September 5th – 8th 2013Nottingham Conference Centre, United Kingdom

www.nspine.co.uk

Using CBT To Treat Chronic Pain

Kate FeenanCognitive Behavioural

Psychotherapist

Agenda Understanding and Treating Chronic Pain

– Chronic pain and the importance of psychosocial factors– Inadequacies of the medical model– An evidence-based bio psychosocial model and CBT approach

What is CBT?

Key Characteristics of CBT

Using CBT to Manage Pain - Five Points for Intervention

Definition of pain

“An unpleasant emotional and sensory experience associated with actual or potential tissue damage, or described in terms of such damage”

(IASP, 1994)

What is Chronic Pain?PAIN 1 and PAIN 2

Distress & Discomfort

UnwillingnessInflexibility

Avoidance

Poor Functioning

Pain

Chronic Pain and SufferingPAIN 2

Significant psychosocial problems Depression, panic, anxiety Fears about the future Decreased pleasure in everyday activities Helplessness, self-esteem losses Impaired physical functioning Reduced frequency and quality of socialisation Significant role changes with family and work systems Side effects of treatment and medication Tremendous cost to society (human & economic)

Impact Of Chronic Pain

Medical Model - Making Things Worse?

It results in no cure or little pain relief, promotes fear avoidance behaviour and physical deconditioning which in turn contributes to increased pain

Focuses the patient on seeking a diagnosis, cure and pain relief and reinforces unrealistic treatment expectations

Adds to anxiety, fear about any unknown conditions, frustration, low mood and a sense of lack of control, helplessness and hopelessness

Encourages ineffective and high health care usage (e.g. multiple investigations with no clear benefit)

Consumes time and effort and can lead to postponement effective pain management and life

Opinion

• “Back pain is a 20th century medical disaster”(Waddell, 2000)

• ……………………………… “chronic pain patients would benefit more from having no medical treatment at all”.

Van Tulder, Koes and Bouter (1995)

Yellow Flags

Psychosocial Risk Factors/Obstacles to Recovery

A = Attitudes: pain is harmful, uncontrollable, one is disabled, passive attitude to rehab

B = Behaviours: fear avoidance, extended rest

C =Compensation: Lack of financial incentive to return to work, history of sick leave

D =Diagnosis and Treatment: health professionals sanctioning disability, expecting fix, conflicting explanations,

over utilisation of h/care

E =Emotions: Fear, anxiety, depression, useless

F =Family: Solicitous spouse, over protective partner

W =Work: Job dissatisfaction, belief that work is harmful

Illness Behaviour Beliefs, Coping, Emotions, Distress

CultureSocial Interactions

The Sick Role

Neurophysiology Physiologic Dysfunction (Tissue Damage?)

SOCIAL

PSYCHO

BIO

The Biopsychosocial ModelEngel (1977), Wadell (1987) & (2002),& Turk et al. (1988)

Psychological therapies for chronic pain

Behavioural – New ways of doing

Cognitive Behavioural- New ways of thinking

Mindfulness and Acceptance- New ways of being

Principles of Cognitive Behavioural Therapy for Chronic Pain

AIM: To help patient acquire cognitive and behavioural skills to overcome obstacles to living well with chronic pain

1. Sound therapeutic alliance2. Reconceptualise pain3. Identify realistic goals4. Present focus and structured5. Identify obstructive factors/thinking errors6. Reinforce progress acknowledging efforts and

achievements in self/activity management

“Men are disturbed not by things,

but the views they take of them”

Epitecus

Central Tenent of CBT

Cognitive Model of emotional disorders (Beck 1967)

3 levels of thinkingEarly life experiences

1. Development of schema, basic beliefs and Dysfunctional assumptions (rules)

Triggers/cuesCritical incident

2. Activation of schema, core beliefs and dysfunctional assumptions

3. Negative Automatic thoughts

Emotions Behaviours Physiological responses

The Maintenance cycle

Environment

Feeling

Negative AutomaticThought

Behaviour

Physical

Common pitfalls in human thought

• Catastrophising – turning mole hills into mountains• Overgeneralising – Drawing global conclusions• Filtering – Only acknowledging information that fits with belief • Labelling – Rigid references ‘I’m a failure’• Black and white – all or nothing• Personalising- interpreting events as being personally related• Fortune telling – predicting outcomes • Disqualifying the positive– negative observational bias, selective

perception • Emotional reasoning – Feelings as facts

The maintenance cycleEnvironment

Social deprivationBenefit dependence

Marital discordUnhelpful employers

litigation

FeelingFear

AnxietyHopeless

Anger

Thoughts – there is something seriously wrong

- I cant go on like this - hurt = harm

- Its not my fault

BehaviourAvoidant/inactive

HelplessDependent

Blame

PhysicalDeconditioned

PainTiredIBS

Obesity

Defining characteristics of CBT InterventionsCognitive interventions

Use of ‘socratic’ questioning and ‘guided discovery’ Spotting errors in thinking Modifying thinking errors Identifying alternative perspectives

Moving from extreme and unhelpful ways of seeing things to a more helpful and balanced way

Behavioural experiments

• Activity scheduling, graded task assignment – pacing, exposure

Establishing new ways of perceiving and acting

In SummaryKey Characteristics of CBT

Assumes that emotion and behaviour are largely determined by the way the individual interprets the world and events

Aims to help patients see the relationship between thinking, feeling and behaviour, together with their joint consequences.

Evidence based Empathic, active and collaborative Structured, focused and goal orientated Emphasis on the present Is educative Self help model

Thank youAny Questions?