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Francis J. Keefe, Ph.D. Duke University Medical Center Reprinted trom: Keefe, F. J. (1996). Cognitive behavioral therapy for managing pain. The Clinical Psychologist, 49(3), 4-5.
I. Description of Treatment
Cognitive behavioral treatment (CBT) for pain management is based upon a cognitivebehavioral model of pain (Turk, Meichenbaum, & Genest, 1983). The hallmark of this model is 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 that helps patients understand that cognitions and behavior can affect the pain experience and emphasizes the role that patients can play in controlling their own pain. The second component of CBT is coping skills training. Training is provided in wide variety of cognitive and behavioral pain coping strategies. Progressive relaxation and cue-controlled brief relaxation exercises are used 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 and range 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 pain episodes. Cognitive restructuring is used to help patients identify and challenge overly negative pain-related thoughts and to replace these thoughts with more adaptive, coping thoughts. The third 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 a progressively wider range of daily situations. Patients are taught problem solving methods that enable them to analyze and develop plans for dealing with pain flares and other challenging situations. Self-monitoring and behavioral contracting methods also are used to prompt and reinforce 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 a psychologist or psychologist-nurse educator team.
II. Summary of Studies Supporting Treatment Efficacy
Although CBT can be used in managing acute pain (Jay, Elliot, Ozolins, & Pruitt, 1985), the treatment procedures described above are those that are most commonly used in the management
of persistent pain. Randomized, controlled studies have been carried out with a number of patient populations. Turner and Clancy (1988) demonstrated the usefulness of CBT in the management of chronic low back pain. CBT produced significant decreases in physical and psychosocial disability when compared to a waiting list control condition. The improvements reported 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 rheumatoid arthritis and found that CBT was superior to both a social support control and no treatment control group in reducing pain behavior, disease activity, and trait anxiety. In our own lab we have 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 and psychological disability relative to an arthritis education and standard care control conditions. Syrjala, Donaldson, Davis et al. (1995) have recently demonstrated the efficacy of CBT in managing cancer-related pain. Thus, evidence suggests that CBT is effective in treating both chronic pain conditions such as back pain and persistent disease-related pain conditions such as arthritis 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: A cognitive-behavioral perspective. New York: Guilford Press.
IV. Resources for Training
Formal training in CBT for pain management is often available through workshops held at the American Pain Society, International Association for the Study of Pain, and the Association for the Advancement of Behavior Therapy. Several centers conducting trials of CBT also provide informal training, predoctoraI training, psychology internship rotations, or postdoctoral fellowships in CBT pain management. For information about training opportunities at these centers contact:
Laurence A. Bradley, Ph.D. Division of Rheumatology 429 Tinsley Harrison Tower University of Alabama-Birmingham Birmingham, AL 35294 Francis J. Keefe, Ph.D. Director, Pain Management Program Box 3159
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
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 pain behavior 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's distress 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 coping skills 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 pain syndromes. 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 cancer treatment: A controlled clinical trial. Pain, 63, 189-198. Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitive-behavioral perspective. New York: Guilford Press. Turner, J. A. & Clancy, S. (1988). Comparison of operant-behavioral and cognitivebehavioral group treatment for chronic low back pain. Journal of Consulting and Clinical Psychology, 58, 573-579.