CBT addresses the correction of distorted thinking processes and the development of strategies (coping) with which to deal effectively with pain, its effects, and psychosocial stressors. CBT has been applied to a number of different chronic pain problems, including low back pain, headache, fibromyalgia, osteoarthritis, rheumatoid arthritis, and temporomandibular joint disorders (Turner and Chapman 1982a). Empirical evidence suggests that CBT is as effective in facilitating psychological adjustment and reducing reported pain levels as standard medical treatment conditions (Compas et al. 1998; Keefe et al. 1992; Morley et al. 1999). However, when return to work was assessed among patients with low back pain specifically, CBT was found to be no more effective than control situations (Scheer et al. 1997).
CBT focuses on internal appraisals of pain and disability by examining and addressing the cognitions, emotions, and behaviors associated with pain and pain-related activities. Conducted in about 8-12 fifty-minute sessions, the therapy is structured, with clear agendas set by the patient and therapist focusing on prominent areas of concern for the patient. The therapist is directive, guiding the use of homework treatments, outlining exercises, and assessing the efficacy of the modalities employed, yet this role remains flexible, with the patient's input guiding any shifts undertaken in the therapy. CBT assumes a collaborative effort between the patient and therapist (Fishman and Loscalzo 1987).
The model for understanding the approach of CBT is illustrated in Figure 6-1. In this model, disturbed emotional and behavioral responses are a direct function of specific maladaptive cognitions (i.e., one's beliefs, expectations, and thought processes). These in turn lead to an array of physiologic changes that can precipitate or exacerbate pain. CBT emphasizes modification of maladaptive cognitions and beliefs (schemata) and the development of effective coping strategies. CBT provides patients with direction and instruction to reappraise thoughts and events occurring in their life experiences. Faulty appraisals and misattributions are reframed and replaced with those that are reality-based (i.e., less irrational). The presumption, then, is that there will be less physiologic arousal occurring within the patient. This diminished arousal in turn would be less apt to accentuate the individual's pain experiences.
In CBT, it is recognized that the patient often cannot control or avoid distressing life events. However, the patient can almost always exert some control over how much distress, suffering, and life disruption those events produce. This control can be achieved by altering one's perceptions of these events, their significance, and their meaning, and by altering one's coping. Unlike in other psychotherapeutic approaches, external contingencies of reward, internal dispositions, and acquired developmental processes are de-emphasized.
The patients with the best long-term results are those who apply CBT skills learned in session to real-life situations. In these sessions, homework is required. This homework entails keeping a diary (much like the pain diary described in Chapter 3 of this book), in which the patient records his or her levels of pain in different situations, along with feelings and thoughts occurring at the time. Homework assignments, if completed properly, help the patient and therapist identify those situations, moods, feelings, and thought processes associated with pain. This process then highlights the points of interventions to work on in therapy (i.e., which cognitions require restructuring and when to employ coping strategies).
Cognitive restructuring, an interactive process involving the Socratic method, is used to teach patients to identify and modify maladaptive, negatively distorted thoughts that may lead to negative feelings, such as depression, anxiety, and anger. The patient is encouraged to examine irrational, self-defeating thoughts and discriminate between these and more rational alternatives. For patients with pain, emotional reactions to pain can be greatly influenced by thoughts. Coping skills training is aimed at helping patients develop a reper-
Cognitive restructuring ^^^
Disturbed emotional and behavioral responses Physiologic changes
Coping skills training
Steps involved in
Cognitive restructuring: Examine one's thoughts. Test the "accuracy" of the thoughts. Identify those thoughts that are maladaptive. Replace the maladaptive thoughts with those that are reality-based.
Coping skills training: Examine one's existing coping skills. Determine the usefulness of existing coping strategies.
Identify those strategies that are maladaptive. Replace the maladaptive coping strategies with reality-based, adaptive alternatives.
Figure 6—1. Modalities involved in cognitive-behavioral therapy.
-P* ui toire of skills for managing pain and stress and providing patients with a general set of problem-solving or coping skills that can be used in a wide range of situations that induce pain.
Coping refers to the strategies used by the person to deal with the pain and life stressors (Weickgenant et al. 1993). The strategies employed are based on how the person appraises a given situation or life event. Components of appraisal include the value or significance the person assigns to the event, the perception of the impact of the event, and the assessment of the resources the person believes himself or herself to have with which to deal with the event.
The diversity and range of coping strategies employed might signal that the patient's repertoire of dealing with pain and its effects on his or her life requires modification. Ineffective coping may possibly be associated with psychiatric disturbances such as depression. For example, depressed patients with low back pain were found to be restricted in the range and types of coping strategies they used when compared with nondepressed patients with low back pain (Weickgenant et al. 1993). The therapist helps the patient develop a broader range of effective coping strategies by examining existing coping strategies, determining their effectiveness, and facilitating the development of a broader range of strategies. Different strategies may need to be employed in different settings, and patients may need assistance in deciphering which strategies would be most effective.
Active coping can involve developing problem-solving strategies (e.g., problem-focused coping, social support seeking). By contrast, passive coping involves internal self-statements that the patient learns to say to him- or herself to facilitate coping and might include wishful thinking, self-blame, and avoidance. For example, depressed patients with low back pain were inclined to be less productive and to employ passive coping strategies when dealing with life stressors, whereas nondepressed patients with low back pain employed active coping strategies. However, the latter group did employ passive coping strategies when attempting to deal with the pain experience (Weickgenant et al. 1993). Coping then may be either problem focused or emotion focused.
To help patients modify coping strategies, the therapist should identify currently employed strategies, assess the utility of these strategies (whether they facilitate the patient's relief), and point out, develop, and refine alternatives. Thus, the patient who tends to employ passive strategies, such as self-
blame and avoidance, might be encouraged to develop strategies that are more active and self-soothing.
CBT has the advantage of broad applicability in a number of situations. It is a relatively low-cost intervention and appears to be cost-effective. On the other hand, CBT has the disadvantage of requiring sustained active patient participation. Also, therapists need to have specialized training in CBT in order to use it effectively.
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