Cognitive Behavioral Therapy and Acceptance and Commitment Therapy
Cognitive Behavioral Therapy and Acceptance and Commitment Therapy
Payal Mapara, PsyD
Ami Student, PsyD
Chronic pain is a significant public health concern globally with ever increasing prevalence rates and costs.1 In the United States alone, at least 116 million people are affected by chronic pain at a cost of 560 to 635 billion dollars annually owing to direct medical care, higher rates of health care utilization, and lost productivity.1 In addition, chronic pain is associated with decreased quality of life2 and increased rates of depression.3,4,5,6
Chronic pain is complex, and understanding the cause and maintenance requires a shift from the biomedical model to the biopsychosocial model. In traditional biomedical models, mind and body are conceptualized as separate entities that function independently of one other. Historically, utilizing the dualistic model to guide treatment has proven to be inadequate across a wide range of medical disorders. This has been particularly true for chronic pain, where psychosocial factors such as emotional distress significantly impact symptom reporting and treatment response.7 The biopsychosocial model frames chronic pain as a complex output of biological factors, psychosocial factors, and environmental factors interacting in a dynamic and reciprocal fashion. Each of these factors contributes to the development, experience, and maintenance of pain and response to treatment.8,9
From the biopsychosocial perspective, ideal chronic pain treatment is multimodal, with treatment plans incorporating several interventions for chronic pain. Potential interventions include but are not limited to pharmacology, manual therapies, procedural therapies, and psychological interventions. This chapter focuses on 2 widely used psychological interventions for chronic pain: cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT).
COGNITIVE BEHAVIORAL THERAPY FOR CHRONIC PAIN
CBT, adapted and studied to treat a wide range of problems (e.g., substance use disorders, insomnia, somatoform disorders, and mood disorders)10 across diverse populations, is based on the premise that cognitions cause and maintain negative emotional states and maladaptive behavioral patterns. More simply put, how individuals think influences how they feel and what they do in response. CBT is short term and goal oriented with the expectation that the patient is an active participant; the therapeutic relationship is marked by collaboration. CBT focuses on how maladaptive cognitive thinking styles (e.g., all or nothing thinking, mind reading, and overgeneralization) and behaviors manifest and the impact that these patterns have on current emotions and functioning. Interventions include goal setting, disputing distorted (or maladaptive) thoughts through Socratic questioning, and behavioral experiments in which individuals trial different coping strategies and record outcomes.
CBT for chronic pain, or CBT-CP, is one of the most widely used and empirically supported psychosocial interventions for chronic pain. CBT-CP incorporates the pain experience into the traditional CBT model: the way an individual thinks, feels, and acts influences pain, and pain in turn impacts thoughts, emotions, and behaviors.
Several meta-analyses have examined the efficacy of CBT for a multitude of chronic pain conditions, including chronic low back pain,11 fibromyalgia,12 arthritis, and orofacial pain.13 The consensus across these studies is that CBT is an efficacious treatment of a multitude of chronic pain conditions. CBT for chronic pain has demonstrated “positive effects” on pain intensity, quality of life, depression, and physical functioning when compared with treatment as usual (TAU) or waitlist.11 Williams, Eccleston, and Morely14 completed a systematic review comparing CBT with both other behavioral treatments and TAU for chronic pain. When compared with behavioral treatments (defined as “treatments that are purely behavioural technologies such as biofeedback”) and TAU, CBT demonstrated small to moderate significant improvements in pain intensity, disability, mood, and catastrophizing.14 From a biopsychosocial perspective, the most robust treatment would be multimodal, with simultaneous interventions targeting different areas of functioning. For example, one would expect that CBT in addition to physical therapy and pharmacotherapy would result in better outcomes than any intervention alone.15
The treatment focus in CBT-CP is on improving self-efficacy, increasing functioning, and improving overall quality of life. Note that identifying the cause of a patient’s pain and finding a “cure” or “fix” for chronic pain are not focal points in treatment, although many report a decrease in pain scores. This is an important distinction for several reasons. The first is that this approach promotes an internal locus of control versus external locus of control (i.e., “Only surgery can help me”). Second, it reinforces active coping and self-management strategies. Third, this approach promotes improvement on measurable, functional goals rather than subjective pain scores. Last, this approach promotes self-efficacy and a focus on how to live life in a valued and functional way.16
A primary goal in CBT-CP is the development and strengthening of active coping for pain, which is defined as managing pain through one’s own resources. Examples of active coping include exercise, use of relaxation techniques, and increasing engagement in valued activities. Many patients with chronic pain seen in medical settings engage in passive coping, defined as managing pain through a reliance on external factors and/or behaviors that reflect perceived helplessness.17 Passive coping includes guarding, excessive rest, activity avoidance, and use of pain medications. Reliance solely on passive coping strategies is associated with higher rates of disability, increased pain, and greater medication utilization.18,19,20 Active coping, on the other hand, is associated with decreased disability19 and higher self-efficacy beliefs.17 Utilizing active strategies can disrupt the passive pain coping cycle often seen in patients with chronic pain. A comprehensive chronic pain care plan includes both passive and active coping strategies.
Common CBT interventions used for chronic pain are listed in Table 27-1.
Goal setting is an integral part of CBT-CP. Setting well-developed, individualized goals helps patients engage in treatment and providers tailor pain care plans and interventions. Goals should be specific and behavioral and avoid vagueness or focusing on pain score reductions. Although reductions in pain scores can be a by-product of CBT-CP, the primary objectives in CBT-CP are to increase pain self-management skills and to improve functioning and quality of life. Pain scores are not always reliable or accurate measures of functioning on their own. When setting goals, it is helpful to use the SMART goal model21:
R—Relevant and personally meaningful
Providers can elicit SMART goals by asking questions such as, “How do you know if you are meeting your goal?” “What would that look like?” “What would you like to get back to or be doing more of if your pain were better managed?” An example of a SMART goal is “I will walk for ten minutes every morning for the next two weeks.” As patients meet their goals, they build confidence in their abilities to engage in important activities and ultimately develop more substantial goals. If patients are unable to meet goals, it provides good clinical information that helps providers work with patients to problem-solve challenges and also adjust goals to reflect the patient’s current level of functioning.
TABLE 27-1 Common CBT Interventions Used for Chronic Pain
Should concentrate on functional goals. Use SMART format
Diaphragmatic breathing, progressive muscle relaxation, and guided imagery are most common techniques
Work “smarter not harder” by alternating periods of activity with breaks to avoid pain flares
Explore and challenge negative thoughts and create and generate an alternative, more balanced thought
Create coping plan with specific behaviors ahead of time to implement in the event of a pain flare
CBT, cognitive behavioral therapy.
The stress response is a sympathetic nervous system response comprising cognitive, emotional, and physiological components, colloquially referred to as “fight or flight.” Signs of the stress response are increased heart rate, shallow breathing, muscle tension, anxiety, and negative beliefs about a particular activity or situation. Chronic pain, as a chronic stressor, can result in a prolonged stress response.
Relaxation training engages the parasympathetic nervous system by targeting the physiological arousal of the stress response and working to calm the body. Relaxation techniques are a direct way to intervene and slow down or stop the stress response. There are several different types of relaxation techniques, with diaphragmatic breathing, progressive muscle relaxation, and guided imagery being the most commonly used for chronic pain. Relaxation techniques offer a direct and purposeful method for patients to experience their body and pain differently. This can be a very powerful experience for patients with chronic pain who hold the belief that they have no control over their bodies or pain. As patients become more adept at eliciting the relaxation response, they can decrease the frequency and intensity of the stress response and their reliance on passive pain management strategies.
Patients with chronic pain often experience frustration and distress over their reduced activity level over time. They may describe themselves as cycling through “good days and bad days” or an up and down cycle characterized by a perceived lack of control and inevitability of pain flares. The result is a profound negative impact on an individual’s confidence in their ability to engage in even the most basic of activities, such as preparing meals or completing chores at home. It often leads to avoidance of activities, increased social isolation, and a higher frequency of pain flares.
Among patients with chronic pain, a common pattern of activity is that individuals will ignore early pain signals and “push through” pain until it is too intense to continue or the activity is complete. This often triggers a pain flare, which can last from hours to days. As this pattern continues to occur, the brain lowers the pain threshold for the activity in an effort to reduce the frequency of flares and stress on the body. Over time, this increased pain sensitivity results in lower amounts of activity, triggering more intense flares and a subsequent overall lower level of general activity.
Time-based pacing involves taking a thoughtful approach to activities and working “smarter not harder” by alternating periods of activity with breaks.21 Individuals create a baseline activity level calculated by identifying how long an activity takes before significant pain, and reduce that time by 20%. For example, if an individual identifies that 10 minutes of walking results in a flare, then they would walk for 8 minutes, take a break, and walk again for 8 minutes, and so on. The goal is to stay below the pain threshold. Between periods of activity, patients are asked to take breaks and engage in relaxing activities that calm the body and lower the stress response. Over time, as individuals are able to engage in more activities with a lower frequency of flares, they become less sensitive to pain. As their pain thresholds increase, periods of rest decrease and we see an overall upward trend in activity level.
Identifying and challenging negative cognitions is a powerful intervention for patients with chronic pain. Negative cognitions are associated with disability, pain intensity, depression, interference with daily activities, and beliefs about one’s ability to cope with pain.16,22,23,24 Cognitions play an important role in motivation to engage and exert effort in treatment and perception of treatment efficacy. For example, pain catastrophizing, defined as ruminating about worst-case scenarios, has been associated with poorer physical and psychological outcomes, even when controlling for pain.13 Although it is known that chronic pain is not simply “in the head,” the beliefs that we hold about our pain and ability to cope have a significant impact on pain experience and treatment outcomes.
Cognitive restructuring is a multistep process, with the first being the identification of negative thoughts. Negative emotions often serve as reliable cues for finding such cognitions. Once the thought is identified, the second step is to explore and challenge the thought by examining facts and looking for alternative perspectives. When challenging beliefs, it is helpful to ask several different questions to better assess the accuracy and validity of the belief, such as “Is this 100% accurate?” “Is there any evidence to contradict this thought?” “Is this thought helpful or harmful to me?” The last step is to generate an alternative, or more balanced, thought. Alternative thoughts should be realistic and unbiased, offering an accurate and healthy perspective on how one interprets experiences.
Pain flares are defined as times pain increases from its average intensity level to a higher level and remains at that higher level for a prolonged period of time (ranging from hours to weeks). Pain flares are a common phenomenon in chronic pain, and although many patients with pain can significantly decrease the frequency of flares through a variety of behavioral techniques, pain flares can still occur periodically. Planning ahead is essential when it comes to managing pain flares. Flare plans should utilize a variety of coping strategies from multiple categories. These may include relaxation techniques, coping statements, distraction activities, ice or heat therapies, and gentle stretches. The purpose of the plan is to provide the patient with a variety of coping strategies for sustaining through the flare in a safe manner without inadvertently prolonging it. For many patients with pain, it is difficult to generate a plan in the midst of a flare. Preparing a flare plan builds confidence within the patient that they have the skills necessary to address a flare should it arise. Moreover, a flare plan can reduce reliance on maladaptive behaviors, such as dangerously escalating usage of opioid pain medications or using illicit drugs or alcohol to address a severe increase in pain intensity.
Mr. S is a 46-year-old married man. He has a history of lower back pain and right knee pain. He reports his pain as insidious in onset with a worsening course over time. His primary care physician referred him after 2 surgeries were only mildly successful at reducing his pain.
He has completed a course of physical therapy with some moderate functional gains. Mr. S is currently prescribed 6 oxycodone 5 mg/325 acetaminophen per day. He manages pain with medication and rest. He reports constipation and fatigue as side effects to pain medications.
Although he was employed for many years in helicopter maintenance, he has not worked in 5 years because of his pain, which has caused his family significant financial stress. He also reports symptoms of depression.
He enjoys being active, spending time with his family, and going to church. He has not been able to go to family functions or church because he cannot sit for long periods of time and does not want to have to explain his pain to others, stating, “nobody understands.”
Mr. S used to enjoy bowling, hunting, and fishing but now spends the majority of his time watching television or playing computer games. He reports that he tried going back to bowling with his friends, but after one night it left him “laid out” for 2 days.
In the following section, we outline a representative 6-session CBT-CP plan for Mr. S that incorporates active coping through these interventions.
Session 1: Assessment and Goal Setting
In session 1, the focus is on assessment and goal setting. Pain assessment includes identification of functional goals and personal values; impact of pain on physical, emotional, and interpersonal functioning; assessment of quality of life; pain coping; and lastly, assessment of diversity factors that may impact treatment. Goal setting involves modifying functional goals into SMART goals. The following is an excerpt from session 1.
Therapist: Mr. S you have shared a lot about how pain impacts your life and how you have been coping. Let me summarize to make sure I got everything. Your goals are to be more active and to improve your physical health so that you can go back to work. Spending time with your family is very important to you, but you have not been able to because the pain gets in the way, especially if you have to do anything that requires sitting or standing too long. When you try to help around the house or be more active, you end up being “laid out” for days at a time, so you spend a lot of time avoiding activities that may hurt. The pain makes you feel frustrated and depressed, which makes it hard to be around other people especially since it’s stressful to explain your pain to other people. So far you found a few things to help with the pain, mainly resting, pain meds, and watching TV Does that about sum it up?
Mr. S: Yes, I think you got it all.
Therapist: Let’s spend some time talking more about the goals that you had mentioned earlier. Goals help guide our treatment and give us specific behaviors to work toward. When setting goals, we use a SMART goal format. Are you familiar?