behaviors that suggest good adaptation to pain and functioning in spite of pain, such as functional independence, exercise, and persistence in pleasurable activities. A sample eight-session
course of CBT for chronic pain is presented in Appendix C. Figure 3 presents a flowchart based on a clinical vignette to illustrate the core principles of CBT in chronic pain.
Figure 3: Illustration Of Cognitive-Behavioral Conceptualization in Chronic Pain Vignette : You are asked to evaluate a 54-year-old construction foreman with depression, chronic temporomandibular pain and headaches, and suspected alcoholism. As part of your assessment, you learn that this patient has catastrophic thoughts about his pain (such as “this pain has ruined my whole life”). His coping repertoire includes drinking between six and eight beers per night before going to sleep. As a result, he is often hung over at work, and was recently put on a temporary paid suspension because he neglected key safety procedures. He has restricted many of his activities outside of work due to pain, and is essentially sedentary when not at work. He lives with his wife and an adult daughter who are deeply concerned about his well-being, and who have taken on most of the household roles to allow him to rest. He feels that his pain is worsening, and his physicians have determined that he is not a good candidate for temporomandibular joint surgery. A diagram illustrating the CBT conceptualization of these problems is presented below. The final three boxes (Behavioral Consequences) may then feed back onto earlier boxes in a cycle.
for the CBT therapist to include up-to-date information regarding the patient’s medical status in order to set realistic expectations for physical functioning. Summary of empirical support for cognitive-behavioral therapy in chronic pain The literature describing the effects of CBT on pain is complicated, chiefly because studies are not consistent in their use of a pain population (e.g., headache pain versus cancer pain) and often include a varied number of techniques under the umbrella of CBT. However, in general, randomized controlled trials have repeatedly shown that CBT is more effective than standard medical care alone for treating certain aspects of chronic pain. Specifically, most of the available evidence suggests that CBT engages the patient in an active process which changes their behavioral and cognitive components as it relates to the perception of their chronic pain (McAbee, 2018). That is, individuals in CBT may learn to feel better about their pain, to be more active and independent, and to experience less depression and anxiety as a result, although their actual pain intensity may not decrease. Cognitive-behavioral therapy has been found to be more effective than standard medical treatment in decreasing difficulties with depression and interference with
In applying CBT to chronic pain, it is important to identify the factors in the environment that are reinforcing negative pain behaviors or punishing well behaviors and to work on targeting those factors directly. The individual behaviors and their reinforcers are assessed through a combination of methods, including direct patient observation, questionnaires, and patient self-monitoring, and are then included in a list to guide treatment. Targeting of well and negative pain behaviors may take place in session (by verbally reinforcing functioning and ignoring pain behaviors) and out of session (e.g., by encouraging the individual to maximize independence or continue pleasant activities despite pain). However, given the degree of control over a patient’s environment that is often necessary to change behavior, treatment will often include spouses or family members – especially when family members are inadvertently providing most of the reinforcement for negative pain behaviors. Therefore, early in CBT treatment, the client’s family members and significant others often receive education regarding the model and are asked to pay less attention to negative pain behaviors and to reinforce competing well behaviors (such as activity, exercise, and expressions of confidence). Naturally, this approach may be perceived as “tough love” and must be presented and discussed with compassion. It is also important
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