Journal_Fall2009_CBT for Pain Management

© 2009 IAIABC IAIABC Journal, Vol. 46 No. 2

77CBT for Pain Management

CBT For Pain Management

Michael Coupland*

Abstract

Chronic pain is a lose-lose situation in the workers’ compensation system. Patients are ensnared in a system not designed to manage the psychosocial drivers of chronic pain. Evaluation of those psychosocial drivers should be provided as soon as 2-6 weeks into an injury in order to identify and inter-vene with patients who are at risk of developing chronic pain. Cognitive behavioral therapy has shown evidence of positive outcomes in short term treatment that addresses the psychological, social and behavioral factors that reinforce pain. These assessment and treatment pathways must avoid creating unwarranted psychological diagnoses and further “medicalizing” the psychosocial aspects of claims.

Psychosocial Interventions for Chronic Pain Management

Chronic pain presents a challenge for patients, medical professionals and

* National Business Development Consultant, Behavioral Medical Interventions, Minneapolis, MN. Email: [email protected]

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IAIABC Journal, Vol. 46 No. 2 © 2009 IAIABC

CBT for Pain Management

claims managers.1 Pain is a subjective experience, not amenable to objec-tive verification. Patients experiencing unremitting pain may be faced with a threat to their well-being and personal fortitude. Medical professionals experience a challenge to their diagnostic and treatment approaches to patient care. Claims managers face the unknown: is this claimant going to recover or ride the “slippery-slope” into a “chronic pain syndrome” associ-ated with delayed recovery, disability and high medical costs?

This author will present three steps to manage these patients/claimants: (1) early intervention risk analysis to identify and manage these claimants; (2) clinical evaluation and management pathways that serve to intervene in patient disability behaviors, rather than treat those psychosocial fac-tors as medical issues; and (3) evidence-based cognitive behavioral inter-ventions that assist the patient/claimant avoid the “slippery slope” into chronic pain, or provide them a lifeline when they have already devolved into chronic pain.

Chronic pain has been defined as, “Pain that persists for at least 30 days be-yond the usual course of an acute disease or a reasonable time for an injury to heal or that is associated with a chronic pathological process that causes continuous pain” (Colorado State Division of Worker’s Compensation Chronic Pain Guidelines, 2007). Chronic pain has three pathways: 1) nociceptive (vis-ceral and tissue insult pain); 2) neurogenic pain (injury to the neurological pathways); and 3) psychogenic pain (pain that cannot be accounted for by either nociceptive or neuropathic pathways that substantially originate in emotional, characterological, social, or psychophysiological origin). The term, Chronic Pain Syndrome, has been used to generally define the belief on the part of the treating provider that the patient’s pain is inappropriate or out of proportion to an existing illness (Ibid).

1 It is beyond the scope of this article to give an exhaustive listing of all references on pain responses and cognitive behavioral therapy. Instead, a selection of gen-eral references is included to inform the reader concerning statements about the nature of pain, people’s responses to it, the relationship between mind and body, and the nature and course of cognitive behavioral therapy in this paper that are clearly established in the literature



The Chronic Pain Continuum (Kertay, 2009) demonstrates the inter-re-lationship of body-mind complexities. A physical impairment is intercon-nected with the patient’s psychological state by a continuum of personal and psychosocial factors. The development of pain and somatic impair-ments can then develop out of those mind-body interconnections.

The first step in assessing a patient with chronic pain complaints is evalu-ation by an appropriate physician to ensure the pain is not a failure of diagnosis and treatment. If there is pathology causing the pain then this should be clinically managed by a medical specialist such as orthopedics, physiatry, or neurology, in accordance with appropriate treatment guide-lines.

On the other hand, patients who have a paucity of objective medical find-ings, or whose diagnosis is one of the functional somatic syndromes such as fibromyalgia syndrome, chronic fatigue syndrome or a mental health disorder should be referred for a clinical assessment of the psychological and psychosocial context surrounding their physical health.

The health and behavior assessment should include:

Personal/medical history•

Work attitudes•

Social support•

Alcohol and drug screening•

Mental status examination•

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Pain attitudes and beliefs / catastrophic thinking•

Health locus of control scale•

Current symptoms •

Psychometric testing such as MMPI-2• TM (Minnesota Multiphasic Personality Inventory-2) or MMPI-2 RF™ (Minnesota Multipha-sic Personality Inventory-2 Restructured Form™) or MBMD™ (Millon™ Behavioral Medicine Diagnostic) (Pearson Assess-ments)

A model short form, early intervention health and behavior risk assess-ment has been developed by Linton and colleagues (1998, 2002, 2003, 2005, 2008) for compensation boards in many countries. The health and behavior assessment places the patient into a high, moderate or low risk factor category. Low-risk patients are most appropriately managed via education materials on chronic pain that they can take home with them. Moderate risk patients are prospects for a self-managed workbook style intervention. High-risk patients are referred to a cognitive behavioral therapy (CBT) intervention program (Linton & Andersson, 2000; Linton & Ryberg, 2001). These studies demonstrated that CBT intervention re-duced the risk for long term leave by three-fold to nine-fold. Physician and physical therapy visits were also significantly reduced.

Given our knowledge that cognitive behavioral treatment of psychosocial factors affecting chronic pain and disability is effective, then why is it not commonly utilized within the workers’ compensation system? The answer may be that these psychosocial factors are non-medical and provision of CBT treatment has required a psychiatric diagnosis in order to get treat-ment authorized; payment has been within the psychiatric evaluation and management procedure codes. In the current litigious, impairment model workers’ compensation system, these codes introduce impairment ratings and compensation factors that although unwarranted become part of the claims settlement process.

Fortunately for both medical and claims professionals there has been a development that resolves this issue. New American Medical Association Health and Behavioral Intervention CPT codes address this conundrum.



The two codes are: CPT 96150 (the initial assessment of the patient to deter-mine the biological, psychological, and social factors affecting the patient’s physical health and any treatment problems) and CPT 96152 (the intervention service provided to an individual to modify psychological, behavioral, cognitive, and social factors affecting the patient’s physical health and well being). The intent of the intervention program is to manage the cognitive, behavioral and psycho-social factors that interfere with recovery from the physical impairment. No psychiatric diagnosis is required under this code for a psychologist or psychiatrist to receive authorization and fee schedule re-imbursement to evaluate and treat a patient with a medical condition. In this manner, the needed evaluation can be provided to these patients who have the requi-site physical health diagnosis without creating an unwarranted psychiatric diagnosis and claim.

The cognitive behavioral therapy (CBT) approach to pain management is based on the premise that chronic pain becomes established when a pa-tient’s cognitions and beliefs, usually automatic and often not conscious, create an impression of the pain event that has a profound impact on both short and long term adjustment to pain. The development of this cognitive behavioral model of pain management has been developing over the past 3 decades. Fordyce (1976) pioneered the behavioral model of multidisciplinary pain management. These programs focused on operant conditioning; overt motor and physiologic self-management techniques such as reinforcement for participation in functional activities, progres-sive relaxation and self-hypnosis. The patient’s behavioral responses to the pain receive social reinforcement within the operant model: behavior that is reinforced increases and behavior that is ignored decreases.

Programs evolved to include more cognitive interventions (Turk, Me-ichenbaum, & Genest, 1983). The CBT model has been shown to be ef-fective in literature review meta-analysis compared to waiting list controls and alternative active treatment. (Morley, Eccleston, & Williams, 1999). The cognitive aspects of CBT have been reviewed and found to contain critical aspects of treatment to not only reduce pain and increase func-tional ability, but also to stabilize mood and decrease disability (Kerns et al., 1986). CBT that focused primarily on the behavioral self-management

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techniques were less effective for patients who demonstrated high levels of negative automatic thinking about their pain (Geisser, Robinson, & Riley, 1999; Turk & Rudy, 1992b).

Cognitive Behavioral Therapy (CBT) focuses on the cognitive processes underlying the assumptions and beliefs concerning that pain, the behav-iors that need to be extinguished and those that need to be reinforced to cope with the pain. The goal of CBT is to achieve functional recovery out-comes of increased physical, social and work activity, mood stability and reduced use of analgesic and opiod medications, despite pain.

Patients may develop an identity as a chronic pain syndrome patient, con-tinuing to seek diagnoses and cure, “doctor shopping” and taking on a sick person role equating chronic pain with disability. The irony is that patients who accept their pain as a chronic condition have less pain, less pain distress and depression, lowered disability and greater function (Mc-Cracken, 1998). The goal of the CBT program is to facilitate acceptance of pain and not equate chronic pain with disability.

There are four stages in the development of chronic pain that the cogni-tive therapy aspect of CBT addresses (Thorn, 2004):

Stress• : the event that triggers a pain response

Appraisal• : emotional and cognitive interpretation of the event

Reappraisal / Coping• : reinterpreting the event and develop-ment of adaptive coping responses

Adjustment:• normalization back to functional activity, psy-chological well-being and retraction from dependency on the medical care system.

Stress Stage

An accident, injury or serious illness is a stressor. The acute pain stressor creates biological, social, personality and attitudinal reactions of the indi-vidual and his or her social system. There is a biological mind-body con-



nection from the stressor which may constrict blood vessels and impact musculoskeletal pain and endocrine changes affecting immune responses. Coping with painful stressors may be more difficult for patients who have comorbid mental health disorders of anxiety and depression and pre-exist-ing personality disorders. For the patient with a pre-existing addiction, a pain event may threaten equilibrium, sobriety and a drug-free lifestyle.

Biological and psychosocial gender role differences are important in the context of pain. Gender has a greater research foundation compared to the other factors; male role is more typically stoic and the female role is more sensitive. Women report higher levels of pain than men (Hasvold & Johnson, 1993; Verbrugge, 1990), use the health care system to a greater degree (Taylor & Curran, 1985), and demonstrate more pain behavior (Keefe et al., 2000; Sullivan, Tripp, & Santor, 2000). Physiological gender differences are considered to account for most of the variance although psychosocial gender ‘role’ also has an effect.

Involvement in the medical system may instill a sense of helplessness and loss of control. The concept of locus of control (LOC) comes into play, as some individuals focus their control internally and self–manage their health within the context of the medical care system, where other indi-viduals focus their intention externally on the medical system to care for them and provide the answers (Bandura, 1986). The internal LOC pa-tients have better outcomes based on measures of learning and perform-ing home exercises, (Harkapaa, 1991; Harkapaa et al., 1991). Successful multidisciplinary treatment leads to increased internal LOC in order to gain greater personal control over pain (Lipchik, Milles, & Covington, 1993)

Appraisal Stage

The initial appraisal of the stressor event is formed within the context of an individual’s personal characteristics, including their general health, belief system, social roles, personality and psychopathology. These are complex and form the core nature of the individual and were derived

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from personal experience, developmental milestones, family, and social and cultural systems. The appraisal stage has two components:

Affective imprint (emotional response)•

Cognitive structuring•

The overall emotional impression of the stress event becomes an affective imprint. The therapy probe that captures this is “Tell me how you felt about the injury/accident/illness?” It is important to reassure the patient that there is no wrong way to feel about an event, but that the emotional imprint that occurred does not have to be an everlasting impression. Cognitive struc-turing is the individual’s judgment of the event. Does the pain outweigh their ability to cope leading to anxiety, fear, avoidance or escape responses? Is there a perception that there has been irreparable harm leading to de-pression and hopelessness? Or is it a life challenge that the individual perceives they can cope with successfully?

With some distance from the initial stress event it is possible to go back and reappraise it within a new context of coping mechanisms that are taught in therapy.

The cognitive appraisal occurred when the patient initially experienced and labeled the seriousness of the event, its impact on critical life areas, and the internal resources the patient perceived they had available to cope with it. Catastrophic thinking may occur at this stage; it has been shown to be a robust predictor of pain, disability, and poor adaptation, over and above other factors such as the degree of disease, pain intensity, mood disorders, and neuroticism. Individuals who catastrophize their pain have poorer outcomes (Flor, Behle, & Birbaumer, 1993; Geisser et al., 1994; Gil et al., 1993; Jacobsen & Butler, 1996; Keefe et al., 1989; Martin et al., 1996; Robinson et al., 1997; Sullivan & Neish, 1999; Sullivan et al., 1997).

Catastrophizing has been shown to be a predictor of pain levels; the greater the catastrophizing, the greater the perceived pain level is (Sul-livan and Neish, 1999). Alternatively there has also been evidence that the pain leads to increased catastrophic thinking. Indeed both are true,



catastrophic thinking leads to increased pain and increased pain leads to catastrophic thinking. Either way, intervention is necessary.

Categories of catastrophic thinking identified by Thorn (2004) include:

All or nothing thinking: I am not able to sit for more than 2 hours, so I cannot go back to my job.

Fortune telling: My back pain will lead to my wife leaving me.

Disqualifying the positive: One good day does not mean I will have others.

Emotional reasoning: I feel so discouraged, there is no way the MRI results are true.

Labeling: All therapists work for the insurance company.

Magnification: My pain is totally out of control.

Mind reader: My doctor thinks he understands my pain.

Should statements: A good physician should be able to see my problem on the MRI.

Personalization: I am being punished by God for not taking care of myself.

Reappraisal / Coping Stage

Once the patient has explored the affective and cognitive components of their pain response, the therapeutic goal is to structure new coping mech-anisms that target specific thoughts and feelings. This starts with reap-praisal exercises. The patient is led through a process of challenging their automatic thoughts (“The pain is going to destroy me on my first day back to work”) and constructing alternative, less catastrophic thoughts (“The pain was irritating”) and is taken therapeutically all the way to successful coping thoughts (“I managed to get through the day and not have to take any additional medications”). This reappraisal exercise is also conducted with the patient’s negative beliefs (“If I am at work, my coworkers are going to load me up with all the worst tasks”) and feelings (“I am afraid the employer will be disappointed in my performance”). These beliefs and feelings are also challenged and the patient develops alternative positive appraisals. Behavioral coping strate-gies are interspersed with the reappraisal exercises. These strategies may

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include therapeutic techniques such as assertiveness training, relaxation exercises, or expressive writing. Homework is given and at the follow up visit the patient is asked to review the coping successes and challenges.

Cognitive restructuring is implemented at this stage of treatment. This technique engages the patient beyond the appraisal stage of identifying negative, automatic thinking and leads to constructing more realistic alter-native beliefs. Cognitive restructuring of the examples given previously are illustrative of this technique:

Automatic Thought: I am not able to sit for more than 2 hours, so I can-not go back to my job at all.

Restructured Thought: I will accept job modifications that allow me to vary my sitting and standing.

Automatic Thought: One good day does not mean I will have others.

Restructured Thought: One good day brings hope that there will be other good days.

Automatic Thought: My pain is totally out of control.

Restructured Thought: I can control my pain.

Catastrophic, negative, distorted automatic thinking has to be allocated sufficient therapy time to allow for very ingrained habits to be evaluated, challenged re-appraised and restructured, in preparation for consolidation into everyday coping strategies. Three to four weeks time may be devoted to this aspect. There can be initial confusion and annoyance as the negative thinking is so reflexive it is difficult to perceive the automatic thoughts. Therapy inherently involves mental and emotional struggling, followed by insight and achievement as the gains of therapy take hold. Therapy does not move in a linear fashion, as patients differ in their circumstances, personal styles and psychosocial factors. Some patients are more naturally insight oriented and this may occur sooner. Others are concrete thinkers and/or resistant, but cognitive behavioral therapy does not require insight orientation as the treatment processes are structured and tangible. The concept of sudden gains in therapy is more apropos, with a sudden epipha-ny taking hold that is insightful and enduring. It just takes a different road map to this gain with each patient.



Adjustment

The last component of treatment is adjustment along many psychosocial and functional domains, not necessarily reduced or eliminated pain. As cognitive, emotional and core beliefs are redefined then the level of pain is of much lesser significance, both to the clinician and the patient. The aspects of functional recovery most relevant to chronic pain patients are activity level, social interactions, work and activities of daily living (ADLs) involvement, medication use, and utilization of medical services. Mood, attitude, energy, and psychological stability are effective markers of affec-tive outcome. Life begins to normalize and the patient is discharged from care with a lifelong set of coping skills:

Pain is a stress related phenomena•

Thoughts, emotions and beliefs influence they way pain is •experienced

Cognitive restructuring is a skill that must be practiced to get •really good at it. The more it is practiced, the easier it is and the more automatic it becomes

Summary

Appropriately trained mental health practitioners may assist patients by intervening in the development of chronic pain. Early intervention leads to the most positive outcomes, and it is patients with a non-catastrophic injury who should ideally be screened by the 2nd to 4th week and by 6 weeks at the latest (Linton, 2003). Patients who have significant degrees of risk factors identified by the screening tool need to be directed to evalua-tion and treatment under the health and behavior assessment CPT codes. Patients who develop chronic pain need to be directed into a multidisci-plinary pain program including evaluation and management of the psy-chosocial factors and comorbid psychological conditions.

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Michael Coupland is National Business Development Consultant for Be-havioral Medical interventions (BMI) a Minneapolis based Behavioral Dis-ability Case Review Company. He is a Certified Psychologist and Certified Rehabilitation Counselor. Mr. Coupland is the developer of the AssessAbility Functional Medicine Evaluation system and co-founded three national Dis-ability Evaluations companies that have performed over 60,000 evaluations. Mr. Coupland is an chapter author of new AMA Guidelines companion text Guides to the Evaluation of Functional Ability.

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