“When the pain doctor said he wanted me to see a psychologist, I said, ‘Do you think it’s all in my head?’” the patient asked. Her physician responded, “Absolutely not! But I do know that I want you to understand all aspects of your pain; its psychological and behavioral manifestations can be as important as the physical.”
For the last decade, the Health and Medicine Division (formerly the Institute of Medicine, or IOM) of the National Academies of Sciences, Engineering, and Medicine in Washington has been investigating the widespread use of opioids as the primary treatment strategy for pain. In 2011, it estimated that 100 million American adults suffer from chronic pain, now defined as a condition influenced by psychological and social factors as well as physical markers, optimally managed by treatments that address both biological causes and psychosocial consequences.
The group noted that over the past 60 years, parallel advances in the scientific understanding of pain and the development of mastery-based therapies have led to the effective application of psychological interventions to chronic-pain problems, specifically, cognitive-behavior therapy. The doctor who referred the patient quoted above to a psychologist was following IOM recommendations by including psychological treatment for the pain she suffered. While he considered medication for the pain of her fibromyalgia, he took an integrative approach to treatment.
“A comprehensive pain-management plan will include assessment and treatment from a cognitive-behavioral perspective, and it will look at pain from three viewpoints — chronicity, prior trauma, and developmental aspects of suffering,” says Georgia Panopoulos, a Minneapolis psychologist who has been working with pain patients for more than 20 years.
What is cognitive-behavior therapy and how does it work?
Cognitive-behavior therapy (CBT) identifies distorted and unhelpful beliefs by using techniques to evaluate and change maladaptive thinking or by using a variety of treatment strategies for learning to refocus attention away from obsessive and ruminative thinking. In the therapy process, attention is paid to avoiding dysfunctional thoughts and belief systems. CBT therapists take an educational role and work collaboratively to help clients understand their distorted beliefs and learn methods for changing them.
They give assignments and homework, testing new alternatives to old ways of solving problems. The therapist gathers data throughout the process to identify therapeutic strategies by assessing problems using brief questionnaires (developed for various psychological problems), specifically targeting pain by keeping a journal of feelings, thoughts, and behaviors.
As an overall treatment approach, cognitive-behavior therapy is goal-directed. The first objective is to help individuals change their view of pain from an overwhelming problem to a manageable one. Patients who are prone to catastrophic thinking benefit from examining the way their situation is viewed and approached. What has been perceived as a hopeless condition can be reframed as a difficult yet manageable situation over which they have some control.
In Panopoulos’ clinic, all patients attend at least four CBT sessions. The initial meeting helps the patient understand the intersection of psychic and physical pain. “We teach people in pain how to relax, the impact of stress on the body, sleep hygiene techniques, and energy conservation,” she says. “This meeting includes a visit with a physical therapist who will talk through the physiological aspects of pain and how it might be managed. By educating a pain patient, he or she becomes much more in charge of responding to the ways that pain impacts his or her life.”
The second objective teaches a person that he or she is actively and ably involved in both treatment and rehabilitation. Reorienting from a passive victim stance to that of a proactive, competent problem-solver helps decrease pain. When an individual becomes successful in managing painful episodes, his or her views change in positive ways.
The third objective instructs the individual to monitor worried thoughts and substitute positive and proactive thoughts in their place. People who live with chronic pain develop sets of conscious and unconscious negative thoughts that perpetuate behaviors and feelings associated with pain. Learning how to meet these thoughts head-on, then substituting positive thoughts and adaptive coping techniques, known as cognitive restructuring, is a primary focus of CBT treatment.
The individual is encouraged to attribute success to his or her own efforts and to be responsible for the gains made by being more in charge of pain.
“CBT helps through identification — of how an individual talks to himself, what his automatic thoughts are, and what core beliefs are attached to the ways that he thinks,” Panopoulos says. “If we can help with these cognitive aspects of pain, the person feels like he is in the driver’s seat, rather than being controlled by the pain.”
Influencing Pain Using CBT
Five key principles underlie the way in which pain patients respond to treatment.
- Perceptions influence behavior. Individuals differ in how they perceive the world. Understandably, chronic pain patients may tend to view the world in a negative light, and those negative perceptions may influence what they do.
Kelly is a 42-year-old woman who is being treated for rheumatoid arthritis. In the early stages of diagnosis, she said, “I sought to find the ‘sweet spot’ and would work to sit still. I thought that if I didn’t move, I would maintain whatever joint strength I had left. Don’t ask me where this idea came from. I know now that it is wrong, but I just believed that my condition would gradually deteriorate the more I moved, so I resisted any suggestion that I needed to stay active in an exercise program.
“To me, the vision of exercise is one of a cardio training program, three days a week at the YMCA. It took consultation with physical and occupational therapy, plus several sessions with a psychologist, to help me incorporate a more effective plan for exercise. I was evaluated for energy conservation, asked to think out loud about the long-range goals for activities of daily living that were most important to me, and consider how I could be in charge of my care plan.” For Kelly, inaccurate information about physical activity, coupled with fear, promoted a distorted perception, which she was able to change into more productive ways to care for herself.
- Behavior creates the environment. Individuals who are miserable and unwilling to do things often become isolated from others. This isolation, in turn, exacerbates feelings of depression and loneliness and can reinforce the belief that no one understands or cares.
“I was hurting most of the time and grumpy as an old bear,” says John, 62, who lives with chronic low-back pain caused by spinal stenosis. “I was angry, irritable, and unpleasant company. Over time, I chased everyone away and was mad that they couldn’t tolerate my moodiness. All I knew to say was, ‘If they understood how I feel, they would be in a bad mood, too.’ Eventually, the pain doctor insisted that I see a psychotherapist. My wife went with me, and I was diagnosed with depression. I was medicated on an anti-depressant that helped some with the pain while we began to talk about how I had isolated myself from everyone. I realized that sitting and stewing over the things wrong with me robbed me of any opportunity to do the things that I could do in spite of the pain. I learned jewelry making and joined a group at the local arts center. While it didn’t get rid of the pain, I could distract myself enough to be with other people who were all busy and enjoying each other in ways that I could participate.”
- Individuals actively assimilate information. In this ongoing process, pain and environmental factors continue to influence perceptions and behavior. As the examples show, both John and Kelly used the new data and adaptive strategies, which helped them feel better about themselves.
- People can learn more adaptive ways to think, feel, and behave. Although we tend to believe that those in chronic pain are products of their physical problems and environmental circumstances that are beyond control, it is possible to influence our thoughts about pain and change ways of coping with it.
Angela, 79, fell as she was rehabbing from a knee replacement. A second surgery was required to repair the damage from the injury. Her subsequent course of rehabilitation was, as she said, “dreadful…just awful pain. I cannot tell you how many times I wanted to give up.”
When physical and occupational therapies were prescribed, Angela said, “I didn’t think I could do anything and certainly didn’t want to talk with either therapist. The rehab center had a psychologist on the staff. She came to see me, and I thought, ‘Oh, my! Now they think I’m crazy.’ But the psychologist listened and wanted to know more about what I could do rather than what I couldn’t manage. I laugh now that I’m at home.
“I’m still not very mobile, but I have a well-defined exercise program. My plan is to walk out the front door to the mailbox and back twice each day. My grandson has given me a Fitbit to wear. I add 20 steps — 10 going and 10 coming — to my exercise every other day. This is all done in addition to my regular physical therapy. My grandson calls me his ‘jock grandmother’ because I take the plan quite seriously. It isn’t easy, but I do feel a sense of accomplishment when I take my exercise, and that is a good thing.”
- Patients are capable of active involvement in their own treatment. A strictly biomedical approach to pain control invites a passive response to treatment. However, successful rehabilitation of a patient with a chronic condition seems to derive from the patient’s willingness to actively participate in getting better.
“The current approach to chronic pain management is that long-term medication management with opioids is not an answer,” says R. Cory Waller, M.D., director of the Center for Integrative Medicine and medical staff chief for the Division of Pain Management of Spectrum Health in Grand Rapids, Michigan. “Once a physician provides good diagnostics that promote the guidance of integrated treatment options, interventional pain strategies are active and collaborative with the patient,” adds Waller, who also serves as the chair of the Legislative Advocacy Committee of the American Society of Addiction Medicine. “Medicines are seen as assistive rather than primary to the longer term goal of quality of life and managing the impact of the pain in activities of daily living.” He states that good pain management is “a pragmatic approach. The patient who successfully deals with pain is active, engaged, and willing to stay in psychological and physical motion.”
Does it really work?
CBT is the gold standard of psychological treatment for individuals with a wide variety of pain problems. The effectiveness of CBT for reducing pain, distress, pain interference with activities, and disability has been well established in current research. Integration of CBT into medical settings in which individuals with chronic pain are treated is “cutting edge treatment.” CBT will continue to be studied in regard to pain treatment, and it will begin to include self-management skills, web-based programs, and tablet applications for interventions.
In the therapeutic approach, cognitive behavior therapists collaborate with their clients to assess and change behaviors. When working with pain patients, the therapist takes an instructional role, using techniques such as guided discovery and dialogue to identify dysfunctional beliefs and help clients develop insights into the beliefs that make pain worse.
“There isn’t a simple fix,” Panopoulos says. “CBT offers three overarching goals of treatment: adjustment, acceptance, and self-management. I teach people that managing pain is like managing any other chronic illness, such as diabetes or a cardiac condition. I want people to have the ability to live their lives in the ways that they want, being as fully in charge as they are able.”
Jackson Rainer is a board-certified clinical psychologist who practices with the Care and Counseling Center in Atlanta, helping people living with chronic illnesses. He writes our “Pain Q&A” column.