DISCLAIMER:Video will be taken at this clinic and potentially used inProject ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow

Project ECHO to use this photo and/or video. If you don’t want your photo taken, please let us know. Thank you!

ECHO Nevada emphasizes patient privacy and asks participants to not share ANYProtected Health Information during ECHO clinics.

.

.

Cognitive Behavior Therapy and Pain Management

ECHO CLINICDr. Michael Lewandowski

.

.

Medical Focus leading to a Rehabilitation Focus

.

.

Cognitive Behavior Therapy - Three interrelated phases

• 1. Emphasis on a distinction between acute versus persistent/chronic pain; pain as manageable/controllable; emphasis on learning a pain self-management approach

• 2. Skills acquisition; behavioral activation and learning adaptive cognitive and behavioral pain coping skills

• 3. Maintenance and relapse prevention; problem-solving

.

.

Characteristics of CBT for chronic pain• Problem-oriented• Educational• Collaborative• Skill acquisition and practice, in clinic and at

home• Encourages expression, and then control, of

maladaptive thoughts and feelings• Addresses the relationships among thoughts,

feelings, physiology, and behavior• Emphasizes relapse prevention and maintenance

.

.

Other key ingredients

• Supportive, respectful, compassionate, understanding therapeutic relationship

• Explicit attention to motivation and readiness to adopt a self-management approach

• Explicit attention to sound behavior change principles (e.g., appropriate goal setting and effective use of social reinforcement)

Jensen, M.P., Nielson, W.R., & Kerns, R.D. (2003). Toward the development of a motivational model of pain self-management. Journal of Pain, 4, 477-492.

.

.

Characteristics of Cognitive-Behavioral Therapies:

1. Thoughts cause Feelings and Behaviors.

2. Brief and Time-Limited.Average # of sessions = 16 VS psychoanalysis = several years

3. Emphasis placed on current behavior.

.

.

4. CBT is a collaborative effort between the therapist and the client.

Client role - define goals, express concerns, learn & implement learning

Therapist role - help client define goals, listen, teach, encourage.

5. Teaches the benefit of remaining calm or at least neutral when faced with difficult situations. (If you are upset by your problems, you now have 2 problems: 1) the problem, and 2) your upsetness.

.

.

6. Based on "rational thought." - Fact not assumptions.

7. CBT is structured and directive. Based on notion that maladaptive behaviors are the result of skill deficits.

8. Based on assumption that most emotional and behavioral reactions are learned. Therefore, the goal of therapy is to help clients unlearn their unwanted reactions and to learn a new way of reacting.

9. Homework is a central feature of CBT.

.

.

CBT: Event => Thoughts => Feelings => Behavior

Behaviors

.

.

Common Components of CBT

• Adoption of a self-management approach• Behavioral activation• Pacing/rest-activity cycling/avoiding pain-contingent rest• Cognitive coping skills training• Relaxation/stress reduction skills training• Problem solving skills training• Cognitive restructuring

.

.

Elements of Cognitive and Behavioral Therapies for Chronic Pain

Cognitive Methods Behavioral Methods Socratic questioning and guided discovery

Monitoring pain and activity levels

Keeping thought change records

Activity pacing

Identifying cognitive errors (automatic thoughts)

Relaxation training

Generating rational alternative thoughts

Breathing retraining

Imagery

Pleasant activity scheduling

Role play and rehearsal

Distraction techniques

.

.

CBT EvidenceBased on numerous RCTs,

reviews and meta-analyses, there is strong support for the efficacy of CBT for improving pain, physical functioning and mood in many chronic pain states.

.

.

Acceptance & Commitment Therapy (ACT)

Based on acceptance and mindfulness

Get to know unpleasant feelings, learn not to act on them, do not avoid situations

Meta-Analysis: When ACT was compared to various forms of CBT a non-significant effect size of 0.16 was obtained. However, an evidence-base evaluation showed that ACT is probably efficacious for chronic pain

Ost. Behav Res Ther 2014;61:105-21.

.

.