Psychology treatments and pain service

Who is the leaflet for?

This leaflet is for patients who have attended an initial clinical psychology appointment in the pain service.

What is its aim?

The leaflet explains to you and your family what is involved in a psychology treatment based on a cognitive behavioural understanding of chronic pain and what you might expect as the outcome.

How could this information help?

This information is written to aid your decision about taking up a series of sessions with a clinical psychologist. It can help you to consider whether this might be helpful and if you would find it practical at this time. At the initial appointment, we talked with you to form a shared understanding of the range of issues you cope with. At your follow up appointment, there will be an opportunity for you to raise any questions and for us to come up with an agreed plan.

What is a cognitive behavioural approach to chronic pain?

A psychological treatment based on a cognitive behavioural approach involves you working with the therapist to consider chronic pain in the context of your life and in identifying problems that it may be realistic to work on. It is a talking therapy and you take an active role. In this process you may look at how you think about yourself, the world and other people. You may consider the links between the things that you do, and how you think and feel. The cognitive behavioural approach teaches you awareness and ways to influence the patterns in your thoughts, feelings and behaviours that may help maintain a vicious circle of suffering and chronic pain.

During your initial appointment, some common problem areas may have been highlighted, for example:

• How you think can affect how you adapt to your chronic pain: Patients often report fear of pain and avoidance of activity, resulting over time in further loss of physical function. They find themselves becoming stuck in a search for the cause or a cure.
• Your mood can be affected by your pain: Patients experiencing chronic pain often suffer symptoms of anxiety, low mood and / or frustration. An example is that patients often have a belief about how they ought to cope with chronic pain, they experience themselves as failing and in time they lose confidence and become de-motivated.
• Your social and family relationships can be affected by how you think about your condition: There may be effects on how you cope currently from your experience of ill health in early life and / or family members coping with illness. How you communicate about ill health may in turn affect your pain condition and cause further difficulties.

How could a cognitive behavioural approach to managing pain help me?

This type of psychological treatment approach focuses on your current ways of coping. It can be useful to look at how your pain can be affected by things that you have experienced in the past. However, the emphasis is on helpful skills you already use for managing chronic pain in situations in the present.

By reflecting on problem situations you experience, it can be possible to gain an increased awareness of how behaviour patterns have a bearing on your pain and also to see options in how you respond. Figure 1 gives an example of how a pattern of thoughts and behaviours may make you feel worse, adding to a cycle of chronic pain. The approach will also help you to see how unhelpful cycles of pain develop. You can try out different ways of responding and encourage the more helpful skills you already use for managing pain. With practice of these skills you may find you can make more informed choices in how you respond to pain and, in turn you may gain an increased sense of control in your life and begin to feel better.

Example situation: starting to practice exercise

What does treatment involve?

Following the initial interview, usually a review appointment will be offered to cover any questions, to agree the contents of an assessment letter and to come up with a plan. For many patients, the focus will be towards valued activities and achieving realistic goals. You may be recommended self-help information if this is all that you require. We will determine whether a cognitive behavioural approach is appropriate for you. If this is required, and if you consider you can commit the time, we will work with you to write a treatment plan. Alternatively, the outcome may be to recommend referral to other specialist pain teams or services.

A typical treatment plan involves a series of six to twelve appointments of duration one hour carried out with the clinical psychologist. Where possible this is on a weekly or fortnightly basis. As part of planning treatment, we work with you to agree realistic goals. The treatment process involves identifying factors that help to maintain ongoing problems that it may be realistic to work on. As well as taking part in sessions, this therapeutic approach usually involves setting homework to complete and information to read between sessions. We review progress with you at each session.

We regularly review how you find the approach and how you feel about progress made. There is a set date for a decision on discharge or further sessions.

There is usually an emphasis on maintaining beneficial change and on working towards discharge.

Benefits

Chronic pain can be viewed as a problem involving interactions of biological factors, behaviour, thoughts, feelings, social relationships and cultural factors. The clinic takes this perspective on a patient’s chronic pain to help them understand and self manage the problem to the best they can. The aim is not to cure pain but to help patients resume everyday activities, feel better and make gains in what they can do. There is substantial research literature to suggest the benefits of a multidimensional approach to pain management, informed by a cognitive behavioural understanding of the problem. Cognitive behaviour therapy is recommended by NICE (the National Institute for Health and Clinical Excellence which produces guidance to promote good quality healthcare) as the treatment of choice for people suffering from anxiety and for people with physical health problems who are suffering depression. It is recommended by the British Pain Society as useful for helping patients living with chronic pain.

Risks

There are no known frequently occurring risks associated with self-management and cognitive behavioural approaches to chronic pain. The clinic will aim to meet the recommended benchmarks and be up-to-date on sufficient quality practice based evidence. The clinic follows a standard assessment schedule to identify problems and as an aid to decisions on suitability. There is the potential to feel worse at stages during therapeutic interventions. The patient and therapist prepare for this in advance by reviewing the patient’s ways of coping. Some patients decide to postpone sessions until they feel they can commit, in which case, brief input can be discussed with the patient that is individually tailored to their needs.

Alternatives

Should you require discussion of this or other options, you can contact one of the clinic nurses, the clinical psychologist, or your general practitioner. You may wish to consider another option for accessing clinical psychology or counselling input via your general practitioner.

Contacts / Further information

• The leading mental health charity in the UK is Mind (opens in a new tab):

Mind, 15-19 Broadway, London, E15 4BO, United Kingdom.

Mind information line telephone number: 0845 766 0163

• More information on cognitive behavioural therapy is available on the British Association for Behavioural & Cognitive Psychotherapies website (opens in a new tab), the lead organisation for CBT in the UK.

• The professional body for psychologists in the UK is the British Psychological Society (opens in a new tab) (BPS).

British Psychological Society, St Andrews House, 48 Princess Road East, Leicester, LE1 7DR, United Kingdom.

BPS general enquiries telephone number: 0116 254 9568

References / Sources of evidence

A recommended book on self-management of chronic pain is: Manage your pain. Practical and positive ways of adapting to chronic pain. Michael Nicholas and Alan Molloy. 2003. Souvenir Press.

Attendance at appointments

We look forward to seeing you at all your psychology appointments. If under exceptional circumstances you cannot attend an appointment, please contact the administrator as soon as possible, so that we may re-schedule your appointment and offer your cancelled slot to another patient.

Due to service demand and Trust policy, we are required to discharge you from the psychology service if you cancel two consecutive appointments or do not attend a scheduled appointment. We will write to you to discharge you from psychology and send a copy to your GP. We acknowledge on occasion there are unexpected circumstances so please do contact us if this occurs. If your GP writes to the service within six months of discharge you can be returned to the psychology waiting list.

Privacy and Dignity

If you have any concerns at any stage, please speak to the sister or clinical nurse specialist at the pain clinic.

The department of pain medicine is compliant with Trust policies for patient confidentiality. Sessions are confidential unless it is thought by the therapist that your own or another person’s safety is at risk or if you wish members of the pain team to share your information. Clinical notes from sessions are kept separate from your medical notes. Your assessment letter is discussed with you before it is sent to your GP.

All therapists receive supervision of their work with clients to ensure patient safety, this is completed anonymously and is strictly confidential. We continue to work on ways to improve the pain service. We would welcome your comments on your experience of clinical psychology as part of the pain service. We would also welcome your feedback on this leaflet. Should you like to comment please write to:

Pain Clinic Administrator, Department of Pain Medicine, Box 215, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ