The webpage is Dr. Christopher Pither’s piece ‘Cognitive Behavioural Approaches to Chronic Pain.’ It’s part of the Wellcome Trust’s website on pain that originally accompanied an exhibition at the Science Museum in London, entitled ‘Pain: Passion, Compassion and Sensibility.’ The website overall is also well worth reviewing, containing webpages on an eclectic range of topics, including scientific research on pain, therapies for pain, the history of how we have conceptualized and treated pain in the past, and cultural issues surrounding pain. All of it is thought provoking as well as useful information to know.
As indicated, Dr. Pither’s article itself is entitled ‘Cognitive Behavioural Approaches to Chronic Pain.’ It is simply the best and most concise description of cognitive behavioral therapy for chronic pain that I have so far come across on the web.
He opens the piece with a compassionate, yet scientifically accurate, description of how chronic pain develops. He reviews the many and complex variables involved. I especially appreciate how he sticks to what the scientific data tell us while at the same time remaining empathic and non-stigmatizing. The importance of this approach to his writing lies in the scientific data: while painful acute injuries and illnesses occur to all of us, likely at a roughly equal rate across all people, what predicts the transition from acute pain to chronic pain are psychosocial factors. To put it another way, those who are at most risk of developing chronic pain once an acute accident or illness occurs are those whose central nervous systems have been previously up-regulated for psychosocial reasons. Now, of course, these consistent scientific findings do not mean that people with chronic pain are to be blamed for their condition. It is simply to assert a common truth that we all know, if we consider it for a bit, which is that the overall context in which an acute injury or illness occurs matters. If an upper respiratory infection occurs in a person whose immune system is already compromised, then that upper respiratory infection will likely take a much different course than if the same infection occurred in someone whose immune system is not already compromised. Similarly, if an acute painful injury or illness occurs in someone whose nervous system is already up-regulated, then the pain is likely to take a different course then if it occurred in someone whose nervous system is not up-regulated. Namely, the pain has a higher likelihood of continuing past the normal healing process of the original acute injury or illness, thus becoming chronic pain. Dr. Pither acknowledges such a scientific based understanding of the development of chronic pain, but does so with compassion and empathy. For after all, that is what people with chronic pain deserve.
All the stakeholders in the field of chronic pain management needs more of this kind of discussion. Whether we are provider, patient, family member, or policy analyst, we have yet to figure out a way to consistently be able to talk about the real psychosocial aspects of chronic pain without raising the specter of stigma. Indeed, all too often, we try to get rid of stigma by denying all the inherent psychosocial aspects of chronic pain. We do so, though, at our own peril. When we deny a major aspect of a health problem in order to resolve a social problem, like stigma, we are bound to have poor outcomes in the management of that health condition. Imagine the cardiovascular field attempting to successfully manage heart disease if its psychosocial components were off limits to discuss and in fact were denied as unrelated. Whether as patient or provider, the management of heart disease would fail if we couldn't discuss the role of smoking, lack of exercise, obesity, poor nutrition, depression, and stress. Similarly, in chronic pain management, we are bound to have poor outcomes if we cannot discuss the role of the psychosocial aspects of chronic pain. But, of course, we need to be able to have this discussion without stigmatizing the patient. Typically, in our field, we don't do a good enough job of walking this fine line. Dr. Pither, however, seems to be able to do it. We should learn from his example.
Dr. Pither also astutely describes the common trajectory of care that patients go through on their way to ending up in a cognitive behavioral based chronic pain rehabilitation program. Because chronic pain is truly a ‘biopsychosocial condition’ that doesn't fit well into the acute medical model of care, providers tend to refer patients back and forth between the medical side of the healthcare system to the mental health side of the healthcare system with neither being able to help very much. All too often this back and forth care goes on too long. Eventually, as Dr. Pither notes, someone refers patients with chronic pain to a cognitive behavioral based chronic pain rehabilitation program where they begin to get the care that most accurately addresses the true biopsychosocial condition that they have.
While rightly claiming that cognitive behavioral based chronic pain rehabilitation programs are the most effective therapy for chronic pain, Dr. Pither’s writing exhibits the scientific values of humility and constraint (i.e., good science tends to provide conservative interpretations of the data, never making greater claims than what the data reveal). I appreciate such humility and constraint. I think that all too often in healthcare, and in the field of chronic pain management in particular, providers tend to promise more than they can deliver. Don’t get me wrong. I don’t think that the multitudes of well-trained professionals in the field are equivalent to the snake oil salespeople of yester year, intentionally making pitches that they know aren’t true. No, what I am saying is that I think there is a pervasive lack of understanding among the stakeholders in the field of what science tells us are the most effective ways to manage chronic pain. Without such knowledge, providers and the public tend to believe that everything we do -- any chronic pain treatment that is commonly provided – is effective. Unintentionally, then, providers of various treatments for pain can tend to go beyond the data and promise substantial pain reduction, if not a cure, when discussing with patients what can reasonably be expected. The sentiment in Dr. Pither’s piece does no such thing. He rightly acknowledges that cognitive behavioral based chronic pain rehabilitation is the most effective treatment, but states, with humility and constraint, that what constitutes the greatest effectiveness in the field of chronic pain management is helping patients to live well despite having chronic pain. We simply do not have cures for chronic pain. Nonetheless, there is hope. People with chronic pain can live well. They just have to learn how and they learn how to do it in cognitive behavioral based chronic pain rehabilitation programs.
Charles Pither, MBBS, FRCA, is a physician and consultant in pain medicine. He practices at RealHealth, London, England.
Please read his piece entitled, ‘Cognitive Behavioural Approaches to Chronic Pain.’ You can find the link to the webpage here.
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Author: Murray J. McAllister, PsyD
Date of last modification: 10-4-2014