CBT for Chronic and Persistent Pain

"Almost half the adult population is living with chronic pain," the Daily Mail reports. A major review suggests that around 28 million adults in the UK are affected by some type of chronic pain (pain that lasts for more than three months). However, behind the headlines, the findings need to be viewed with a pinch of salt as the responders were recruited from pain related links. This would artificially swell the suggested number of people that experience chronic pain – minimising the true picture of actual sufferers. So I thought I would take the opportunity to represent what the condition looks like. This is a typical (if there is such a thing) presentation of chronic pain, and a little bit about the journey we went on.

Mary (not her real name) had a road traffic accident two years before commencing Cognitive Behavioural Therapy for the management of her chronic pain. Fundamentally, chronic pain has a significant impact on quality of life. It usually leads to a disabling cycle of distress and prevents many people from living life to the full. Chronic pain is different from acute pain, sudden onset that is likely to be short-lived and requires a different approach to its management. There is no single treatment for the management of chronic pain, a problem that requires simultaneous attention to biological and psychosocial interventions. Cognitive behavioural therapy is the psychological treatment of choice for chronic pain. 

Mary was in her stationary car at a T-junction, when another car steered into her at 30 miles-per-hour. The car struck the front, forcing Mary’s car to complete a half turn. The other car then stopped suddenly by the side of Mary’s car, impacting her car at the initial collision. This severe jolt and abrupt halt caused Mary to slam against her driver door. Mary’s main injury from this collision was a broken pelvis, for which she was hospitalised but made a good physical recovery. At first, the break-in Mary’s hips caused her to be paralysed from the waist down. However, after three days she recovered some sensation in her legs which indicated that she would be able to walk again once she had recovered. Indeed, after six weeks of in-patient care, Mary was able to walk out of the hospital. Two years on, she has full physical movement of her legs and body. However, Mary is still experiencing persistent and chronic pain which becomes extreme after walking long distances. 

The fundamental principles of CBT promote the concept and application of long-term self- management and are crucial to enable the patient to reach and maintain their therapy goals in the long-term. At the beginning of treatment, the therapist will collaborate with the client to set goals to work towards as part of the subsequent course of therapy. In the initial stages of Mary’s therapy, her therapist wanted to know “what does the pain stop you from doing?” and “what would you be doing differently if your pain was not affecting your life?”. 

Mary identified her goals to be:

  • To be able to attend social events at least once a week with family and friends, g. going to the cinema, restaurants and parties
  • To go on my once a week to buy food shopping for the family
  • Twice a week, to either complete the school drop off or school pick up
  • To return to work full time, attending work 5 hours per week, fulfilling my role as a project manager in Building Control
  • To travel to at least one client meeting a week, being present for the duration of the meeting

Once initial goals are agreed, the next stage of therapy is to understand how the pain affects the individual. Here is Mary’s illustrated pain-cycle as an example:

 

Understanding the process of how ‘this-leads-to-this’ maps out the maintaining factors and identifies how the process affects her in a moment by moment. In CBT, we explore this cycle by looking at the relationship between thoughts, emotional feeling, physical feelings and behaviours as in the four systems model below:

 

After examining several situations, we start to build a picture of the maintaining factors of the condition. Maintaining factors could include helpful and unhelpful behaviours, thoughts, assumptions, physical reactions and emotions.

Identifying the maintaining factors, in light of the goals, directs the interventions to target changing or breaking the individual cycles of chronic pain. For Mary, this started by examining specific situations when she felt the most distress. Understanding what happened in a snapshot in time gave Mary insight into what could be done next. For example, we looked at what happened when Mary avoided social events:

It was looking at events in the example above that gave Mary the opportunity to build behavioural experiments to test out her assumptions about the relationship between pain and avoidance.

Experiments include pacing herself at social events, contrasting consistent and non-consistent days on pain medication and gently challenging the ‘no go’ list of activities, to name but a few.

A turning point in our therapy came from a behavioural experiment we devised after examining the consequences of not going to a restaurant for her sister-in-law’s birthday. She decided to accept a neighbour’s invitation to a BBQ with her family. It seemed achievable as she could ‘escape’. The results, which included working around the obstacle of an annoying gentleman who dominated the evening, reflected that she enjoyed socially navigating her way around him, satisfied by the tête-à- tête with her family and friends. When I asked, “and what about the pain?”, Mary said, “It was awful but not as bad as spending an evening with him”. Mary looked at the wall and reflected in silence for a moment and then just said three words that cemented her recovery: “… I get it”.

There are many CBT interventions available for the management of chronic pain. For Mary, she found the most useful techniques to be (in no particular order): 

  • Activity scheduling that targeted her assumptions about the harmfulness of pain
  • Pacing activities
  • Detached, mindfulness-based cognitive therapies (different from mindfulness)
  • Contrasting medication and non-medication days with different activities

By the end of therapy, Mary had returned to work full time and was achieving her other treatment goals 80% of the time. Together, we built up a therapy blueprint which is a working document of her treatment plan. This blueprint also detailed her understanding of what the problems were that she had worked on, and also what she had learnt. Importantly, this included the interventions that did not help, as well as the things that did help. Towards the end of therapy sessions were tapered off, giving Mary the opportunity to be her therapist.

The aim of the cognitive behavioural approach to chronic pain is not to eradicate the experience of pain. By definition, chronic pain is not going to go away. As therapists, the vital part of our role is helping clients to come to terms with this. It is crucial for the individual being treated to learn how to live and to have a full life. Acceptance can be a very difficult thing to reach, as it was for Mary. However, it allowed us to explore all the alternatives and map out how she would like her life to be, in light of her chronic pain. Sometimes, we all have to tolerate the unpleasant guest at a party.

References: 

NHS. 2016. Almost half of all UK adults may be living with chronic pain. [ONLINE] Available at:http://www.nhs.uk/news/2016/06June/Pages/Almost-half-of-all-UK-adults-may-be-living-with- chronic-pain.aspx. [Accessed 7 July 2016].

Article by Lee Grant BSc (Hons), MSc Mental Health Studies, BABCP Accredited.

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