, Kelly Smerz2 and Brad K. Grunert3, 4
(1)
Wisconsin Rehabilitation Medicine Professionals, Milwaukee, WI, USA
(2)
Milwaukee, WI, USA
(3)
Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
(4)
Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
Psychological factors play a major role in perception, reaction, and perpetuation of pain, especially in patients with chronic pain, as we have discussed in Chaps. 1 , 2 , and 3 . From the inception of multidisciplinary pain programs, psychological approaches have been the most important component to change and reverse “pain behaviors” and for teaching patients new strategies and approaches to improve their function despite pain. These techniques have included a very strict “operant model” in which physicians/clinicians, family members, third party payers, and society in general do not reinforce pain behaviors but help the patient to unlearn pain and disability behavior and replace them with well and healthy behaviors.
Cognitive and Cognitive Behavioral treatments, which teach coping with pain while improving function, have been the most common psychological approach to chronic pain along with specific relaxation and breathing techniques and biofeedback. All are useful in teaching our patients living with chronic pain to decrease their pain perception and regain control over pain. That is why Howard Rusk, M.D., one of the leaders in the field of rehabilitation once said “Medicine has added years to life, but rehabilitation adds life to years.”
This chapter, by Dr. Brad Grunert, a rehabilitation health psychologist and his colleague, Dr. Kelly Smerz, provides an excellent and up–to–date review of the role of the psychologist and Cognitive Behavioral coping strategies in helping patients with chronic pain. the evidence-based strategies. In conjunction with education, appropriate medications and physical rehabilitation are essential components of a multidisciplinary approach to treating individuals with chronic pain.
Dr. Grunert is a trusted colleague with whom I have worked for the past 30 years and I extend my sincere gratitude to him and Dr. Smerz for their contribution to this book.
Sridhar Vasudevan, M.D.
Cognitive Behavioral Therapy (CBT) interventions are the most widely used psychological approaches to managing chronic pain. These approaches rely on several common elements. The first of these is providing a rationale for the intervention. The patient and therapist collaboratively define what chronic pain is, how it differs from acute pain, and the differences between managing acute versus chronic pain. The rationale for implementing each CBT intervention is then developed with the patient. It is essential that patients not only comprehend the nature of the intervention but that they also are active participants in developing a plan for implementation. This collaborative approach between the therapist and the patient provides a platform for modifying and customizing each intervention to the particular needs and demands of each patient’s unique situation. While there are many similarities between patients in their development of a CBT intervention plan, the need for individualizing the plan is paramount to long-term success and commitment to managing chronic pain.
One of the frequent commonalities observed in the chronic pain population is the proclivity of patients to catastrophize their pain. Rather than developing strategies for coping with their pain, they engage in efforts to avoid provoking their pain. Typically this leads to decreasing activity, social withdrawal, and worsening depression. Patients begin to avoid the very things in their lives which made them meaningful simply as a means of controlling their exposure to pain. As this trend progresses, patients actually become physically debilitated, often to the point where they can no longer engage in previously enjoyable activities. They can no longer tolerate being up and around in social settings and their range of rewarding life experiences shrinks further. The loss of physical activity and social interaction results in depression and further isolation. By developing an understanding of the differences between acute and chronic pain, patients can formulate strategies to reverse these losses. Knowing that their chronic pain is benign and that decreasing activity and socialization will only magnify the morbidity associated with these conditions allows the chronic pain patient to consider alternate responses to their pain. This in turn assists them in abandoning the interventional role of medicine in “curing” their pain and leads to greater self-reliance in their pain management. It is at this point that CBT interventions are most likely to be successfully implemented into the management plan of the patient.
In this chapter we will present a variety of coping strategies for chronic pain. These will include: (1) relaxation/arousal reduction techniques; (2) self-talk; (3) stress-inoculation training; (4) internal distraction; (5) external distraction; (6) pacing; (7) mindfulness; and (8) acceptance and commitment strategies. While we will present basic components of each of these coping strategies, it is important to realize that these will only be successfully incorporated by the patient if they are personalized through collaboration with the individual who will be applying them. This collaborative process of tailoring the techniques is the core of the CBT intervention.
Relaxation/Arousal Reduction Techniques
Research shows that decreased arousal levels lead to a decreased subjective experience of pain and discomfort. There are a variety of techniques that have been developed to assist individuals in reducing their overall arousal level and consequently their subjective experience of pain. Relaxation training tends to enhance control over the individuals’ arousal level. It also enhances a sense of personal control and self-efficacy for the individual practicing it. Pain tends to be magnified by anxiety and relaxation is an excellent means to counteract anxiety.
One of the primary techniques developed in order to achieve relaxation is autogenic relaxation (Jacobson 1962). With implementation of autogenic relaxation techniques, the individuals focus on a particular area of their body and devote their attention to this. They focus on the desired sensations in that area of the body that they wish to achieve. An example of this may be something as simple as mentally repeating “my hands feel warm and heavy,” which they focus on in an almost meditative type of state. Systematically the individual would go through their entire body using various phrases to enhance their relaxation. There is a strong focus on controlled breathing throughout this type of relaxation. In many respects it shares a great deal with hypnotic induction except that there is no therapist who is conducting this with them.
Progressive muscle relaxation is a second technique that has been developed to assist individuals in reducing their overall arousal level (Bernstein and Borkovec 1973). Progressive muscle relaxation relies on a tension–relaxation cycle implemented by the individual. Again, the focus is on separate areas of the body at the beginning. This protocol initially begins with 16 muscle groups that are addressed in a systematic manner. The individual will tense the muscle group and then rapidly release the tension, triggering a relaxation response. As the patient becomes more proficient with this technique, the muscle groups are combined thereby shortening the induction. The speed with which the individual can achieve a deeply relaxed state increases. Again, there is a focus during this on controlling breathing to assist in triggering a deeply relaxed state.
Breathing control is a widely used relaxation technique. Deep controlled breaths allow patients to again decrease their arousal level. By taking a deep breath, holding it and then slowly exhaling, the individual can trigger a significant decrease in their overall arousal level. One of the advantages of using controlled breathing is that this is a technique that can be used anywhere at any time. It is not obvious to others when this is being implemented, even when out in public. The focus is truly internal and on an individual simply modulating their own breathing. This again enhances their sense of personal control and self-efficacy and gives them a relaxation technique that they can use anywhere, anytime.
A final technique that has been used to teach relaxation is biofeedback training. This can take a variety of forms. Typically, the individual is focusing on some type of physiologic feedback that is being provided to them with the goal of monitoring one’s overall arousal level. By decreasing their arousal level in various forms, such as increasing their hand temperature, decreasing their muscle activity or decreasing their heart rate, patients can learn how to achieve a more relaxed state. This training is then gradually generalized until the individual is able to accomplish this without the need of actually having the monitoring equipment present. Again, they are frequently able to achieve a deeply relaxed state which again counters the increases in pain that they may experience in various situations.
Self-Talk
Self-talk refers to that inner dialogue, or inner narrator, that exists inside each of us. This narrator provides a running commentary on our thoughts, emotions, interactions, and behaviors as we navigate through daily life. The nature of this inner dialogue is influenced by past and current life experiences that shape beliefs, attitudes, assumptions, and habits. The cognitive therapy component of CBT recognizes that the content of our thoughts can have significant consequences for our emotional state and our behavior. Often we become so habituated to our own style of thinking that we do not notice what it is that we are saying to ourselves. When all is well, this may not be a problem. However, during times of stress and distress these automatic thoughts can become overly negative and highly detrimental to our emotional well-being.
Certain patterns of self-talk, or problematic thinking, are common among chronic pain patients and are important targets for therapy. Catastrophic thinking, for example, is something we observe frequently in our work with pain patients. It is also well documented in the pain psychology literature (Caudill 2009; Ehde et al. 2014). In catastrophic thinking, worries, fears, and other anxieties become amplified in a manner that unnecessarily heightens distress and compromises coping. These catastrophic fears can be about the pain itself (e.g., “My pain is worse today and therefore it will never improve”) or the ways in which pain is perceived as impacting various aspects of the patient’s life (e.g., “I’ll never be able to do anything worthwhile again”). Negative beliefs and assumptions about oneself can also emerge as the person struggles to deal with the challenges of chronic pain. Changes or losses in valued roles or identities—breadwinner, homemaker, primary parent—can contribute to an inner dialogue that focuses on feelings of failure, worthlessness, and lack of value. If the despair associated with these thoughts is severe enough, suicidal thinking can ensue.
Cognitive therapy offers several strategies for targeting this maladaptive self-talk. Generally one of the first goals of treatment is to teach patients how to recognize their own self-talk. This can be challenging given that our thoughts patterns may be so subtle, automatic, or habitual, that we do not actually realize what we are saying to ourselves (“It’s just how I think, doc.”). After teaching the patient how to take his or her thoughts off “auto-pilot,” it can then be helpful to facilitate a sense of curiosity as to where certain maladaptive thoughts patterns originated. This type of intervention can guide patients in questioning their own attitudes, beliefs, and schemas, which may or may not be accurate in the context of chronic pain (e.g., “Where did you learn that you have less value as a person if you are unable to work?”). Through this line inquiry, patients can learn to challenge, reframe, and rethink unhelpful thought patterns that are compromising their well-being.
Stress Inoculation Training
Stress inoculation training was developed by Meichenbaum (1977) as an iterative process to assist people in confronting stressful situations. It has been adapted for use with chronic pain patients as a means of assisting them in planning ahead and coping with situations and then refining their coping skills and abilities. Stress inoculation training is heavily reliant on skill acquisition and implementation with subsequent reevaluation and fine tuning of the process. Once skills are acquired by the individual, a plan for using them in response to particular stimuli or situations is developed. The skills can be any of the many cognitive coping skills that are discussed in this chapter. These skills are then applied in response to the stimuli which provoke increases in pain or present particular challenges to individuals encountering them. These challenges can include both the emotional aspects, as well as the physiologic demands of confronting various situations. After the individual addresses the set of stressful stimuli and incorporates the coping plan, the application is then reviewed with identification of strengths and weaknesses of the implementation as it took place. This is then followed up by additional planning and skill acquisition for future implementation when this particular constellation of stressors is again encountered.
An example of applying stress inoculation training in the context of chronic pain may be something as simple as shopping at a mall. It is important to identify what the constraints of the situation are. The individual hopefully will have a map of the shopping mall available to them. They can then plan how far it is for them to ambulate from an area where they park into the mall. They can identify appropriate rest points where they can sit and practice some of the skills available to them. They can focus on whether or not they are able to pace themselves appropriately and build in stop points throughout the entire task. Additionally, they can identify whether or not they need a cart or someone to accompany them in order to carry any of the goods that they buy.
These patients also need to determine what skills are available to them and how applicable these are to the particular setting. These skills may include techniques such as internal distraction, appropriate self-talk, external distraction or pacing. They then proceed with implementing the plan. Following this they go back and revisit how successful they were in accomplishing the task that they outlined and how successful they were in implementing their skillset to cope with the difficulties that arose. This troubleshooting after the implementation is a key part of the entire stress inoculation training process. Following this, the individual then formulates a new plan for their next trip to the mall identifying some of the trouble spots and also strategies that they can utilize to overcome these.
Used in this manner, stress inoculation training is an ongoing process helping individuals to refine their skills and to develop new skills that they may need in order to cope with particular situations that arose and posed significant challenges for them. They can also develop a plan anticipating when they will experience an increase in pain during the entire process. This anticipation can then be planned for with implementation of an appropriate set of skills to assist them in managing their pain. This iterative process continues until the individuals feel capable and confident in confronting the situation that they have been exposed to while applying their pain management plan.
Internal Distraction
Guided imagery and hypnosis interventions can provide a source of internal distraction from chronic pain. These interventions generally focus not only on diminishing the experience of the pain itself, but also on enhancing well-being and empowerment and reducing emotional arousal and distress. Although generally taught in the clinician’s office, both guided imagery and self-hypnosis are tools given to the patient to practice at home. In fact, at home practice is a strongly encouraged aspect of this treatment modality.
Belleruth Naparstek, who is well-known for her work in the area of guided imagery, describes this imagery process as “a kind of directed day dreaming” (1994, p. 4). She notes that in guided imagery, the power of the imagination is used to promote physical healing and emotional well-being. According to Naperstack, effective imagery interventions incorporate all of the senses and generally involve an altered state of awareness characterized by both a relaxed focus and energized alertness. Hypnosis is often described quite similarly, and Jensen and Patterson (2014) remark that it can be difficult to determine when an intervention crosses into a hypnotic realm. As such, there may be a fine line that exists between guided imagery and hypnosis.
Guided imagery and hypnotic interventions for chronic pain often incorporate images and suggestions for pain reduction and relaxation. Naparstek (1994) encourages the use of images that help the person “soften” and “open” to the experience of the pain. She explains that pain sensations are better managed when we learn to relax and breathe into them. This helps to counteract or natural inclination to resist and “wall-off,” which can paradoxically heighten the pain. Images and suggestions for improvements in sleep, coping, energy, and mood—the attendant disruptions of chronic pain—also seem to be important. In fact, research has shown that use of hypnosis to improve these other associated symptoms of pain is important in patient satisfaction, even if the pain itself is only temporarily or minimally improved (Jensen and Patterson 2014).
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