On Pain Research, Research Mentoring and Ethical Research Challenges with a Pain Leading Expert

Emilia Chiscop-Head, PhD
Interview with Duke psychologist and researcher Francis Joseph Keefe, PhD

Francis J. Keefe, PhD is a Professor in the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center with secondary appointments in Psychology &Neuroscience, Anesthesiology and Medicine. Dr. Keefe is also Editor-in-Chief of PAIN, the journal of the International Association for the Study of Pain, and he is a member of the Duke Cancer Institute.

Francis Keefe leads the Duke Pain Prevention and Treatment Research Program and has played a key role in establishing multidisciplinary pain programs at Duke. One key focus of his work was to increase access to behavioral therapies through smart technology and to integrate behavioral interventions in primary care and other clinical settings.

Dr. Francis Keefe is also a renowned mentor and one of the recipients of the 2020 School of Medicine Mentoring Awards. He was invited to share his good mentoring practice in a recent research town hall hosted by the Duke Office of Scientific Integrity in May 2021.

- I see that your research has a lot to do with managing pain. What can you tell us about pain?

Francis Keefe, PhD: I have been clinically involved for more than 30 years with patients having pain. What continues to amaze me is how much people vary in their abilities to cope with or manage pain. One person would be very active enjoying their life; the other person with seemingly the same medical condition would be confined to a wheelchair.

"We can think pain almost like an orchestra playing, with the different sections producing the output we call pain."

Eric Cassel’s book “The Nature of Suffering and the Goals of Medicine” provides insights on an essential difference that not all doctors make: between sensorial pain and suffering, defined as the psychological or emotional impact of pain. How do you differentiate between the two?

Francis Keefe, PhD: I have attended lectures by Eric Cassel. His work influenced one of my career mentors and his book has been very influential in the years following its publication. However, we now know that the view of pain that he had in that book is somewhat outdated. At that time, he defined pain as the perception caused by noxious stimulation, thus, you've got noxious stimulation going into the nervous system and you have this conscious experience of pain. He defined suffering as the emotional distress, the unpleasantness, awfulness caused by the pain. More recent research, however, shows us that pain can occur in the absence of noxious input, such as, for example the phantom limb pain. In other words, people can report pain in amputated limbs without any clear evidence of noxious input. We also know from brain imaging studies that when somebody reports pain, that it is just not the sensory circuits that fire. Instead, there is matrix of circuits in the brain firing away. Along with the sensory circuits, other areas of the brain are activated, e.g. areas responsible for emotions, thoughts, stress, and pain control. So, we can think pain almost like an orchestra playing, with the different sections producing the output we call pain. Interestingly imaging studies have shown individuals who, early in the course of a painful condition, show more activity in emotion-related brain circuits are more likely to develop persistent pain.

We often assess pain by asking a patient to give it a number from 0 (no pain) to 10 (pain as bad as it can be).  Given what we now know about pain from brain imaging and other studies, it is clear that using a single number of this scale, e.g. an 8 on a 0 to 10 scale does a pretty poor job of capturing the full experience of pain. The number a patient gives represents a combination of things.

Recognizing the complexity of pain, the International Association for the Study of Pain has defined pain as an unpleasant sensory and emotional experience.

To summarize, we now know that pain and what Cassel called suffering are integrally related and not as distinct as he proposed. Unfortunately, one of the glaring problems in medicine, despite all these scientific advances is that in so many clinical settings, pain continues to be viewed as a simple sensation warning of tissue damage, rather than a complex experience influenced by thoughts, feelings, stress, and our own abilities to modulate pain

- A number of your articles focus on the role of Cognitive Behavioral Therapy (CBT) in managing pain. What have you found out?

FK: CBT is a way of approaching pain as this complex experience influenced by cognition - what you're thinking about the pain, future and others – and by your behaviors (e.g. becoming inactive, isolated, and restricting your lifestyle because of becoming overly fearful of things that might increase pain fearful avoidare you becoming very). So what can we do to help someone manage pain by addressing these factors?

Over the past 25 years, protocols for delivering CBT for people with both acute and chronic pain have become standardized and they're very widely used across the world. CBT basically teaches people cognitive skills (e.g. meditation, imagery, how to use coping self-statements) and behavioral skills (how to set goals, problem solving, using activity pacing) to better manage pain. In fact, of all the psychosocial treatments for pain, CBT is considered the golden standard.

There is evidence from hundreds of studies supporting CBT’s efficacy in reducing pain and emotional distress related to pain as well as increasing people's involvement in valued activities, getting back to things that they want to do.  CBT may be particularly useful in reducing the intake of pain medications. Some of the current NIH studies (funded by the HEAL initiative) that I’m working on are looking at that. One of the current trends is to integrate CBT into clinical practice, given that clinicians interact with patients experiencing pain directly, and to a larger scale than mental health practitioners do.  Along these, we are teaching physical therapists, nurses and other clinical professionals to do brief CBT interventions in the context of their visits with patients.

To increase access to CBT, we've also developed an online program for training in pain coping skills. The program is called painTRAINER (https://healthsciences.unimelb.edu.au/departments/physiotherapy/chesm/patient-resources/paintrainer) and is hosted at the University of Melbourne – Australia.  It educates users about advances in our understanding and uses an interactive/experiential approach to teach them how to develop and apply pain coping skills. Our goal with painTRAINER is to address pain from a public health perspective. The program is free to users and clinicians.  It is becoming widely used over the world and it is being incorporated into primary care settings. People like it because they can access it any time of the day or night and can integrate the skills they learn into their daily life routines.

- You studied the efficacy of loving-kindness meditation in breast cancer patients. What do you know? What do you think doctors and scientists could do to ensure that meditation practice is more broadly embraced by patients, given its many benefits? How long should a daily meditation routine last in order to be effective?

FK: Loving kindness is a very particular type of meditation, focused on compassion for one’s self and others. It's a series of exercises where the emphasis is focusing on very positive feelings and then observing what happens when you do that. You begin by focusing on positive feelings for someone you love unconditionally (e.g. a child) and observing your response. Later you focus on directing positive feelings to someone who might be neutral (e.g. a store clerk), and then on yourself.  Still later you practice directing positive feelings to people in your neighborhood, country, and the world.  Finally, you are asked to observe the effects of focusing those positive feelings on somebody who has harmed you. It's a very interesting and effective form of meditation. It differs from more typical mindfulness meditation approaches that you have focus on the breath and other sensations that occur during quiet sitting or walking. Loving kindness is very important when you have pain or other medical symptoms because so many of these people with these conditions report their lives are dominated by negative emotions (anxiety, depression, irritability). Research studies show that loving kindness seems to be particularly beneficial for increasing the level of one’s positive emotions, something very important in persons with chronic pain. That being said, in pain research, the effects of mindfulness meditation has been studied more. Reviews of multiple studies of people having chronic pain show that mindfulness meditation reduces both the intensity component, and the emotional unpleasantness component of pain. Mindfulness meditation also has been found to reduce depression, anxiety, and improves both mental and physical quality of life.  Research also shows that the more minutes you practice meditation in a day, the more likely you're going to get such benefits that day and, according to some studies, even the next day.

In sum, meditation practices can make a real difference for people with chronic medical conditions. How can clinicians support patients’ use of meditation? Often asking a simple question such as “have you ever considered using meditation?” can have a big impact on a patient’s use of meditation or other pain coping techniques.

- You also studied discrimination and depression symptoms among African Americans with Osteoarthritis…

FK: We found that people with chronic pain who experienced discrimination were more depressed than people who did not. Interestingly, those who practiced CBT didn't show that relationship.

- An important part of your research on pain focused on women but also on men. What are the key differences between these groups that doctors and non-medical professionals need to know?

FK: Women with osteoarthritis pain reported more pain and more physical disability then men, but they were also more active in their coping efforts on a daily basis. Women were particularly prone to use what we call emotion focused coping strategies to deal with pain. It could be that women are more willing than men to acknowledge the pain, how it affects their life and are more willing to address it actively, rather than try to ignore it.

- How do spouse and patient beliefs/perceptions/culture impact pain and pain behavior?

FK: We have conducted studies in which one member of a couple had pain (e.g. cancer-related pain).  In these studies, we measured an overly negative set of beliefs about pain, called pain catastrophizing, in both the patient and their partner. Faced with pain, people who catastrophize tend to feel overwhelmed, helpless, and ruminate about pain. What we found is that, patient reports of pain were lowest in couples in which neither member tended to engage in pain catastrophizing. Pain was somewhat higher if one member tended to catastrophize, and highest when both members tended to catastrophize about pain.  Why do people engage in pain catastrophizing? One theory about why people catastrophize is that for some of us it is a way to deal with emotional impact and elicit support and help from others. While there may be some benefits of pain catastrophizing in terms of immediate help, in the long run catastrophizing is linked too much poorer outcomes in terms of increased pain, disability, and emotional distress."It is very important to work with mentees just the way we do with our colleagues, and show them the same level of respect and courtesy and not see them as somehow below us and overly direct and micromanage them."

"It is very important to work with mentees just the way we do with our colleagues, and show them the same level of respect and courtesy and not see them as somehow below us and overly direct and micromanage them."

- You are a recipient of the Duke Mentoring Awards. What do you think that makes you an excellent mentor?

FK: Being in a place like Duke really helps. I have been fortunate to have worked a lot with top notch psychology graduate students; psychology interns, and post-doctoral fellows who are drawn to Duke because of the work that has been done here over the years. They are bright and motivation, and in most cases. I feel like I simply have to nurture them and they're just going to blossom.  As a mentor, it is important to have a genuine interest in the person: what is their focus, how do they really want to direct their career, what is their ultimate goal. My own mentoring benefitted greatly from my early career experiences as a mentee. My mentors encouraged me to explore various pathways and opportunities and choose what is important for me. It is very important to work with mentees just the way we do with our colleagues, and show them the same level of respect and courtesy and not see them as somehow below us and overly direct and micromanage them.

- What is a mistake that mentors should avoid?

FK: I think some mentors and mentees have difficulties communicating.  I think mentoring it's almost like a family relationship sometimes. It's hard in families to address the difficult things and people avoid them. But if you can address those issues often, it really makes a difference. You want to address issues early and often. It's like downshifting your fears while riding a bicycle up a hill: you’ve got to address it early and usually not just once but many times. In terms of topics to communicate about: I would target specifically authorship issues, which are common sources of misunderstanding and miscommunication.

- What can institutions and departments do to support good mentoring?

FK: I think Duke is already doing things to identify the good mentors. Recognizing good mentors and raising their contributions up is important.  As is, giving them opportunities to share what they've learned like the town halls that you host at the Duke Office of Scientific Integrity.

Another thing that could be done and it is perhaps a little controversial is to give top notch mentors a salary supplement or pay a portion of the salary for mentoring. This is not something that has been done traditionally. Another thing that we can do is to train students about the value of making changes during their studies and - if they need to change a mentor or an advisor because it is not a good fit – not see that as a tragedy.

"To me it's not ethical if you're researching pain and ignore the emotional impact."

- What are some of the research integrity challenges in your research areas?

FK: The fact that there are scientists and clinicians who simply think that pain is a sensory experience due to noxious input which can be measured just looking at the neural impulses is, in my view, an ethical issue. Researchers and clinicians need to understand that pain is an unpleasant sensory and emotional experience. And they need also to focus on ways to address the emotional aspects of the experience. To me it's not ethical if you're researching pain and ignore the emotional impact.

- What research misconduct in psychological research troubled you most?

FK: Following the 9/11 terrorist attacks a number of psychologists got involved in government sponsored torture. The federal authorities at that time who planned out the torture hired psychologists to be present during torture, to make sure it was safe, legal and effective. The American Psychology Association, which is the chief association of all psychologists apparently changed some ethical guidelines during that time to enable psychologists to be involved in this government sponsored torture possible. A major investigation led by a law firm ended up with a 500 page report which found out that the psychologists were involved in dark sites where prisoners were held and tortured This was not something that just occurred after 9/11, but happened over a 15 year period, and after 9/11 it really took off. And the psychologists involved were paid millions of dollars. This led to an uproar among psychologists; and a number of leaders of the American Psychological Association resigned. What hit me personally was that I know a number of individuals around the world who have devoted a good part of their career to working with pain in torture victims. I know that the pain of these victims is often not taken seriously because of the context in which it occurred and because they are simultaneously dealing with emotional problems related to torture.

- How can we best train the next generation of researchers to conduct their research with outmost rigor and ethics?

FK: I think the push for open and transparent science - which is very much embraced by the new generation of researchers - is tremendously important for conducting research that is replicable and rigorous. The more transparent the scientific process becomes and more people are willing to share their research data, the more ethical and impactful science will be. Ethical research is impactful research.


This interview is part of a series of interviews with renowned scholars, scientists and influential leaders invited to share their outstanding work and views on topics related to research integrity. 


Read all the articles in the Research Interviews Series:

John Dolbow

Jennifer Lansford

Paula McClain

Brandon Garrett

Christian Simon

Patrick Charbonneau

Nimmi Ramanujam

Nicolas Cassar

Ada Gregory

Adrian Bejan

Walter Sinnott-Armstrong