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Behavioral Therapy for Chronic Pain
Aaron Beck (cited by Weinrach,
1988) says cognitive
therapy is a short-term treatment intended for treating anxiety and
Beck says further that this therapy is based on a view of
stipulates that an individual’s dysfunctional behavior is caused
or inappropriate ways of interpreting their experiences. Aaron Beck
that this approach requires counselors to focus on the
cognitions as well as their feelings. He says that
what we feel
influenced by what we think, and that in order to feel better we need
to avoid dysfunctional
thoughts (Aaron Beck cited by Weinrach, 1988). Aaron Beck’s
greatest contribution is the
formulation of the cognitive
model of emotional disorders and the development of cognitive
therapy, which is
derived from that model (Weinrach, 1988).
The Gate Control
theory of pain was proposed by Melzack and
Wall in the year
1965. It explains the current understanding of biopsychosocial nature
perception (Grant & Haverkamp,
Melzack and Wall postulated that a neural gate mechanism exists that
pain stimulation to pass through to higher brain centers or suppresses
on the circumstances. Not only do nerve impulses travel to the brain
injured area, but certain psychological and socio-environmental factors
also stimulate the brain to send signals that can either close or
gate mechanism and therefore modulate the perception of pain. Melzack
emphasize that counselors should focus their pain management
interventions on the
modulation of this gate mechanism. Their clients will also benefit from
understanding this connection (Grant
& Haverkamp, 1995).
cited by Grant & Haverkamp (1995), says that the biopsychosocial model
of pain distinguishes between pain suffering and pain behaviors. Pain
thought of as a sensation caused by nociception- activity from
nerve fibers that signal the central nervous system that something bad
happening. Fordyce says that suffering is the affective response to
nociception and is observed only indirectly through pain behaviors.
says that pain behaviors are the overt actions individuals engage in
suffer or are in pain. Fordyce emphasizes that these behaviors can
or decrease the experience of suffering and then they become the
the biopsychosocial model of pain has been found to be the most useful
to understanding and managing pain (Gatchel & Oordt, 2003). In
experience pain, the distinction between cure and management is
for many chronic pain sufferers a medical cure is not available so the
will have to deal with the pain. Using a pain management approach will
the individual hope because even though the pain may never completely
they can still reduce its effect on their daily lives (Grant and
therapy (CBT) teaches
relaxation techniques, stress management, and other ways to help you
pain. Areas that contribute to pain management include physical,
and social factors (Erstad, 2005). Erstad (2005) states
that cognitive-behavioral therapy is based on the idea that thought and
behavior patterns can affect symptoms and disabilities, and therefore
obstacles to recovery. Erstad emphasizes that when a person feels a
type of pain starting or getting worse, they probably have a sense of
will progress. If the person is used to the pain being severe or
may expect the pain to become more intense.
Erstad stresses that this
may make the person feel out of control or helpless. This stress
trigger physical changes in the body, such as blood pressure, the
stress hormones, muscle tension, and more pain (Erstad, 2005).
Erstad, (2005), goes on to
cognitive-behavioral skills can alter the way a person’s mind
body. When the person shifts their
thinking away from the pain and changes their focus to more positive
their life, the person changes the way their body responds to the
pain and stress. According to Erstad, (2005) the goal of
therapy is to change the way a patient thinks about the pain so that
and mind respond better when they have episodes of pain. Therapy
changing the patient’s thoughts about illness and then helping
positive ways of coping with illness.
Approach To Chronic Pain Management
Researchers who have reviewed the literature on the
efficacy of CBT treatment for chronic pain management have generally
that the results are consistently positive (Grant & Haverkamp,
researcher found that a CBT program produced gains in cognitive,
behavioral domains that were maintained for at least 12-months, in
no change in the wait list control group. Additionally, significant
in reported pain levels were found when CBT interventions were compared
placebo medication group (Engstrom cited by Grant and Haverkamp, 1995),
with an educational-information program (Keefe et al., cited by Grant
Holzman, & Kerns cited by Grant & Haverkamp
(1995), state that when clients perceive
themselves as active participants in their own change process, they are
likely to attribute successful outcomes to their personal competence,
highly motivated, and demonstrate greater behavior change. Turk et al.
in pain management counselors should act as a collaborator with clients
achieving their goals, rather than as an expert who has the solutions
or a quick
fix (Grant & Haverkamp, 1995).
According to Grant & Haverkamp (1995) Cognitive-Behavior
Therapy for pain management counseling is firmly based in a strong,
respectful regard for client’s struggle and experience. CBT pain
also active, time limited, and structured in a style that may be less
to some other counselors. Counselors need to be sensitive to the fact
active approach may also be a new experience for the client and that
be quite skeptical. Part of their skepticism may be due to previous
experiences the individuals have had with past treatment efforts.
also be angry, discouraged and defensive, especially if other
have suggested that their pain is caused by underlying psychological
For these clients, a collaborative approach is essential to ensure
is not misinterpreted as another message that the pain is “all in
(Grant & Haverkamp, 1995).
Grant & Haverkamp (1995) say assessment is the
first step to determine whether physical, affective, cognitive, and
factors are interacting with the clients response to pain, whether CBT
is appropriate, and whether there are any other problems that need to
addressed before pain management is begun (e.g., deal with or rule out
disorders, severe depression, or anxiety first). The assessment should
and detailed about the client (Grant & Haverkamp, 1995).
According to Grant and Haverkamp (1995), it is also
important for the counselor to determine how clients understand their
what they believe is causing it, and what they think will help.
have frightening conceptualizations of the problem; they may think that
spine is crumbling under them, or if they have migraine headaches that
due to a cerebral aneurism. It is important for the counselor to elicit
fears as clients may be too embarrassed to discuss it.
Grant & Haverkamp, (1995), emphasize that is
essential that at the end of the assessment that the counselor’s
of the problem be discussed with the client to determine if the client
with the case formulation and the proposed intervention plan. Grant
Haverkamp point out that this will enforce the collaborative nature of
relationship and helps the counselor develop the plans that fit the
own unique experience of the problem. Researchers found that
post-treatment improvement in pain and disability to be associated with
pretreatment agreement with the philosophy of a pain management
approach (Shutty, DeGood, & Tuttle cited by Grant & Haverkamp,
Intervention Approaches used in pain
management are as
of the Pain Problem
Holzman et al. cited by Grant
& Haverkamp, (1995)
state that the purpose of the following CBT interventions is to assist
in reconceptualizing their pain problem from that of a medical symptom
out of their control to a belief that pain perception is amenable to
through physical and psychological interventions. Holzman et al.
the explanation of the construct of chronic pain and the CBT approach
vital first step in the counseling process, because it is important
clients believe the concept makes sense and are prepared to experiment
if it applies to them.
Holzman et al. state that it is important to establish
specific and mutual goals. Goals need to be specific, measurable, and
reference to pain or distress (Philips cited by Grant & Haverkamp,
give as an example, rather than “I would like to be able to
of exercise without increasing my pain,” the goal can be phrased
“Walk at a
brisk speed for 30 minutes, four times a week.” Holzman et al.
goals provide a means of evaluating counseling progress and avoiding
miscommunication and unrealistic counseling expectations.
Daily Pain Diary
Philips (cited by Grant & Haverkamp, 1995) suggests
for at least first few weeks of counseling that clients keep a record
frequency, duration and intensity, sleep patterns, and medication
record is based on hourly ratings.
Exercise: Many chronic pain clients are physically
inactive. Therefore, an exercise program
is an important intervention strategy for overcoming physical
and the belief that any activity beyond the minimal is damaging
Turk & Holzman, 1986, cited by Grant & Haverkamp, 1995).
emphasizes that the program needs to be graduated, so that clients
up to therapeutic levels, and carefully explained in terms of long-term
benefits, such as increased muscle strength, flexibility, and sense of
Relaxation training: Relaxation training is
one of the
most common techniques used in chronic pain management programs
al., 1986; Melzack & Wall, 1982, cited by Grant & Haverkamp,
points out that the aim of these techniques is to teach clients to
physiological arousal and muscle tension on demand. Relaxation
include deep breathing, progressive muscle relaxation, relaxing
cue-controlled relaxation, autogenic relaxation, or hypnosis. The
benefit of relaxation training is that it can also be used to enhance
which is frequently disrupted with chronic pain (Grant & Haverkamp,
Biofeedback: Some researchers have found that
electromyograph biofeedback may benefit clients who do not respond to
relaxation training, but the lower cost of simple relaxation normally
the treatment of choice (Blanchard, Andrasik, Evans, Applebaum, &
cited by Grant & Haverkamp, 1995).
Philips and Wade et al. cited by Grant and Haverkamp,
(1995) state that anxiety and frustration have been shown to accompany
pain, as a response to pain intensification, prolonged elevations in
or anticipation of increased pain. Philips et al. (cited by Grant &
Haverkamp, 1995) stress that over a period of time the feelings of
become such a part of the pain that clients may have a problem
between pain and feelings of anxiety. Both
anxiety and emotional arousal that is caused by pain can also be
stressful life events or daily hassles. Clients learn that emotions do
cause pain but do affect it by either increasing intensity levels or
undermining coping abilities (Grant & Haverkamp, 1995).
Anxiety management entails instructing clients to
recognize the signs and symptoms of increased arousal. This begins
by helping clients identify a recent stressful experience and having
relive it through imagery. Philips points out that clients learn, by
instruction, practice, and homework, how to use deep breathing and
skills to defuse these responses (Philips, cited by Grant &
1995). As clients recognize situations that are consistently stressful
them, the counselor and client use problem-solving skills to generate
Depression management. Turk & Holzman cited by
Grant & Haverkamp, 1995, emphasize
that chronic pain can lead to decreased activity, lowering of
sense of despondency and hopelessness, and a decreased sense of control
pain. This can also lead to what Beck (cited by Grant & Haverkamp,
called a negative cognitive shift in which positive information
to an individual is filtered out and negative self-information is
admitted. Beck stresses that these negative cognitions have been shown
associated with the development of depression (Beck, cited by Grant
The counselor must emphasize to the client that
chronic pain is the cause rather than the consequence of depression and
the result of diminishing coping responses and pleasurable activities
Keefe et al. cited by Grant & Haverkamp, 1995). Having clients
their thinking patterns before introducing this topic is useful helping
start to pay attention to their thought processes. Clients are then
taught and will
be able to challenge distorted thinking patterns and substitute more
realistic, coping self-statements.
Once again, when discussing this topic with clients,
the counselor must emphasize that chronic pain is the cause rather than
consequence of depression and is the result of diminishing coping
pleasurable activities (Brown, 1990; Keefe et al., 1992, cited by Grant
Haverkamp, 1995). It is usually easy for clients to identify examples
negative thinking patterns and the effects these thoughts have on their
and coping abilities. Having clients monitor their thinking patterns
introducing this topic is useful in helping them start to pay attention
their thought processes. Clients are then taught to recognize and
distorted thinking patterns and substitute more positive, realistic,
self-statements (Philips, cited by Grant & Haverkamp, 1995).
In depression management clients are encouraged to
schedule daily activities that because of their pain, they have
stopped. It may
be difficult for the client at first to identify any pleasurable
believe that it is possible to enjoy something despite the persistence
The counselor’s patience and sensitivity can encourage clients to
and to test out their negative predictions, and to judge the effect of
increasing their activities on mood and sense of control over pain. The
increasing activities also helps to divert attention away from the
is another form of pain control (Holzman, cited by Grant &
Cognitive restructuring and reconceptualizing the pain
experience are designed to increase self-efficacy and change appraisals
the ability to manage pain. In addition to these interventions, there
group of strategies called cognitive reappraisal, or reinterpretation
techniques, that seek to use cognitions to change pain sensations.
methods for assisting with episodic, increased pain levels and can be
with relaxation exercises.
The following are some examples of these techniques:
1. In transforming the sensation, clients may
to imagine that the area of discomfort is a tight knot that is slowly
undone, and as the knot loosens, the pain becomes less and less.
2. In transformation of context, the client
acknowledges the pain but imagines himself or herself in a context in
does not matter, such as an actress giving the performance of her life.
Limiting the scope of pain involves asking clients to draw an imaginary
around the pain area and to slowly make the circle smaller.
Clients whose pain persists
acknowledge that it is affecting
not only their own lives, but also the lives of family members.
Client’s who feel
guilty, may begin to have difficulty being assertive about additional
which may lead to pain being used as an indirect method for needs
(Philips, cited by Grant & Haverkamp, 1995). Assertiveness training
helpful in assisting clients to state their needs more directly.
Generalization and Maintenance
In the final stages of counseling, it is important to
prepare clients for continuing to cope with their pain even after
complete. This is achieved first, by clients monitoring effectiveness
techniques they are using, not just in pain reduction but also in their
of coping and control. Clients may find that certain techniques are
effective for different pain levels or that some work as pain
strategies and others as episodic management strategies (Philips, cited
Grant & Haverkamp, 1995).
Second, Holzman (cited by Grant & Haverkamp, 1995)
stresses that future difficulties are anticipated and, through problem
coping strategies are generated. Holzman points out that process models
self-management and problem-solving skills for situations that cannot
predicted. The issue addressing relapse should be discussed due to the
that most clients will experience a period during which the techniques
seem to be less effective.
In the last session, the counselor and client should go
over the progress made and also the strategies learned. To reinforce
gains and the effectiveness of counseling the counselor recommends that
client repeat the assessment battery of psychological questionnaires
comparisons or review the areas covered in the assessment interview.
also encouraged to view their gains as the result of their own efforts.
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