Developing an Observational Self: How to Cope with Pain Series

From the time before Socrates in ancient Greece there stood a temple built upon a spring at a location the Greeks would have considered the center of the world. Inscribed on the walls of this holy temple was the simple phrase, “Know Thyself”.

This simple phrase inspired Socrates to a life of learning and teaching, and, from him, Plato learned to be a philosopher and later came to teach Aristotle. Subsequently, Western civilization, in large measure, began.

This maxim – “Know thyself” — and others similar to it were not uncommon in the ancient world. Indeed, a few thousand years previously, early Hindus and later Buddhists practiced a form of moment-to-moment self-knowledge, later coming to be called mindfulness.

The directive inherent to this maxim has two components. The first is to pay attention. In observational selfother words, slow down and observe what’s happening. In today’s language, we might express the maxim as something like, “Get out of your head and notice what’s going on around you.” When we carry out such a dictum, we become observant and reflective. We see or otherwise perceive things that we might not have heretofore noticed. We subsequently create opportunity to consider what it is we observe.

Good things happen when we do. We see good things and become appreciative. We stop and smell the roses because we were observant enough to even notice them as we walked by and as a result we are able to appreciate their visual and olfactory beauty. Whereas in one moment our kid might be bugging us because of her need for attention is interrupting our apparent need to make a phone call or put dinner on the table, in the next moment, once we get out of our head, we recognize just how funny or cute the kid is and we subsequently are overwhelmed by how much love we have for her.

So much of life goes unnoticed because we are simply and persistently reacting to whatever thoughts, feelings and needs that pop into our attention. Whatever pops into our heads tends to have a sense of immediacy to which we react impulsively, without thinking in the sense of thoughtful consideration. It’s just a never-ending chain reaction of stimulus and response, like billiard balls knocking into each other. Notice that when we live life as if we are a player in a video game that goes on in our head, simply and persistently reacting to whatever momentary thought, feeling, or need that pops into our head, so much of what goes on around us gets missed.

We don’t see how cute our kid is in that moment. We don’t notice that our spouse made coffee for us before leaving for work. We don’t smell the fresh air. We don’t taste our lunch. We don’t fully appreciate how funny it was when our coworker or neighbor made that comment yesterday.

Instead, we were busying ourselves with the immediacy of whatever popped into our head at the time.

Notice too all the things we could have done in those moments but didn’t do simply because it never occurred to us. When we react to whatever thought, feeling or need that pops into awareness at any given time, it’s as if the reaction that we have is the only possible thing to do at the time. We might even justify the reaction, if anyone ever were to ask us about what we did, by saying ‘Oh, I had to,’ as if the thing we did was the only possible thing that could have been done. However, it’s not really true, and this point brings us to the second good thing that happens when we get out of our heads and start to observe what in actuality is happening in any given moment.

Namely, we become liberated from being a passive recipient of what happens to us to an active decision-maker of a well-informed life. By observing what in actuality is happening in life, and by considering the various possible ways we might respond, we exercise choice. No longer is our life dominated by the apparent ‘must’ and ‘have to’ and ‘got to’, but rather we are free to choose. When we pay attention, we recognize that we do not have to simply endure things happening to us. We are not victims. We have the power to choose among a number of different options as long as we slow down enough to recognize and consider the options that are available to us.

The simple maxim – Know thyself”, then, is a truth that sets us free. It’s freedom from a determinism of automatic reactions to whatever life gives us. We no longer ‘have to’ do this, that, or the other thing, but are free to choose how we live our life. We no longer ‘can’t’ do anything but the reaction that we have automatically done countless times in the past and are now free to choose how we might respond and move forward. From moment to moment, we are free to choose how to respond even to the things in life that we do not choose – like bad things that happen to us. We still are free to choose how we react to them and the perspective by which we see them.

In sum, the second good thing that happens when we observe what’s happening is that we become intentional about what we do, how we react to things, and even how we perceive the things around us.

This ability to observe life and intentionally choose how to respond to the things that come up from moment to moment is the main goal of psychotherapy. Freud called this ability the development of an ‘observing ego’ and considered analysis a way to develop this ability. In more recent psychotherapies, we call it an ‘observational self’. It’s the ability, as described, to step out of any given moment, consider what’s happening, and intentionally choose how to react. Of course, in this day and age, we also call it ‘mindfulness’.

What does developing an observational self have to do with pain?

The development of the ability to step out of the moment and reflect on how to react to pain is the initial and most important thing to do in pain management. Everything else in pain management follows from this skill.

Pain has a sense of immediacy about it. It’s a sensation that is inherently emotionally alarming and to which we automatically react with avoidance behaviors – we stop what we’re doing, pull away and guard. This sensory, emotional and behavioral experience happens all at once, of course, and it happens automatically. We don’t typically choose any of it. The sensation just is alarming and we pull away and guard without ever intending to do so.

For example, if you were out hiking in the woods and, without looking, you stepped in a hole and twisted your ankle, you’d have pain. That is to say, you would have a sensation that was emotionally alarming and to which you would stop walking and guard your ankle in some manner. The whole experience would be almost instantaneous. It would also be automatic, in a sense. The alarming sensation and behavioral avoidance would occur without any intentional decision-making on your part.

However, if you had chronic pain, and you set out to pay attention to the pain that occurred with activities, you could learn to make the whole experience more intentional. You would do so in a multiple step process. You would first simply pay attention to the pain that occurs and not be taken by surprise by it. Chronic pain often has a degree of predictability that the pain of an acute injury doesn’t have. So, by paying attention, you could practice the skill of not being taken aback by the pain. Just as importantly, you could recall that you have chronic pain and that you’ve had it for some time and you know what it is. In most cases, chronic pain is the result of the nervous system having become highly reactive to the stimuli of activities that are normally not painful to do – like walking, sitting, standing up, laying. You could consider that, even though it is painful, these activities are safe to do– that you are not injuring yourself even though it is painful. In this manner, you start to control the sense of emotional alarm that you have with pain. You set out to intentionally remain emotionally grounded in the presence of pain. To this end, you also practice taking deep, diaphragmatic breaths to assist you in remaining calm. From this new-found perspective, you can also choose how to behaviorally react. You intentionally choose to engage in the activity and have the sensation while practicing remaining calm.

Suppose, for example, every time an individual with pain sits down she knows she’ll experience pain. More often than not, however, she doesn’t keep this fact in mind and she goes about her day, like most of us, simply reacting to whatever pops into her attention. She does this and then that, checking things off her to do list. Each time she sits down, she lets out a soft groan, grabs whatever is within reach in order to brace herself, and becomes, for an instant or two, emotionally and physically tense. The pain is severe and it takes her breath away.

She could, though, with some proper coaching from a psychologist at her pain clinic, set out to learn and practice the ability to step out of the moment and pay more attention to her actions. She could then practice slowing down the process of experiencing pain. In doing so, she pays attention to what she does and predicts the severe pain prior to sitting down. In this way, she isn’t taken by surprise each time. With knowing that it’ll hurt, she takes some deep diaphragmatic breaths as she works and reminds herself that even though it is painful she isn’t injuring herself every time she sits down. She intentionally recognizes that it is safe to sit down even though it hurts badly. In these ways, she practices remaining grounded while having pain. With her budding abilities to remain calm in the presence of pain, she intentionally sets out to control her pain avoidance behaviors. She makes the decision to stop letting out the groan because she’s predicted the pain and isn’t taken aback by it as she sits down. She intentionally stops her tendency to abruptly reach out for something to hold on to while she sits, reassuring herself that it is safe to sit down. She also tries to refrain from grabbing her back and instead sets out to remain as calm as she can be in the presence of her pain, even severe pain. She intentionally does all things, moreover, on a repetitive basis through the course of her day, day after day. She discusses her strategies with her psychologist each week, and her psychologist gives her pointers, which she tries at home. Over time and with practice, she gets better and better at it. By developing her abilities to pay attention, observe herself and engage in intentional decision-making, she comes to be able to control, in part, her experience of pain. She comes, in other words, to be able to control the alarming and behavioral aspects of pain and subsequently becomes able to remain grounded and productive in the course of her day, even though she continues to have severe pain.

This description is what good coping looks like. Good coping is not getting rid of pain, but getting so good at reacting to pain that it is no longer as problematic as it once was. It requires the development of an observational self from which you can have pain, remain aware of how you are reacting to it, and intentionally attempting to remain grounded and active while having pain.

From the river Ganges to the temple at Delphi and all the way through to the modern pain clinic, the dictum to know thyself travels through time because good things happen when we follow it. The ability to pay attention and engage in intentional decision-making when having pain is the initial and most important skill to develop in pain management.

Author: Murray J. McAllister, PsyD

Date of last modification: 6-19-2016

Chronic Pain Rehabilitation

A central tenet of chronic pain rehabilitation is that what initially caused your pain is often not now the only thing that is maintaining your pain on a chronic course. Let’s unpack this important statement.

It’s no accident that healthcare providers commonly refer to chronic pain syndromes as ‘complex chronic pain’ or ‘complicated chronic pain.’ It’s because pain, of course, typically starts with an acute injury or illness, but it isn’t typically maintained on a chronic course by the initial injury or illness. For after all, injuries and illnesses tend to heal. Rather, something else takes over to maintain pain long past the healing of the initial injury or illness that started it all. In most cases, this transition from pain of an acute injury or illness to chronic pain involves the development of central sensitization.

Central SensitizationCentral sensitization is a condition of the nervous system in which the nervous system becomes stuck in a heightened state of reactivity so that the threshold for stimuli to cause pain becomes lowered. As a result, light amounts of stimuli to the nerves, which typically aren’t painful, become painful. In normal circumstances, it takes a high level of stimuli – like a slug in the arm – to cause pain, but in chronic pain states any little thing might be enough to cause pain. Simple movements hurt, even such movements as sitting down or getting up from a chair or walking. The amount of stimuli to, say, the low back that is associated with these movements shouldn’t be painful, but they are because the nerves in the low back have become increasingly sensitive — so sensitive, in fact, that any amount of stimuli to them is enough to cause pain.

This condition of central sensitization explains why not only simple movements can hurt, but also why light amounts of tactile pressure can hurt. Patients with chronic pain often have had a healthcare provider ask them, “Does this hurt?” when lightly touching or pressing the painful area of their body during an examination. This light amount of pressure is often enough to send the patient through the roof. In other circumstances, you might notice that a hug or massage, which typically should feel good, is enough to cause pain. It’s all because the nerves in the painful area of the body have become so reactive that any little thing sets them off.

Other forms of stimuli, beyond that which is associated with movement and touch, can also become painful once the transition from acute pain to chronic pain occurs. As most anyone with chronic pain knows, stress can cause pain too. The stress of a bad night’s sleep or the stress of work or family problems shouldn’t typically cause pain, but it does once the nerves become stuck in the highly reactive state of central sensitization. It may also be why changes in weather can cause pain. Emotional stress or changes in temperature or barometric pressure shouldn’t typically be enough stimuli to cause pain but they do once pain occurs as a result of central sensitization.

Sensitive nerves are normal in acute injuries or illnesses

The sensitivity of the nervous system is normal in acute pain. Say, for example, you step on a nail. We often think that the resulting tissue damage from the injury (in this case the puncture wound from the nail) is the only thing that matters when it comes to pain. However, even in cases where there is demonstrable tissue damage, we also need a nervous system to have pain. Without nerves and a brain, we would never be able to feel the tissue damage associated with an injury.

In our example, the nerves in the foot detect the tissue damage and send messages along a highway of nerves from the foot, up the leg and to the spinal cord. From the spinal cord, the messages travel up to the brain, where the messages are processed by different parts of the brain. The result of this processing is the production of pain. In other words, the brain produces pain in the foot. The brain and spinal cord (i.e., the central nervous system) produces pain in response from messages sent from nerves in the foot (i.e., the peripheral nervous system).

In this process, the brain and the rest of the nervous system team up with the endocrine (hormonal) system and the immune system. With the help of hormones and neurotransmitters, the brain tells the immune system to flood the area around the injury with inflammation. Inflammation is white blood cells and certain chemicals that assist in fighting infection and repair of the tissue damage. While engaged in these activities, inflammation also makes the nerves in the area around the injury super sensitive, which, again, is why the area of the body around an injury becomes so painful to touch or pressure. In most cases, the injury heals and the brain tells the immune system that inflammation is no longer needed and so the inflammation subsides. As a result, the pain of the injury also subsides upon healing because without the inflammation the nerves return to their normal level of sensitivity. So, they stop sending messages to the brain when normal levels of stimuli to the foot occur, such as when walking on the foot.

However, sometimes, the nervous system remains stuck in a vicious cycle once the tissue damage associated with the acute injury heals. The brain, in a sense, continues to call for inflammation even after the tissue damage is repaired. With the continued presence of inflammation, the nerves in the area of the initial injury remain sensitive so that any stimuli to them, even if they wouldn’t typically be painful, continue to produce pain. The continued pain thereby keeps the brain calling for more inflammation, thus eliciting continued sensitivity of the nerves to normal stimuli and subsequently more pain.

When this process continues past the point of healing of the initial injury, it’s called central sensitization, as we’ve discussed.

Complex or complicated chronic pain

Once central sensitization occurs, any number of things can reinforce it. Just think of all the stressful problems that occur or can occur as a result of having chronic pain. Loss of work and subsequent disability can cause loss of income and significant financial hardship. The loss of work is often a blow to one’s sense of self-worth and self esteem. Chronic boredom or social isolation can also set in. Pain often produces insomnia, which further wears on the nerves. Because pain is also emotionally alarming, people with chronic pain also commonly become fear-avoidant of different activities that are associated with pain. Such distress lends itself to becoming persistently focused on pain so that life becomes predominated by pain and its associated difficulties. Anxiety and depression can secondarily occur.

All of these problems are stressful. The stress associated with these problems affects the nervous system. It makes an already reactive nervous system more reactive. The threshold that the nervous system has for producing pain becomes lower and lower. As a result, the pain of chronic pain tends to become worse and more widespread.

Notice, though, that the initial injury or illness associated with the onset of pain isn’t getting worse. It may not even be a factor at all anymore, for as we’ve discussed, most injuries and illnesses heal (e.g., lumbar strains). Sometimes, of course, the initial condition associated with onset of pain continues (e.g., rheumatoid arthritis). However, in either case, the nervous system is now also playing a role in the cause of pain. The nervous system is now maintaining pain on a chronic course. Any number of stressful problems that occur as a result of the pain can then play a further exacerbating role in the long-term maintenance of chronic pain.

So, a central tenet of chronic pain rehabilitation is that, in most typical situations, what initially caused your pain is not now the only thing that is maintaining your pain on a chronic course.

What to do about chronic pain?

The public and even some healthcare providers commonly don’t take into account the role that the nervous system plays in maintaining chronic pain. Instead, the focus of care tends to remain on looking for evidence of any lingering tissue damage or disease associated with the initial injury or illness, respectively. The presumption is that pain must be caused by either tissue damage or disease and so the initial condition that started the pain must remain unhealed. The possibility never gets considered that the nervous system has changed so that the threshold for stimuli to cause pain has lowered.

This type of thinking leads to a lot of repetitive interventional and surgical procedures. In a pain clinic, it is not uncommon to see patients who have had numerous epidural steroid injections, neuroablation procedures or spine surgeries, repeated at the same site of the initial injury. The presumption is that the tissue damage associated with the initial injury remains unhealed and so is therefore the “pain generator”. However, repetitive attempts to rectify the tissue damage associated with the initial injury often remain ineffective because the pain is no longer due (or predominantly due) to tissue damage associated with the initial injury. Rather, the pain has transitioned from acute pain to chronic pain and as such it is due to the nervous system having lowered its threshold for producing pain. Simple movements and light touch hurt – not because the tissue damage is so great – but because the central nervous system maintains the peripheral nerves in a highly sensitive state.

From here we can see why the afore-mentioned central tenet is so important to chronic pain rehabilitation. In contrast to the typical interventional and surgical forms of pain management, chronic pain rehabilitation focuses its interdisciplinary therapies on the nervous system. Chronic pain rehabilitation aims to down-regulate the nervous system so that the nervous system is not so reactive and more approximates a normal threshold for producing pain. In other words, the goal is to get to a state of the nervous system in which it again requires the force of a slug in the arm to cause pain, and not just a simple movement like walking or sitting or a light touch.

Chronic pain rehabilitation is an empirically effective form of pain management – meaning, numerous scientific studies over the last four decades have shown that interdisciplinary chronic pain rehabilitation helps people to reduce pain, get off narcotic pain medications, and return to work in some capacity.

The key components of interdisciplinary chronic pain rehabilitation are the following:

  • Cognitive-behavioral based pain coping skills training
  • Mild aerobic exercise
  • Use of antidepressants and anti-epileptics for pain
  • Relaxation therapies
  • Exposure-based milieu therapies

All of these therapies are pursued in a coordinated fashion on a daily basis over a number of weeks. Patients learn them and become adept at independently pursuing them. As a result, patients continue to engage in them on an independent basis over the lifetime.

The target of all these therapies is the nervous system, particularly the central nervous system (i.e., the brain and spinal cord). They improve the health of the nervous system and in doing so they reduce the sensitivity of the overall nervous system and thereby reduce pain. In other words, interdisciplinary chronic pain rehabilitation focuses care on what’s now maintaining your pain and not on what initially started it way back when.

Author: Murray J. McAllister, PsyD

Date of last modification: 2-14-2016

A Healthcare Educational System

Coping gets short shrift in our healthcare system. We don’t spend a lot of time or money on it. Instead, we devote the vast majority of our healthcare resources to various procedures and medications that attempt to cure conditions, or at the very least attempt to get rid of the symptoms that on-going health conditions cause. We hardly spend any time or money on what patients themselves can do to keep the conditions from disrupting their lives.

At the Institute for Chronic Pain, we believe this lack of attention to coping is a mistake. It’s a mistake because it leads to poorer health and greater costs. Let’s explain how a significant lack of attention to coping leads to these unfortunate outcomes and then review what we might do about it.

A healthcare delivery system

For the most part, we have a healthcare delivery system. I mean this statement quite literally. The predominant way in which we provide healthcare in our society is that when something ails us we seek a healthcare expert who provides or delivers to us a procedure or therapy or medication that makes us well. The standard name for this type of healthcare is the ‘acute medical model’ of care. In such care, health is brought about by the healthcare provider. The provider has a certain expertise in what ails us. As patients, we lack this expertise and so rely on the provider to use his or her expertise in order to do something therapeutic to us. As such, healthcare providers do things to us to make us well, as long as we do what they recommend. Patients don’t have much role in the acute medical model, besides being compliant and patient with the recommended therapies and procedures and medications. The real power lies in the provider who provides healthcare. In this way, we come to healthcare providers in a state of ill-health and health gets delivered to us. As stated, we have a healthcare delivery system.

The acute medical model is all well and good, especially if we have cures for what ails us, or at least the ability to keep us alive in a medical emergency. When having an acute appendicitis or a heart attack, it usually pays to be compliant with the emergency room provider’s recommendations. In such situations, we become the passive recipient of the intellectual and technical expertise of a healthcare team that delivers us from a state of poor health and danger to a state of relative better health and safety. We can think of any number of acute health conditions for which this model of care is well suited and can produce dramatic, life-changing, indeed life-saving, results.

Perhaps it’s because the acute medical model can produce such results that it has become the predominant model of providing healthcare in our society. Whatever the reason, it has become the paradigm by which we conceptualize healthcare. By it’s terms, we understand the roles of providers and patients – those who provide healthcare and those who receive it. We use it to understand what we are supposed to do when being unwell – we rely on our healthcare providers to make us well. We use it to understand the healthcare system itself – we have a healthcare delivery system.

The practical consequences of the predominance of this way of understanding healthcare are numerous. Because the procedures, therapies, and medications of the acute medical model are valued in our society, they are typically reimbursed well. They are also reimbursed readily – they tend to have few obstacles to payments. As such, it’s largely how hospitals and clinics make money to pay salaries and other expenses and to make a profit. It’s largely how healthcare providers earn their living. It’s how the pharmaceutical and medical technology industries pay employee salaries and create value for shareholders. It’s also largely what patients want. Who doesn’t want a cure?

The predominance of the acute medical model can also lead to some unfortunate consequences, particularly when it comes to the role of the patient. As patients, we tend to believe that the acute medical model can deliver on its promise of making us well more often than it can in actuality. We might acknowledge that it can’t cure us of everything, but surely, we tend to think, it can keep us well enough. As such, the focus on healthcare in our society tends to remain on what healthcare providers and their technical expertise can do for us. Power and responsibility remain with the healthcare providers, even in cases where their power to make us well is not so great. This subtle form of dependency on the healthcare system to deliver wellness can therefore become increasingly problematic: it’s fine in the cases of acute appendicitis or acute heart attack, but not so fine in conditions where there is no cure.

Chronic health conditions are the bane of our society, generally, and of our healthcare delivery system, specifically. Conditions such as chronic pain, heart disease, type II diabetes, obesity, asthma, and others have become ubiquitous in our society. Whereas our grandparents, we might say, lived in an age of infectious illness (think influenza at the beginning of the twentieth century or polio in the early to mid-twentieth century), we live now in an age of chronic illness. Such chronic health conditions are what now burden us. Despite the magnitude of this problem, the healthcare delivery system isn’t particularly well-suited for this challenge even though, as a society, both as patients and healthcare providers, we tend to look to it for the solutions. It has no cures, to be sure. However, it can’t even keep us all that well. At best, it maintains the status quo of the current less-than-healthy state of the patient. Management and stability of pain, blood pressure, cholesterol, and blood sugars become the goal. Patients, in this model, are to remain compliant with the medication and other therapy regimens in order to keep their numbers within some acceptable range of poor health. Notice how patients remain subtly dependent on the delivery of healthcare in this system and yet the healthcare that is delivered is not so great.

Because of these factors, chronic conditions are also the main financial drain on our healthcare system. Chronic health conditions constitute 86% of the cost of our healthcare delivery system and are the leading cause of disability (CDC, 2015). Acute medical emergencies notwithstanding, for this devotion of healthcare dollars, our system of delivering healthcare fosters a subtle form of dependency in exchange for chronic, mediocre states of health and outright disability. Obviously, we don’t get a lot of bang for our buck.

The role of the patient in coping with health problems

So, what’s missing in this picture? It’s the lack of emphasis on what patients can do for themselves in responding to their own chronic health conditions. In the predominance of the acute medical model of delivering care, both patients and providers forget that patients themselves have a role to play in their health. We call it coping.

We might define coping as our cognitive, emotional and behavioral responses to a problem, such as a health condition. In acute health conditions, the typical coping response is the following: cognitively, we don’t know what’s going on and we need answers in the form of a diagnosis and treatment plan; emotionally, we’re concerned, if not alarmed and frightened; this emotional alarm is helpful because it motivates us to act and seek the help of those who do know what to do; and so, behaviorally, we seek healthcare providers who have the requisite expertise to do something to make us well again. This is what good coping looks like in acute medical model healthcare. If, however, as we do in our society, we continue to apply this model of healthcare to chronic conditions we don’t fair so well: cognitively, as patients, we remain lacking the requisite expertise to adequately respond to our condition; emotionally, we remain concerned, if not alarmed, by our on-going state of health and so remain motivated to continue seeking help from those who are supposed to deliver us out of our state of poor health; behaviorally, then, we continue to seek acute medical care – its procedures, therapies, and medications, which simply maintain the status quo. Lack of knowledge or expertise, emotionally alarmed, and dependent – these are not the characteristics of good coping, at least not in the context of chronic health conditions.

What’s lacking when we allow the acute medical model to predominate in our healthcare system is the capacity to:

  1. Cognitively, teach patients what they have, how it develops and why it continues on a chronic course; how to tolerate an understanding of the patient’s own role in these causal factors; and how they can respond to it.
  2. Emotionally, empower them so that they remain both confident in their own expertise of how to self-manage the condition and motivated to do so over the long-term.
  3. Behaviorally,  coach patients on how to make meaningful, productive and sustained changes in their lifestyle so as to improve their state of health and well-being.

The acute medical model simply fails to provide these kinds of help, as it’s not designed to provide it.

Nonetheless, outside the acute medical model, in what’s called the ‘rehabilitation model of care,’ we have healthcare providers who assume this role of using their expertise to teach, empower, and motivate patients to cope well with chronic health conditions. They are health psychologists and other rehabilitation providers. You find them in chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and, increasingly, cutting-edge interdisciplinary primary care clinics where you can see both a primary care physician and a primary care health psychologist.

Notice that the number of such providers and programs pale in comparison to the procedures, therapies, and medications of the acute medical model. As a society and as a healthcare delivery system, we continue to value external, technological procedures and pills over internal coping and lifestyle change, even though the latter is oftentimes more effective. Healthcare providers continue to refer patients to acute medical model care despite the option to refer them to rehabilitation, or coping-based, care. Patients continue to seek the former more than the latter. Insurance companies too continue to reimburse procedural- and pharmaceutical-based care at exponentially higher rates than education and counseling-based care.

It seems our priorities are out of whack when it comes to the greatest health needs of our society. In the case of chronic care, we don’t need more acute medical care, but more educational-based care.

A healthcare educational system

So, what if in addition to a healthcare delivery system we also had a healthcare educational system? What would it look like? Beginning with primary care, it would involve clinics that have not only primary care medical providers, but also primary care health psychologists. So, for example, type II diabetes patients would obtain medication management and nutritional counseling, as they do now, but also meet with a health psychologist to focus on the following:

  • Tolerating and accepting greater degrees of ownership and responsibility for their diabetes and overall health
  • Understanding the role that patients play in the development and maintenance of the condition
  • How to make incremental lifestyle changes to improve their diabetes and overall health
  • How to sustain these changes over time

In the limited number of primary care clinics that operate in this manner, the focus of such care is not to deliver well-being to patients, but to educate them, empower them, and motivate them to improve their well-being themselves. As a result, patients no longer remain in the afore-mentioned subtle dependency on the expertise of their healthcare providers. Through a healthcare educational system, patients become experts themselves.

Health psychologists, thus, operate under the principle that knowledge is often insufficient
for sustained meaningful change. In our current acute medical model, the education and counseling that medical providers engage in typically ends with the provision of information: information, such as that smoking is bad for you; that you should lose weight; that you should exercise more; that you should learn to manage your stress; and so on. However, who doesn’t know these things? Simply knowing these things isn’t typically enough to successfully quit smoking, lose weight, start exercising or manage stress. Information is therefore insufficient for successful lifestyle change.

As such, we typically need someone to sit down and go over how to apply this information in ways that lead to long-term successful lifestyle change. However, no one, in our current healthcare delivery system, sits down with patients and actually goes over how to cognitively tolerate and accept such information or how to understand the individual’s role in achieving these goals; no one sits down with them and shows how to become empowered, confident and motivated to pursue and maintain these health goals; no one sits down and clarifies how to actually make incremental behavior changes that can successfully meet these lifestyle goals; no one develops a trusting relationship over time in which these often sensitive discussions can be had, as a coach has with the athlete that he or she trains; and no one can meet with patients on a periodic basis over time, with extended appointment times that last anywhere from fifteen minutes to an hour. No expert healthcare provider performs this role, except for the health psychologist.

What would it be like to have a trusting relationship with someone in your primary care clinic in which you can have up to an hour appointment, without the sense of being rushed, to discuss sensitive issues about how your health affects your life, but also how your life affects your health, to learn and grow, and to become a healthier and happier person, despite having some chronic condition? You’d become an expert at coping with your chronic condition and as such you’d know how to manage it so well that it would no longer disrupt your life in any significant way: what occupies your time, attention and energy would be your job, family and other life pursuits – not your chronic pain, diabetes, or heart disease.

Outside the primary care office, a healthcare educational system would also have specialty clinics. They would be interdisciplinary in nature, such as chronic pain rehabilitation programs, cardiac rehabilitation programs, diabetes education programs, and the like. Patients would seek care in these clinics in order to obtain advanced education and training in the self-management of their respective conditions. The function of these programs is typically two-fold. First, their intensity allows patients to take the next step in developing their expertise, which is to actually start reducing their dependency on the healthcare delivery system. By participating in these programs, patients get so good at self-managing their condition that they are able to reduce the amount of medications they take. Coping, in the form of healthy cognitive, emotional and lifestyle behavior changes, comes to be able to substitute for some of the medications that patients have heretofore relied on to manage their condition for them. Second, the intensity of these programs allow patients to learn and regain the confidence that they can return to some type of meaningful work.

Of course, a healthcare educational system wouldn’t replace a healthcare delivery system. There is a time and place for acute medical model care. Medical emergencies occur and the acute medical model is best suited to respond to such cases. Even in the acute phases of what might turn out to be a chronic condition, there can be a role for the acute medical model. So, for example, patients can often benefit from acute medical model pain or cardiac management in the early phases of these conditions, even when the conditions subsequently later become chronic.

However, the vision we are entertaining involves a re-setting of priorities or emphasis when it comes to the roles of both the healthcare delivery system and a healthcare educational system. Patients and healthcare providers wouldn’t continue to repetitively seek acute medical model procedures and therapies long after a condition has clearly become chronic. Rather, everyone involved would see the point of switching the emphasis away from vainly attempting to deliver well-being to patients and towards educating, empowering and motivating patients to successfully improve their own well-being. In so doing, as a society, we would have to modify the value we place on the acute medical model, seeing that it has high levels of value in only certain contexts, and we would have to increase the value we place on rehabilitation-based care.

An important and essential part of this re-evaluation of our healthcare system would be the role of the reimbursement arm of our system – health and disability insurance companies and government institutions. They too would have to modify the value they place on each of the respective types of healthcare. Currently, reimbursement rates for acute medical model procedures and therapies are exponentially higher than rehabilitation, or coping-based, therapies. This system of valuation cannot but influence what type of care gets provided. To be sure, it’s one of the reasons that the acute medical model predominates in our healthcare system.

What if, though, the reimbursement rates for medical providers were the same whether they provided education and counseling or a procedure? What if the health psychologist’s cognitive behavioral therapy was reimbursed at the same rate as medical providers’ education and counseling, or medical providers’ procedures? What if nutritional counseling and physical therapy were reimbursed commensurate to these other therapies as well? If the reimbursement rates of all these therapies were at least within the same ballpark, even if they weren’t exactly identical, we would have a very different healthcare system. Healthcare providers would stop being incentivized to provide acute medical care to conditions that are clearly chronic and they’d be incentivized to take the time to sit down with their patients and have the lengthy, oftentimes sensitive, discussions about how to cope with a long-term health problem.

Specialty care would significantly change too. In the vision we are entertaining, the value that we place on acute medical care would be commensurate with the value of coping-based care. Reimbursement rates for interventional procedures and surgeries would no longer be astronomically higher than interdisciplinary rehabilitation programs. To acknowledge that there may be a time and place for such former procedures, suppose that reimbursement rates declined only as they were repeated over time for the same condition. So, patients and providers might pursue interventions and surgeries, especially in the acute phases of a condition, but their value would decline as they get repeated long after it is clear that the condition is chronic. The reimbursement rates of interdisciplinary rehabilitation care would then start to become commensurate with acute care, especially when it comes to care for chronic conditions. In so doing, we’d stop incentivizing healthcare providers to deliver acute care to chronic conditions. The result would be that as a healthcare system we’d come to start valuing the right treatment for the right condition at the right time. We’d all obtain better care at a lower cost.

Whether you’re a patient, a provider or a representative of an insurance company, maybe it’s time to start demanding a healthcare educational system that focuses on coping-based care.

References

Center for Disease Control. (February 3, 2015). Chronic disease prevention and promotion. Retrieved from http://www.cdc.gov/chronicdisease/.

Author: Murray J. McAllister, Psy.D.

Date of last modification: April 12, 2015

A Webpage Worth the Read

Those of you who are connected to one of our social media sites know that we tend to post daily on the latest news and research in the field of chronic pain management. We recently came across a description of cognitive behavioral therapy for chronic pain on the web, which we initially thought we’d send out on one of our daily posts. After finding myself reading it for a second time, however, I thought that it was too good to simply send out on social media without more comment than the usual line or two of introduction that we tend to provide.

The webpage is Dr. Christopher Pither’s piece ‘Cognitive Behavioural Approaches to Chronic Pain.’ It’s part of the Wellcome Trust’s website on pain that originally accompanied an exhibition at the Science Museum in London, entitled ‘Pain: Passion, Compassion and Sensibility.’ The website overall is also well worth reviewing, containing webpages on an eclectic range of topics, including scientific research on pain, therapies for pain, the history of how we have conceptualized and treated pain in the past, and cultural issues surrounding pain. All of it is thought provoking as well as useful information to know.

As indicated, Dr. Pither’s article itself is entitled ‘Cognitive Behavioural Approaches to Chronic Pain.’ It is simply the best and most concise description of cognitive behavioral therapy for chronic pain that I have so far come across on the web.

He opens the piece with a compassionate, yet scientifically accurate, description of how chronic pain develops. He reviews the many and complex variables involved. I especially appreciate how he sticks to what the scientific data tell us while at the same time remaining empathic and non-stigmatizing. The importance of this approach to his writing lies in the scientific data: while painful acute injuries and illnesses occur to all of us, likely at a roughly equal rate across all people, what predicts the transition from acute pain to chronic pain are psychosocial factors. To put it another way, those who are at most risk of developing chronic pain once an acute accident or illness occurs are those whose central nervous systems have been previously up-regulated for psychosocial reasons. Now, of course, these consistent scientific findings do not mean that people with chronic pain are to be blamed for their condition. It is simply to assert a common truth that we all know, if we consider it for a bit, which is that the overall context in which an acute injury or illness occurs matters. If an upper respiratory infection occurs in a person whose immune system is already compromised, then that upper respiratory infection will likely take a much different course than if the same infection occurred in someone whose immune system is not already compromised. Similarly, if an acute painful injury or illness occurs in someone whose nervous system is already up-regulated, then the pain is likely to take a different course then if it occurred in someone whose nervous system is not up-regulated. Namely, the pain has a higher likelihood of continuing past the normal healing process of the original acute injury or illness, thus becoming chronic pain. Dr. Pither acknowledges such a scientific based understanding of the development of chronic pain, but does so with compassion and empathy. For after all, that is what people with chronic pain deserve.

All the stakeholders in the field of chronic pain management needs more of this kind of discussion. Whether we are provider, patient, family member, or policy analyst, we have yet to figure out a way to consistently be able to talk about the real psychosocial aspects of chronic pain without raising the specter of stigma. Indeed, all too often, we try to get rid of stigma by denying all the inherent psychosocial aspects of chronic pain. We do so, though, at our own peril. When we deny a major aspect of a health problem in order to resolve a social problem, like stigma, we are bound to have poor outcomes in the management of that health condition. Imagine the cardiovascular field attempting to successfully manage heart disease if its psychosocial components were off limits to discuss and in fact were denied as unrelated. Whether as patient or provider, the management of heart disease would fail if we couldn’t discuss the role of smoking, lack of exercise, obesity, poor nutrition, depression, and stress. Similarly, in chronic pain management, we are bound to have poor outcomes if we cannot discuss the role of the psychosocial aspects of chronic pain. But, of course, we need to be able to have this discussion without stigmatizing the patient. Typically, in our field, we don’t do a good enough job of walking this fine line. Dr. Pither, however, seems to be able to do it. We should learn from his example.

Dr. Pither also astutely describes the common trajectory of care that patients go through on their way to ending up in a cognitive behavioral based chronic pain rehabilitation program. Because chronic pain is truly a ‘biopsychosocial condition’ that doesn’t fit well into the acute medical model of care, providers tend to refer patients back and forth between the medical side of the healthcare system to the mental health side of the healthcare system with neither being able to help very much. All too often this back and forth care goes on too long. Eventually, as Dr. Pither notes, someone refers patients with chronic pain to a cognitive behavioral based chronic pain rehabilitation program where they begin to get the care that most accurately addresses the true biopsychosocial condition that they have.

While rightly claiming that cognitive behavioral based chronic pain rehabilitation programs are the most effective therapy for chronic pain, Dr. Pither’s writing exhibits the scientific values of humility and constraint (i.e., good science tends to provide conservative interpretations of the data, never making greater claims than what the data reveal). I appreciate such humility and constraint. I think that all too often in healthcare, and in the field of chronic pain management in particular, providers tend to promise more than they can deliver. Don’t get me wrong. I don’t think that the multitudes of well-trained professionals in the field are equivalent to the snake oil salespeople of yester year, intentionally making pitches that they know aren’t true. No, what I am saying is that I think there is a pervasive lack of understanding among the stakeholders in the field of what science tells us are the most effective ways to manage chronic pain. Without such knowledge, providers and the public tend to believe that everything we do — any chronic pain treatment that is commonly provided – is effective. Unintentionally, then, providers of various treatments for pain can tend to go beyond the data and promise substantial pain reduction, if not a cure, when discussing with patients what can reasonably be expected. The sentiment in Dr. Pither’s piece does no such thing. He rightly acknowledges that cognitive behavioral based chronic pain rehabilitation is the most effective treatment, but states, with humility and constraint, that what constitutes the greatest effectiveness in the field of chronic pain management is helping patients to live well despite having chronic pain. We simply do not have cures for chronic pain. Nonetheless, there is hope. People with chronic pain can live well. They just have to learn how and they learn how to do it in cognitive behavioral based chronic pain rehabilitation programs.

Charles Pither, MBBS, FRCA, is a physician and consultant in pain medicine. He practices at RealHealth, London, England.

Please read his piece entitled, ‘Cognitive Behavioural Approaches to Chronic Pain.’ You can find the link to the webpage here.

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Author: Murray J. McAllister, PsyD

Date of last modification: 10-4-2014

Mind Reading: How to Cope with Pain Series

No, this post isn’t about telepathy. It’s about a common problem faced by people with chronic pain and how to overcome it.

Mind reading defined

The phrase “mind reading” is a piece of technical jargon used in cognitive behavioral therapy and chronic pain rehabilitation programs. It refers to a particular type of thinking in which a person thinks that other people are judging him or her even though the other people might not ever say anything. As such, mind reading is a type of thinking that involves an assumption – an assumption that you know what others are thinking.

Mind reading involves two essential components. First, it is an assumption in which you think you know what others are thinking. Second, you assume that what others are thinking are negative judgments about you.

Mind reading typically occurs without much awareness on the part of the person who is doing it. When engaged in mind reading, you don’t intentionally set out to do it. Rather, it happens almost automatically. Before you even know it, you’re doing it, thinking that others are judging you and coming to feel judged and reacting accordingly. It’s for this reason that psychologists consider mind reading as a type of automatic negative thought. (We have previously discussed a different type of automatic negative thought in our blog post on catastrophizations.)

Typically, mind reading doesn’t accurately represent what others are really thinking. When engaged in mind reading, we tend to think we know what others are thinking of us, but this ‘knowing’ is more often than not an unwarranted assumption. Usually, we really can’t say with any degree of certainty that the assumption is accurate. Indeed, if we step back and think about it, as we are doing right now, it might be more accurate to say that most people don’t spend a lot of time judging us as they go about their own life activities. In reality, most people are too involved in their own business to notice us with any more than a casual glance in our direction. Despite this fact, when mind reading, the assumption that others are negatively judging us feels so accurate. We feel so certain that they are judging us. As such, we simply react as if it is really happening when in all likelihood it isn’t. Psychologists oftentimes call mind reading a type of cognitive distortion. In other words, mind reading is a type of thinking (i.e., cognition) that distorts reality, leading us to believe things and react to others in ways that aren’t accurate to what’s really going on in the thoughts of others.

Mind reading leads to emotional and behavioral reactions that are indicative of being judged by others, even though, typically, in reality, the other people aren’t really judging us. We might feel anxious or ashamed or angry or defensive. We might start fretting about why people are so judgmental or what we might say if they say something first. We might also change our plans in response to these perceived judgments of others. You might, for instance, hurry through the grocery store because you just ‘know’ that everyone is judging you by the way they look at you. Maybe, you leave the family reunion early because you just ‘know’ that Aunt So-and-So is snickering behind your back. Such thoughts and their subsequent feelings and behaviors typically occur automatically, in the background of your awareness, and it all goes on unquestioningly, without you ever checking it out against reality.

Every one of us engages in mind reading. Some people only do it on occasion and as such it doesn’t cause a whole lot of problems. Some people, though, engage in it more often. For them, it can become problematic.

It’s stressful to feel as if you are the object of judgment. It wears on your ability to cope with the problems of life. It saps your enthusiasm for the activities of life. It can also lead to anxiety of different kinds as well as depression. (We bring this fact up not to judge, but simply to acknowledge it and provide an explanation.)

So, while everyone does it, we can see mind reading as a type of thinking that occurs along a spectrum from those who do it less often to those who do it more often.

Mind reading and living with chronic pain

Mind reading can occur in all walks of life including in those who live with chronic pain. No doubt, at least some readers have already started to apply this notion of mind reading to themselves and have begun to identify examples of it from their own lives.

Countless patients over the years have expressed to me their ambivalence over the use of a disability parking permit. They report feeling conspicuous when they park in a disability marked spot, thinking that they need to justify their use of the spot to every passerby. I have had a few patients acknowledge that they really don’t need their cane, in terms of the potential of falling, but carry one anyway because it signals to others that their slow gait is justified. Countless patients have reported that they hardly ever go to parties anymore because they know that everyone judges them if they acknowledge that they aren’t working and are disabled.

Notice the assumptions that are happening in these examples. In each, the people think they know that others are judging them for having chronic pain or being disabled by pain and have subsequently changed their behavior as result. It’s like there is a persistent low-grade fear that pervades their daily experience – a subtle worry of what others think and what they might say, given a chance. Notice, too, that such subtle worry or fretting so often goes on automatically and unquestioningly, without a lot of awareness, at least until it gets named.

The persistent, low-grade nature of mind reading can take a toll. Such worry and fretting take energy. It’s one more drain of energy among all the other drains that can occur when living with chronic pain (such as insomnia, sedating medications, and the pain itself). It can come to justify social isolation and lack of activity outside the home. Mind reading can also lead to anxiety and depression and can even trigger panic if you are already prone to such problems.

In all, when it comes to living with chronic pain, mind reading makes coping with pain more difficult.

Common reactions to learning about mind reading

The notion of mind reading is commonly introduced and discussed in cognitive behavioral therapy and in the coping skills training courses that occur in a chronic pain rehabilitation program. Usually, once introduced, patients know exactly what we are talking about and can quickly come up with examples from their own lives. As discussed earlier, everyone does it, including those with chronic pain.

However, some people become troubled by the discussion and express one of two common objections.

One objection is that the notion of mind reading seems like a judgment itself. In other words, it seems like a criticism and that what we are saying is that people worry too much about what other people are thinking.

The intention, here, is not to criticize, but simply to acknowledge a problem that we all share to one extent or another. We don’t want to be in a position in which we maintain a pretense that we never worry or fret about what other people think of us. We all do it. There need be no shame in acknowledging it and nor should it be a criticism to talk about how we each do it. Moreover, it is a mark of strength to acknowledge one’s own problems, learn about them, and to learn about how to overcome them. Our discussion today is simply an opportunity to learn about a common problem and how to overcome it.

The other objection is that sometimes other people really do judge or criticize us. You may have someone in your life right now who does it. Perhaps it is a spouse or other family member or your supervisor at work. Maybe they tend to doubt the legitimacy of your pain or your sense of disability and have expressed, “Aw, come on now, it can’t be that bad!” Such judgments hurt and can make a lasting impression. You fret about it now, having conversations in your head with this person about what you could or should have said. These kinds of judgments from someone close to you and the resulting fretting can easily lead to persistent, low-grade worry that maybe everyone judges you similarly. This worry then can further lead to changing your behavior in public or with family in anticipation of what these other people might say. Notice how easy it is to start mind reading.

So, yes, the objection is a point well taken. Other people can in fact be judgmental.

And yet, is this fact the exception or the rule? Might we not agree that most people, most of the time, are simply too preoccupied by their own thoughts and worries to notice us, let alone think about us for long enough to actually judge us? I think most of us would agree that people don’t judge us as much as we tend to think they do.

It is this tendency that we are discussing – the tendency to mind read. So, while it is true that sometimes people really do judge us, maybe we can also spend too much time and energy worrying and fretting about what others think of us because in reality most people aren’t judging us.

So, what can we do about it?

Overcoming mind reading

The first step in overcoming the tendency to mind read is to simply learn about it, as we are right now. The second step is to learn to identify it in yourself. The third step is to get good at challenging it, once identified, by talking yourself through it in the moment.

As described above, usually the notion of mind reading gets introduced in cognitive behavioral therapy or in the group coping skills training within a chronic pain rehabilitation program. The discussion involves the use of examples, sometimes made up examples, but other times examples from the actual lives of patients. By using examples, the component parts of mind reading are identified and clarified. The use of this post is intended to provide a somewhat similar experience for the reader.

The next step is for you, the reader, to consider the role of mind reading in your life. Reflect on when you might do it and identify some examples from your own life. Perhaps, discuss them with your health psychologist or while you participate in your chronic pain rehabilitation program.

What you are doing while reflecting on examples from your daily life is getting better at identifying instances of mind reading. It’s important to develop this skill of identifying instances of mind reading in your life. As you get good at it, you can then use it to identify instances of mind reading in the moment. It’s the skill of becoming more aware of what it is that you are thinking and recognizing in the moment that you are engaged in mind reading – worrying about what others are thinking of you and changing your behavior accordingly.

The skill of being able to identify or recognize that you are mind reading is an example of a more broad skill that psychologists call developing an ‘observational self’ (what was once called an ‘observing ego’). An observational self is the ability to step out of any given moment and reflect on what we are thinking and feeling and doing. In short, it is our ability to think about our thinking. It is our observational self that allows us to be able to step out of the moment and recognize that we are mind reading – “Oh, there I go again, I’m mind reading right now.”

Without an ability to step out of the moment and recognize that we are mind reading, we go on in life engaged in mind reading without awareness, allowing it to guide our behavior and sap our energy and abilities to cope with pain. So, this skill of being able to identify and recognize our thinking is important.

But, what do we do once we recognize in the moment that we are mind reading?

You use your understanding to provide reassurance that your mind reading is unwarranted and as such you can be more self-confident in your daily activities. This further skill takes practice.

Say, for example, you go to the grocery store and park in a disability spot because you have a disability permit. You are not in a wheelchair, though, and so as you get out of your vehicle you start to worry about what others are thinking of you. Initially, you are automatically convinced that they are thinking, ‘Hey, what’s wrong with you? You don’t look disabled! You shouldn’t be parking there!’ You start to feel nervous and look down as you walk into the store, not wanting to make eye contact with anyone. But then you recall our discussion and this notion of mind reading. You use your understanding of it to identify that you are doing it right now! You think to yourself, “Oh, there I go again!”

As a result of this recognition, you talk yourself through it. You recall that mind reading relies on an unwarranted assumption – that just because some people are judgmental doesn’t mean that everyone is judgmental. You subsequently reassure yourself that in all likelihood the people passing you by right now are not judging you. Instead, they are likely lost in their own thoughts, hardly noticing you. You can then say to yourself, “I can be confident right now” and you lift your head up walk into the store.

Now, of course, at first you are not going to be very good at it. You might fail to recognize that you are mind reading and only come to think about it long after the fact. At other times, you might recognize it, but be unable to stop it or provide any meaningful reassurance to yourself. For instance, you might try to reassure yourself, but the words seem flat and empty. In other words, the nervousness of worrying what others are thinking might continue to get the best of you.

With practice, however, you will get better at it. Over time, you come to believe your reassuring self-talk more and more. Maybe you also start predicting that you will start mind reading before you even do it and begin providing reassurance preemptively. At some point, with practice, you begin to notice a budding sense of self-confidence. You find that you are a little lighter in your step and have a little more energy when you are out in public or when you are spending time with family.

As you practice, it’s important to recognize that you will never get to the point where you won’t ever mind read again. No matter how good you get at recognizing your mind reading and providing yourself with reassurance, you will never gain one hundred percent control over your thoughts and be able to stop mind reading forever.

A more realistic goal is to get to a point, with practice, where you engage in mind reading less and less often and that, when you do mind read, you catch it early in the process and successfully provide yourself with reassurance. When you can do all that, you will be more self-confident and better able to cope with pain.

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-8-2014

CBT and Central Sensitization

A study published this month in Pain produced what is likely some of the most important research findings this year for the field of chronic pain rehabilitation. The study demonstrated that basic CBT interventions can reduce central sensitization (Salomons, et al., 2014).

Countless studies in the past have shown that CBT and CBT-based chronic pain rehabilitation programs are effective in reducing self-reported pain in chronic pain patients. In these studies, we have had to infer that CBT reduces central sensitization: because CBT is effective at reducing chronic pain based on verbal self-report, and because central sensitization is a leading cause of chronic pain, we have inferred that CBT must reduce central sensitization. Now, we have a study that directly demonstrates it.

In their well-designed study, Salomons, et al., are the first to experimentally induce a form of central sensitization in a group of previously pain-free subjects, deliver a CBT intervention, and measure the reduction in central sensitization that results from the CBT intervention. As such, they are the first to demonstrate that CBT reduces central sensitization as measured in the laboratory and not simply rely on inferences based on self-reported pain levels.

The study design

The study consisted of 34 healthy women who did not have pain. Through a series of pain-provoking procedures, the researchers induced secondary hyperalgesia in these healthy women. Secondary hyperalgesia is a type of central sensitization. Central sensitization is largely considered a common, if not the most common, cause of chronic pain. In secondary hyperalgesia, the nerves in the general location of the pain become reactive in an increasingly wider area. As a consequence, it takes less and less stimuli to cause pain in this widening area around the site of the original pain.

Along side this series of pain-provoking procedures, the researchers provided half the group of healthy women with a few basic cognitive behavioral interventions for pain. The CBT intervention consisted of both providing the subjects with information about the sensory, cognitive, and affective aspects of pain and engaging them in cognitive restructuring in order to reduce the stress response that accompanies pain. Cognitive restructuring is an intervention that helps people to make sense of their pain differently, from understanding it as something that is alarming or frightening to understanding the pain as something that is more benign and not harmful or perhaps even beneficial. For the other half of women, they provided a psychotherapy focusing on becoming more assertive in interpersonal communication skills.

By comparing CBT for pain with a non-pain related psychotherapy, they attempted to determine the effectiveness of the CBT itself.

The provision of some form of psychotherapy to both groups is important because it controlled for the effectiveness of non-specific therapeutic factors of psychotherapy. Let me explain. To do so, we need to stray from our original topic a bit.

One of the most consistent findings in the last four decades of psychotherapy outcome research has been that a large percentage of what accounts for the effectiveness of psychotherapies are factors that are common to all psychotherapies. So, whether we are talking about cognitive behavioral therapy for pain or diabetes or depression, or psychodynamic therapy for dysfunctional relationship patterns, or family systems therapy for teenage behavior problems, they all tend to have some things in common, which contributes to what makes them effective. That is to say, despite having some obvious differences, they each share certain factors and these factors are in part what make them all effective.

These factors tend to be characteristics of the relationship between the provider and the patient. We tend to refer to these characteristics in general as the qualities of the ‘therapeutic relationship.’ For example, research consistently finds that, in whatever type of psychotherapy that one pursues, the development of a relationship with an expert provider who takes the time to listen to you and provide mutually respectful, caring, and honest feedback leads people to become motivated to make healthy behavior change – whether it is in learning how to manage pain or diabetes, overcome depression, develop healthy relationships, or change problematic teenage behaviors. In other words, the therapeutic relationship that you have with a healthcare provider is what leads, in part, to making healthy changes that can improve health.

So, in a study aiming to determine how CBT is effective for managing pain, Salomons, et al., needed to make sure that they were measuring what is unique to CBT for pain and not the general effectiveness that all the psychotherapies have in common. To do so, they compared CBT to a psychotherapy that was not for pain, but which would have the general therapeutic factors that are common to all therapies, including the CBT for pain. This study design thus allows the researchers to conclude that if CBT for pain is in fact more effective, then what’s making it more effective are those things that are unique to CBT. In other words, the therapeutic relationship might play a role in both psychotherapies equally, but if one is more effective, such as the CBT, then what’s pushing it over the top are those things that are unique to CBT.

So, let’s get back to what Salomons, et al., found.

Cognitive behavioral therapy and central sensitization

While both groups of study subjects reported less pain intensity, those who underwent CBT reported that the pain they had was less unpleasant and therefore more tolerable. These findings that CBT reduces pain and makes pain more tolerable are largely similar to most clinical trials of CBT for pain.

The more interesting and important finding was that the subjects who received CBT exhibited a 38% reduction in the area of secondary hyperalgesia. Recall that secondary hyperalgesia is a form of central sensitization in which the nerves around the site of pain become more reactive in a widening area. In this increasing area around the original site of pain, less and less stimuli are required to generate pain. Secondary hyperalgesia is thought to be one of the ways an acute injury can transition to chronic pain even after the acute injury has healed. In their study, Salomon, et al., experimentally induced secondary hyperalgesia and subsequently showed that CBT can reduce it.

To my knowledge, no previous study has directly demonstrated a reduction in a form of central sensitization with CBT interventions.

A possible explanation for this finding is that CBT reduces the stress response that occurs with pain. By coming to think about pain differently, the change in thinking corresponds to changes in the neural network of the brain. These changes in the brain might subsequently alter the hormonal and inflammatory responses of the stress response, which subsequently makes the nerves in the peripheral area around the site of the original pain less reactive. As such, the cognitive restructuring corresponds to changes in the brain that reduce the stress response, which lead to downstream reductions in nerve reactivity.

Whatever is the explanation, the findings of Salomons, et al., are important as they can lead us to greater confidence as to why CBT and CBT-based chronic pain rehabilitation programs are effective at reducing chronic pain.

References

Salomons, T. V., Moayedi, M., Erpelding, N., & Davis, K. D. (2014). A brief cognitive-behavioral intervention for pain reduces secondary hyperalgesia. Pain, 155, 1446-1452. doi: 10.1016/j.pain.2014.02.012

Author: Murray J. McAllister, Psy.D.

Date of last modification: 9-2-2014