A New Psychological Treatment for Chronic Pain

By Ann Marie Gaudon, PNN Columnist

Cognitive behavioural therapy (CBT) has dominated the field of psychological treatment for chronic pain for the last three decades. Studies have shown that it is effective, yet some researchers say CBT also has its limits and could be improved upon.

As CBT treatment approaches continue to evolve, what is noteworthy is a departure from the logic of everyday thinking. “Suffering” is not seen as pathology, but rather as inherent in the human condition. We don’t want it and we don’t like it, but suffering is inescapable.

Following this principle, the utility of “normal thinking, analyzing, and problem-solving” is called into question. Our brains have evolved into powerful problem-solvers that serve very well with things are external to us. For example:

Problem: your car malfunctions and no longer starts. If you have the knowledge and skills, you find the problem and repair the car. Problem solved. If you do not have the skills, you find someone who does and repairs it for you. Problem solved.

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But chronic pain is an internal problem that cannot be easily solved. No matter the effort from our powerful problem-solving brains, doctors and patients often cannot work it out. For a sufferer to spend a lifetime attempting to analyze and logically think their way to being pain-free can be a lifetime spent in futility.

Acceptance and Commitment Therapy

Newer psychological approaches such as Acceptance and Commitment Therapy (ACT) are guided by the premise that we cannot change the pain we’re left with, so let’s change our response to that pain. ACT was outlined in a 2014 article in the journal American Psychologist.

ACT differs notably from traditional CBT in method. Rather than challenging and changing thoughts, ACT seeks to reduce their influence over our behaviour. This core treatment process is called “psychological flexibility,” which is the ability to contact the present moment fully and consciously, based on what the situation affords.

In other words, we act on our long-term values rather than short term impulses, thoughts and feelings. I have a personal example of this:

“Knowing that I love to dine out and see live theatre, my partner reserved an evening of these as a surprise birthday present for me. After the reservations were made, I endured a serious back injury, which makes sitting for long periods particularly painful. He offered to cancel immediately, but I stopped him.

My thoughts told me, ‘Don’t go! You’ll be in more pain. Stay home and protect yourself!’

I applied a few of the many skills I have learned through ACT and was able to hold these thoughts lightly, and essentially not buy into them. I committed to continue with the dinner and theatre plans, and accept the pain in the service of my value of nurturing a social life. Result: my pain was not in charge -- I was.”

Why would one choose these strategies? It’s because thoughts and emotions tend to be unreliable indicators of long-term value. They ebb and flow constantly and we have little control over them. If we act based solely on them, we can lose out on experiences that bring true meaning and vitality to our lives.

In my case, I could have held onto my thoughts tightly and isolated myself at home with my pain, but instead I chose not to buy into those thoughts, to be willing to have the pain (acceptance), and commit to an experience which brought richness to my life. I knew my evening out would not reduce or eliminate my pain. I chose to do something of value to me -- the pain came along for the ride.

The catch is that unhelpful thoughts and emotions can dominate without a person even being aware of them. This results in “psychological inflexibility,” which leads to rigid, ineffective behaviour. If I let my thoughts run the show, the result would have been that I isolated myself at home with my pain and likely more suffering. Other positive behaviours and experiences would have been essentially blocked from me. No thank you.

Evidence to support ACT for chronic pain continues to grow, and its efficacy is about the same as CBT at this point. This is no small feat, considering CBT has been the gold standard for decades.

There are at least six randomized controlled trials which support the use of ACT for chronic pain. Most show ACT increases the acceptance of pain, along with improvements in anxiety, depression, and reductions in disability. This psychological flexibility significantly improves life satisfaction, disability, emotional distress and fear of movement.

It will be interesting to see future studies as ACT continues to advance and helps us find new and different ways “to act successfully in the world.”

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Ann Marie Gaudon is a registered social worker and psychotherapist in the Waterloo region of Ontario, Canada with a specialty in chronic pain management.  She has been a chronic pain patient for over 30 years and works part-time as her health allows. For more information about Ann Marie's counseling services, visit her website.

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

Can Reading Help Relieve Chronic Pain?

By Pat Anson, Editor

A good book is not only hard to put down -- it may also help relieve symptoms of chronic pain by triggering positive memories, according to a small British study.

Researchers at the University of Liverpool brought together a group of ten people with severe chronic pain once a week to read literature together aloud. The reading material included short stories, novels and poetry, and covered a wide variety of genres and topics.

While passages were read aloud in the “Shared Reading” exercise, regular pauses were taken to encourage participants to reflect on what is being read, on the thoughts or memories it stirred, and how the reading matter related to their lives.

Researchers compared the Shared Reading group to another group practicing a form of cognitive behavioral therapy (CBT).

While participants in the CBT group were encouraged to manage their emotions by focusing on the pain experience, Shared Reading encouraged pain sufferers to recall positive memories from their past before the onset of chronic pain.

"Our study indicated that shared reading could potentially be an alternative to CBT in bringing into conscious awareness areas of emotional pain otherwise passively suffered by chronic pain patients,” said Josie Billington, a researcher at the University’s Centre for Research into Reading, Literature and Society.

"The encouragement of greater confrontation and tolerance of emotional difficulty that Sharing Reading provides makes it valuable as a longer-term follow-up or adjunct to CBT's concentration on short-term management of emotion."

Researchers say Shared Reading has a therapeutic effect because it helps participants recall a variety of life experiences -- from work, childhood, family and relationships -- not just memories that involve chronic pain.

The study, published in the BMJ Journal for Medical Humanities, was funded by the British Academy.

While many pain sufferers are deeply skeptical of CBT, meditation and similar forms of “mindfulness” therapy, there is evidence that they work for some. A recent study found that CBT lessened pain and improved function better than standard treatments for low back pain.

Another study at Wake Forest University found that mindfulness meditation appears to activate parts of the brain associated with pain control.

Negative Thoughts About Sleep Make Pain Worse

By Pat Anson, Editor

Negative thoughts about pain and not being able to sleep can worsen chronic pain conditions like fibromyalgia, arthritis and back pain, according to British researchers.

“Pain-related sleep beliefs appear to be an integral part of chronic pain patients' insomnia experience,” said Nicole Tang, a psychologist in the Sleep and Pain Laboratory at the University of Warwick. "Thoughts can have a direct and/or indirect impact on our emotion, behaviour and even physiology. The way how we think about sleep and its interaction with pain can influence the way how we cope with pain and manage sleeplessness.”

Tang and her colleagues developed a scale to measure beliefs about sleep and pain in chronic pain patients, along with the quality of their sleep.

The scale was tested on four groups of patients suffering from long-term pain and bad sleeping patterns, and found to be a reliable predictor of future pain and insomnia.

"This scale provides a useful clinical tool to assess and monitor treatment progress during these therapies," said Esther Afolalu, a graduate student and researcher at the University of Warwick. 

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"Current psychological treatments for chronic pain have mostly focused on pain management and a lesser emphasis on sleep but there is a recent interest in developing therapies to tackle both pain and sleep problems simultaneously."

Researchers found that people who believe they won't be able to sleep because of their pain are more likely to suffer from insomnia, thus causing more pain. The vicious cycle of pain and sleeping problems was significantly reduced after patients received instructions in cognitive-behavioural therapy (CBT), a form of psychotherapy in which a therapist works with a patient to reduce unhelpful thinking and behavior.

The study, published in the Journal of Clinical Sleep Medicine, is not the first to explore the connection between pain and poor sleep.

A 2015 study published in the journal PAIN linked insomnia and impaired sleep to reduced pain tolerance in a large sample of over 10,000 adults in Norway. Those who had trouble sleeping at least once a week had a 52% lower pain tolerance, while those who reported insomnia once a month had a 24% lower tolerance for pain.