A brief review of cognitive behavioural approaches for pain management
Posted Jun 07 2011 8:39pm
Cognitive behavioural approaches for pain management are not exactly the same as cognitive behavioural therapy for mental health problems. While there are some underlying concepts that are the same, cognitive behavioural approaches for pain management include a wider range of strategies, and are far less readily defined than the very structured approach used in mental health. In fact it has only been in the last few years that research into the process of change in pain management have been conducted.
What defines a cognitive behavioural approach?
The assumption that people can learn to accept their chronic pain
That people can broaden their self-concept beyond being “a patient” into being “a person with pain”
That people can learn or re-explore skills to deal more effectively with their pain (Morley, Biggs & Shapiro)
Managing or living well despite pain
Pain behaviour that limits living well becomes the target
CBT provides the skills to (ultimately) change behaviour
Provided by any/all members of the interdisciplinary team (common treatment model)
What are the goals of this approach?(NB in no particular order!)
To reduce pain intensity
Increase functional activity, including work
Reduce/rationalise use of health care
Improve quality of life
One of the main aims of this approach is to ultimately help the person with pain become his or her own therapist – to effectively self manage pain.
How do we do this?
The exact combination of strategies and approaches that “do the trick” in this kind of approach is not yet known. It could even be that the specific techniques that people learn may not, in themselves, be all that important. Maybe it’s the emphasis throughout treatment that there is hope for a life even if pain is present that helps patients become people again. Research simply doesn’t tell us this yet.
Certainly, in the years that I’ve been working in pain management, the core elements have changed little, with perhaps, the addition of graded exposure and the mirrorbox and laterality work for certain problems.
How do we begin with this approach?
Assessing what the person with pain considers to be the main problem (the problem/s that pain “causes”, rather than pain alone)
Asking why he or she is looking for help right now (what were the triggers? It could be the person, or someone else who has initiated the treatment-seeking)
Identifying the changes he or she wants to see (how will the person know treatment has been successful?)
Listing the behavioural difficulties the person is currently having
Some of the ways I do this are to ask the person“what would you be doing now if pain was less of a problem?”
There’s a reason I use that phrase “less of a problem”, because I pretty much don’t refer to pain intensity again. Pain is likely to be present and to fluctuate throughout treatment and afterwards. I want to model that it’s the fear of pain, rather than the pain itself that is most disabling. Even when pain is intense, it’s more helpful to relax and go “with” the pain than be fearful and tense the body to resist it.
A first step is often to introduce a model of pain and how it affects the individual. This is a personalised model of pain, individualised for this person – but based on what we currently know about pain from research. Various explanations can be used, but I draw from what the person tells me about their experience of pain to generate their specific model.
Most times, it seems to help people to discuss a current neurobiological model of pain – and this is often where “Explain Pain” or similar descriptions can be really helpful. Taken at a pace that people can manage, and using their own examples, helps people to quickly grasp information that many medical students only begin to learn in 3rd and 4th year of study.
How does this step help?
Cognitive behavioural theory suggests that people appraise or judge situations very quickly, on the basis of past learning, current arousal state, and future predictions. Automatic thoughts then generate an emotional response. This emotional response influences behaviour. The relationships between these four factors can be bidirectional.
By giving people a more accurate and more realistic view of their pain – as something that can be understood (at least in part), and managed, and isn’t signalling harm – people can be far less distressed by it. You can think of how your knowledge that a flu jab is a helpful way to prevent getting the flu and how this helps you cope with the sting of the needle, and compare it with how you would interpret and respond to being stuck with a dirty needle wielded by a hoodlum in a dark alley! The thoughts and beliefs we hold about sensations influence emotions and behaviour.
Eliciting an individual’s automatic thoughts about pain, and helping them recognise that the way they view their pain may be accurate-but-unhelpful, is one part of the cognitive behavioural approach to pain management that all members of the team need to reinforce.
The remainder of a cognitive behavioural approach to managing pain is focused on helping people engage with activities they value, and doing so in a way that (1) is manageable for now and (2) recognises the sensitive nervous system can be stirred up quickly by things other than physical activity. Skills are developed to set goals, manage gradual increases, problem solve ways around obstacles, manage arousal levels, and work with thoughts and beliefs that become stirred up by doing things differently.
What about people who are really, really fearful of moving and avoid things? Take a look at that reference below – it’s a review of the approaches that have been used for people in this situation. More on it very soon…
Bailey, K. M., Carleton, R., Vlaeyen, J. W., & Asmundson, G. J. (2010). Treatments addressing pain-related fear and anxiety in patients with chronic musculoskeletal pain: A preliminary review. Cognitive Behaviour Therapy, 39 (1) DOI: 10.1080/16506070902980711