ORLANDO – Patients often create an internal narrative that serves to delay or prevent recovery from chronic pain, which is why cognitive-behavioral therapy should be routinely considered among chronic pain control strategies, an experienced pain clinician said.
“CBT is designed to teach patients to identify maladaptive assumptions, thoughts, ideas, expectations, and attitudes. By teaching patients to shift from self-defeating thought processes to strategies for coping, they can be given the motivation and tools for change,” said Daniel M. Doleys, Ph.D., a psychologist and director of a pain management practice in Birmingham, Ala.
Dr. Daniel M. Doleys
Pain can be a conditioning process that patients reinforce with statements they tell themselves, such as: “I am disabled,” “I cannot function with pain,” and “There is nothing I can do for my pain,” according to Dr. Doleys, who spoke at the meeting, which was cosponsored by the Journal of Family Practice. These beliefs become self-established truths that might not change without an intervention that involves some form of retraining.
“CBT is an overarching term for a cluster of therapies,” Dr. Doleys said. Of these, acceptance and commitment therapy (ACT), which combines acceptance, mindfulness, and behavior-change strategies to increase psychological flexibility, is one example that is potentially useful in chronic pain patients, he said. Core principles, besides acceptance and heightened consciousness of one’s self within the current set of circumstances, include an emphasis on defining values and setting goals.
On the basis of these goals, patients can define a new narrative that they can use to replace thought processes that hold them back from change.
For some patients, the assertion that conditioned thoughts might be playing a role in sustained pain may come as “a bit of a shock,” Dr. Doleys said. Indeed, he suggested, patients need to understand these concepts and recognize their own motivation for change. In some cases, an unrecognized reward for enduring chronic pain, such as attention from others, can be a subtle but formidable obstacle to change.
“You cannot always know what is reinforcing to a patient,” Dr. Doleys noted. He indicated that even patients might not be aware of factors that contribute to a reluctance to take meaningful steps toward recovery. However, he cautioned that clinicians who never encourage their patients to address the psychological component could have the effect of “absolving patients from responsibility” for taking this step.
Characterizing chronic pain “as an experience, not an event,” Dr. Doleys suggested that one of the principles of CBT overall and mindfulness CBT strategies in particular is to change the orientation to adverse sensory signals. He cited work with animals in which fear conditioning can be unlearned. The data from these studies suggest new learning does not erase fear memories but changes the conditioned response.
There is a lengthening list of strategies, such as biofeedback, mindfulness training, and autogenic therapy, which have been used to help patients adapt to and eventually modify the impact of pain signaling. Dr. Doleys said individual studies of CBT for chronic pain have not been consistently supportive, but a 2013 Cochrane Reviews of CBT consolidating data from multiple studies does support a modest benefit overall. He suggested that CBT might not be a cure for chronic pain but part of a comprehensive strategy aimed at encouraging patients to focus on function and recovery rather than the narrower goal of pain control.
“Treat the patient, not the pain,” Dr. Doleys advised. In helping patients to work toward functional improvements, he suggested that patients must be given realistic expectations and enlisted to participate in their own recovery. CBT might be an important tool in this process.
Dr. Doleys reported financial relationships with Medtronic and Evzio. The meeting was held by the American Pain Society and Global Academy for Medical Education. Global Academy and this news organization are owned the same company.