Pain Management: Cognitive Therapy for Chronic Pain & Fibromyalgia-Abb10

Introduction
Self-help has received increased attention in the last 20 years and has been studied as both a stand-alone treatment and a component of multitreatment approaches for a range of physical and mental health conditions. In working with and studying individuals who have chronic illnesses, we have recently developed and tested self-help treatments that are portable, broadly disseminable, and cost-effective. These characteristics are particularly important in the management of chronic physical illnesses because many patients who undergo complex or expensive medical treatments do not have the resources to obtain psychological treatments, may be house-bound or too disabled to participate in traditional psychotherapy, or may be uncomfortable with the group formats often offered in communities.

Self-help is typically more cost efficient and can be made available to a greater number of patients than traditional individual therapy. Research has investigated the application of self-help to chronic illnesses in which chronic pain, depressive symptoms, and disability are common. Much of this work has focused on the application of cognitive-behavioral treatment (CBT), which promotes skill development, problem solving, and self-management by using behavioral and cognitive therapies and principles, delivered through a self-help format. Self-help delivered via group formats, workbooks, books, audiotapes, minimal contact formats, telephone delivery systems, and Internet-based delivery systems has been effectively used to reduce pain, pain-related disability, depression, and anxiety in arthritis (Lorig & Holman, 1993; Lorig, Ritter, Laurent, & Fries, 2004), low back pain (Buhrman, Faltenhag, Strom, & Andersson, 2004; Moore, Von Korff, Cherkin, Saunders, & Lorig, 2000; Von Korff et al., 1998), headache (Andersson, Lundstrom, & Strom, 2003; Blanchard et al., 1985; Devineni & Blanchard, 2005; Haddock et al., 1997; Jurish et al., 1983; Strom, Pettersson, &Andersson, 2000), and temporomandibular joint disorder (TMD) (Dworkin et al., 1994; Townsend, Nicholson, Buenaver, Bush, & Gramling, 2001). Self-help appears to achieve reductions in pain and disability primarily through increases in self-efficacy, and these changes can be maintained over long periods. Further, the efficacy of self-help in the form of minimal contact treatment (MCT) has been examined in greatest detail within the headache literature. A metaanalysis of 20 controlled clinical trials concluded that home-based behavioral treatment of headache yields treatment effects that are equivalent or superior to clinic-based treatments (Haddock et al., 1997).

In this article we present a rationale for self-help and focus on a particular type of self-help—minimal contact treatment—that we used to deliver CBT.

Minimal Contact Treatment
In MCT, self-regulation skills are introduced in the clinic, with training and practice occurring primarily at home via written materials and audiotapes. Meta-analyses of the self-help literature suggest that some degree of therapist contact may have incremental benefits (Gould & Clum, 1993), and in MCT the therapist contact can be delivered by diverse methods, including infrequent in-person meetings, telephone calls, and/or mailings and use of electronic contacts such as electronic mail. However, issues of confidentiality need to be discussed and ground rules established before using electronic communication strategies.

Minimal contact interventions have been used as a viable, cost-effective alternative for many chronic headache sufferers, averaging a fivefold increment in cost-effectiveness (Haddock et al., 1997). Therefore, MCT may be more affordable than individual or group therapy for many individuals seeking care. Additionally, MCT produces gains that appear to be as well maintained as an intensive individual protocol (Blanchard et al., 1988). For patients who have limited resources, travel a long distance for specialty care, or are resistant to seeking mental health care, MCT may be particularly useful. We have also found that many of our medical colleagues are interested in having these resources available to their patients who are unable or unwilling to pursue a referral to our outpatient clinic. Overall, the development of brief, self-help-oriented, minimal contact interventions has the potential to increase vastly the number of patients who can successfully access and benefit from these interventions.

 Patient Considerations
One of the clinical challenges facing practitioners is determination of which patients are most suited to self-help or MCT. Lacking empirical guidance from the literature, we recommend a stepped care approach for those individuals who are not clinically depressed, severely disabled, cognitively impaired, or socially isolated or who do not have a personality disorder. The intake can include a discussion of the value of self-management of pain and an orientation to self-management techniques. In discussing this framework with both patients and practitioners, we have found it useful to use the analogy of managing diabetes, which balances the judicious use of medications with lifestyle changes that require problem solving and attention "24/7." After this discussion, the patient can be guided to an appropriate workbook, provided with a relaxation tape, and sent home with a 1-month follow-up appointment, using a single intervening telephone call to check on progress and answer any questions that have arisen. At the follow-up visit further discussion of self-management occurs, including ongoing assessment of understanding and motivation as well as problem solving about implementing self-help. At this point, a decision can be made about continuing the minimal contact approach or intensifying treatment to include individual or group treatment. As the case of Mary demonstrates, some individuals are slow to engage with minimal contact interventions and may not connect with self-management skills presented early (e.g., relaxation and goal setting), although they may experience success later when cognitive or communication skills are addressed. For the individual who never engages with workbooks or audiotapes (see the case of Steve), clinic-based individual or group therapy may be the best method for developing pain self-management skills.
- Buenaver, Luis, McGuire, Lynanne & Jennifer Haythomthwaite; Cognitive-behavioral self-help for chronic pain; Journal of Clinical Psychology; Nov 2006; Vol. 62; Issue 11.

Cognitive-Behavioral Therapy for Patients with Chronic Pain

- Lim, J. A., Choi, S. H., Lee, W. J., Jang, J. H., Moon, J. Y., Kim, Y. C., & Kang, D. H. Cognitive-behavioral therapy for patients with chronic pain: Implications of gender differences in empathy. Medicine, (2018), 97(23), e10867. doi:10.1097/MD.0000000000010867

Personal Reflection Exercise #4
The preceding section contained information about cognitive-behavioral self-help for chronic pain. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 13
According to Buenaver et al., what is the rationale behind self-help cognitive-behavioral therapy?
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