17 AugCBT for Chronic Pain: An Integrative Approach to Pain Management by Kathryn Malone, LCSWThe pulsating throb of a migraine or dull ache of lower back pain can make it difficult to function at your best. When you spend most days feeling tired, achy or sore, it might feel nearly impossible to live the life you had once imagined. Effective pain management most often involves a multimodal approach, requiring various interventions such as medication, physical therapy, nutritional guidance, or participation in a support group. Additionally, individual counseling is often a key component of successful treatment, as chronic pain affects all aspects of functioning including mental health. Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) has proven to be a particularly effective modality of treatment when addressing the challenges of chronic pain. CBT focuses on the reciprocal relationship between our thoughts, feelings and behaviors with the understanding that we can create positive change by impacting just one of these domains. If we challenge an unhelpful thought, we can ultimately change the way we feel and what we do as a result. However, if left unchallenged, negative automatic thoughts can have deleterious consequences. For example, if a person experiencing chronic pain begins to feel hopeless (emotion), they might say to themselves “I will never be able to live an active life again” (thought) and then decide to stay in bed for the day (behavior). Uninterrupted, this cycle can ultimately lead to social isolation as well as depression. However, working with a CBT therapist, one can learn to challenge these cognitive distortions and develop a more adaptive way of thinking. The objectives of CBT-CP are to reduce the negative impact of pain on daily life by improving physical and emotional functioning and increasing effective coping skills. The therapist works with the patient in short-term, structured therapy sessions to aid in developing the following skills: Cognitive Coping – Negative automatic thoughts can heighten the perception of pain and lead to feelings of frustration and despair. Patients learn to identify and challenge unhelpful thinking patterns by using a thought record and developing a coping plan. Patients learn to label negative thought patterns such as catastrophizing (assuming the worst possible outcome will happen). Patients learn to challenge negative thoughts by asking questions such as “is this true?” or “is this thought helpful?” and develop positive coping statements that can be used when stressful situations arise. Exercise and Pacing – Avoiding physical activity to circumvent pain can lead to deconditioning over time. Patients begin an exercise program (such as walking, yoga, aquatic therapy, or riding a stationary bike) in order to increase strength and endurance and learn the skill of time-based pacing to ultimately find a balance between being sedentary and pushing too hard. Relaxation Training – Chronic pain leads to chronic stress which can activate the “fight or flight” response. Patients learn the pain management benefits of these relaxation techniques: deep breathing, progressive muscle relaxation and guided imagery. By implementing these skills, patients learn that they can return the body to a calm state. Pleasant Activities – Many people living with chronic pain find themselves avoiding activities they once enjoyed in an effort to reduce pain. Patients work towards increasing pleasant activities in their lives which not only offers a healthy distraction but often leads to increased socialization and a greater sense of purpose. After identifying pleasurable activities and planning implementation at a realistic pace, the patient also learns to identify obstacles and practices problem-solving strategies. Sleep – Poor sleep is often associated with chronic pain as it can be hard to obtain restful slumber when pain flares up. Patients learn to identify sleep interfering behaviors, create positive sleep associations and establish a consistent sleep-wake schedule in order to achieve restoration. The goal of CBT-CP is to help those suffering develop the belief that they can better manage and control pain. By implementing and practicing these essential skills, patients not only develop an increased sense of self-efficacy but they can actually change the way they experience and interact with pain and ultimately improve functioning in all areas of life.