Cognitive Behavioral Therapy for Chronic Pain, Unpacking the Basics: Sessions 3 and 4

Main points, no filter

o   Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) sessions 3 & 4 focus on goal setting, exercise, and pacing

o   The goals you set are your personal goals, not something decided by your therapist

o   Exercise begins with small, intentional movement (we aren’t asking you to run a marathon here)

o   Pacing helps to break the overactivity cycle associated with chronic pain

CBT-CP Goal Setting Session

You may be wondering why we need to set goals in therapy at all. Well, it’s important to have a direction to head in, otherwise we can end up spinning our wheels and feeling stuck. Like I’ve said before, if nothing changes, then nothing changes. So, we need to think about where you would like to see change happen and create a path forward.

But my goal is to not have pain

I hear you. You just want the pain to stop. You want to get back to having a “normal” life. Unfortunately, chronic pain is chronic. So that means I cannot promise that we can get you to that magic 0 out of 10 pain score that you dream about. But what I can do is help you to create a life that does not revolve around pain. I can help you to think outside the box and discover new passions and purpose and make the pain feel smaller (even if it isn’t a “zero”).

What if I can’t imagine anything being different?

I often hear from patients experiencing chronic pain that they simply cannot imagine anything being any different (or any better). You might feel like you have been going through the motions day after day without allowing yourself to see a different future. You may struggle to identify a goal because you have been living with chronic pain for such a long time and feel defeated. That’s completely understandable. This is where we have wiggle room in treatment and can really take some time to dive into what is important to you as an individual. We may even take a session to discuss values and see what is important to you in terms of creating a fulfilling life. Once we know what means the most to you, we can work together to create meaningful goals.

SMART Goals in CBT-CP

Now, you may be thinking that this is just another “cookie cutter” therapy tool where I force you into some formula to create goals that I have decided for you ahead of time. The reality is that during this session, we will collaborate to discover what you would like to see differently and how we can work together to make that happen.

·         Specific. Feeling happier is great, but what does “happy” look like for you?

·         Measurable. Being able to measure a goal is important so we know if you are making progress.

·         Attainable. We want you to be able to accomplish your goals based on the resources you have available.

·         Realistic. We want to set you up for success in achieving your goal.

·         Time-bound. When do you want to accomplish the goal? Maybe your goal is short-term, or maybe it’s long-term.

So why use a formula for goals at all? Well, sometimes we have an idea of what we would like to see differently but are not quite sure how to get there. For example, it is not uncommon for people to want to lose some weight. Great. But we need to know how to go about that so we can see if we are making progress. That might include adding in exercising, cutting down on calories, substituting higher fat foods for more fruits and vegetables. There are many ways to get there. Maybe you want to reconnect with family or friends, be more active, find more joy in life, or just watch your child or grandchild play sports. By using the SMART goal formula, it allows us to make a concrete plan to help you be successful.

CBT-CP Exercise and Pacing Session

Session four of CBT-CP focuses on exercise and behavior pacing. Being more physically active may have already been a goal you set for yourself, but this session allows us to break things down step by step without feeling like you are overdoing it.  

Exercising with chronic pain

You have probably been told by many providers that you need to start exercising to help manage your chronic pain. And you have probably thought that this is an impossible and unrealistic task. Let’s talk a bit about the myths and reality of adding in some mild exercise and movement.

The myth about exercise and movement with chronic pain

·         Exercise will increase pain

·         Exercise must be intensive to matter

·         Exercise will cause additional damage to your injury or body

The reality about exercise and movement in cognitive behavioral therapy for chronic pain

·         Motion is lotion

·         Even if you haven’t exercised in years, it’s possible to find an exercise that works for you

·         Underactivity or not moving at all will actually increase pain

·         Starting with small, intentional movement is key

·         I will meet you where you are, if one minute of movement is where we start, then that sounds great to me

When we think of exercise, we often think of running, weight lifting, or hours spent at the gym. Intense exercises to get our hearts racing and work up a sweat. And sure, those are all forms of exercise. But when we are talking about incorporating exercise in chronic pain management, we are thinking more about gentle movement to begin regaining your strength. Thinking about exercising when you are experiencing chronic pain can be overwhelming and scary. Often, people have a fear that if they are active again that this will cause more damage and pain. Sometimes, it was an activity that caused the initial injury that led to the chronic pain, so it is understandable for people to feel as though movement is the enemy.

Hurt does not equal harm. Anytime we begin incorporating movement after we have been underactive, we are going to hurt a little. For example, if I work on the fourth floor of a building and have been taking the elevator daily for a year, it is going to hurt when I start taking the stairs. Any new exercise or movement may cause some soreness. But this does not mean that I have caused my body new damage or harm. It just means my body and muscles are reacting and adjusting to the change, and that is okay.

Exercise to incorporate in chronic pain management might include

·         Gentle stretching

·         Brief walks (one minute is better than zero minutes, so I am fine if we start there)

·         A peddler

·         Swimming

Exercise and movement can really be anything we decide. If you want to be able to just walk to the mailbox or go for a walk around the block, then that’s a great goal. Muscles are “use em or lose em”, so we just need to get them working a little bit at a time and find the right movement for you.

Pacing behavior with chronic pain

Growing up, you may have heard your parents or guardian tell you to “pace yourself!” when it came to running around the park or maybe when eating sweets. Well, in this session, I am going to ask you to pace yourself in your activities. And that might be frustrating to hear. I get it, when I want to get something done, I want to get it done. I don’t think about taking breaks throughout, and we often have a tendency to just “push through” things so we can check them off of the list. Even a person that does not experience chronic pain is going to feel it if they push through too many activities without taking a break. But with chronic pain especially, we need to have a balance, otherwise we get stuck in a vicious overactivity cycle.

Chronic pain overactivity cycle

1.      You engage in too much activity (we’ve all overdone it at some point)

2.      Your pain increases because of the excessive activity

3.      The increased pain leads to increased rest

4.      After a period of increased rest, you fall behind, and then you engage in too much activity again

And round and round you go. You have probably had days that you would consider to be “good” pain days and “bad” pain days. On good pain days (or perhaps just tolerable pain days), you may find yourself with a to do list a mile long that you are motivated to complete. Or maybe you just feel like everything has piled up and you need to push through because somebody has to do it. You might decide to start to clean the house, go grocery shopping, catch up on laundry, or maybe even get in some yard work on these days. After you have pushed yourself to get through those tasks, you likely end up “out for the count” for a few days owing to an increase in pain.

So how does pacing in CBT-CP work?

·         Pacing is based on time

·         Combining pacing with rest breaks allows activity to be spread out over time so you don’t overdo it

·         Pacing allows for increased cycles of activity and rest, so over the course of a few cycles, you are able to get more things done without “hitting a wall”

You may be wondering why we would base pacing on time versus pain. People with chronic pain often wait until they feel an increase in pain to take a break. But here’s the thing. If you wait until your pain increases, then you’ve already gone too far. The idea with pacing is that we have you stop an activity before the pain increases so we can avoid that overactivity cycle.

For example, if you have chronic lower back pain, standing to wash the dishes may be extremely difficult and lead to an increase in pain. With pacing, we can break it down into smaller steps. Maybe that includes standing and washing the dishes for 5-7 minutes, then sitting down for the next 7-10 minutes for a break. And you get to decide what that break looks like, so long as it is something that does not aggravate lower back pain. You can take an actual break where you sit and relax for a few minutes, or, it can be an active break. Sounds counter-intuitive, right? You can use your break time to engage in a different activity, such as sitting on the couch and folding the bath towels. Pacing is not necessarily about starting and stopping repeatedly, but rather preventing yourself from overdoing a certain activity that is going to increase your pain. After your break, you then engage in another “cycle” of pacing, where you are active again for a period of time and then take another break. As time goes on, we slowly increase the amount of active time.

Pacing isn’t just for chores. We can also use pacing for enjoyable activities and hobbies. When you have chronic pain, you often stop engaging in previously enjoyed activities because of the pain. Maybe playing an instrument, gardening, or painting increase your pain, so you avoid the activity altogether. With pacing, we can get you back to engaging in some of these activities one step at a time.

A month into treatment

So, if you’ve been following along, we’ve talked through the first month or so of treatment, which is a quarter of the way to making some positive changes to help manage your chronic pain. Stick with us over the next few weeks to learn more about CBT-CP and how it may be of benefit to you. Want to get started now? Schedule a consult today! Don’t forget, you can try some skills at any time by downloading the free Pain Coach App (here for Google Play) Pain Coach - Apps on Google Play  or (here for Apple) ‎Pain Coach by VA App - App Store.