Cognitive behavioural therapy

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296 HEALTH PSYCHOLOGY
Fig. 12-3 Psychology and pain treatment
their bodily functions. Biofeedback aims to decrease anxiety and tension and therefore to decrease pain. However, some research indicates that it adds nothing to
relaxation methods. Hypnosis is also used as a means to relax the individual. It seems
to be of most use for acute pain and for repeated painful procedures such as burn
dressing.
I Cognitive methods: A cognitive approach to pain treatment focuses on the individuals’
thoughts about pain and aims to modify cognitions which may be exacerbating their
pain experience. Techniques used include attention diversion (i.e. encouraging the
individual not to focus on the pain), imagery (i.e. encouraging the individual to have
positive, pleasant thoughts) and the modification of maladaptive thoughts by the use
of Socratic questions. Socratic questions challenge the individual to try and understand their automatic thoughts and involve questions such as ‘What evidence do you
have to support your thoughts?’ and ‘How would someone else view this situation?’.
The therapist can use role play and role reversal.
I Behavioural methods: Some treatment approaches draw upon the basis principles of
operant conditioning and use reinforcement to encourage the individual to change
their behaviour. For example, if a chronic pain patient has stopped activities that they
belief may exacerbate their pain, the therapist will incrementally encourage them to
become increasing more active. Each change in behaviour will be rewarded by the
therapist and new exercises will be developed and agreed to encourage the patient to
move towards their preset goal.
The three components of psychological therapy are often integrated into a cognitive
behavioural treatment package (CBT).
Cognitive behavioural therapy
Cognitive behaviour therapy (CBT) is increasingly used with chronic pain patients. CBT is
based upon the premise that pain is influenced by four sources of information: cognitive
sources such as the meaning of the pain (‘it will prevent me from working’); emotional
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sources such as the emotions associated with the pain (‘I am anxious that it will never
go away’); physiological sources such as the impulses sent from the site of physical
damage and behavioural sources such as pain behaviour that may either increase the
pain (such as not doing any exercise); or decrease the pain (such as doing sufficient
exercise). CBT focuses on these aspects of pain perception and uses a range of psychological strategies to enable people to unlearn unhelpful practices and learn new ways of
thinking and behaviours. CBT draws upon the three treatment approaches described
above namely respondent methods such as relaxation and biofeedback, cognitive
methods such as attention diversion and Socratic questioning and behavioural methods
involving graded exercises and reinforcement. Several individual studies have been
carried out to explore the relative effectiveness of CBT compared to other forms of
intervention and/or waiting list controls. Recently, systematic reviews have been published which have synthesized these studies in terms of CBT for adults and for children
and adolescents.
CBT and adults:
van Tulder et al. (2000) carried out a systematic review of randomized controlled trials which had used behavioural therapy for chronic non-specific low
back pain in adults. Their extensive search of the data bases produced six studies of
sufficient quality for inclusion and involved methodological practices such as blinding of
outcome assessment, adequate length of follow-up and a high quality randomization
procedure. The analysis showed that behavioural treatments effectively reduced pain
intensity, increased functional status (e.g. return to work) and improved behavioural
outcomes (e.g. activity level). In a similar vein, Morley et al. (1999) carried out a systematic review and meta analysis of trials of CBT and behaviour therapy for chronic pain in
adults excluding headache. Their data base search produced 25 trials for inclusion. The
analysis showed that CBT was more effective than alternative active treatment
approaches such as relaxation, exercise and education in terms of pain experience,
positive coping, and the behavioural expression of pain. In addition, the results showed
that CBT was more effective than waiting list controls on all these outcome measures and
also for mood, negative coping such as catastrophizing and social functioning. Overall,
therefore psychological therapies which include CBT seem to be an effective way to
reduce aspects of chronic pain.
CBT and children and adolescents:
Due the success of psychological therapies
with adult children with chronic and or recurrent pain are also increasingly offered some
form of psychological intervention. At times this takes the form of CBT. However, it also
takes the form of individual components such as relaxation and reinforcement. Eccleston
et al. (2002, 2003) searched a range of data bases and located 18 trials which included
some form of psychological therapy and sufficient information to be entered into the
analysis. These trials were for chronic or recurrent headache, abdominal pain and sicklecell pain and involved over 800 patients with about half receiving the psychological
treatment which was mostly relaxation or CBT. The control groups received standard
medical care, placebo or were waiting list controls. The results of their analysis showed
that psychological therapies were very effective at reducing headache in children and
adolescents. However, the authors concluded that there was no evidence to date for their
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