CENTER ON BEHAVIORAL MEDICINE

ADDITIONAL MATERIAL

EFFECTIVE TREATMENTS

   Traditional Approaches-Psychological:  Related Paper

Effective Treatments Index

Cognitive Behavioral Therapy for Chronic Pain


Permission graciously given by the author to reproduce this paper.

Cognitive Behavioral Therapy for Chronic Pain

Anna Schreiner
2006

         
Aaron Beck (cited by Weinrach, 1988) says cognitive therapy is a short-term treatment intended for treating anxiety and depression. Beck says further that this therapy is based on a view of psychopathology that stipulates that an individual’s dysfunctional behavior is caused by excessive or inappropriate ways of interpreting their experiences. Aaron Beck emphasizes that this approach requires counselors to focus on the individual’s thoughts or cognitions as well as their feelings. He says that what we feel is 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 of pain perception (Grant & Haverkamp, 1995). Melzack and Wall postulated that a neural gate mechanism exists that can allow pain stimulation to pass through to higher brain centers or suppresses it depending on the circumstances. Not only do nerve impulses travel to the brain from an injured area, but certain psychological and socio-environmental factors can also stimulate the brain to send signals that can either close or modulate the gate mechanism and therefore modulate the perception of pain. Melzack and Wall 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).

Fordyce cited by Grant & Haverkamp (1995), says that the biopsychosocial model of pain distinguishes between pain suffering and pain behaviors. Pain is typically thought of as a sensation caused by nociception- activity from specialized nerve fibers that signal the central nervous system that something bad is happening. Fordyce says that suffering is the affective response to this nociception and is observed only indirectly through pain behaviors. Fordyce says that pain behaviors are the overt actions individuals engage in when they suffer or are in pain. Fordyce emphasizes that these behaviors can exacerbate or decrease the experience of suffering and then they become the primary focus of intervention.

Currently, the biopsychosocial model of pain has been found to be the most useful approach to understanding and managing pain (Gatchel & Oordt, 2003). In individuals who experience pain, the distinction between cure and management is important because for many chronic pain sufferers a medical cure is not available so the patient will have to deal with the pain. Using a pain management approach will offer the individual hope because even though the pain may never completely go away, they can still reduce its effect on their daily lives (Grant and Haverkamp 1995).


Cognitive-behavioral therapy (CBT) teaches relaxation techniques, stress management, and other ways to help you cope with pain. Areas that contribute to pain management include physical, psychological, 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 may be obstacles to recovery. Erstad emphasizes that when a person feels a familiar type of pain starting or getting worse, they probably have a sense of how it will progress. If the person is used to the pain being severe or long-lasting, they may expect the pain to become more intense.

Erstad stresses that this thinking may make the person feel out of control or helpless. This stress response can trigger physical changes in the body, such as blood pressure, the release of stress hormones, muscle tension, and more pain (Erstad, 2005). Erstad, (2005), goes on to say that cognitive-behavioral skills can alter the way a person’s mind affects their body.  When the person shifts their thinking away from the pain and changes their focus to more positive aspects of their life, the person changes the way their body responds to the anticipated pain and stress. According to Erstad, (2005) the goal of cognitive-behavioral therapy is to change the way a patient thinks about the pain so that their body and mind respond better when they have episodes of pain. Therapy focuses on changing the patient’s thoughts about illness and then helping them adopt positive ways of coping with illness.

Cognitive-Behavioral Approach To Chronic Pain Management

Researchers who have reviewed the literature on the efficacy of CBT treatment for chronic pain management have generally concluded that the results are consistently positive (Grant & Haverkamp, 1995). One researcher found that a CBT program produced gains in cognitive, affective, and behavioral domains that were maintained for at least 12-months, in contrast to no change in the wait list control group. Additionally, significant reductions in reported pain levels were found when CBT interventions were compared with a placebo medication group (Engstrom cited by Grant and Haverkamp, 1995), and with an educational-information program (Keefe et al., cited by Grant & Haverkamp, 1995).

Turk, Holzman, & Kerns cited by Grant & Haverkamp (1995), state  that when clients perceive themselves as active participants in their own change process, they are more likely to attribute successful outcomes to their personal competence, be more highly motivated, and demonstrate greater behavior change. Turk et al. say that in pain management counselors should act as a collaborator with clients in 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, empathetic, respectful regard for client’s struggle and experience. CBT pain management is also active, time limited, and structured in a style that may be less familiar to some other counselors. Counselors need to be sensitive to the fact that this active approach may also be a new experience for the client and that they may be quite skeptical. Part of their skepticism may be due to previous negative experiences the individuals have had with past treatment efforts. Clients may also be angry, discouraged and defensive, especially if other professionals have suggested that their pain is caused by underlying psychological problems. For these clients, a collaborative approach is essential to ensure counseling is not misinterpreted as another message that the pain is “all in their head.” (Grant & Haverkamp, 1995).


Grant & Haverkamp (1995) say assessment is the first step to determine whether physical, affective, cognitive, and socio-environmental factors are interacting with the clients response to pain, whether CBT approach is appropriate, and whether there are any other problems that need to be addressed before pain management is begun (e.g., deal with or rule out psychiatric disorders, severe depression, or anxiety first). The assessment should be thorough 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 pain, what they believe is causing it, and what they think will help. Client’s may have frightening conceptualizations of the problem; they may think that their spine is crumbling under them, or if they have migraine headaches that they are due to a cerebral aneurism. It is important for the counselor to elicit these 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 conceptualization of the problem be discussed with the client to determine if the client agrees with the case formulation and the proposed intervention plan. Grant & Haverkamp point out that this will enforce the collaborative nature of the relationship and helps the counselor develop the plans that fit the client’s own unique experience of the problem. Researchers found that clients’ post-treatment improvement in pain and disability to be associated with pretreatment agreement with the philosophy of a pain management treatment approach (Shutty, DeGood, & Tuttle cited by Grant & Haverkamp, 1995).


Intervention Approaches used in pain management are as follows:  Reconceptualization of the Pain Problem

Holzman et al. cited by Grant & Haverkamp, (1995) state that the purpose of the following CBT interventions is to assist clients in reconceptualizing their pain problem from that of a medical symptom that is out of their control to a belief that pain perception is amenable to change through physical and psychological interventions. Holzman et al. emphasize that the explanation of the construct of chronic pain and the CBT approach is a vital first step in the counseling process, because it is important that clients believe the concept makes sense and are prepared to experiment to see if it applies to them.

Goal Setting


Holzman et al. state that it is important to establish specific and mutual goals. Goals need to be specific, measurable, and without reference to pain or distress (Philips cited by Grant & Haverkamp, 1995). They give as an example, rather than “I would like to be able to increase my level of exercise without increasing my pain,” the goal can be phrased as “Walk at a brisk speed for 30 minutes, four times a week.” Holzman et al. also state that 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 of pain frequency, duration and intensity, sleep patterns, and medication intake. This record is based on hourly ratings.


Physical Interventions


Exercise: Many chronic pain clients are physically inactive.  Therefore, an exercise program is an important intervention strategy for overcoming physical deconditioning and the belief that any activity beyond the minimal is damaging (Philips, 1988; Turk & Holzman, 1986, cited by Grant & Haverkamp, 1995). Philips emphasizes that the program needs to be graduated, so that clients slowly work up to therapeutic levels, and carefully explained in terms of long-term benefits, such as increased muscle strength, flexibility, and sense of well-being.


Relaxation training: Relaxation training is one of the most common techniques used in chronic pain management programs (Holzman et al., 1986; Melzack & Wall, 1982, cited by Grant & Haverkamp, 1995). Philips points out that the aim of these techniques is to teach clients to reduce physiological arousal and muscle tension on demand. Relaxation techniques can include deep breathing, progressive muscle relaxation, relaxing imagery, cue-controlled relaxation, autogenic relaxation, or hypnosis. The additional benefit of relaxation training is that it can also be used to enhance sleep, which is frequently disrupted with chronic pain (Grant & Haverkamp, 1995).

Biofeedback: Some researchers have found that electromyograph biofeedback may benefit clients who do not respond to simple relaxation training, but the lower cost of simple relaxation normally makes it the treatment of choice (Blanchard, Andrasik, Evans, Applebaum, & Rodichok, cited by Grant & Haverkamp, 1995).


Emotional Interventions


Anxiety Diffusion.


Philips and Wade et al. cited by Grant and Haverkamp, (1995) state that anxiety and frustration have been shown to accompany chronic pain, as a response to pain intensification, prolonged elevations in pain levels, or anticipation of increased pain. Philips et al. (cited by Grant & Haverkamp, 1995) stress that over a period of time the feelings of anxiety become such a part of the pain that clients may have a problem differentiating between pain and feelings of anxiety.  Both anxiety and emotional arousal that is caused by pain can also be heightened by stressful life events or daily hassles. Clients learn that emotions do not 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 in-session by helping clients identify a recent stressful experience and having them relive it through imagery. Philips points out that clients learn, by means of instruction, practice, and homework, how to use deep breathing and relaxation skills to defuse these responses (Philips, cited by Grant & Haverkamp, 1995). As clients recognize situations that are consistently stressful for them, the counselor and client use problem-solving skills to generate new ways of responding.


Depression management. Turk & Holzman cited by Grant &  Haverkamp, 1995, emphasize that chronic pain can lead to decreased activity, lowering of self-esteem, a sense of despondency and hopelessness, and a decreased sense of control over pain. This can also lead to what Beck (cited by Grant & Haverkamp, 1995) called a negative cognitive shift in which positive information relevant to an individual is filtered out and negative self-information is readily admitted. Beck stresses that these negative cognitions have been shown to be associated with the development of depression (Beck, cited by Grant & Haverkamp, 1995).


The counselor must emphasize to the client that chronic pain is the cause rather than the consequence of depression and is also the result of diminishing coping responses and pleasurable activities (Brown, Keefe et al. cited by Grant & Haverkamp, 1995). Having clients monitor their thinking patterns before introducing this topic is useful helping them start to pay attention to their thought processes. Clients are then taught and will be able to challenge distorted thinking patterns and substitute more positive, realistic, coping self-statements.


Once again, when discussing this topic with clients, the counselor must emphasize that chronic pain is the cause rather than the consequence of depression and is the result of diminishing coping responses and pleasurable activities (Brown, 1990; Keefe et al., 1992, cited by Grant & Haverkamp, 1995). It is usually easy for clients to identify examples of their negative thinking patterns and the effects these thoughts have on their mood and coping abilities. Having clients monitor their thinking patterns before introducing this topic is useful in helping them start to pay attention to their thought processes. Clients are then taught to recognize and challenge distorted thinking patterns and substitute more positive, realistic, coping 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 activities or believe that it is possible to enjoy something despite the persistence of pain. The counselor’s patience and sensitivity can encourage clients to experiment 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 clients increasing activities also helps to divert attention away from the pain, which is another form of pain control (Holzman, cited by Grant & Haverkamp, 1995).


Cognitive Reappraisal


Cognitive restructuring and reconceptualizing the pain experience are designed to increase self-efficacy and change appraisals about the ability to manage pain. In addition to these interventions, there is a group of strategies called cognitive reappraisal, or reinterpretation techniques, that seek to use cognitions to change pain sensations. These are methods for assisting with episodic, increased pain levels and can be combined with relaxation exercises.


The following are some examples of these techniques:

1. In transforming the sensation, clients may be asked to imagine that the area of discomfort is a tight knot that is slowly being 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 which it 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 circle around the pain area and to slowly make the circle smaller.


Socio-environmental Interventions


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 needs, which may lead to pain being used as an indirect method for needs gratification (Philips, cited by Grant & Haverkamp, 1995). Assertiveness training may be 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 counseling is complete. This is achieved first, by clients monitoring effectiveness of the techniques they are using, not just in pain reduction but also in their sense of coping and control. Clients may find that certain techniques are more effective for different pain levels or that some work as pain prevention strategies and others as episodic management strategies (Philips, cited by Grant & Haverkamp, 1995).


Second, Holzman (cited by Grant & Haverkamp, 1995) stresses that future difficulties are anticipated and, through problem solving, coping strategies are generated. Holzman points out that process models self-management and problem-solving skills for situations that cannot be predicted. The issue addressing relapse should be discussed due to the fact that most clients will experience a period during which the techniques will 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 these gains and the effectiveness of counseling the counselor recommends that the client repeat the assessment battery of psychological questionnaires for score comparisons or review the areas covered in the assessment interview. Clients are also encouraged to view their gains as the result of their own efforts.

 
References

Estrad, S. (2005). Cognitive-behavioral therapy for pain management. Retrieved March 15, 2006, from http://www.webmd.com/hw/chronic_pelvic_pain/tv3092.asp

Gatchel, R. J. & Oordt, M. S. (2003). Clinical Health Psychology and Primary Care:  Practical Advice and Clinical Guidance for Successful Collaboration. Washington, DC: American Psychological Association.

Grant, L. D, Haverkamp, B. E. (1995). A cognitive-behavioral approach to chronic pain management. Journal of Counseling and Development, 74(1), p. 25. Retrieved March 13, 2006, from ProQuest database.

Weinrach, S. G. (1988). Cognitive therapist: A dialogue with Aaron Beck. Journal of Counseling and Development, 67(3), p. 159. Retrieved March 13, 2006, from ProQuest database.