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Cognitive-Behavioral Therapy for Chronic Pain:

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Beverly E. Thorn, Ph.D., ABPP Professor Emerita, Psychology The University of Alabama bthorn@ua.edu Behavioral Pain Management Team: http:\\PMT.ua.edu National Register of Health Service Psychologists November 8, 2019

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Disclosure

• The presenter has no conflicts to disclose.

Objectives:

1. Historical/present day assessment/treatment of chronic pain 2. CBT Framework 3. Common Therapeutic Factors 4. Treatment Rationale – Gate Control Model 5. Treatment Conceptualization – Stress-Appraisal-Coping Model 6. Stress Appraisal & Relaxation Techniques 7. Cognitive Appraisal & Restructuring Techniques 8. Activity Pacing & Behavioral Activation Techniques 9. Emotional Awareness & Disclosure Techniques

• 10. Assertive Communication Techniques
• 11. Evidence Base & Mechanisms
• 12. Challenges

Definition of Pain

• An unpleasant sensory & emotional

experience associated with actual or potential tissue damage, or described in terms of such damage (International Association for the Study of Pain)

– Avoids tying pain to a stimulus – Pain is always a psychological state

Chronic Pain

• Pain lasts more than 3-6 months
• Or pain lasts longer than normal time of

healing

• Pain interferes with normal daily function

Chronic Pain is a Public Health Problem

▪ > 37% Americans experience chronic pain ▪ Costs > 600 billion/yr

Historical & Current Treatment

• f Chronic Pain

Biomedical –> Biopsychosocial

Which one has low back pain?

Used with permission: Burel Goodin, Ph.D.

Which one is most likely to get opioids/surgery?

Used with permission: Burel Goodin, Ph.D.

Which one is more likely to be told (or treated as) the pain is “all in your head”?

Used with permission: Burel Goodin, Ph.D.

Biomedical Model of Pain (Pain Specificity Theory)

Specificity Theory: Tissue damage = pain; Nociception = pain

Tissue Damage & Pain

• Tissue damage and pain perception are

related

But….tissue damage is less predictive than expected (especially chronic pain)

• Many people without any back pain show

significant disc abnormalities

• True for back, hip, and knee

Blankenbaker et al., 2008; Borenstein et al., 2001; Brinjiki W et al, 2015; Carragee, Alamin, Miller, & Carragee, 2005; Jarvik et al., 2005; Jensen et al., 1994; Link et al., 2003.

What does Predict Pain & Disability?

What does Predict Pain & Disability?

• Many studies, similar findings
• Representative study:

– Workers with low back injuries – Depression, fear avoidance, and fear of movement (i.e., cognitive and affective variables) predicted 85% of the variance in recovery 6 months later – Actual physical pathology was a very poor predictor (George & Beneciuk, 2015).

Gate Control (Melzack & Wall, 1965) & Neuromatrix Model of Pain (Melzack, 1990)

Biopsychosocial Model of Illness

Engel, 1977

• Social support
• Poverty
• Work and Employment
• Cultural Preferences
• Nociception
• Tissue Damage
• Effects of medications
• Mood Disturbance
• Attitudes and Beliefs
• Lack of Self-efficacy

But….. Where Are We Really?

Spine 2011

SHARP INCREASE IN OPIOID PRESCRIPTIONS AND DEATHS

Other (Huge) Concerns

• Tolerance, abuse, physical dependence
• Diversion
• Overdose

Opioids and Pain

• In 20 years, opioids for chronic pain increased from 200% for

morphine to almost 900% for hydrocodone

Manchikanti, Helm, Janata, Vidyasagar, & Grider, 2012

• Meta-analysis:

– opioids are better than placebo for pain relief and ability to function – compared to other analgesic drugs, opioids show only a small edge

• ver non-opioids in pain relief

– no greater advantage to function

Furlan, Sandoval, Mailis-Gagnon, & Tunks, 2006

• Opioids provide pain relief comparable to Cognitive

Behavioral Therapy (CBT) but poorer improvements in function.

Okifuji and Turk (2015)

Recent Shifts

• Recognition of opioid epidemic
• Discourage medication as first-line treatment
• Encourage pain self-management training

– Include patient education about chronic pain – Include cognitive-behavioral therapy (including CT, BT, MBSR, ACT)

(Institute of Medicine, 2011; Nat’l Pain Strategy, 2016; Am College Physicians, 2017; Center for Disease Control, 2018; Healthy People 2020)

(re)Enter Pain Self-Management

• Positive adjustment to chronic pain is “more

dependent on effective self-care than on the quality of the diagnostic or therapeutic interventions of the physicians.” Michael VonKorff (1999)

Goals of Pain Treatment

• Identify and treat/manage underlying disease/pathology
• Reduce the incidence and severity of pain
• Optimize individual’s functioning/productivity
• Reduce suffering and emotional distress
• Improve overall quality of life
• Consolidate care (& minimize interactions with

healthcare system)

Used with permission: Robert Kerns, Ph.D.

Why CBT for Pain Self-Management?

• Uses biopsychosocial model
• Gives relevant information, including how brain

processes pain

• Provides Skills training in pain self-management

(e.g., stress management, cognitive appraisal/restructuring, behavioral pacing, behavioral activation, assertive communication)

• Collaborative treatment/Therapeutic support

Components of Cognitive Behavioral Therapy for Chronic Pain

Free download: http://pmt.ua.edu/publications https://www.guilford.com/books/ Cognitive-Therapy-for-Chronic- Pain/Beverly-Thorn/ 9781462531691

General Session Structure

• 90-min (group), 50-min (individual)
• Collaborative & interactive
• Relevant information about pain (“pain facts”)
• Skills training
• Weekly Prescription (homework)

Common Therapeutic Factors

• Believing (in) the patient:

“Your pain is real”

• Validation, de-stigmatization

Rapport (Therapeutic Relationship) Conceptual framework or rationale for symptoms and treatment procedure (provides buy-in) Expectation of help (shaped through therapeutic relationship and tx rationale)

• Empowerment (Self-efficacy &

Hope) Active participation of client and therapist

• The unifying bond of chronic

pain If group tx, group cohesiveness

Treatment Rationale: The Brain Process & Modifies Pain Signals

• Provides a different perspective on pain

(reconceptualizing pain)

• Provides a biological (aka “real”) explanation
• Explains role of cognitions and emotions

New Way

Biopsychosocial Model

• Role of brain and spinal

cord

• Importance of emotions,

thoughts, behaviors, etc.

• CNS changes
• Gate Control/Neuromatrix

Model of Pain

Biomedical Model

Explaining Pain to Patients:

Old Way

• Tissue damage =

pain

• The more tissue

damage, the more pain

• Remove/repair the

damaged tissue, remove the pain

Treatment Rationale: Gate Control/Neuromatrix Model of Pain

Gate Control/Neuromatrix Theory Simplified….

Gate-Control Theory Simplified

Image from Thorn et al., 2017: Learning About Managing Pain: Patient Workbook; http://pmt.ua.edu/publications.html

Conceptual Framework: The Stress-Pain Connection

– Transactional Model of Stress/stress-appraisal- coping model (Lazarus & Folkman, 1984) – Stress and pain are related – pain causes stress and stress worsens pain – Stress is physical, emotional, cognitive, and behavioral – The stress response and the relaxation response – Stress management tools an important skill

Diaphragmatic (Belly) Breathing

• Easy to learn
• Reliably creates the

relaxation response

• Brief
• Portable
• Provides a focus

Judgments About Stress

Stress-Appraisal-Coping Model Simplified….

Cognitive Appraisal & Restructuring Techniques

• Stress Appraisal (threat, loss, challenge)
• Automatic thoughts
• Deeper underlying beliefs

– “should beliefs” (intermediate beliefs) – Core beliefs

Automatic Thoughts & Deeper Beliefs

Automatic Thoughts, Intermediate Beliefs, Core Beliefs

Noticing, Examining, & Changing Unhelpful Thoughts

• Start with a stressful situation

– What was happening? (thoughts, feelings, actions) – Did the thoughts work for or against you?

• Act like a jury for your thoughts

– What’s the evidence that it’s true? False? – What’s the verdict? – Come up with a more helpful/realistic thought

Cognitive Appraisal & Restructuring Techniques

• Stress Appraisal (threat, loss, challenge)
• Automatic thoughts
• Deeper underlying beliefs

– “should beliefs” (intermediate beliefs) – Core beliefs

Automatic Thoughts & Deeper Beliefs

Automatic Thoughts, Intermediate Beliefs, Core Beliefs

Examining & Changing Deeper Beliefs

• Intermediate Beliefs (“should beliefs”)

– Rules we hold for self & others – Very relevant to chronic pain re: cause & how it should be treated

• Core Beliefs

– Self-judgments about worthiness, lovability – “disabled chronic pain patient” vs well person w/ pain – Acting “As If” exercise

Cognitive Appraisal & Restructuring Techniques

• Stress Appraisal (threat, loss, challenge)
• Automatic thoughts
• Deeper underlying beliefs

– “should beliefs” (intermediate beliefs) – Core beliefs

Activity Pacing (& Behavioral Activation) Techniques

• Cycle of dysfunction leading to disability
• “Underdoers” (avoiding pain, but decreasing

strength & endurance, and increasing disability)

• “Overdoers” (pushing the limits beyond pain

exacerbation → fatigue, pain flare-ups, rebound convalescence)

• Discrimination between soreness from physical

activity and pain exacerbation

Fear of Movement and (Re)injury

• Finding the balance between overdoing it and

underdoing it.

• Rest-Activity Cycle
• Physical activity can be anything
• Walking to get things for yourself instead of asking others
• Enjoyable activities too! (e.g. gardening, grilling, baking)
• Goal: increase participation in meaningful activities,

manage fatigue, increase function, & reduce pain flair-ups (Also promotes a sense of self-efficacy).

Activity Pacing

Emotional Awareness & Disclosure Techniques

(Mark Lumley, Wayne State Univ)

• Suppressing negative emotions is maladaptive
• Appropriate acknowledgment/expression is adaptive

(reduces distress, increases perceptions of control, promotes general health benefits)

• Often, transient increase in negative affect

immediately after, and more delayed (~ a month) long-term benefits

• Not a communication exercise – for self

Typical Expressive Writing Exercise

• This exercise is just for you – not a communication tool
• Write (or talk) about an unresolved stressor in your life.
• Choose something you may have never talked or written

about before, may be uncomfortable sharing.

• Write (or talk) for 10 minutes.
• Spelling, grammar, sentence structure doesn’t matter.
• If you run out of things to say, repeat yourself until the

10 minutes are up.

• Do this 3 more days in a row.

Aggressive Passive Assertive

Assertive Communication

Learning Assertive Communication

• You have a right to ask
• In a clear and respectful way:

– Ask for what you want – Say no to something you do not want

• Use “I” Statements – avoid blame
• Making simple requests
• Planning for more complex requests

Context for Assertive Communication with Healthcare Workers

• Patients with chronic pain often feel stigmatized,

devalued, and disbelieved

• Patients feel at the mercy of health care system
• Patients feel they have no agency
• Patients do have control over their

communication approach

• Patients can better prepare for a visit

Evidence Base for CBT

• Strong efficacy for pain reduction, functional

enhancement, lower depression

• Most psychosocial treatments have ~ =

efficacy

• Shared vs. treatment-specific mechanisms

http://annals.org/aim/fullarticle/2673506/literacy-adapted-cognitive- behavioral-therapy-versus-education-chronic-pain-low http://annals.org/aim/fullarticle/2673752/shining-lamp-efforts-transform- pain-care-america

Ann Intern Med. doi:10.7326/M17-0972

Heterogeneity of Treatment Effects

Key (Hypothesized) Mechanisms

• Therapeutic Alliance
• Group Cohesion
• Reconceptualizing Pain
• Self-efficacy
• Catastrophic Thinking
• Acceptance

Full integration as part of medical treatment

• Buy-in from system
• Buy-in from providers
• Mechanism for staffing and work-flow

accommodation

• Financing

What’s Our Vision?

The Challenges of Implementation: Posts

• n DailyMail.com (2/27/18) :
• “Enough of all the badmouthing opiates!”
• “CBT, which has all the scientific backing of

mumble, mumble…”

• “Talk therapy does squat for long-term chronic

pain.”

• “No health insurance company is going to pay

for that.”

The Challenges of Implementation…

• Culture Shift?

– Patient – Provider – General public

• Reimbursement structure/sustainability
• Integration into healthcare system
• Durability issues

Finding Good Pain Treatment is Hard. If You’re Not White, It’s Even Harder (NYT, August, 2016)

• Ms. Lewis, the former dollar

store employee, said the best balm for her pain had been 10 weeks of group cognitive behavioral therapy, which aims to help people change how they think about pain.

• “I learned so much I was

actually shocked,” Ms. Lewis said of her cognitive behavioral therapy.

• “It’s about triggering your

brain to go to something else,

• ther than the pain.”

https://www.nytimes.com/2016/08/10/us/how-race-plays-a-role-in- patients-pain-treatment.html?_r=0

Simple actions. Deep resonance. Wide ripples.

– Colette Lafia