Cognitive Approaches

As with most forms of psychotherapy, cognitive approaches are the most well researched. Cognitive therapy focuses on issues such as the thoughts and attitudes individuals have towards their pain experience and the resulting beliefs that can govern or intensify their pain experience. It is a well established fact that a person who thinks negatively is more likely to be depressed. A depressed person is more likely to notice whatever is negative in their life as well as to magnify or exaggerate what is wrong. This can have a direct flow through effect to their tendency to notice the pain more. Some studies support the belief that the more a person notices pain the more intense it is likely to feel.

The cognitive therapists design their intervention around these facts and will:

• seek to identify those ways of thinking that cause the patient’s experience of pain to worsen,
• help the patient understand how these thought patterns will impact on their pain experience,
• Teach the patient to notice these thought patterns, challenge the underlying beliefs and replace them with other thoughts that are less catastrophic and more reality based than simply being negative.

Common Pain Beliefs

A good starting point is to use the following 11 pain beliefs to identify beliefs that are often assumed:

1. All pain equals harm. Because I hurt it means I am re-injuring myself
2. Because I am in pain I cannot enjoy life
3. The degree of pain I feel is in direct correlation to the physical damage or degeneration at my injury site.
4. The best way to deal with pain is to limit the amount of activity I do and rest frequently.
5. Nothing can make my pain lessen
6. Because I cannot control my pain I am stupid or weak.
7. I deserve the pain I experience.
8. My pain experience is due entirely to factors associated with injury or disease. My outlook and beliefs do not influence my ability to cope.
9. I can only cope with my pain by fighting it in every way possible. I cannot afford to let go for a moment.
10. Because I struggle to cope with my pain it is ok to take more medication than the prescribed amounts.
11. It is not worth doing anything unless I can make the pain go away completely and return to life as it was prior to my injury.

‘ABC’...

One cognitive approach works on what is called the ‘ABC approach’. From this approach the initial letters of the alphabet are taken to stand for:

The key with this approach is to teach the patient to identify their own negative thought processes and replace these negative thoughts or responses with ones that are more likely to improve their quality of life.

Relaxation

It is natural for muscles near a pain site to become tense. When muscles stay tense for too long, they tend to become stressed and will become an additional source of pain. To make it worse it is possible for the muscle fibres to “forget” how to relax and for the baseline for relaxation to change.

Traditionally relaxation has been taught to patients by showing them how to relax sequences of muscle groups by alternatively tensing and then relaxing the muscles. This often starts with the feet, moves to the calves, thighs, pelvic area, stomach, shoulders, arms, neck, and finishes with the head and face. The whole process can take 15-20 minutes and can be guided by a tape recording or CD which the patient can use whenever they need to do so.

There is a lot more to relaxation than is commonly believed. The large number of people who live very stressed lives and who struggle to relax are clear evidence of this. Relaxation can be guided in a number of ways. These can include using visual imagery, progressive relaxation that teaches the person how to relax each muscle group one at a time, biofeedback, hypnosis and by means of associating relaxation with pleasant existing memories.

Relaxation has the benefit of:

• Helping a person relax (It shouldn’t be under estimated how little a person who suffers chronic pain can relax).
• Improving the chances for getting to sleep.
• Reducing anxiety (it is almost impossible to be anxious and relaxed simultaneously).
• Reducing the impact of stress on a person’s life and improving their ability to recover from stress.

Sleep Hygiene

Many patients have developed unhealthy sleeping patterns due to their pain condition. They may struggle to get to sleep, awaken during the night because of the pain and struggle to get back to sleep, or awaken early in the morning without feeling at all rested. When this situation becomes habitual, the patient is likely to feel more irritable during the day, develop the habit of having catnaps during the day, have reduced energy and be more susceptible to depression and pessimism.

A surprising number of patients develop unhelpful responses to their sleeplessness. Common responses include:

• Trying to stay awake for as long as possible, until they are exhausted and then going to bed.
• Watching TV until late and they are tired.
• Having a “nightcap” alcoholic drink.

Encouraging the patient to develop a sleep routine in which they go through a process they learn to associate with sleep can be very helpful. At the same time it is important to offer the patient a number of interventions they can try at night that avoids their becoming very tense, becoming desperate to sleep, angry at themselves or getting caught up in a racing mind that jumps from topic to topic. Interventions include forms of relaxation that utilize diaphragmatic breathing, thought stopping using approaches such as mindfulness or other meditational approaches and learning how to create a body awareness that is as close to a hypnogogic state of rest as possible.