A Cognitive Behavioural Therapy Approach to Chronic Pain Management

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A Cognitive Behavioural Therapy Approach to
Chronic Pain Management

• Presented by
• Andrew G Remenyi, PhD

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Presentation headings

• CBT
• Chronic pain CBT
• Chronic pain traps as problem formulations
• CBT interventions
• Inductions as adjunct learning strategies

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CBT Assumptions

• Clients actively process information
• Cognitions interact with physiological,
  behavioural, and emotional responses
• Behaviour interacts with environmental events
• Effective treatment addresses cognitive,
  behavioural and emotional dimensions
• Client must actively participate

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Cognitive Behaviour Therapy defined

• A rubric applied to a wide variety of therapeutic
  techniques based on somewhat different
  conceptualisations.
• Common elements of interventions
• Usually active
• Time-limited
• Fairly structured
• Assume that affect and behaviour are largely
  determined by the way in which the individual
  construes the world.
• Help client identify, reality-test and correct
  maladaptive, distorted conceptualisations and
  dysfunctional beliefs.
• Help client to recognise the connections among
  cognition, affect, and behaviour, together with
  their joint consequences.
• Help client to monitor the role that negative
  thoughts and images play in the maintenance of
  maladaptive behaviour.
• Help client test out the effects of cognitions
  and beliefs through selected homework
  assignments.

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Cognitive Behaviour Therapy defined

• CBT involves the application of a range of
  cognitive, behavioural, and environmental
  interventions.
• It is different from some forms of counselling in
  that it is a structured form of therapy
• The evidence base for the efficacy and
  effectiveness of CBT for a wide range of
  psychological disorder is significant (e.g.,
  depressive disorder, panic disorder, GAD, OCD.
  PTSD, CFS, chronic pain, cancer, bulimia
  nervosa).
• Core beliefs (schema), intermediate beliefs
  (assumptions) and automatic thoughts are 3 levels
  of cognition which are formed as a result of
  experiences and exposure to events, people, and
  situations (some critical), and which in turn
  result in subsequent experiences and exposure
  being processed and interpreted in a particular
  way.
• You can use your mind to make things worse or
  better.

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Examples of intermediate beliefsof patients with
chronic pain

• If I feel unwell then it means that my condition
  is deteriorating
• If I take all my medicines as indicated then I
  should have no health problems
• If I stay as healthy as I can then it will stop
  my disease from worsening
• If my doctor tells me something then it must
  always be correct
• Doctors should be able to answer all my questions
• If I have a new symptom then it means that my
  disease has progressed

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Questions to identify evaluate automatic
thoughts

• Generic
• Identifying thoughts
• What was passing through my mind just before I
  felt this way?
• What did that situation mean to me? What does it
  say about me as a person?
• What is the worst thing that could happen in this
  situation?
• What have I just been thinking about?
• Evaluating thoughts
• What experiences have I had which show me that
  this thought is not completely true all of the
  time?
• If I were trying to help someone I cared about to
  feel better, if they were having this thought,
  what would I tell them?
• What advice might someone I cared about give me
  if they knew that I was thinking in this way?
  What would they say? Would they agree with my way
  of thinking? If not, why not? What aspect would
  they have a different view on?

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Questions to identify evaluate automatic
thoughts

• Specific
• Identifying thoughts
• What does this mean to me about my health? My
  future health? my life expectancy?
• What is the worst thing that could happen to my
  health?
• When I felt (physical symptom) what went through
  my mind?
• Evaluating thoughts
• If someone I loved had (name of chronic medical
  problem) and thought this, what might I point out
  to them?
• When I am feeling better physically, how do I
  tend to think about this?
• Are there any aspects of my experiences of (name
  of chronic medical problem) which contradict this
  thought?

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Sample CBT Homework Tasks

• Monitor thoughts when experiencing nausea
• Write down predictions about what the surgeon
  will say if you ask him to explain the problem
  again
• Count the number of times that your spouse tells
  you to be careful
• Test out the belief If I take the medication Dr
  Smith gave me, I will be drowsy all day
• Write down in the present tense a description of
  everything that happens in My nightmares about
  the operation
• Every time you feel sad or angry, fill in the
  first three columns of the Thought Record

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Compliance with Homework Tasks

• Before
• What homework have you agreed to do?
• What is the purpose of the assignment?
• How often will you carry out this homework
  assignment
• Where will you carry out this homework
  assignment?
• When will you carry out this homework assignment?
• What are the possible obstacles to carrying out
  this
• assignment?
• How can you overcome these obstacles?
• After
• What did you actually do as homework?
• What happened to prevent you from being able to
• complete the homework?
• What have you learned from completing this
  homework?

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General CBT Treatment Strategies

• Behavioural
• Exposure-based
• Reinforcement
• Modeling
• Role Play rehearsal
• Activity scheduling
• Experimenting, behavioural assignments
• Relapse prevention management

• Cognitive
• Identifying, evaluating, modifying automatic
  thoughts
• Attention training, selective attention, divided
  attention, attention switching, distraction
• Identifying thinking biases
• Identifying, evaluating
• modifying intermediate beliefs
• Identifying, evaluating modifying schemata
• Identifying, evaluating managing imagery

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Theories and Frameworks

• CBT is always driven by 2 interacting
• formulations by the therapist
• Problem-level formulation Outlining the factors
  which contribute to discrete problems
• Case-level formulation Idiosyncratic elements of
  the individuals life history, beliefs, supports.

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Results of Chronic Pain

• Significant psychosocial problems
• Depression, panic, anxiety
• Fears about the future
• Decreased pleasure in everyday activities
• Helplessness, self-esteem losses
• Impaired physical functioning
• Reduced frequency and quality of socialisation
• Significant role changes with family and work
  systems
• Side effects of treatment and medication
• Tremendous cost to society (human economic)

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CBT approach to Chronic Pain Management

• Assessment
• Formulation
• Problem-level formulation
• Case-level formulation
• Treatment

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CBT approach to Chronic Pain Management

• Assessment
• Pain diaries, self-report measures, illness
  representation, pain behaviours, relationships
  lifestyle, general psychological symptoms,
  associated environmental circumstances and
  consequences.
• Formulation
• Problem-Level Cognitive-behavioural mediators of
  the relationship between pain and depression,
  level of activity, medication, treatments and
  relationships)
• Internal locus of control
• Catastrophising appraisals
• Perceptions of coping ability
• Affective response to pain
• Expectations and fear of activity

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CBT Approach to Chronic Pain Management

• Problem-level formulation (Activity - Pain -
  Anger)
• Sudden Movements Pain in back
• cause me pain
• Muscle tension Here we
  go again
• - another day in hell
• Slamming and
• banging things Anger I
  shouldnt be
• around like this

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Problem-level formulation

• Linking catastrophising, pain and depression
• Pain This is dreadful
• I cant stand this any longer
• Lowered Depression
• pain threshold
• Reduced Passive coping
• activity strategies

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Case-level formulation

• Common Chronic Pain Beliefs
• These commonly relate to themes of self-efficacy,
  control,
• pain itself and pain management strategies.
• There is nothing I can do to help with the pain
• I have no control over pain
• If I am in pain then it will interfere with all
  my plans
• Fluctuations in my pain are completely random
• Its impossible to understand my pain
• Other people think that I am making it up
• If I do something when I am in pain, then I may
  cause harm to myself
• If I avoid things which make my pain worse, then
  this is better for me
• Pain medication should only be taken as a last
  resort

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Treatment goals

• Promoting re-conceptualisation (e.g., Gate
  Control Theory, questioning thoughts)
• Avoiding chronic pain traps
• Promoting pain-coping strategies
• Reducing catastrophising (helpful self-talk)
• Contingency management
• Pacing (do what you plan, not what you feel like
  doing)
• Motivational contracting
• Relapse prevention and management

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The CBT chronic pain management process

• A very useful problem-level formulation is that
  by Peck (1982, 1986).
• It requires psycho-educational discussion with
  the client and individualisation of its
  application to the client with particular
  case-level formulation details.
• Client and therapist work together as a
  problem-solving team
• They evaluate and review evidence of the
  contribution to the problem of cognitions,
  feelings, and behaviours, as they proceed.
• Sessions are structured as to time, and agenda
  items are negotiated.
• Clients are asked to provide feedback on
  significant events between sessions. Forms are
  used. Homework is given. Active involvement is
  crucial.
• Client therapist summarise learning and
  progress.

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Behavioural (Do) Rehabilitation (Recovery) A
Self-Management Model

• Injury
• (Nociceptive Input)
• Acute Subjective
• Chronic Pain
  (Genetics, constitution)
• Experimental Past
  Learning
• (Culture)
• Pain Behaviour
• (Observable Reactions)
• Effective, Adaptive Ineffective,
  Maladaptive
• COPING
• SKILLS
• Other problems
  Current Learning
  (traps)
• Relationships/support/social anxiety 1.
  Activity

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Preconditions to the use of hypnosis with chronic
pain clients

• Alert client to the possibility and purposes of
  using hypnosis
• Educate client re the nature and process of
  hypnosis
• Gain client agreement to the use of hypnosis
• Check that, in addition to the chronic pain,
  there are no psychopathological or medical
  co-morbid conditions contra-indicating the use of
  hypnosis (e.g., psychosis, personality disorders
  such as paranoia, substance-induced disorders,
  major depression, dementia, etc.)

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Another way of learning

• You will get a long way with many clients just
  talking them through this model and encouraging
  them to apply it to their own experience. At the
  conscious, rational level, many of us respond
  well.
• At the more experiential, sub-conscious,
  self-discovery and self-management level, many
  respond better and most respond differently.
• The experiential level introduces a new
  perspective, a different level of arousal, and
  this enhances learning. Remember the old
  definition of learning ....a more or less
  permanent change in behaviour as a result of
  increased arousal.
• The novelty of using words differently sets off
  mental and emotional sparks. The language shapes
  how we think, feel and behave.

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Learning through Inductions

• An induction, because it is novel for most
  clients, and uses language differently from that
  used in interviews, in dialogue, in counselling,
  and in argument, can have the following effects
• Fixating attention (thus excluding normal
  peripheral foci)
• Encouraging passivity (thus learning to observe
  and ceasing to analyse)
• Increasing receptivity (thus learning to tolerate
  unusual experiences)

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Learning through Inductions...

• Some of us call this trance, hypnosis, or the
  effects of the language of induction and it
  involves stimulating meaningful associations in a
  clients thoughts, feelings and responses through
  individualised suggestions that acknowledge and
  incorporate his or her uniqueness.
• The form and content of language you use is the
  professional tool you use to create the ambiance
  and conditions for learning, but the content is
  also drawn from the clients life experiences.
  Hypnosis, in this way, becomes what you do with
  people not to people.

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Characteristic Process in Inductions

• Capturing attention
• Holding attention still
• Re-directing attention inward
• Inner searching with positive expectations
• Re-orienting to wakeful awareness

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Hypnotic Inductions are like great sex!

• They involve
• Seduction, reassurance, trust, and re-direction
  of attention
• Mutual consent, mutual participation, and
  co-operation
• A lot of focus on each other as well as on ones
  own internal events
• If you say or do the wrong thing, it can ruin the
  mood completely

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Assume these case-level client details

• Client has a history of handling illness and pain
  ineffectively
• Client tends to be very anxious, fearful, and
  vaguely guilty for being in the situation they
  are in
• Client has a relatively dependent type of
  personality (external locus of control) and poor
  self-esteem
• Sample induction re Behavioural Rehabilitation
  Model Subconscious exploration to enhance
  insight or resolve conflict

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The Activity Trap

• (inactivity, overactivity, inappropriate
  activity)
• Client advised to take it easy
• Client avoids pain by avoiding
• activities
• Client gradually gives up work,
• social and recreational activities
• Slips into invalid role
• ? Focus on pain Loss of rewards
  from environment
• lifestyle

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Management of Activity Trap

• Chronic pain patients have very restricted
  activities - often cannot stand or sit for long
  they find it difficult to walk very far, ride in
  a car, climb stairs, bend over, or reach for
  something - if patient avoids these for fear of
  pain, he/she cannot do many other normal
  activities required in everyday life (i.e., work,
  shop, visit friends, go to the movies).
• Restricted activity and low activity levels
  treated in two steps
• 1. Increasing the persons tolerance for
  simple activities such as walking, standing,
  sitting, or climbing stairs by the behavioural
  procedure of successive approximation
• 2. Generalising these newly developed
  tolerances into the everyday activities that the
  person performed before the chronic pain problem
  developed
• Important activities planned must match but not
  exceed persons tolerance for each exercise

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Assume these case-level client details

• Client has developed the bad habit of being
  inactive
• Client has given up work of all kinds
• Client has severely restricted their usual social
  and recreational activities
• Client is depressed
• Client exhibits marked pain behaviours
  (exaggerated stoop, limp, and shuffle constant
  sighing and self-piteous tone)
• Sample induction re Activity Trap

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Chronic Treatment Trap

• Client consults doctor
• Expectation of a cure
• Treatment fails
• Client is frustrated
  Doctor is frustrated
• with doctor
  with client
• Treatment shopping Labels pain as
  psychogenic - refers client to
• psychiatrist/psychologist
• Client tries to prove pain
  is
• real - resists treatment
  

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Management of Chronic Treatment Trap

• Try to promote attitude change in the direction
  of patients accepting their chronic pain problem,
  taking some responsibility for their own
  rehabilitation.
• Need for client to accept not being able to
  remove their pain, and to endorse the treatment
  goal of learning how to live with the pain
  problem.
• If the experience of chronic pain is normalised
  and guilt feelings are alleviated, progress may
  be made.
• Goal of treatment to reduce pain behaviour
  through behavioural procedures of extinction and
  reinforcement of incompatible behaviour.
• Pain behaviour is not reinforced, whereas normal
  behaviour, or well behaviour is attended to.
• Important to explain that focusing on pain
  increases its intensity, whereas distraction or
  diversionary activities reduce pain sensations.

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Chronic Medication Trap

• Drug prescription
• Tolerance
• Physiological
  Little or no relief
• Dependence
• Client demands more
• Drug Increased
• Dependence
• Psychological
• Dependence
• Low regard Low self-
  Low expectation Possible

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Management of Chronic Medication Trap

• Pain cocktail - useful technique for
  detoxification. Its goal is to remove patient
  from all analgesics and other nonessential
  medication (e.g., psychoactive drugs -
  tranquillizers and antidepressants).
• May be used on an outpatient or an inpatient
  basis
• Use pain cocktail on a time-contingent schedule
  as opposed to a pain-contingent schedule which is
  what most pain sufferers rely on.
• Time-contingent schedule extinguishes the learned
  association between pain and medication taking,
  since it is now delivered according to the clock
  rather than the pain
• Goal
• ? To reduce physical dependence on the drug as
  the patients body gradually adapts to
  functioning without it
• ? To reduce psychological dependence as
  patients learn to take the medication less
  frequently until finally they feel confident
  without it

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The Resentment Trap

• Inactivity
• Focus on ? In
  coupling Shift of duties
• on pain
  activities to partner
• Client becomes
  Relationship Lack of
• boring, grouchy becomes less
  reciprocity or
• Demanding rewarding
  fairness in
  division of labour
• Partner feels angry
• Client feels misunderstood
• Relationship problems develop

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Management of Resentment Trap

• Patients and families may need help identifying
  roles, responsibilities and activities the
  patient can resume or take on for the first time.
• Teach patients to contract with their spouses,
  try out changes and communicate about the
  results can all take time and therapeutic skill.
• Often another member of the family (often
  partner) will have taken over the patients old
  family responsibilities - therefore considerable
  reshifting and renegotiation may be necessary to
  re-establish a new role for the patient.
• Setting up new, more positive family interactions
  in which reciprocity is gradually re-established
  can be a major therapy goal.

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