Chapter One
WHY FOCUS ON COGNITIONS IN CHRONIC PAIN?
Our thoughts, usually automatic and often not immediately conscious, have a profound impact on both our short-term and long-term adjustment to pain. Cognitive therapy focuses specifically on the cognitive process and the assumptions and beliefs that underlie this process. Cognitive-behavioral therapy (CBT) is a wider approach, often based on a reinforcement (or "operant") model: Thoughts or behaviors that are rewarded increase, and thoughts or behaviors that are ignored decrease. Although all CBT now includes some cognitive interventions, descriptions of CBT approaches typically contain only passing mention or brief coverage of the cognitive components. Simply put, there is a shortage of specific information focusing on cognitive therapeutic interventions for pain management. And that brings us to this book.
WHY COGNITIVE APPROACHES ARE IMPORTANT IN PAIN MANAGEMENT
The multidisciplinary treatment of chronic pain has been the norm for several decades. Historically, the first pain clinics to include a psychological component to their treatment approach were based on the operant model of pain (Fordyce, 1976), and as such were strongly behavioral. In a strict operant model, behavior is determined by reinforcement, and cognitions are irrelevant to the prediction of behavior (Fordyce, Fowler, & DeLateur, 1968). Although the psychological treatment of chronic pain has since expanded to include the cognitive, its heritage is decidedly behavioral. Today's psychologically based interventions are grounded within a cognitive-behavioral model (Turk, Meichenbaum, & Genest, 1983) and do consider cognitive factors, including appraisals, beliefs, and expectations, as well as ongoing cognitive processes, such as automatic thoughts and self-statements. However, the behavioral aspects of psychological treatment for pain have been around longer and are more thoroughly researched than the cognitive aspects. Thus there is more behaviorally based than cognitively based information available to the practitioner. This book tries to remedy that.
Although it is not always clear which components of CBT are the critical agents of change, it is fair to say that the cognitive components are crucial aspects of treatment-not only to reduce pain, but also to improve mood and decrease disability (see, e.g., Kerns, Turk, Holzman, & Rudy, 1986). CBT focused primarily on teaching behavioral self-management skills is less effective for patients who engage in high levels of negative automatic thinking about their pain (Geisser, Robinson, & Riley, 1999; Turk & Rudy, 1992b); therefore, these patients might be especially suited for a cognitive treatment focus. In addition, when offered first in a CBT program, cognitive treatment modules allow for greater cumulative improvement (Knapp & Florin, 1981). (See Chapter 3 for a more thorough discussion of the relevant research literature.)
For some patients, an unfortunate consequence of dealing with chronic pain may be that they come to develop a personal identity as "chronic pain patients." Such persons continue to seek diagnoses and medical cures, often "shopping" from doctor to doctor, to no avail. They also take on a "sick person" role, equating chronic pain with disability. The paradox is that patients who accept their pain as a chronic condition have lower perceived pain levels, less pain-related distress and depression, less avoidance of activities, lower levels of disability, and greater daily function (McCracken, 1998). "Acceptance" here is defined as recognizing that one has a chronic condition that cannot necessarily be cured, letting go of fruitless attempts to rid oneself of the pain, working toward living a satisfying life despite the pain, and not equating chronic pain with disability. In fact, it has been suggested that one of the main aims of CBT should be to facilitate patients' acceptance of their pain, and, in doing so, to broaden their identity beyond that of "disabled chronic pain patients" (Morley, Shapiro, & Biggs, 2004).
This goal, however, requires starting with a patient who is often a passive recipient of the biomedical "curative" approaches (surgery, medication); moving her toward being an active collaborator in pain self-management strategies (aimed not at eliminating the pain, but rather at increasing function in spite of the pain); and facilitating the ultimate goal of adopting a new identity as a person with pain. Obviously, patients will vary widely in terms of their level of motivation and commitment to take on a very new approach. The typical patient, though, has been well steeped in a medicalized approach to dealing with health-related problems, and thus may enter into CBT with little understanding of what is involved-or may assume that such approaches are for those without "real" pain. Thus it is probably unrealistic to expect typical patients with pain to adopt behavioral self-management strategies, without first helping them to change their mindset. Helping clients to become aware of and examine the thoughts, beliefs, and cognitive schemas that are shaping their coping attempts is an important first step in motivating them to take on a new set of strategies, and ultimately a new identity for themselves. Such cognitive motivational techniques are the essence of this book.
The father of operant treatment for chronic pain, Wilbert Fordyce, asserted that we must get patients with chronic pain to relinquish "ownership" of their pain, indicating that patients who "own" their pain have come to incorporate the pain/illness into their sense of personal identity (W. E. Fordyce, personal communication, October 22, 1999). This goal may be of immense therapeutic value, because many sufferers do experience chronic pain as "their pain." Yet a key to successful treatment is the clinician's understanding and acknowledgment of each patient's pain experience. The challenge of cognitive therapy is to begin within the cognitive and emotional framework of the patient and gradually shape the patient's cognitions toward a different phenomenological experience. Regardless of the causes of the pain (and these are always multifaceted), it is the patient's experience of pain that is key to cognitive therapy. As we will see, there is clear evidence that the patient's cognitive experience of pain predicts adjustment to a greater extent than any other variable.
Bear in mind that a cognitive approach to pain does not imply a person's pain is not real. Many patients with chronic pain, upon being referred to a mental health practitioner, conclude that the physician believes their pain is psychogenic, functional, or psychologically based (in other words, not "real"). Indeed, when pain persists beyond the point at which an injury is declared to be healed, or when someone has pain but no physical etiology can be found, the patient is often assumed to be willfully exaggerating the pain or making it up to get out of something unpleasant. This is rarely the case. Although there are some few individuals who knowingly fake their pain symptoms, persons characterized as malingerers or those with factitious disorder make up a small percentage of the patients we are likely to see for pain management (Boothby & Thorn, 2002). But many sufferers from pain have had insult added to injury by these inferences. An unfortunate related misconception is that patients over-report the level of pain and distress they actually feel, and have more pain behaviors and greater dysfunction than are warranted by the physical aspects of the pain.
When patients feel that the reality of their pain has been delegitimized by medicine, they are less receptive to potential interventions by mental health practitioners. I have a favorite cartoon: a man sitting in a psychologist's office, who exclaims, "Of course the pain is in my head. It's a headache!" Pain is a perception, and like all perceptions, it is filtered through the brain. I often tell my clients that in a way, the pain is in their heads-not in the way that others have implied, but because all pain, even for a broken leg, is in the head. Pain is only perceived as pain because the brain interprets the stimulus as pain. Since the brain is the organ that processes cognitions and emotions, the brain is responsible for integrating sensory, cognitive, and emotional information as part of the interpretive process involved in pain perception. The patient's cognitive and emotional experience of his pain is the reality. To really do cognitive therapy, the practitioner must successfully "get into the patient's head" as it relates to his pain.
FROM THE BIOMEDICAL MODEL TO THE BIOPSYCHOSOCIAL MODEL
The biopsychosocial model of pain provides a conceptual rationale for including cognitive interventions in pain management strategies. First proposed by Engel (1977), the biopsychosocial model acknowledges biological processes, but also highlights the importance of experiential factors. Prior to the currently accepted biopsychosocial model, a biomedical model dominated all illness conceptualization for almost 300 years and still dominates in the popular imagination. The biomedical approach to pain was, and is, purely mechanistic and reductionistic. This approach sees a simple causal link between the amount of damage to the body and the amount of pain: The more damage, the more pain.
As we now know, the experience of pain does not correspond with amount of tissue damage. We have a wealth of research to support this fact, and here is just one example: In a study exploring the important predictors of disability in workers with low back injuries, researchers found that actual physical pathology accounted for only 10% of the disability 1 year after the evaluation. However, 59% of the disability was explained by psychosocial variables (Burton, Tillotson, Main, & Hollis, 1995). Unfortunately, despite evidence to the contrary, in many ways medicine still operates as if the physical source of the pain is the most important predictor of the experience of pain.
Another common misconception is that acute injury always produces pain. If you break your leg, everyone expects you to be in pain. The fracture can be seen on the X-ray; it is quantifiable; it is therefore considered "real," and pain is seen as justified. Nevertheless, the relationship between acute injury and the experience of pain is not as automatic as one might think. For example, during World War II, many U.S. soldiers as well as citizens were severely injured in a battle in Anzio, Italy. Frank Beecher, who was one of the medics there and later went on to become a pain researcher, observed that the meaning of the pain had a great deal to do with a person's experience of pain. Injury to the soldiers meant that they were going home, and many, even those with traumatic amputation of a limb, did not need pain medication. The citizens, on the other hand, had no means of escape; with similar injuries, they experienced fierce pain and required a great deal of analgesic medicine (Beecher, 1959). This example holds personal relevance for me, because my father was one of those who lost a limb at Anzio. Although he didn't remember being interviewed by Beecher, he did remember thinking, "This is my ticket home!"
In their now famous gate control theory of pain, Melzack and Wall (1965, 1982) proposed that the brain plays a dynamic role in pain perception, as opposed to simply being the passive recipient of pain signals. They originally hypothesized that a gating mechanism in the spinal cord can widen or narrow as a result of descending signals from the brain, thus allowing relatively more, or fewer, pain signals to ultimately reach the brain. They also suggested that psychological factors can inhibit or enhance the sensory flow of pain signals, and thus influence the way the brain ultimately responds to painful stimulation. If psychological processes can actually change the way the brain processes pain, this holds tremendous potential for psychological interventions. The gate control theory opened the door for pain to be included within the biopsychosocial model of illness.
There is growing research support for the idea that cognitive and emotional activity, such as hypervigilance to potential pain and fear of reinjury, can amplify pain signals and "rewire" the brain circuitry associated with pain perception, thereby increasing the experience of pain. (See Appendix A for more details on the pathophysiology of pain.) For example, in a study using functional magnetic resonance imaging (fMRI), researchers demonstrated that distinct areas of the brain are involved in pain processing versus pain anticipation (Ploghaus et al., 1999). More importantly, although the level of brain activation in the regions associated with sensory pain processing remained stable across time, the level of activation in the more cognitive-emotional pain anticipation regions increased over time. Thus it appears that cognitions, emotions, and pain experiences can actually change the way the brain processes input from pain receptors.
The example above involves psychological processes that increase brain signals associated with pain. It is even more intriguing to consider the possibility that adaptive cognitions and emotions can reduce pain signals and temper the perceptual experience of pain. With the advent of fMRI and other increasingly sophisticated neuroimaging technology, the future holds great promise in helping us quantify pain in a very different way, including a greater appreciation of the importance of cognitive and affective mechanisms in the pain experience.
NOMENCLATURE USED FOR DEFINING, DIAGNOSING, AND TREATING PAIN DISORDERS
Taxonomies of pain, pain diagnoses, and pain treatment methods will not be covered in depth as part of this book. However, some brief information is provided below, as well as references to other resources.
Definitions of Pain
Consistent with the biopsychosocial model of pain, the International Association for the Study of Pain (IASP) defines "pain" as an unpleasant experience that accompanies both sensory and emotional modalities; may or may not be accompanied by identifiable tissue damage; and is influenced by multiple factors, including cognitive, affective, and environmental (Merskey, 1986; Merskey & Bogduk, 1994; emphasis added). Although the IASP does not provide definitions of "chronic pain," "acute pain," or "recurrent pain," since these terms are frequently used clinically and in the research literature, brief descriptions of these and other relevant terms are included in Table 1.1. (See Turk & Okifuji, 2001, for a fuller discussion of pain taxonomy.)
Continues...
Excerpted from Cognitive Therapy for Chronic Pain by Beverly E. Thorn Copyright © 2004 by The Guilford Press. Excerpted by permission.
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