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Psychotherapy with Chronic Pain Patients

Jimmie D. Cole, Ph.D.


In 1988 my wife and co-therapist, Molly Cole, and I developed a group psychotherapy program for chronic pain patients that is now known as Coping Skills Development (CSD). Chronic pain problems include physical, psychological and social issues (Fordyce, 1995). The CSD program addresses the psychological dimension. This dimension is important because chronic pain fits into a person's life and belief system. CSD focuses on restructuring the chronic pain patient's belief system by encouraging them to stop looking for medical solutions to their problems and move on with their lives (Cole, 1992).

In today's world, outcome measures which demonstrate measurable results are expected. Psychological interventions which help return chronic pain patients to work or show a reduction in medical costs will be approved for treatment. There has been little work on outcome measures for pain therapies which focuses on these direct benefits which are referred to as "hard" data (Wilson, 1993; Hubbard, Tracy, Morgan & McKinney, 1996).

The result was the CSD program which was a psychoeducational group approach to patient self-management of pain. CSD combined teaching coping skills, teaching pain self-management, and identifying and working through issues that affect psychological adjustment after an accident or illness. Since any type of stress may aggravate pain, a combination of stress management skills and techniques were taught in order to achieve a reduction in unnecessary stress. These coping skills were as follows: acknowledging and expressing feelings appropriately, assertiveness training, self acceptance and self-esteem, exercising, faith, being positive and meditation. CSD taught relaxation/self-esteem messages and provided audio cassette tapes for a rehearsal of skills training. In addition to learning how to handle stress, chronic pain sufferers learned to be as active as they could be. Physicians and physical therapists were consulted to get the pain sufferer moving. Sexual and sleeping difficulties were discussed according to the needs of the individual. The groups met for seventy-five minutes once a week for sixteen weeks. Groups were kept small (five to eight) so that members could get to know each other and support each other. The objective of the CSD program was to help people develop coping skills in order that they may avoid unnecessary disability, avoid the overuse of medication, relieve as much physical and emotional suffering as possible, and lead satisfactory and productive lives.

This report is based on 88 chronic pain patients who completed the CSD program and 28 chronic pain patients who were evaluated but did not either complete the program or participate and were classified as controls. These patients were evaluated and treated in a private psychological practice in Lafayette, Louisiana. Lafayette is in the heart of the Acadian, or better known as Cajun, culture. The population is approximately one hundred thousand with a greater population area of five hundred thousand. It is a shopping and medical center for south central Louisiana. The primary employment besides retail and health care is the oil industry and farming. The oil industry is based both on land and offshore and has a significant injury factor.

A large number of chronic pain patients have been observed to be depressed. Depression has interfered with treatment and also has been a deterrent to return to work. On the other hand, depression can be a motivating factor for addressing the behavioral components to chronic pain. If the depression is resolved, the patient is more likely to cope with the pain and move on with his life. Therefore, it is important to measure depression both pre and post treatment. Using the Beck Depression Inventory (BDI) (Beck, (1978) the participants scored a pre BDI score with a mean of 26.15, which is in the high moderate range of depression. The post BDI score is an average of 18.5, which is below the moderate level of depression.

While it is encouraging for the patient to report he is less depressed, the question remains, how does this relate to what was referred to previously as "hard" data (Wilson, 1993) concerning return to work activity? The data presented shows that when the patients entered the CSD program, only 10.3% were working or in training, while 68.2% were on compensation. At one year follow up 30.7% were at work or in training, while only 23.9% were still on compensation. A comparison of the controls who were demographically similar to the treatment group revealed that at one year follow-up only 7% were working and 39% were still on compensation.

Two other outcome measures that have been viewed as "hard" data are continued health care visits and use of narcotic pain medication (Wilson, 1993). When the patients were initially referred, they were generally being seen on a routine basis of weekly psychotherapy, going to physical therapy several times a week and were also continuing to see one or more physicians. One year follow-up data showed 81.8% were having one or less health care visit per month. The data showed that 74.7% of the patients were using medication at admission. This was reduced to 44.3% at one year follow-up. The reduction of drug usage demonstrates another significant cost saving.

Each year thousands of dollars are wasted as patients search for physical treatments for problems that actually have psychological issues at their root. Psychological interventions can save money and improve patient functioning by encouraging patients to stop looking for unrealistic medical solutions to their discomfort. This data supports the premise that psychotherapy can be useful in addressing the psychological problems that prevent chronic pain patients from getting on with their lives.

References

    Beck, A. T. (1978). Beck Depression Inventory. The Psychological Corporation, San Antonio, TX.

    Cole, Molly. (1992). Psychological help and the chronic pain patient. Louisiana Rehabilitation. 5(1), 6-7.

    Fordyce, W. E. (Ed.). (1995). Back pain in the workplace: Management of disability in nonspecific conditions: a report of the task force on pain in the workplace of the International Association for the Study of Pain. Seattle, WA: IASP Press.

    Hubbard, J. E., Tracy, J., Morgan, S.F., & McKinney, R.E. (1996). Outcome Measures of a Chronic Pain Program: A Prospective Statistical Study. Clinical Journal of Pain, 12(4), 330-337.

    Wilson, P. R. (1993). Outcome and Income. Clinical Journal of Pain, 9(1), 1-2.


Jeff McKee
Saturday, April 25, 1998