Occupational therapy & the cognitive behavioural approach for pain management

I have always resisted being labelled. I am much more than my gender, my marital status, my diagnosis, my professional background.  I also feel quite uncomfortable about being told what I may or may not do (maybe that’s where my kids get it from?!). I don’t like being told what is and isn’t ‘my role’ or someone else’s role.  I’m interested in what works and doing it well and at the right time for the right reason.  Today’s post is the first of a two-part commentary on a paper by Robinson, Kennedy and Harmon published in the American Journal of Occupational Therapy this month in which it is argued that occupational therapists who offer cognitive behavioural therapy ‘without sufficient attention to occupational therapy’s professional domain could lead to occupational therapists’ duplicating the interventions of other multidisciplinary team members.’ (Robinson, Kennedy & Harmon, 2011).

The paper also includes critiques of the ‘acceptability’ of psychological interventions, and suggests that ‘the use of CBT reflects psychosocial understandings of chronic pain that are frequently incompatible with clients’ interpretations of their experiences.’ They go on to say ‘many therapists have adopted the evidence to support psychological interventions without critical consideration of these interventions’ role within their professional domain or their acceptability to clients.’ The tone of this part of the paper strongly suggests that by using a CBT approach, occupational therapists do not directly address the occupational needs of people with chronic pain, and that if they do use it, it may not be acceptable to patients, and it could lead to duplicating service delivery.

Where do I start with this? There are several points that I think Robinson, Kennedy and Harmon may have misinterpreted about a cognitive behavioural approach to pain management and to the ways in which interdisciplinary pain management works.  I want to add here that I hope some of the funders of treatment services for people with chronic pain in New Zealand will also take a good look at their assumptions about both of these things as well.

A cognitive behavioural approach to pain management is not exactly the same as cognitive behavioural therapy for depression or anxiety.  In pain management, while cognitive behavioural therapy as used for mood management can be one of the therapeutic strategies used, the CBT approach is broader than this.  Basically, the CBT approach conceptualises the problem of disability and distress as due to inaccurate understandings about pain (such as hurt = harm, or that pain must dictate behaviour), and thus, inappropriate activity levels are maintained, and these in turn lead to negative mood states.  Of course, these relationships are usually reciprocal, and this is a very simplified version of the approach.

The aims of a CBT approach are to:

• Help the person reconceptualise themselves as able to manage and do despite experiencing ongoing pain
• Help the person set new behavioural goals to reduce disability (aka ‘re-engage in occupations’ to use occupational therapy jargon)
• Reinforce progress and acknowledge achievements
• Identify obstacles to progress
• Help the person acquire skills to overcome these obstacles (Medical Practice Guidelines, Hunter Integrated Pain Service, Updated July 2005)

One of the main features that distinguishes a cognitive behavioural approach from the majority of other treatments for pain is the assumption that people are able to make changes in the way they understand their pain, given sufficient information and strategies to do so, and that by doing so, they’re able to re-engage in important activities.  In other words, even if chronic pain itself doesn’t change, people can think of themselves as primarily ‘well’ people who simply have pain.

Robinson, Kennedy and Harmon describe and critique ‘psychosocial understandings of chronic pain’ and to me what they say smacks of the old dualist notion that mind and body are separate.  When they say “…the clinician may discount the presence of an organic cause and interpret the person’s experience within a psychosocial model”, it suggests to me that the authors have not really come to grips with pain as a function of the brain’s interpretation of incoming information from the body (or lack of input from the body).  “Organic” factors or not, pain is an experience and is therefore ‘psychological’ – and it’s also biological because the brain is made up of cells and other ‘organic’ material.  We’re not talking here about mystical ‘energies’ or forces!

But their biggest reservation about CBT being used by occupational therapists seems to be twofold: that clients don’t like so-called ‘psychological’ approaches, and that these approaches don’t “directly address the occupational needs of people with chronic pain.”

While some people that I see don’t initially feel happy with a nonmedical approach to their pain, it doesn’t take long to establish that people are aware of their beliefs about their pain, and they can also see how their beliefs lead to emotions and behaviours – and vice versa.  The heart of the CBT approach is that it is collaborative.  By working together to identify the various factors that influence pain and disability (occupational performance limitations), people with chronic pain are readily able to apportion relevance to biophysical/biomedical, psychological and social components that affect their ability to do what they want.

While the authors don’t quite go as far as saying that therapists shouldn’t give patients accurate information about our current knowledge of pain, they do imply that by using a psychological explanation (sic),  patients are “de-legitimized by the suggestion that psychological factors are at play in the chronic pain experience…” I think that if clinicians fail to explore the relevance of thoughts and emotions and values etc, and instead support patients misunderstanding of their pain as fixed, permanent and unable to be modified, then they do their patients great harm.  And when better to explore thoughts and beliefs than when the person is getting in and out of the car or walking up and down stairs? Who better to do this than the clinician standing beside them as they do this?

One of the most important goals for pain management is to reduce disability or increase functional activity.  In fact the purpose of using a CBT approach is to increase the person’s ability to choose to engage in the things they want to do.  For this reason I strongly refute the idea that by using a CBT approach therapists may not be “critical[ly] consider[ing] these interventions’ role within their professional domain…”.  As I said before, who and when better to explore thoughts and beliefs than the clinician who is standing beside the person while they practice getting in and out of the car or walking up and down stairs?

I have reached my word limit for today – there will be more though, because there are several other points I need to make in response to this review.  Read on if you’re keen to see why I believe both occupational therapists and physiotherapists (and psychologists, nurses, social workers and other allied pain clinicians) are justified working in pain management using a cognitive behavioural approach, why I fail to see that this approach should be confined to clinical psychologists, and why I believe the CBT approach (and others aligned to a CBT approach such as ACT) should be employed at the earliest opportunity and right through until the person with pain is able to manage their situation independently.

Robinson, K., Kennedy, N., & Harmon, D. (2011). Is Occupational Therapy Adequately Meeting the Needs of People With Chronic Pain? American Journal of Occupational Therapy, 65 (1), 106-113 DOI: 10.5014/ajot.2011.09160