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Behavioral Medicine: How to Incorporate Into Pain Management

‘Cognitive-behavioral interventions improve psychological and physical functioning. They help patients let go of the struggle against pain and move toward achieving their most valued life goals. Medical management is also more effective if depression, anxiety, and other mental health symptoms are addressed.’ —Mark Jensen, PhD
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Being Open

Patients learn to become more “open” to their experience of pain using 2 principles: willingness to accept (versus avoidance or escape) and cognitive defusion (versus fusion with thoughts). The principle of willingness to accept describes the process of allowing internal experiences (thoughts, feelings, body sensations, and memories) regarding pain to come and go without struggling with or becoming fused with them. When learning about cognitive defusion, patients begin to create distance from thoughts, images, emotions, and memories and perceive them as what they are. This can work to help the patient create distance from these experiences and realize that they are not identified by their thoughts. This way the patient can work to respond to these experiences through evaluating their workability given their values, rather than accepting or “buying into” them in a literal way.

Being Present

Patients learn to become more “present” with their experience of pain using 2 other principles: contact with the present moment (versus living in the past or future) and observing the self (versus dominance of the conceptual self). The principle of making contact with the present moment describes how patients become more aware of and experience the here and now. Mindfulness is essential to this process! Mindfulnes is neither a special mystical state, nor a form of relaxation. Mindfulness is an exercise in just noticing, or awareness. The purpose is not to change or judge, but rather to be fully in the present moment, noticing when the mind wanders and bringing it back. It involves being able to operate from a different and separated point of view.

The aim of mindfulness is to increase awareness of one’s body functions, feelings, and the content of thoughts. Each therapy session begins with a mindfulness exercise. Observing the self involves patients accessing a transcendent sense of self, a continuity of consciousness that is always changing. In other words, patients learn to contact their thoughts and feelings about pain from the perspective of a separate observer.

Taking Action

Patients also learn to “take action” despite their experience of pain using these principles: valued directions (versus lack of values clarity) and committed action (versus lack of consistent action). The principle of valued directions describes the process of discovering what is most important to one’s true self, whether it be personal growth, leisure, citizenship, social relationships, health, work/education, spirituality, family, parenting, and/or intimate relationships.  

Making a committed action involves the patient setting goals according to their values and carrying them out responsibly. Patients are asked to state and write down commitments in the form of specific, measurable, achievable, realistic, and tangible steps that they are now willing to take, along with what activities they are willing to do.

At the end of the intervention, patients are taught how to maintain their progress by continuing to:

  • Practice mindfulness and acceptance exercises
  • Set short-term goals each week
  • Monitor their progress

Patients are also prepared for relapse and setbacks. When they have a setback, as when they fail to live up to or keep their commitments, they are trained to recommit to their action plan. The patient then gets back on track by noticing the setback and bringing their awareness back to their valued directions. ACT has been shown to have modest support, but CBT has strong, long-standing research to support the treatment of chronic, non-cancer pain, according to the American Psychological Association.23

Cognitive-Behavioral Therapy

CBT has been shown to be highly efficacious in the treatment of a number of chronic pain conditions, including fibromyalgia,10 headaches,24 low back pain,11,25 osteoarthritis,26 and rheumatoid arthritis.27 Furthermore, meta-analytic comparisons have substantiated these findings and have proven CBT to be a skill of utmost importance in pain management.28,29 CBT for pain is based upon the cognitive-behavioral model of pain.30

The cognitive-behavioral model is grounded on the notion that pain is a complex experience that is influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior.31 In other words, “as I think, so I feel (and do)!” CBT for pain has three components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills.32 The goals of CBT are to:

  • Reduce the impact pain has on the patient’s daily life
  • Learn skills for better coping with pain
  • Improve physical and emotional functioning
  • Reduce pain and the reliance on pain medication

CBT is a structured, time-limited, present-focused approach to psychotherapy that helps patients engage in an active coping process aimed at changing maladaptive thoughts and behaviors that can serve to maintain and exacerbate the experience of chronic pain. There are a number of established protocols that have been published for CBT for pain.33 One particular protocol, “Treatments That Work,” reviews pain education topics, such as chronic pain syndrome and theories of pain.

Last updated on: May 12, 2017
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