September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom
description
Transcript of September 5 th – 8 th 2013 Nottingham Conference Centre, United Kingdom
September 5th – 8th 2013Nottingham Conference Centre, United Kingdom
www.nspine.co.uk
Using CBT To Treat Chronic Pain
Kate FeenanCognitive Behavioural
Psychotherapist
Agenda Understanding and Treating Chronic Pain
– Chronic pain and the importance of psychosocial factors– Inadequacies of the medical model– An evidence-based bio psychosocial model and CBT approach
What is CBT?
Key Characteristics of CBT
Using CBT to Manage Pain - Five Points for Intervention
Definition of pain
“An unpleasant emotional and sensory experience associated with actual or potential tissue damage, or described in terms of such damage”
(IASP, 1994)
What is Chronic Pain?PAIN 1 and PAIN 2
Distress & Discomfort
UnwillingnessInflexibility
Avoidance
Poor Functioning
Pain
Chronic Pain and SufferingPAIN 2
Significant psychosocial problems Depression, panic, anxiety Fears about the future Decreased pleasure in everyday activities Helplessness, self-esteem losses Impaired physical functioning Reduced frequency and quality of socialisation Significant role changes with family and work systems Side effects of treatment and medication Tremendous cost to society (human & economic)
Impact Of Chronic Pain
Medical Model - Making Things Worse?
It results in no cure or little pain relief, promotes fear avoidance behaviour and physical deconditioning which in turn contributes to increased pain
Focuses the patient on seeking a diagnosis, cure and pain relief and reinforces unrealistic treatment expectations
Adds to anxiety, fear about any unknown conditions, frustration, low mood and a sense of lack of control, helplessness and hopelessness
Encourages ineffective and high health care usage (e.g. multiple investigations with no clear benefit)
Consumes time and effort and can lead to postponement effective pain management and life
Opinion
• “Back pain is a 20th century medical disaster”(Waddell, 2000)
• ……………………………… “chronic pain patients would benefit more from having no medical treatment at all”.
Van Tulder, Koes and Bouter (1995)
Yellow Flags
Psychosocial Risk Factors/Obstacles to Recovery
A = Attitudes: pain is harmful, uncontrollable, one is disabled, passive attitude to rehab
B = Behaviours: fear avoidance, extended rest
C =Compensation: Lack of financial incentive to return to work, history of sick leave
D =Diagnosis and Treatment: health professionals sanctioning disability, expecting fix, conflicting explanations,
over utilisation of h/care
E =Emotions: Fear, anxiety, depression, useless
F =Family: Solicitous spouse, over protective partner
W =Work: Job dissatisfaction, belief that work is harmful
Illness Behaviour Beliefs, Coping, Emotions, Distress
CultureSocial Interactions
The Sick Role
Neurophysiology Physiologic Dysfunction (Tissue Damage?)
SOCIAL
PSYCHO
BIO
The Biopsychosocial ModelEngel (1977), Wadell (1987) & (2002),& Turk et al. (1988)
Psychological therapies for chronic pain
Behavioural – New ways of doing
Cognitive Behavioural- New ways of thinking
Mindfulness and Acceptance- New ways of being
Principles of Cognitive Behavioural Therapy for Chronic Pain
AIM: To help patient acquire cognitive and behavioural skills to overcome obstacles to living well with chronic pain
1. Sound therapeutic alliance2. Reconceptualise pain3. Identify realistic goals4. Present focus and structured5. Identify obstructive factors/thinking errors6. Reinforce progress acknowledging efforts and
achievements in self/activity management
“Men are disturbed not by things,
but the views they take of them”
Epitecus
Central Tenent of CBT
Cognitive Model of emotional disorders (Beck 1967)
3 levels of thinkingEarly life experiences
1. Development of schema, basic beliefs and Dysfunctional assumptions (rules)
Triggers/cuesCritical incident
2. Activation of schema, core beliefs and dysfunctional assumptions
3. Negative Automatic thoughts
Emotions Behaviours Physiological responses
The Maintenance cycle
Environment
Feeling
Negative AutomaticThought
Behaviour
Physical
Common pitfalls in human thought
• Catastrophising – turning mole hills into mountains• Overgeneralising – Drawing global conclusions• Filtering – Only acknowledging information that fits with belief • Labelling – Rigid references ‘I’m a failure’• Black and white – all or nothing• Personalising- interpreting events as being personally related• Fortune telling – predicting outcomes • Disqualifying the positive– negative observational bias, selective
perception • Emotional reasoning – Feelings as facts
The maintenance cycleEnvironment
Social deprivationBenefit dependence
Marital discordUnhelpful employers
litigation
FeelingFear
AnxietyHopeless
Anger
Thoughts – there is something seriously wrong
- I cant go on like this - hurt = harm
- Its not my fault
BehaviourAvoidant/inactive
HelplessDependent
Blame
PhysicalDeconditioned
PainTiredIBS
Obesity
Defining characteristics of CBT InterventionsCognitive interventions
Use of ‘socratic’ questioning and ‘guided discovery’ Spotting errors in thinking Modifying thinking errors Identifying alternative perspectives
Moving from extreme and unhelpful ways of seeing things to a more helpful and balanced way
Behavioural experiments
• Activity scheduling, graded task assignment – pacing, exposure
Establishing new ways of perceiving and acting
In SummaryKey Characteristics of CBT
Assumes that emotion and behaviour are largely determined by the way the individual interprets the world and events
Aims to help patients see the relationship between thinking, feeling and behaviour, together with their joint consequences.
Evidence based Empathic, active and collaborative Structured, focused and goal orientated Emphasis on the present Is educative Self help model
Thank youAny Questions?