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Contextual Cognitive-Behavioural Therapy for Chronic Pain (Including Back Pain) 

Contextual Cognitive-Behavioural Therapy for Chronic Pain (Including Back Pain)
Contextual Cognitive-Behavioural Therapy for Chronic Pain (Including Back Pain)

Lance M. McCracken

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date: 24 January 2022

In many ways our main cognitive-behavioural treatment methods for chronic pain have stayed very much the same for the past 25 years. Perhaps this is a product of early success (Flor et al. 1992). There could be other factors: a lack of a truly well-integrated and progressive theory of human behaviour and suffering. Maybe there were other battles, such as to hold onto some piece of territory in a field where psychological methods are clearly the underdog. Psychological methods for pain are set in a culture where solutions for pain that look like a fix, including medications or even high technology devices, have much greater immediate appeal. These apparent solutions it seems are much more enticing than approaches that require learning, facing discomfort and uncertainty, approaches that say the answer to your pain requires change in your behaviour.

At the same time that CBT for pain was enjoying its successes clinical psychology outside of pain management has been growing and changing faster than inside pain management. This is an impression, said with no data. If it is true, what does it mean?

Increasing research findings outside of pain management and, increasingly, inside of pain management, demonstrate that there is more than one way to live a full life when one has been suffering with chronic pain. Methods available from CBT as it has been practised for 25 years are one way (Morley et al. 1999). These methods are varied but tend to include training in coping and methods designed predominantly to change, control, or decrease unwanted physical and emotional feelings, or dysfunctional or misleading thoughts and beliefs (e.g. Williams et al. 1996; DeJong et al. 2005). Another way, rather than coping with or attempting to control feelings, thoughts, or beliefs, is to a focus on contextual change around all of the painful and discouraging experiences that arise with chronic pain.

Contextually-based therapies, like ACT and CCBT or mindfulness-based approaches, aim to manipulate the contextual elements that afford psychological experiences their influence over behaviour patterns. They do not primarily aim to manipulate the content of psychological experiences themselves. They aim not to decrease sensations, emotions and thoughts but to modify how they are experienced. Contextual change is not superficial. It attempts to get to the roots from which suffering and behaviour disruption emerge, largely in the interaction of processes of language and cognition with direct experience. Contextual processes are perhaps less naturally apparent in our everyday experience. Contextual methods are perhaps subtle, sometimes illogical, metaphorical or paradoxical, not dominantly change-oriented, and typically flexible in their balance between change and acceptance.

There are now more than ten recent trials investigating contextual approaches for chronic pain, including acceptance or mindfulness-based methods. Six of these are fully randomized and controlled and some of the remaining ones are non-randomized or partially controlled effectiveness studies. Most of controlled studies are small in scale. Findings from these studies are encouraging. They are encouraging because they show impacts on variables of high importance, such as work status and healthcare use. They are also encouraging because they include process analyses. There is additional work to do: larger randomized trials, and development work to produce versions of treatment that allow greater access, outside of specialty care, and versions that deliver greater impact more efficiently.

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