cognitive behavioural

Making the most of a referral for pain management


This is a post for people who may refer someone for pain management, or someone who is personally being referred. When I talk about pain management, I’m meaning a multidisciplinary or interdisciplinary pain management programme where participants learn about their pain, develop strategies to cope with life despite their pain, and get involved in reactivation.

The contents of a cognitive behavioural pain management programme (eg INPUT, ADAPT, vary considerably – it’s essential that the approach includes these concepts:

  • That clients can learn to accept the chronicity of their pain.
  • That clients can change their relationship to their pain in a way that allows them to broaden their sense of identity/self beyond the pain to that of “a well person with pain”.
  • That clients can learn or re-explore skills to deal more effectively with their pain, e.g., relaxation training, activity-rest cycling, graded exercise, attention management. (Morley, Biggs & Shapiro) (more…)

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Preventing relapse has to be one of the most difficult parts of pain management – what do you do to keep someone going with their new skills while at the same time not allowing them to become dependent on your encouragement?

Some strategies have included spacing the final few sessions some time after the bulk of the intervention; providing access to a support group; providing explicit instruction on ‘ways to manage high risk situations’; periodic telephone consultations – and now, ‘an automated, telephone-based tool for maintenance enhancement’ (Naylor,MR., Keefe, FJ., Brigidi, B., Naud, S., Helzer, JE., 2008).

Therapeutic Interactive Voice Response (TIVR) has four components: a daily self-monitoring questionnaire, a didactic review of coping skills, pre-recorded behavioral rehearsals of coping skills, and monthly personalized feedback messages from the CBT therapist based on a review of the patient’s daily reports.  The first three components are pre-recorded and all four can be accessed remotely by patients via touch-tone telephone on demand.

Sounds great – and the response looks favourable.  Maybe this is one way to maximise outcomes, while minimising cost and therapist time? My only concern is the need for participants to be (1) adherent to completing questionnaires on a very regular basis, and (2) comfortable with auditory-only feedback and using a telephone.  Both of these aspects require high levels of commitment to the process – and good literacy.

Nevertheless, it does demonstrate that technology can provide a way for therapy to maintain input with lower costs, which can only be good for our patients.

Naylor MR, Keefe FJ, Brigidi B, Naud S, Helzer JE, (2008). Therapeutic Interactive Voice Response for chronic pain reduction and relapse prevention. Pain. 134(3):335-45. Epub 2008 Jan 4.