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Cognitive-Behavioral Therapy for Chronic Pain
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In the last section, we discussed external and internal factors that affect a client’s perceptions of pain. These factors that affect a client’s perceptions of pain come under three categories, which were: biological; social; and personality.
In this section, we will examine concepts of automatic thoughts. These concepts of automatic thoughts include: negative automatic thoughts; helplessness; and automatic thought evaluation.
3 Concepts Regarding Automatic Thoughts
#1 Negative Automatic Thoughts
The first concept of automatic thoughts we will discuss is different types of negative automatic thoughts. As was discussed in the previous section, clients with chronic pain often shape their surroundings through the eyeglass of their pain. Consequently, this negative world interpretation also increases the client’s suffering because they begin to experience feelings of helplessness and weakness.
To break this cycle, I feel it is necessary to break the cycle of negative automatic thoughts. Some of these mindsets may look familiar to you as they resemble closely some of the mindsets common in borderline personality disorders. As you listen to the list, think of some of your clients, perhaps those with fibromyalgia or arthritis, and try and pick out any that may fit their mindset: all-or-nothing thinking; fortunetelling; disqualifying the positive; emotional reasoning; labeling; magnification or minimization; mental filter; mind reading; overgeneralization; "should" statements; and personalization.
Marie, a 54 year old client of mine who has been suffering from fibromyalgia for over 30 years. Recently, Marie’s daughter, Anne, and two children had moved back into her home following the daughter’s divorce. Suddenly, Marie was faced with increasing responsibilities for child care, food preparation, and homemaking. Her self-expectations were to help her daughter through this difficult time by making it easy for her, thus taking the load on herself. However, Marie was unable to set limits or attend to her own needs.
A few months after her daughter moved in, Marie experienced a severe pain flare-up, during which she constantly told me, "I just can’t handle my life." In this situation, Marie was overgeneralizing. Because she could not balance her needs and the needs of her daughter, she automatically believed her life was falling apart.
Think of your Marie. What kind of negative thoughts is he or she perpetuating?
The second concept of automatic thoughts we will discuss is the feeling of helplessness that many clients experience as a result of their automatic thoughts. As you probably noticed while listening to the list of automatic thoughts discussed previously in this section, many of these mind sets produce an extremely apocalyptic view of the world. As a result, many clients begin to feel that they have no ability to change their environment, as they perceive it.
Marie, my fibromyalgia client, had begun to believe that her life could not be maintained. She had set such high, unrealistic expectations for herself that it was impossible for her to reach them in her condition. To counteract this, I asked Marie to write out a list of Realistic Expectations.
For instance, I suggested it might be helpful if her daughter began to take on more of the child-rearing responsibilities, not only for Marie’s sake, but for Anne’s as well, who needed to learn a bit more independence. I asked Marie to include in her list other ways that she could take care of herself, for instance, allowing a bit more time in the day to rest.
After a few weeks, Marie returned with the following list of expectations:
I expect myself to be a good grandmother, not a mother, to the children.
I expect my daughter to be able to feed and dress her children and to take them and pick them up from school.
I expect to have time to myself to attend to my pain and other health problems.
Often, I have found, by changing the client’s expectations of their environment, they can easily change their feelings of helplessness in the world.
Think of your chronic pain client. Could he or she benefit from building Realistic Expectations?
#3 Automatic Thought Evaluation
In addition to negative automatic thoughts and helplessness, the third concept of automatic thoughts is teaching the client to evaluate the automatic thought. Most often, the automatic thought arises as a result of an unnatural stressor that pushes its way into the client’s life. When this occurs, the client immediately delves into his or her automatic thoughts that provide an easy, automatic, and detrimental interpretation of reality.
However, once the client can identify their main automatic thought, they can evaluate it and deconstruct its reasoning. Ashley, a thirty-two year old client suffering from chronic back pain, would constantly state, "This pain is just eating me up!" and "I can’t do anything because of it!" After she had identified these automatic thoughts, I asked her to look out for them the next time she starts to think in that way. I asked her to write down the time, the stressful situation that brought on the thought, and the evidence that the thought is not true.
A few weeks later, Ashley returned and stated, "Well, it was about 9:00am, and I had been walking around a lot more than usual. My pain just started to flare-up and I was getting really irritable. I kept thinking to myself, ‘I can’t believe all that medicine is not working! I am missing soooo much work!’ But when I calmed down, I realized that I had been able to stay at work on Thursday, when the pain was minor and still get up in the morning on Friday. Plus, I feel better being distracted at work than sitting around feeling useless at home." By reasoning her way out of her thought, Ashley could more easily detach herself from the automatic thought. Think of your Ashley. Could he or she benefit from evaluating his or her automatic thoughts?
Technique: Shouting Down Your Thoughts
Another technique that many of my clients find to be more appealing is Shouting Down Your Thoughts. Because so much anger builds up during a pain flare-up, releasing this anger becomes very important in decreasing the emotional distress of the client.
Twenty-two year old Jackson had broken his leg in nineteen different places during a car accident. He often experienced severe pain as his bones tried to repair themselves. Jackson had also internalized the automatic thought, "I can feel my bones healing wrong. The doctor does not know what he’s talking about, there is something really bad going on here!"
When this automatic thought began to take hold of him, I asked Jackson to "Shout it Down." I asked him to think of a mantra that he could shout over again that could challenge his own thoughts and also release some anger about his situation. Jackson chose the mantra, "I’m fine! This is how my body works!"
When he was alone in his home, he often shouted these phrases, or variations. He stated, "It definitely relieved a lot of built-up anger. But I wasn’t shouting negative thoughts, they were positive, but the act of shouting allowed me to assert myself vocally when I couldn’t do it physically." Think of your Jackson. Would Shouting Down his or her automatic thoughts release built-up anger?
In this section, we discussed concepts of automatic thoughts. These concepts of automatic thoughts included: negative automatic thoughts; helplessness; and automatic thought evaluation.
In the next section, we will examine three concepts related to core beliefs. These three concepts of core beliefs include: negative life events; self-identification; and culturally influenced core beliefs.
Peer-Reviewed Journal Article References:
Ehde, D. M., Dillworth, T. M., & Turner, J. A. (2014). Cognitive-behavioral therapy for individuals with chronic pain: Efficacy, innovations, and directions for research. American Psychologist, 69(2), 153–166.
Gebler, F. A., & Maercker, A. (2014). Effects of including an existential perspective in a cognitive-behavioral group program for chronic pain: A clinical trial with 6 months follow-up. The Humanistic Psychologist, 42(2), 155–171.
Kerns, R. D., Burns, J. W., Shulman, M., Jensen, M. P., Nielson, W. R., Czlapinski, R., Dallas, M. I., Chatkoff, D., Sellinger, J., Heapy, A., & Rosenberger, P. (2014). Can we improve cognitive–behavioral therapy for chronic back pain treatment engagement and adherence? A controlled trial of tailored versus standard therapy. Health Psychology, 33(9), 938–947.
What are three concepts related to automatic thoughts? To select and enter your answer go to .