hygiene). A patient may come to believe that a certain CAM approach is a “magic bullet” to cure his or her pain and focus all of his or her attention on the search for a perfect supplement or massage technique rather than on simple self-care and lifestyle
changes. In such a case, a healthcare provider may need to educate the patient about the importance of healthy living with chronic pain in conjunction with CAM use.
Psychosocial treatments Psychosocial treatments can be used in concert with pharmacological and CAM approaches for effective
respond in a way that is appropriate to the emotional intensity of the event as he or she perceives it but that is out of proportion to the way most people would respond to the same event. Such responses are often unhelpful or negative and serve to reinforce distorted cognitions, making the relationship cyclical. The role of the CBT therapist is to break this cycle by (a) overtly explaining this model and (b) working with the individual to identify, challenge, and replace unhelpful or irrational thoughts and the detrimental behaviors that result. Most CBT protocols include training in behavioral coping strategies such as stress management and relaxation (e.g., deep breathing, meditation), promotion of health behaviors (e.g., exercise, proper diet, behavioral alternatives to smoking), and a focus on behavioral activation (e.g., physical activity, socializing, engaging in pleasurable events and activities). In contrast with other psychotherapies, CBT tends to be skills based, prioritizing here-and-now symptoms and functioning over past events or experiences. Cognitive-behavioral therapy also tends to be more structured and formalized than general supportive psychotherapy and often involves homework activities. Cognitive-behavioral therapy for chronic pain The application of CBT to chronic pain is based on two ideas: that an individual’s beliefs about pain are associated with disability and mood problems resulting from pain and that changes in patients’ beliefs about pain are associated with improvements in functioning (Black, 2020; Wolters Kluwer Health, 2017). The cognitive (C) component of CBT for chronic pain focuses on promoting thoughts shown to contribute to functioning and well-being and challenging thoughts that maintain problems associated with pain. For example, patients who believe that their pain represents ongoing physical damage are unlikely to engage in exercise or stretching, and this inactivity may, in turn, make their pain worse. Patients who believe that their pain is completely overwhelming and unmanageable may become depressed and, as a result, they may withdraw from meaningful social relationships. The role of the CBT therapist is to teach the client how to identify his or her cognitions (thoughts and beliefs) about pain, evaluate whether these thoughts and beliefs are accurate or helpful, and change inaccurate or unhelpful cognitions into cognitions that are more accurate and balanced. This process is referred to as cognitive restructuring. Often, patients are asked to keep logs of weekly events that include their cognitions about the events and their emotional reactions, and to review these weekly logs in session. There is no standardized format for such a thought diary; however, Appendix B provides a sample format specific to pain. The behavioral (B) aspect of CBT for pain typically involves modeling of behavioral skills that have been shown to be helpful in reducing chronic pain, including engaging in pleasurable activities, problem solving, assertiveness and effective communication, persisting in tasks despite pain, exercising, and pacing activities (that is, getting things done at a steady pace, rather than in bursts of activity). The behavioral elements of CBT for pain also draw heavily on the operant conditioning principles described earlier in this course. Specifically, the therapist focuses on improving functioning by working to extinguish negative pain behaviors while reinforcing well behaviors. Negative pain behaviors are any pain behaviors that provoke reinforcement from the environment (such as praise, aid, or help) and are associated with poor outcomes and disability. Well behaviors are
management of chronic pain. These treatments may include feedback-based interventions, cognitive-behavioral therapy, and relaxation training. When managing chronic pain, the importance of collaboration and treatment coordination among members of the healthcare team cannot be overstated. Effective interprofessional collaboration can help to coordinate individual treatment goals and foster improved patient outcomes for patients living with chronic pain. For a patient with chronic orofacial pain, such a team could include a dentist, a behavioral and/or mental health professional, and a physical therapist. Other members of such a team could include a neurologist and/or a neurosurgeon. For a dentist who is not familiar with prescribing drugs other than for acute pain, or for medically compromised patients, the team should also include the patient’s primary care physician. Brief feedback-based interventions Because chronic pain is a complex problem and involves many aspects of an individual’s life, the most widely used interventions (such as cognitive-behavioral therapy) involve multiple sessions over time. However, a few single-session interventions based primarily on education and problem-solving around chronic pain show promise. One such intervention is the use of the Pain Explanation and Treatment Diagram, which is designed to be completed by the clinician and the individual seeking care following a formal assessment for chronic pain (Pain-Ed, 2018). This intervention includes discussion of pain risk factors and problem-solving around common difficulties in chronic pain such as exercise, sleep, and problematic behaviors. This tool takes approximately 10 minutes to complete and is then provided as a reference to the person seeking care. The individual with chronic pain is encouraged to reflect on the relevance of each problem and to incorporate the recommended treatments into his or her lifestyle. Although there is no direct clinical evidence that this intervention reduces pain intensity or interference, patients have reported high levels of satisfaction and increased self-efficacy through its use (Pain-Ed, 2018). Longer-term psychosocial approaches to chronic pain management include cognitive-behavioral therapy and relaxation training. Cognitive-behavioral therapy Cognitive-behavioral therapy (CBT) is a treatment approach that originated with the work of the psychologist Albert Ellis and psychiatrist Aaron Beck in the 1950s and 1960s. Cognitive- behavioral therapy is one of the most validated and empirically supported forms of psychological treatment for a range of psychiatric disorders, including depression, anxiety, and behavioral control problems (American Psychological Society, 2017; National Alliance on Mental Illness, 2021). As its name indicates, CBT includes both cognitive (C) and behavioral (B) elements. In fact, CBT is really an umbrella term describing a large group of varied treatments. However, all CBT approaches have in common the basic idea that in conjunction with learning and behavior, an individual’s cognitions (thoughts, attributions, beliefs) can either enhance or interfere with effective coping. In the CBT model, environmental events do not affect mood and functioning directly but are first mentally processed by the individual. If an individual is prone to distorted thinking (such as ignoring positive information, catastrophizing, or taking things too personally), then the emotional impact of the event will become exaggerated and negative. The individual may then
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