By Andrew L. Martin, PsyD
The American Psychological Association is currently developing the first-ever clinical practice guidelines for behavioral treatment of chronic pain. The Veterans Administration (VA) and Health and Human Services have both conducted separate systematic literature reviews with the following findings and recommendations: 1) Strong support for cognitive behavioral treatment to reduce pain intensity/frequency and restore function; 2) Moderately strong support for mindfulness-based treatments for the same purpose; and 3) Strong recommendation to include behavioral treatment in the interdisciplinary, stepped care of chronic pain.1,2
Other approaches under study include Acceptance and Commitment Therapy (ACT), biofeedback, emotional awareness and expression, and behavioral therapy, with ACT having the strongest preliminary support thus far.
Who is a good candidate for behavioral treatment of chronic pain?
• People who have stopped moving almost entirely and need help reducing weight and re-conditioning their bodies
• People who move too much and might benefit from greater acceptance of their condition, as well as help modifying beliefs that cause overexertion
• The very anxious, who could use help learning how to relax their nervous system using techniques like mindfulness
• The very depressed, who could use help creatively reintroducing pain-tolerant enjoyable activities into their lives
• Those with great difficulty sleeping, who need advanced sleep behavior intervention
Finally, persons who are catastrophizing their pain are good candidates for referral, and this behavior may be the first or only indicator shown to you and your staff. Chronic pain can radicalize people’s thinking, and exaggerated negative thinking can make people notice their pain even more. Such thinking falls in three domains – rumination, magnification and helplessness (from Michael Sullivan’s Pain Catastrophizing Scale).
Examples of catastrophized thoughts include: “I keep thinking about how much it hurts,” or, “I keep thinking about how badly I want the pain to stop” (rumination); “I become afraid that the pain will get worse,” and, “I wonder whether something serious may happen” (magnification); and “I worry all the time about whether the pain will end,” or, “It’s awful and I feel that it overwhelms me” (helplessness).
You can imagine what some patients think when they are referred to mental health for their chronic pain, so it is important to validate what they feel. Providers should be able to explain that they understand the patient’s pain is real. The ideal approach is to teach patients ways to live a fuller life despite their pain. That said, depression and anxiety (especially traumatic stress) can exacerbate chronic pain, so an uncontrolled mental health condition is also a good referral indicator.
For a quick but deeper understanding of the behavioral treatment of chronic pain, I recommend reviewing the patient handouts in Jennifer Murphy’s VA protocol for cognitive behavioral treatment of chronic pain (available online).3
1. Kligler B, Bair MJ, Banerjea R, et al. Clinical Policy Recommendations from the VHA State-of-the-Art Conference on Non-Pharmacological Approaches to Chronic Musculoskeletal Pain. J Gen Intern Med. 2018; 33 (Suppl 1): 16-23. doi:10.1007/s11606-018-4323-z
2. Tick, H., & Nielsen, A. (2019). Academic Consortium for Integrative Medicine & Health Commentary to Health and Human Services (HHS) on Inter-agency Task Force Pain Management Best Practices Draft Report. Global advances in health and medicine, 8, 2164956119857656.
3. Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs.
Andrew L. Martin, PsyD, joined Orthopaedic & Spine Center and the Interventional Pain Management Team as their Pain Psychologist in January 2021. osc-ortho.com