Pain is the most common reason for patients to enter healthcare. In patients with chronic nonmalignatn pain, the original nociceptive source of the pain is no longer sufficient to explain the pain that the patient is currently experiencing. Chronic pain, therefore, is best understood as a chronic disease to be managed versus an acute symptom to be cured. Each individual’s perception of pain varies in all its domains (i.e. somatic, emotional, cognitive and behavioral). Then perception of experience of pain also includes emotions, thoughts, behavior and social processes; a bidirectional causal relationship is applicable here. That is why the management of chronic nonmalignant pain focuses on the impact of pain, on the general physical condition of the patient, changes in social roles and social functioning and behaviour related to health care (1). The management of chronic pain becomes multidisciplinary, the psychotherapy is basic part of it and nurses are important part of the team.The advantage is if the nurse also underwent the psychotherapy training. Some patientsmay be otherwisehesitant to accept a referral for psychotherapy, some may be concerned that visiting psychotherapy will affect access to pain doctor or future treatment. Patient has to get information that his/her pain is real but also must be treated the comorbid problems, namely anxiety disorders, depression, etc. Further, he/she must be reassured that he/she will continue to see other members of medical pain team and that will not create any problems to pain management.
A variety of psychotherapeutic approaches may be offered in the treatment of the patient with chronic nonmalignant pain. Unless the cognitive behavioral therapy (CBT) is in pain management largely used also other psychotherapeutical approaches, primarily family, dynamic, client centered, operant therapy and acceptance and commitment therapy are important among others. Operant behavioral therapy (2) suggests that reinforcement of pain behaviors, often by partner or family in one’s social environment, could lead to maintenance of subjective reports of pain and increased disability. The operant approach opened the possibility of managing pain as a behavior problem (in relation to the patient’s external environment) and stimulated the development of behavioral methods. On the basis of works by Beck, Rush, Shaw and Emery, Turk worked out CB model of chronic pain in the early 1980s (3). The cognitive behavioral approach introduced the investigation of mental processes, and therapeutic methods focused on the modification of thinking and images to improve emotional and behavioral functioning. In the 1990s, on the basis of the work of Turk and Salkovsky (focusing on the study of anxiety and depression in chronic pain), CB therapy of chronic pain starts to incorporate cognitive therapy to an increasing extent. While it was originally used for treatment of those with depression and anxiety disorders, it has been used over the last two decades among the most efficacious psychological models for the treatment of chronic nonmalignant pain and a broad range of related pain psychological disorders. CBT helps individuals resolve their problems concerning maladaptive emotions, behaviors, and cognitions through a goal-oriented, systematic process. As a patient’s experience of pain is individual in all the above mentioned pain components, the therapeutic approach focuses on emotions, thoughts, opinions, beliefs, behavior and other somatic complaints. Therefore, the use of CBT is dominant worldwide in the treatment of patients with chronic nonmalignant pain, altered mental states, irrational cognitive schemas and pain behavior. This is why when CBT is incorporated into multidisciplinary approach it looks ideal. A next close approach to CBT is acceptance and commitment therapy (ACT) (4), which teaches patients to observe and accept thoughts and feelings without judgment and whout trying to change them (5). The aim of ACT is to develop greater psyhological flexibility of thoughts, feelings and behaviors associated with pain.
Who will profit from CBT
Patients who are referred for CBT are often in long-term incapacity for work or are already receiving social benefits, have decreased functional capacity, impaired social roles, experience chronic fatigue and often suffer from sleep disorders. After some time they become socially isolated and dissatisfied with their role in the family as well as with their competences. The patients rely too much on support provided by the social and health care system, which is intensified by the never-ending search for the second opinions of other doctors, repeated iatrogenic surgical solutions, and thus never-ending pain treatment (6). Perpetual attempts at adapting oneself to pain and its negative consequences often result in a number of emotional problems the most frequent of which are depression and fear related with pain as well as other phobic responses (fear of social interaction, of leaving a safe environment, fear of blood, illness and death) (7). Chronic pain, fear and depression also have a negative impact on other cognitive functions: decreased focus of attention, worsened memory and increased failure in cognitive tasks (8). For all those patients CBT can be helpful.
CBT as a part of multidisciplinary pain program
CBT may be used as individual or group therapy. Individual CBT is a short, structured therapy consisting of up to 5-10 sessions. The therapist is always active and directive in conducting this therapy, seeking the client’s active cooperation. In pain management centres of the highest level CBT is organized as a multidisciplinary pain management program in a group concept conducted by a team of experts (anesthesiologist, clinical psychologist, physiotherapist and nurse) trained in CBT. Program combines psychotherapy, pharmacotherapy and physiotherapy. All members of the team have equal status. The whole multidisciplinary pain management team meets to evaluate current problems, the course of the programme and the treatment; they also meet with every new patient following the initial and complex algesiological, psychological, physiotherapeutic examination, nursing and occupational counseling to evaluate the expected effect of treatment and motivation for the patient’s participation in the program; they also meet with every patient once a week for treatment evaluation, and, if needed, to communicate with doctors who recommended the patients for the program. The programs vary in content and duration and are adapted to groups of individuals with a particular diagnosis (headaches, back pain, fibromyalgia, rheumatoid arthritis). The accessibility of multidisciplinary pain management programs is limited by the financial situation of the health care system and by the staff who should undergo training in CBT. The basic factors that are preconditions for a successful multidisciplinary pain management program are: direct and indirect positive reinforcement of pain behavior, positive reinforcement of required behavior, physical condition, cognitive reframing and education (9). Besides the above six therapeutic principles, there are other factors that influence the process of therapy success. Therapy will be more effective if all staff members of the Pain Management Centre are trained in CBT, the team is regularly supervised and if there is no need to assure stable pharmacotherapy. The treatment is primarily focused on reducing the undesirable impact of chronic pain on life, that is, on improving the quality of life, and not on decreasing or removing the pain. CBT has been applied in a number of diagnoses: back pain, headaches, fibromyalgia, rheumatoid arthritis, orofacial pain and others. It is the most effective tool to help remove impaired cognitive schemas, teaches adaptive behavior and coping, reduces pain behavior, anxiety, fear and catastrophic interpretation of somatic symptoms, increases activity and self-confidence and improves social roles (10-13).
Connection among some nursing theories and psychotherapeutical approaches
The number of nurses which nowadays gets degrees in psychotherapy is rating rapidly (14). The nurse can help psychotherapist in holistic assessment, prevention, and treatment in a variety of settings. Education and competence, of course, can differ in different countries. Nursing differs from medical and psychological approaches. Medicine is interested in biological disorders. Psychology is the study of mind and behavior. Whereas nursing is specialized in human science and views persons as adaptation systems. It is first necessary that nurses-psychoterapists understand their work from a theoretical base. That means how psychoterapeutical approaches can fit with the philosophy of nursing theories. A psychoanalytic, psychodynamic and interpersonal therapy is particularly compatible for example with Peplaus´ nursing theory (15, 16). Peplau identifies needs, frustration, conflicts and anxiety as really vital factors which the nurse can evaluate in the context of patient´s history and present. Rather strong philosophical similiarity also exists between human nursing care (for example Leininger´s (17) or Watson´s theory (18)) and client centred approach of psychotherapy. In nursing, caring is the basic philosophy which is based on the relationship between the nurse and the patient and highlights value on positive regard, acceptance, human being and care. CBTfor example corresponds with nursing theories relevant to adaptation, for instance Roy Adaptation Model (RAM). Roy´s theory assumes that human behavior is adapative and that changes in inside and outside of environment can affect the patient´s feeling and behavior. RAM sees the individual as a set of systems (biological, psychological and social). The individual strives to maintain a balance between these systems and the outside world, but there is no absolute level of balance. Individuals fight to live within a unique group in which he/she can cope (19). The basic blocks of nursing models based on RAM are: health (the person’s state of well-being), person (recipient of nursing), environment (person’s significant surroundings), and nursing (the actions taken by nurses on behalf/in connection with the patient/family/group) (20).
Integration of CBT and RAM
The main reason why pain nurses should obtain especially CBT training is probably the need of multidisciplinary approach in treatment of chronic nonmalignant pain. Interestingly, RAM and CBT share similar processes (21). The CBT therapist examining the way how a patient in a cognitive way creates and understands the world around, and an evaluation of the processes by which the patient acts on cognitions (i.e. behaviors). The final behaviors and cognitions are challenged through a behavioral or cognitive experiments in the person’s thinking, behaving, interacting with the environment. The therapist begins by helping the patient to uncover schemas that are unconsciously influencing feelings, behaviors and thoughts (22). Once the schemas are maked out, the therapist assists the patient to do experiments with alternative responses in order to evaluate the proof of this wrong reasoning. Similarly, the nurse using the RAM practises an assessment of the stimuli that are impacting the patient´s present problem, or ineffective responses in the four adaptive modes: physiologic, self-concept/group identity, role function, and interdependence (23). The patient and nurse-psychotherapist together identify needs related to integrated, compensatory, or compromised levels of adaptation within the modes. Further evaluation assesses the impact of specific stimuli on the identified needs within each mode. The nurse and patient build goals that are tested, retested, evaluated, reevaluated, revised until the patient demonstrates an adaptive response that meets his/her goals (24). So it is necessary to emphasize, that CBT and also RAM view patient as a holistic, creative, and mostly self-determined human being. One’s sense of him/herself is the basic stone that theoretical and psychological change theory begins with in cognitive and behavioral development. If a patient is satisfied, pleased with, and comfortable with self, change is not of interest at the time. If a patient’s view of his/herself, the world and the future is somehow built in a manner that influences behavioral choices in ways that cause stress, pain, or problems in life, that person may be interested to exchange. That connection cannot be neglected in the work of nurse-CB therapists and shall lead to integration of both theories.
Current CBT of chronic nonmalignant pain is holistic, structured and targeted at the individual’s quality of life. CBT is an integral part of pain management. This treatment should be available as a core part of any chronic pain service. The nurse is a basic part of any multidisciplinary program of pain management, where CBT is used. It is possible for a CB therapist nurse using the RAM, also to use CBT as a conceptual-theoretical system for practicing psychotherapy. By integrating a nursing model to CBT strategy, a nurse CB therapist is in a unique position to provide biopsychosocial integrative and holistic care in multidisciplinary pain management.
This study was supported by the Ministry of Health, Czech Republic – conceptual development of research organization, Motol University Hospital, Prague, Czech Republic 00064203
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