Cognitive-Behavioral Therapy

Goals of Cognitive-Behavioral Therapy (CBT) include modifying symptoms, changing maladaptive behaviors, and promoting emotional growth and development. It is based on cognitive theory, which maintains that irrational beliefs are directly responsible for generating dysfunctional emotions like stress, depression, anxiety, and their resultant self-defeating behaviors like social withdrawal. It posits that we can control these emotions and their effects by deconstructing the beliefs that caused them. The process whereby patients learn to refute cognitive distortions and replace their counterproductive beliefs with more accurate and beneficial ones is called cognitive restructuring. Other cognitive-behavioral interventions that have been shown to be useful include coping skills training and relaxation training. These techniques are often applied together, as part of a comprehensive treatment approach. Cognitive-behavioral treatment may include education; identifying and modifying counterproductive thoughts; and instructing the patient in the use of coping strategies. Moreover, cognitive-behavioral treatment often consists of a combination of these modalities or is applied in combination with other therapies such as medication or exercises.

Contingency Management

Contingency Management involves helping patients to change their maladaptive behaviors. It is based on the operant conditioning principles of B.F. Skinner. It involves the use of social reinforcers to increase “healthy” behaviors.(e.g., exercise, non-medical conversation) and decrease “illness” behaviors. In the session-by-session course of therapy care is taken to systematically reinforce useful adaptive behaviors and to avoid reinforcing problematic maladaptive behaviors. This process is made quite overt to the patient, explaining that behavior that is reinforced can be expected to increase. A clear distinction is made between the observed effect of reinforcement and the motivation of the behavior, pointing out that such a relationship between cause and effect does not imply that the behavior is being carried out deliberately in order to obtain the reinforcement. Didactic teaching and insight strategies may also be used to help the patient achieve an understanding of the factors that may be controlling his or her behavior. These princi­ples should be applied by everyone involved with the patient. For example, the physical therapist sets a realistic expectation of exercises to be performed at each session. The starting point is set lower than the patient’s ability, but is increased slowly and systematically towards an individualized goal. Each successfully performed increment is positively reinforced by all treatment staff.

Acceptance & Commitment Therapy (ACT)

The primary goal of Acceptance and Commitment Therapy (ACT) is not necessarily to reduce discomfort, but to increase the patients’ ability to engage in activities that are personally important to them. In contrast to therapies that focus on controlling painful experience, this promotes acceptance of it and other uncomfortable events, such as fear, anxiety and fatigue. Acceptance is not the same as resigning oneself to suffering, but alters the experience, thereby reducing suffering. It is emphasized as a means of redirecting the patients’ energy away from struggling with those things that keep them from engaging in meaningful activities to actually participating in the activities, even though they may be painful or fear-provoking (e.g. traveling, playing sports, going out with friends).

The application of ACT to chronic pain was based on the observation that patients desire to limit uncomfortable or painful experiences often led them to restrict their activities. This may help to avoid the issue, but it also results in less active, stimulating, and meaningful lives. As a result, over time, patient’s lives may become narrow and inflexible. ACT seeks to assist patients by helping them to identify important values in their lives (e.g., “being a good father”), and by helping them to direct their efforts to achieve this. Commonly, patients’ illness prevent them from living up to their values (i.e., “I can’t play with my child because I’m in pain”). Treatment involves exposure to previously avoided activities, while emphasizing a wider and more flexible range of behaviors. In this process, acceptance of what cannot be changed (e.g., pain, fatigue, negative thoughts and emotions) is learned, along with the means to recognize and alter those things that can be changed (i.e., behaviors directed towards a valued life). Patients who struggle with controlling their chronic pain tend to experience greater suffering and disability while those who accept it have a higher quality of life and better emotional, social, and physical functioning.

Coping Skills Training

Coping Skills Training is usually carried out in a group context where patients are taught techniques to manage the challenges they experience.

Mindfulness Training

Mindfulness Training is based on the ancient practice of meditation and seeks to produce a state of conscious relaxation. It can bring about a sense of calm, patience, and clarity as well as reduce muscle tension and pain. Mindfulness training enables one to become more clearly aware of the contents of an experience, allowing one to respond effectively to situations without getting caught up in judgmental or emotional reactions. It is sometimes combined with other therapies that assist patients in perceiving discomfort as a distant part of them. This skill of detachment helps to regain a sense of control.

Relaxation Training

Relaxation techniques modify a patient’s physiological response to pain. They teach people how to relax tense muscles, reduce anxiety and alter their state of mind. Both physical and mental tension can make pain worse. Headaches or back pain, muscle tension or spasms can be part of the problem. Relaxation-based therapies have been recognized as beneficial for chronic pain. Common techniques include biofeedback, progressive muscle relaxation, guided imagery, and hypnosis. They are some of most widely used non-pharmacologic treatments for pain. They help the patient to focus on feelings of wellbeing as well as diminish tension, anxiety, depression, and inactivity.

Biofeedback

The term "biofeedback" refers to a mind–body therapy in which instrumentation is utilized to provide feedback to the patient regarding a physiologic process. Biofeedback has been used to help people learn to regulate biological processes, such as heart rate, muscle tension, blood pressure, and vasoconstriction. Over time, the patient learns to control the biofeedback signal, which is typically an auditory or visual analog of the physiologic changes. The most frequently used methods of biofeedback are electromyographic (EMG) or muscle tension biofeedback, and thermal (peripheral skin temperature) biofeedback.

Progressive Muscle Relaxation

Progressive Muscle Relaxation (PMR) is a systematic relaxation method developed in the late 1920’s by Dr. Edmond Jacobson. In PMR, patients tense and then let go of the tension in various muscle groups, from one end of the body to the other. With practice over days or weeks, enhanced awareness of the body and increased ability to relax quickly and easily can be gained. Typically, patients are taught PMR and then use a recording of the exercise for home practice. Over time, fewer and fewer muscle groups are tensed and released and, eventually, the person can relax the body at will without tensing beforehand. A combination of PMR, diaphragmatic breathing training, and biofeedback is often used in behavioral interventions.

Guided Imagery

Guided Imagery can reduce the perception of discomfort by providing a competing cognitive focus for the patient’s discomfort, muscle tension, and autonomic and emotional arousal. Sessions can occur in the presence of an instructor or can occur with audio-tapes or CDs. Typically, a guided imagery session will begin with a relaxation exercise to focus attention and relieve the patients’ tension before the actual guided imagery occurs. The initial exercise may involve a breathing exercise or visualizing a "safe" place. The session will then move into more specific guided images.

Hypnosis

Hypnosis is defined by the American Society of Clinical Hypnosis as "a state of inner absorption, concentration and focused attention." Hypnosis is typically induced by a trained therapist. A hypnosis session usually has several components. It begins with induction of the hypnotic state by the hypnotherapist, who then gives suggestions once an adequate hypnotic state is achieved and then guides the patient out of hypnosis. Sessions are typically individual, but can be in a group. Sessions vary in number, but may be as few as one or as many as a dozen. Patients can also be taught self-hypnosis and be provided with tapes for home practice.