Hello my Zebras and Spoonies! Thanks for coming and hanging out with me today, I’m glad that you are here. Today I want to talk about psychotherapy for pain management. This is an often hot topic in the support groups that I’m a part of. For reasons that I am all too familiar with, the knee jerk response to getting a referral to a therapist is that we are being dismissed. However, that might not be the case and there is research to support the use of therapy for those with chronic illness. So, let’s get it into!
My first recommendation is that if your provider is recommending that you see a therapist: you should clarify with them the reason that they think you should be receiving this care. Ask them what they feel the benefits would be to you and what diagnosis they would use to make the referral. These two pieces of information will tell you a great deal about what your provider is thinking and will help you decide whether or not the provider is dismissing your chronic illness into the psychiatry world. Your provider should be willing to discuss the rationale behind any recommendation that they are making. I personally think it is a huge red flag if a provider is not willing to have this conversation. Good care is based upon a logical process of thought. Thus, they should be able to explain to you how they came to this recommendation. If they can’t, it is an indication that there isn’t a good foundation of reason for their recommendation. If they won’t, it is an indication that they are more interested in maintaining power roles then creating a productive relationship with you.
The second thing I have to say is that I am a huge advocate for taking care of our mental health. For those that don’t already know, I have a ANCC Psychiatric-Mental Health Nursing Board Certification. Thus, I could be considered biased when I say that I feel almost everyone who has a chronic illness would benefit from receiving mental health services. Having a chronic illness means that you will be put into a grief cycle and for that alone it can be immensely helpful to have a therapist to talk to. Having chronic illness means that you will have a bunch of stuff that you are thinking about and worried about that you probably don’t want to constantly dump on the people that you are close to. Because of this having a therapist that specializes in chronic illness can be very helpful. Not to mention that having a chronic illness increases the risk for having a mental health diagnosis with depression and anxiety being high on the list. There are many benefits that a therapist can provide to someone with chronic illness. But the key is finding someone that specializes in chronic illness management.
The thing that I see questioned and debated in the support groups the most is having psychotherapy for chronic pain management. I’m going to focus my post on that topic. Psychotherapy for pain management can be very useful. But there are somethings to keep in mind.
Like all therapy it is only as good as the therapist that you are working with. Because of this, don’t be afraid to switch to a different therapist if the one you are working with doesn’t feel right or isn’t helpful. Therapists are individuals with individual styles. Doesn’t matter which discipline of therapy they work with (CBT, DBT, ACT, etc.) they will still have their own style. Getting CBT from two different therapists can be completely different experiences. Not to mention that they are people and just like when we are meeting anyone there is the factor of personality. This is someone that you are going to spend a good amount of time with and someone you will talking about pretty personal topics with. So it is pretty important that you actually like your therapist as a person. If you find their personality abrasive or triggering it is going to be really hard to work with them regardless of how good they are at their job.
Cognitive Behavioral Therapy (CBT) is the approach most often used when getting psychotherapy for chronic pain management. However, CBT doesn’t help for everyone. It is the type of therapy with the highest efficacy for chronic illness and chronic pain management which is why it is the approach most often used. However, if it isn’t working for you then the second highest efficacy is Acceptance and Commitment Therapy (ACT) and can be worth trying.
CBT is based on several core principles, including:
- Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
- Psychological problems are based, in part, on learned patterns of unhelpful behavior.
- People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.
In context of chronic pain management, CBT sits on the same principles. The thought is that the ways that we think about our pain can help or hinder us in how well we cope with or manage that pain. Learned patterns of behaviors can contribute to a worsening of our pain symptoms. We can learn better ways to cope with and manage our pain thereby improving our pain and becoming more effective in our lives.
CBT treatment usually involves efforts to change thinking patterns. These strategies might include:
- Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
- Gaining a better understanding of the behavior and motivation of others.
- Using problem-solving skills to cope with difficult situations.
- Learning to develop a greater sense of confidence in one’s own abilities.
CBT still involves efforts to change thinking patterns when treating chronic pain. Evaluation of your emotions and thoughts around your pain can help you better understand the relationship you have with your pain. Being angry at or afraid of your pain can have an impact on the ways that you cope with or manage your pain. The relationship we have with our pain will determine the behaviors that we engage in regarding our pain. There generally isn’t much focus on understanding the behavior or motivation of others when you are receiving therapy for pain management. There will be a huge focus on helping you build problem solving and coping skills. There is also a huge focus on helping you feel more empowered in your pain management.
CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:
- Facing one’s fears instead of avoiding them.
- Using role playing to prepare for potentially problematic interactions with others.
- Learning to calm one’s mind and relax one’s body.
Again, CBT is going to stay with it’s core treatment set when treating chronic pain. There will be a focus on facing your emotions regarding pain which is commonly fear of having pain or increasing your pain. Roleplaying might be used if you need help in learning how to self advocate and how to have difficult conversations regarding your pain. Relaxation skills among other coping skills will be taught.
CBT is all about shifting the way that you think about things and using coping skills to better handle the symptoms you are having. That being said, it generally doesn’t reduce your pain. It can, if stress is triggering flares or is making your symptoms worse. But what it generally does is improve your ability to tolerate your symptoms. Since being symptom free is generally not a realistic goal, this can be helpful. It can also help you find a better mindset where you can better problem solve which can be helpful for pain management. It can also help you break out of harmful behavioral patterns that are increasing your pain.
If you are going to get CBT for pain management, make sure that the therapist you are seeing is a specialist in both CBT and chronic illness or chronic pain management. Other therapists will not be as helpful. It can be helpful to research potential therapists before committing to an appointment. Most therapist have a website with a profile that you can read. It will cover their education and experience as well as what they focus on in their practice. Don’t be afraid to give them a call for a brief interview. Most therapists will give you 15 minutes of their time to answer questions about their practice. Just keep in mind that many don’t have secretaries and they are likely to be in a session when you call. This means that they are most likely going to return your call between sessions or at the end of their day. Lastly, keep in mind that there are other approaches then CBT that are used for chronic pain management. If the therapist seems like a good fit, they might be worth a try even if they don’t use CBT.
Remember that telehealth can increase your access to specialized providers. Most insurances now cover telehealth. This opens up a lot more options for you getting the kind of therapist that you need. Thus, it can be helpful to call your insurance before you start looking for a therapist. Find out what kind of services are covered, what types of appointments are covered and find out if the licensure of the therapist matters for coverage. Often times your insurance will have a list of therapists that accept their insurance and are in the preferred group. This list can be a great place to start your search since you know your insurance will cover them. After all, it doesn’t matter how amazing a therapist is if you cannot afford to see them.
Know that there are several types of licensure for therapists. There are: advanced practice psychiatric nurses (PMHNP or psychiatric mental health nurse practitioner), there are licensed clinical social workers (LCSW), clinical psychologists (CP), and there are psychiatrists (MD, usually presented as DR. ____). Each license has a different scope of practice. The biggest thing to know is that you need a PMHNP or MD if you are going to be prescribed medications. Generally, these two licenses will have more focus on medication than counseling or talk therapy. So, it isn’t a matter of one license being better then the other but rather about knowing what services they can provide and what their focus of treatment will be. It is also important to know if your insurance covers that kind of provider for talk therapy.
As a final note, I personally found ACT and ERPT way more helpful than CBT. This is because I personally have autism and OCD which both tend to respond better with ACT and ERPT. ACT is Acceptance and Commitment Therapy with the focus being learning how to sit with uncomfortable states of being and being functional rather then trying to change your state of being. ERPT is Exposure Response Prevention Therapy which is based on ACT but then actively exposes you to the things that trigger uncomfortable feelings as a way to train you to better cope with them. Those with autism often have strong OCD traits even if not meeting the full criteria for an OCD diagnosis. This means that things like intrusive thoughts, ritualized behaviors and need for sameness are often barriers for CBT. Those with OCD or OCD traits often find it difficult or impossible to change their thoughts. It’s the nature of having obsessions. ACT and ERPT are the gold standards for those with OCD and OCD related disorders or OCD traits.
Well, that’s about it for my rambling today. Thanks for coming and spending some time with me. If you like what you read, click on that like button. It really does help! Until we talk again, you take care of yourselves!