Cognitive Behavioural Therapy for Chronic Pain

Everyone knows that pain is an inevitable part of life. Many times we fall down, hurt or injure ourselves and our body informs us that we are in pain and we should extend care towards it. We are suggested a number of strategies to deal with this pain. “Turn pain into power” is often preached to those who are suffering. However, this represents a grievously uni-dimensional and an extremely simplistic perspective of pain. While temporary pain resolves with the healing of its underlying cause, but for those who are suffering from chronic pain, the scenario is rather different.

A period of 12 weeks is the usual benchmark for considering acute or temporary pain to have transformed into chronic pain. The latter is considered to be relatively more disabling and debilitating and causing significant health, economic and emotional consequences.

According to a notable survey conducted by Saxena, Jain and Bhatnagar in 2018, 19.3% of the Indian adult population (approximately 180 to 200 million adults) suffer from chronic pain and much of it remains unrelieved and untreated. A majority of these individuals are females and belonging to the age group of 60 and above.

Several psychosocial problems such as distress, anxiety, depression, unemployment, marital issues and suicide occur as a result of chronic pain which also increase affective experiences of anger, fear and frustration. Most individuals find it difficult to effectively navigate through these emotions and the negative mental spaces that take a toll on every other area of their lives. Here, psychologists play an important role in helping individuals deal with such emotions in an effort to soften the demanding process.

Individualized psychotherapeutic programs for pain management are devised in order to help clients better understand and manage their emotions. Some of these techniques include mindfulness, hypnotherapy, coping skills training, and acceptance based interventions amongst several others.

One such procedure is referred to as cognitive-behavioural therapy (CBT). When therapists use CBT as a pain management technique, instead of eradicating it, they focus on helping individuals learn how to better manage their pain and the feelings, behaviours and thought processes that accompany the discomfort. A CBT therapist aims to provide a supportive and empathetic environment in which the client and the therapist actively and collaboratively work towards pain management through cognitive restructuring techniques and behavioural strategies.

The following strategies provide a general understanding of CBT applied for pain management-

1. Psycho-education

In general, psycho-education refers to the process of providing an understanding of the client’s current mental health difficulties to him/her through relevant facts. This has been widely helpful in providing clients with the ability to understand the impact their condition has had on different areas of their lives and to process emotions regarding it. In psycho-education for pain management, the client is given an opportunity to re-conceptualise their pain from a biomedical standpoint to a more multidimensional one.

In addition to this, an initial understanding of CBT is also provided. The CBT therapist attempts to facilitate an individual’s identification, awareness and evaluation of his/her thoughts with respect to their overall rationality and helpfulness. The knowledge of negative automatic thoughts that we tend to engage in on a general basis such as catastrophizing, dichotomous thinking, generalization amongst others are identified through practice and eventually altered in order to enhance and influence adaptive mood and behaviours.

2. Behavioural Strategies

In the initial stages of therapy, behavioural strategies which are a part of CBT can be utilized in order to help clients understand the impact of behaviour on emotions. Chronic pain often leads to avoidance of activity and fear of movement. Therefore, the need for appropriate physical exercise is provided to the clients and an activity schedule is collaboratively devised. This encourages participation in different enjoyable and meaningful activities and reduction in future avoidance of them. Through activity pacing, the client’s day is divided into activity and rest cycles so that he/she can accomplish tasks in a thoughtful and sensible way.

3. Pain Diary and Cognitive Restructuring

Clients are advised to maintain a journal to write down their negative automatic thoughts related to pain as explained to them during psycho-education. Thought processes like “I can’t handle it”, “I want my life to end” and their underlying negative emotions are altered by systematically analysing them and then disputing them. As the client attempts to challenge his/her unhelpful thoughts, alternative balanced and adaptive thoughts are discussed to replace them. With enough practice, clients become more accustomed to recognizing how their emotions, cognitions, and interpretations modulate their pain in positive and negative directions. This would result in them gaining greater perception of control over their pain. Simultaneously negative self-talk is challenged and adaptive coping methods are reinforced.

4. Distraction and relaxation techniques

Chronic pain brings with it extreme stress which tends to compromise the immune system and lead to an increase in health ailments such as heart disease, diabetes and more, which tend to further increase pain. To tackle this stress, the client’s preoccupation with pain is reduced by diverting their attention through different relaxation exercises such as guided imagery, deep breathing, and progressive muscle relaxation. These have been found to be helpful in keeping the client’s stress levels under control.

The effectiveness of CBT interventions for relieving chronic pain continues to be studied extensively to this day. Many clients yield significant benefits as CBT has shown to have a positive impact on their emotional and functional well-being, and therefore essentially improving their perceived quality of life. Overall, the clients move forward from experiencing helpless, dependent and passive lifestyles towards becoming more active agents in the process of self-management of their pain.

-Tanya Bakshi

Psychologist

Chetana Counselling Centre, Pune

References

(2020). Retrieved 13 May 2020, from https://www.apa.org/helpcenter/pain-management.pdf

Kumar, S. and Mohanty, S. (2007) Psychological Management of Chronic Pain. Journal of Indian Health Psychology. 2:121-127

Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs.

Roditi, D., & Robinson, M. E. (2011). The role of psychological interventions in the management of patients with chronic pain. Psychology research and behavior management, 4, 41–49. https://doi.org/10.2147/PRBM.S15375

Saxena, A. K., Jain, P. N., & Bhatnagar, S. (2018). The Prevalence of Chronic Pain among Adults in India. Indian journal of palliative care, 24(4), 472–477. https://doi.org/10.4103/IJPC.IJPC_141_18

Sturgeon J. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag.2014;7:115-124 https://doi.org/10.2147/PRBM.S44762