by James L. McAbee, Ph.D.
Individuals living with chronic pain often present with a myriad of 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. In doing so, they further reduce their functional capacity and involvement in daily life. The resulting changes in behavior increase the likelihood of time spent ruminating over and brooding about their pain with thoughts like “Will this ever get better?” or “I can’t do anything anymore.” This pattern is known in the psychological literature as pain catastrophizing (Gatchel, 2017; Leung, 2012; Quartana, 2009) and is driven by fears associated with pain as well as a sense of helplessness or hopelessness when faced with the demands of managing pain.
Pain catastrophizing can lead to increased negative emotions such as anxiety and depression, which may also be influenced by decreased socialization and increased isolation. Patients may 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. If left untreated, this cycle leads to less time spent tending to the important territories of life. The patient’s boundaries of life shrink inward, and pain overshadows the land.
Cognitive behavioral therapy (CBT) is the most efficacious therapeutic intervention used by clinical psychologists and has been researched and validated across many 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 that contribute to and/or maintain the patient’s presenting concern and negative emotions. A therapy session using this approach is more active than traditional psychotherapies, and it challenges the patient to make changes in both behavioral and cognitive patterns. In CBT we are focused 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 patient 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 that 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. This also allows patients to leave with information in hand to review between sessions. I find this approach keeps patients connected to the material in their everyday environment, and they are able to return to the next session with any questions that need 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 pleasurable activity scheduling 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 of my patients 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 in identifying 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 my 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. We have 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 a map of this process is established, together the patient and provider can begin to collaboratively examine how thoughts and behaviors influence the 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 that lead to more adaptive behaviors, reduction in negative emotions, and greater desired outcomes. Patients are encouraged to experiment with these new patterns of thinking and behaviors to determine whether or not 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 health care, 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. More importantly, 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 management 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. Ask your patients about their 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 their 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 that should be addressed in treatment. Speak with the psychologists to whom you refer routinely about your patients, and although we “CBTers” are “doers,” we also enjoy talking and collaborating with other providers in the patient’s care.
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: 10.1037/0278-618.104.22.168
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.