Cognitive-Behavioral Therapy for Chronic Pain : No Prescription Required Beverly E. Thorn, Ph.D., ABPP Professor Emerita, Psychology The University of Alabama bthorn@ua.edu Behavioral Pain Management Team: http:\\PMT.ua.edu National Register of Health Service Psychologists November 8, 2019
Roll Tide!
Disclosure • The presenter has no conflicts to disclose.
Objectives: 1. Historical/present day assessment/treatment of chronic pain 2. CBT Framework 3. Common Therapeutic Factors 4. Treatment Rationale – Gate Control Model 5. Treatment Conceptualization – Stress-Appraisal-Coping Model 6. Stress Appraisal & Relaxation Techniques 7. Cognitive Appraisal & Restructuring Techniques 8. Activity Pacing & Behavioral Activation Techniques 9. Emotional Awareness & Disclosure Techniques 10. Assertive Communication Techniques 11. Evidence Base & Mechanisms 12. Challenges
Definition of Pain • An unpleasant sensory & emotional experience associated with actual or potential tissue damage, or described in terms of such damage ( International Association for the Study of Pain ) – Avoids tying pain to a stimulus – Pain is always a psychological state
Chronic Pain • Pain lasts more than 3-6 months • Or pain lasts longer than normal time of healing • Pain interferes with normal daily function
Chronic Pain is a Public Health Problem ▪ > 37% Americans experience chronic pain ▪ Costs > 600 billion/yr
Historical & Current Treatment of Chronic Pain Biomedical – > Biopsychosocial
Which one has low back pain? Used with permission: Burel Goodin, Ph.D.
Which one is most likely to get opioids/surgery? Used with permission: Burel Goodin, Ph.D.
Which one is more likely to be told (or treated as) the pain is “all in your head”? Used with permission: Burel Goodin, Ph.D.
Biomedical Model of Pain (Pain Specificity Theory) Specificity Theory: Tissue damage = pain; Nociception = pain
Tissue Damage & Pain • Tissue damage and pain perception are related
But ….tissue damage is less predictive than expected (especially chronic pain) • Many people without any back pain show significant disc abnormalities • True for back, hip, and knee Blankenbaker et al., 2008; Borenstein et al., 2001; Brinjiki W et al, 2015; Carragee, Alamin, Miller, & Carragee, 2005; Jarvik et al., 2005; Jensen et al., 1994; Link et al., 2003.
What does Predict Pain & Disability?
What does Predict Pain & Disability? • Many studies, similar findings • Representative study: – Workers with low back injuries – Depression, fear avoidance, and fear of movement (i.e., cognitive and affective variables) predicted 85% of the variance in recovery 6 months later – Actual physical pathology was a very poor predictor (George & Beneciuk, 2015).
Gate Control (Melzack & Wall, 1965) & Neuromatrix Model of Pain (Melzack, 1990)
Biopsychosocial Model of Illness Engel, 1977 • Social support • Poverty • Mood Disturbance • Work and Employment • Attitudes and Beliefs • • Cultural Preferences Lack of Self-efficacy • Nociception • Tissue Damage • Effects of medications
But….. Where Are We Really ?
Spine 2011
SHARP INCREASE IN OPIOID PRESCRIPTIONS AND DEATHS
Other (Huge) Concerns • Tolerance, abuse, physical dependence • Diversion • Overdose
Opioids and Pain • In 20 years, opioids for chronic pain increased from 200% for morphine to almost 900% for hydrocodone Manchikanti, Helm, Janata, Vidyasagar, & Grider, 2012 • Meta-analysis: – opioids are better than placebo for pain relief and ability to function – compared to other analgesic drugs, opioids show only a small edge over non-opioids in pain relief – no greater advantage to function Furlan, Sandoval, Mailis-Gagnon, & Tunks, 2006 • Opioids provide pain relief comparable to Cognitive Behavioral Therapy (CBT) but poorer improvements in function. Okifuji and Turk (2015)
Recent Shifts • Recognition of opioid epidemic • Discourage medication as first-line treatment • Encourage pain self-management training – Include patient education about chronic pain – Include cognitive-behavioral therapy (including CT, BT, MBSR, ACT) (Institute of Medicine, 2011; Nat’l Pain Strategy, 2016; Am College Physicians, 2017; Center for Disease Control, 2018; Healthy People 2020)
(re)Enter Pain Self-Management • Positive adjustment to chronic pain is “more dependent on effective self-care than on the quality of the diagnostic or therapeutic interventions of the physicians.” Michael VonKorff (1999)
Goals of Pain Treatment • Identify and treat/manage underlying disease/pathology • Reduce the incidence and severity of pain • Optimize individual’s functioning/productivity • Reduce suffering and emotional distress • Improve overall quality of life • Consolidate care (& minimize interactions with healthcare system) Used with permission: Robert Kerns, Ph.D.
Why CBT for Pain Self-Management? • Uses biopsychosocial model • Gives relevant information, including how brain processes pain • Provides Skills training in pain self-management (e.g., stress management, cognitive appraisal/restructuring, behavioral pacing, behavioral activation, assertive communication) • Collaborative treatment/Therapeutic support
Components of Cognitive Behavioral Therapy for Chronic Pain
https://www.guilford.com/books/ Cognitive-Therapy-for-Chronic- Free download: Pain/Beverly-Thorn/ http://pmt.ua.edu/publications 9781462531691
General Session Structure • 90-min (group), 50-min (individual) • Collaborative & interactive • Relevant information about pain (“pain facts”) • Skills training • Weekly Prescription (homework)
Common Therapeutic Factors Rapport (Therapeutic Relationship) Expectation of help (shaped • Believing (in) the patient: through therapeutic “Your pain is real” relationship and tx rationale) • Validation, de-stigmatization Active participation of client and therapist Conceptual framework or • Empowerment (Self-efficacy & rationale for symptoms and Hope) treatment procedure (provides buy-in) If group tx, group cohesiveness • The unifying bond of chronic pain
Treatment Rationale: The Brain Process & Modifies Pain Signals • Provides a different perspective on pain (reconceptualizing pain) • Provides a biological (aka “real”) explanation • Explains role of cognitions and emotions
Explaining Pain to Patients: Biopsychosocial New Way Old Way Biomedical Model Model • Tissue damage = • Role of brain and spinal pain cord • The more tissue • Importance of emotions, damage, the more thoughts, behaviors, etc. pain • CNS changes • Remove/repair the • Gate Control/Neuromatrix damaged tissue, Model of Pain remove the pain
Treatment Rationale: Gate Control/Neuromatrix Model of Pain
Gate Control/Neuromatrix Theory Simplified….
Gate-Control Theory Simplified
Image from Thorn et al., 2017: Learning About Managing Pain: Patient Workbook ; http://pmt.ua.edu/publications.html
Conceptual Framework: The Stress-Pain Connection – Transactional Model of Stress/stress-appraisal- coping model (Lazarus & Folkman, 1984) – Stress and pain are related – pain causes stress and stress worsens pain – Stress is physical, emotional, cognitive, and behavioral – The stress response and the relaxation response – Stress management tools an important skill
Diaphragmatic (Belly) Breathing • Easy to learn • Reliably creates the relaxation response • Brief • Portable • Provides a focus
Judgments About Stress
Stress-Appraisal-Coping Model Simplified….
Cognitive Appraisal & Restructuring Techniques • Stress Appraisal (threat, loss, challenge) • Automatic thoughts • Deeper underlying beliefs – “should beliefs” (intermediate beliefs) – Core beliefs
Automatic Thoughts & Deeper Beliefs Automatic Thoughts, Intermediate Beliefs, Core Beliefs
Noticing, Examining, & Changing Unhelpful Thoughts • Start with a stressful situation – What was happening? (thoughts, feelings, actions) – Did the thoughts work for or against you? • Act like a jury for your thoughts – What’s the evidence that it’s true? False? – What’s the verdict? – Come up with a more helpful/realistic thought
Cognitive Appraisal & Restructuring Techniques • Stress Appraisal (threat, loss, challenge) • Automatic thoughts • Deeper underlying beliefs – “should beliefs” (intermediate beliefs) – Core beliefs
Automatic Thoughts & Deeper Beliefs Automatic Thoughts, Intermediate Beliefs, Core Beliefs
Examining & Changing Deeper Beliefs • Intermediate Beliefs (“should beliefs”) – Rules we hold for self & others – Very relevant to chronic pain re: cause & how it should be treated • Core Beliefs – Self-judgments about worthiness, lovability – “disabled chronic pain patient” vs well person w/ pain – Acting “As If” exercise
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