James L. McAbee, Ph.D.
Individuals living with chronic pain often present with myriad complaints and a decrease in quality of life driven, in many cases, by a lack of adaptive coping skills. Frequently, patients apply conventional wisdom, opting to reduce their activity levels and “resting” as a response to their pain and, in doing so, further reduce their functional capacity and involvement in daily life. These changes in behavior increase the likelihood of time spent ruminating over and brooding about their pain- “will this ever get better?”, “this might get worse”, “nothing seems to help me or my pain”, “I can’t do anything anymore”. Such thought patterns are known in the psychological literature as “Pain Catastrophizing” (Gatchel, 2017; Leung, 2012; Quartana, 2009), and are driven by fears associated with pain and a sense of helplessness/hopelessness when faced with demands to manage pain. This form of thinking leads to increased negative emotions such as anxiety and depression, which can also be influenced by decreased socialization and increased isolation. Patients can then experience physical deconditioning from inactivity and once they engage in some form of activity again they often misinterpret an increase in pain, any experience of new pain, or activity-related soreness as confirmation that that activity is “dangerous”, thus reinforcing the cycle of negative thinking and behaviors. Over time, if left untreated, this cycle leads to less time spent tending to the important territories of life, the boundaries of life shrink inward, and pain overshadows the land.
Cognitive Behavioral Therapy (CBT) is the most efficacious therapeutic intervention utilized by clinical psychologists and has been researched and validated across a multitude of diagnostic categories. CBT is a collaborative, problem-focused intervention that is intended to be delivered in a time-limited format, and which challenges the problematic thoughts/beliefs and behaviors which contribute to and/or maintain the patient’s presenting concern and negative emotions. A therapy session in this approach is more active than traditional psychotherapies and challenges the patient to make changes in both behavioral and cognitive patterns. In CBT the focus is on ‘doing’ things, not just ‘talking’ about things. CBT for Chronic Pain (CBT-CP) can help patients to break free from the chronic pain cycle, and evidence suggests that this modality of psychological intervention improves patients’ functioning and quality of life (Hoffman, Papas, Chatkoff, &Kerns, 2007; Morley, Williams, & Eccleston, 1999; Turner, Mancl, & Aaron, 2006).
As one can see in the cycle of chronic pain described above there are various entry points for intervention from a psychological perspective. In my clinical practice, the initial meeting with a patient is focused on normalizing the patient’s experience, reassuring them that they are not “crazy” nor are they meeting with a psychologist because their pain is “all in their head”, common concerns of patients referred to a pain psychologist. The information gathered via the clinical interview and the patient’s responses to screening instruments and questionnaires, their self-report of current difficulties and observations of their behavior permit more comprehensive feedback regarding the conceptualization of their situation and the opportunity to educate them about the rationale for how CBT-CP can be helpful. I find that when I reflect back to the patient my understanding of their condition (in their own words) paired with printed materials depicting the relationships of how chronic pain impacts their thoughts, feelings, and behaviors, and the cycle of chronic pain, patients are able to relate to the information, understand these connections and “see” problem areas in their lives, thus demystifying the process of treatment.
The overarching goals of CBT-CP are to promote adaptive coping by increasing self-efficacy in the management of pain, reduce avoidant behaviors, reduce “catastrophizing”, reduce negative or unhelpful beliefs about their pain, reduce negative mood symptoms, increase physical activity, to shift the perspective from pain to improved functioning, and to increase general quality of life despite having chronic pain. The intervention itself works toward achieving these goals through liberal use of psychoeducation about factors that perpetuate chronic pain and those which reduce the experience of chronic pain through the acquisition and development of adaptive coping skills. In essence, the goal of CBT-CP is to help patients reclaim the lost territories in their lives, and to have a life worth living despite chronic pain.
CBT-CP sessions are highly structured with the provider setting an agenda of important topics and specific skills to be introduced and developed during a session; however, assisting patients in the development of their own behavioral goals is equally, if not more, important. After all, the goal of CBT is to promote self-efficacy. Printed materials are always given in my practice to allow visual integration of the topics covered in session. Doing so allows patients to leave with information in hand which they can review between sessions. I find that this approach allows patients to remain connected to the material in their everyday environment and to return to the next session with any questions to be clarified. CBT-CP sessions are initially focused on increasing general activities to promote behavioral activation and increase functioning. The use of psychoeducation about how to properly pace activities without overexerting oneself (and possibly a few gentle reminders of the perils of inactivity) allow for development of specific, measurable, achievable, relevant, and time-limited goals (SMART Goals). Integration of scheduling pleasurable activities is also conducted in these early phases of treatment. In addition to increasing general activity, these “new” behaviors begin to inconspicuously challenge patients’ assumptions of “I can’t do anything”, and also begin to improve negative mood symptoms. As one patient eloquently stated, “I’m learning that I can do nothing and hurt, or I can hurt and do some things I enjoy”.
Of course, CBT would simply not be CBT without the “C”. Assisting patients to identify problematic, maladaptive, and unhelpful cognitive patterns is a critical component of the intervention. Providing patients with psychoeducation about the powerful influence thinking has on their behaviors and emotions helps to ground them in their own internal experiences and in their everyday lives. Normalizing problematic thinking can be a validating experience for patients. I always tell patients when reviewing a list of the 12 most common cognitive errors, “If you identify with these, congratulations, you have a normal brain!”. As we review the list together many patients will say, “oh yeah, I do that” and will frequently provide a recent example from their lives. However, simply identifying problematic thoughts is not enough for change to occur, it is essential to “do” something about it. The use of thought logs allows patients to identify their thoughts and beliefs about their pain in relation to a triggering event and their emotional, physical, and behavioral reactions. Once we have a “map” of this process, together the patient and provider can begin to collaboratively examine how thoughts and behaviors influence emotions and outcomes of the situation in question, and to decide what to “do” about it. Cognitive restructuring is the process of developing more balanced, adaptive, and helpful thought patterns which lead to more adaptive behaviors, reduction in negative emotions, and greater desired outcomes. Patients are then encouraged to experiment with these new patterns of thinking and behaviors to determine whether this change was effective. CBT-CP trains patients to become behavioral scientists in their own right- continuously positing hypotheses and testing new behaviors to (dis)confirm the null hypothesis.
Like any other field of healthcare, pain psychology is also concerned with significant and reliable change. In order to determine whether or not the intervention is effective, we must have a system of objective measurement. Therefore, empirical assessments of symptoms are given on an ongoing basis to track patients’ progress and to better inform treatment. Not only is CBT-CP an evidence-based practice, we generate our own practice-based evidence! These data can be utilized for various purposes in the context of treatment. For example, data can be used to challenge patients’ maladaptive beliefs that they are “not getting any better” when subjective reports of difficulties remain high despite the evidence of lower scores compared to the baseline. Equally important, it is quite validating for patients to witness positive change in their objective measures and enhances motivation for sustained behavioral change, particularly in cases where their pain scores remain unchanged, but their function and quality of life is improved.
CBT-CP is an effective intervention to complement a comprehensive approach to pain management. If you are a non-psychologist pain provider, you might find yourself asking, “how do I know that my patients are receiving ‘good’ CBT”. Aside from witnessing a change in your patients’ behaviors (i.e. increased behavioral activities, decreased “catastrophizing” talk, increased self-efficacy, improved mood), ‘good’ CBT is informed by ongoing assessment. It is important for clinicians to ask about patients’ experiences with their pain psychologist to determine the topics discussed and skills developed and ask them directly if they are routinely completing brief assessment measures and receiving feedback in treatment. I personally welcome collaboration with pain providers and encourage patients to sign release of information forms so that I can communicate with other members of the pain management team. This open communication allows for other providers to see what the patient and I are doing, and to provide them with practice-based evidence of patients’ progress. Moreover, it is helpful to hear other potential concerns that have developed over the course of treatment outside the initial referral or the patients’ reports which ought to be addressed in treatment. Speak with the psychologists to whom you refer routinely about how patients are progressing, although we “CBTer’s” are “doers”, we also enjoy talking with other providers.
Gatchel, R. J., & Neblett, R. (2017). Pain Catastrophizing: What clinicians need to know. Practical Pain Management, 15(6). Retrieved from: https://www.practicalpainmanagement.com/pain/other/co-morbidities/pain-catastrophizing-what-clinicians-need-know
Hoffman, B.M., Papas, R.K., Chatkoff, D.K., & Kerns, R.D. (2007). Meta-analysis of psychological interventions for chronic low-back pain. Health Psychology, 26(1), 1-9. doi: 10.1037/0278-6126.96.36.199
Leung, L. (2012). Pain Catastrophizing: An updated review. Indian Journal of Psychological Medicine, 34(3), 204–217. http://doi.org/10.4103/0253-7176.106012
Morley, S., Eccleston, C., & Williams, A. (1999). Systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain, 80(1-2), 1-13. http://dx.doi.org/10.1016/S0304-3959(98)00255-3
Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical review. Expert Review of Neurotherapeutics, 9(5), 745–758. http://doi.org/10.1586/ERN.09.34
Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The Pain Catastrophizing Scale: Development and validation. Psychol. Assess., 7: 524–532.
Turner, J.A., Mancl, L., & Aaron, L.A. (2006). Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: A randomized, controlled trial. Pain, 121(3). 181-194.