8

Managing Pain

There is encouraging evidence that people can be taught nonpharmacological ways to cope with physical pain, particularly that which results from extreme psychological stress. This chapter examines the literature on pain management for clues about how to help people survive and function when environmental challenge is so severe that stress involves physical pain. (For this chapter the committee benefited from a commissioned paper by Laura Darke [1990].)

It is widely accepted that pain is worse when anxiety is high, and thus, that it can be controlled to an appreciable degree when anxiety can be diminished (Sternbach, 1966). Factors involved in the control of anxiety and stress (see Druckman and Swets, 1988) are similar to those important in the control of pain. It should be mentioned at the outset, however, that pain, like anxiety, has adaptive properties. People born congenitally incapable of experiencing pain often suffer serious injuries and even early death because they lack the capacity to take appropriate action cued by the experience of pain from a truly harmful stimulus. Our focus on the management or reduction of pain should not dismiss its beneficial nature under certain circumstances.

ASPECTS OF PAIN

To place pain management in context, it is useful to distinguish among four dimensions of pain (Loeser, 1980): nociception, pain, suffering, and pain behavior. It will quickly become evident that pain does not arise from a direct linkage between nerve stimulation and the cortex.



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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE 8 Managing Pain There is encouraging evidence that people can be taught nonpharmacological ways to cope with physical pain, particularly that which results from extreme psychological stress. This chapter examines the literature on pain management for clues about how to help people survive and function when environmental challenge is so severe that stress involves physical pain. (For this chapter the committee benefited from a commissioned paper by Laura Darke [1990].) It is widely accepted that pain is worse when anxiety is high, and thus, that it can be controlled to an appreciable degree when anxiety can be diminished (Sternbach, 1966). Factors involved in the control of anxiety and stress (see Druckman and Swets, 1988) are similar to those important in the control of pain. It should be mentioned at the outset, however, that pain, like anxiety, has adaptive properties. People born congenitally incapable of experiencing pain often suffer serious injuries and even early death because they lack the capacity to take appropriate action cued by the experience of pain from a truly harmful stimulus. Our focus on the management or reduction of pain should not dismiss its beneficial nature under certain circumstances. ASPECTS OF PAIN To place pain management in context, it is useful to distinguish among four dimensions of pain (Loeser, 1980): nociception, pain, suffering, and pain behavior. It will quickly become evident that pain does not arise from a direct linkage between nerve stimulation and the cortex.

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE Nociception is defined as “mechanical, thermal or chemical energy impinging upon specialized nerve endings that in turn activate A-Delta and C fibers, thus initiating a signal to the central nervous system that aversive events are occurring ” (Loeser, 1980:313). Thus, nociception is the basic physiological event that is presumed to create the conditions for the experience of pain. In practice it is inferred from a person's self-report. The fact that these afferent fibers travel in a complex fashion to many parts of the central nervous system provides an anatomical, although incompletely understood, basis for the modulating effects that higher mental processes have on the perception of pain (Gatchel et al., 1989). Pain is defined as the perception of nociceptive stimulation. As with other kinds of perception, there may not always be a precise match between what is perceived and what actually exists. For example, in phantom limb pain, a patient perceives pain in an extremity that has been surgically or traumatically removed. Conversely, nociception can occur without the perception of pain, as when a soldier in combat is unaware for a period of time of a wound that is doubtless creating nociceptive input. The theoretical basis of this view of pain is derived from Melzack and Wall's (1965) “gate-control” theory of pain, which proposes that there is a neurophysiological mechanism in the dorsal horn of the spinal cord that can increase or decrease the transmission of nerve impulses from the peripheral afferent nociceptive fibers. This gate is influenced by efferent nerve impulses from the brain, forming a physiological basis for the effects (reviewed below) that thought and emotion can have on the experience of pain (Gatchel et al., 1989). Conditions that “open the gate” and enhance pain perception are anxiety, depression, and focus on the pain; those that close the gate include relaxation, optimism, and distraction. Suffering can be defined as the evaluative or affective response to the perception of pain, but it can be present also without pain, as when a loved one dies or withdraws. Indeed, loss or the threat of loss are believed central to the experience of suffering (Bakan, 1968). According to existential writings (e.g., Gendlin, 1962), suffering can be lessened if a person sees some meaning to the ordeal he or she is undergoing (see below). Pain behavior is defined as the observable behaviors associated with either pain or suffering. Thus, pain behavior may or may not always arise from nociception. Examples are moaning, teeth-clenching, guarded gait, irritability, and avoidance of activity (Turk et al., 1985). The extensive work of Fordyce (1988; described in detail below) is based on the distinction between nociception/pain and suffering/pain behavior. In the former there is a physical input that cues the body to an

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE aversive event that must be attended to in order to prevent or minimize bodily injury. In the latter, the person's reports of suffering from pain may not be entirely, or even importantly, related to organic nociception but rather may be associated with complex psychological factors having little to do with tissue injury. Acute Versus Chronic Pain Acute pain is linked to nociception. Chronic pain can evolve from acute pain and is said to be present when healing time is past, that is, when there is no nociception, generally regarded as a period of 6 months from an injury or event. It is more often associated with suffering and disability. Depression and anxiety magnify chronic pain more than they do acute pain (Kelly, 1986), and traditional medical treatments seldom help (Gatchel et al., 1989). The profiles of a well-known personality assessment instrument, the Minnesota Multiphasic Personality Inventory (MMPI), discriminate between acute and chronic pain patients, the latter showing elevations in the “neurotic triad,” hypochondriasis, depression, and hysteria. This pattern is believed to be due to the constant wearing away of the person's energy from the ongoing pain, his or her preoccupation with it, and despair from not improving (Sternbach, 1974; Barnett, 1986). Psychological Factors in Pain Pain used to be considered strictly a function of physical injury, but in recent years there has been increasing appreciation of psychological factors. These factors (see Peck, 1986) lay the groundwork for consideration of pain management. Fear, Anxiety, and Depression In general, there is a linear relationship between anxiety and the experience or perception of pain (Cohen and Lazarus, 1973; Wilson, 1981), especially for acute pain. The nature of the anxiety usually relates to fear of death or of disability and fear of the unknown. Hospitalization generally brings with it radically new situations to be adjusted to, loss of one's normal freedom and control, separation from family and other social supports, and procedures that occasion nociception. It should also be mentioned that pain behaviors can serve as excuses to escape from or avoid fearsome situations, referred to by psychoanalysts as secondary gain; for many people, especially men, complaints of pain are more acceptable than reports of fear. Depression is also associated with the experience of pain (Halpern, 1978); some symptoms of depression, like sleep disturbance and lethargy, can

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE themselves exacerbate pain over the long term or can contribute to chronic pain. Of course pain from a traumatic event like a serious injury often leads to depression that both causes and is itself caused by loss of occupational function, decreases in cognitive and sexual functioning, and changes in physical appearance. Perceived Control Over Noxious Stimuli As with fear and anxiety, pain perception seems to increase if a person does not believe he or she has some degree of control over the nociceptive stimulation (Averill, 1973; Geer et al., 1970; Glass et al., 1973). In addition, extended periods of helplessness can also contribute to depression. Attention/Distraction Distraction from a painful stimulus can decrease the perception of pain, and attention to it can increase pain (Blitz and Dinnerstein, 1971; Turk, 1978; Turk et al., 1983). Cognitive Appraisal Along the lines of Lazarus's (1966) classic work on appraisal and fear, the way a person construes his nociceptive pain can affect subsequent pain experience and behavior. A literary example is in Stephen Crane's Red Badge of Courage, in which a soldier during a Civil War battle wishes to be wounded so that his courage will not be questioned. Nonfictional wartime examples were reported by Beecher (1956), who found during World War II that soldiers about to be sent home because of their wounds reported far less pain than civilians with comparable wounds created by surgery. In general, the meaning of a nociceptive stimulus can affect how one reacts to it, whether one can continue to function and how much discomfort will be experienced; certainly, commitment and strong belief in a cause is a time-honored factor in coping with all sorts of ordeals, whether painful or not. Coping Style A person's cognitive coping style, in terms of avoiding or seeking information, has been shown to interact with the benefits of information provided prior to a painful or threatening event. Byrne (1964) originally classified styles of coping along a “repression-sensitization” continuum: repressors are said to prefer to cope by denial and avoidance; sensitizers prefer confrontation with the stressor. Some studies have found that sensitizers do better when information is provided than when it is not, while repressors show the opposite pattern. For example, Andrew (1970) found that repressors used more medication postoperatively. Shipley et al. (1978, 1979) similarly found repressors to have higher heart rates during a medical procedure and to require more tranquilizers than sensitizers when they had been given information about the procedure. Learning Factors Responses to nociceptive stimuli can be greatly

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE influenced by observation of how others respond to them (Craig and Weiss, 1975). Such social modeling actually affects the experience of painful stimuli. Pain behavior can be influenced by contingencies, like the presence of a solicitous spouse (Fordyce, 1976, 1978); this forms the basis of his work with chronic pain (described below). TREATING ACUTE PAIN Acute pain refers to relatively short-term suffering and disability resulting from trauma. The perception of acute pain is influenced by a number of psychological factors, and recovery is likely to be aided by several nonpharmacological approaches that enable people to manage the pain. A number of these approaches are described in the following paragraphs. Placebo and Expectation Placebo refers to the improvement based on expectation of gain rather than on the operation of a specifically effective therapeutic agent. (This distinction, of course, would not hold if one's theory of change postulated expectation of gain as itself an active therapeutic agent.) There is some intriguing evidence that placebo-based improvement in pain perception has a biochemical basis: expectation of benefit may release beta-endorphins, endogenous opioids which inhibit transmission of pain signals (Levine et al., 1978). Thus, in addition to being a response to a stressor, the release of endorphins might occur under the psychological conditions known to induce an expectation of benefit. Psychological Support Psychological support includes describing to patients how they can expect to feel following surgery or trauma (see appraisal section below) and other general psychotherapeutic efforts that reduce anxiety and depression. Sensory and Procedural Information Classic work by Janis (1958) showed that surgery patients with moderate levels of anticipatory fear suffered less pain postoperatively than patients with either low or high levels of such fear. His work was followed by Egbert et al. (1963, 1964), who found that providing patients with information preoperatively about their surgery led to their being released earlier and experiencing less pain. Sensory information involves telling patients what sensations to expect during or after a medical procedure; procedural information entails telling them about the medical procedure itself. The former tends to be more helpful for most people than the latter (Johnson, 1983), probably

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE because of lessened anxiety that comes from knowing that certain sensations are normal. Having been told that a certain kind and degree of pain is to be expected, a patient may be less concerned about the pain being experienced because it is not construed as a sign that something is wrong. When procedural information helps, it may be due to the opportunity it allows a patient to rehearse the upcoming event in his or her imagination and thus become desensitized to the anxiety associated with the event (Wolpe, 1958). Relaxation Training Relaxation training is a powerful treatment for increasing pain tolerance in some situations. For example, patients instructed in breathing and relaxation prior to their first attempt to get out of bed after surgery reported less incisional pain and used fewer analgesics than control patients (Flaherty and Fitzpatrick, 1978). In the laboratory, relaxation has been effective for reducing cold pressor pain (pain produced by immersing the hand in ice water) and also for decreasing pain ratings (e.g., Stevens and Heide, 1977; Stone et al., 1977). This effect is likely due to reducing anxiety and increasing a sense of control (Peck, 1986). Enhancement of Personal Control As already mentioned, people generally experience less pain and stress if they can exercise a degree of control. An intriguing and promising medico-psychological procedure is a patient-controlled analgesia (PCA) machine that allows a patient to administer his or her own pain killers with a preset upper limit. Such a device and procedure would be expected to impart a sense of greater control, and it has been found that patients achieve better relief from pain with the PCA and even use less analgesic medication (White, 1986). A recent study with labor pain showed that satisfaction was very high: patients preferred the PCA to techniques that actually reduce pain intensity more completely, such as epidural morphine. In general, being active rather than passive is better because activity can be distracting in itself (see Gal and Lazarus, 1975). Many empirical findings support the notion that if patients do not believe that they can control or terminate an aversive event, it is perceived as more painful (e.g., Averill, 1973). A PCA machine allows a patient an increased degree of control over a noxious event, which theoretically should decrease both anxiety and perceived pain. Of course, having a PCA machine means a patient's attention must be engaged to administer the analgesia, and so must be focusing on pain. But this would be true in any case. In traditional nurse-administered analgesia, a patient is often very focused on the pain because the system requires that a patient wait until the pain is substantial before requesting medications. And even after a patient requests the medication, he or she must wait

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE until the nurse has the time to fulfill the request. This alternative obviously does not allow the patient to be distracted from the pain. In fact, quite the opposite. Under certain conditions, distraction can be pain reducing, as discussed in the next section. Cognitive Coping Skills Training There are two main cognitive strategies proposed for pain relief (Turk et al., 1983), and they are more useful for mild to moderate pain than for extreme pain: to alter a person's appraisal of pain and to direct attention away from pain. One strategy of cognitive coping involves providing information about painful medical procedures (Janis, 1958). Such information may lead to enhanced self-efficacy (Bandura, 1977) because a person acquires information that can be used to take effective coping action (Anderson and Masur, 1983). For example, a person about to have a dye injected for assessment purposes could be told that “When the dye is injected (procedural), you will feel a hot flash (sensory)” (Anderson and Masur, 1983:10). Six types of diversion strategies can be distinguished: imagination-inattention: pleasant imagery incompatible with feeling pain, such as imagining something very positive during dental treatment (Horan et al., 1976); imaginative transformation of pain: reinterpreting pain into a sensation like numbness, something that is a part of Lamaze “natural childbirth ” training, in which women are encouraged to substitute “pressure” for pain; imaginative transfer of context: reframing the pain in some other context so as to interrupt the flow of negative thinking and facilitate the generation of coping strategies; external attention-diversion: focusing on external aspects of the environment, such as counting ceiling tiles (Barber and Cooper, 1972); internal attention-diversion: focusing attention on other self-generated thoughts, such as doing complex mathematical operations; and dissociation from pain: thinking that a painful bodily part, e.g. an arm, belongs to someone else. The first, second, and sixth of these strategies were found by Tan (1982) to be the most helpful. We note that many of these strategies are sometimes embedded in hypnotic inductions. All of these techniques for diverting attention from painful stimulation are consistent with cognitive research, which shows a limited supply of attentional resources: attention to one channel of input blocks the processing of input on other channels (Kahneman, 1973). Stress Inoculation Training “Stress inoculation training” refers to the kinds of strategies just described (Turk et al., 1983). The approach

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE basically entails three interrelated steps: educating a person about the nature of pain; describing in detail the techniques available for coping with pain; and encouraging practice in and application of techniques that make sense to the patient. (The other usage of the term refers to training techniques, as in sports, whereby a person is presented with a challenge beyond the level that is likely to be encountered in game conditions, such as setting a pitching machine to hurl a baseball at 110 miles per hour.) Biofeedback Biofeedback refers in general to the use of sophisticated instrumentation that provides a person immediate information on minute changes in such functions as muscle activity, heart rate, and blood pressure. This knowledge can be used by the person to control such somatic and autonomic activity to some extent. Some fairly controlled studies (reviewed by Chapman, 1986) show that biofeedback from tension of muscles in the forehead is significantly better than no treatment or a placebo in reducing subjective ratings of chronic headache pain. There is no evidence, however, that biofeedback is superior to relaxation training alone in reducing acute pain; its effectiveness is most likely mediated by reducing anxiety (Gatchel et al., 1989), perhaps by enhancing sense of control. Hypnosis The history of anesthesia is closely connected with hypnosis, for hypnosis was used widely in the middle and late nineteenth century by physicians like Bernheim and Charcot to reduce pain. The introduction of ether and other anesthetic drugs diminished the use of hypnosis, although it has been enjoying a resurgence of interest in childbirth, dentistry, and in treating the pain brought on by a variety of assessment and medical procedures (Hilgard and Hilgard, 1975). Except for its relaxation components, it is doubtful that putting someone into a hypnotic trance by itself reduces pain. Rather it is the suggestions that are given that are operative, such as intimating that a limb has become numb or that it is not one's own, or that “strong sensations” will “not matter.” It is believed that cognitive strategies of diversion or dissociation can be strengthened by encouraging their use under hypnosis. A limiting factor, of course, is that people vary widely on how susceptible they are to hypnosis. TREATING CHRONIC PAIN As we have just seen, treating acute pain is concerned primarily with reducing nociception and influencing psychological factors in the perception of nociception. With chronic pain, the focus is on decreasing suffering, whether pain related or not, and decreasing pain behaviors

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE and disability. It should be emphasized at the outset that success in the management of chronic pain is often not associated with reduction in reports of the experience of pain; rather, with reduction in such things as medication usage and with increase in activity (Fordyce et al., 1973). The goal is far less on nociception and the experience of pain than it is on “working through the pain ” and adopting a “no pain no gain” philosophy that encourages restoration of function. This emphasis on pain behaviors is important (Gatchel et al., 1989). The idea is to “tough it out.” What often happens is that increased activity can reduce nociception, as with back sprains, for which increase in muscle tone can itself reduce nociception over time as well as reduce chances of recurrence of acute attacks. The principal researcher in this area is William Fordyce at the University of Washington, and his program is of the “pure operant” variety that rewards the patient for gradually increasing general activity level and social interaction, decreasing the use of pain medication, and reducing reliance on all pain-related health care services. Fordyce's group focuses on the modification of maladaptive learned contingencies. Over time pain behaviors get reinforced by attention, nurturance, rest, avoidance of responsibilities and other burdens, and the receipt of money for disability. At the same time, healthy behavior is not reinforced or is even punished, possibly by cut-off of benefits or by a family worried about the patient's efforts to “get going.” Fordyce's basic approach is to reverse the contingencies. The results are very positive in enabling chronic pain patients to regain functions that have been compromised by pain and suffering (see, e.g., Fordyce, 1976). Other behavioral programs that add to the basic approach include relaxation training and group discussion and support. Another approach to treating chronic pain is through cognitive interventions, such as reducing stress with the use of covert self-statements that serve to decatastrophize the pain (Turk, 1978; Ellis, 1962; and Meichenbaum and Cameron, 1983). The old-fashioned method of “counter irritation” has been more formally developed into a method of intervention which is generally referred to as “stimulation-produced analgesia.” Neurostimulatory techniques for pain control include central stimulation, spinal cord stimulation, and peripheral stimulation. Peripheral stimulation is an outgrowth of what previously was referred to as counter irritation. It now involves mechanical or electrical stimulation of the peripheral nerves in the form of acupuncture, transcutaneous electrical nerve stimulation (TENS), and intramuscular injection of a local anesthetic to alleviate pain, increase range of motion, and enhance exercise tolerance. These methods are often used for the management of chronic pain, and they are generally

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE administered by physicians or physical medicine specialists rather than psychologists. To the extent that counter irritation is helpful by providing a distraction, psychologists have developed many interventions (e.g., guided imagery, cognitive distraction techniques, hypnotic suggestion) that utilize distraction to manage both acute and chronic pain. In general, a patient needs to learn about pain, particularly the distinction among the four aspects of pain, and the utility of various approaches for dealing with each one, especially suffering and pain behavior, which are separate from the acute nociception-pain phases that do require and merit medical attention. There is a wide variety of diseases and medical conditions for which accepted (pharmacologic or otherwise somatic) treatment does not provide complete relief. Examples of these are rheumatoid arthritis, pneumococcal pneumonia, and degenerative spinal disease. Furthermore, there are diseases, some of them progressive, for which there is no known treatment for the pain they cause. Examples include terminal cancers and central pain conditions such as thalamic pain syndrome. For these latter problems, integrating psychological and somatic interventions often constitutes the most promising approach. CONCLUSIONS There is encouraging evidence in the pain-control literature that people can be taught nonpharmacological ways to cope with physical pain. Many of the procedures known to be useful for reducing anxiety also favorably influence pain because alleviating stress is known to decrease a person's experience of pain. Central to current understanding of pain is the role of cognitive factors, that is, a person's construals of nociceptive input can have a profound effect on whether and how severely he or she actually experiences pain. Of particular importance are perceived control and the meaning attached to a painful experience. Procedures that enhance a person's control or sense of control appear to reduce pain because of the often demonstrated reduction of anxiety associated with increased control. For many individuals, information about what to expect from painful experiences, such as surgery, reduces the experience of pain. Distraction is an effective strategy for coping with pain. Relaxation training is also useful for controlling pain, perhaps due in part to distraction as well as to the reduction of worry and anxiety. Suggestions given under hypnosis to susceptible individuals can also help them cope with pain, for example, imagining that an affected limb is not really a part of them. Chronic pain can be managed by identifying and controlling psycho-

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE logical perpetuating factors. In most cases this would involve combining a variety of pure behavior-learning approaches with other cognitive-behavioral and relaxation interventions to encourage a patient to increase activity level even if experiencing discomfort and pain. REFERENCES Anderson, K.O., and F.F. Masur 1983 Psychological preparation for invasive medical and dental procedures . Journal of Behavioral Medicine 6:1-40. Andrew, J.M. 1970 Recovery from surgery with and without preparatory instruction, for three coping styles. Journal of Personality and Social Psychology 15:223-227. Averill, J.R. 1973 Personal control over aversive stimuli and its relationship to stress . Psychological Bulletin 80:286-303. Bakan, D. 1968 Disease, Pain, and Sacrifice: Toward a Psychology of Suffering. Chicago: University of Chicago Press. Bandura, A. 1977 Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84:191-215. Barber, T.X., and B.J. Cooper 1972 The effects on pain of experimentally induced and spontaneous distraction . Psychological Reports 31:647-651. Barnett, J. 1986 The Comparative Effectiveness of the Millon Behavioral Health Inventory and the Minnesota Multiphasic Personality Inventory as Predictors of Treatment Outcome in a Rehabilitation Program for Chronic Low Back Pain. Unpublished Ph.D. dissertation, University of Texas Health Sciences Center, Dallas. Beecher, H.K. 1956 Relationship of significance of wound to the pain experienced. Journal of the American Medical Association 161:1609-1613. Blitz, B., and A.J. Dinnerstein 1971 Role of attentional focus in pain perception: manipulation of response to noxious stimulation by instructions. Journal of Abnormal Psychology 77:42-45. Byrne, D. 1964 Repression-sensitization as a dimension of personality. In B.A. Maher, ed., Progress in Experimental Personality Research, Vol. 1. New York: Academic Press. Chapman, S.L. 1986 A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches. Pain 27:1-43. Cohen, F., and R.S. Lazarus 1973 Active coping processes, coping dispositions, and recovery from surgery . Psychosomatic Medicine 35:375-389. Craig, K.D., and S.M. Weiss 1975 Vicarious influences on pain threshold determinations. Journal of Personality and Social Psychology 19:53-59. Darke, L. 1990 Psychological Factors in the Management of Pain. Unpublished manuscript, Pain Management Center, University of California, Los Angeles.

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IN THE MIND'S EYE: ENHANCING HUMAN PERFORMANCE Wilson, J.F. 1981 Behavioral preparation for surgery: benefit or harm? Journal of Behavioral Medicine 4:79-102. Wolpe, J. 1958 Psychotherapy by Reciprocal Inhibition. Stanford, Calif.: Stanford University Press.