CBT Variant Helps Patients Cope With Severe Pain

A type of cognitive-behavior therapy (CBT) called contextual cognitive behavior therapy may help patients with severe, persistent, and disabling pain, preliminary results published in the October Behaviour Research and Therapy suggest.

Lance McCracken, Ph.D., of the Pain Management Unit of the University of Bath in England, and colleagues studied 84 subjects with severely disabling chronic pain that had lasted for 11 years on average and that had not been relieved by surgery, opioid analgesics, or antidepressants.

Subjects were given intensive group therapy five days a week, six hours a day, for three or four weeks.

During this therapy, subjects were taught not only how to recognize pain sensations and negative thoughts having to do with pain, but to accept them as well. This approach runs counter to the traditional CBT approach to managing pain, which consists of first recognizing pain sensations and related negative thoughts, then trying to change or eliminate them.

An example of how the new approach works is as follows:

An individual in pain might be reluctant to attend a party because he or she thinks, “I can't attend because I hurt too much, and it's embarrassing to be around other people when I hurt.” The person would be encouraged to identify this faulty thinking pattern, but then to accept it—in other words, simply “bring the thought along to the party.”

The rationale for this approach is that by accepting pain or a pain-related thought a person can mitigate its distressing and disabling impact. In fact, in some studies using experimental lab conditions conducted by other researchers, acceptance of pain appeared to lead to greater pain tolerance than did psychological efforts to control pain.

In addition to being trained to accept pain and pain-related thoughts, subjects also embarked on other kinds of training designed to get them to tolerate pain and to engage in activity regardless of pain. For instance, they engaged in sensation-focusing exercises to come to the realization that it is possible to be active and enjoy life even when one is in pain. They performed relaxation exercises to increase bodily awareness and to improve productive functioning. They scrutinized their health habits and chose meaningful directions to pursue in their lives.

“We integrated the physical therapies, occupational therapies, and health education so that they worked along the same principles of the [psychological] treatment,” McCracken explained to Psychiatric News. “In a sense, the whole [package] was contextual cognitive-behavior therapy, including both acceptance-based and skills-training methods.”

The subjects were assessed with a battery of tests before treatment, after treatment, and three months later. The tests included the Beck Depression Inventory, the Pain Anxiety Symptoms Scale, and the Sickness Impact Profile, all of which are widely used for clinical outcome assessment and in research with chronic pain sufferers.

The subjects were found to experience significant improvement in emotional, social, and physical functioning following treatment, compared with their situations before being treated. For example, they demonstrated an 18 percent reduction in pain and in pain-related anxiety, a 25 percent reduction in physical disability, a 39 percent reduction in psychosocial disability, a 41 percent reduction in depression, and a 62 percent reduction in hours of rest needed daily because of pain.

Moreover, most improvement continued three months after the end of the therapy. For instance, compared with pretreatment score, the pain score at follow-up was 11 percent less, and depression was 41 percent less. Also at follow-up, as compared with pretreatment, analgesic use and physician visits were significantly reduced.

And as for subjects' Chronic Pain Acceptance Questionnaire scores, they had been 49 percent on average before the therapy began and were 61 percent on average at the three-month follow-up—a significant difference.

Thus, the psychological and physical improvements that the subjects experienced throughout the study appeared to be due to their increased acceptance of pain, McCracken and his group concluded.

McCracken said that his team has nine-month follow-up data, but have not yet analyzed it.

The study was funded by the Royal National Hospital for Rheumatic Diseases NHS Trust and the West Virginia University Eberly College of Arts and Sciences and Office of Academic Affairs.

An abstract of “Acceptance-Based Treatment for Persons With Complex, Long-Standing Chronic Pain: A Preliminary Analysis of Treatment Outcome in Comparison to a Waiting Phase” can be accessed at<www.sciencedirect.com> by clicking on “Browse A-Z” of journals, then “B,” then “Behaviour Research and Therapy.”> ▪