September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom

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

Distress & Discomfort Unwillingness Inflexibility Avoidance Poor Functioning Pain Chronic Pain and Suffering PAIN 2

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) Impact Of Chronic Pain

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

Illness Behaviour Beliefs, Coping, Emotions, Distress Culture Social Interactions The Sick Role Neurophysiology Physiologic Dysfunction (Tissue Damage?) SOCIAL PSYCHO BIO The Biopsychosocial Model Engel (1977), Wadell (1987) & (2002),& Turk et al. (1988)

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.Sound therapeutic alliance 2.Reconceptualise pain 3.Identify realistic goals 4.Present focus and structured 5.Identify obstructive factors/thinking errors 6.Reinforce progress acknowledging efforts and achievements in self/activity management

“Men are disturbed not by things, but the views they take of them” Epitecus Central Tenent of CBT

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 EmotionsBehaviours Physiological responses

The Maintenance cycle Environment Feeling Negative Automatic Thought Behaviour Physical

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 Feeling Fear Anxiety Hopeless Anger Thoughts – there is something seriously wrong -I cant go on like this -hurt = harm -Its not my fault Behaviour Avoidant/inactive Helpless Dependent Blame Physical Deconditioned Pain Tired IBS Obesity

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?