Cognitive Behavior Therapy in the Management of Chronic Pain

You've been diagnosed with chronic pain and the doctor has suggested a referral to a psychologist. Why a psychologist? Does the doctor think your pain is all in your head? Not at all. Here's what to expect in a referral to a psychologist with specialized training in the management of diseases such as chronic pain.

Individuals with chronic pain experience a significant number of symptoms besides pain (e.g., fatigue, tenderness, sleep disturbance), in addition to a decrease in physical functioning, and disruptions in psychological functioning (e.g. memory problems, diminished mental clarity, mood disturbances, and lack of well-being). The specific cause or causes of the chronic pain may not always be known. Even when known traditional treatment typically focuses on reducing the pain and other symptoms through medication management. Treating chronic pain with this approach alone benefits less than 50% of patients with chronic pain and only about 12% of those patients achieve lasting improvements in functional status. Additional treatment approaches are sorely needed.

Recently, psychological and behavioral therapies have been used with increasing frequency to help manage persistent illnesses such as chronic pain. The decision your physician makes in referring you to a psychologist has little to do with the treatment of psychiatric disorders and a lot to do with these interventions being very good at changing behavioral and social factors that play a role in the development of pain and its maintenance. Among these interventions is the use of cognitive behavior therapy (CBT). CBT has been well studied as an additive approach to traditional medical management of chronic pain. To date, the scientific literature supports the use of CBT with chronic pain to produce modest improvements in pain, fatigue, physical functioning, and mood. While CBT is not curative or universally beneficial in all patients, the benefits are sufficiently large enough to help patients manage their conditions.

After thirty years of research, we know that the experience of pain involves both the body's physical circuitry - nerves, spinal cord, brain - and normal psychological factors such as awareness of the pain and emotional reactions to the pain. These normal psychological factors can be modified to a patient's advantage when pain is properly managed. We now also know that the physical circuitry of patients with chronic pain respond differently than they do when they experience other types of pain such as acute pain.

The onset of chronic pain can develop from multiple sources, such as trauma, disease, medical procedures, physical and psychological stresses, etc. Individuals typically have very little control over these precipitating events. The maintenance of chronic pain and its long-term consequences on the lives of individuals similarly may seem beyond personal control. One focus of CBT is to help identify untapped opportunities for control within the realms of both biological and psychological processes. These pockets of potential control can help individuals deal more effectively with their disease.

An example would be that two individuals might have identical cases of chronic pain, yet experience and respond to the pain in markedly different ways. The reason for such differences is in part due to the fact that people think about pain in different ways. Thinking about pain occurs in two stages. When pain elevates (or flares up), the individual experiencing the pain must determine the degree to which the increased pain is harmful or threatening. The individual must then decide if he or she is capable of controlling and dealing with the elevated pain. If coping resources are adequate, in many cases the flare-up can be appropriately managed. However, if a patient feels as though he or she cannot control or handle this flare-up, then emotional reactions such as anxiety or depression can further worsen the pain and lead to potentially "maladaptive" responses. Maladaptive responses (i.e., responses on the part of the patient that may unknowingly worsen the problem might include isolation (i.e., not scheduling activities because you are not sure you will be able to do them), and diminished use of behaviors such as exercising.) This example demonstrates how the manner in which a chronic pain patient responds to a flare-up can determine whether the flare-up is self-limited (goes away spontaneously) or becomes a vicious downhill spiral. Fortunately, much has been learned about supplying patients with skills designed specifically to manage the symptoms of worsening pain and its effects on functioning over the long-term.

One method of supplying patients with pain management skills is through CBT. Cognitive behavior therapy originated within the traditional psychotherapy literature and was initially used to treat depression and anxiety. Each application of CBT uses a different set of specific skills, but each of the skills share a common scientific foundation based on learning and cognitive principles. The techniques used to change behavior are based on principles of classical and operant conditioning (e.g., extinction, positive and negative reinforcement, shaping, prompts), and observational learning. The techniques used to produce changes in thinking are based largely on the development of problem solving skills and principles of attributional change (i.e. changes in automatic thinking and beliefs about pain).

CBT is an effective approach for changing thinking and behavior and is not limited to thoughts and/or behaviors of a psychiatrically disordered nature. Consequently, CBT has been found to be effective in promoting health in medical conditions such as coronary disease, asthma, obesity, and other chronic illnesses including pain disorders.

Cognitive behavior therapy typically involves three distinct, but often overlapping phases:

1. Educational phase: In the educational phase patients receive current as well as known information about their disease and the role that they can play in the management of their pain; which includes how the brain interprets pain signals.
2. Skills training phase: Training is provided in a variety of cognitive and behavioral pain coping skills such as: relaxation training, activity pacing, pleasant activity scheduling, problem solving and sleep hygiene.
3. Application phase: In the application phase patients learn to apply their skills in progressively more challenging real-life situations.

The skills training phase can include many different strategies for managing pain and suffering. While the techniques that fall into this category are numerous, the ones most commonly used to manage chronic pain include:

Time-based pacing skills/graded activation. When asked, individuals with pain will frequently stat that they pace their activities in order to prevent flare-ups. The most common form of pacing is "task-based pacing" where the number of jobs is limited, or rest breaks are taken between the conclusion of one job and the start of another, even when the task or job is broken into parts. This form of pacing, however, rarely leads to adequate pain control or improved functioning. Associating activity with the conclusion of a tasks can still allow the pain to elevate to such high levels that very long recovery periods are required in order to control the pain. Long recovery periods can greatly diminish the potential for additional productive time later in the day. A better but somewhat unnatural approach to pacing is "time-based pacing." Here, activity is based upon time, not the completion of a task. The time can be as short as several minutes or as long as several hours, depending upon how much time can be spent on a specific task without elevating the pain. Once a safe amount of time is identified for a given activity, the individual stops and rests based upon time, rather than upon task completion. Since no flare-up has occurred, the recovery period needed will not be lengthy and the individual can return to the task without additional pain. When this strategy is applied many times throughout a day, a week, or a month, the pain is better managed and, despite taking more frequent rest breaks, more is actually accomplished in the long run. Graded activation programs emphasize short activity followed by a short rest. Such slowly advancing programs have the tendency to improve functional status over time, along with either stable or improved levels of symptoms.

Pleasant activity scheduling. Pleasant activity scheduling is often used as a CBT skill along with time-based pacing. It is usually easier to begin a pacing schedule by pacing pleasurable activities rather than job-related or lesser desired activities. Scheduling pleasant activities is preferable to spontaneity since pain and fatigue tend to reduce spontaneous pleasurable activity. Gradually expanding function through new activities promotes positive feelings, new opportunities for social interaction, and confidence in the body's ability to function at a higher level.

Problem-solving skills. The experience of chronic pain offers up problems that most non-pain or otherwise healthy individuals never need to address. Programmatic problem-solving strategies can be taught to patients that help to break large problems down into solvable pieces. Examples of such problems might include caring for multiple children, performing demanding aspects of your job, or staying with an exercise program. What is taught in CBT therapy is a strategy for solving problems, not solutions to individual problems; thus therapy participants receive a tool that can be carried into the future. When applied successfully, individuals learn methods to overcome barriers to improved function and attain a greater sense of control over the process of adapting to a chronic illness like chronic pain.

Relaxation skills. Relaxation is much more than flopping on the couch and watching TV. As taught in CBT, the relaxation response (e.g., to control your body's ability to relax specific muscle groups, to generate a sense of calm and heaviness, or to quiet a racing mind) has strong support as a method to manage both pain and the insomnia often reported by chronic pain patients. While there is no consensus as to the best method of teaching the relaxation response, (e.g., progressive muscle relaxation, audio training tapes, visual imagery, hypnosis, biofeedback) all appear to be equally effective in the training for management of pain. However, it is important that the psychologist use a training method that is tailored specifically for the chronic pain patient.

Sleep hygiene. It is not unusual for chronic pain patients to also have experienced a chronic sleep problem. The problems usually center around both achieving sleep onset and sleep maintenance, and both appear to be related to the "racing mind" or alpha intrusions into the sleep activity. Fortunately there are behavioral methods of improving sleep. Improving sleep often helps with other symptoms as well. Sleep hygiene strategies focus on several sleep related events including timing strategies (having regular sleep routines), sleep behaviors (attempting to sleep only when in need of sleep), and behavioral avoidance of stimulating activities before bed such as emotionally charged conversations, watching action movies, or consuming nicotine or caffeine. It also involves retraining the brain to achieve a quieting response when it's time to go into sleep.

Changes in thinking. Thought behaviors are as habitually emitted as overt behaviors that someone else in addition to the person can see and count. Some of the habitual thinking behaviors associated with chronic pain requires restructuring. Changes in thinking are best brought about when individuals with pain actually experience real-life success associated with changes in behavior rather than in the isolation of a therapy office. Four types of experiences are recommended:

• Mastery experiences - actually trying many of the coping skills discussed and developed in the training process as described above.
• Modeling - watching a trusted other person experience success or give testimonial of success in implementing changes in their experience with pain.
• Social persuasion - having a trusted other person convince patients of the benefits of a technique that might help them as well.
• Physiological feedback - gathering indirect evidence of benefits (e.g. biofeedback, sleep logs, pain logs and other monitoring records of physiological changes).

Changes in thinking are helpful in that willingness to use CBT skills over the long-term, often starts with the belief that personal effort is needed and can lead to improved management of the disease.

Relapse Prevention. Teaching coping skills is only the first step in the use of CBT. Successful use of CBT must also be practiced and used over time in order to create new patterns (habits) of behavior. Not until CBT skills become part of the everyday, routine lifestyle of the individual with pain will true benefit be realized. For this reason, improvement is typically slow and requires a lot of stick-to-itiveness on the part of the patient. Although benefits of training will in some cases be seen very quickly, most benefits are noted three to six months later - after the skills have been applied and incorporated into the life of the patient. There is a payoff for all this personal effort. The benefits of CBT are more likely to be permanent changes than those seen in other types of therapy. It is common for individuals who receive CBT training to report experiencing improvements years after initial therapy, even if the initial CBT therapy was quite brief. To help with relapse prevention, booster sessions are often recommended so that the use of skills can be maintained.

How is CBT Offered?

Individuals seeking CBT for chronic pain should be aware of how CBT is most often provided. CBT for chronic pain is most commonly provided by a doctoral level psychologist with advanced training in behavioral medicine and pain management. Other professionals such as physicians, nurses, social workers, and physical therapists with training or supervision in behavioral medicine may also teach these types of pain management skills. CBT is typically provided on an individual basis because not all pain patients respond to the same instruction or training; however, some CBT training is provided in small group settings. Since any chronic illness or disease is a family issue and not just the patient's problems, spouses are often encouraged to attend the training sessions. Spouses can be quite beneficial in helping the pain patient in learning and implementing pain management skills in real life situations. The number of training sessions can vary depending upon the number of skills being taught and the motivation of the patient, but they typically range between as few as six to as many as eighteen sessions. CBT for chronic pain is not like traditional forms of psychotherapy or even like CBT for psychiatric disorders, which can involve not only many more sessions than mentioned here, but also focuses on cognitive behaviors often alien to chronic pain patients. However, with chronic pain comes depression. Even though the depression experienced by chronic pain patients often does not involve the same psychological dynamics of clinically depressed patients, CBT training has been shown to be effective in this aspect of training as well. Training sessions might be held weekly or spaced every couple of weeks and extended over several months. If the individual also experiences anxiety or clinical depression along with pain it may be necessary to tailor the therapy to address these mood issues as well.

Thinking drives emotional and behavioral responses to illness and helps to determine whether adaptation to illness is consistent with or opposed to long-term health. Methods of changing behavior and thinking patterns have been shown to be effective in improving health for many physical illnesses. The clinical studies of CBT in chronic pain support the utility of including CBT along with traditional medical treatment to add further benefit to such patients. Accept your referral to the psychologist. Trust your judgment and the knowledge that you possess about your pain problem and then make the decision if this approach to the management of your pain is best for you.