Beverly E. Thorn
Over one-third of Americans report chronic pain of one type or another. The causes of chronic pain are multi-faceted, and often do not involve identifiable tissue damage. Opioid therapy for chronic pain has a high risk for opioid dependency, addiction, and possible death. CBT is a proven alternative intervention. This article describes a 10-session CBT program for the treatment of chronic pain.
Maria is a 50-year-old widowed Hispanic female who works as a line supervisor at a manufacturing plant. She has a history of low back pain, osteoarthritis of the knees, hypertension, diabetes, and depression. She arrived at your office early, was neatly dressed and well-groomed, walked with a cane, and presented herself somewhat defensively regarding why she was sent to see you: “My doctor can’t deal with women crying in his office, and he also gives me less meds for my pain because I’m Hispanic. I don’t mind talking about my husband and how hard that has been, but I resent the idea that I’m a drug seeker or something!”
She reports having four grown children, ages 29, 27, 24, and 22, with seven grandchildren. Her husband of 30 years passed away of a myocardial infarction two years ago; she is still grieving his loss and is somewhat withdrawn, although she has close and supportive family ties. She reports struggling with whether or not to retire early, but does not want to lose some of the benefits she would receive if she waited until the age of 55. She is considering knee replacement surgery. Her primary care physician prescribed citalopram (20 mg daily) when her husband died, and she feels that it has helped her cope with his loss. Maria also takes daily beta-blockers for hypertension, metformin for diabetes, and tramadol (200 mg per day, with up to an additional 200 mg as needed) for low back pain. She also takes over-the-counter ibuprofen to reduce knee inflammation.
Recently, Maria has been asking for early refills of the tramadol, saying that the medication is no longer working to control her back pain. At a recent visit with her PCP, she was tearful, despondent, and asking for “something stronger for her pain.” The PCP increased her citalopram (a serotonergic antidepressant) to 40 mg daily, but before he was willing to consider a stronger analgesic medication, he asked her to see a psychiatrist, which she refused by saying, “I am not crazy.” She was willing to go for “a few sessions of counseling” to help her cope with the stress of being a widow, contemplating knee replacement surgery, and wondering about early retirement, but she was angry that the PCP would not prescribe a stronger analgesic medication, especially because many of her friends told her that tramadol was “like taking a baby aspirin” for pain. She felt certain that her PCP thought she was making her pain up, or that the pain was “all in her head.” How can you be the most helpful for her?
Nature of Chronic Pain
Chronic pain (CP) is often defined as pain lasting beyond 3–6 months (or a normal period of healing), and of a severity that interferes with daily functioning. CP is a widespread and growing problem in the U.S., and it disproportionately affects minorities, women, and financially disadvantaged individuals. The Institute of Medicine estimates over 116 million Americans (37.3%) experience CP, costing $600 billion annually (Institute of Medicine, 2011).
Although a biomedical approach to the assessment and treatment of pain persists in the healthcare system, it is now known that tissue damage and pain do not share a one-to-one relationship. Psychosocial factors are critically involved in the experience of pain, and hence a biopsychosocial model is more appropriate as it guides successful interdisciplinary pain management.
Causes of chronic pain are multi-faceted, often (but not always) include acute injury, and may or may not include identifiable tissue damage. Factors removed from the original cause (e.g., interpersonal, social, and environmental factors, but also including comorbid diseases, invasive medical procedures, and pain medications) often make the situation worse. Furthermore, the brain is more plastic than previously assumed, and painful experiences can (and do) sensitize the brain to react to stimuli that may not have previously been perceived as painful.
Consistent with a biopsychosocial conceptualization, the International Association for the Study of Pain (IASP) defines “pain” as an unpleasant experience that accompanies both sensory and emotional modalities, which may or may not be accompanied by identifiable tissue damage, and is influenced by multiple factors, including cognitive, affective, and environmental (IASP Taxonomy Working Group, 2014).
Chronic pain frequently co-occurs with psychological disorders, particularly anxiety and depression. As the number of physical symptoms a patient experiences increases, the likelihood of mood disorders escalates. Reciprocally, the presence of negative emotions makes the pain experience worse. Although depression (and other mood disorders) is associated with chronic pain, there is no scientific evidence to support a psychogenic model of pain that mood disorders predate and explain the presence of chronic pain.
Interventions with Chronic Pain
Opioid therapy for chronic pain has skyrocketed in the past two decades, as have opioid-related dependency and death by overdose. In response to the opioid crisis, recently published clinical practice guidelines (Dowell, Haegerich & Chou, 2016; Qaseem, Wilt, McLean & Forciea, 2017; VA/DoD, 2017) specifically recommend that opioids not be prescribed as a first line of treatment for chronic pain, and that non-pharmacological, evidence-based pain self-management treatments be incorporated into a comprehensive treatment approach. These include patient education and cognitive behavioral therapy (CBT).
Research has shown that compared to opioids, CBT-based approaches provide comparable relief, but better improvements in function (Okifuji & Turk, 2015). In some states, a biopsychosocial approach to the treatment of pain has become the law. For example, a 1992 Colorado workers’ compensation law mandated the use of a biopsychosocial model of care for injured workers, and later research showed that Colorado inflation of costs was one-third that of the national average since the implementation of the law (Bruns, Mueller, & Warren, 2012). Furthermore, using Medicare reimbursement rates and comparing the cost of a typical lumbar fusion to a standardized 10-session group CBT approach, the authors calculated that the surgical costs alone were 168 times greater than the CBT costs (Bruns et al., 2012).
Components of Cognitive Behavioral Therapy
for Chronic Pain
Broadly defined, CBT is the common standard of psychosocial intervention for chronic pain management. Outcome studies have shown that cognitive-behavioral interventions not only reduce pain, but also increase adaptive coping responses, self-efficacy, and physical functioning, and decrease maladaptive cognitions (Hoffman, Papas, Chatkoff & Kerns, 2007; Morley, 2011). Importantly, there are many different interventions employed under the general rubric of CBT, making comparisons of specific psychosocial treatments difficult, with a danger of inaccurate conclusions about treatment superiority.
Colleagues and I have hypothesized that effective pain management approaches engage several components: cognitive content (what a person thinks), cognitive processes (how a person attends to and interprets sensations and emotions), and altering behavior (what a person does to manage pain and associated stressors; Day, Jensen, Ehde, & Thorn, 2014). Obviously, there are a variety of ways to target these processes. Below, I highlight components of a 10-session structured CBT program that includes all of these overlapping elements. Further details (and an accompanying treatment manual with handouts and audio links for relaxation exercises) can be found in Thorn (2017)—Cognitive Therapy for Chronic Pain: A Step-by-Step Guide, (2nd edition). Table 1 provides an outline of topical coverage for each session.
In terms of format, I favor group treatment to capitalize on group process and reduce feelings of invalidation and stigma. I find that starting with approximately seven participants provides enough “floor time” for each group member, and comfortably accommodates potential drop-outs or the occasional missing group member. For groups, a 90-minute session is needed. Although by necessity, groups are less flexible than individual sessions, each cohort of group members will affiliate differently, and there will be variability in divergence or commonality of concerns. Individual formats allow for greater flexibility and ability to respond to the unique needs of a given client (i.e., spending more time on certain key components and omitting or spending less time on other aspects). For individuals, 50 minutes per session is sufficient.
Non-Specific (Common) Therapeutic Factors
Non-specific therapeutic factors include patient perceptions of their relationship with the therapist, client treatment expectancy, and (in the case of group treatments) group affiliation or cohesion (Castonguay, Constantino, & Holtforth, 2006). There is a large body of research in the psychotherapy literature pointing out that any type of psychosocial intervention must capitalize on enhancing these factors. I believe that these common therapeutic factors are particularly important when treating individuals with chronic pain.
Patients with chronic pain often feel invalidated by the medical system (especially if a pathophysiological “cause” cannot be found or “curative” surgery should have corrected the problem). Stigma associated with having chronic pain is widely reported. Since there is often no visible manifestation of pain that validates one’s illness (e.g., being in a wheelchair, limb amputation), people with chronic pain are not generally judged by others to be disabled. Furthermore, pain is a subjective phenomenon and cannot be measured using common biomedical techniques, yet self-report is often considered suspect. When a patient is referred to a psychologist for pain management, the patient’s assumption is that they are being discounted as someone whose pain is “all in their head,” and thus an initial (and perhaps ongoing) barrier that must be surmounted is achieving an affiliative bond with the patient. I often begin to develop a therapeutic alliance with the client by simply stating that their pain is real (not, “I believe your pain is real,” but “Your pain is real”), and real pain causes a lot of stress that interferes with many aspects of life. I explain that psychologists can teach clients how to better manage stress, which in turn affects one’s ability to manage their chronic pain. The first key, then, is honoring the patient’s experience of pain as real.
Knowledge About Pain
Knowing how pain is filtered in the brain (and being able to teach patients these facts in user-friendly, jargon-free terms) is increasingly seen as important in biopsychosocial treatment approaches. There is a relatively small but growing research literature examining the effect of pain neurophysiology education for patients with chronic pain. And, in one systematic review, it was noted that that multi-session CBT preceded by pain neurophysiology education resulted in significantly greater long-term benefits compared to neurophysiology education alone (Clarke, Ryan, & Martin, 2011). Furthermore, treatment-based reductions in “pain as damage” conceptualizations are associated with reductions in perceived disability, pain behaviors, and depression.
Based on this research, I have chosen to incorporate a simplified explanation of the gate-control/neuromatrix model of pain, first proposed in 1965 as a rationale for CBT and other psychosocial treatments (Melzack & Wall, 1965). What was proposed was a revolutionary idea: The central nervous system is not a mere passive recipient and transmitter of pain signals, but can modulate the experience of pain by changing sensory input getting to the somatosensory cortex, where pain is “mapped.” There is now strong evidence that neural networks involved in emotion and cognition have connections to the somatosensory cortex. Importantly, these networks also send descending signals to a spinal cord gating mechanism, thereby modulating the transmission of pain signals. Emotions and cognitions can provide inhibitory or excitatory modulation, and thus reduce or exacerbate the overall experience of pain.
Clients describe the above information as a crucial turning point in re-conceptualizing their pain. Interactive education regarding the gate-control/neuromatrix model provides a biological (aka “real”) explanation of pain perception, does not put the patient in the position of trying to justify their pain by continually seeking validation of tissue damage, and, importantly, sets the stage for empowering the patient to take a more active role in their pain management by changing the way the brain processes pain. There is now evidence that CBT can reverse some of the negative neural changes associated with chronic pain (i.e., a specific pattern of reduced gray matter): After an 11-week CBT program, patients in the CBT (but not the control) condition showed increased volume in prefrontal and posterior parietal cerebral cortex and reduced volume in the somatosensory cortex (Seminowicz et al., 2013). The volume increases are thought to be associated with patients’ reconceptualization of their pain and greater sense of control (cognitive and mechanisms proposed in the gate-control/neuromatrix theory to exert inhibition of pain signals at the spinal cord gating mechanism).
In presenting a user-friendly version of the gate-control/neuromatrix model, I use a simple diagram of the brain (see Figure 1), which we then turn into a worksheet to interactively discuss what might “open the gate” to more pain signals, and in turn, what might “close the gate.” From this point on, every cognitive and behavioral skill taught is referred to as a “gate closer.”
The Stress-Pain Connection and Relaxation Techniques
The second most important broad concept to teach patients about pain is helping them understand the connection between stress and pain. The stress response is multi-faceted, involving biological, emotional, cognitive, and behavioral reactions to environmental events judged to be taxing one’s capacity to cope. The stress response has well-known short-term and long-term deleterious effects, and pain is a stressor in and of itself. Furthermore, other stressors make pain worse. It is thought that long-term or severe stressors sensitize stress-response homeostatic mechanisms, creating an imbalance and increasing overall stress reactivity.
Teaching patients to produce a relaxation response in their bodies may help to reset the “stress thermostat.” It is important to give patients with pain an early success experience. Teaching diaphragmatic breathing (or “belly breathing”) is easy to learn and an immediate way to teach them to elicit the relaxation response. Diaphragmatic breathing is usually quite brief (three minutes or less) and appeals to patients because they can do it quickly and often throughout the day (and they often perceive immediate effects).
I also teach longer relaxation techniques during the course of the 10-week program (passive relaxation and mindfulness awareness). Passive relaxation is similar to progressive muscle relaxation, where the client is guided to focus his or her attention on sequential muscles and body regions, eventually progressing through the entire body. Since some patients report difficulty releasing their muscles after contraction, and since patients with chronic pain may have generalized muscle sensitivity, I teach the technique passively, without the tension component.
Teaching patients to produce a relaxation response in their bodies may help to reset the “stress thermostat.”
Although mindfulness instruction does not target relaxation as a key goal of practice, it reliably elicits the relaxation response. Training typically begins by teaching patients to focus their attention on the breath as it enters and leaves the body, simply noticing whatever arises without reacting with attachment or aversion. When the mind wanders away from the object of focus, clients are instructed to notice where it went (“thinking” or “planning”) and then non-judgmentally return to the breath. The process of non-judgmentally observing and letting go of thoughts, emotions, and sensations as they arise is an example of engaging cognitive processes, rather than cognitive content (Day et al., 2014).
Cognitive Appraisal and Restructuring Techniques
Traditionally, cognitive therapy techniques are thought to provide mechanisms for helping clients examine and change the content of their thoughts (Beck, 1976). I have come to view cognitive therapy techniques as a way to also help clients become more aware of their inner dialogue and create a different relationship with their thoughts. In these ways, cognitive therapy techniques can be thought of as targeting cognitive content and cognitive process. I target cognitions in three specific ways: 1) the stress appraisal process, 2) automatic thoughts, and 3) deeper beliefs.
First, as I teach patients about stress and its connection to pain, I introduce the ways we can judge a stressful situation: a threat, a loss, or a challenge. I discuss how the same stressful situation, judged three different ways, produces divergent moods (anxious, depressed, or energized) and different behavioral actions (avoidance, giving up, or engagement). Certainly, one can judge a stressful situation as both a threat and a loss, and the point of the exercise is not to get patients to become experts at categorization, but to notice the connection between appraisals, emotions, and actions. I ask patients to consider stressful situations during the upcoming weeks and ask them to consider how they are judging the situation, and whether they could view aspects of it as a challenge rather than a threat or loss.
Second, I teach patients how to recognize automatic thoughts (thoughts just under the surface of awareness) and the impact of this running judgmental commentary on their emotions and actions. Negative automatic thoughts about pain have a deleterious effect on emotions and actions, and, in the parlance of this treatment program, “open the pain gate.” Catastrophic thinking about pain is a common automatic thought process that is a robust predictor of adjustment. For example, “There is nothing I can do to control this pain.” Research has shown that reductions in pain catastrophizing mediate the extent of positive pain-related outcomes (Bergbom, Boersma, & Linton, 2012), so it may be particularly important to teach clients to recognize negative automatic thoughts, such as the example given above. Once they begin to recognize negative automatic thoughts, clients are often able to change them to make them more realistic, or sometimes just dismiss them as a passing thought. Developing the skill of noticing and identifying automatic thoughts and images allows clients to have more control over how their thoughts affect their mood and actions.
The third component of cognitive therapy in this program involves helping clients identify deeper underlying beliefs: intermediate beliefs (the rules we hold for ourselves and others) and core beliefs (as a worthwhile or loveable person). Patients embroiled in the medical system have deeply held beliefs about the cause of their pain and how it should be treated. In cognitive therapy terms, these can be thought of as intermediate beliefs. These beliefs, often shaped by the healthcare system, teach patients passivity and dependence on an interventional biomedical system. Cultural values continue to reinforce such beliefs, and therefore, they are important to get patients to examine, and possibly challenge.
At the deepest level, core beliefs about the self are the most difficult to challenge. For patients with chronic pain, the downward spiral into disability often leads them to adopt the belief of a “disabled chronic pain patient.” Our goal is to gradually help patients develop a core identity different from “patient with pain,” if appropriate to the individual’s circumstances. The specifics of these cognitive techniques as they relate to pain management are beyond the scope of this article, but can be found in detail in Thorn, 2017.
Behavioral Pacing and Behavioral Activation Techniques
It is important to help individuals suffering from chronic painful conditions to re-engage with moderate physical activity if possible. Patients with pain tend to overdo or underdo, and many cycle between the two tendencies. A common scenario is when someone with low back pain is having a relatively good day and decides to make up for lost time by engaging in a flurry of physical chores and other activities. As a consequence, he or she typically initiates a pain flare-up, and thereafter concludes that physical activity is hurtful and should be avoided. Other patients avoid unnecessary activity most of the time because they are afraid to (re)injure themselves and cause more pain than they already have. Over time, these patients do less and less, setting up a downward spiral of dysfunction eventually leading to disability.
Helping patients initiate small physical activity goals (behavioral pacing) allows them to gradually increase physical conditioning and extinguish the fear associated with the thought of activity. The goal of behavioral pacing is not to engage in physical activity to the point of exhaustion, but to participate in activity-rest cycles that are individually tailored to meet the needs of the patient. I start by asking patients how far they believe they can walk without worsening their pain. (Note that walking is just an example and another activity may be more appropriate for individual clients.) For some, walking across the room, or to their mailbox, may be as much as they feel they can do. Start where they are; then, ask them to do only half of that amount, and rest. If they feel good after the rest (or at least no worse), encourage them to do the other half, and rest again. Gradually (over time), I ask clients to initiate small increases in activity using the activity-rest cycle.
In addition to engaging in less physical activity, individuals with chronic illness (including chronic pain) tend to let pleasurable or previously satisfying activities fall away as the demands of their situation take precedence. Most psychologists are familiar with behavioral activation procedures for the treatment of depression. This technique has been shown to be helpful with those suffering from chronic pain as well; it certainly assists with the depression and negative affectivity that often accompanies chronic pain. I start by asking clients what they enjoy doing, or what they miss doing, and help them identify small pleasurable activities that they feel they can set as goals. After helping the client identify about five small goals for the upcoming week, I move to helping clients specify when they will do their activities (and trouble-shoot potential roadblocks with them). It is important to note that behavioral activation does not require large, complex, or expensive activities, but rather, getting the client to identify and engage in small pleasurable activities throughout the day.
The goal of behavioral pacing is not to engage in physical activity to the point of exhaustion, but to participate in activity-rest cycles that are individually tailored to meet the needs of the patient.
Emotional Awareness and Disclosure Techniques
Emotional awareness and disclosure techniques have been shown to be effective in reducing distress, increasing perceptions of control, and promoting general health benefits for individuals with chronic pain (Lumley, Sklar & Carty, 2012). Such techniques usually involve asking patients to write about their feelings, particularly ones they would rather avoid, in response to an unresolved stressful life event. Topics chosen by patients often revolve around experiences of trauma, loss, or illness. For some patients, negative feelings associated with their chronic pain (e.g., anger, fear, or depression) could be the focus of their writing. Others may choose a traumatic event (or events) earlier in their lives that has gone unresolved. Expressive writing (or other forms of emotional disclosure, such as privately speaking into a recorder or speaking to a neutral listener) helps patients acknowledge strong negative feelings in a safe manner without risk of hurting others or exposing themselves to retaliation or judgment. Furthermore, emotional disclosure exercises provide an opportunity for a deeper understanding than may have been achieved through avoiding the topic and suppressing emotions.
The general format for expressive writing exercises involves writing (or speaking) continuously for at least 10 minutes, for at least 34 days in a row. The repetition in the task may serve an exposure/extinction process to previously suppressed negative thoughts and emotions. This exercise is not meant to be used as a communication tool with significant others, but some clients may wish to share their writing with the therapist. This should not be a requirement, but can enhance benefit. It is not unusual for there to be a short-term increase in negative affect following the exercise, which resolves and is followed by enhanced mood and function. This should be mentioned to patients. Further, it is important to emphasize that you are not advocating for the unrestrained expression of emotions in all situations, which could be dangerous in some cases (e.g. abusive relationships) or potentially hurtful to relationships. Thus, it is useful to help the patient distinguish between emotional expression exercises that help them get in touch with, express, and potentially better understand their own strong emotions—and assertive communication exercises, which are meant to be an interpersonal communication tool.
It is also common for individuals with chronic pain to feel stigmatized, invalidated, and angry, which may initiate aggressive outbursts.
Assertive Communication Techniques
Assertive communication techniques empower your clients to appropriately express their wants and needs in interpersonal situations and to make simple, direct requests or responses without apology, justification, or hostility. Although it is not unusual to include assertiveness training in CBT protocols, there is very little research looking at the efficacy of this specific technique as it relates to chronic pain. Since assertiveness training directly impacts interpersonal functioning, which is compromised from the stress of chronic illness, there is merit to including it. Furthermore, since individuals with chronic pain utilize the healthcare system more frequently than other individuals, assertive communication skills can enhance patients’ working relationships with healthcare providers. I find that individuals with chronic illnesses find assertiveness skills with healthcare providers particularly relevant and useful; they come to understand that assertiveness is much more effective in meeting their needs than a passive stance or aggressive outbursts when interacting with the healthcare system becomes frustrating.
Many people have difficulty with assertiveness, often vacillating between a passive stance or aggressive demands. I begin assertiveness training by leading a discussion about the difference between passive, aggressive, and assertive communication, focusing on differences in words used, tone of voice, body language, and effect of each type of communication on the recipient. It is not uncommon for patients with chronic pain to feel as if they do not have the right to ask for what they want because they are already relying on others more than they would like to. On the other hand, it is also common for individuals with chronic pain to feel stigmatized, invalidated, and angry, which may initiate aggressive outbursts. I have also observed that patients with chronic pain may use their illness as a reason for saying no (e.g., “You know I can’t sit on bleachers! Why do you even ask me if I want to go to Bobby’s game?”). I find it helpful to normalize both passive and aggressive communication styles as common, especially in stressful situations. It should be emphasized that learning and practicing assertiveness skills provides an avenue for self-empowerment and being heard by others.
I tell patients that the most straight-forward means of practicing assertive communication is to look for opportunities to ask for what they want, or say no to something they do not want. A key tip here is to avoid the tendency to justify why one is asking (or saying no), especially considering the tendency to justify requests based on one’s illness. Just ask (or say, no thank you). In more complex problem situations, I prescribe a four-step “recipe”: 1) State the problem situation in a simple, direct way, avoiding accusations or blame; 2) Say how you feel in this situation; 3) Tell the other person what you want; 4) Talk about how honoring your request will help you and your relationship. A final tip for assertiveness is using “I” statements (e.g., “When you go to the movies without me, it makes me feel bad. I would like you to ask me, even if I don’t want to go every time. If you asked, it would make me feel closer to you.”) instead of “you” statements (e.g., “You are doing this annoying thing to make me mad and if you loved me you’d quit doing it”).
Evidence Base for This CBT Approach
I have used aspects of this treatment approach in my clinical research with a mixed group of patients with chronic pain (Johnson & Thorn, 1989), in a specific-treatment-component analysis study of patients with headache (James et al., 1993), in a clinical trial for patients with headache (Thorn et al., 2007), in a trial of mindfulness-based cognitive therapy for patients with headache (Day et al., 2014), and in clinical trials of literacy-adapted group therapy for multiply disadvantaged patients with chronic pain at low income community health centers (Eyer & Thorn, 2015; Thorn et al., 2011, Thorn et al., in press). These studies have been funded by The National Institutes of Health, The Marchionne Foundation, the National Headache Foundation, and the Patient Centered Outcomes Research Institute. Each of these clinical research studies has provided an opportunity for me to revise and refine the treatment manual, so that it will be easier to use and understand for practitioners who may be less familiar with a structured psychosocial treatment program with a cognitive conceptualization and approach. The most recent manual can be found in Thorn (2017) and, for a literacy-adapted version of the patient workbook, at http://pmt.ua.edu/publications.html.
In the opening clinical example above, Maria was reserved and defensive about being sent to a psychologist for pain, and initially only wanted to express grief about the loss of her husband. After giving adequate time to process her bereavement, I was able to help her acknowledge a common therapeutic theme of important stressors in her life (e.g., her loss, possible surgery, the prospect of early retirement, and significant chronic pain in her knee and low back).
Like many other patients, Maria thought that the gate-control idea of pain made a lot of sense, and helped her buy into the premise that learning skills to manage stress (including paying attention to her thoughts, learning more about the bidirectional impact of emotions and pain, regularly invoking the relaxation response, and learning to pace her activities) could change the way the brain processes pain, and in turn, change her experience of pain.
Maria was most readily receptive to the relaxation exercises, and comfortably incorporated the belly breathing into her routine several times a day. She found herself doing the relaxation even while waiting in line at the grocery store. She didn’t find the longer passive muscle relaxation exercise useful, but was intrigued by the mindfulness exercise because she was able to understand that observing her thoughts, rather than getting swept away by them, reduced their emotional impact.
Although the behavioral pacing exercises did not have an immediate effect, she did acknowledge beginning to take more small breaks during her work day, which helped with the back pain. In doing so, she was also more productive. Since Maria was close to her family, she began increasing pleasurable activities with her grandchildren, which she had let drop away in the past two years. This enhanced her mood, and her family was also relieved to see her re-engaging.
After Maria got skillful at recognizing negative automatic thoughts, she made an important connection: she realized that she sometimes took a tramadol because she was catastrophizing about her life and was swept away by negative emotions. She realized that in this case, her “think → feel → act” connection was inadvertently leading her to take more medication, not for physical pain but for psychological pain. This realization helped her begin to reduce the tramadol use on her own.
As Maria was characteristically passive in her communication, assertiveness training was especially useful, particularly with her healthcare professionals. She realized that specifying what she wanted helped them understand her concerns. She and her primary care physician were able to agree to try a different analgesic medication that was a stronger non-steroidal anti-inflammatory drug (NSAID) than over-the-counter, but without opioids. She was able to successfully toggle the prescribed NSAID and acetaminophen with good back pain relief.
Maria was not initially willing to engage in the expressive writing exercise, but she eventually made the connection between her core beliefs about being “damaged goods” and the early childhood abuse that she previously suppressed through prayer. When she was able to recognize her rage at having been abused, and put it down on paper, she noticed that it had less of a hold on her. This freed her up to go back and work on some of her deeper beliefs.
At the end of treatment, Maria still had pain that interfered with her daily life, but she no longer felt like a hapless victim of circumstance. She was able to articulate numerous pain-management skills to help “close the gate,” and she knew when she was making things worse and what to do about it. She commented that the work we had done with her pain management seemed to help relieve her depression as well, and she felt more hopeful overall. I asked her if, knowing what she knew now about the treatment approach, she would recommend it to others, and she said, “Absolutely! I still have pain, but it doesn’t have me.”
The case illustration provided above gives a sense of using a structured, evidence-based CBT program for chronic pain in a real-world setting with an individual patient. In individual treatment, there is more room for flexibility than with groups, and thus Maria and I worked for several weeks on issues of primary emotional concern once I had earned her trust. In Maria’s case, examining her deeper core beliefs, clarified and processed during the emotional disclosure activity (expressive writing), was particularly salient and spanned four weeks instead of one. At all times, I focused on a structured program of pain management, albeit broadly defined, and grounded treatment on the gate-control model of pain: real pain, processed in the brain, is directly influenced by one’s thoughts, emotions, and behaviors. Recognizing these connections, and practicing the pain self-management techniques taught in the program, can help “close the gate” to pain signals, reduce overall pain, and enhance one’s life despite having a chronic illness.
Beverly E. Thorn, PhD, ABPP, is Professor Emerita of Psychology at the University of Alabama, a licensed psychologist, and board certified in Clinical Health Psychology by the American Board of Professional Psychology. Since her official retirement in September 2016, she has remained professionally active, focusing her research and clinical efforts on dissemination and implementation of psychosocial treatments for chronic pain in low-income, multiply disadvantaged populations. She also consults with healthcare settings to integrate psychosocial approaches into comprehensive chronic pain management.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Oxford, England: International Universities Press.
Bergbom, S., Boersma, K., & Linton, S. J. (2012). Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability. Behaviour Research and Therapy, 50(11), 726-734.
Bruns, D., Mueller, K., & Warren, P. A. (2012). Biopsychosocial law, health care reform, and the control of medical inflation in Colorado. Rehabilitation Psychology, 57(2), 81-97.
Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, Practice, Training, 43, 271-279.
Clarke, C. L., Ryan, C. G., & Martin, D. J. (2011). Pain neurophysiology education for the management of individuals with chronic low back pain: A systematic review and meta-analysis. Manual Therapy, 16(6), 544-549.
Day, M. A., Jensen, M. P., Ehde, D. M., & Thorn, B. E. (2014). Toward a theoretical model for mindfulness-based pain management. The Journal of Pain, 15(7), 691-703.
Day, M., Thorn, B.E., Ward, L.C., Rubin, N., Hickman, S., Scogin, F., & Kilgo, G. (2014). Mindfulness-based cognitive therapy for the treatment of headache pain: A pilot study. Clinical Journal of Pain, 2(9), 941-952.
Dowell D, Haegerich TM, Chou R. (2016). CDC guideline for prescribing opioids for chronic pain in the United states. Journal of the American Medical Association. 315(15):1624-1645.
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.
James, L.D., Thorn, B.E., & Williams, D.A. (1993). Goal specification in cognitive behavioral therapy for chronic headache pain. Behavioral Therapy, 24, 305-320.
Johnson, P.R. & Thorn, B.E. (1989). Cognitive behavioral treatment of chronic headache: group vs. individual treatment format. Headache, 29, 358-365.
International Association for the Study of Pain. (2014). Classification of chronic pain, second edition (revised). Descriptions of chronic pain syndromes and definitions of pain terms. Retrieved from www.iasp-pain.org/Publications/News/Content.aspx?ItemNumber=1673.
Institute of Medicine [IOM]. (2011). Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press.
Lumley, M.A., Sklar, E.R., & Carty, J.N. (2012). Emotional disclosure interventions for chronic pain: From the laboratory to the clinic. Translational Behavioral Medicine: Practice, Policy, Research, 2, 73-81.
Melzack, R., & Wall, P. D. (1965). Pain mechanisms: A new theory. Science, 150(3699), 971-979.
Morley, S. (2011). Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: Progress and some challenges. Pain, 152(3, Supplement), S99-S106.
Okifuji, A., & Turk, D. C. (2015). Behavioral and cognitive–behavioral approaches to treating patients with chronic pain: Thinking outside the pill box. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 33(3), 218-238.
Qaseem A, Wilt TJ, McLean RM, Forciea MA. (2017) Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain. Annals of Internal Medicine. 166(7): 514-530.
Seminowicz, D. A., Shpaner, M., Keaser, M. L., Krauthamer, G. M., Mantegna, J., Dumas, J. A., . . . Naylor, M. R. (2013). Cognitive-behavioral therapy increases prefrontal cortex gray matter in patients with chronic pain. The Journal of Pain, 14(12), 1573-1584.
Slavin‐Spenny, O. M., Cohen, J. L., Oberleitner, L. M., & Lumley, M. A. (2011). The effects of different methods of emotional disclosure: Differentiating post‐traumatic growth from stress symptoms. Journal of Clinical Psychology, 67(10), 993-1007.
Thorn, B.E. (2017). Cognitive Therapy for Chronic Pain: A Step-by-Step Guide, 2nd edition. Guilford Publications.
Thorn, B.E., Day, M.A., Burns, J., Kuhajda, M., Gaskins, S., Sweeney, J., … Cabbil, C. (2011). Randomized trial of group cognitive-behavioral therapy compared to a pain education control for low literacy rural people with chronic pain. Pain, 152, 2710-2720.
Thorn, B.E., Eyer, J.C., Van Dyke, B. P., Torres, C.A., Burns, J.W., Kim, M. …. Tucker, D.H. (in press) Literacy-Adapted Cognitive-Behavioral Therapy vs Education for Chronic Pain at Low-Income Clinics: A Randomized Controlled Trial. Annals of Internal Medicine.
Thorn, B. E., Pence, L.B., Ward, L.C., Kilgo, G., Clements, K.L., Cross, T.H., … Tsui, P.W. (2007). A randomized clinical trial of cognitive behavioral treatment targeted at the reduction of catastrophizing in chronic headache sufferers. Journal of Pain, 68(12), 938-949.
VA/DoD (2017). Clinical practice guideline for opioid therapy for chronic pain. The Opioid Therapy for Chronic Pain Work Group, Department of Veterans Affairs, Department of Defense, Office of Quality and Performance, Office of Evidence Based Practice. Accessed at www.healthquality.va.gov/guidelines/Pain/cot/ on 2 August 2017.