Cognitive Therapy in Pain Management

Cognitive/behavioral therapy has a number of objectives. The first is to help patients change their view of their problem from overwhelming to manageable. Patients who are prone to catastrophize benefit from examining the way they view their situation. What has been perceived as a hopeless condition can be reframed as a difficult yet manageable situation over which the patient can exercise some control.

The second objective is to convince patients that their treatment is relevant to their problem and that they must be actively involved both in that treatment and in their rehabilitation. They need to understand how relaxation training, cognitive restructuring, adaptive coping skills, and pacing behaviors can help decrease their pain. Patients must reorient their view away from that of passive victim to that of proactive, competent problem solver. When individuals are successful in managing painful episodes, their views change. They eventually begin to believe themselves capable of overcoming any acute flare-up of pain.

The third objective is to teach patients to monitor maladaptive thoughts and substitute positive thoughts. Persons with chronic pain are plagued, either consciously or unconsciously, by negative thoughts related to their condition. These negative thoughts have a way of perpetuating pain behaviors and feelings of hopelessness. Learning how and when to attack these negative thoughts and to substitute positive thoughts and adaptive management techniques is an important component of cognitive restructuring. Patients must be encouraged to attribute success to their own efforts; they need to feel that they are responsible for the gains they make. Finally, problems and lapses need to be discussed so that the patient will have an advance "game plan" to manage short-term setbacks.

Most chronic pain patients need support in maintaining their gains. Important aspects of contingency management include 1) giving specific homework assignments, 2) offering appropriate examples to patients, 3) helping to organize a daily routine and schedule, 4) recruiting support from family members, 5) encouraging outside activities and involvement, 6) linking the patient to appropriate resources, 7) monitoring progress and, 8) actively following patients after treatment.

One way patients actively participate in a pain management program is through regular monitoring of their own progress. By recording data on their pain intensity, activity levels, moods, and medications, participants gain a better understanding of their condition and of the factors that impact it. Regular monitoring takes time and effort but offers insights. Therapists should regularly inspect patients¹ forms and questionnaires to obtain up-to-date information and to underscore the importance of completing these documents.

Unfortunately, the progress made over the course of a structured program is sometimes reversed within six months. This outcome is inevitable for some proportion of the participants in any program designed to change behavior. A way to prevent relapse is to offer a structure for follow-up, possibly including individual sessions with the group facilitator and meetings with regular support groups.

This article was excerpted from the book Mastering Chronic Pain: A Professional's Guide to Behavioral Treatment. by BW Pain Management Center physician Dr. Robert N. Jamison, Ph.D., published by Professional Resource Press, Sarasota, FL, 1996.