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10 Minute CBT in Primary care
Introduction to CBT & chronic pain
Dr Alison Salvadori
Consultant Clinical PsychologistClinical Service Manager
Talking Therapies
Aims of session
• Introduction to 10 minute CBT
• Using CBT with people with chronic
pain during a brief consultation
• Resources & further training
• Support from Talking Therapies
Aims of psychological approaches in chronic illness
◼ Improve relationships with health professionals
◼ Increase functional activities
◼ Improve mood and quality of life
◼ Symptom control
◼ Encourage self-management and care of chronic disease
◼ Reduce repeated attendances due to emotional factors (e.g. excessive anxiety)
Principles of CBT
◼ How we think (cognitions) influences how we feel (emotionally andphysically) and our behaviour
◼ Our internal reactions are not simply related to events but to the meaning we attach to a particular event
THOUGHTS
FEELINGS BEHAVIOUR
PHYSICAL SYMPTOMS
ENVIRONMENT
The Five areas or Cognitive-Behavioural Model (CBM)
‘Men are disturbed, not by things, but by the principles and notions which they form concerning things’
Epictetus AD 55-135
The basic cognitive principle
Event Emotion
Event Cognition Emotion
The ‘common sense’ model
The cognitive model
The importance of thoughts
◼ It is not events that matter, but the meaning of these events to the particular individual
◼ The same event will have different emotional consequences depending on the interpretation
◼ Therefore, to understand people’s distress, we must first understand their thoughts (cognitions)
◼ Empathic statements:
◼ “I can understand why you might be feeling so low if you are having the thought that you are a failure....”
Changing unhelpful thoughts
◼ One aim of CBT is to identify and evaluate any distressing thoughts that interfere with functioning
◼ We may be able to reduce distress by helping people to change their perspective
◼ Thoughts best viewed as opinions open to investigation and evaluation rather than facts
◼ Highlighting and labelling (rather than arguing with) unhelpful thoughts can be helpful in brief consultations
The role of behaviour
◼ Behaviour or what we do can also affect how we think and feel
◼ Some behaviours designed to ‘cope’ with problems may actually have a key role in maintaining them by creating a vicious cycle
◼ CBT suggests that changing behaviour is a powerful way of changing thoughts and emotions
◼ Facilitating behaviour change is one of the most important interventions for the primary care setting
Case example 1:
John has severe, intractable back pain and has given up work due to the pain.
How might he react to this life experience?
Different thoughts cause differing feelings and behaviour….1
Thoughts My life is ruined by this pain. I’m a worthless person because I can’t work. What’s the point in living?
Feelings
Physical symptoms
Behaviour
Different thoughts cause differing feelings and behaviour….
Thoughts My life is ruined by this pain. I’m a worthless person because I can’t work. What’s the point in living?
Feelings Sad / low / depressed
Physical symptoms
Pain worsens. Lethargy, tiredness.
Biological symptoms of depression
Behaviour Stop self-caring. Reduce activity levels, excessive resting. Withdraw
from others.
Different thoughts cause differing feelings and behaviour….2
Thoughts What if this is actually due to cancer? The pain could become even more unbearable.
Feelings
Physical symptoms
Behaviour
Different thoughts cause differing feelings and behaviour….2
Thoughts What if this is actually due to cancer? The pain could become even more unbearable.
Feelings Anxious, panicky
Physical symptoms
Shaky, sweaty, racing heart. Other anxiety-related symptoms
Behaviour Try not to think about the worst, avoid reminders of illness or excessive reassurance-seeking (frequent attendances at health professionals)
Different thoughts cause differing feelings and behaviour….3
Thoughts This is wrong! It’s not fair. I shouldn’t feel this way! The doctors should be doing more to help me!
Feelings
Physical symptoms
Behaviour
Different thoughts cause differing feelings and behaviour….3
Thoughts This is wrong! It’s not fair. I shouldn’t feel this way! The doctors should be doing more to help me!
Feelings Angry, bitter, resentful
Physical symptoms
Physical tension (may worsen pain), Difficulty sleeping
Behaviour Aggression towards family and medical professionals
THOUGHTS
FEELINGS BEHAVIOUR
PHYSICAL SYMPTOMS
ENVIRONMENT
The Five areas or Cognitive-Behavioural Model (CBM)
Using the CBM in primary care consultations
◼ The five-areas CBM is an effective starting point for bringing CBT strategies into a primary care consultation
◼ Simply ‘map out’ problems by asking relevant questions from each section of the chart
Choose a recent, typical and specific example to discuss
◼ Encourage the patient to choose the most important issue from the agenda to cover first
◼ Then ask for a specific and ‘typical’ example of the problem
◼ Who? What? Where? When? What happened?
◼ E.g.: Last Friday morning when I accidently broke a coffee cup, I started to feel very low and tearful....
Explore an example using the CBM: Useful questions
ThoughtsWhat was going through your mind?
Did you have any images?
What did you say to yourself?
What’s the most difficult thing about this?
What’s the worst that might happen?
Feelings
How did you feel emotionally?
How did that thought make you feel?
You seem quite [sad] when you say that...?
BehaviourWhat did you do when...?
How do you usually react in that situation?
Is there anything you are avoiding now?
What would you do differently if you felt better?
Physical symptoms
Which physical symptoms did you notice?
How is this affecting you physically?
Which symptoms bother you most?
What was happening in your body?
Background / environmental factorsWhat else is going on in your life that could be affecting how you feel?
Are there demands at home? Are there financial difficulties?
Do you have someone you can talk to about the problem?
Are there difficulties at work? Are you unable to work / unemployed?
Pain
◼ Pain can be a symptom of many long-term conditions
◼ Depression, anxiety, lack of distraction and lack of sleep all heighten the experience of pain
◼ Loss of fitness, stamina and flexibility mean that ordinary daily activities result in increased pain
Gate control theory of pain
◼ Pain ‘messages’ flow along peripheral nerves to the spinal cord and brain
◼ There are ‘nerve gates’ in the dorsal horn of spinal cord
◼ These inhibit (close) or facilitate (open) nerve impulses from the body to the brain
◼ When the ‘gates’ are more open, an individual will experience more pain (and v.v.)
◼ These ‘gates’ are influenced by many factors (including diameter of the peripheral nerve fibres and ‘instructions’ coming down from the brain)
Factors which open the pain gates (increase pain)
◼ Emotional: depression, anxiety, anger, stress, helplessness and hopelessness
◼ Physical: inactivity, injury, long-term use of drugs
◼ Behavioural: Poor pacing of activities, excessive resting, having no outside interests, avoidance behaviours designed to eliminate pain
◼ Cognitive: focusing on pain, worrying about pain, remembering bad things associated with the pain, low self-esteem and self-criticism
Factors which close the pain gates (reducing pain)
◼ Emotional: positive attitude, decreasing depression, taking control of your life, stress management
◼ Physical: relaxation training and meditation, short-term use of pain medication, aerobic exercise
◼ Behavioural: increasing activity levels, outside interests and hobbies, social interaction
◼ Cognitive: distraction from the pain, thoughts that
help cope with the pain, acceptance strategies
‘Boom and bust’ syndrome
◼ Patients in pain often reduce their activity levels
◼ Then on a ‘good day’ they over-exert themselves and
become exhausted
◼ This leads to an overall reduction in physical fitness
and reinforced belief in the need for constant rest
“I must rest all the time, I can’t do anything without becoming exhausted”
Overview of chronic pain
Thoughts
Pain ‘catastrophising’; unhelpful beliefs about the best way to cope
with pain (e.g. I should always rest)
Hypervigilance (constant thinking or worrying about pain)
Low self esteem & self criticism
Feelings
Low mood
Anger and frustration
Anxiety and worry
Behavioural factors
‘Pain behaviours’ e.g. Sighing, groaning, talking about pain
Reduced activity; excessive rest
Social isolation and withdrawal
Avoidance behaviours designed to eliminate pain
Physical symptoms
Pain, weakness and stiffness
Lethargy and fatigue, Poor sleep
Anxiety-related symptoms
Side effects of medication
Management of chronic pain
◼ Acknowledge that the pain is extremely distressing and disruptive to patients’ daily lives
◼ Holistic (dual) approach involves provision of both medical treatments and emotional support
◼ Change focus of treatment from curing or eliminating pain to coping with pain and improving lifedespite presence of pain
◼ Identify and treat concurrent mood disorders – e.g. significant depression with antidepressants
CBT strategies in chronic illness and LTCs
◼ Physical strategies
◼ Relaxation, massage, graded physical exercise
◼ Behavioural strategies
◼ Increase positive and meaningful behaviours, pacing,
goal-setting
◼ Cognitive strategies
◼ Acceptance, managing uncertainty, encourage self-
reassurance, distraction, distancing from negative
thoughts, problem-solving
Key messages: Introduction to CBT
◼ Thoughts, feelings (physical and emotional) and behaviour are linked
◼ May form vicious cycles that maintain difficulties
◼ Identifying the cycle may enable patients to make positive change
◼ HCP must be confident in helping patients identify and distinguish thoughts, behaviour, feelings etc
Recommended reading
Want to know more? Further modules available:
◼ Communication skills
◼ Anxiety
◼ Depression
◼ LTC
◼ MUS
How can we help you?:• Joint working
• Cost savings
• Improved engagement
• Increased self-management
•Reduced use of services
• Training provision
Getting a patient to see us:• Be upbeat – ‘there is some great support
available – are you interested?’
• Let us call them – don’t expect patient to self-refer
• We aim to improve coping and well-being
• Link between mind/body e.g. anxiety (palpitations) & depression (pain threshold)
• Psychologists work with all sorts of people to improve performance/functioning e.g. sports
• What have they got to lose by having a well-being call?
Berkshire Health Economics Evaluation CSRIs
Initial findings from 108 matched CSRIs (beginning and end of treatments)
• 26% reduction in GP appointments
• 67% reduction in ED attendances
• 60% reduction in Ambulance calls
• 50% reduction in X-Rays
• 3 months saving per patient approx £550 (& benefits
lasts 26m)
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Any questions?
Dr Alison SalvadoriConsultant Clinical PsychologistService Manager IAPT LTC
Talking Therapies 0300 365 2000
