate analgesics but
understands that Eric’s back pain is a problem and would like to get him into a
program that would help his pain. After reviewing the options, recommend a program
for Eric.
A. Eric receives reinforcement for his pain behaviors, including
1. Monetary compensation.
2. Supportive care from others.
3. Relief from work and family responsibilities.
B. A behavior modification program might help Eric exhibit fewer pain behaviors.
1. This type of program would probably teach Eric’s family to ignore his chronic
complaints about his pain and encourage him to resume his normal life’s
activities.
2. This program would probably systematically reinforce Eric’s desirable,
normal behaviors such as getting up without complaints of pain, getting dressed,
interacting with his family, and so forth.
3. Such programs tend to be successful in helping patients to be more active and
to request less medication.
C. A cognitive or cognitive behavioral therapy program might be a good alternative
if Eric has the motivation to self-regulate his behavior.
1. Such programs place more responsibility on the patient and on the desire to
change one’s own behavior than behavior modification programs do.
2. A cognitive pain management program would include stages in which Eric
would reconceptualize his pain and the role of psychology in the perception of
pain, acquire new skills to cope with pain, and follow-through the
reconceptualization and learning by practicing these skills.
3. Some research has indicated that Eric might make slower progress in a
cognitive pain management program but that his gains would increase, making
this type of program potentially more successful than a behavior modification
program.
164
165
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Pasha, even whilst they were conspiring to perpetrate the Treaty of
Sevres. Greece likewise was adopting the insolent attitude of the
conqueror, more galling to the Turks than the domination of any
other foe. Upon the Commission instituted to govern the affairs of
Turkey in general and Constantinople in particular, England glanced
with wary eye at the deeds of her colleagues, France, Italy, and
Greece. It might be urged that England has quite enough to do with
her own vast territories and enormous responsibilities without adding
to the burden by taking more than a nominal interest in the
development of Turkey. Against such a view the men on the spot
protest with indignation. There is a land of inestimable fruitfulness. It
lies on the route of valuable British possessions. It is possessed by a
race holding high repute amongst the peoples of that part of the
world which is not averse to England. Widely advertised Armenian
massacres ought not to be permitted to blind the untravelled to the
fact that the Turk is regarded very highly by most people who know
him well. His faults of cruelty and corruption he shares with all
Eastern peoples. His virtues of cleanliness, sobriety, and (in the
country) honesty and industry mark him out for peculiar admiration. I
have to confess that I met nobody who expressed dislike of the Turk.
I met everywhere people who spoke with contempt of the Greek and
the Armenian.
“Tell me,” I said to a British officer in Constantinople, “why does
everybody hate the Armenians? I do not myself know any of these
people; but I can find nobody with a good word to say for them. I
have just heard one educated man declare that the only thing to do
with the Armenians is to massacre them.”
“It is certainly true,” he replied. “There is a saying in this part of the
world that it takes two Jews to make a Greek, two Greeks to make a
Levantine, and two Levantines to make an Armenian. Perhaps that
explains it.”
“You mean that they are notorious beyond all words for
commercial dishonesty and extortionate dealing? But is that all? That
is very bad, of course; but does it explain all the bitter hate?”
“I don’t know; but I don’t believe for a moment that it is purely a
hatred of Christianity. The Turks are a warlike race. They hate the
pacifism of races like the Jews and the Armenians. To them it is
effeminate weakness. They despise the drunkenness of Christian
tribes. They are abstainers by religion. And the plundering of the
peasants by Christian extortioners has done more to set the
Crescent against the Cross than any preaching of Christian doctrine
could have done by itself.”
“I am proposing to return to this part of the world to visit Armenia in
the spring, unless the Bolsheviks from Angora capture it between
now and then.”
“Well, good luck to you!” said the young Englishman. “Nothing
would tempt me to go. Please remember that if half the Armenians
reported to have been massacred had really died, there would not
have been any Armenians left to visit!”
The Bolsheviks have captured Armenia, and the Allies do nothing
to help. Therein the Armenians have a real grievance. Their really
marvellous propaganda had secured them the sympathy of the
whole Western world. They had received distinct or tacit promises
from the Allies and the League of Nations. But neither the one nor
the other has done anything to save them from their frightful fate at
the hands of Russian Bolsheviks and Kemalist Turks.
Prince S——, the nephew of Abdul Hamid, is a cultured Turkish
gentleman of the very first order. His beautiful little daughter was
educated in England. She speaks perfect English, her father
admirable French. Over the Turkish coffee, thickly sweet and
delicious, we discussed the future of Turkey. I had met the prince
and his daughter first in Switzerland, at Caux, overlooking the
Montreux end of the Lake of Geneva. The Castle of Chillon, and
mountains of Savoy on the French side make a picture of
extraordinary beauty. Then, as in Constantinople, he spoke warmly
of England. I have seldom met a foreigner who had a higher opinion
of England and English institutions. In Turkish matters the prince
appears to stand half-way between the Turkish Nationalists and the
representatives of the old order. He looks for the day of an
independent Turkey, self-governing and governing with intelligence;
but he appears to think that day has not yet arrived. Before that,
there should be universal education for Turkey, free and progressive.
The rich, natural soil of agricultural Turkey should be subject to
intensive cultivation on modern scientific lines. Land should be made
available for all would-be cultivators; estates limited in size, but not
alienated from the owners by the State.
Till the day of its emancipation arrives this patriot prince would
have for Turkey the assistance of England. It was obvious to the
least interested amongst us that Constantinople suffered atrociously
from the divided authority of the Allies. Who were their masters—
French, Italian, British, or Greek—the wretched Turks really did not
know. Each set of nationals in authority got into the others’ way.
There were general suspicions and dislikes. Could the prince have
had his way, Turkey would have been ruled jointly by Turks and
British until education in responsibility had gradually but surely fitted
the Turks to be absolute masters in their own house.
This amiable cultured Turkish gentleman admitted the awful
atrocities committed by the Turkish Government in the past against
the Armenians, and regretted them. His secretary and not himself
spoke of equally fearful cruelties practised upon the Turks by
Armenians—the same dreadful game of reprisals with which a mad
world appears to be anxious to destroy itself.
A marked feature of the British personnel in Turkey is the extreme
youth of most of its members. Those who do not take themselves
and their work very seriously do not suffer. Those who are
conscientious and have their country’s interests really at heart suffer
acutely, not only through the physical strain of getting things done
against indifferent officialism in a country of unequalled opportunities
and matchless interest, but from the mental pain which is born of
seeing great opportunities passed by, or seized by wiser people in
the interests of nations other than England.
There is a new-born Socialist Movement in Constantinople—at
least, it calls itself Socialist. It came into being as the result of a
successful tram strike. As a matter of fact it is really a Trade Union
Movement. It has little knowledge of the economics of Marx. Its
leader would be described as a Radical in England. I have the same
view about the Socialist Movement that Prince S—— has about the
Nationalist Movement—that a period of education would be a
valuable and is, indeed, a necessary precedent to the agitation for
Socialist government, even municipal government.
When we boarded the train in Constantinople it was intensely hot.

Within an hour of leaving it blew so cold that the women of our party
were constrained to put on their furs. For two days the intense cold
lasted. Not until we had passed over the bleak moor and forest lands
of Bulgaria, reminiscent of certain parts of Scotland, did we begin to
feel anew the warmth of autumn days. Milder Serbia warmed our
blood, and we ventured to make an excursion into Belgrade, where
the express rested for four hours. Tired of train food, we betook
ourselves in a party to the Hôtel Moscou and enjoyed a first-rate
supper amongst the joyous Serbs.
I hope to see Belgrade by day in order to revise my opinion of the
city. As it is, I have the poorest opinion of it. Its streets are paved
with cobble-stones and are full of shell-holes which would hold the
proverbial horse and cart! In the pitch black of the night—for the
streets were either badly lighted or not lit at all—we were constantly
tumbling into the smaller of these unspeakable holes or twisting our
ankles on the round cobble-stones. One required the feet of a
mountain goat to maintain oneself erect in such abominable
thoroughfares.
But a pleasing experience superseded the unpleasant memory of
Belgrade streets. I had been given a letter to post to Budapest by a
lady in Constantinople, who feared it might be opened if posted in
that city. I had given a solemn promise that this should be done. To
venture into those Belgrade streets alone was impossible. I had to
wait until my fellow-delegates had done feasting. Time passed, and
still they ate and ate. Soon it would be impossible. The train was due
to leave in a little while. I waited. The eating went on. I rose to go
alone. M. Marquet’s kind French heart was touched. He went with
me. We wandered over half Belgrade before we found the post
office, and when we found it it was closed! We walked to the back of
the premises, and there were two young men packing letters into
bags. In a mixture of French, English, and German we contrived to
make them understand we wanted a stamp. One of them, smiling
broadly, took out his pocket-book and produced the necessary
article, sticking it on to the letter himself, which he then pushed into
his bag. We laid down a substantial coin. But with a graceful bow
and a fine smile he declined payment. We shook hands cordially and
parted, the travellers with a happier estimate of Belgrade than its
stones had supplied!
If one can in any real measure judge a country’s state from the
railway train, Serbia and the highlands of Jugo-Slavia are enjoying
considerable prosperity. At the time we passed through the country
the same abundance of produce was everywhere visible as in
Belgium. In addition, the little pigs for which Serbia is renowned were
numberless. They ran all over the lines at the railway stations and
clustered in herds round every cottage door. The neat, bright comfort
of the mountain farms of the Tyrol made a very profound impression,
and were a real joy to those of us who were on the look out for as
much happiness and prosperity as we could discover in a world torn
with sorrow.
A rush round the city of Trieste, a long wait in the railway station in
Venice on account of a serious railway accident just ahead, a peep
at Milan, a glimpse at Lausanne, and we were on the last stage of
our long journey to Paris. The journey had been fairly comfortable
with the exception of the last day. There was no water for washing in
our carriage. I mean by “our carriage” the one in which the English
delegates were. We gave mighty tips, but the attendant would not be
comforted and refused to get us more water! He protested savagely
at the amount of water the English people used. He complained of
the number of times we thought it necessary to wash ourselves. We
were thoroughly in disfavour. We bore the discomfort and the feeling
of not looking our best till we got to Paris. There came relief,
cleanliness and good coffee. Twelve more hours and we should see
the home faces once more and recount our adventures to interested
friends.
Every one of us vowed we would not go abroad again for a very
long while. Every one of us has broken that pledge. It must be so.
The human spirit, once having escaped from the circumscribing
atmosphere of native city or even country, will never more be content
to be environed perpetually by so much less than it has known. It
must go out again and again to the scenes and the people it has
known in other lands, or break its wings against the bars of its cage,
imprisoned in the infinitely small and narrow. Let all who can travel,
for the broadening of their minds, the widening of their outlook, the
strengthening of their sympathies. And let those who cannot travel
read, so that they may know what the men and women of other
lands are thinking and feeling, and may co-operate with them in the
shaping of brighter and better things for mankind.
CHAPTER XV
THE DISTRESSFUL COUNTRY
Late one evening I was returning home from a Fabian lecture

when a tall, middle-aged man, with slightly wavy hair and a pair of
merry blue eyes, accosted me. He carried under his arm a large and
rather untidy brown-paper parcel, which looked as though it might
contain groceries and gave him the appearance of the middle-class
father of a family. His voice was soft and pleasant, his accent
unmistakably Irish.
“Pardon me, madam, but are you an Irishwoman?” he asked
interestedly.
“No,” I replied. “I was born in Yorkshire. But why do you ask?”
“Forgive me, but your voice carries a long way, and I could not
help hearing a part of your conversation with the lady who left you at
Hampstead. You were talking about Ireland. Your voice and the kind
things you said about Ireland made me think you might be an
Irishwoman.”
“No,” I said again; “I am not Irish, but I am going to Ireland to-
morrow.”
“Ah!” he said, drawing a deep breath. “And why are you going to
Ireland at a time like this? Surely not for pleasure?”
“No, indeed; there can be no pleasure in Ireland for anybody with
a spark of human feeling. I am going to Ireland to try to discover the
truth, if that is possible.”
“You are a newspaper woman, then?” was the next query. I made
no further answer, feeling that the conversation with a perfect
stranger, albeit a courteous and sympathetic one, had gone on long
enough, when he began to speak with added warmth both of speech
and manner.
“Ah! you English people, you do not understand, you never will
understand Ireland. In your imagination you have peopled our island
with devils and conceive it to be your duty to exterminate the plague.
‘The dirty Irish’ is the way you think about us. Hunting down Irishmen
is by some Englishmen regarded as legitimate sport. I am a native of
Cork. I am not a Sinn Feiner. I do not want to see Ireland cut loose
from the Empire. And I deplore as much as anybody the murders on
both sides. But I understand my countrymen. I doubt if you do. I very
much doubt if you can. The differences are too great. But whosoever
goes to Ireland without clearly realizing that the English and the Irish
are two distinct and separate nations will fail to understand the things
he sees and hears when he gets there. I am constantly hearing talk
on this side about the possibility of Ireland making terms with
Germany, becoming even a German province if she secures self-
government.” Here his voice became louder and his manner more
excited than ever; the newspaper he was holding dropped from his
hand and fluttered away in the wind. “Surely if such people
understood the racial differences between English and Irish they
would realize that the same applies, though in a much greater
degree, to the German and Irish?”
“Believe me,” I said, holding out my hand, “there are many people
in this country who do understand and who labour continuously to
create understanding in others. They yearn to bring about peace
between the two countries. Between peoples who speak the same
language war is a crime. I am going to Ireland to get more
knowledge about her, to talk to her people directly. And when I return
I shall join the band of workers for peace and reconciliation.”
He raised his hat, renewed his apologies for detaining me, and
disappeared. Under the gas lamp I caught a glimpse of tears on his
lashes—tears of a strong man for Ireland, his native land, a suffering
thing he cannot help.
The Labour Party’s delegation to Ireland had not included a
woman. Several members of the Women’s International League, and
a few Quaker women on errands of mercy, had visited the country.
This was some time before the Labour Party had decided upon an
official visit. The secretary of the party had received from an
Irishwoman a letter imploring him to include a woman amongst his
investigators, but it was not thought wise to do this by the men on
account of the danger and inconvenience. When one of the
executive proposed my name as one of the delegates Mr.
Henderson, with the most paternal solicitude, suggested that the
Executive Committee ought not to take upon itself the responsibility
of running any woman into such real danger as existed for travellers
in general and investigators in particular in Ireland at that time. So
the proposal fell to the ground.
No such objection was raised when the delegation to Russia was
appointed. On the contrary, Mr. Henderson strongly pressed me to
go to Russia. I cannot imagine that the concern of this genuinely
kind-hearted man for the safety for his women colleagues was in
abeyance on that occasion. Mr. Henderson had been to Russia and
suffered considerable danger himself. I can only conclude that this
serious-minded colleague of mine believed the danger to be greater
in Ireland under British rule than in Russia under the rule of the
Bolsheviks! I agreed to go to Russia with some reluctance on my
own account. Not because of any fear of going. Atrocity stories and
wild tales of epidemics had no terrors for me. But the time of the
proposed Russian visit was inopportune. I had received invitations to
go to Poland, Spain, and Hungary. Preparations for the journey to
Madrid had already been made and had to be cancelled.
But there were no obstacles to the Irish visit. I wanted to go.
Irishwomen wanted me to go. I received one pressing letter after
another. The Labour Party’s objection was laughed to scorn. I must
say the idea that women who have lived more summers than they
care to confess cannot be allowed to take the responsibility for their
own lives, but must be a burden and a charge, whether they like it or
not, on the consciences of their men comrades is in these days
vastly amusing; particularly to the women of the Labour Movement,
whose conception of progress is of equality of effort, of danger, of
suffering, and of reward for men and women.
None the less, I understood and valued at its very real worth the
altogether gracious and kindly thought which lay at the root of the
action of the Labour Executive.
It was impossible to resist the pleading of Irishwomen that as
many women as could do so should go over there and see with their
own eyes what the women and children of Ireland are called upon to
endure.
On Saturday, January 15, 1921, I left Euston for Holyhead, alone,
and without having in any way advertised my intention. I landed in
Dublin in the evening and proceeded to friends in one of the
suburbs. We drove from the station in a jaunting-car. In such a
fashion did I get my first glimpse of Dublin under what the majority of
Irishmen consider to be foreign occupation. Westland Row Station,
as well as Kingstown Harbour, was full of soldiers and police.
Passengers coming off the boat were heavily scrutinized. We were
closely examined in the train. In the streets and public places of all
sorts in every town I visited during the ten days of my visit, even in
country villages and lanes, the atmosphere was tense with the
expectation of the sudden assault, the quick firing of rifles, the rough
arrest, the climbing of military lorries on to the footpaths, the
humiliating search, the heart-breaking insult. Women and men alike
feared these things. Here was an equality of treatment which nobody
objected to so far as Irishwomen were concerned, least of all the
Republican women themselves, who would think shame of
themselves if they were unwilling to suffer what their men are called
upon to endure. But the pity of it! Little children are often victims.
Boys and girls have been shot dead.
On this night the streets of Dublin were lively with the clatter of
armoured cars and lorry loads of singing soldiers not too sober.
Occasionally a distant shot was heard. Now and then a side-car
packed with merry little dare-devils flaunting their green flag
provocatively for the sheer fun of the thing would rattle past. One
trembled for the ignorant folly of madcap youth.
My host, who is one of the best-known and most highly respected
citizens of Dublin, did everything in his power to bring me into touch
with every shade of Irish opinion, so that I might judge of things for
myself without bias or pressure from outside. I never was in any
country where there were fewer attempts to make proselytes. He
himself is a Quaker, and has a long record of devoted service to his
country and to the less fortunate of his fellow-citizens to his credit,
which inspired confidence and respect. His beautiful wife and lovely
children gave me a warm Irish welcome, and, although an
Englishwoman and, therefore, a justifiable object of suspicion, I was
never permitted for a moment to feel myself an intruder.
From Saturday night till Tuesday morning the hours were packed
with incident. I think it would have been difficult for anybody to see
more people and hear more tales of woe than it was my lot to see
and hear during these ten days in Ireland. Amongst my new
acquaintances were Republicans of all sorts, Nationalist Home
Rulers, Unionists, Labour Party officials, Trade Unionists, Quakers,
humble citizens with no particular political affiliations, Catholic priests
and Protestant ministers boys and girls from the country “on the run”
in the city, newspaper men, writers of books and pamphlets, British
officers, lawyers by the dozen, ex-soldiers, high-born ladies, the
widows of men executed in the rebellion of 1916, suffragettes,
women doctors, temperance folk, members of the Irish Republican
Army, commercial travellers, and men and women suspected of
being British agents and spies. I should like to disclose the names of
all these interesting persons. In most cases I have full authority to do
so. But when that permission is coupled with a declaration that they
do not care two pins about the consequences to themselves, I am
involved in too great a responsibility to be reckless in a matter where
human life and liberty are so manifestly involved.
But because I believe even the present British Government, more
profligate of its power than any Government of modern times in this
country, would scarcely dare to mishandle a man so great in the
esteem, not only of Ireland but of the whole world of culture, I feel I
may write freely of that towering personality, Mr. G. W. Russell (“Æ”),
whom I met several times in Dublin, always to my great spiritual
profit.
Picture a face and figure not unlike those of William Morris in the
prime of his life, with a tenderness joined to his strength which I
imagine was less conspicuous in the English poet. Masses of wavy
hair tossed back but occasionally falling over a fine square forehead,
a full mouth, glorious eyes full of humour and gentleness, a soft
musical voice; the frame of a Viking, the heart of a saint, the
imagination of a poet, the vision of a prophet; a man to whom
children would run with their troubles, whom women would trust
unflinchingly, whom men would serve with utter loyalty; the
embodiment of the real Ireland, the Ireland that is not known in
England—this is the man whose devoted, lifelong work for the
salvation of Ireland is being wantonly and savagely annihilated by
British troops.
Mr. Russell spoke without a trace of bitterness, though I know he
suffers keenly, when he told me of the destruction of Irish creameries
and of the difficulties which co-operative enterprise is meeting with in
every part of Ireland. He edits the Irish Homestead, and there he has
voiced the complaints of Irish co-operators in language of the
greatest beauty; but to hear him tell the story himself was a pleasure
fraught with pain to his English auditor.
“It cannot be that the system of reprisals has become an integral
part of the British nation’s scheme of justice?” he asked, as we sat
talking by the fire in the house of a friend. “It would be too terrible to
think that that were true.”
“The British people do not know all that is happening here,” I
replied. “Oh, I know they ought to. Enough has been said and written
about it. The ignorance of affairs outside the little circle of their own
interests of the average man and woman makes me almost despair
of democracy at times. But there is this explanation of the inactivity
of the British public about Irish matters. In the first place, very many
people know nothing. Those who do read that part of their daily
paper which is not devoted to the sporting news or the Divorce Court
proceedings read a partial tale. The news is generally coloured in
favour of Dublin Castle and the Black and Tans. I cannot believe that
British co-operators would be content to tolerate the things which are
being done to Irish co-operative enterprises if they knew the facts.”
I was given a tiny yellow book containing the facts which I
promised to help circulate in England. It is an amazing story. The
statements would have appeared incredible to me had I not seen
with my own eyes the blackened walls and twisted machinery of the
gutted creameries in several parts of Ireland. Forty-two attacks by
the Crown forces on these village and country town institutions had
been made up to the time of my conversation with “Æ.” In these
attacks the factories were burned down, the machinery destroyed,
the stores looted, the employés beaten and sometimes wounded
and killed.
Questioned in Parliament, the Government has excused itself by
declaring that the creameries were centres of propaganda and of
Sinn Fein activity. They alleged that in two cases shots were fired at
the troops from the buildings. The most searching inquiries by
responsible people, including Sir Horace Plunkett, failed to produce
any evidence in support of the charges of the Government. But Mr.
Russell is not concerned about the result of these inquiries. He
wants a Government inquiry into the whole of the circumstances
connected with this particularly lamentable form of reprisal, and this
inquiry is steadily denied. Why?
Travellers in Ireland to-day see all over the country these new
ruins, centres of village industry and culture utterly wrecked, and the
peasant farmers and their families driven back to their lonely farms
to live in poverty and isolation; driven back to feed not only upon
their own scant produce but upon the black passions of hate and
individualism from which the co-operative idea had begun so
successfully to rescue them.
“Surely the English workmen begin to realize the connexion
between our problem and theirs,” said another distinguished co-
operator. “If our economic life continues to be so seriously disturbed,
or if it be destroyed, we cannot buy from England as we have been
doing. Do you know that, with the single exception of India, Ireland is
the best customer that England possesses within the British
Empire?” The political views of this cultured gentleman are distinctly
non-Republican, yet his house is not safe from the official intruder,
and he is tormented hourly with the sense of outrage and injustice
which the destruction of his life’s labours must necessarily produce.
“To us it would be simply unbelievable but for the other follies we
have seen perpetrated by your statesmen, that any Government with
the least knowledge of the world-situation could willingly add to its
dangers and difficulties. Yet I cannot believe that the members of the
British Government are all ignorant and stupid.” This third speaker
was a man who had served with distinction in the British Army during
the war. But the droop of his figure, the gloom in his eye, the bitter
curl of his lips—everything about him spoke of a confidence lost and
a faith killed.
“Two millions of adult people in Great Britain either wholly or
partially unemployed; wives and children beginning to hunger;
industrial strife on a scale hitherto unimagined clouding the horizon;
men by the million trained to kill, ready to be used by one side or the
other in a class war; hate and violence the fruit of it all, and appalling
suffering for all classes before one side recognizes the right of the
workers to an assured and abundant life and the other side realizes
that Russia’s way is not the way even for Russia. All this and more—
and yet the British Government actually or tacitly encourages the
troops to add Irish tens of thousands to the British millions of
workless, starving, hating men and women, and is slowly but surely
converting the only revolution in history which makes a point of
preserving the rights of private property into something which will be
akin to a class war for a Communist republic—an issue which I
should deeply deplore.”
I am bound to confess that I discovered no substantial evidence
that the civil war in Ireland has either a Communist basis or a
Communist ideal. The utter conservatism of the Irish is the most
striking thing about them. Their determination to win self-government
is based almost entirely upon that conservatism, the love of the
Ireland of history, the passion for the Irish tongue, the devotion to the
ancient faith, their love of the soil—these things and the memory of a
thousand wrongs put upon them by the alien conqueror have much
more to do with Irish discontent than any desire to hold the land in
common and convert the industries from private to public ownership
and control; which ideas would, indeed, be repugnant to the last
degree to the peasant owners of the South and West of Ireland.
Speaking on this point with some of the workingmen leaders I
asked how far, in their opinion, the Communist propaganda had
captured the Irish workers. “Scarcely at all,” was the quick reply.
“There was fearful anger over the cruel death of Connolly. His
execution did a great deal to unite the Labour Movement in Ireland
with the Republican Party. It was the sheer brutality of it. The poor
fellow hadn’t more than forty-eight hours to live. He had been shot in
the scrimmage in Dublin, and gangrene had set in. Yet they dragged
him out of his bed groaning with pain, put him on a chair and shot
him—the brutes! They think it’s all in the day’s work to shoot a ‘dirty
Irishman.’ But our people will never forget Connolly and the way he
died. No; the Irish workers are not Communists. They just hate
England and want to be quit of her.
“Ay, and there’s the case of Kevin Barry while you’re on about the
killing. Do you know they tortured that poor lad to get him to tell the
names of his comrades? We have his affidavit. They bruised his
flesh and twisted his limbs and then they hanged him—hanged him,
mind you, when the poor lad begged that he might be shot as a
prisoner of war! Your Prime Minister calls it war when he wants to
excuse the murders of his own hired assassins. But if so, our men
are prisoners of war when they are captured. Who ever heard of a
civilized nation hanging prisoners of war? But praise be to God,
every time you hang a boy like Kevin Barry you make hundreds of
soldiers for the Republican Army. Eighteen hundred men in Dublin
joined up the day Kevin was hanged.”
The little man who thus broke in began to fill with tobacco the bowl
of his small black pipe, and when he had lit it he turned on me,
fiercely demanding: “Why have you come to Ireland now? Why didn’t
you come before? Why don’t more of you come? How many
thousands of our brave boys have got to be killed before you folks
find out what your bloody troops are doing to Irish men, women, and
children?” And he flung himself out of the room.
I felt sorry to have appeared indifferent for so long, and said so to
the rest of the assembled company. “But to tell you the truth, I have
lived all these years under the impression that Irish men and women
preferred to win their own battles in their own way; that they
regarded rather as an intrusion any effort of English people to help
and advise them. From the first hour of my political life I have been a
supporter of self-government for Ireland; but I never dreamt that you
wanted me, or any of the rest of us, to come to Ireland to say so. I
believed that you wanted to work out your own salvation.”
“So far as advice is concerned you were right,” said a young fellow
with a large freckled face and fine eyes. “I reckon the English can’t
teach us much about politics.”
“I’m not so sure,” I said very softly. “After all, you have not got what
you have been fighting for during more than a hundred years, and
you have not got rid of the oppression that has tormented you for
several hundreds of years. Perhaps it is possible that co-operation
might have done it. We can all teach each other something. Ireland
has glorious lessons for us English. Perhaps you could have learnt a
little of something from us.”
There was a long pause, and I continued: “It is of the first
importance to carry the plain matter-of-fact people of England with
you. Ordinary men and women in England have a strong sense of
justice, but their imagination is weak. They find it difficult to
understand what they do not endure themselves. They find it hard to
believe in the wounds unless they can lay their fingers on the prints.
You must admit that some of the things which are happening in
Ireland are almost incredible. One thing which makes it difficult to
open and keep open the minds of English people on the subject of
Ireland’s wrongs is what they regard as Ireland’s wrongdoing, the
killing of soldiers and police. Of course, a certain section of the
newspaper press exploits this to the last degree. Why do you do it?
Why use the methods so hateful in the others? Why put an argument
in the mouths of the enemy? Why soil and stain a good cause?”
“Because we are at war,” was the prompt reply. “You have just
heard that your Prime Minister says so. He justifies the methods of
the Government because it is war. We do not like killing people; but
can we be expected to sit quietly whilst our own men and women are
killed and their property looted? It isn’t in human nature. Would
Englishmen sit quiet under such provocation? We don’t like it. And,
remember, we don’t kill innocent people like the other side. Every
person executed by the Irish—executed, mark you, not murdered—is
tried by the Republican Courts and found guilty on substantial
evidence of traitorous conduct or brutal murder.” He folded up the
copy of the Irish Bulletin he had been reading, and then proceeded:
“I’m glad you came over. I wish others would come. I’m sure you’ll
help Ireland. Tell your people that if it’s war they want, war they will
get till every young man in Ireland is dead. Then they can begin with
the old men and the women—they’ve begun with the women—and
after that they’ll have to wait till the children grow up. But they’ll find
them every bit as keen as their fathers. It’s in the blood of us. There
are only two ways to peace, and God knows we want peace. You
can either give Ireland her freedom, or you can sink the whole
country in the sea. It’s the peace of the dead you’ll get if you won’t
have that of the living.”
It is only fair to say that nine out of every ten of the Republicans to
whom I spoke expressed sorrow and regret that the policy of
violence had been adopted instead of that of passive resistance.
“But now that the fighting has been begun it is very difficult to stop
it without laying ourselves open to the charge that we are
weakening, or without giving the British Government the opportunity
of saying that its policy of reprisals has succeeded. The very thought
of these things is hateful to the sons and daughters of a brave
fighting race.” The distinguished old lady who said this drew herself
up as she spoke with the dignity of a queen and flashed swords and
daggers from her fine proud eyes.
Her house had been searched twice by Crown forces. They did
some small damage to doors and windows, nothing serious, for she
is a woman of property and social position, an outstanding example
of the thing I found to be true, that the severity of the reprisals, the
ruthlessness of the visitations, the length and discomforts of the
imprisonments were generally in proportion to the means or in
accordance with the religious beliefs of the suspects. Age and sex
did not count.
During an official reprisal which I witnessed in Cork, the blowing-
up of two excellent shops in one of the main thoroughfares, when
armed troops kept the crowd moving, and armoured cars, fully
manned, kept the roads, I heard an old woman tremblingly ask a
good-natured Tommy carelessly swinging his rifle as he moved
people along the pavement, what the matter was. “We’re only going
to send all you bloody Catholics to hell,” was the cheerful reply.
To refer once more to the searchings of private houses and shops:
I investigated three cases, the one to which I have referred, the
house of the old lady and her secretary, and two others, both shops.
The usual practice is to knock loudly and demand admittance, but to
give no time for anyone to run to the door, which is frequently burst
open. Sometimes shots are fired into the passage as a precaution,
killing or wounding perchance the man who is descending the stairs
to answer the summons, which often comes in the middle of the
night. A soldier stands guard over each member of the family. If the
house be big enough each is placed in a separate room. If it be small
they are turned into the streets and guarded there. A rigorous search
is made, beds stripped, mattresses sometimes bayoneted, drawers
opened and their contents tossed out, pictures pulled off the walls,
letters opened and read, cupboards emptied—the whole house
turned topsy-turvy. A shop is usually looted of half its contents.
Recently, in the attempt to restore discipline, the householder has
been requested to sign a paper stating that the soldiers left all in
order and stole nothing. But no opportunity of checking is allowed,
and the dazed and frightened woman (it is generally a woman, for
the men are “on the run”) signs quickly, and would sign anything to
get the soldiers and police out of the house and her terrified children
into their beds.
In the case of the little sweet and tobacco shop the whole family,
including two young children and an old woman, were turned into the
street at midnight and made to stand there in the pouring rain for two
hours. The gentle young Irish mother with the soft voice and
seductive Irish drawl told me the story.
“It was me brother they wanted. He’s in the arrmy. But it’s weeks
since Oi saw the face av him. Oi couldn’t tell thim where he was, but
they wouldn’t belave me. It nearly broke me heart to see thim poke
thurr bayonets thru the pickshure av the Blessed Virgin. An’ all the
swates was trampled on the flure. The bits av tobaccy wint into the
pockets av the crathurs. An’ the pore children was gittin’ thurr deaths
av cold in the rain outside. An’ now the pore lambs will nut slape
widout a light over thurr beds in the noight furr the fear av the cruel
men that is on them. An’ what have Oi done but keep moi house an’
pay moi way like an honest woman? Shure,” she said, with a droll
look and a twinkle, “if Oi knew whurr moi brother was, would Oi be
tellin’ the soldiers? Oi would not, indade. Wolfe Tone is the name av
him. An’ wouldn’t they be afther shootin’ at sight a man wid a name
loike that?”
The Irish sense of humour never forsakes them even in their
deepest distress. Mrs. A. Stopford Green, the widow of the great
historian and herself an historian of merit, told me of a Catholic priest
who had his home invaded and sacked. Standing amongst the
wreckage of his little home, he exclaimed, between tears and smiles:
“Glory be to God! They’ve taken everything they could lay their
hands on. But there’s one thing they haven’t taken, because they
can’t take it, and that is—the laugh!”
I came to one house in order to have an interview with a young
Irish patriot who is “on the run.” He came secretly and at great risk to
himself. He was cheerful and jolly; but, like everybody else in Ireland,
he showed clear signs of strain and of an imminent breakdown. Eight
times his premises had been searched, and each time valuable
things had been stolen. Even whilst we talked a telegram from a
friend arrived to say that the night before they had raided him again
and taken away a pair of much-prized army boots.
A splendid type of cultivated and idealistic young manhood, he
was hunted hourly from pillar to post on suspicion of ill-doing; but his
life’s work had been humanitarian, designed by the slow but sure
methods of education and co-operation to win the suspicious and
illiterate peasant from his bondage to ignorance and intolerance.
He had been tried once and acquitted. He and his friend had been
lodged in the guard-room. There was a struggle, and bombs, and the
dead and mutilated body of his friend was carried out. The story was
set about that the two of them had thrown the bombs at the troops.
The bombs were lying loose in the guard-room. Nobody believed a
story so thin. The pacific reputation of the two men was well known.
Everybody asked why live bombs were left lying about in such a
place. Were they put there to furnish an excuse for premeditated
crime? Some believed this. Nothing is clear. In the subsequent
inquiry before a Military Court composed of young and ignorant
officers with a natural prepossession in favour of their profession and
caste, it was denied that Clun’s body was mutilated. But a reliable
witness told me that he had counted thirteen bayonet wounds.
The first thing which impressed me about the Sinn Feiners I met
was their culture, then their courage, finally their spirituality. I speak
now of those I met in the city—probably two hundred. Many of them
would have been shot at sight if they had been seen coming out of
their hiding-places to meet me. At the moment of writing more than
one of those with whom I talked lies in a dark and dismal prison cell,
notably Desmond Fitzgerald, head of the Republican Propaganda
Department.
What amazed me continually was the entire absence of bitterness
in the speech of most of these people. Bitterness they must have
felt, and yet so sure are they of the goodness of their cause and of
its ultimate triumph, that they can talk with calmness and even
humour of the tragic events of which so many of them are the central
figures.
“They say in England that this is first and foremost and all the time
a religious quarrel; that the domination of Irish politics by the Pope is
to be greatly feared if Ireland gets self-government. What have you
to say to that?” I asked the handsome youth whose effective
propaganda has filtered through to every country in Europe. It is one
of the important facts of the present situation that the conduct of
England towards Ireland is breeding a cynical contempt for England
throughout the world.
“I have to say of the first statement that it is not true, and of the
question that the fear is groundless. The Irish priests have tried in
vain to stop the ambush. They have denounced it from their pulpits.
But they have protested in vain. This defiance is the symbol of a
conviction that the place of the priest is at the altar. When he leaves

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Psychology of Health and Health Care A Canadian

II. The Meaning of Pain

III. The Measurement of Pain

IV. Pain Syndromes

Cancer pain is caused by either a malignancy or by treatment of a malignancy.

Exploring Health on the Web

This website is maintained by the American Chronic Pain Association, an

Creating Chronic Pain

Understanding the Impact of Chronic Pain

Living with No Pain

From Films for the Humanities & Sciences:

From Fanlight Productions:

Videos from the Web:

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1. The ______ system allows us to interpret certain sensory information as pain.

2. Primary afferents convey sensory impulses to the

3. Myelinated afferent neurons are called

4. More than half of all sensory afferents are

8. Nociception refers to the process of perceiving ________.

12. Recent research gave participants __________ to reduce people’s feelings of

14. _____ are chemicals that carry information between nerves.

17. The dorsal horns are located in the

18. The substantia gelatinosa is

19. Which structure is most capable of modulating sensory input?

ANS: c REF: Pain and the Nervous System

20. Sensory input information passes through what brain structure?

21. What brain structure contains a representation of the skin’s surface?

24. Pain is usually defined as

30. Physicians are likely to underestimate the pain of

37. With regard to gender,

a. women sense pain more quickly than men.

38. Specificity theory hypothesizes that

d. is less important in pain perception than the cerebellum.

43. The gate control theory of pain assumes

46. Which of these methods have been used to measure pain?

47. The Visual Analog Scale is considered to be

ANS: d REF: The Measurement of Pain

49. A personality inventory sometimes used to assess pain is the

51. Which of these techniques measures muscle tension as an index of pain?

54. With regard to migraine headaches,

58. The two most common types of pain are

61. Unlike rheumatoid arthritis, osteoarthritis

b. affects mostly men.

63. The three primary kinds of headaches are:

65. Almost ____ of all cancer patients’ pain was untreated.

c. the amputated limb is a leg.

69. The tendency to catastrophize is associated with ________.

71. One variation of cognitive behavioral therapy, encourages participants to _____

72. Approximately _____ % of all terminal cancer cases experience pain.

73. Medical procedures used in pain management have traditionally included

ANS: d REF: Managing Pain

74. Opiate drugs