March 20, 2018

Dr. Michael Lacroix: Strategies for Addressing Chronic Pain With Cognitive Behavior Therapy (CBT)

By Dr. Michael Lacroix, Director of Behavioral Health Services, Coventry Workers’ Comp Services

Dr. Michael LacroixIn the ongoing discussion about managing chronic pain, the workers’ comp industry is beginning to talk about cognitive behavior therapy (CBT). The technique, which focuses on changing thoughts and behaviors in order to produce changes in feelings or emotions, has been shown over the last 50 years to be effective for treating psychiatric and psychological conditions, specifically depression and anxiety. It has also been found useful for a wide range of medical disorders with a psychological component, including those involving chronic or acute pain.

In light of this, a recent Cochrane meta-analysis, or summary of studies, has received some attention. After reviewing data from dozens of clinical trials comparing CBT or behavior therapy with no-treatment controls, the authors of “Psychological therapy for adults with longstanding distressing pain and disability” concluded that, “Psychological therapies can help people with chronic pain reduce negative mood (depression and anxiety), disability, catastrophic thinking, and in some cases, pain.1 Overall, CBT proved superior to both no-treatment controls and to behavior therapy without the cognitive component in improving disability, mood and catastrophic thinking, and these effects were maintained for at least six months. Other studies have shown that adding an exercise component to CBT leads to further improvements.2,3

Getting patients off the couch
On the face of it, the data argues for referring chronic pain patients to clinical psychologists or other psychotherapists schooled in CBT. A number of pain management programs “manage” the patients’ pain by doing exactly that. This may be the most appropriate option in cases where the chronic pain condition comes with psychological or psychiatric co-morbidities. However, consider two points: 1) In cases where psychological co-morbidities are relatively minor, referrals to licensed mental health practitioners may be overkill. 2) I would further argue that CBT is likely to be most effective if it is taken out of the therapist’s office and integrated into the broader canvas of the patient’s life and, in the case of workers’ comp, into a formal program focusing on increasing physical capabilities with a goal of wellness and return-to-work.

To the first point, the CBT knowledge base has reached well beyond the rarified circle of clinical psychologists. Most masters-level rehabilitation counselors and nurses with psychiatric backgrounds learn basic principles and techniques of CBT as part of their formal education. Other medical personnel can learn CBT techniques as well. Books about using CBT for various psychological conditions, including chronic pain, are even available to the general public.4,5,6 I’m not suggesting that many chronic pain sufferers have the drive to conquer their pain problems without assistance, but nurses and counselors educated in CBT techniques can train clients to use them—particularly those clients early in the emergence of a potential chronic pain disability, before the psychological overlay takes root. This approach should also be useful in identifying complicated cases early. With very complicated cases, these professionals can work in conjunction with the treating clinical psychologists, psychiatrists and clinical social workers.

An approach with multiple benefits
Using masters-level rehabilitation counselors and nurse case managers instead of licensed mental health personnel would have the twin advantages of cutting down dramatically on the cost of service delivery and of broadening the range and the number of personnel who can deliver the treatment. This is no different from what has been happening in medicine over the last several decades. The first and second levels of assessment and treatment are now often nurses and physician’s assistants, with the physician coming in on the more difficult cases.

As noted previously, incorporating exercise is a key to success with chronic pain. Using appropriately trained front-line nurses and masters-level rehabilitation counselors to deliver a structured CBT program would allow for better integration with a parallel physical exercise program and with return-to-work efforts. This would enhance the integration of CBT techniques into the patient’s life and rehabilitation—which is difficult to do from a psychologist’s office without adding more consultations and more ancillary personnel.

The Cochrane reviewers concluded that, “CBT is a useful approach to the management of chronic pain.” That’s excellent news. However, as I have argued previously7, innovations in the delivery of treatment to chronic pain patients are necessary if we want to have an impact in the real world beyond research studies and patients fortunate enough to have good mental health coverage. We know what works. Our challenge now is to find ways to deliver those active ingredients more cost-effectively and to more chronic pain sufferers.

About Dr. Michael Lacroix
Dr. Michael Lacroix is the Director of Behavioral Health Services for Coventry Workers’ Comp Services. He is a licensed psychologist in Florida and has attained Diplomate status in Rehabilitation Psychology from the American Board of Psychological Specialties and as a forensic examiner from the American Board of Forensic Examiners. Dr. Lacroix has authored and/or presented over 100 scientific publications and papers throughout his career. His major areas of interest and specialization include trauma (short-term intervention as well as long-term consequences); rehabilitation psychology, with emphasis on issues of clinical and vocational assessment, behavioral medicine, with emphasis on psychosomatic disorders; and psychotherapy, with emphasis on cognitive-behavioral therapy and hypnosis.

About Coventry Workers’ Comp Services
Coventry Workers Comp ServicesCoventry Workers’ Comp Services, is the leading provider of cost and care management solutions for property and casualty insurance carriers, (workers’ compensation and auto insurers), third-party administrators and self-insured employers. We design best-in-class products and services to help our partners restore the health and productivity of injured workers as quickly and as cost effectively as possible. We accomplish this by developing and maintaining consultative, trusting partnerships with our clients and stakeholders, built on a foundation of innovative and customized solutions that support the claims management process.

Coventry WCS is a WorkCompWire Advertising Partner.
This is not a paid placement.

1Williams AC de C, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD007407. DOI: 10.1002/14651858.CD007407.pub3
2Flor, H., Fydrich, T., & Turk, D.C. Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 1992, 49, 221-230.
3Van Tulder, M.W., Koes, B., & Seistal, S., et al. Outcome of invasive treatment modalities on back pain, and sciatica: An evidenced based review. European Spine Journal, 2006, 15, S82-S92.
4Willson, R., and Branch, R. Cognitive Behavioural Therapy for Dummies. Wiley, 2006.
5Otis, John D. Managing Chronic Pain. Oxford University Press, 2006.
6Dewitt, D., & Romaine, D.S. The Complete Idiot’s Guide to Back Pain. Alpha Books, 1999.
7Lacroix, M. Chronic Pain: Never Surrender!

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