September 5th – 8th 2013
Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Using CBT To Treat Chronic Pain
Kate Feenan
Cognitive 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
Chronic Pain and Suffering
PAIN 2
Pain
Distress &
Discomfort
Poor
Functioning
Unwillingness
Inflexibility
Avoidance
Impact Of Chronic Pain
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)
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
The Biopsychosocial Model
Engel (1977), Wadell (1987) & (2002),& Turk et al. (1988)
Culture
SOCIAL
Social Interactions
The Sick Role
PSYCHO
BIO
Illness Behaviour
Beliefs, Coping,
Emotions, Distress
Neurophysiology
Physiologic Dysfunction
(Tissue Damage?)
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.
2.
3.
4.
5.
6.
Sound therapeutic alliance
Reconceptualise pain
Identify realistic goals
Present focus and structured
Identify obstructive factors/thinking errors
Reinforce progress acknowledging efforts and
achievements in self/activity management
Central Tenent of CBT
“Men are disturbed not by things,
but the views they take of them”
Epitecus
Cognitive Model of emotional disorders
(Beck 1967)
3 levels of thinking
Early life experiences
1. Development of schema, basic beliefs and Dysfunctional assumptions (rules)
Triggers/cues
Critical incident
2. Activation of schema, core beliefs and dysfunctional assumptions
3. Negative Automatic thoughts
Emotions
Behaviours
Physiological responses
The Maintenance cycle
Environment
Negative Automatic
Thought
Feeling
Physical
Behaviour
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 cycle
Environment
Social deprivation
Benefit dependence
Marital discord
Unhelpful employers
litigation
Thoughts
– there is something seriously wrong
- I cant go on like this
- hurt = harm
- Its not my fault
Feeling
Fear
Anxiety
Hopeless
Anger
Physical
Deconditioned
Pain
Tired
IBS
Obesity
Behaviour
Avoidant/inactive
Helpless
Dependent
Blame
Defining characteristics of CBT Interventions
Cognitive 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 Summary
Key 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 you
Any Questions?