Useful Guide To Cognitive Behavioural Therapy (CBT) for CRPS and Persistent Pain
What is Cognitive Behavioural Therapy or CBT for CRPS/RSD (Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy) and persistent or chronic pain? How is CBT going to help you with your CRPS or chronic pain? You’re probably thinking “I’m not crazy! The pain is real! So why has my doctor said I need to see a psychologist and consider psychological treatments?” All of these questions are quite normal and no neither we nor your doctors are saying that your pain is in your head because it isn’t. But trying to understand and apply some of the various psychological treatments or therapies that are available can help you begin to cope, manage and accept your CRPS and chronic pain physically, psychologically and emotionally.
The psychological effects of Complex Regional Pain Syndrome (CRPS) should never be underestimated in any way and after being diagnosed with CRPS, you can ask for psychological therapies as part of your treatment plan if you are not offered it. Cognitive Behavioural Therapy for CRPS and chronic pain is just one of those psychological therapies that can help you learn to alter the way you think which will then lead to altering how you actually feel and cope with your pain. Learning to apply the techniques from CBT can eventually help you to self manage your chronic pain and CRPS/RSD. Usually a course of CBT for chronic pain and CRPS/RSD is considered a talking type of therapy (British Association for Behavioural & Cognitive Psychotherapies). This Cognitive Behavioural Therapy or CBT for CRPS and Persistent Pain blog is in the blog series by Burning Nights CRPS Support ‘Series of Alternative Therapies/Treatments). CBT therapy for CRPS or chronic pain will usually involve various techniques such as:
Exposure Therapy or Graded Exposure Therapy
Stress Management and Identifying the stress within your life
Pain Related Fear Avoidance
One of the main issues that can cause a lot of problems including the advancement of the condition amongst other things and that is fear of moving your CRPS limb due to pain reasons. It is known as fear avoidance or pain related fear avoidance. This means that when you are going to move your CRPS limb or extremity that you immediately think that it will be very painful when you move it so you stop moving the limb or extremity or you don’t move your limb because you know it is going to be extremely painful for you. The fear of injury or movement has been identified as a potential predictor of chronic disability in Complex Regional Pain Syndrome type I (CRPS-I). It is this fear or injury combined with the increased pain sensitivity may lead to excessive guarding of your CRPS limb and overprotective behaviours that may worsen the pain problem. It is paramount that patients and their family receive early education on the perils of disuse of the affected limb. Fear of movement is quite common as movement could trigger pain in a patient with CRPS. This could lead to disuse atrophy and could hamper physical rehabilitation.
How does CBT actually help your CRPS or chronic pain?
Living with Complex Regional Pain Syndrome (CRPS) or chronic pain will usually involve various health professionals which may include psychologists, mental health experts or counsellors. One of the treatments suggested for CRPS or chronic pain is psychological treatment and one of those treatments is Cognitive Behavioural Therapy or CBT for short. They will teach you to help control your pain without the use of medication. It will also teach you to cope both emotionally as well as physically with all the problems that CRPS and chronic pain throw at you. You’ll probably be reading this and thinking “there’s no way I can cope with the amount of pain I’m in without the help of medication.” Well, the answer is, YES you will be able to cope without medication sometimes and that is what CBT and psychological treatments are there to try and help you achieve that fact of living through the pain or flare ups without medication.
Having chronic pain or a chronic pain condition like Complex Regional Pain Syndrome, patients can very easily get into bad habits of doing some exercise or an activity and then resting for a short time, then as you rest you begin to think negatively, saying phrases like ‘I can’t carry on, I’m in too much pain.‘ The way Cognitive Behavioural Therapy works is it helps to point out the negative ways of acting and how you think. This in turn will help make positive changes to our thoughts and life, which then in turn reduces the pain. (Get Self Help, UK) The main focus is on how you THINK and ACT now rather than what has happened in the past. CBT helps you to try and make sense of your overwhelming problems by simply breaking them down into smaller and more manageable parts.
According to a research study, evidence does exist to say that Cognitive Behavioural Therapy is effective in treating chronic pain conditions and chronic pain in general including chronic pain from cancer (Keefe, F.J. 1996.) Bruehl, S. & Chung, O.H. (2006) also state that cognitive behavioural therapies are effective treatments for CRPS Type I or CRPS-I.
There have also been a number of cognitive–behavioural exposure in vivo treatments have been developed, specifically targeting catastrophic (mis)interpretations of bodily symptoms including pain (Vlaeyen, J. et al. (IASP Press 2012). These fear-reducing techniques are based on experimental and clinical findings that when individuals expose themselves to painful movement, rather than avoid them, they can readjust their expectancies about the associations between movements and increased pain.
Factors Contributing To Chronic Pain and CRPS
According to GET Self Help there are a number of factors that actually contribute to more pain on top of your chronic pain or chronic pain condition like CRPS/RSD. They believe (GET Self Help Cognitive Behaviour Therapy Self-help resources) that those factors are:
- Doing too much too soon after illness
- Resting too much and for too long
- Boom & Bust – basically you do far too much when you have energy but that results in more tired feelings and more pain
- Disturbed Sleep
- Thinking about chronic pain
- Life Stress & Low Mood – eg. financial worries
- Mental fatigue – poor short term memory, easily distracted, difficulty concentrating
- Pain catastrophising
- Pain related fear avoidance
What Happens In A Cognitive Behavioural Therapy (CBT) Session?
Cognitive Behavioural Therapy (CBT) sessions can be either on your own with the therapist or in a group setting and it just depends on the sort of problems you need help with as to how many sessions of CBT that you need. Each session is between 30-60 minutes in length and on average is between 5 – 20 weekly sessions. You should be able to see a therapist in many settings such as the therapists own office or their home, local hospitals, clinics or your doctors offices/surgeries. You can buy CDs or MP3s so you can carry on with your CBT while you are at home, during your lunch hour or on your way home. Your therapist may also give you goals to try and achieve in between the face-to-face appointments. Some CBT therapists can also do telephone or even Skype appointments to help check on how you’re doing and give you some tips on getting over any difficulties you may have been having as you try to practice what the therapist has been helping you with. (British Association for Behavioural & Cognitive Psychotherapies)
It is during these CBT sessions that you work with your therapist or psychologist to break down your problems into individual parts ie. thoughts, physical feelings and actions. You need to also remember that your therapist won’t tell you what to do but they will help you decide on what areas you need to work on to help improve things. Together you will study each of the areas and decide whether they are not helpful or unrealistic and then also determine the effect that these areas have on you and on each other. (NHS Choices) Your therapist will then be able to help you work out how to change unhelpful thoughts and behaviours. They will help you set goals for you to accomplish and it does involve some hard work on your part not only in the sessions themselves but also outside of the sessions. CBT doesn’t solve things instantly it is not a quick therapy by any means. Once you learn and overcome your goals then your life will be helped in a good way, so you can eventually deal with your chronic pain or CRPS/RSD in every day life which is so important.
The Mayo Clinic has some very good information to how each session is planned, confidentiality issues, the steps in the sessions and length of psychotherapy. Visit the MAYO CLINIC website for CBT.
What Helpful CBT Techniques Are There?
There are a few things that you can do yourself in between your sessions of CBT or even to do before your sessions starts (GET Self Help Resources):
- Pace and Monitor your activities – This is where your Burning Nights CRPS Support Pain Diary comes into play or an Activity or Rest Diary (template from GET Self Help) (Another template is from the Beck Institute) See where the times that your pain is worse due to a certain activity or if it isn’t so bad, what were you doing?
- Try learning how to pace yourself by planning your day out and don’t forget to include your rest periods, don’t try and cram everything in just 1 part of the day
- Reward yourself when you’re doing well by giving yourself a treat of some kind
- Do some form of gentle exercise – please remember to speak to your Doctor before you go and do exercise that you’ve never done before and get their opinion on how much you should do
Another very good CBT technique for chronic pain or CRPS/RSD is GOAL SETTING. This is where you decide on short term goals and build up using just small steps by breaking down your goals into smaller and smaller pieces. MIND TOOLS website has an excellent page on goal setting and the 5 golden rule, here they are:
- Set goals that motivate YOU – Those important goals that you want to try and make. If you set goals that you’re not interested in then you won’t make those goals and so won’t have success in achieving them. Write down WHY the goal is important to you.
- Set what is called SMART goals – SMART is an abbreviation for:
Specific – This is to set specific goals that are clear and well defined
Measurable – You need to set measurable goals that include dates, precise amounts etc.
Attainable – Remember to set attainable goals that you are sure that you can possibly and easily achieve those goals and they are not to far out of your reach
Relevant – This concerns setting relevant goals to you and the way you want your life to go
Time Bound – You need to set time-bound goals that have an actual date or deadline that you want to achieve
- Set goals in WRITING – When you write goals down it makes them real and so there’s no excuse for forgetting them! Make sure you write your goal in a positive way and possibly use a To Do List and don’t forget to post your written goals somewhere they are visible, don’t just put them in a drawer so you can forget about them.
- Make an ACTION plan – Write out the steps that you need to make to reach your goal, make sure you don’t make each step too big otherwise you will start thinking negatively because you can’t reach those steps.
- Don’t forget to STICK WITH IT all! It wont be all achievable straight away, remind yourself of the goals and steps along the way. Give yourself a reward for each step and goal you attain and they are all ongoing so don’t forget!
Advantages and Disadvantages of Cognitive Behavioural Therapy for your CRPS or chronic pain
There are several advantages as well as disadvantages of Cognitive Behavioural Therapy for CRPS or chronic pain just as there are with other treatments.
- CBT treatments have been demonstrated to be effective through clinical research
- CBT may be helpful in cases where medication on its own hasn’t worked
- CBT is able to be completed in a fairly short length of time, so you won’t need to spend years seeing a counsellor/therapist or if paying privately, you won’t need to spend hundreds of pounds
- CBT can be easily incorporated into your life
- Once you have learnt the CBT skills you can continue to use them after the treatment has finished and can be used in any number of situations or conditions
- The way that CBT is structured you can access the treatment in a number of ways such as CDs, self help books, group settings, individual one-to-one sessions, apps and other technology
- To actually benefit from Cognitive Behavioural Therapy or CBT you must commit yourself to the process otherwise you won’t be able to get the most out of it. Your therapist can’t make your issues go away without you doing the background work outside of the CBT sessions
- If you have learning difficulties or complex mental health issues or needs then CBT may not be considered suitable as CBT does require structure sessions
- If you attend regular CBT sessions outside your home as well as the background work outside of these sessions can mean that it does take up quite a lot of your time
- CBT involves confronting your anxieties and your emotions which may mean that you experience some initial periods where you feel emotionally uncomfortable or very anxious. Some people are not able to cope with this level of confrontation
- There is no scope within CBT for personal exploration and examination of emotions, or of looking at troubling issues from various perspectives. If these issues need to be addressed then CBT may not be suitable but instead you would need to consider other types of psychological therapy such as of psychodynamic counselling. For mental health conditions, some critics believe that because CBT only addresses the current issues it doesn’t focus the underlying reasons of those mental health conditions
How To Find A CBT Therapist
If you’re in the UK please speak to your GP as they may be able to refer you for Cognitive Behavioural Therapy (CBT) as it is free on the NHS. However you may have to wait to actually see someone. You are able to access CBT sessions on a private basis which would obviously have to be paid for. Contact your GP and ask if they can recommend a local therapist for CBT to help you with your CRPS or chronic pain. If they are unable to help you or if the therapist does not take on clients on a private basis please check the various associations below for further details. In the UK the cost of private CBT sessions do vary around the country, however the cost is approximately £40-100 per session.
Please remember to always check the qualifications and credentials of your therapist if you have referred yourself to one. Here are the associations for UK & Ireland, USA and Europe:
UNITED KINGDOM & IRELAND: British Association for Behavioural & Cognitive Psychotherapies – Online CBT Therapist Register
Cognitive Behavioural Therapy for CRPS/RSD and Chronic Pain can be a worthwhile tool to help you with your thoughts, feelings and eventually help you cope with everyday life while having chronic pain or a chronic pain condition like CRPS. Please seek advice from your doctor before starting any new treatments including CBT.
Have you tried Cognitive Behaviour Therapy (CBT) for your CRPS / RSD or chronic pain? What are your thoughts on CBT? Did it help you? Tell us what you think in our comments box below the blog. Don’t forget to check out the other psychological therapies for CRPS or chronic pain in our blog series!
CITED ARTICLES/JOURNALS/STUDIES for CBT:
- Akerblom, S. et al. (2015) ‘The Mediating Role of Acceptance In Multidisciplinary Cognitive Behavioral Therapy for Chronic Pain,‘ The Journal of Pain. Received 10 December 2014. Accepted 22 March 2015. Published Online 31 March 105. Available from: < http://www.jpain.org/article/S1526-5900(15)00600-8/abstract > doi: http://dx.doi.org/10.1016/j.jpain.2015.03.007
- Bowers, E, ‘Managing chronic pain: A Cognitive-Behavioral Therapy Approach,’ WebMD Feature. Available from: <http://www.webmd.com/pain-management/features/cognitive-behavioral>
- Bruehl, S. & Chung, O.H. (2006) ‘Psychological and behavioral aspects of complex regional pain syndrome management,’ Clin J Pain. 2006 Jun; vol 22(5): pp430-7. Available from: <https://www.ncbi.nlm.nih.gov/pubmed/16772797>
- de Jong, J. et al. (2005) ‘Reduction of pain-related fear in complex regional pain syndrome type I: The application of graded exposure in vivo,’ Pain. 2005, Vol 116, pp 264–275. Full Text Available from: <https://s3.amazonaws.com/academia.edu.documents/41633648/Reduction_of_pain-related_fear_in_comple20160127-7390-1yjz9fm.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1516116042&Signature=0njciMMwPNJIFUGhIK5lp4WfHxQ%3D&response-content-disposition=inline%3B%20filename%3DReduction_of_pain-related_fear_in_comple.pdf>
- den Hollander, M. et al. (2016) ‘Expose or protect? A randomized controlled trial of exposure in vivo vs pain-contingent treatment as usual in patients with complex regional pain syndrome type 1,‘ Pain. 2016. Vol 157.10: pp 2318-2329. Available full text from: <https://www.researchgate.net/profile/Johannes_Vlaeyen/publication/305382403_Expose_or_protect_A_randomized_controlled_trial_of_exposure_in_vivo_vs_pain-contingent_treatment_as_usual_in_patients_with_complex_regional_pain_syndrome_type_1/links/57f64bc508ae886b8981b8e2.pdf>
- Finan, P.H. et al. (2014) ‘Cognitive-Behavioral Therapy for Comorbid Insomnia and Chronic Pain,’ Sleep Med Clin. 2014, June 1. Vol 9(2), pp 261-274. Available from: <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248667/> doi: 10.1016/j.jsmc.2014.02.007
- Keefe, F.J. (1996) ‘Cognitive Behavioral Therapy for managing pain,‘ The Clinical Psychologist. 1996. vol 49 (3) pp 4-5. Available from: <http://www.apa.org/divisions/div12/rev_est/cbt_pain.html >
- Lee BH, Scharff L, et al. (2002) ‘Physical Therapy and Cognitive-Behavioral Treatment for Complex Regional Pain Syndrome‘ NCBI Pub Med.Gov. 2002 Jul. 141(1).pp 135-140. Available from: <http://www.ncbi.nlm.nih.gov/pubmed/12091866 > PMID: 12091866 [PubMed indexed for MEDLINE]
- Lee, B. et al. ‘Physical Therapy and cognitive-behavioral treatment for complex regional pain syndromes,’ Available from: <http://www.cebp.nl/media/m1063.pdf>
- MayoClinic staff (2013) ‘Cognitive Behavioral Therapy‘ Mayo Clinic. Available from: <http://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/basics/definition/prc-20013594 > Updated on 21.02.2013
- NHS Choices (2016) ‘Cognitive Behavioural Therapy (CBT),’ NHS Choices website. Accessed 16/01/2018. Available from: <https://www.nhs.uk/conditions/cognitive-behavioural-therapy-cbt/>
- Pither, C. ‘Cognitive Behavioural approaches to Chronic Pain,’ The Wellcome Trust. Available from: <http://www.wellcome.ac.uk/en/pain/microsite/medicine3.html >
- Vlaeyen J, Morley S, Linton SJ, Boersma K, de Jong J (2012) ‘Pain-related fear: exposure-based treatment for chronic pain,’ Seattle, WA: IASP Press, 2012. Available as a citation: <http://www.diva-portal.org/smash/record.jsf?pid=diva2%3A619674&dswid=-4737>
Essential Websites for Cognitive Behavioural Therapy:
- British Association for Behavioural & Cognitive Psychotherapies – This is the British Association for those who deal with psychotherapies. This is a good resource, you can find a therapist in your area, gives tips on self help and explains simply what CBT actually is. Available from: <http://www.babcp.com >
- Cognitive Behaviour Therapy Self-Help Resources – Available from: <http://www.getselfhelp.co.uk/chronicfp.htm >
- Vivyan, C. GET Self Help Cognitive Behaviour Therapy Self-help resources) Chronic Fatigue & Chronic Pain. Available from: <http://www.getselfhelp.co.uk/chronicfp.htm >
- Beck Institute for Cognitive Behavior Therapy – Available from: <http://www.beckinstitute.org/cognitive-behavioral-therapy/ >
- Mayo Clinic for Cognitive Behavioral Therapy – Available from: <http://www.mayoclinic.org/tests-procedures/cognitive-behavioral-therapy/basics/definition/prc-20013594 >
- PainPsych (2015) ‘CBT – Managing Chronic Pain,’ Available from: <http://www.painpsych.com/Cognitive-behavioral-therapy-and-Chronic-Pain.html>
- Academy of Cognitive Therapy Available from: <http://www.academyofct.org/ >
- European Association of Behavioural and Cognitive Therapies Available from: <http://eabct.eu/ >
- Mind Tools – Golden Rules for Goal Setting – Available from: <http://www.mindtools.com/pages/article/newHTE_90.htm >
Last Updated: 16/01/2018