Presentation on theme: "Leeds Institute of Health Sciences Is CBT what we do? Stephen Morley."— Presentation transcript:
Leeds Institute of Health Sciences Is CBT what we do? Stephen Morley
I really dont know … ` I dont know what you do or how it compares with a definition / description of CBT So is CBT what we do ?
An email from Neil – 4 April 2008 Im wrestling with the question: What do we mean by CBT in the pain management field? CBT = Cognitive Therapy with a strong Beckian flavour I am not entirely comfortable with this … reading … Dennis Turks chapters … he barely touches on the cognitive therapy tradition of Beck et al…. hes drawing on broad-based cognitive social learning theory tradition… with which I am much more comfortable!
Email from Neil …. … not sure that cognitive therapy as applied to depression, panic disorder etc can be simply borrowed and applied to chronic pain … an emphasis on the links between pain and emotion and risks psychopathologising chronic pain … I prefer my chronic pain models to be much broader and biopsychosocial … … Am I just getting old and out of step? … I recognise that a full and considered reply is a big ask but Id appreciate any pointers to CBT / pain and CBT literature that might help me to get my head round this.
A current usage of the term The term CBT varies widely and may include self instructions … relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about pain and goal setting … varying selection of these strategies … embedded in a more comprehensive pain management program that includes functional restoration, pharmacotherapy, and general medical management. Gatchel et al. Psychol Bull 2007; 133: p606
The evidence: What do people report they do? Unpublished data from Morley et al, Pain 1999: 80 1-13 CBT treatment components across trials Heterogeneity between studies Is the model like a shotgun or supermarket sweep?
General protocol in CBT Principles 1.Collaborative and consultative engagement 2.Active practice of skills 3.Education about chronic pain and its treatment Goals 1.Improved physical fitness 2.Reduced disability 3.(Re) introduction to work 4.Increase in effective problem solving 5.Increase in adaptive problem solving 6.Reduction in pain related fear 7.Reduction in pain related depression From: Morley & Eccleston, CBT for chronic pain in adults, In press Howards 3 Rs Remoralise Remediate Rehabilitate
Principles … Do you use behavioural principles ? Analysis of antecedents, behaviours and consequences –Setting conditions –Discriminative stimuli –Identify reinforcers –Contingency management Do you use key cognitive therapy elements? Identify core non-functional beliefs e.g. if I move I will harm myself Design individualised behavioural experiments to test belief – behaviour link
Issue 1: The influence of non-specific effects It is difficult to know whether change is due to non-specific effects –designing plausible controls Morley, Pain 2004: 109; 205-206. / Morley & Keefe, Pain 2007: 127: 197-198 CBT superior to WLC CBT Equivalent to other active treatments Plausible rival hypotheses: 1.Influence of expectation, therapist effects, group effects, attention etc. 2.Different treatments produce the same cognitive- behavioural changes (common process or different processes)
Issue 2: Precision of the cognitive model Getting more precise specifications of CBT-going beyond some changes in coping will be associated with and precede some changes in outcomes CognitiveOutcome Time to abandon brute empiricism not all possible pain –related coping strategies and attributions were assessed Nielsen & Jensen, Pain 2004;109: 233-241.
Issue 3: Testing causal models We need to test causal models 2 strategies –Cross lagged panel designs in trials and cohorts Pre treatmentEnd of treatment Causal process Outcome Pre treatmentMid-treatmentEnd of treatment Causal process Outcome
Cognitive mediators of change Several studies of correlations support perceived control, catastrophizing –Issues: temporal priority, autocorrelation, treatment specific (rather than just change), non-specificity for different outcomes Lag sequential regression analyses e.g. –Burns et al n < 90 (mid treatment to end of treatment) –Morley et al n = +500 (end treatment to 9/12 follow up) Control for treatment –Turner et al (2007) end of treatment to 1 year follow up –Individual mediator analysis: Perceived control, Self-efficacy, catastrophising –Group mediator analysis: Self efficacy
Issue 3: Testing causal models Experimental Defusion vs DistractionDefusion vs Thought Control Masuda et al BRAT 2004; 42: 477-485
Issue 4: Disaggregating chronic pain CBT for - –Chronic low back pain –Osteo arthritis –Rheumatoid arthritis –Fibromyalgia
Diagnostic category e.g. the headache personality –Transdiagnostic psychological processes Psychological typology – MMPI, MPI, SF36 –Structural models, description still need functional account for interventions Functional models –Fear avoidance –More general avoidance formulation Issue 4: Disaggregating chronic pain