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Cognitive Behavioral Therapy for Managing Pain

Francis J. Keefe, Ph.D.

Duke University Medical Center

Reprinted trom:Keefe, F. J. (1996). Cognitive behavioral therapy for managing pain. The ClinicalPsychologist, 49(3), 4-5.

I. Description of Treatment

Cognitive behavioral treatment (CBT) for pain management is based upon a cognitive-behavioral model of pain (Turk, Meichenbaum, & Genest, 1983). The hallmark of this modelis the notion that pain is a complex experience that is not only influenced by its underlying

pathophysiology, but also by an individuals' cognitions, affect, and behavior (Keefe & Gil,1986).

CBT for pain management has three basic components. The first is a treatment rationale thathelps patients understand that cognitions and behavior can affect the pain experience andemphasizes the role that patients can play in controlling their own pain. The second componentof CBT is coping skills training. Training is provided in wide variety of cognitive and behavioralpain coping strategies. Progressive relaxation and cue-controlled brief relaxation exercises areused to decrease muscle tension, reduce emotional distress, and divert attention trom pain.Activity pacing and pleasant activity scheduling are used to help patients increase the level andrange of their activities. Training in distraction techniques such as pleasant imagery, counting

methods, and use of a focal point helps patients learn to divert attention away from severe painepisodes. Cognitive restructuring is used to help patients identify and challenge overly negativepain-related thoughts and to replace these thoughts with more adaptive, coping thoughts. Thethird component of CBT involves the application and maintenance of learned coping skills.During this phase of treatment, patients are encouraged to apply their coping skills to aprogressively wider range of daily situations. Patients are taught problem solving methods thatenable them to analyze and develop plans for dealing with pain flares and other challengingsituations. Self-monitoring and behavioral contracting methods also are used to prompt andreinforce frequent coping skills practice.

CBT for pain management is typically carried out in small group sessions of 4 to 8

patients that are held weekly for 8 to 10 weeks. The groups are typically led by apsychologist or psychologist-nurse educator team.

II. Summary of Studies Supporting Treatment EfficacyAlthough CBT can be used in managing acute pain (Jay, Elliot, Ozolins, & Pruitt, 1985), thetreatment procedures described above are those that are most commonly used in the management

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of persistent pain. Randomized, controlled studies have been carried out with a number ofpatient populations. Turner and Clancy (1988) demonstrated the usefulness of CBT in themanagement of chronic low back pain. CBT produced significant decreases in physical andpsychosocial disability when compared to a waiting list control condition. The improvementsreported by patients receiving CBT were maintained up to 12 months following treatment.

Bradley, Young, Anderson et al. (1987) conducted a study of CBT in patients having rheumatoidarthritis and found that CBT was superior to both a social support control and no treatmentcontrol group in reducing pain behavior, disease activity, and trait anxiety. In our own lab wehave evaluated the efficacy of CBT in managing osteoarthritic knee pain (Keefe, Caldwell,Williams et al., 1990). At post-treatment, CBT produced significant reductions in pain andpsychological disability relative to an arthritis education and standard care control conditions.Syrjala, Donaldson, Davis et al. (1995) have recently demonstrated the efficacy of CBT inmanaging cancer-related pain. Thus, evidence suggests that CBT is effective in treating bothchronic pain conditions such as back pain and persistent disease-related pain conditions such asarthritis or cancer.

III. Clinical References Describing the Approach

Keefe, F. J., Beaupre, P. M. & Gil, K. M. (in press). Group therapy for patients with chronic

pain. In R. J. Gatchel & D.C. Turk (Eds.), Psychological approaches to pain management:

A practitioner's handbook. New York: Guilford.

Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: Acognitive-behavioral perspective. New York: Guilford Press.

IV. Resources for Training

Formal training in CBT for pain management is often available through workshops held at theAmerican Pain Society, International Association for the Study of Pain, and the Association forthe Advancement of Behavior Therapy. Several centers conducting trials of CBT also provideinformal training, predoctoraI training, psychology internship rotations, or postdoctoralfellowships in CBT pain management. For information about training opportunities at thesecenters contact:

Laurence A. Bradley, Ph.D. Division ofRheumatology

429 Tinsley Harrison Tower

University of Alabama-Birmingham

Birmingham, AL 35294

Francis J. Keefe, Ph.D.

Director, Pain Management Program

Box 3159

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Duke University Medical Center

Durham, NC 27710

Dennis Turk, Ph.D.

Center for Pain Evaluation/Pain Treatinent Institute Center for

Sports Medicine and Rehabilitation Baum Boulevard at Craig

St.Pittsburgh, P A 15213

v. References

Bradley, L. A., Young, L. D., Anderson, J. 0., Turner, R. A., Agudelo, C. A., McDaniel, L. K.,Pisko, E. J., Semble, E. J., & Morgan, T. M. (1987). Effects of psychological therapy on painbehavior of rheumatoid arthritis patients: Treatment outcome and sixmonth follow-up. Arthritis&Rheumatism, 30, 1105-1114.

Jay, S. M., Elliot, C. H., Ozolins, M. & Pruitt, C. (1985). Behavioral management of children'sdistress during painful medical procedures.Behaviour Research and Therapy, 23, 513-520.

Keefe, F. J., Caldwell, D. S., Williams, D. A., Gil, KM., Mitchell, D., Robertson, D.,Robertson, C., Martinez, S., Nunley, J., Beckham, J. C., & Helms, M. (1990). Pain copingskills training in the management of osteoarthritic knee pain: A comparative study.

Behavior Therapy, 21, 49-62.

Keefe, F. J., & Gil, K M. (1986). Behavioral concepts in the analysis of chronic painsyndromes.Journal of Consulting and Clinical Psychology, 54, 776-783.

Syrjala, K L., Donaldson, G. W., Davies, M. W., Kippes, M. E., & Carr, J. E. (1995).Relaxation and imagery and cognitive-behavioral training reduce pain during cancertreatment: A controlled clinical trial. Pain, 63, 189-198.

Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: Acognitive-behavioral perspective. New York: Guilford Press.

Turner, J. A. & Clancy, S. (1988). Comparison of operant-behavioral and cognitivebehavioralgroup treatment for chronic low back pain.Journal of Consulting and Clinical Psychology, 58,573-579.