I. What is Chronic Pain (Definitions)?
There a number of sources that define pain conditions or seek to classify pain, but according to the International Association for the Study of Pain (The IASP was established in 1973) pain is defined as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This IASP definition was later updated to include “…Many people report pain in the absence of tissue damage… if they (the patients) regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain.” A University of North Carolina biological psychology teacher defines the pain experience as “the experience evoked by a harmful stimulus, directs your attention toward a danger and holds your attention” (Kalat, 2012). A doctorate level addictions specialist describes chronic pain as persistent pain characterized by “dull or “aching” pain that “can contribute to feelings of hopelessness, depression and possible suicidal thinking by patients (Doweiko, 2012). Distinguished Oxford authors of the “Pain Survival Guide” indicate that chronic pain is enduring and is unlike acute pain that usually lasts for short periods of time “from a few days…to several weeks to several months” as patients heal from their injuries (Turk & Winter, 2011). Specifically, the Oxford doctor notes that “pain has become chronic when…it goes well beyond the expected course…and it alters our lifestyle” (Turk & Winter, 2011). The simplistic definition (that does not exist) would be, “if the pain does not go away after medical intervention and a period of recovery it must be chronic” thereby compelling us to seek relief.
Symptoms and indicators of Chronic Pain (Turk & Winter, 2011):
- Enduring pain that will not subside (persistent)
- Evidence of an enduring physical pathology (injuries, tissue damage, disease such as a musculoskeletal condition like arthritis, pelvic pain, neck and back pain)
- Constant tension headaches (Migraine)
- Pain causes stress/irritability
- Negatively impacts quality of life (avoidance of certain activities)
- Fatigue, loss of sleep
- Poor concentration (distracted by dull aching pain)
- The pain may or may not have an identifiable cause (“85% of the people with lower back pain, doctors are unable to determine a cause” ((Turk & Winter, 2011))
- Emotions of Chronic pain include: feelings of agitation, anxiety, anger, aggressiveness, defensiveness, dependency, despair, depression, craving relief, inability to control reactions, frustration, hopelessness, lament for better days, longing for relief, loneliness, stress
- Faulty Thinking/Cognition: negative self-appraisal skills, negative automatic thoughts, poor decision making skills, black and white thinking, reactive vs. proactive thought processes, anticipates negative actions, faulty assessments, blaming others (transference), stuck in negative thought patterns
Will CBT help reduce my chronic pain problems? CBT will help reduce chronic pain and pain related problems because it is effective for a number of pain problems and pain related issues. First of all, CBT is a mainstream treatment, and after 30 years of research using “randomized controlled trials (RCT)” the practice is proven efficacious for a wide array of chronic pain and related problems. In fact, experts from the university of Washington noted that 22 RCTs were specifically conducted on lower back pain and resulted in “…positive effects on pain, pain interference with activities, health-related quality of life, and depression” (Ehude et al., 2014). The same panel of subject matter experts also reviewed headache activity and found average pain reductions from “30% to 60% across all studies.” The group also found that CBT worked well with chronic temporomandibular disorder (TMD). CBT seven showed improvement via web-based interventions and improved “mood, physical activity, work productivity, medication use, and physical visits (Ehude et al., 2014). Holistically, CBT works best in combination with other treatments to target chronic pain and related problems.
However, there are some gaps and barriers in CBT application requiring more research and promotion of CBT in a multi-modal approach. It is unknown if patients with neurological issues can be helped with CBT techniques since randomized trials have yet to occur. Patients must be willing to do homework to assess their situation, improve and reinforce learning and maintenance of skills. A study in 2004 indicated that “68% of the patients would improve if therapy involved homework (Johnson & Kazantzis, 2004). Motivation is a critical part of CBT and moreover homework reinforces the development of new neural networks. CBT interventions work well for a range of adult and adolescent or older populations, but not appropriate for those with low intelligence (Ehude et al., 2014), or with Traumatic Brain Injury patients (TBI) (Ehude, et al., 2014). More research is required for those specific populations. In addition, primary care providers may not consider using CBT in addition to treatment as usual due to lack of CBT knowledge (Beissner et al., 2009). Even with such barriers exist, CBT is proven effective across most populations, primary care providers require more knowledge of CBT practices and CBT research must be expanded to those with neurological issues such as TBI.
III. How is chronic pain linked to body function, feelings and neuroplasticity? (Bio-physiology)?
The general consensus among the scientific community is that body, mind and perceptions are positively or negatively influenced by internal and external learning stimulus in a process known as neuroplasticity. So what does this mean? Humans are a system of systems that integrate a number of “biological, psychological and social factors” (Garland & Howard, 2009) into a single structure that is able to learn, change and adapt to conditions over time. In fact, a recent clinical update by the International Association for the Study of Pain (IAS), indicated that the union of “Mind-body Medicine and Neuroplasticity” represent the new way forward for treatment of chronic pain (IAS, 2014). In essence, whether we are young or old this process of mind and body regeneration can restore or hinder human resilience based on sensory feedback loops. Mechanically, a negative stimulus (chronic pain) travels down two pathways within the body. As pain is sensed it moves through the dendrites or neural pathways of the spinal cord to multiple locations in the brain. Once the pain stimulus reaches the brain it is channeled to “body oriented” sensors within the somatosensory cortex; and is simultaneously routed to the emotional parts of the brain that consists of the “hypothalamus, amygdala and the cingulated cortex” (Kalat, 2014). In other words, duel mind body sensory processing occurs simultaneously.
The feedback from the two sensors results in “gate” like functions (Kalat 2014) that impact pain appraisal many ways. As Kalat states, “Gate theory” was originated by Melzak and P.D. Wall in 1964 proposing that stimulus “inputs close the gates for pain messages” and outputs open the message gates. Oxford scholars provided a simple example of this theory indicating that during pre-arthritis conditions (or no injury) the gate remains closed, and after the disease or injury manifests the gate is open to send messages to the brain (Turk &Winter, 2009). The scholars further added that surgery (a gate fix) can sometimes cause more problems than it solves indicating that a “wiring function” is an over simplified representation of a very complex system of neural networks that can lead to a myriad of psychological issues. This can be seen in the form of negative emotions such as fear, anxiety, anger, frustration, depression, daily stress; and physical indicators such as headaches, trembling, dull persistent aches, facial expressions, voluntary immobility and limited physical interactions with others. Mind and body are a complex system of systems that deserve a multi-modal approach to treatment rather than singular approaches such as drug therapy?
IV. What are the non-psychopharmacological (non-drug) Evidence Based Practices (EBP) used to treat the chronic pain?
Again there are a number of options for non-psychopharmacological practices for chronic pain, but the key phrase here is efficacy through clinical trials or long term studies. Hence, a well known and respected medical data base recommends an array of treatments that include: Psychological Therapy (this would include CBT for chronic pain), Physical Therapy (PT), and Occupational Therapy (OT) (Medscape, 2014). In a like manner, the “Pain Survival Guide” identifies surgery as an option, along with thermal therapies, electrical or ultrasound stimulation, biofeedback, and pain clinics that may use a combination of techniques to reduce pain (Turk & Winter, 2007). Various techniques work for different people and all clients are unique in their own right, but luckily CBT is evidence based and includes an array of techniques.
Consequently, this manual focuses on CBT practices that are proven to increase the effectiveness of other therapies or as a stand-alone intervention (Eccleston et al., 2003; Beissner et al., Turk & Winters, 2006; Nickel et al., 2007; Garland & Howard, 2009). Note that there is no set standard for CBT programs and the interventions must be tailored to the unique individual. In general, the following interventions have proven effective in a number of combinations as follows. First, it is important for the client to understand the program and Psychoeducation for chronic pain is an important step in understanding the condition of chronic pain and the CBT approach. It may include educational topics such as “physiology, anatomy of pain, exercise, the consequences of chronic inactivity and the benefits and side effects of medication in managing chronic pain” (Eccleston et al., 2003)). In addition, Cognitive Restructuring/skills helps patients to stop or reappraise automatic and/or irrational negative thoughts such as catastrophic thinking, overgeneralized beliefs and pain-related fear. Problem solving techniques listening skills are also taught to help clients to think rationally and to understand messages for others rather than spontaneously (Johnson & Kazantzis, 2004). Other CBT training techniques seeks to identify behavioral patterns and conditions through self monitoring of “pain, activity, mood and medication” can be enabled by cell phone applications, homework and worksheets (Johnson & Kazantzis, 2004). Self-reporting or family based reporting helps the therapist and client to identify and address chronic pain problems. In addition, CBT also utilizes “Mindfulness Based Cognitive Therapy to reduce stress. In total, there are many non-psychopharmacological based solutions, but CBT offers a vast set of tools to help patients take control of their own symptoms, to manage stress and negative patterns of thinking and behavior.
V. What are the Evidence Based Practice psychopharmacological treatments?
I recommend that patients and family visit medscape.com to read the medication summary for chronic pain syndrome that provides significant detail on non-narcotic, analgesic and anti-depressant medications. In general, the medical data base recommends that clients begin with over the counter medications such as: “analgesics such as paracetamol, ibuprofen, aspirin, or naproxen” (Medscape, 2014), that are primarily “Nonnarcotic, nonsteroidal anti-inflammatories” (Turk & Winters, 2006). If over the counter medications do not work than prescription drugs (opioids and anti-depressants) are the other options, but Medscape states that people should “avoid barbiturate or opiate agonists.” However, opioids are “an effective means of reducing acute pain,” but they “have a high abuse liability” and more importantly there is evidence that opioids did not significantly reduce chronic pain in patients during “placebo-controlled trials” (Garland, 2014). Isn’t that an interesting tidbit of information for pain suffers? In addition, prescription and “off the shelf” drugs can cause side effects that include “dizziness, constipation, and loss of concentration” (Turk & Winters, 2006). Interestingly, there only a “few studies that show the effectiveness of selective serotonin reuptake inhibitors (SSRIs)” (Preston & O’Neal, 2010), but Medscape notes that anti-depressants like “flouxetine (Prozac) aroxetine (Paxil), and sertraline (Zoloft), as well as the selective serotonin/norepinephrine reuptake inhibitor (SNRI), duloxetine (Cymbalta), are commonly prescribed medications for chronic pain” (Medscape, 2014) and may help patients to cope with secondary effects of chronic pain (depression). Of note, it may take up to four weeks for anti-depressants to take effect, hence concurrent therapies such as CBT are important multi-phasic strategies for dealing with chronic pain symptoms.
VI. What are the CBT related goals of for chronic pain?
To begin, the following list is crafted as a starting point for goal development; however each goal must be tailored to the unique individual. The first goal is to establish a baseline or starting point to set conditions for quantifiable achievement of subsequent goals. Goal two focuses on self-management practices. Goal three builds on goal two and ensures compliance with medication schedules and doses. Goal four targets negative cognitions that contribute to negative self appraisals and ability to accomplish goal five. The last goal also focuses on social support and involves utilization of family in treatment strategies.
Here are six recommended CBT goals that represent a general trend in goal selection from a review of numerous peer review articles and academic books. In addition, one must be able to follow up and assess the selected goals, hence breakout paragraphs contain common sense approaches to assess goals accomplishment. As time goes by each individual and their therapist should add a seventh goal which focuses on maintenance strategies.
The CBT goals follow:
1. Establish baseline data through self monitoring and reporting (Turk & Winter, 2007)
2. Increase competencies and confidence in pain self-management skills (Nickel, et al. 2008).
3. Increase adherence to medication schedules and dosages (Preston, et al.2010).
4. Decrease “established patterns of ...automatic thinking”(Nickel, et al., 2008), irrational thoughts and negativity.
5. Increase ability to engage in “social, recreational and occupational endeavors that have been limited or terminated by pain” (Johnson & Kazantzis, 2004).
6. Reduce the number of incidents of negative self-control due to pain stimulus and social interaction (reduces signs of disability to improve quality of life).
How to assess CBT Goals:
1. Establish baseline data through self monitoring and reporting (Turk & Winter, 2007)
a. Identify the degree of compliant based on adherence or non-adherence to prescribed medication schedules
and appropriate dosage using a worksheet or a cell phone application.
b. Rate your current pain level using a worksheet or a cell phone application.
c. Assess your mood state based on a worksheet or a cell phone application.
d. Identify daily physical activities that you want to improve or a new program of activity that the person in pain
wants to increase or decrease in terms of distance, time, and/or repetitions. Track weekly progress.
e. Identify and lists primary stressors or life events (work on reducing the most important first).
f. Identify and lists positive events or activities that the person in pain wants to continue or return to (include at least one social activity).
g. Identify and list automatic or irrational thoughts and beliefs that are related to your chronic pain condition.
h. Rate the person’s proficiency level in self-management skills that reduce chronic pain states. Use a single rating from 1 to 10 scale (10 is the least use of management skills and 1 is the worst ability to manage self (consider how well you stick to medication schedules, dosages, adherence to a routine exercise program (3 to 4 times per week), emotional self-regulation, level of agitation/aggressiveness, anxiety, feeling down or hopeless). This is a broad indicator, but there is at least one thing you can improve each week if you try. That is progress in self-management (actively working to make quality of life better).
i. Take a Beck’s depression scale.
j. Rate how well the person in pain sleeps on a scale of 1 to 5: (1) Is the best rating (no sleep problems); (2) The person in pain rarely experiences some difficulty sleeping; (3) The person in pain experiences some difficulty sleeping (seldom feels tired in the next day), (4) The person in pain experiences loss of sleep on most nights with tiredness in the day, (5) Significant loss of sleep that interferes with daily function.
2. Increase competencies and confidence in pain self-management skills (Nickel, et al. 2008).
a. Visits the pain web site to read information on chronic pain and shares experience with others.
b. Sets aside time to meditate daily to reduce stress caused by muscle tension.
(1) Get your family or a friend involved and have them meditate with you.
(2) Take a class on meditation to develop self “awareness and acceptance of the body where it is” (Johnson & Kazantzis, 2004).
c. Schedules pleasurable activities to distract from pain.
d. Seeks social interaction and activities to reduce negative feelings of stress or feelings of isolation. The person in pain adopts relaxing lifestyle changes to reduce stress.
e. Adheres to a nutrition program to promote better health (takes a good multi-vitamin).
f. Develops good sleep practices: implements a routine sleep schedule, controls environment (reduces noise, uses white noise, dark room), turns off cell phone alerts in sleeping areas, does not watch TV in sleeping areas, exercises early rather than before bed time, reduces and modifies activity levels if the resulting pain is causing loss of sleep, works to reduce emotional conflict or problems) (Turk and Winter 2005).
3. Increase adherence to medication schedules and dosages.
a. Uses a daily tracking mechanism to promote adherence to schedules.
b. Sets daily alarms on cell phone. Enslists a family member or friend to “double check” adherence to prescribed drug schedules.
c. Records dosage/quantity taken and enlists family members to monitor pill counts (this can be to offset addictions or to help those who forget). A prudent person or family member knows when they need help or when they need to help others. Asking for help is a positive step in treatment and recovery. Volunteering to help a person in pain means you care deeply about others.
4. Decrease “established patterns of ...automatic thinking”(Nickel, et al., 2008), irrational thoughts and negativity.
a. Keeps a daily log of the following: irrational thoughts, all or nothing thinking, depressive thoughts, and negative feedback to self and/or to others.
b. Identifies and plans to correct irrational thought patterns through cognitive reframing techniques. Engages in positive self-talk.
5. Increase ability to engage in “social, recreational and occupational endeavors that have been limited or terminated by pain” (Johnson & Kazantzis, 2004).
a. Implements a schedule of physical activity.
b. Paces physical activities to enable resumption of activities. Adjusts to body messages and works within abilities. Indeed, it is not uncommon for pain suffers to fear moving and a return to normal activities (because it hurts), but CBT methods encourage the person in chronic pain to schedule activities using a graduated exposure approach to activities called pacing (Johnson & Kazantzis, 2004).
c. Seeks social support in activities. Specifically, encouragement from others is important and social activities such as: spiritual pursuits, athletic events, clubs, and organizations can provide motivation and an outlet for stress.
d. Develops a personal mission statement for life. Defines a new mission for self that can be spiritual, physical, community based volunteer work or an entrepreneurial idea that will provide a service or product to others. Focus on life events (doing) rather than pain.
6. Reduce the number of incidents of negative self-control due to pain stimulus and social interaction (reduces reactionary signs of disability to improve quality of life).
a. Implements self-monitoring of thoughts (cognitions) and behavioral acts as a part of CBT treatment (See Worksheet recommendations in the back of the guide (X)).
b. Target awareness and monitoring of mood state, exercise and medication intake using cell phone applications or worksheets listed in the rear of this manual.
VII. What is CBT for chronic pain (Definition)? According to the Encyclopedia of Cognitive Behavioral Therapy, CBT “is an active, directive, collaborative, structured, dynamic, problem oriented, solution-focused, and psychoeducational model of treatment” (Freeman et al., 2005) that is focused on chronic pain reduction and associated pain problems. This singular course of action is contrary to drug treatment models that are passive in nature. They only require the patient to adhere to drug schedules/dosages and do not address the implications of chronic pain that negatively impact how we live, play and work. CBT is a holistic program that generally consists of the following: “assessment” (establishing the baseline), “education” (understanding pain), “skill acquisition” (learning to deal with pain and its implications), “generalization” (How to apply new CBT skills to everyday life), “and maintenance” (sustaining after the initial treatment plan) according to a number of experts (Johnson & Kazantzis, 2004; Freeman et al., 2005).
VIII. Summary of CBT Techniques (Freeman et al., 2005; Turk & Winter 2005; ).
1. Cognitive coping and restructuring:
a. Thinking differently can be done in a number of ways. Restructuring how a person feels involves “cognitive reappraisal” of thoughts and distorted thinking patterns enables the pain sufferer to redesign negative internal dialogues. In fact, the same methods are proven to work for stress also. CBT for stress includes “Cognitive Restructuring” to manage symptoms of chronic pain (Freeman, et al., 2004).
b. Clients can become their own pain managers and can accomplish this through developing alternative ways of dealing with situations as follows: Use problem solving method to generate better responses to painful situations; stop thinking negative thoughts (use “thought stopping” to recognize and cease unproductive thought routines); use re-appraisal of one’s own abilities (list your mental strengths based on past experiences); take classes or read up on interpersonal communications and information processing skills to build social support (think and know that you are not alone in your pain), understand stress and coping strategies to promote new learning (take psychoeducational classes on coping strategies) , practice self-dialogue to cope and restructure automatic thoughts and ingrained patterns. In total this will help reduce daily stress and promote positive neural patterns of growth.
c. Reject back and white thinking. For example, a person with chronic pain may think “if I don’t drink then my pain will not go away.” Conversely, this person should recall the numerous times when pain went away without the use of alcohol. Suffering from chronic pain is not an “all or nothing event”, hence pausing to consider the opposite of what you are experiencing is beneficial. Indeed, clients in pain do experience the same problems time and time again, but it is how we process the perception of pain that makes a difference in a positive or negative outlook on life. Statements like “I will never feel better” are simply not true.
d. Chronic pain can cloud a person’s rational thought processes and can cause more stress so objectively evaluate how you feel. Here are seven examples of what not to do (Freeman, et al., 2004):
(1) Don’t ignore the positive thoughts (success can be repeated).
(2) “Don’t think with the heart!” Pain can take control of a person’s emotions, but we control how we feel. Think before acting reflexively. Use a decision making process.
(3) Do not use negative self appraisal. For example, one should not say that “I am so stupid” when it understood that pain clouds thinking. Simply accept that people with pain will forget things from time to time because they lose sleep and can lack concentration. Don’t label yourself because of a chronic condition.
(4) Don’t catastrophize! Ruminating on the worst possible scenario does not help matters. This is negative thinking. Consider the best possible outcome. Be aware of bad things, but do not get stuck on one negative course of action or outcome (Nickel, et al., 2008)
(5) Don’t compare yourself to others. Clients must focus on what they can do. Every person has different strengths (others cannot walk in your shoes). Some people would call this the emotion of envy. Your self- worth is not determined by others, but by many external factors.
(6) Don’t demand perfection in yourself, because this causes more personal stress. “No one is perfect.” Stop using the words “I should have or ought to” since you must pace yourself mentally and physically based on your condition. Do the best you can within you capabilities.
(7) Don’t minimize at the expense of your health and well being! If chronic pain becomes seemingly unbearable it is ok to let others know that you are not at your best. Take actions to reduce the pain. It is ok to pause and drink water, take a break, take medications, or to relax as part of self-management strategies.
2. Relaxation Training (Turk & Winter 2005).
a. Learning to relax is an important strategy to reduce daily stress that is aggravated by chronic pain. Tension can directly impact how well a person sleeps, interacts with other, and influences how well they think. Turk and Winter (2005), oxford scholars indicate that inability to relax becomes a “viscous cycle” that leads to impairment. When you learn to relax sleep is more possible and tension subsides.
b. Review your schedule and determine if the sack is too full. Create a manageable schedule.
c. When you are “stressed out’ by everyday problems you are in a state of excitatory function. Indications include muscle tension, weight gain, and increased blood pressure that only makes chronic pain worse. This stress uses energy and produces harmful chemicals that are harmful to neural growth.
d. Relaxation practices release this stress to conserve energy. Implement a simple practice of releasing stress through relaxation. In its rudimentary form, a person in pain can can simply breathe in while simultaneously squeezing a fist and holing the breath for five seconds and then crunch the arm into a bicep curl locked against the upper shoulder. Hold it tight until you begin to quiver and then exhale and relax (Turk and Winter, 2005). Compare the one side to the other side of the body. You are now more relaxed. This relaxation process can be repeated from the top of the body to the bottom. For example, close your eyes tightly, inhale and tense all the muscles in your face for five seconds then relax. Do this process of systematic relaxation down the body structure.
e. Clients should take a class on relaxation (Mindfulness Training) “the practice of cultivating a state of metacognitive awareness of present moment thoughts, emotions, sensations and perceptions” to reduce chronic pain (Garland, 2014). Meditation practices can help clients to be more aware of self in the present moment.
3. Guided imagery: There is a wide variety to techniques that leverage a guided imagery approach. This is a way of reducing negative automatic images, faulty beliefs, and expectations. Many people with chronic pain do experience fear, concern and may avoid activities. Consequently, a combination of psychoeducation and visualization processes can provide new motivation for patients who may experience avoidance behaviors. The general idea is to replace a clients negative images with positive expectations that are inspired by imagery or visualization. For example, an adult with an injury may not return to an activity such as tennis even though they are able to do so (a doctor approves the activity). Inactivity due to persistent pain is often a problem in recovery or maintenance of chronic injuries. Guided imagery and psychoeducation can inspire clients to resume previous activities (pictures of people enjoying certain activities or recalling the pleasure of walking or biking can be beneficial (Turk & Winter 2005)).
4. Distraction: This technique diverts attention away from the chronic pain state by using pleasurable or exciting activities. Kalat (2014) indicates that when we experience pleasurable activities the body releases natural chemicals called dopamine that can reduce pain. Therefore, pleasurable activities or excitement cause releases that make clients feel better. Common activities include listening to music, calling a friend (social support), relaxation exercises or physical activity (Turk & Winter 2005).
5. Psychoeducational classes: This is a way for clients to learn more about chronic pain and is a normal part of educating clients on ways to get better. This may include discussion of the cycle of treatment using CBT, formulation of goals, expectations and outcomes, therapeutic tasks, problem solving, practical application of techniques and maintenance strategies (Nickel, et al., 2008).
6. Homework: This is an essential part of CBT interventions wherefore self-assessment, monitoring, and learning new techniques are emphasized. So why should patients do homework? In a 2004 study, Johnson and Kazantzis found that “68% of all patients would improve when therapy involved homework, compared to only 32% when therapy did not involve homework. Patients who are actively address chronic pain at home are increasing their therapeutic success rate by 50%. Patients with chronic pain should remember that as new learning occurs new neural networks are formed and pain related neuroplastic connection are strengthened by exercises and application. Clients can master beneficial techniques to distract, relax, and think differently to reduce pain. It takes work to activate new growth and CBT homework weakens negative neural connections (closes the gate) and strengthens (opens the gate) for neurogenisis or new growth through new learning (Johnson & Kazantzis (2004); Kalat (2013); Garland & Owen, (2009); Turk & Winter (2005).
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There a number of sources that define pain conditions or seek to classify pain, but according to the International Association for the Study of Pain (The IASP was established in 1973) pain is defined as: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This IASP definition was later updated to include “…Many people report pain in the absence of tissue damage… if they (the patients) regard their experience as pain, and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain.” A University of North Carolina biological psychology teacher defines the pain experience as “the experience evoked by a harmful stimulus, directs your attention toward a danger and holds your attention” (Kalat, 2012). A doctorate level addictions specialist describes chronic pain as persistent pain characterized by “dull or “aching” pain that “can contribute to feelings of hopelessness, depression and possible suicidal thinking by patients (Doweiko, 2012). Distinguished Oxford authors of the “Pain Survival Guide” indicate that chronic pain is enduring and is unlike acute pain that usually lasts for short periods of time “from a few days…to several weeks to several months” as patients heal from their injuries (Turk & Winter, 2011). Specifically, the Oxford doctor notes that “pain has become chronic when…it goes well beyond the expected course…and it alters our lifestyle” (Turk & Winter, 2011). The simplistic definition (that does not exist) would be, “if the pain does not go away after medical intervention and a period of recovery it must be chronic” thereby compelling us to seek relief.
Symptoms and indicators of Chronic Pain (Turk & Winter, 2011):
- Enduring pain that will not subside (persistent)
- Evidence of an enduring physical pathology (injuries, tissue damage, disease such as a musculoskeletal condition like arthritis, pelvic pain, neck and back pain)
- Constant tension headaches (Migraine)
- Pain causes stress/irritability
- Negatively impacts quality of life (avoidance of certain activities)
- Fatigue, loss of sleep
- Poor concentration (distracted by dull aching pain)
- The pain may or may not have an identifiable cause (“85% of the people with lower back pain, doctors are unable to determine a cause” ((Turk & Winter, 2011))
- Emotions of Chronic pain include: feelings of agitation, anxiety, anger, aggressiveness, defensiveness, dependency, despair, depression, craving relief, inability to control reactions, frustration, hopelessness, lament for better days, longing for relief, loneliness, stress
- Faulty Thinking/Cognition: negative self-appraisal skills, negative automatic thoughts, poor decision making skills, black and white thinking, reactive vs. proactive thought processes, anticipates negative actions, faulty assessments, blaming others (transference), stuck in negative thought patterns
Will CBT help reduce my chronic pain problems? CBT will help reduce chronic pain and pain related problems because it is effective for a number of pain problems and pain related issues. First of all, CBT is a mainstream treatment, and after 30 years of research using “randomized controlled trials (RCT)” the practice is proven efficacious for a wide array of chronic pain and related problems. In fact, experts from the university of Washington noted that 22 RCTs were specifically conducted on lower back pain and resulted in “…positive effects on pain, pain interference with activities, health-related quality of life, and depression” (Ehude et al., 2014). The same panel of subject matter experts also reviewed headache activity and found average pain reductions from “30% to 60% across all studies.” The group also found that CBT worked well with chronic temporomandibular disorder (TMD). CBT seven showed improvement via web-based interventions and improved “mood, physical activity, work productivity, medication use, and physical visits (Ehude et al., 2014). Holistically, CBT works best in combination with other treatments to target chronic pain and related problems.
However, there are some gaps and barriers in CBT application requiring more research and promotion of CBT in a multi-modal approach. It is unknown if patients with neurological issues can be helped with CBT techniques since randomized trials have yet to occur. Patients must be willing to do homework to assess their situation, improve and reinforce learning and maintenance of skills. A study in 2004 indicated that “68% of the patients would improve if therapy involved homework (Johnson & Kazantzis, 2004). Motivation is a critical part of CBT and moreover homework reinforces the development of new neural networks. CBT interventions work well for a range of adult and adolescent or older populations, but not appropriate for those with low intelligence (Ehude et al., 2014), or with Traumatic Brain Injury patients (TBI) (Ehude, et al., 2014). More research is required for those specific populations. In addition, primary care providers may not consider using CBT in addition to treatment as usual due to lack of CBT knowledge (Beissner et al., 2009). Even with such barriers exist, CBT is proven effective across most populations, primary care providers require more knowledge of CBT practices and CBT research must be expanded to those with neurological issues such as TBI.
III. How is chronic pain linked to body function, feelings and neuroplasticity? (Bio-physiology)?
The general consensus among the scientific community is that body, mind and perceptions are positively or negatively influenced by internal and external learning stimulus in a process known as neuroplasticity. So what does this mean? Humans are a system of systems that integrate a number of “biological, psychological and social factors” (Garland & Howard, 2009) into a single structure that is able to learn, change and adapt to conditions over time. In fact, a recent clinical update by the International Association for the Study of Pain (IAS), indicated that the union of “Mind-body Medicine and Neuroplasticity” represent the new way forward for treatment of chronic pain (IAS, 2014). In essence, whether we are young or old this process of mind and body regeneration can restore or hinder human resilience based on sensory feedback loops. Mechanically, a negative stimulus (chronic pain) travels down two pathways within the body. As pain is sensed it moves through the dendrites or neural pathways of the spinal cord to multiple locations in the brain. Once the pain stimulus reaches the brain it is channeled to “body oriented” sensors within the somatosensory cortex; and is simultaneously routed to the emotional parts of the brain that consists of the “hypothalamus, amygdala and the cingulated cortex” (Kalat, 2014). In other words, duel mind body sensory processing occurs simultaneously.
The feedback from the two sensors results in “gate” like functions (Kalat 2014) that impact pain appraisal many ways. As Kalat states, “Gate theory” was originated by Melzak and P.D. Wall in 1964 proposing that stimulus “inputs close the gates for pain messages” and outputs open the message gates. Oxford scholars provided a simple example of this theory indicating that during pre-arthritis conditions (or no injury) the gate remains closed, and after the disease or injury manifests the gate is open to send messages to the brain (Turk &Winter, 2009). The scholars further added that surgery (a gate fix) can sometimes cause more problems than it solves indicating that a “wiring function” is an over simplified representation of a very complex system of neural networks that can lead to a myriad of psychological issues. This can be seen in the form of negative emotions such as fear, anxiety, anger, frustration, depression, daily stress; and physical indicators such as headaches, trembling, dull persistent aches, facial expressions, voluntary immobility and limited physical interactions with others. Mind and body are a complex system of systems that deserve a multi-modal approach to treatment rather than singular approaches such as drug therapy?
IV. What are the non-psychopharmacological (non-drug) Evidence Based Practices (EBP) used to treat the chronic pain?
Again there are a number of options for non-psychopharmacological practices for chronic pain, but the key phrase here is efficacy through clinical trials or long term studies. Hence, a well known and respected medical data base recommends an array of treatments that include: Psychological Therapy (this would include CBT for chronic pain), Physical Therapy (PT), and Occupational Therapy (OT) (Medscape, 2014). In a like manner, the “Pain Survival Guide” identifies surgery as an option, along with thermal therapies, electrical or ultrasound stimulation, biofeedback, and pain clinics that may use a combination of techniques to reduce pain (Turk & Winter, 2007). Various techniques work for different people and all clients are unique in their own right, but luckily CBT is evidence based and includes an array of techniques.
Consequently, this manual focuses on CBT practices that are proven to increase the effectiveness of other therapies or as a stand-alone intervention (Eccleston et al., 2003; Beissner et al., Turk & Winters, 2006; Nickel et al., 2007; Garland & Howard, 2009). Note that there is no set standard for CBT programs and the interventions must be tailored to the unique individual. In general, the following interventions have proven effective in a number of combinations as follows. First, it is important for the client to understand the program and Psychoeducation for chronic pain is an important step in understanding the condition of chronic pain and the CBT approach. It may include educational topics such as “physiology, anatomy of pain, exercise, the consequences of chronic inactivity and the benefits and side effects of medication in managing chronic pain” (Eccleston et al., 2003)). In addition, Cognitive Restructuring/skills helps patients to stop or reappraise automatic and/or irrational negative thoughts such as catastrophic thinking, overgeneralized beliefs and pain-related fear. Problem solving techniques listening skills are also taught to help clients to think rationally and to understand messages for others rather than spontaneously (Johnson & Kazantzis, 2004). Other CBT training techniques seeks to identify behavioral patterns and conditions through self monitoring of “pain, activity, mood and medication” can be enabled by cell phone applications, homework and worksheets (Johnson & Kazantzis, 2004). Self-reporting or family based reporting helps the therapist and client to identify and address chronic pain problems. In addition, CBT also utilizes “Mindfulness Based Cognitive Therapy to reduce stress. In total, there are many non-psychopharmacological based solutions, but CBT offers a vast set of tools to help patients take control of their own symptoms, to manage stress and negative patterns of thinking and behavior.
V. What are the Evidence Based Practice psychopharmacological treatments?
I recommend that patients and family visit medscape.com to read the medication summary for chronic pain syndrome that provides significant detail on non-narcotic, analgesic and anti-depressant medications. In general, the medical data base recommends that clients begin with over the counter medications such as: “analgesics such as paracetamol, ibuprofen, aspirin, or naproxen” (Medscape, 2014), that are primarily “Nonnarcotic, nonsteroidal anti-inflammatories” (Turk & Winters, 2006). If over the counter medications do not work than prescription drugs (opioids and anti-depressants) are the other options, but Medscape states that people should “avoid barbiturate or opiate agonists.” However, opioids are “an effective means of reducing acute pain,” but they “have a high abuse liability” and more importantly there is evidence that opioids did not significantly reduce chronic pain in patients during “placebo-controlled trials” (Garland, 2014). Isn’t that an interesting tidbit of information for pain suffers? In addition, prescription and “off the shelf” drugs can cause side effects that include “dizziness, constipation, and loss of concentration” (Turk & Winters, 2006). Interestingly, there only a “few studies that show the effectiveness of selective serotonin reuptake inhibitors (SSRIs)” (Preston & O’Neal, 2010), but Medscape notes that anti-depressants like “flouxetine (Prozac) aroxetine (Paxil), and sertraline (Zoloft), as well as the selective serotonin/norepinephrine reuptake inhibitor (SNRI), duloxetine (Cymbalta), are commonly prescribed medications for chronic pain” (Medscape, 2014) and may help patients to cope with secondary effects of chronic pain (depression). Of note, it may take up to four weeks for anti-depressants to take effect, hence concurrent therapies such as CBT are important multi-phasic strategies for dealing with chronic pain symptoms.
VI. What are the CBT related goals of for chronic pain?
To begin, the following list is crafted as a starting point for goal development; however each goal must be tailored to the unique individual. The first goal is to establish a baseline or starting point to set conditions for quantifiable achievement of subsequent goals. Goal two focuses on self-management practices. Goal three builds on goal two and ensures compliance with medication schedules and doses. Goal four targets negative cognitions that contribute to negative self appraisals and ability to accomplish goal five. The last goal also focuses on social support and involves utilization of family in treatment strategies.
Here are six recommended CBT goals that represent a general trend in goal selection from a review of numerous peer review articles and academic books. In addition, one must be able to follow up and assess the selected goals, hence breakout paragraphs contain common sense approaches to assess goals accomplishment. As time goes by each individual and their therapist should add a seventh goal which focuses on maintenance strategies.
The CBT goals follow:
1. Establish baseline data through self monitoring and reporting (Turk & Winter, 2007)
2. Increase competencies and confidence in pain self-management skills (Nickel, et al. 2008).
3. Increase adherence to medication schedules and dosages (Preston, et al.2010).
4. Decrease “established patterns of ...automatic thinking”(Nickel, et al., 2008), irrational thoughts and negativity.
5. Increase ability to engage in “social, recreational and occupational endeavors that have been limited or terminated by pain” (Johnson & Kazantzis, 2004).
6. Reduce the number of incidents of negative self-control due to pain stimulus and social interaction (reduces signs of disability to improve quality of life).
How to assess CBT Goals:
1. Establish baseline data through self monitoring and reporting (Turk & Winter, 2007)
a. Identify the degree of compliant based on adherence or non-adherence to prescribed medication schedules
and appropriate dosage using a worksheet or a cell phone application.
b. Rate your current pain level using a worksheet or a cell phone application.
c. Assess your mood state based on a worksheet or a cell phone application.
d. Identify daily physical activities that you want to improve or a new program of activity that the person in pain
wants to increase or decrease in terms of distance, time, and/or repetitions. Track weekly progress.
e. Identify and lists primary stressors or life events (work on reducing the most important first).
f. Identify and lists positive events or activities that the person in pain wants to continue or return to (include at least one social activity).
g. Identify and list automatic or irrational thoughts and beliefs that are related to your chronic pain condition.
h. Rate the person’s proficiency level in self-management skills that reduce chronic pain states. Use a single rating from 1 to 10 scale (10 is the least use of management skills and 1 is the worst ability to manage self (consider how well you stick to medication schedules, dosages, adherence to a routine exercise program (3 to 4 times per week), emotional self-regulation, level of agitation/aggressiveness, anxiety, feeling down or hopeless). This is a broad indicator, but there is at least one thing you can improve each week if you try. That is progress in self-management (actively working to make quality of life better).
i. Take a Beck’s depression scale.
j. Rate how well the person in pain sleeps on a scale of 1 to 5: (1) Is the best rating (no sleep problems); (2) The person in pain rarely experiences some difficulty sleeping; (3) The person in pain experiences some difficulty sleeping (seldom feels tired in the next day), (4) The person in pain experiences loss of sleep on most nights with tiredness in the day, (5) Significant loss of sleep that interferes with daily function.
2. Increase competencies and confidence in pain self-management skills (Nickel, et al. 2008).
a. Visits the pain web site to read information on chronic pain and shares experience with others.
b. Sets aside time to meditate daily to reduce stress caused by muscle tension.
(1) Get your family or a friend involved and have them meditate with you.
(2) Take a class on meditation to develop self “awareness and acceptance of the body where it is” (Johnson & Kazantzis, 2004).
c. Schedules pleasurable activities to distract from pain.
d. Seeks social interaction and activities to reduce negative feelings of stress or feelings of isolation. The person in pain adopts relaxing lifestyle changes to reduce stress.
e. Adheres to a nutrition program to promote better health (takes a good multi-vitamin).
f. Develops good sleep practices: implements a routine sleep schedule, controls environment (reduces noise, uses white noise, dark room), turns off cell phone alerts in sleeping areas, does not watch TV in sleeping areas, exercises early rather than before bed time, reduces and modifies activity levels if the resulting pain is causing loss of sleep, works to reduce emotional conflict or problems) (Turk and Winter 2005).
3. Increase adherence to medication schedules and dosages.
a. Uses a daily tracking mechanism to promote adherence to schedules.
b. Sets daily alarms on cell phone. Enslists a family member or friend to “double check” adherence to prescribed drug schedules.
c. Records dosage/quantity taken and enlists family members to monitor pill counts (this can be to offset addictions or to help those who forget). A prudent person or family member knows when they need help or when they need to help others. Asking for help is a positive step in treatment and recovery. Volunteering to help a person in pain means you care deeply about others.
4. Decrease “established patterns of ...automatic thinking”(Nickel, et al., 2008), irrational thoughts and negativity.
a. Keeps a daily log of the following: irrational thoughts, all or nothing thinking, depressive thoughts, and negative feedback to self and/or to others.
b. Identifies and plans to correct irrational thought patterns through cognitive reframing techniques. Engages in positive self-talk.
5. Increase ability to engage in “social, recreational and occupational endeavors that have been limited or terminated by pain” (Johnson & Kazantzis, 2004).
a. Implements a schedule of physical activity.
b. Paces physical activities to enable resumption of activities. Adjusts to body messages and works within abilities. Indeed, it is not uncommon for pain suffers to fear moving and a return to normal activities (because it hurts), but CBT methods encourage the person in chronic pain to schedule activities using a graduated exposure approach to activities called pacing (Johnson & Kazantzis, 2004).
c. Seeks social support in activities. Specifically, encouragement from others is important and social activities such as: spiritual pursuits, athletic events, clubs, and organizations can provide motivation and an outlet for stress.
d. Develops a personal mission statement for life. Defines a new mission for self that can be spiritual, physical, community based volunteer work or an entrepreneurial idea that will provide a service or product to others. Focus on life events (doing) rather than pain.
6. Reduce the number of incidents of negative self-control due to pain stimulus and social interaction (reduces reactionary signs of disability to improve quality of life).
a. Implements self-monitoring of thoughts (cognitions) and behavioral acts as a part of CBT treatment (See Worksheet recommendations in the back of the guide (X)).
b. Target awareness and monitoring of mood state, exercise and medication intake using cell phone applications or worksheets listed in the rear of this manual.
VII. What is CBT for chronic pain (Definition)? According to the Encyclopedia of Cognitive Behavioral Therapy, CBT “is an active, directive, collaborative, structured, dynamic, problem oriented, solution-focused, and psychoeducational model of treatment” (Freeman et al., 2005) that is focused on chronic pain reduction and associated pain problems. This singular course of action is contrary to drug treatment models that are passive in nature. They only require the patient to adhere to drug schedules/dosages and do not address the implications of chronic pain that negatively impact how we live, play and work. CBT is a holistic program that generally consists of the following: “assessment” (establishing the baseline), “education” (understanding pain), “skill acquisition” (learning to deal with pain and its implications), “generalization” (How to apply new CBT skills to everyday life), “and maintenance” (sustaining after the initial treatment plan) according to a number of experts (Johnson & Kazantzis, 2004; Freeman et al., 2005).
VIII. Summary of CBT Techniques (Freeman et al., 2005; Turk & Winter 2005; ).
1. Cognitive coping and restructuring:
a. Thinking differently can be done in a number of ways. Restructuring how a person feels involves “cognitive reappraisal” of thoughts and distorted thinking patterns enables the pain sufferer to redesign negative internal dialogues. In fact, the same methods are proven to work for stress also. CBT for stress includes “Cognitive Restructuring” to manage symptoms of chronic pain (Freeman, et al., 2004).
b. Clients can become their own pain managers and can accomplish this through developing alternative ways of dealing with situations as follows: Use problem solving method to generate better responses to painful situations; stop thinking negative thoughts (use “thought stopping” to recognize and cease unproductive thought routines); use re-appraisal of one’s own abilities (list your mental strengths based on past experiences); take classes or read up on interpersonal communications and information processing skills to build social support (think and know that you are not alone in your pain), understand stress and coping strategies to promote new learning (take psychoeducational classes on coping strategies) , practice self-dialogue to cope and restructure automatic thoughts and ingrained patterns. In total this will help reduce daily stress and promote positive neural patterns of growth.
c. Reject back and white thinking. For example, a person with chronic pain may think “if I don’t drink then my pain will not go away.” Conversely, this person should recall the numerous times when pain went away without the use of alcohol. Suffering from chronic pain is not an “all or nothing event”, hence pausing to consider the opposite of what you are experiencing is beneficial. Indeed, clients in pain do experience the same problems time and time again, but it is how we process the perception of pain that makes a difference in a positive or negative outlook on life. Statements like “I will never feel better” are simply not true.
d. Chronic pain can cloud a person’s rational thought processes and can cause more stress so objectively evaluate how you feel. Here are seven examples of what not to do (Freeman, et al., 2004):
(1) Don’t ignore the positive thoughts (success can be repeated).
(2) “Don’t think with the heart!” Pain can take control of a person’s emotions, but we control how we feel. Think before acting reflexively. Use a decision making process.
(3) Do not use negative self appraisal. For example, one should not say that “I am so stupid” when it understood that pain clouds thinking. Simply accept that people with pain will forget things from time to time because they lose sleep and can lack concentration. Don’t label yourself because of a chronic condition.
(4) Don’t catastrophize! Ruminating on the worst possible scenario does not help matters. This is negative thinking. Consider the best possible outcome. Be aware of bad things, but do not get stuck on one negative course of action or outcome (Nickel, et al., 2008)
(5) Don’t compare yourself to others. Clients must focus on what they can do. Every person has different strengths (others cannot walk in your shoes). Some people would call this the emotion of envy. Your self- worth is not determined by others, but by many external factors.
(6) Don’t demand perfection in yourself, because this causes more personal stress. “No one is perfect.” Stop using the words “I should have or ought to” since you must pace yourself mentally and physically based on your condition. Do the best you can within you capabilities.
(7) Don’t minimize at the expense of your health and well being! If chronic pain becomes seemingly unbearable it is ok to let others know that you are not at your best. Take actions to reduce the pain. It is ok to pause and drink water, take a break, take medications, or to relax as part of self-management strategies.
2. Relaxation Training (Turk & Winter 2005).
a. Learning to relax is an important strategy to reduce daily stress that is aggravated by chronic pain. Tension can directly impact how well a person sleeps, interacts with other, and influences how well they think. Turk and Winter (2005), oxford scholars indicate that inability to relax becomes a “viscous cycle” that leads to impairment. When you learn to relax sleep is more possible and tension subsides.
b. Review your schedule and determine if the sack is too full. Create a manageable schedule.
c. When you are “stressed out’ by everyday problems you are in a state of excitatory function. Indications include muscle tension, weight gain, and increased blood pressure that only makes chronic pain worse. This stress uses energy and produces harmful chemicals that are harmful to neural growth.
d. Relaxation practices release this stress to conserve energy. Implement a simple practice of releasing stress through relaxation. In its rudimentary form, a person in pain can can simply breathe in while simultaneously squeezing a fist and holing the breath for five seconds and then crunch the arm into a bicep curl locked against the upper shoulder. Hold it tight until you begin to quiver and then exhale and relax (Turk and Winter, 2005). Compare the one side to the other side of the body. You are now more relaxed. This relaxation process can be repeated from the top of the body to the bottom. For example, close your eyes tightly, inhale and tense all the muscles in your face for five seconds then relax. Do this process of systematic relaxation down the body structure.
e. Clients should take a class on relaxation (Mindfulness Training) “the practice of cultivating a state of metacognitive awareness of present moment thoughts, emotions, sensations and perceptions” to reduce chronic pain (Garland, 2014). Meditation practices can help clients to be more aware of self in the present moment.
3. Guided imagery: There is a wide variety to techniques that leverage a guided imagery approach. This is a way of reducing negative automatic images, faulty beliefs, and expectations. Many people with chronic pain do experience fear, concern and may avoid activities. Consequently, a combination of psychoeducation and visualization processes can provide new motivation for patients who may experience avoidance behaviors. The general idea is to replace a clients negative images with positive expectations that are inspired by imagery or visualization. For example, an adult with an injury may not return to an activity such as tennis even though they are able to do so (a doctor approves the activity). Inactivity due to persistent pain is often a problem in recovery or maintenance of chronic injuries. Guided imagery and psychoeducation can inspire clients to resume previous activities (pictures of people enjoying certain activities or recalling the pleasure of walking or biking can be beneficial (Turk & Winter 2005)).
4. Distraction: This technique diverts attention away from the chronic pain state by using pleasurable or exciting activities. Kalat (2014) indicates that when we experience pleasurable activities the body releases natural chemicals called dopamine that can reduce pain. Therefore, pleasurable activities or excitement cause releases that make clients feel better. Common activities include listening to music, calling a friend (social support), relaxation exercises or physical activity (Turk & Winter 2005).
5. Psychoeducational classes: This is a way for clients to learn more about chronic pain and is a normal part of educating clients on ways to get better. This may include discussion of the cycle of treatment using CBT, formulation of goals, expectations and outcomes, therapeutic tasks, problem solving, practical application of techniques and maintenance strategies (Nickel, et al., 2008).
6. Homework: This is an essential part of CBT interventions wherefore self-assessment, monitoring, and learning new techniques are emphasized. So why should patients do homework? In a 2004 study, Johnson and Kazantzis found that “68% of all patients would improve when therapy involved homework, compared to only 32% when therapy did not involve homework. Patients who are actively address chronic pain at home are increasing their therapeutic success rate by 50%. Patients with chronic pain should remember that as new learning occurs new neural networks are formed and pain related neuroplastic connection are strengthened by exercises and application. Clients can master beneficial techniques to distract, relax, and think differently to reduce pain. It takes work to activate new growth and CBT homework weakens negative neural connections (closes the gate) and strengthens (opens the gate) for neurogenisis or new growth through new learning (Johnson & Kazantzis (2004); Kalat (2013); Garland & Owen, (2009); Turk & Winter (2005).
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