Psychotherapy Bulletin

Psychotherapy Bulletin

Cognitive Behavioral Therapy (CBT) for Rural Women With Chronic Pain

Implications for a Group Setting

Chronic pain is a debilitating symptom that may or may not have an organic cause. In rural communities, chronic pain may be more difficult to treat due to patients’ limited access to care, lower socioeconomic status (SES), and geographic isolation (Thorn et al., 2011). Psychosocial approaches are viable options for treatment, including Cognitive Behavioral Therapy (CBT) and relaxation training designed specifically for those living in these areas. In chronic pain treatment, CBT focuses on cognitive restructuring in order to decrease catastrophic thinking, maladaptive pain coping, and beliefs of self-control in managing pain (Turner et al., 2007), and research suggests that techniques such as progressive muscle relaxation and biofeedback assist in reducing pain (Jenson, 2011). To understand the use of CBT in this context, however, it is necessary to first understand the subjective experience of chronic pain, as well as how it is managed clinically.

The Experience of Chronic Pain

Conditions related to chronic pain vary in clinical manifestation depending on the extent of the pain as well as duration. Initially, chronic pain such as fibromyalgia was viewed with skepticism, as there is no apparent organic cause and biomedical interventions are not seen as efficacious.

In the case of chronic back pain, identifying the extant of the pain is difficult to define. Acute low back pain is identified as 0 to 7 days of pain; low sub-acute pain is identified as 7 days to 3 months; and chronic back pain is viewed as more than 3 months (Frank, 1993). This low back pain may be seen associated with anatomical trauma or no trauma whatsoever. In both cases, it can be displayed by shooting pain accompanied with tingling, numbness, or burning. Furthermore, 70-85% of individuals will experience back pain some time in their life (Frymoyer, 1988), and is the second leading cause for physician visits (Hart et al., 1995).

Persistent pain is viewed as chronic if endures beyond anatomical healing; this varies according to the initial injury or origin of the pain (for example, back pain identified beyond 6 months post-healing would be considered chronic; for post-herpetic neuralgia, beyond 3 months) (Apkarian, Baliki & Geha, 2009).

Treatment of Chronic Pain

After diagnosis is verified, patients with chronic pain tend to be referred to pain management specialists, often pain centers where a multidimensional approach is initiated. This could include pharmacological, medical, and analgesic approaches that in most cases fail to alleviate pain symptoms or improve outcomes such as reduction of pain, physical range of function restoration, and symptom relief maintenance (Apkarian, Baliki & Geha, 2009). Given the limitations of existing physiological treatments for chronic pain, psychosocial approaches may hold promise for more effective intervention, as they address the underlying cognitive processes of those affected by long-term experiences of pain, such as catastrophizing, fear, depression, disability, and symptom severity (Apkarian, Baliki & Geha, 2009).

CBT and Chronic Pain

Cognitive restructuring is a component of CBT. Unrealistic thought processes that follow pain or the fear of future pain can lead to a maladaptive coping response (e.g., catastrophic thinking), which are found to be linked with higher levels of pain (Jenson, 2010).

Cognitive restructuring involves teaching the patient helpful and reassuring thoughts to accompany the negative thoughts, as well as teaching the patient distraction and strategies to combat irrational thoughts. Some studies have interpreted activation in the right prefrontal cortex as correlated with a patient’s beliefs about his or her control of the identified pain, as well as the analgesic response (Jenson, 2010).

Another component of Cognitive Behavioral therapy is adaptive cognitive coping in response to initial pain. Healthy cognitive coping includes ignoring pain and developing positive counter beliefs to negative thought processes (Jenson, 2010). Behavioral interventions include coping with pain by engaging in healthy behaviors, such as goal setting with hobbies, socializing, or involvement with events not related to pain. Engaging in positive interactions contributes to more relief of pain through better psychological function versus engaging in pain behaviors that increase the subjective experience of pain (Jensen, 2011). Treatment effects include such factors as rumination, self-efficacy, and control (Turner et al., 2007).

Women and Chronic Pain

There has been a growing amount of research in sex differences of pain experiences. It appears that women experience pain more than men, possibly due to various factors including hormonal differences, early life exposure to pain, pain coping, and stereotypical gender roles in pain expression (Bartley & Fillingim, 2013); this heterogeneity complicates the research and clinical practice in this arena. Also, woman report higher rates of chronic pain related diagnosess such as fibromyalgia, Irritable Bowel Syndrome, temporomandibular disorders, chronic tension headaches, and interstitial cystitis (Fillingim et al., 2009). Interestingly, even though research supports a higher report of pain-related issues, no studies have reached a consensus on whether women experience pain at a lower threshold.

Some experimental studies have not been able to replicate pain sensitivity, while others have suggested there is a greater pain sensitivity response in woman (Fillingim et al., 2009). Regarding studies on pain coping skills, women differ from men on a psychosocial level. For example, men tend to utilize distraction and problem solving techniques whereas as women use a large range of coping skills such as social support, positive statements, and attentional focus (Bartley & Fillingim, 2013). Women also report higher rates of skepticism and feeling blamed or belittled when revealing chronic pain symptoms to healthcare providers; this gender difference may help identify the various experiences of pain, specifically from a woman’s perspective (Werner & Malterud, 2003).

Rural Health, Diverse Populations, and Chronic Pain

The needs of residents of rural areas in reference to chronic pain are unique. Due to comparatively limited to access to care, low socioeconomic status (SES), and low literacy levels, barriers to treatment are structurally different in small towns in comparison to larger metropolitan areas (Thorn et al., 2011). As chronic pain is a major healthcare issue, being geographically isolated also complicates the issue and contributes to a higher risk for poor pain outcomes (All, Fried, & Wallace, 2000).

The need to identify lower cost and more effective therapeutic interventions (e.g., CBT, relaxation training) become even more pressing in these communities. A group setting, specifically with CBT would satisfy that need in rural areas. Little to no cost is associated with maintaining and facilitating a group oriented with CBT. Under the supervision of psychologists, CBT training can be manualized and constructed in such a way that technicians with little experiences may be capable to serve the community. Furthermore, specialized training or expertise (e.g. a licensed psychologist) is not always granted for this line of treatment. Many support groups similar to this framework are housed within local facilities, such as hospitals, community areas and churches; thus, expanding the opportunities to the rural population.

Implications for CBT in Group Settings

Cost effective treatments are ideal in rural areas due to geographic limitations and access to care challenges. Offering group treatment for women with chronic pain may improve access to services and offer a more cohesive experience for patients. The following proposed group format follows the stages of CBT according to Corey (2000). Detailed descriptions will be provided for each stage, as well as information for the possible future utilization and creation of a group for women dealing with chronic pain in a rural location.

Corey’s Stages in Cognitive Behavioral Therapy

Out of the wide variety of interventions employed by CBT, this group would focus primarily on three components: (1) cognitive restructuring; (2) behavioral/coping training; and (3) relaxation training. Although other concepts would come into play (modeling, pain management, social support, etc.) (Corey, 2000), these three elements would be emphasized throughout the progression of the group. Intervention techniques would include worksheets, homework (e.g., thought processes, journaling of pain, daily relaxation practice), and relaxation training for five minutes upon closing of the group. Common worksheets include the ABC’s worksheet, in which A is identified by activating event, B is Behavioral outcome and C is consequence to the behavior. This assists individuals in the process of evaluating cognitive processes involved with specific events and evaluating outcomes of irrational thinking patterns.

Initial stage

According to Corey (2000), the initial stage would consist of an educational component on such topics as collaborative empiricism and the uniqueness of this intervention. Over the span of approximately two to three groups, the patients should be able to define CBT and the intent of its use. Because the group would be action-focused, patients should also be willing to collaborate with the group as a whole and utilize homework assignments to the best of their ability outside the group.

Storming/Norming (transition)

This stage consists of the leader(s) assisting the group to focus on conflict resolution instead of conflict management. Through examination of group dynamics, conflicts and power struggles can be brought to the group to resolve or explore. A major portion of this interaction in CBT involves modeling by group leader(s); the interactions group leader(s) have with group members and/or each other can teach new conflict management skills. It would be vital to initiate relaxation training (e.g., progressive muscle relaxation, hypnosis, guided visualization) at the end of each session in order to inhibit any anaphylactic response (e.g., pain flare up) because of this conflict.

These interactions of examining the conflict and resolving or norming it build a stronger supportive group based on a kind of kinship (what Corey terms “moving beyond the security of cohesiveness”; pg. 100, Corey). This collaboration and cooperation facilitates cohesion of the group. Ultimately, it is hoped that, through identification of shared experiences of pain and challenging thought processes, a sense of closeness and opportunities for self-disclosure would arise among chronic pain group members.

Working stage

The working stage incorporates many of the additional interventional techniques from CBT, including modeling, behavioral rehearsal, reinforcement, cognitive restructuring, homework assignments, and problem solving (Corey, 2000). Modeling would remain consistent from the group leader(s) to ensure patients within the group are able to see representative and rational behavior. Structurally, a session could consist of a “check in” referencing a relevant topic, such as pain symptoms and coping strategies utilized over the last week; the group could then progress to a problem-solving exercise with effective feedback.

Throughout and across sessions, cognitive restructuring could be utilized. If cognitive distortions arise during any part of the session, a group leader or fellow group member could bring it to everyone’s attention and assist in finding alternative ways to challenge the thinking. For example, if a group member discusses going through the steps of problem solving but states she “could not deal with the pain” in response to the situation, her peers can help her identify this unhealthy thinking. For example, some members might say in response that she is able to cope and has done well for herself, thereby supporting the member and helping her challenge her thinking. She can then utilize that feedback to challenge the identified problematic thinking process the following week, as an outside of group homework assignment.

Mourning stage (termination)

The termination stage would be designated as one or both of the final two sessions, indicated clearly in the informed consent form regarding group. These sessions would focus on receiving feedback from the group, a process shown to be beneficial in the termination stage of CBT-oriented group therapy (Corey, 2000). Learning how to respond to pain symptoms with new tools is fundamental to group members receiving continued benefit from their CBT training. During this process, members would also be guided by the group leader(s) to identify potential challenges and setbacks. Effective feedback, support, and identification of individual post-group goals would be used to assist in decreasing subjective experience of pain and resolving interpersonal conflict

Summary and Limitations

Although the challenges facing this population are daunting, utilizing a gender-focused, multidimensional Cognitive Behavioral Therapy and relaxation training approach may assist women in rural settings coping with chronic pain. Limitations to this format would include the potential difficulty some group members may have investing time in outside activities (e.g., such as homework around practicing healthy thinking skills or challenging negative pain responses); in those cases, group members are unlikely to benefit from this form of treatment. In addition, the rigidity of an overly-structured program might take attention away from the underlying meaning of the group member’s behavior (Corey, 2000). Despite these potential concerns, Cognitive Behavioral Therapy and relaxation training may be an attractive, gender-responsive, and cost-effective option for chronic pain treatment in women, especially in a rural geographic location.

Cite This Article

San Miguel, A. (2014). Cognitive-behavioral therapy (CBT) for rural women with chronic pain: Implications for a group setting. Psychotherapy Bulletin, 49(2), 43-46.


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