tulips

What is the difference between using cognitive behavioural therapy – and using a cognitive behavioural approach?


My last post generated an enormous amount of discussion about whether clinicians who are not psychologically trained, or who haven’t completed a psychology degree, or indeed, should carry out treatments using a cognitive behavioural approach. This is my answer! But note well, these are not my words, but drawn from two of the most eminent researchers and clinicians I know. And yes, I think you can ALWAYS learn more skills – and apply them within your practice with an eye to optimising the quality of your interactions and outcomes.

The first is from Professor Turk:

Capture

This excerpt is from Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

In this paper, Turk identifies the many influences on our experience of pain, and on subsequent disability, that are amenable to “top down” approaches. As he points out in this excerpt, a cognitive behavioural approach is a way to conceptualise the person and his or her experience. The perspective is as important as the content of therapy. The best way I can put this is to show the following clip from this paper – and ask readers if they agree, based on the findings from pain science research.

assumptions of CBT approach

 

 

 

 

 

 

 

 

 

 

 

 

 

 

So, it’s clear to me anyway, that our modern view of pain as an experience that people go through in the context of their life implies that tissues and nociception are only part of the picture. Along with this is the recognition that our treatments exert their influence not just through the so-called “active ingredients” of whatever modality we choose to use. At the same time as we “treat”, the people coming to see us interpret and place expectations on what will happen in that “third space”. Their understanding of what could and should happen influences their response – and even if we don’t recognise this! What this means to me is that we have a responsibility to be mindful and thoughtful about everything that goes on between the person “treating” and the person “seeking”, because these influences are always happening. For more information on the neurobiology of treatment seeking and relief, Benedetti’s book on The Patient’s Brain should be a mandatory reference, though there are others.

Turning to whether those clinicians who primarily touch people, or advise on movements and bodies (ie physiotherapists) should adopt a cognitive behavioural approach, I’m going to snip from a paper by Harding and Williams (1995). What’s scary is that this paper was written waaaay back then, but some clinicians in this area of practice STILL don’t recognise that this is a legitimate approach for them to take. Back to the snip:

Capture1

Here’s a further snip from that same paper, explaining how and why providing accurate information, and helping people identify unhelpful ways of thinking is an important component, especially within a team environment.

“The cognitive component of a CP management programme involves teaching patients to identify thoughts and beliefs which underpin maladaptive behaviours and which adversely affect mood. There is a particular focus on anxiety and depression. Once patients can identify the very disabling cognitions, they try to use cognitive restructuring to identify and challenge longstanding beliefs and immediate judgements (Turk et al, 1983), with resultant improvement in mood and in practical coping with the pain.
Cognitive restructuring is a task that varies in complexity. Although this complexity sometimes requires the specialised skills of clinical psychologists or others with appropriate training, there are many occasions when less experienced professionals may help patients apply the principles to great effect.
One of the more disabling habits of thinking identified in many CP patients is catastrophising: expecting only the worst to happen and feeling
unable to cope with it. Research shows that patients who use catastrophising frequently cope poorly with CP (Jensen et al, 1991; Keefe et al,
1992). Team members are therefore taught to recognise catastrophising and to help patients to challenge it when it occurs, such as during exercises,
practical activities or planning.”

I know we can argue about the language used here (remember when this was published), but here’s my rationale for physically-oriented clinicians to actively use cognitive and behavioural approaches. When do you think people are likely to think those unhelpful thoughts? When is it most likely they will recall those scary images and immediately experience distress – and then avoid? Is it likely to be sitting quietly in a clinic room where the only expectation is to talk? Or is it more likely to happen when engaged in doing something that represents the thing the person is afraid of? When do you think emotions are most likely to be present? And when do you think it’s most likely that an experiment disproving the unhelpful assumption might best be carried out? I think it’s likely to be when you and the person are beginning to do some movements.

Along with cognitive aspects, there are also behavioural ones. “Changing Behavior: Providing positive consequences for learning a new behaviour such as a previously feared exercise is likely to reinforce it, particularly when the reinforcements are provided immediately and frequently for small achievements in the early stages. The focus is moved away from unhelpful behaviours, and shaping (Becker, 1989) rather than criticism is used to achieve the finally desired exercise or posture. Pain is not denied, only the pain behaviour is not reinforced.”

And further: “Goal Setting: Exercises are seen as part of the ‘building blocks’ to achieve a range of patient goals, so although they may improve local biomechanics, they constitute steps to  achieving activity goals and general fitness, rather than being prescriptive on the basis of the assessment.”–  yet more“Pacing: Since patients’ exercises are learnt with pacing on a quota not pain basis, practices like ’no pain, no gain’ and ‘pushing through the pain barrier‘ are discouraged. They learn to set exercise baselines at what can easily be managed rather than the most they or the therapists think they can do. Patients are thus enabled to challenge and resolve fears (such as bending the back, or weight bearing through a chronically painful knee) rather than to be precipitated into anxiety and avoidance.”

Still more “Education: Patients need information with written back-up to make choices and help them bring about behaviour change…Education is interactive and involves practical experience, not just discussion.”

“Recording Progress: Charts and exercise sheets are used to demonstrate and reinforce a behaviour change (such as regular and increasing exercise rather than pain determined exercise). They are filled in by patients, not therapists, to reinforce patients’ improvement.”

“Challenging Thoughts and Feelings: Physiotherapists who can help patients capture and challenge unhelpful cognitions, when they are confronted with feared situations such as physical activity, are likely to catalyse big improvements in function and mood. Unhelpful cognitions about exercise may be challenged on the basis of realistic estimates of physical capacity and of risk of harm.”

Finally, “Maintenance and Self-attribution: If improvement is seen as the patient’s achievement – ‘I did it’ – right from the start, rather than ‘the physiotherapist cured/fixed me up’, they will have a greater sense of future self-management.”

Further to my post about interdisciplinary working: An inter-disciplinary team is not hierarchical but involves sharing of skills, and it is quite usual, for example, for the psychologist to address the psychological implications of the physiotherapist‘s initiatives and vice versa. The physiotherapist has a lot of patient contact, so mutual feedback with other members of the team is important both in timetabled team meetings and informally. Good team integration helps patients understand how to tackle the complex experience of CP using the techniques, and prevents mixed messages from the staff which may confuse and discourage patients. Where integration is achieved, differences apparent to patients are easily resolved.” So much for concern about scope.

While these papers are old and the language reflects this, the cognitive behavioural approach is now firmly established as a helpful way to conceptualise the experience and problems of people living with pain. As Vlaeyen and colleagues indicated in their recent book “Pain-related Fear”, the skills rather than the professional discipline is what is important. Turk and others say that by using a cognitive behavioural approach, people are able to attribute change to themselves, rather than on any mythical theory about application of hands.

As Harding and Williams state: “When improvement occurs, it is important that it is credited to patients, both my themselves and by staff. Hands-on physiotherapy is tremendously rewarding, and rapid dramatic results produce in therapists quite a buzz of pride in their skills. Patients sense this and physiotherapists will remember being told: “Oh you are wonderful, no one else has been able to help me, such healing hands…etc”. However this is not helpful to patients. The unspoken message is: “I couldn’t do without you”. Physiotherapists guidance can be acknowledged but it is patient’s hard work and the renegerative capacity of their bodies which bring about change, catalysed by professional help” (p. 686).

So, to conclude, I think clinicians of all colours and stripes should be ready to adopt a cognitive behavioural approach. It is a perspective about a person experiencing pain, not a therapeutic procedure or set of actions. It’s a way of seeing people from within a biopsychosocial perspective. All the actions you then take as a professional will naturally reflect your unique clinical scope – but as far as I know, using effective communication (eliciting a person’s understanding of their pain and situation, and reflecting what you’ve heard) and being able to think of people as active participants in their own health doesn’t constitute stepping out of anyone’s scope.

cb perspective

References

Harding, V., Williams, A., (1995). Extending physiotherapy skills using a psychological approach: Cognitive behavioural management of chronic pain. Physiotherapy, 81(11), p681 – 688.

Turk (2003). Cognitive-behavioral approach to the treatment of chronic pain patients. Regional Anesthesia and Pain Medicine, 28(6), p 573-579.

Vlaeyen, J., Morley, S., Linton, S., Boersma, K., & de Jong, J. (2012). Pain-related fear. Seattle: IASP Press.

9 comments

  1. Bronnie, for me the question that arises is – who is to decide whether the coping strategies (thoughts, feelings, behaviours) of another human being experiencing pain are to be categorized as “maladaptive”? How is any clinician expected to be able to make this value-laden decision? The psychologists do have a case to answer, at least in my opinion.

  2. I think you’d really like Acceptance and Commitment Therapy then John, because the criterion against which coping strategies and thoughts and beliefs are compared are those values that the individual holds – and whether the coping strategies etc are workable in light of those values. The question clinicians must ask themselves and the person is “How well is this working for you in your life? Is it bringing you closer to the life you want to live, expressing the values you want to express?”
    I recommend reading Russ Harris’ blog (he’s an Australian doctor), and the work of Steven Hayes and colleagues for more information on this. To me it brings humanity, respect and individuality into an approach to human distress.

    1. Bronnie, I do indeed like the ACT approach, which blends in nicely with mindfulness mediation. But I freely admit to not knowing the direction(s) in which academic psychology is moving in the context of pain management. That terms such as “catastrophizing,” “somatizing,” and “fear avoidance” are still being used in the pain medicine literature concerns me. Do you know if the views of people in pain have been sought in relation to the use of these potentially stigmatizing labels? Can you or someone else can enlighten me? P.S. Please excuse me playing the Devil’s Advocate in this blog.

      1. I don’t mind the Devil’s Advocate visiting now and then! It makes me think. I am ambivalent about the terms catastrophising and pain-related anxiety and avoidance (or pain-related fear). I’ve found them extremely useful concepts in therapy, to the point where people I’ve worked with have ended up poking fun at their own “mind’s” way of letting them know that they’re afraid or over-evaluating the risk. At the same time I know these terms have been used pejoratively, which is something I abhor. In NZ I don’t think the term somatizing is used much, if at all, and if so is more likely to be used by psychiatrists or neurologists/neurosurgeons when faced with a situation they can’t find on imaging. I know there needs to be a term for these unhelpful thinking and behavioural patterns, and given the ongoing stigmatisation of people living with chronic pain, I can’t see ANY term no matter how benign originally NOT being used pejoratively in reference to people in this group. To me it’s not the label as such, it’s the intent behind it. If a clinician sits in judgement and indicates that the person demonstrating these patterns “should” or “must” change, and that they’re somehow immune themselves from this pattern of thinking and doing, then I think the clinician needs a reality check! And it’s not helpful. When, however, it’s used as part of guided discovery, in a dialogue between the person and clinician, in the manner of learning to understand how and why these patterns exist, and how they affect the individual, then it’s another whole ball game. I like to think that’s what I do. But of course I might be wrong – would a person seeing me ever tell me that I got it wrong?!
        How would you describe these patterns of thinking and behaviour so that they are recognised for the risk factors they are for ongoing and unnecessary disability and distress, but without the negative connotations?

  3. Very interesting post Bronnie. It is very interesting that it was suggested that long ago for physios as I only started hearing about it when i became more involved with chronic pain. I like the comments at the end as well It makes a very nice piece for discussion for my class. thanks

    Lesley Singer (Norris)

    Faculty Lecturer Course co-ordinator Graduate Certificate in Chronic Pain Management McGill Faculty of Medicine School of Physical and Occupational Therapy McGill University physiotherapist Kinatex West Island

    ________________________________

    1. I think the paper really only applied the approach to chronic pain management, but since then it’s been so widely applied in other areas like COPD, cardiac rehab, diabetes, asthma and so many other areas that I think it’s become a real generic approach. Thanks for your comments!

  4. Bronnie, thank you for your thoughtful and enlightening response. Attempting to answer the question expressed in your final paragraph takes me into very unfamiliar territory. When we believe that these patterns of thinking and behaviour can be “risk factors for ongoing and unnecessary disability and distress,” how are we able to usefully distinguish between cause and effect?

    1. I think there are studies using causal modelling (path analysis) where the paths from cognitions to emotions to behaviours have been established, but it’s not something can put my hand on my heart and give you a range of readings to show this. What I do know is that catastrophising reduces when pain intensity reduces (eg after hip arthroplasty) and is elevated prior to surgery, so there are elements of state characteristics, but also I know of twin studies where it’s shown to be a trait tendency, along with anxiety sensitivity and negative affectivity. It’s complex! Certainly where catastrophising is addressed via cognitive reframing or reality testing or accurate information, catastrophising reduces as well as measures of distress (low mood, anxiety) and measures of disability. Again, this is a path analysis with pre and post intervention measurement. Not sure if I’ve answered your question!
      I think the approach is critical – I usually ask the person if it’s working to think like that, what’s the effect of thinking like this – does it increase pain and avoidance or does it galvanise a person into action? Mostly it seems to do the former and people will often acknowledge this, but there are some (like me) who feel that there is some utility to “hoping for the best but planning for the worst” – but the workability criterion is useful here, if it’s not useful and gets in the way, then it’s helpful to develop a different perspective.

      1. Bronnie, I don’t think my question is currently answerable. Whatever model of human cognition (if there are any such useful models) we employ for path analysis, the statistical data derived therefrom will always be correlational. But as I said above, I am attempting to navigate unfamiliar territory. A neuropsychologist might be able to shed more light on this question.

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