http://informahealthcare.com/pgm ISSN: 0032-5481 (print), 1941-9260 (electronic) Postgrad Med, 2014; 127(2): 242–250 DOI: 10.1080/00325481.2015.1000230
ORIGINAL RESEARCH
Replication of a cognitive behavioral therapy for chronic pain group protocol by therapists in training David Cosio
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Pain Psychologist, Anesthesiology/Pain Clinic, Jesse Brown VA Medical Center, Chicago, IL, USA
Abstract
Keywords
According to the American Psychological Association (Division 12), there is strong, long-standing research support for cognitive behavioral therapy (CBT) to treat chronic pain. Furthermore, metaanalytic comparisons have shown CBT to be highly efficacious. However, not all researchers agree with this conclusion. The purpose of the current pilot study was to determine whether a CBT outpatient, group-based treatment facilitated by junior therapists benefited veterans who suffer from mixed idiopathic, chronic, noncancer pain, thus replicating results from effective CBT programs from the past. A sample of 46 veterans aged 33 to 81 years with chronic, noncancer pain who participated in an outpatient CBT pain group therapy protocol at a Midwestern Veterans Affairs Medical Center between November 3, 2009, and September 2, 2010 was evaluated. All participants completed a pre- and postintervention assessment. Paired-samples t tests were conducted to evaluate the impact of the program on veterans’ scores on assessment measures. No significant difference was found between the pre- and posttest primary outcome measures of pain intensity. A significant difference was established between the pre- and posttest secondary outcome measure of catastrophizing. However, there were no other significant differences found among the remaining pre- and posttest secondary outcome measures of pain interference, disability, and psychological distress. Training junior therapists on how to use CBT protocols may be enhanced by paying greater attention to what mechanisms are responsible for the desired outcomes among veterans with chronic pain.
Chronic pain, cognitive behavioral therapy, group psychotherapy, junior therapists, veterans
Introduction Cognitive behavioral therapy (CBT) has strong, long-standing research support to treat chronic, noncancer pain according to the American Psychological Association [1]. Historically, CBT has been shown to be highly efficacious in the treatment of fibromyalgia [2], headaches [3], low back pain [4,5], osteoarthritic knee pain [6], and rheumatoid arthritis pain [7]. Furthermore, meta-analytic comparisons have substantiated these findings and have proven CBT for pain management to be a skill of utmost importance to trainees and their supervisors [8,9]. Cognitive behavioral therapy for pain management is based upon the cognitive-behavioral model of pain [10]. This model is grounded on the notion that pain is a complex experience that is influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior [11]. Cognitive behavioral therapy for pain management has 3 components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills [12]. Cognitive behavioral therapy interventions engage individuals in an active coping process aimed at changing maladaptive thoughts and behaviors that can serve to
History Received 13 June 2014 Accepted 26 June 2014 Published online 19 January 2015
maintain and exacerbate the experience of chronic pain. Past research has shown that CBT for pain management decreases pain intensity [13,14], increases readiness to adopt a self-management approach [15], decreases pain severity and interference [16], decreases functional disability [2,4], decreases catastrophizing [17], creates changes in coping [18], and decreases levels of distress [2,13] among individuals with chronic pain. Empirically based practices (EBPs) are specific psychological treatments that have been consistently shown in controlled clinical research to be effective for ‡ 1 mental or behavioral health conditions. The Department of Veterans Affairs (VA) is receptive to the dissemination of EBPs, and is committed to making them widely available to veterans with mental and behavioral health conditions when they are shown to be effective [19]. Cognitive behavioral therapy for pain management is a specific EBP being nationally disseminated in the VA system. Pain is one of the most common reasons veterans consult with their primary care providers and is one of the most prevalent symptoms reported by returning veterans [20]. In fact, almost half of patients within VA health care settings experience pain on a regular
Correspondence: David Cosio, PhD, Anesthesiology/Pain Clinic, Jesse Brown VA Medical Center, 820 South Damen Avenue, #124, Chicago, IL 60612, USA. Tel: +1 312 569 8703. Fax: +1 312 569 8120. E-mail: [email protected] 2015 Informa UK Ltd.
Replication of CBT protocol in veterans with chronic pain
DOI: 10.1080/00325481.2015.1000230
Awareness Knowledge and beliefs • Condition specific • Knowledge • Personal perceptions
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Skills building Self-regulation skill and ability • Goal setting • Self-monitoring and reflective listening • Decision making • Planning and plan enactment • Self-evaluation • Management of emotional response Maintenance Social facilitation • Influence • Support
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Materials and methods Pain education school
Cognitive behavioral pain group
Participants
Engagement in selfmanagement behavior
Health status
Peer support group
Figure 1. Integrated theory of health behavior change model.
basis [21]. Previous research has found that past military service may contribute to hypersensitivity to pain symptoms [22-24]. Cognitive behavioral therapy has been investigated in the past with veterans in conjunction with aerobic exercise for Gulf War illness [25] and those with comorbid chronic pain and posttraumatic stress disorder [26]. However, research investigating the use of group-based CBT with veterans who suffer from mixed idiopathic, chronic, noncancer pain is scarce. Group-based CBT may be best facilitated with the use of empirically validated techniques collected into one convenient handbook. A treatment manual, from a research perspective, is described as an assortment of structured interventions in the context of an articulated theory of change [27-29]. There are several potential advantages in utilizing treatment manuals in research and practice, including enhancing the internal validity of research studies, increasing the ability to replicate research methods, and facilitating training of trainees [29]. In addition, a gap exists between research and the way psychotherapy is practiced in the real world [30-32]. In fact, the literature has indicated that master’s-level clinicians are predominately providing direct patient care [28]. Thus, there is a need for research on translating empirically supported, manualized therapies into user-friendly, population-based practices. The results of clinical trials and clinical experience could help inform adaptations to better suit the needs of veterans with chronic pain. The current pilot study tested the following hypotheses: that veterans who elected to participate in a manualized, CBT pain management group facilitated by junior therapists would report (1) a decrease in pain severity (primary outcome); (2) an increase in readiness to adopt a selfmanagement approach and wellness-focused coping strategies; and (3) a decrease in pain interference, functional disability, catastrophizing thoughts, illness-focused coping strategies, and levels of psychological distress (secondary outcomes) upon completion of the intervention.
Fifty-two veterans originally registered to participate in a 12-week, CBT pain management group in an outpatient pain clinic at a Midwestern VA Medical Center between November 3, 2009, and September 2, 2010. Forty-six veterans (88%) between the ages of 33 and 81 years completed the intervention; 76% were African American, 17% were Caucasian, and 7% identified as being Hispanic/Latino. Most of the participants were male (93%), with a small sample of female veterans (7%), which is reflective of the typical veteran profile [33]; 46% were aged 35 to 54 years, and the youngest returning veterans (aged 18–34 years) were the least represented age group (2%). Individuals diagnosed solely with cancer pain were excluded from the current pilot study. Otherwise, there were no other exclusion criteria used during this investigation. Procedure Prior to participating in the pain management groups, the veterans had to complete a preliminary pain health education program [34]. The program consisted of an introduction class followed by 12 one-hour classes offered weekly that were led by guest speakers from > 20 different disciplines within the facility. On average, the duration between the termination of the education groups and the initiation of the current CBT groups was £ 1 month. The preliminary pain health education program served as an avenue to provide awareness according to the Integrated Theory of Health Behavior Change (ITHBC) model [35], which purports that health behavior change can be enhanced by fostering knowledge and beliefs (awareness), increasing self-regulation skills and abilities (skill building), and enhancing social facilitation (maintenance). Thus, the CBT group provided the skill building necessary for health behavior change (Figure 1). Participants from the pain education program had the option to participate in the CBT intervention. The names of potential candidates who elected to participate for the next available group offering were collected. Each veteran in this sample was subsequently scheduled for 12 weeks of 1-hour CBT group sessions. Veterans voluntarily participated in the pain management groups and were free to withdraw at any time. Veterans were given free parking validation/transportation reimbursement if they were qualified for such programs and attended the sessions. The current pilot study protocol was reviewed and approved by the affiliated university’s institutional review board and the VA’s Research and Development office. A waiver of informed consent was granted due to the retrospective nature of the study and the minimal risk to subjects who participated. Intervention Cognitive behavioral therapy is a structured, time-limited, present-focused approach to psychotherapy that helps patients develop strategies to modify dysfunctional thinking patterns and maladaptive behaviors in order to assist them in resolving current problems. The 12-week CBT pain group was
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Group • • • • Group • • • • • Group • • • • Group • • • • • • Group • • • • Group • • • • • • •
1: Introduction to chronic pain Set group rules The impact of pain The general goals of treatment Set S.M.A.R.T. goal 2: Theories of pain/ diaphragmatic breathing Battle buddy Review last week′s session Discuss theories of pain Introduce relaxation techniques Practice diaphragmatic breathing 3: Progressive muscle relaxation/ guided imagery Battle buddy Review last week′s session Introduce progressive muscle relaxation Introduce visual imagery exercises 4: Automatic thoughts and pain Battle buddy Review last week′s session Explore how automatic thoughts lead to emotions Explore the relationship between emotion and pain Review a list of cognitive errors Introduce ABC model 5:Cognitive restructuring Battle buddy Review last week′s session Explore the connection between negative thoughts and pain Introduce cognitive restructuring 6: Stress management Battle buddy Review last week′s session Define stress Explain the fight/fight response Review common sources of stress Discuss the relationship between stress and pain Examine ways to decrease strss
Group • • • • • Group • • • • Group • • • • • • • Group • • • • Group • • • • • Group • • • • •
7: Time-based pacing Battle buddy Review last week′s session Introducing time-based pacing Discuss steps to appropriate pacing Review pacing techniques 8: Pleasant activity scheduling Battle buddy Review last week′s session Identify pleasant activites Schedule activites during the next week 9: Anger Management Battle buddy Review last week′s session Define anger Discuss the relationship between anger and pain Introduce anger management Discuss response styles Introduce assertive responding 10: Sleep hygiene Battle buddy Review last week′s session Discuss the necessity of sleep Review ways to improve sleep 11: Relapse prevention/ flare-up planning Battle buddy Review last week′s session Discuss relapse prevention and flare-up planning Review stages of flare-up management Creat a relapse prevention plan 12: Post-test/ feedback session Share progress of S.M.A.R.T. goal Review what learned in past 11 weeks All members to provide feedback Termination Last minute business
Figure 2. Session-by-session breakdown of CBT for chronic pain protocol [36].
adapted from a manualized “Treatments That Work” protocol [36]. The protocol reviews pain education topics, such as chronic pain syndrome and theories of pain. The protocol introduces cognitive concepts, such as automatic thinking and cognitive restructuring, and behavioral strategies, such as relaxation techniques (diaphragmatic breathing, progressive muscle relaxation, and visual imagery), time-based activity pacing, and pleasant activity scheduling (Figure 2). Cognitive behavioral therapy is typically limited to 10 weekly treatment sessions and is administered individually, but can be delivered in a group format (J. McKellar, personal communication). Cognitive behavioral therapy for chronic pain has been disseminated nationwide by the VA Office of Mental Health Services and National Pain Management Program Office. Group therapy for chronic pain management has become a common treatment format [37]. The Otis manual [36] was adapted to a group format in order to make the intervention more time efficient for the therapists in training, to provide a mechanism for veterans to learn coping skills from others, to help veterans realize they are not alone, and to help veterans gain valuable social support from others. Several noteworthy adaptations were made to the current manual: (1) Each session began with a “Battle Buddy” check-in, where members coupled with another veteran, reviewed their progress with
their SMART (simple, measurable, attainable, realistic, and timely) goals and elicited support and comments from the other member; (2) each session was facilitated by the use of a dry-erase board and flipchart so all the group members could follow along as examples of concepts were reviewed; and (3) during each session, members were encouraged to support other members by providing suggestions for other techniques that they found effective. The sessions beyond the 10-week standard being evaluated in the current pilot study are based on additional anger management and stress management themes deemed especially important within the veteran population. Participants were seen on a weekly basis (or biweekly if there was a holiday on a meeting day). Psychology trainee therapists cofacilitated the groups with a licensed psychologist identified as a CBT training consultant. Employing trainee therapists to conduct the current groups is representative of how master’slevel clinicians are responsible for more and more direct patient contact [28]. Past research has shown that trainee therapists with limited training in behavioral protocols produce positive outcomes [38]. The supervision and teaching role of a psychologist takes into account individual and cultural differences of the members of the health care team and of the participants.
Replication of CBT protocol in veterans with chronic pain
DOI: 10.1080/00325481.2015.1000230
Month 0
Veterans signed-up to participate in CBT groups (n = 52) Dropouts Veteran discontinued (n = 6) Veterans elected to participate in CBT groups (n = 46)
Month 12
Veterans completed CBT group (n = 46)
Dropouts Veteran incompletes (n = 5)
Entered into analysis using BOCF (n = 46)
Figure 3. Flowchart of study participants.
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Outcome measures As part of the introduction and conclusion of the CBT group, all participants completed a pre- and postintervention assessment. The preintervention assessment was completed at the beginning of the first session and the postintervention assessment was completed at the end of the last session (the 12th) of the protocol. The assessments included a battery of measures, including the Readiness Questionnaire (M. Jensen, personal communication), the Brief Pain Inventory–Short Form (BPI) [39], the Oswestry Disability Index (ODI) [40], the Coping Strategies Questionnaire–Catastrophizing Scale (CSQ) [41], the Chronic Pain Coping Inventory–Short Form (CPCI) [42], and the Brief Symptom Inventory-18 (BSI-18) [43]. These key psychological tests were chosen based on their brevity and ease of administration, as well as their reliability and validity in prior research [44]. Readiness questionnaire. Participants were asked to select 1 statement out of 5 possibilities that best describes their stage of readiness to adopt a self-management approach to their pain. Scores ranged from 1 to 5, with higher numbers indicating a more advanced stage of readiness to adopt a selfmanagement approach to their pain. The temporal stability for this measure in previous research was 0.63 [45], but for the current pilot study it was 0.14. Thus, the instrument was eliminated from the analysis due to poor internal consistency. Brief pain inventory–short form (BPI). The BPI asks patients to rate their pain at the time of responding to the questionnaire (pain severity right now). The BPI also asks for ratings of the degree to which pain interferes with 7 daily activities. The internal consistency of the BPI in past research ranged from a = 0.80 to a = 0.87 for pain severity and from a = 0.89 to a = 0.92 for pain interference. Chronbach’s alpha for the current pilot study was a = 0.84 for pain severity and a = 0.85 for pain interference. Oswestry disability index (ODI). The ODI is used to measure a patient’s permanent functional disability. The ODI consists of 10 questions in which the patient selects the answer that best describes their typical pain or limitations within the past 2 weeks. The test has been used for 25 years and is considered the gold standard of functional outcome tools. The internal consistency of the ODI in past research was a = 0.85. Chronbach’s alpha for the current pilot study was a = 0.74.
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Coping strategies questionnaire–catastrophizing scale (CSQ). The CSQ uses a 0 to 5 Likert scale to rate 5 items that measure negative self-statements, castastrophizing thoughts, and ideations about one’s pain. Data analysis has shown that the Catastrophizing Scale was internally reliable (a = 0.81) and had high test-retest reliability over 6 months. Chronbach’s alpha for the current pilot study was a = 0.87. Chronic pain coping inventory–short form (CPCI). Eight strategies for coping with chronic pain were assessed using the 16-item short form of the CPCI. Participants were asked to rate each coping strategy by how many days they engaged in the activity in the past week. The validity of the CPCI has previously been established, and the median internal consistency ranges from a = 0.70 to a = 0.94. Chronbach’s alpha for the current pilot study was lower (a = 0.62). Thus, the instrument was eliminated from the analysis due to poor internal consistency. Brief symptom inventory-18 (BSI-18). The BSI-18 requires respondents to rate their level of distress over the past 7 days using a 5-point Likert scale. The BSI-18 provides a global distress score that is calculated based on all 18 items. The internal consistency of the BSI was reported to be a = 0.89. Chronbach’s alpha for the current pilot study was a = 0.85. Analytic methods The current pilot study used a quasi-experimental, singlegroup, pre/posttest design. A univariate analysis of variance (ANOVA) and independent samples t tests identified differences on demographic and outcome variables at baseline. Chi-Squares were utilized to compare complete versus noncomplete assessments by demographic characteristics. Paired-samples t tests were conducted to evaluate the impact of the intervention on veterans’ scores on the primary outcome variable of pain intensity and the secondary variables of pain interference, functional disability, catastrophizing, and levels of psychological distress. Outcome studies used an intention-to-treat analysis. A power analysis was calculated with an anticipated effect size (Cohen’s d) of 0.80, a probability level £ 0.05, and a total sample size of n = 46. The observed statistical power (1-tailed hypothesis) was equal to 0.85. For the 5 cases missing data at postintervention, a baseline-observation carried-forward approach was used [46]. SPSS version 20 was used for all outcome analyses. The results are presented using Transparent Reporting of Evaluations with Nonrandomized Designs guidelines.
Results Baseline characteristics Of the 46 veterans who elected to participate in the CBT pain group, 41 (89%) completed both the pre- and postintervention measure (Figure 3). The most frequent reason for participant withdrawal was unwillingness to complete the postintervention questionnaire. Only 3 of 4 groups witnessed departures.
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The third and fourth groups had > 1 member leave. Past research has shown that when a group member fails to benefit from treatment, or leaves prematurely due to dissatisfaction, others in the group are likely to follow [47]. Veterans had mixed idiopathic chronic pain conditions, including 57% reporting “head/neck/thorax/shoulder” pain, 83% reporting “trunk/abdomen/back/buttock” pain, and 78% reporting “legs/thighs/feet” pain delineated from the diagrams on the BPI. The reported pain score at baseline in the current pilot study was 5.98 (moderate pain). The participants reported being in the severe level (mean [M] = 49.17) of disability as measured by the ODI, and reported 42% of pain relief at baseline during the prior 24 hours. Participants reported being in the preparation stage (M = 3.11) of readiness to adopt a selfmanagement approach before beginning the intervention. Veterans engaged in a moderate level of catastrophizing (M = 12.13), and low levels of illness-focused (~ 2.02 days/ week) and wellness-focused (~ 1.92 days/week) coping strategies. At baseline, veterans reported poor overall emotional health (M = 23.20) when compared to community norms. Veterans who completed both assessments (n = 41) on average attended 10 group sessions, whereas noncompleters (n = 5) attended 6 sessions, which was halfway through the protocol and significantly different (P = 0.00) from completers. Differences at preintervention. At preintervention, veterans who completed the intervention were less likely to engage in wellness-focused coping strategies at baseline (M = 18.49, standard deviation [SD] = 6.89) compared to noncompleters (M = 24.80, SD = 4.45). Veterans who completed the intervention were more likely to engage in catastrophizing reactions (M = 12.73, SD = 6.92) then noncompleters (M = 7.20, SD = 3.11). Examples of such responses include, “I feel I can’t go on,” “I feel I can’t stand it anymore,” and “I feel my life isn’t worth living [41].” These findings are not surprising, as the aim of the CBT intervention is to decrease catastrophizing thoughts and increase wellness-focused behaviors (ie, relaxation). Noncompleters appear to have been adequate in both skills at baseline, which may explain their premature departure from the intervention. Differences among CBT Co-Led groups Four groups were conducted during the 1-year period of the current research study. Each group was conducted by a different combination of licensed psychologist and junior therapist in training. At baseline, there were no significant differences found among the groups in measures of readiness to adopt a self-management approach (P = 0.92), functional disability (P = 0.88), catastrophizing (P = 0.36), global distress (P = 0.12), and illness-focused (P = 0.31) and wellnessfocused (P = 0.56) coping (Table I). These findings suggest that the groups were the same at preintervention in terms of client factors. There were no significant differences found between pre- and postintervention assessments for the 4 groups: Wilks’ l = 0.74, F(4, 12) = 1.05, P = 0.41. Therefore, we can assume that there were no therapist effects.
Postgrad Med, 2014; 127(2):242–250
Intervention outcome The primary outcome measure for the current pilot study was pain severity. There was no significant mean difference found between pre- and postintervention assessments of the primary outcome measure of pain severity (right now), t(45) = 0.60, P = 0.55. In terms of secondary outcome measures, there was a significant mean difference found between the pre- and postsecondary outcome measure of catastrophizing, t(45) = 2.05, P = 0.05, d = 0.24, but not for any of the other secondary measures of pain interference, t(45) = –0.56, P = 0.58; disability, t(45) = 1.53, P = 0.13; and global psychological distress, t(45) = 1.67, P = 0.10 (Table II).
Discussion Evidence of CBT’s effective use in group format among veterans with chronic, noncancer pain is limited. In order to conduct research aimed at demonstrating an intervention to be effective, traditional research designs require a specific, identifiable, replicable treatment [48,49]. Treatment manuals are an important aspect of the move toward empirically supported practice [28], especially in the VA system. It is imperative that other research teams replicate outcome findings of these manualized interventions with other populations because treatment studies are often conducted by the team that developed the treatment [29]. Furthermore, there are a number of different treatments that can be classified as CBT interventions (eg, motivational interviewing, mindfulnessbased, acceptance-based, etc), but each may have its own emphasis, or mechanism. In addition, the utilization of treatment manuals has been found to be an important issue facing health practitioners [27,50]. The results of the current pilot study suggest that the CBT groups for chronic pain failed to decrease pain intensity and functional disability—findings that are inconsistent with past research [2,4,13,14]. One reason may be that the current pilot study only used pre- and postintervention assessments, whereas CBT tends to do better at follow-up. A second reason may be that the veterans may be physically doing more but the pain intensity remains the same. Yet another reason may be that veterans who suffer from chronic pain may be a unique group of individuals due to the dualism of active duty and civilian life [51]. Of note, the current sample of veterans seek services at a medical center with the third highest level of homelessness, fourth highest level of addictions, and fifth highest level of severe mental illness of the complex 1B VA facilities in the nation (P. Fore, Mental Health Service Line meeting, April 9, 2012, personal communication). Therefore, a better adjustment to continuing pain may have proven to be a more realistic goal than actual pain reduction and a decline in functional disability. Despite these considerations, pain providers should continue to encourage veterans to engage in a multidisciplinary approach to pain management, and increase their self-management and their use of the lessons learned during the pain education program. The findings from the current pilot study suggest that the CBT groups may have had a small effect on catastrophizing. This finding corroborates past research, which has found that
2.90 1.449 3.17 1.337 3.30 1.494 3.07 1.141
4.00 – 3.25 1.708 3.18 1.286 2.80 1.474 3.00 1.095 4.00 0.000
3.34 1.235 2.50 1.195 2.00 1.732
0.16
0.54
2.71
0.92
0.75
0.08
P
50.80 11.71 50.67 12.51 46.20 16.21 48.86 16.36
54.00 – 51.00 4.163 49.88 13.16 53.47 13.13 37.00 11.65 44.00 29.46
48.91 15.88 51.00 5.76 47.33 7.02
M (SD)
F
48.56 14.36 58.00 4.000
M (SD)
M (SD)
0.85
0.29
P
49.61 14.69 45.60 7.668
0.20
1.07
t
3.12 1.327 3.00 1.225
3.16 1.290 2.33 1.528
Significant at P < 0.01 level. Significant at P < 0.05 level.
b
a
4
3
2
Group 1
75+
65–74
55–64
45–54
35–44
Age 25–34
Hispanic
Caucasian
Race African Am.
Noncompleters
Assessments Completers
Female
Sex Male
M (SD)
Readiness
0.23
1.35
0.10
F
0.60
1.13
t
Disability
0.88
0.26
0.91
P
0.55
0.27
P
Table I. Baseline outcome measure scores by patient characteristics (n = 46).
12.50 6.964 14.33 5.433 9.100 7.866 12.14 6.916
15.00 – 8.75 7.890 13.71 6.536 13.13 7.170 8.83 4.309 8.33 9.713
12.23 6.817 10.88 7.864 14.33 5.033
M (SD)
12.73 6.921 7.20 3.114
11.65 6.644 19.00 6.557
M (SD)
1.09
0.94
0.29
F
3.14
1.85
t
Catastrophizing
0.36
0.47
0.75
P
a
0.01
0.07
P
23.10 14.04 24.58 11.93 15.20 10.49 27.79 13.09
15.00 – 22.25 14.25 24.71 12.65 22.67 13.05 24.67 11.40 18.33 23.63
24.17 13.77 23.25 9.161 11.67 4.933
M (SD)
23.56 13.53 20.20 5.975
22.56 13.00 32.33 8.505
M (SD)
2.04
0.22
1.31
F
0.55
1.28
t
Global distress
0.12
0.95
0.28
P
0.59
0.21
P
13.65 3.432 12.25 5.238 9.95 4.902 12.46 3.815
16.00 – 13.50 3.028 13.03 4.881 11.17 4.224 11.00 4.837 10.83 4.856
12.13 4.474 12.63 4.619 10.67 4.856
M (SD)
12.20 4.637 11.50 2.424
1.25
0.61
0.21
F
0.3
0.02
t
Illness coping
12.12 4.534 12.167 3.329
M (SD)
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0.31
0.69
0.82
P
0.75
0.99
P
19.95 6.878 19.88 7.592 20.65 6.741 16.96 6.707
24.00 – 26.63 5.170 17.74 8.700 16.90 4.940 21.50 3.937 22.50 3.279
19.79 7.157 16.31 6.530 19.67 4.252
M (SD)
18.49 6.890 24.80 4.453
19.31 7.129 17.17 2.021
M (SD)
0.70
1.96
1.96
F
1.99
0.52
t
0.56
0.11
0.11
P
b
0.05
0.61
P
Wellness coping
DOI: 10.1080/00325481.2015.1000230
Replication of CBT protocol in veterans with chronic pain 247
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Postgrad Med, 2014; 127(2):242–250
Table II. Paired t tests of outcome measures of veterans (n = 46).
Variables
a
Pain severity right now Pain interference Disability Catastrophizing Global distress a
Pre-M (SD)
Post-M (SD)
M diff (SD)
5.98 2.038 3.91 1.068 49.17 14.10 12.13 6.817 23.20 12.92
5.80 2.247 4.01 0.940 46.91 13.98 10.46 7.229 20.57 12.20
0.174 1.970 –0.103 1.244 2.261 10.03 1.674 5.534 2.630 10.71
95% CIs t
P value
Lower
Upper
0.599
0.552
–0.411
0.759
–0.56
0.576
–0.473
0.266
1.529
0.133
–0.717
5.239
0.031
3.317
–0.551
5.812
2.052
0.046
1.665
0.103
b
In each case a decrease in scores suggests improvement. Significant at P £ 0.05 level.
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b
a reduction in catastrophizing mediates the outcome of CBT for chronic pain [17]. In fact, the construct of catastrophizing was originally found to mediate the outcome of CBT when compared with a wait-list control group [52]. Even though the treatment effect was not impressive (d = 0.24) and significant changes in psychological adjustment were not witnessed after completing the CBT intervention, the small effect size may translate into a bigger population change. The current pilot study has some limitations. This study used a quasi-experimental, single-group, pre/posttest design rather than a randomized controlled trial with a control group. There are 2 reasons why a control group was deemed unnecessary for the current pilot study: (1) the ethical consideration of leaving veterans without treatment, and (2) the use of a consistent intervention with prior implementation as an acceptable method. The current pilot study meets these requirements through its use of a manualized, empirically supported intervention [29]. This study also explores the benefits of programming when based on patient self-selection, which is aligned with the spirit of autonomy expected from self-management outlined in the ITHBC model. However, this study did witness multiple departures in the groups, which highlights the importance of social factors in chronic, noncancer pain and the need for group treatment to capitalize on these social influences [47]. The participants in the current CBT group intervention showed no changes in symptom severity or functional status. One explanation may be that this study solely relied on selfreport data, which may foster uncertainty. For example, the temporal stability of some of the measures (readiness and coping questionnaires) was questionable and thus eliminated from the analyses. It is also possible that the ITHBC model used in the course of treatment (which includes pain education) may account for the high completion rate for the CBT pain groups and have instigated the change process, which was later detected by the assessment measures utilized in this study. The self-regulation skills and abilities of all veterans with chronic, noncancer pain may also differ as the current sample was predominately African American and did not include a representative sample of the youngest returning veterans (aged 18 to 34 years) when compared with the typical veteran profile [33]. The current findings may appear
seemingly different from epidemiological data on veterans with pain, but may provide information about the psychosocial distinctiveness of pain experiences in a marginalized veteran population. Despite these limitations, the current pilot study is the first known replication of an effective, CBT group protocol facilitated by junior therapists and catered to veterans who suffer from mixed idiopathic, chronic, noncancer pain conditions. To date, Division 12 has recognized CBT only for chronic low back pain, chronic headache, fibromyalgia (multicomponent), and rheumatologic pain (multicomponent) [1]. The current study included veterans who suffer from back pain, neck pain, extremity pain, head pain, and fibromyalgia/soft tissue pain. Past research in this area has predominately used samples consisting of civilians with chronic pain conditions and licensed providers.
Conclusion Cognitive behavioral therapy for pain management has strong, long-standing research support, but some researchers have suggested that Division 12 of the American Psychological Association has “not set too high of a bar in terms of standards” (K. Vowles, personal communication at the American Pain Society, May 2, 2014). In fact, research investigating CBT interventions has been shown to have “weak effects on pain, moderate effects on mood, and negligible effects on disability” (M. Sullivan, personal communication at the American Pain Society, May 2, 2014). The findings from the current pilot study also illuminate the need for teachers, supervisors, and other providers involved in the professional development of junior therapists to pay greater attention to what mechanisms are responsible for the desired outcomes (eg, catastrophizing) and what kind of treatment is the best for a veteran with chronic pain (either group or individual CBT interventions). This may be accomplished by translating current manuals into user-friendly core elements.
Acknowledgments An earlier version of this paper was presented at the National Pain Week 2012 conference and the regional American Pain Society–Midwest conference in 2012. That version of this
DOI: 10.1080/00325481.2015.1000230
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paper was modified to reflect the comments received at the conferences. The author would like to thank all the veterans and junior therapists/supervisors who made this research possible, especially Bonnie Yap, Scott Sperling, and Susan Payvar. The author would also like to thank the staff members at the Jesse Brown VA Medical Center anesthesiology/pain clinic department for their vision and ongoing support of the pain psychology training program. Permission was obtained from the Department of Symptom Research to use the BPI in a publication and research trial. Permission was obtained from MAPI Research Trust, Lyon, France, to use the ODI in a publication and research trial. Permission to use the BSI-18 is inherent in the qualified purchase of the test materials.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
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ORIGINAL RESEARCH
Replication of a cognitive behavioral therapy for chronic pain group protocol by therapists in training David Cosio
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Pain Psychologist, Anesthesiology/Pain Clinic, Jesse Brown VA Medical Center, Chicago, IL, USA
Abstract
Keywords
According to the American Psychological Association (Division 12), there is strong, long-standing research support for cognitive behavioral therapy (CBT) to treat chronic pain. Furthermore, metaanalytic comparisons have shown CBT to be highly efficacious. However, not all researchers agree with this conclusion. The purpose of the current pilot study was to determine whether a CBT outpatient, group-based treatment facilitated by junior therapists benefited veterans who suffer from mixed idiopathic, chronic, noncancer pain, thus replicating results from effective CBT programs from the past. A sample of 46 veterans aged 33 to 81 years with chronic, noncancer pain who participated in an outpatient CBT pain group therapy protocol at a Midwestern Veterans Affairs Medical Center between November 3, 2009, and September 2, 2010 was evaluated. All participants completed a pre- and postintervention assessment. Paired-samples t tests were conducted to evaluate the impact of the program on veterans’ scores on assessment measures. No significant difference was found between the pre- and posttest primary outcome measures of pain intensity. A significant difference was established between the pre- and posttest secondary outcome measure of catastrophizing. However, there were no other significant differences found among the remaining pre- and posttest secondary outcome measures of pain interference, disability, and psychological distress. Training junior therapists on how to use CBT protocols may be enhanced by paying greater attention to what mechanisms are responsible for the desired outcomes among veterans with chronic pain.
Chronic pain, cognitive behavioral therapy, group psychotherapy, junior therapists, veterans
Introduction Cognitive behavioral therapy (CBT) has strong, long-standing research support to treat chronic, noncancer pain according to the American Psychological Association [1]. Historically, CBT has been shown to be highly efficacious in the treatment of fibromyalgia [2], headaches [3], low back pain [4,5], osteoarthritic knee pain [6], and rheumatoid arthritis pain [7]. Furthermore, meta-analytic comparisons have substantiated these findings and have proven CBT for pain management to be a skill of utmost importance to trainees and their supervisors [8,9]. Cognitive behavioral therapy for pain management is based upon the cognitive-behavioral model of pain [10]. This model is grounded on the notion that pain is a complex experience that is influenced by its underlying pathophysiology and the individual’s cognitions, affect, and behavior [11]. Cognitive behavioral therapy for pain management has 3 components: a treatment rationale, coping skills training, and the application and maintenance of learned coping skills [12]. Cognitive behavioral therapy interventions engage individuals in an active coping process aimed at changing maladaptive thoughts and behaviors that can serve to
History Received 13 June 2014 Accepted 26 June 2014 Published online 19 January 2015
maintain and exacerbate the experience of chronic pain. Past research has shown that CBT for pain management decreases pain intensity [13,14], increases readiness to adopt a self-management approach [15], decreases pain severity and interference [16], decreases functional disability [2,4], decreases catastrophizing [17], creates changes in coping [18], and decreases levels of distress [2,13] among individuals with chronic pain. Empirically based practices (EBPs) are specific psychological treatments that have been consistently shown in controlled clinical research to be effective for ‡ 1 mental or behavioral health conditions. The Department of Veterans Affairs (VA) is receptive to the dissemination of EBPs, and is committed to making them widely available to veterans with mental and behavioral health conditions when they are shown to be effective [19]. Cognitive behavioral therapy for pain management is a specific EBP being nationally disseminated in the VA system. Pain is one of the most common reasons veterans consult with their primary care providers and is one of the most prevalent symptoms reported by returning veterans [20]. In fact, almost half of patients within VA health care settings experience pain on a regular
Correspondence: David Cosio, PhD, Anesthesiology/Pain Clinic, Jesse Brown VA Medical Center, 820 South Damen Avenue, #124, Chicago, IL 60612, USA. Tel: +1 312 569 8703. Fax: +1 312 569 8120. E-mail: [email protected] 2015 Informa UK Ltd.
Replication of CBT protocol in veterans with chronic pain
DOI: 10.1080/00325481.2015.1000230
Awareness Knowledge and beliefs • Condition specific • Knowledge • Personal perceptions
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Skills building Self-regulation skill and ability • Goal setting • Self-monitoring and reflective listening • Decision making • Planning and plan enactment • Self-evaluation • Management of emotional response Maintenance Social facilitation • Influence • Support
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Materials and methods Pain education school
Cognitive behavioral pain group
Participants
Engagement in selfmanagement behavior
Health status
Peer support group
Figure 1. Integrated theory of health behavior change model.
basis [21]. Previous research has found that past military service may contribute to hypersensitivity to pain symptoms [22-24]. Cognitive behavioral therapy has been investigated in the past with veterans in conjunction with aerobic exercise for Gulf War illness [25] and those with comorbid chronic pain and posttraumatic stress disorder [26]. However, research investigating the use of group-based CBT with veterans who suffer from mixed idiopathic, chronic, noncancer pain is scarce. Group-based CBT may be best facilitated with the use of empirically validated techniques collected into one convenient handbook. A treatment manual, from a research perspective, is described as an assortment of structured interventions in the context of an articulated theory of change [27-29]. There are several potential advantages in utilizing treatment manuals in research and practice, including enhancing the internal validity of research studies, increasing the ability to replicate research methods, and facilitating training of trainees [29]. In addition, a gap exists between research and the way psychotherapy is practiced in the real world [30-32]. In fact, the literature has indicated that master’s-level clinicians are predominately providing direct patient care [28]. Thus, there is a need for research on translating empirically supported, manualized therapies into user-friendly, population-based practices. The results of clinical trials and clinical experience could help inform adaptations to better suit the needs of veterans with chronic pain. The current pilot study tested the following hypotheses: that veterans who elected to participate in a manualized, CBT pain management group facilitated by junior therapists would report (1) a decrease in pain severity (primary outcome); (2) an increase in readiness to adopt a selfmanagement approach and wellness-focused coping strategies; and (3) a decrease in pain interference, functional disability, catastrophizing thoughts, illness-focused coping strategies, and levels of psychological distress (secondary outcomes) upon completion of the intervention.
Fifty-two veterans originally registered to participate in a 12-week, CBT pain management group in an outpatient pain clinic at a Midwestern VA Medical Center between November 3, 2009, and September 2, 2010. Forty-six veterans (88%) between the ages of 33 and 81 years completed the intervention; 76% were African American, 17% were Caucasian, and 7% identified as being Hispanic/Latino. Most of the participants were male (93%), with a small sample of female veterans (7%), which is reflective of the typical veteran profile [33]; 46% were aged 35 to 54 years, and the youngest returning veterans (aged 18–34 years) were the least represented age group (2%). Individuals diagnosed solely with cancer pain were excluded from the current pilot study. Otherwise, there were no other exclusion criteria used during this investigation. Procedure Prior to participating in the pain management groups, the veterans had to complete a preliminary pain health education program [34]. The program consisted of an introduction class followed by 12 one-hour classes offered weekly that were led by guest speakers from > 20 different disciplines within the facility. On average, the duration between the termination of the education groups and the initiation of the current CBT groups was £ 1 month. The preliminary pain health education program served as an avenue to provide awareness according to the Integrated Theory of Health Behavior Change (ITHBC) model [35], which purports that health behavior change can be enhanced by fostering knowledge and beliefs (awareness), increasing self-regulation skills and abilities (skill building), and enhancing social facilitation (maintenance). Thus, the CBT group provided the skill building necessary for health behavior change (Figure 1). Participants from the pain education program had the option to participate in the CBT intervention. The names of potential candidates who elected to participate for the next available group offering were collected. Each veteran in this sample was subsequently scheduled for 12 weeks of 1-hour CBT group sessions. Veterans voluntarily participated in the pain management groups and were free to withdraw at any time. Veterans were given free parking validation/transportation reimbursement if they were qualified for such programs and attended the sessions. The current pilot study protocol was reviewed and approved by the affiliated university’s institutional review board and the VA’s Research and Development office. A waiver of informed consent was granted due to the retrospective nature of the study and the minimal risk to subjects who participated. Intervention Cognitive behavioral therapy is a structured, time-limited, present-focused approach to psychotherapy that helps patients develop strategies to modify dysfunctional thinking patterns and maladaptive behaviors in order to assist them in resolving current problems. The 12-week CBT pain group was
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Group • • • • Group • • • • • Group • • • • Group • • • • • • Group • • • • Group • • • • • • •
1: Introduction to chronic pain Set group rules The impact of pain The general goals of treatment Set S.M.A.R.T. goal 2: Theories of pain/ diaphragmatic breathing Battle buddy Review last week′s session Discuss theories of pain Introduce relaxation techniques Practice diaphragmatic breathing 3: Progressive muscle relaxation/ guided imagery Battle buddy Review last week′s session Introduce progressive muscle relaxation Introduce visual imagery exercises 4: Automatic thoughts and pain Battle buddy Review last week′s session Explore how automatic thoughts lead to emotions Explore the relationship between emotion and pain Review a list of cognitive errors Introduce ABC model 5:Cognitive restructuring Battle buddy Review last week′s session Explore the connection between negative thoughts and pain Introduce cognitive restructuring 6: Stress management Battle buddy Review last week′s session Define stress Explain the fight/fight response Review common sources of stress Discuss the relationship between stress and pain Examine ways to decrease strss
Group • • • • • Group • • • • Group • • • • • • • Group • • • • Group • • • • • Group • • • • •
7: Time-based pacing Battle buddy Review last week′s session Introducing time-based pacing Discuss steps to appropriate pacing Review pacing techniques 8: Pleasant activity scheduling Battle buddy Review last week′s session Identify pleasant activites Schedule activites during the next week 9: Anger Management Battle buddy Review last week′s session Define anger Discuss the relationship between anger and pain Introduce anger management Discuss response styles Introduce assertive responding 10: Sleep hygiene Battle buddy Review last week′s session Discuss the necessity of sleep Review ways to improve sleep 11: Relapse prevention/ flare-up planning Battle buddy Review last week′s session Discuss relapse prevention and flare-up planning Review stages of flare-up management Creat a relapse prevention plan 12: Post-test/ feedback session Share progress of S.M.A.R.T. goal Review what learned in past 11 weeks All members to provide feedback Termination Last minute business
Figure 2. Session-by-session breakdown of CBT for chronic pain protocol [36].
adapted from a manualized “Treatments That Work” protocol [36]. The protocol reviews pain education topics, such as chronic pain syndrome and theories of pain. The protocol introduces cognitive concepts, such as automatic thinking and cognitive restructuring, and behavioral strategies, such as relaxation techniques (diaphragmatic breathing, progressive muscle relaxation, and visual imagery), time-based activity pacing, and pleasant activity scheduling (Figure 2). Cognitive behavioral therapy is typically limited to 10 weekly treatment sessions and is administered individually, but can be delivered in a group format (J. McKellar, personal communication). Cognitive behavioral therapy for chronic pain has been disseminated nationwide by the VA Office of Mental Health Services and National Pain Management Program Office. Group therapy for chronic pain management has become a common treatment format [37]. The Otis manual [36] was adapted to a group format in order to make the intervention more time efficient for the therapists in training, to provide a mechanism for veterans to learn coping skills from others, to help veterans realize they are not alone, and to help veterans gain valuable social support from others. Several noteworthy adaptations were made to the current manual: (1) Each session began with a “Battle Buddy” check-in, where members coupled with another veteran, reviewed their progress with
their SMART (simple, measurable, attainable, realistic, and timely) goals and elicited support and comments from the other member; (2) each session was facilitated by the use of a dry-erase board and flipchart so all the group members could follow along as examples of concepts were reviewed; and (3) during each session, members were encouraged to support other members by providing suggestions for other techniques that they found effective. The sessions beyond the 10-week standard being evaluated in the current pilot study are based on additional anger management and stress management themes deemed especially important within the veteran population. Participants were seen on a weekly basis (or biweekly if there was a holiday on a meeting day). Psychology trainee therapists cofacilitated the groups with a licensed psychologist identified as a CBT training consultant. Employing trainee therapists to conduct the current groups is representative of how master’slevel clinicians are responsible for more and more direct patient contact [28]. Past research has shown that trainee therapists with limited training in behavioral protocols produce positive outcomes [38]. The supervision and teaching role of a psychologist takes into account individual and cultural differences of the members of the health care team and of the participants.
Replication of CBT protocol in veterans with chronic pain
DOI: 10.1080/00325481.2015.1000230
Month 0
Veterans signed-up to participate in CBT groups (n = 52) Dropouts Veteran discontinued (n = 6) Veterans elected to participate in CBT groups (n = 46)
Month 12
Veterans completed CBT group (n = 46)
Dropouts Veteran incompletes (n = 5)
Entered into analysis using BOCF (n = 46)
Figure 3. Flowchart of study participants.
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Outcome measures As part of the introduction and conclusion of the CBT group, all participants completed a pre- and postintervention assessment. The preintervention assessment was completed at the beginning of the first session and the postintervention assessment was completed at the end of the last session (the 12th) of the protocol. The assessments included a battery of measures, including the Readiness Questionnaire (M. Jensen, personal communication), the Brief Pain Inventory–Short Form (BPI) [39], the Oswestry Disability Index (ODI) [40], the Coping Strategies Questionnaire–Catastrophizing Scale (CSQ) [41], the Chronic Pain Coping Inventory–Short Form (CPCI) [42], and the Brief Symptom Inventory-18 (BSI-18) [43]. These key psychological tests were chosen based on their brevity and ease of administration, as well as their reliability and validity in prior research [44]. Readiness questionnaire. Participants were asked to select 1 statement out of 5 possibilities that best describes their stage of readiness to adopt a self-management approach to their pain. Scores ranged from 1 to 5, with higher numbers indicating a more advanced stage of readiness to adopt a selfmanagement approach to their pain. The temporal stability for this measure in previous research was 0.63 [45], but for the current pilot study it was 0.14. Thus, the instrument was eliminated from the analysis due to poor internal consistency. Brief pain inventory–short form (BPI). The BPI asks patients to rate their pain at the time of responding to the questionnaire (pain severity right now). The BPI also asks for ratings of the degree to which pain interferes with 7 daily activities. The internal consistency of the BPI in past research ranged from a = 0.80 to a = 0.87 for pain severity and from a = 0.89 to a = 0.92 for pain interference. Chronbach’s alpha for the current pilot study was a = 0.84 for pain severity and a = 0.85 for pain interference. Oswestry disability index (ODI). The ODI is used to measure a patient’s permanent functional disability. The ODI consists of 10 questions in which the patient selects the answer that best describes their typical pain or limitations within the past 2 weeks. The test has been used for 25 years and is considered the gold standard of functional outcome tools. The internal consistency of the ODI in past research was a = 0.85. Chronbach’s alpha for the current pilot study was a = 0.74.
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Coping strategies questionnaire–catastrophizing scale (CSQ). The CSQ uses a 0 to 5 Likert scale to rate 5 items that measure negative self-statements, castastrophizing thoughts, and ideations about one’s pain. Data analysis has shown that the Catastrophizing Scale was internally reliable (a = 0.81) and had high test-retest reliability over 6 months. Chronbach’s alpha for the current pilot study was a = 0.87. Chronic pain coping inventory–short form (CPCI). Eight strategies for coping with chronic pain were assessed using the 16-item short form of the CPCI. Participants were asked to rate each coping strategy by how many days they engaged in the activity in the past week. The validity of the CPCI has previously been established, and the median internal consistency ranges from a = 0.70 to a = 0.94. Chronbach’s alpha for the current pilot study was lower (a = 0.62). Thus, the instrument was eliminated from the analysis due to poor internal consistency. Brief symptom inventory-18 (BSI-18). The BSI-18 requires respondents to rate their level of distress over the past 7 days using a 5-point Likert scale. The BSI-18 provides a global distress score that is calculated based on all 18 items. The internal consistency of the BSI was reported to be a = 0.89. Chronbach’s alpha for the current pilot study was a = 0.85. Analytic methods The current pilot study used a quasi-experimental, singlegroup, pre/posttest design. A univariate analysis of variance (ANOVA) and independent samples t tests identified differences on demographic and outcome variables at baseline. Chi-Squares were utilized to compare complete versus noncomplete assessments by demographic characteristics. Paired-samples t tests were conducted to evaluate the impact of the intervention on veterans’ scores on the primary outcome variable of pain intensity and the secondary variables of pain interference, functional disability, catastrophizing, and levels of psychological distress. Outcome studies used an intention-to-treat analysis. A power analysis was calculated with an anticipated effect size (Cohen’s d) of 0.80, a probability level £ 0.05, and a total sample size of n = 46. The observed statistical power (1-tailed hypothesis) was equal to 0.85. For the 5 cases missing data at postintervention, a baseline-observation carried-forward approach was used [46]. SPSS version 20 was used for all outcome analyses. The results are presented using Transparent Reporting of Evaluations with Nonrandomized Designs guidelines.
Results Baseline characteristics Of the 46 veterans who elected to participate in the CBT pain group, 41 (89%) completed both the pre- and postintervention measure (Figure 3). The most frequent reason for participant withdrawal was unwillingness to complete the postintervention questionnaire. Only 3 of 4 groups witnessed departures.
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The third and fourth groups had > 1 member leave. Past research has shown that when a group member fails to benefit from treatment, or leaves prematurely due to dissatisfaction, others in the group are likely to follow [47]. Veterans had mixed idiopathic chronic pain conditions, including 57% reporting “head/neck/thorax/shoulder” pain, 83% reporting “trunk/abdomen/back/buttock” pain, and 78% reporting “legs/thighs/feet” pain delineated from the diagrams on the BPI. The reported pain score at baseline in the current pilot study was 5.98 (moderate pain). The participants reported being in the severe level (mean [M] = 49.17) of disability as measured by the ODI, and reported 42% of pain relief at baseline during the prior 24 hours. Participants reported being in the preparation stage (M = 3.11) of readiness to adopt a selfmanagement approach before beginning the intervention. Veterans engaged in a moderate level of catastrophizing (M = 12.13), and low levels of illness-focused (~ 2.02 days/ week) and wellness-focused (~ 1.92 days/week) coping strategies. At baseline, veterans reported poor overall emotional health (M = 23.20) when compared to community norms. Veterans who completed both assessments (n = 41) on average attended 10 group sessions, whereas noncompleters (n = 5) attended 6 sessions, which was halfway through the protocol and significantly different (P = 0.00) from completers. Differences at preintervention. At preintervention, veterans who completed the intervention were less likely to engage in wellness-focused coping strategies at baseline (M = 18.49, standard deviation [SD] = 6.89) compared to noncompleters (M = 24.80, SD = 4.45). Veterans who completed the intervention were more likely to engage in catastrophizing reactions (M = 12.73, SD = 6.92) then noncompleters (M = 7.20, SD = 3.11). Examples of such responses include, “I feel I can’t go on,” “I feel I can’t stand it anymore,” and “I feel my life isn’t worth living [41].” These findings are not surprising, as the aim of the CBT intervention is to decrease catastrophizing thoughts and increase wellness-focused behaviors (ie, relaxation). Noncompleters appear to have been adequate in both skills at baseline, which may explain their premature departure from the intervention. Differences among CBT Co-Led groups Four groups were conducted during the 1-year period of the current research study. Each group was conducted by a different combination of licensed psychologist and junior therapist in training. At baseline, there were no significant differences found among the groups in measures of readiness to adopt a self-management approach (P = 0.92), functional disability (P = 0.88), catastrophizing (P = 0.36), global distress (P = 0.12), and illness-focused (P = 0.31) and wellnessfocused (P = 0.56) coping (Table I). These findings suggest that the groups were the same at preintervention in terms of client factors. There were no significant differences found between pre- and postintervention assessments for the 4 groups: Wilks’ l = 0.74, F(4, 12) = 1.05, P = 0.41. Therefore, we can assume that there were no therapist effects.
Postgrad Med, 2014; 127(2):242–250
Intervention outcome The primary outcome measure for the current pilot study was pain severity. There was no significant mean difference found between pre- and postintervention assessments of the primary outcome measure of pain severity (right now), t(45) = 0.60, P = 0.55. In terms of secondary outcome measures, there was a significant mean difference found between the pre- and postsecondary outcome measure of catastrophizing, t(45) = 2.05, P = 0.05, d = 0.24, but not for any of the other secondary measures of pain interference, t(45) = –0.56, P = 0.58; disability, t(45) = 1.53, P = 0.13; and global psychological distress, t(45) = 1.67, P = 0.10 (Table II).
Discussion Evidence of CBT’s effective use in group format among veterans with chronic, noncancer pain is limited. In order to conduct research aimed at demonstrating an intervention to be effective, traditional research designs require a specific, identifiable, replicable treatment [48,49]. Treatment manuals are an important aspect of the move toward empirically supported practice [28], especially in the VA system. It is imperative that other research teams replicate outcome findings of these manualized interventions with other populations because treatment studies are often conducted by the team that developed the treatment [29]. Furthermore, there are a number of different treatments that can be classified as CBT interventions (eg, motivational interviewing, mindfulnessbased, acceptance-based, etc), but each may have its own emphasis, or mechanism. In addition, the utilization of treatment manuals has been found to be an important issue facing health practitioners [27,50]. The results of the current pilot study suggest that the CBT groups for chronic pain failed to decrease pain intensity and functional disability—findings that are inconsistent with past research [2,4,13,14]. One reason may be that the current pilot study only used pre- and postintervention assessments, whereas CBT tends to do better at follow-up. A second reason may be that the veterans may be physically doing more but the pain intensity remains the same. Yet another reason may be that veterans who suffer from chronic pain may be a unique group of individuals due to the dualism of active duty and civilian life [51]. Of note, the current sample of veterans seek services at a medical center with the third highest level of homelessness, fourth highest level of addictions, and fifth highest level of severe mental illness of the complex 1B VA facilities in the nation (P. Fore, Mental Health Service Line meeting, April 9, 2012, personal communication). Therefore, a better adjustment to continuing pain may have proven to be a more realistic goal than actual pain reduction and a decline in functional disability. Despite these considerations, pain providers should continue to encourage veterans to engage in a multidisciplinary approach to pain management, and increase their self-management and their use of the lessons learned during the pain education program. The findings from the current pilot study suggest that the CBT groups may have had a small effect on catastrophizing. This finding corroborates past research, which has found that
2.90 1.449 3.17 1.337 3.30 1.494 3.07 1.141
4.00 – 3.25 1.708 3.18 1.286 2.80 1.474 3.00 1.095 4.00 0.000
3.34 1.235 2.50 1.195 2.00 1.732
0.16
0.54
2.71
0.92
0.75
0.08
P
50.80 11.71 50.67 12.51 46.20 16.21 48.86 16.36
54.00 – 51.00 4.163 49.88 13.16 53.47 13.13 37.00 11.65 44.00 29.46
48.91 15.88 51.00 5.76 47.33 7.02
M (SD)
F
48.56 14.36 58.00 4.000
M (SD)
M (SD)
0.85
0.29
P
49.61 14.69 45.60 7.668
0.20
1.07
t
3.12 1.327 3.00 1.225
3.16 1.290 2.33 1.528
Significant at P < 0.01 level. Significant at P < 0.05 level.
b
a
4
3
2
Group 1
75+
65–74
55–64
45–54
35–44
Age 25–34
Hispanic
Caucasian
Race African Am.
Noncompleters
Assessments Completers
Female
Sex Male
M (SD)
Readiness
0.23
1.35
0.10
F
0.60
1.13
t
Disability
0.88
0.26
0.91
P
0.55
0.27
P
Table I. Baseline outcome measure scores by patient characteristics (n = 46).
12.50 6.964 14.33 5.433 9.100 7.866 12.14 6.916
15.00 – 8.75 7.890 13.71 6.536 13.13 7.170 8.83 4.309 8.33 9.713
12.23 6.817 10.88 7.864 14.33 5.033
M (SD)
12.73 6.921 7.20 3.114
11.65 6.644 19.00 6.557
M (SD)
1.09
0.94
0.29
F
3.14
1.85
t
Catastrophizing
0.36
0.47
0.75
P
a
0.01
0.07
P
23.10 14.04 24.58 11.93 15.20 10.49 27.79 13.09
15.00 – 22.25 14.25 24.71 12.65 22.67 13.05 24.67 11.40 18.33 23.63
24.17 13.77 23.25 9.161 11.67 4.933
M (SD)
23.56 13.53 20.20 5.975
22.56 13.00 32.33 8.505
M (SD)
2.04
0.22
1.31
F
0.55
1.28
t
Global distress
0.12
0.95
0.28
P
0.59
0.21
P
13.65 3.432 12.25 5.238 9.95 4.902 12.46 3.815
16.00 – 13.50 3.028 13.03 4.881 11.17 4.224 11.00 4.837 10.83 4.856
12.13 4.474 12.63 4.619 10.67 4.856
M (SD)
12.20 4.637 11.50 2.424
1.25
0.61
0.21
F
0.3
0.02
t
Illness coping
12.12 4.534 12.167 3.329
M (SD)
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0.31
0.69
0.82
P
0.75
0.99
P
19.95 6.878 19.88 7.592 20.65 6.741 16.96 6.707
24.00 – 26.63 5.170 17.74 8.700 16.90 4.940 21.50 3.937 22.50 3.279
19.79 7.157 16.31 6.530 19.67 4.252
M (SD)
18.49 6.890 24.80 4.453
19.31 7.129 17.17 2.021
M (SD)
0.70
1.96
1.96
F
1.99
0.52
t
0.56
0.11
0.11
P
b
0.05
0.61
P
Wellness coping
DOI: 10.1080/00325481.2015.1000230
Replication of CBT protocol in veterans with chronic pain 247
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Table II. Paired t tests of outcome measures of veterans (n = 46).
Variables
a
Pain severity right now Pain interference Disability Catastrophizing Global distress a
Pre-M (SD)
Post-M (SD)
M diff (SD)
5.98 2.038 3.91 1.068 49.17 14.10 12.13 6.817 23.20 12.92
5.80 2.247 4.01 0.940 46.91 13.98 10.46 7.229 20.57 12.20
0.174 1.970 –0.103 1.244 2.261 10.03 1.674 5.534 2.630 10.71
95% CIs t
P value
Lower
Upper
0.599
0.552
–0.411
0.759
–0.56
0.576
–0.473
0.266
1.529
0.133
–0.717
5.239
0.031
3.317
–0.551
5.812
2.052
0.046
1.665
0.103
b
In each case a decrease in scores suggests improvement. Significant at P £ 0.05 level.
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b
a reduction in catastrophizing mediates the outcome of CBT for chronic pain [17]. In fact, the construct of catastrophizing was originally found to mediate the outcome of CBT when compared with a wait-list control group [52]. Even though the treatment effect was not impressive (d = 0.24) and significant changes in psychological adjustment were not witnessed after completing the CBT intervention, the small effect size may translate into a bigger population change. The current pilot study has some limitations. This study used a quasi-experimental, single-group, pre/posttest design rather than a randomized controlled trial with a control group. There are 2 reasons why a control group was deemed unnecessary for the current pilot study: (1) the ethical consideration of leaving veterans without treatment, and (2) the use of a consistent intervention with prior implementation as an acceptable method. The current pilot study meets these requirements through its use of a manualized, empirically supported intervention [29]. This study also explores the benefits of programming when based on patient self-selection, which is aligned with the spirit of autonomy expected from self-management outlined in the ITHBC model. However, this study did witness multiple departures in the groups, which highlights the importance of social factors in chronic, noncancer pain and the need for group treatment to capitalize on these social influences [47]. The participants in the current CBT group intervention showed no changes in symptom severity or functional status. One explanation may be that this study solely relied on selfreport data, which may foster uncertainty. For example, the temporal stability of some of the measures (readiness and coping questionnaires) was questionable and thus eliminated from the analyses. It is also possible that the ITHBC model used in the course of treatment (which includes pain education) may account for the high completion rate for the CBT pain groups and have instigated the change process, which was later detected by the assessment measures utilized in this study. The self-regulation skills and abilities of all veterans with chronic, noncancer pain may also differ as the current sample was predominately African American and did not include a representative sample of the youngest returning veterans (aged 18 to 34 years) when compared with the typical veteran profile [33]. The current findings may appear
seemingly different from epidemiological data on veterans with pain, but may provide information about the psychosocial distinctiveness of pain experiences in a marginalized veteran population. Despite these limitations, the current pilot study is the first known replication of an effective, CBT group protocol facilitated by junior therapists and catered to veterans who suffer from mixed idiopathic, chronic, noncancer pain conditions. To date, Division 12 has recognized CBT only for chronic low back pain, chronic headache, fibromyalgia (multicomponent), and rheumatologic pain (multicomponent) [1]. The current study included veterans who suffer from back pain, neck pain, extremity pain, head pain, and fibromyalgia/soft tissue pain. Past research in this area has predominately used samples consisting of civilians with chronic pain conditions and licensed providers.
Conclusion Cognitive behavioral therapy for pain management has strong, long-standing research support, but some researchers have suggested that Division 12 of the American Psychological Association has “not set too high of a bar in terms of standards” (K. Vowles, personal communication at the American Pain Society, May 2, 2014). In fact, research investigating CBT interventions has been shown to have “weak effects on pain, moderate effects on mood, and negligible effects on disability” (M. Sullivan, personal communication at the American Pain Society, May 2, 2014). The findings from the current pilot study also illuminate the need for teachers, supervisors, and other providers involved in the professional development of junior therapists to pay greater attention to what mechanisms are responsible for the desired outcomes (eg, catastrophizing) and what kind of treatment is the best for a veteran with chronic pain (either group or individual CBT interventions). This may be accomplished by translating current manuals into user-friendly core elements.
Acknowledgments An earlier version of this paper was presented at the National Pain Week 2012 conference and the regional American Pain Society–Midwest conference in 2012. That version of this
DOI: 10.1080/00325481.2015.1000230
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paper was modified to reflect the comments received at the conferences. The author would like to thank all the veterans and junior therapists/supervisors who made this research possible, especially Bonnie Yap, Scott Sperling, and Susan Payvar. The author would also like to thank the staff members at the Jesse Brown VA Medical Center anesthesiology/pain clinic department for their vision and ongoing support of the pain psychology training program. Permission was obtained from the Department of Symptom Research to use the BPI in a publication and research trial. Permission was obtained from MAPI Research Trust, Lyon, France, to use the ODI in a publication and research trial. Permission to use the BSI-18 is inherent in the qualified purchase of the test materials.
Declaration of interest The author reports no conflicts of interest. The author alone is responsible for the content and writing of the paper.
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