The Cognitive–Behavioral Approach to Pain Management

Phase 1: Assessment

The assessment phase serves several distinct functions, as outlined in Box 42-5 . Information for assessment is obtained by interviewing patients and significant others, as well as by using standardized self-report measures and observational procedures ( ). During the assessment phase, the psychosocial and behavioral factors that are probably having an impact and the patient responses that might be expected to be important during treatment are evaluated. Attention should be given to identification of any factors that might be impediments to rehabilitation. All this information is integrated with the biomedical data and is used in formulating the components and process of treatment ( ). There should be a close relationship between the information acquired during the initial assessment phase and the nature, focus, and goals of the therapeutic regimen and evaluation of progress.

Phase 2: Reconceptualization

The crucial element in successful treatment is bringing about a shift in the patient’s thinking and behavior from well-established, habitual, and automatic but ineffective responses toward systematic problem solving and planning, control of affect, behavioral persistence, or disengagement and acceptance, when appropriate.

Reconceptualization involves continually reorienting patients from their belief that the symptoms or physical impairments are overwhelming, unmanageable, all-encompassing sensory experiences resulting solely from tissue pathological changes to a belief that symptoms and disability as experiences can be differentiated, systematically modified, and controlled, at least to some extent, by the patients themselves. Reconceptualization of maladaptive views is the framework of cognitive–behavioral treatment that provides validity and incentive for the development of proficiency with various coping skills used for control of symptoms.

The process of cognitive restructuring focuses on identification of anxiety-engendering and other maladaptive appraisals and expectations and subsequent consideration of more appropriate alternative modes of interpretation. It is designed to help patients become aware of the role that thoughts and emotions play in potentiating and maintaining stress and physical symptoms. The therapist elicits the patient’s thoughts, feelings, and interpretations of events; gathers evidence for or against such interpretations; identifies any habitual self-statements, images, and appraisals that occur; tests the validity of these interpretations; identifies automatic thoughts that set up an escalating stream of negative, catastrophizing ideation; and helps examine how such habitual thoughts exacerbate stress and interfere with performance of adaptive coping responses. The therapist encourages patients to test the adaptiveness of specific thoughts, beliefs, expectations, and predictions. Patients’ actual performance may be used as a way to assist in cognitive restructuring. That is, self-monitoring of any thoughts, mood, and behavior associated with exacerbation of pain can be used to demonstrate their interactions, and self-monitoring of successful accomplishment of home practice tasks can be used to combat patients’ maladaptive beliefs about the helplessness of their situation or their own functional limitations.

As noted, treatment is viewed as a collaborative process by which the therapist carefully elicits the troublesome thoughts and concerns of patients, acknowledges their bothersome nature, and then constructs an atmosphere in which patients can critically challenge the validity of their own beliefs. Rather than suggesting alternative thoughts, the therapist attempts to elicit competing thoughts from the patient and then reinforces the adaptive nature of these alternatives. Patients have well-learned and frequently rehearsed thoughts about their condition. Only after repetitions and practice in cueing more benign and positive interpretations and evaluations will patients come to change their perspectives.

Significant others (e.g., family members, partners, friends) are important in that they may unwittingly undermine patients’ efforts to change their conceptualizations. The therapist should attempt to ascertain how significant others respond to the patient and when their manner of response is an inappropriate attempt to help the patient alter these conceptualizations. This may be accomplished by encouraging the patient to discuss the responses of significant others directly with them.

Throughout treatment, it is important to permit and even to urge patients to express their concerns, fear, and frustrations, as well as their anger directed toward the health care system, insurance companies, employers, social system, family, fate, and, importantly, themselves ( ). Failure to address these feelings will inhibit motivation and success. In some patients, stress may have a direct effect on the physiological contributors to pain (e.g., muscle tension; ), whereas in other patients, stress may have a less direct effect on their physical symptoms but will be related to emotional distress. In either case, the therapist can note that there is a great deal that can be done by people with persistent pain to control their levels of arousal and emotional distress once these are identified as problems.

Self-control is presented in such a way that the patient can understand its role by using personally relevant examples. Patients are encouraged to review stressful episodes and to examine the course of the symptoms that followed at that time. For example, a recent conflict with a partner might be examined to determine whether the patient’s becoming upset had any effect on the physical and psychological symptoms experienced. Imaginal presentation or recall of previous symptomatic exacerbations can be especially useful. Patients can be asked to recall not only the situation but also their thoughts and feelings. With the help of the therapist, they can then discover the impact of thoughts and feelings on the experience of symptoms. In this manner, the therapist engages patients in a dialogue. The patients’ maladaptive thoughts and feelings should be used by the therapist to illustrate how such thinking may influence inappropriate behavior and amplify the problem.

Cognitive errors ( Box 42-6 ), frequently observed in individuals with chronic pain, can be related to the emotional difficulties associated with living with pain. Variability in pain reporting and disability in those with chronic pain may be accounted for by maladaptive thoughts; in contrast, physical factors appear to contribute very little to variability in pain and disability. Once the cognitive errors that contribute to pain perception, emotional distress, and disability are identified, they become the target of intervention. Patients should be asked to generate alternative, adaptive ways of thinking and of responding to minimize stress and dysfunction (e.g., “I’ll just take one day at a time,” “I’ll try to relax and calm myself down,” and “Getting angry doesn’t accomplish anything; I’ll try to explain how I feel”).

At this point the therapist introduces the concept of pain behavior and operant learning ( ) and discusses the important role that significant others may play in unwittingly and inadvertently reinforcing and thereby maintaining the patient’s overt expression of pain, distress, and suffering. Such types of behavior as grimacing, lying down, avoiding certain activities, and moaning are offered as examples of pain behavior. The patient’s significant other is encouraged to recall examples of the patient’s specific pain behavior and how that person (i.e., the significant other) responded to such behavior. Significant others may be asked to complete a diary of the patient’s pain behavior and their responses to such behavior. This homework assignment serves to highlight the role that pain has come to play in their lives and the importance of significant others in treatment. Questions put to the significant other include “How do you know when your spouse is experiencing severe pain?” “What do you do in response?” and “What impact does it have?”

At this time, education begins in a more formal manner. A simplified conceptualization of pain based on the gate control model of is presented and contrasted with the unidimensional sensory–physiological model held by many patients. The interaction of thoughts, mood state, and sensory aspects of a situation is presented in a clear, understandable fashion by using the patient’s self-monitored experiences as illustrations ( , ). For example, the impact of anxiety is briefly considered and related to the exacerbation of pain. Data from patient diaries are extremely useful to make this point more tangible. Patients can review recent stressful episodes and examine the course of the pain that followed at that time. One coronary patient, who had been aware of a connection between periods of tension and the intensity of his pain, attributed the pain to changes in the state of his heart. As the details of his situation were examined, an alternative explanation emerged, namely, that the nature of his pain was stress related. Muscle tension in the chest and shoulders increased when he was feeling stressed, but his heart rate and pulse remained unchanged. The patient’s misattribution prevented appropriate action from being taken to reduce the muscle contraction that aggravated the chest wall pain. Reappraisal of the pain stimulus improved his ability to control the pain through timely and target-appropriate interventions, which in turn improved his sense of self-efficacy ( ).

To facilitate this reappraisal process, the therapist introduces the notion that the patient’s experience of pain can be viewed as consisting of several manageable phases rather than one overwhelmingly undifferentiated assault. In this way, patients come to view their pain as being composed of several components that go through different phases that are, in part, influenced by their reactions. Patients are not the helpless victims of pain, nor need they be passive pawns. The therapist and patient have collected data to support this more differentiated view of pain, thus providing the basis for the intervention program that will follow.

Negative thoughts and pain-engendering appraisals and attributions are reviewed in treatment so that the patient will not be surprised when and if they inevitably do arise. Rather, the patient is encouraged to use the negative cognitions and feelings as reminders or as cues to analyze their basis and influence and to initiate more adaptive coping strategies. Patient diaries can provide information that becomes the focus of discussion. For example, patients who recorded thoughts that they felt “incompetent” and “helpless” in controlling their pain during a specific episode should be encouraged to become aware of when they engage in such thinking and to appreciate how such thoughts may magnify their pain and become self-fulfilling prophecies. Alternative thoughts, such as realistic appraisal of the situation and their coping resources, are encouraged, and patients are reinforced to use one or more of the coping strategies covered during the skills training. The patient is encouraged to divide the situation into stages, as described earlier, and to acknowledge that the most severe pain is usually relatively transitory. Such cognitive restructuring is incorporated throughout the treatment regimen. The therapist also integrates examples of when patients have been resourceful in their life and guides patients to consider how these skills can be applied to the pain situation.

Phase 3: Skills Acquisition

There are many potential benefits from the use of self-management strategies. As patients learn to self-regulate physiological responses and manage problematic situations, they can develop an increased sense of personal control over the pain and the factors that influence pain and combat the pervasive sense of demoralization. With self-management strategies, instead of being a passive recipient of a medical intervention (such as medication or anesthetic nerve block) that may provide some modest symptomatic relief, the patient plays an active role in learning and applying skills to manage the episodic or persistent pain problem.

During the skills acquisition phase, the therapist provides practice in the use of a variety of cognitive and behavioral coping skills that are geared toward altering the patient’s response to environmental contributors to pain, bolstering coping skills (e.g., attention diversion, relaxation skills for dealing with specific symptoms), changing maladaptive interpretations, and changing factors that might contribute to stress (e.g., inappropriate communication patterns).

In all cases, it is essential for patients to understand the rationale for the specific skills being taught and the tasks they are being asked to perform. Unless patients understand the rationale for the treatment components and have the opportunity to raise issues and sources of confusion about them, they are less likely to persevere in the face of obstacles, benefit from therapy, or maintain therapeutic gains.

Again, it is essential for therapists to keep in mind patients’ perspectives and how they perceive each skill and assignment. The therapist’s skills and the relationship that is established between the therapist and patient oil the gears of treatment; without a satisfactory therapeutic alliance, treatment will grind to a halt. Treatment should not be viewed as a rigid process with a fixed set of techniques but should be flexibly adapted to the specific needs of each patient. First, the therapist discusses the rationale for using a specific method. Assessing whether the skills are in patients’ repertoires, teaching patients the skills needed, and having them practice these skills in the therapeutic setting follow. As patients develop proficiency, they are encouraged to use these skills in their homes. Progress and impediments to successful use of the various coping skills included within treatment sessions are discussed during subsequent sessions.

Problem Solving

A problem-solving orientation has been shown to be particularly useful in treating patients with chronic pain ( ). A useful way to think about pain is as a set of sequential problems rather than simply as a single overwhelming problem. That is, many patients view pain as their sole overriding problem. An alternative that is encouraged by cognitive–behavioral therapists is that chronic pain causes an array of small and large problems—familial, occupational, social, recreational, and financial—as well as physical problems. They may not be able to eliminate the problem of pain, but it is feasible to address problems that are created by the presence of persistent pain.

The important first step in problem solving is to help patients identify situations that are associated with pain (e.g., “When X occurs in situation Y, I feel Z”). Self-monitoring can help identify the links between thoughts, feelings, behavior, and pain and thereby identify the problems ( Fig. 42-1 ). Patients need to think of the difficulties that they encounter as problems to be resolved. Next, they must try out alternatives to achieve the desired outcome. Patients need to learn that there is not usually a single solution or alternative to solve problems, and they need to weigh alternatives (advantages and disadvantages) by trying different solutions, evaluating the outcomes, and recycling the process as needed. In this way, lack of success in any one attempt will not be taken as complete failure, but rather such setbacks and lapses will be viewed as learning trials and occasions to consider alternatives.