Welcome back to the Healing Pain Podcast with Dr. Beverly E. Thorn, PhD
Whether you are a practitioner or a patient interested in learning more about psychological informed care, you will benefit a lot from Dr. Beverly E. Thorn’s research which focuses on investigating the important components of cognitive behavioral therapy for chronic pain. Beverly is Professor Emerita of psychology at the University of Alabama. She is the recipient of the 2018 Wilbert E Fordyce Clinical Investigator Award from the American Pain Society. She explains why the cognitive model is important in the treatment of chronic pain care, what should be included in cognitive treatment for chronic pain, and how many sessions are required to see meaningful change. She also touches on the importance of motivational enhancement and assertiveness, why treatments designed for those with pain should be simple and accessible, as well as some of the mechanisms, the similarities, and the differences between cognitive behavioral therapy and mindfulness approaches for chronic pain.
On the podcast, we are talking about the importance of Cognitive Behavioral Therapy and mindfulness approaches in the treatment of chronic pain. Joining us as our special guest is Dr. Beverly Thorn. Beverly is Professor Emerita of Psychology at the University of Alabama. She is the recipient of the 2018 Wilbert E. Fordyce Clinical Investigator Award from the American Pain Society. Her research has focused on investigating the important components of Cognitive Behavioral Therapy for chronic pain. Since retiring in 2016, she has remained actively involved in making more comprehensive and interdisciplinary treatment available to everyone with chronic pain.
On this episode, you will learn why the cognitive model is important in the treatment of chronic pain care, what should be included in cognitive treatment for chronic pain and how many sessions are required to see meaningful change. The importance of motivational enhancement and assertiveness, why treatments designed for those with pain should be simple and accessible. As well as some of the mechanisms, the similarities and the differences between Cognitive Behavioral Therapy and mindfulness approach for chronic pain. This is a great podcast whether you are a practitioner or a patient interested in learning more about psychologically informed care.
Beverly has spent over 30 years working with the cognitive model with regards to chronic pain populations and especially with regard to implementing these interventions with those who have low literacy. She is a wealth of knowledge and experience. I hope you walk away from this episode with a list of notes and nuggets as I did. Beverly has also provided us with a gift to accompany this podcast, which you can download for free. It’s called Ten Reasons It’s Not All in Your Head. This is a great PDF handout whether you’re someone with pain or you’re a practitioner who treats chronic pain. This can be part of your pain education arsenal that you use with your patients. To download it, all you have to do is go to www.DrJoeTatta.com/107Download. You can simply text on your cell phone the word 107Download to the number 44222. Let’s begin with the incredible, Beverly Thorn.
Cognitive And Mindfulness-Based Pain Care with Dr. Beverly E. Thorn, PhD
Beverly, welcome to the show. It’s great to have you here.
Thank you for having me.
I was excited to meet you at the World Congress on Pain in Boston. You gave a great lecture on cognitive treatments for chronic pain. Plus, you gave me a great free book, which is always such a great bonus. I want to thank you for the great lecture there and I wanted to thank you for the book. It’s a wonderful book and I know it’s based on years of your research, study and pivotal research in working with people with chronic pain from a cognitive and the mindfulness perspective. You are a health psychologist who has specialized in chronic pain. Give us a little bit of the background about who you are and what you’ve done throughout your career.
My area is clinical health psychology. What that means is for the entirety of my career, I’ve worked with and studied the impact of psychology on chronic health conditions. I don’t work so much with mental illness per se as I work helping people manage and prevent chronic health conditions that are so rampant in our society now. We are a different brand of psychologists. Most people think of psychologists as, “I’m going to get in your head. You’re going to get in my head and you’re going to analyze me.” We don’t do that stuff. We work with real-life situations to help people cope better and we give them co coping management skills to do that.
At times when people have chronic pain, going to see psychologists can be beneficial for them to help them cope. “I don’t want to talk about my history with my family or my parents.” I love that that approach is more, “We don’t get into your head,” but cope with what’s happening. Can you talk a little bit about the distinctions between health psychology versus rehabilitation psychology versus a general clinical psychologist?
Before I do that, I’m going to pick up on something that you said and that is the patient who is hesitant to go to a psychologist for managing chronic pain. One of the biggest battles that we fight is to help patients understand that we deal with real physical conditions. We help them with real physical conditions. If their physician is sending them to us, it’s not because their physician thinks that their pain is in their head, that their pain is not real. We deal with people who have real pain and we can still help people with real pain via psychology. The difference between a clinical psychologist, a health psychologist, and a rehab psychologist is that clinical psychologists have traditionally been trained to assess, diagnose, and treat mental illness. For example, depression and anxiety. That’s been very useful and continues to be very useful means of helping people cope with life.
Health psychologists study and work with patients to either prevent or manage chronic physical health conditions. Then rehab psychologists also help people deal with often injury-related conditions, for example, a spinal cord injury or a head injury. There’s quite a bit of overlap nowadays too. We’re all trained in a broad and general sense when we’re trained at the Doctoral level. We’re a psychologist first, a clinical psychologist next, and then a rehab psychologist or a clinical health psychologist. We layer the specialization similar to what happens in medical school. For people who go to medical school, they first learn the basics of being a physician. Then they start doing their residencies and get more and more progressively specialized.
That’s helpful for the public to figure out who they would like to go see and what’s appropriate for them. It’s even helpful for people who are interested in psychology and they’re trying to figure out, “Which direction do I want to go in in school or which direction do I want to go in as far as graduate programs?” From that health psychology, that broader umbrella of health psychology, how did you wind up focusing in on chronic pain?
When I was going to graduate school back in the dark ages, I knew I wanted to do something with the brain. I found the brain fascinating and there are so many answers in the guts of the brain. I knew I wanted to study the facts of the brain, but I also wanted to work with people. I was looking for a graduate program where I could do research on the brain and work with people. Back then, this was in the late ’70s, they didn’t have clinical health psychology graduate programs, but I found a program called bio-clinical psychology. I satisfied the degree requirements of two degrees, one in neuroscience and one in clinical psychology. My main advisor was a neuroscientist. He worked on morphine and the effects of morphine on the brain. He wasn’t so interested in the effects of morphine on pain, he was more interested in the effects of morphine on tolerance, dependence and what happens during withdrawal. At that time I thought, “I don’t want to work in the area of drug dependence.” I flipped a coin and said, “I’ll work in the area of pain.” I started seeing patients and there were so many of them. I started seeing patients who had chronic pain and it clicked for me. I felt I had something to offer them that was a unique perspective and didn’t involve drugs. It wasn’t a fight with drugs and I went from there.
How many years did you work in clinical practice? Did you teach? Did you research? How did that all start to develop?
After my residency, I went straight from my residency to Ohio State University for six years. I loved it there but I married a man in Alabama, so I moved back to Alabama. I was at the University of Alabama for 30 years and retired. I’m still doing research. I still have graduate students, but I’m less actively involved in research and teaching than I have been. I’m at the point in my career where I’m trying to help change the culture that we live in, in terms of a biomedical model culture where we treat everything biomedically and solely biomedically and instead help people understand that that’s living on bread and water. What we want to do is help give them at least a three-course meal, if not a five-course meal to help them manage chronic illnesses and chronic pain.
Chronic pain is perhaps our biggest chronic illness that we have. It’s a symptom of a lot of the other noncommunicable diseases. Some people look at it as a disease in and of itself. There’s some controversy over there. Let’s start to work our way into the cognitive model for chronic pain. First, explain what a cognitive model is and why it’s important for chronic pain.
The cognitive model of pain says that our thoughts influence our feelings, influence our behavior. All three of those influence how we adapt to any chronic physical conditions including chronic pain. It’s not a one-way street, thoughts to feelings to behavior. Our feelings influence our thoughts and our behaviors influence our feelings. These are two-edged arrows, every which way. The importance here is that we’re talking about all of these factors which are psychological factors, our thoughts, what we tell ourselves inside our head, our feelings. Whether we’re anxious, angry, depressed or content and our behaviors, whether we go to bed and say, “I’m not going to deal with that,” or whether we get out and take a walk, all of those influence how we adjust to chronic pain. That’s a very simplified model, but it’s a model that works very well in the management of chronic illness.
We don’t have a lot of research on chronic pain. We have a growing body of research on chronic pain. As we look back at that body, when we look at things like exercise, when we look at the mindfulness-based approaches, CBT has probably the most research and the most evidence for chronic pain at this time.
Cognitive Behavioral Therapy, one of the things we have to make sure everybody understands is that it’s broadly defined and it’s a big umbrella term now. Depending on who’s talking about it, the techniques that are involved and even sometimes the theoretical approach to Cognitive Behavioral Therapy can be different. Arguably, acceptance and commitment therapy is a Cognitive Behavioral Therapy. It has its own theoretical focus and it also has its own specific techniques. Whereas mindfulness-based stress reduction, also arguably a Cognitive Behavioral Therapy, comes from a little bit of a different perspective and has different but compatible techniques. Cognitive Behavioral Therapy depends on the practitioner. Although I incorporate some mindfulness and some motivational enhancement techniques, I’m much more of a “Traditional Cognitive Behavioral Therapist.” I help people recognize their thoughts and deal with their thoughts. I also give them traditional relaxation exercises and other techniques like assertiveness training that help so much dealing with the medical population as well.
As people start to open up to the idea that Cognitive Behavioral Therapy can help someone with pain, you mentioned relaxation training. What is the framework of what a course of treatment looks like, whether it’s the number of treatment sessions? What is covered in the treatment session in a CBT course for chronic pain?
If you look at the research literature, a course of CBT could be as short as one session or it could be as long as ten, fifteen sessions. The ones that I have researched and done have been ten sessions. They’re usually an hour and a half long. I prefer a group pain management because it helps with people not feeling alone. People with chronic pain are very isolated and they feel like a freak. They feel like they’re the only person in the world who’s ever been told or somebody has implied that the pain is all in their head, that the pain is not real. I like to get them in a group because then the group cohesion factor is also very important and play on that. It’s called a common therapeutic factor. We infused pain education into our model of treatment.
In each session, we’re teaching them about a critical point regarding chronic pain. For example, one of the main critical points is the fact that the brain is the organ in our body that perceives pain and the brain is a huge filter. That brain can filter out pain signals to make them less apparent or the brain can enhance pain signals to make them much more difficult to manage. If we know that the brain has that power and we know that our techniques can help us manage the brain, we can quiet the brain down and reduce the pain signals that are getting to our outer center in our brain. Everything is built on that. We talk about the importance of stress management. We teach them about the parts of stress because it’s not just a physical thing, it’s an emotional thing, it’s a cognitive or thoughts related thing. It’s happening in your body. It’s happening when you’re stressed. It’s also happening in your behavior. Then we teach them that relaxation technique, especially if they’re practiced on a regular basis. It can quiet or reduce the stress thermostat. It can reset the stress thermostat so that they’re more not as reactive to smaller stressors and we’re less and less reactive.
Our body becomes less reactive, our mind becomes less reactive. Then our behaviors can be more thoughtful and more responsive rather than a reflex knee-jerk reaction. We do relaxation. One of our modules in our ten-session unit is always assertiveness training. Not only to help people understand that they have a right to say no and that they have a right to ask for what they want, but to teach them the appropriate way to do that. Often people, even without chronic pain, we’re not very assertive. We’re either passive or we’re aggressive. That doesn’t work very well, and it certainly doesn’t work very well in the medical community. We teach people how to work with their practitioners to ask for what they want. We teach them how to work with their family members because chronic pain is a severe stressor on the family. We want to help knit that unit together as much as possible. We also teach them something called expressive writing or emotional expression exercises where this is one of the units. It’s not typical in every CBT program, but there’s good research backing so we’ve incorporated it into our unit.
What we do is we teach people to write down their deepest thoughts and feelings about an unresolved emotional experience. It can be related to their pain or it doesn’t have to be related to their pain. For some people, that is very empowering. For some people, it’s like, “It didn’t do much for me.” It depends on the person. We focus a few sessions on the cognitive part of Cognitive Behavioral Therapy. That’s perhaps my contribution to the field that I’ve expanded the cognitive part of Cognitive Behavioral Therapy and all of that. What we teach people is how to recognize automatic thoughts and then how to ask themselves, “Is this completely true or is part of this a distortion that’s not serving me well?” For my brand of cognitive therapy, we don’t necessarily insist that people change those thoughts. What we have discovered is that just being aware that they’re in their head and they’re telling themselves these negative perhaps distorted thought patterns is having an impact on them. Being aware of that, what they often do is create a different relationship to the thought. It’s not necessary for them to make them change that thought. What happens is they naturally start developing a different relationship to their thoughts. This is very similar to act.
It sounds like you’ve started to tweeze away at the cognitive restructuring part of it. You probably know some of the research rather than I do, but there’s controversy over whether you can change thoughts. The traditional cognitive mind would be you would challenge the thought and try to mold it or change it. Wherein some of the third wave psychology it’s significantly less than that. It’s just noticing the thought is there, potentially naming it and allowing it to move on. The technical word they use is diffuse and have less of an impact on you. When did you start to soften to that a little bit versus the hard cognitive model?
We had two different sessions. One was recognizing the thoughts and getting people to recognize what they were telling themselves and asking them, “Is this working for you?” Then the next session was to examine whether it’s truthful and to change the thought. I started recognizing that people were coming back in between the week and they’d go, “Now you made me realize that I’m thinking this thought,” and I said to myself, “That’s BS. I don’t need to be thinking that thought.” I realized that the structure of changing the thought, like which part is unrealistic, which part is negative, change that into a positive thought. They didn’t need that, they did it for themselves. They didn’t do it formally but I do believe they changed their thoughts. I’ll give you an example and this was the one that was most prominent for me of all time. This was working with core beliefs in Cognitive Therapy, which are the deepest part. They are the roots.
According to Beth, they are the things that develop our core beliefs about our worthiness or worthlessness as a person, our lovability, they develop in childhood. In bad times, those negative core beliefs come out big time. We have a unit on core beliefs. I was working with a group of people who suffered from headaches. I had a woman in there who had only gone through the eighth grade and she was 84. I didn’t even think she was getting a whole lot out of the group, but she was staying every week and she was doing the relaxation. She liked the relaxation. I didn’t think she was getting anything about the cognitive stuff, but that was okay. She was there. I’m going into the core beliefs and talking about how we see ourselves as people who have a role. It could be a role we don’t want to have or a negative aspect of it.
I’m talking away and people are relating and suddenly she banged her fist on the desk and said, “Are you telling me that I don’t have to be the servant of my entire family at all times?” She hadn’t said a word in days. I said, “Yes, I’m telling you that.” She said, “Things are going to change from now on. I’m going to start standing tall with my brother. When he needs to go to dialysis, he’s going to have to give me a two-hour notice or he’s going to have to take a cab. I’m going to do this with my daughter.” She changed her whole persona based on the recognition that she was telling herself, “You must be this certain way to be lovable and to be worthwhile to your family.” She changed it immediately and I do believe it was a change. I don’t believe it was like, “I recognize my thought. I labeled it and then I diffused it.” We reached the same end goal with these things and that’s the good news.
We’re all aiming for the center point of that bullseye. There are a lot of different ways to hit that bullseye. It also makes me wonder and I’m sure if someone wants to be a great PhD for someone to delve further into from a clinical perspective. As practitioners, we have our own judgments and expectations. Do we have any idea who might benefit more from cognitive restructuring versus just noticing?
That’s the way that our research is starting to move into mechanisms research. What characteristics about you make you more likely to benefit from recognizing and accepting and letting it pass versus what characteristics in me make me benefit most from recognizing and changing the thoughts? One of the many difficulties is you’d have to have very large numbers of participants to have the statistical power to tease those things apart. Behavioral trials are different from medicine trials. In medicine trials, it’s not unusual to have 3,000 people in a sample. In behavioral trials, it’s pretty unusual to have 100 people per treatment. The other thing that makes it difficult to tease apart is, for example, in my treatment program, we teach recognizing and accepting as well as teaching, recognizing and changing.
I don’t usually separate those treatments out because I try to take the best from everything and you use it. Unless we separate them out and make them not realistic in a clinical sense, then we’re not going to be able to answer these questions. However, this gets into an interesting conversation that I had with the head of Patient-Centered Outcomes Research Institute. His name is Dr. Joe Selby and he was talking about the tyranny of the averages. Let’s say, the Cognitive Behavioral Therapy arm got this much reduction in pain and this much reduction in interference in their life due to pain. The people in the usual medical career got this much reduction and we compare those two. On average, it doesn’t tell us who is doing best in which arm. We are starting to do something called heterogeneity of treatment effects. It’s an interesting and complicated area of research. We did those analyses on our clinical trial. We found some very unexpected and very interesting results about who benefited most from group pain education versus who benefited most from group Cognitive Behavioral Therapy.
My last years of research has been focused on drilling down to the nuggets of Cognitive Behavioral Therapy and group therapy for chronic pain. That is so we can simplify it and offer it to people who are multiply disadvantaged, particularly literacy challenged and low educational attainment. I’ve heard for years since I published my first book in 2004, “This doesn’t work. This cognitive therapy, this reading and writing-based. This workshop, worksheet-based therapy doesn’t work for people who have low socioeconomic status.” My response has always been, “Why shouldn’t it? Let’s simplify it. Let’s drill it down to make it the most important, the simplified means.” What we have done over the past years is to develop a very simplified literacy adapted cognitive behavioral ten-session treatment program for chronic pain. Where we don’t even assign written homework, which is very controversial in the CBT field.
We give them audio CDs every week summarizing what we’ve done with them and we give them audio relaxation CDs. These people are multiply disadvantaged. We thought we were going to be handing them MP3 links, but MP3 links are not going to work with this population. We had to burn CDs. We structured the CBT so that we did a lot of the work for them. Then in the group education, we gave them the pain facts. The same relevant pain facts. We used a biopsychosocial model and we did the group treatment in very interactive based. What we wanted to see is do both of them work equally compared to usual medical care? Even as important, for whom does each of these works best? Our big surprise was that for the most disadvantaged, the ones with the poor literacy, the ones with the poor educational attainment did better in CBT than education, which is almost counterintuitive because CBT arguably takes more work. It takes more cognitive. It takes more reading and writing, not the way we designed in any way.
Then those in education, literacy level didn’t matter. We think what happened was we have structured the CBT in such a simplified way that the structure and the extra help we gave them with the audios made it doable for those with very low literacy. Whereas in education, the people with higher literacy just took the information and ran with it. That’s the important kind of research that’s starting to happen in the biopsychosocial pain field. It’s so important because this was only in one study. If that’s replicated and we start to know that, then for many people, group pain education might be enough along with their other treatments. For the disadvantaged folks, perhaps for folks who are more depressed or perhaps for folks who catastrophize more, then CBT may be a necessary adjunct after the pain education.
That’s fascinating because I had this conversation with a psychologist. This was probably her opinion because she was in resources. She said, “People who are “smarter” and who are more highly intelligent, do better with CBT when they have pain.” That is stuck in my head. I started looking into your research which says quite the opposite. It also makes me think, you have a PhD, I have a DPT. We both have spent years reading research and going on continuing education courses. We’re so smart on some level, but yet what works for people is when you can take all that information and distill it into something that’s structured, simple, easy and approachable.
Nowadays, you leverage technology to continually drive those principles home. Both of us have worked with students. They have so much knowledge, but they have a difficult time now explaining to someone and distilling that down into bite-size chunks that people can take home. Pain is a complicated thing when you look at the neuroscience behind it. I think Lorimer Moseley’s work is pivotal in that area. He’s been brilliant about distilling things down into simple. Even at some of his work, I look at it and I’m like, “That’s a little bit too complex.” Is the wave of the future making things simple for people?
In any field of medicine, biomedical intervention or allied medicine as physical therapy and psychology sometimes called, we have a moral obligation. It’s a moral ethical obligation to do some of the work for our patients, especially patients with chronic pain or any chronic illness. The stress of the chronic illness lowers their ability to think, reason, do abstract thinking, and their energy level. Even so, we live on a day-to-day basis with our terminology. Other people don’t live with that terminology. Every one of us has had the experience of taking our car into the shop and then throwing some terms in us. They live with those terms. They are comfortable with those terms. They mean nothing to us. Every one of us has had the experience of going to a physician and been told that you haven’t done that. We come out of there going, “I don’t know what that means.” We can do the same with psychological terms. We can do the same with physical therapy terms. We have an obligation to translate that down, to simplify that down.
I tell my students, “Folksify it. You’re talking to your grandmother here. Talk to your grandmother but you don’t use those terms with your grandmother.” It’s been such an interesting learning experience for us. Since 2004, when I first published my cognitive therapy book, I started getting responses from readers. These were mostly practitioners. They were like, “This is great except is this going to work for the common man?” I realized my terminology was way too up here to bring it down. It’s difficult for people who have been in school for so long, but we’ve got to do it. Is the wave of the future to simplify? Yes. We’re way too much in our own heads when we go a lot of schooling. That’s one of the reasons why it’s so good for us to have to talk to the public and to have to talk to social media and to reporters because they’re not going to let you get away with that fancy terminology stuff.
The few podcasts I’ve done and the radio shows that I’ve been on, sometimes you only have five minutes. You have to really distill your message down into these bite-size chunks. People from all over the country of all different shapes, sizes and educational levels can say, “I got that. That was good. That was five minutes of an education or maybe five minutes of a quick cognitive nugget that changed my perception of what’s happening.” I’m so happy we’re on the same page with that. I almost feel like as pain professionals, we need a course that teaches us how to simplify things.
We have this bedrock foundation of Cognitive Behavioral Therapy. In Cognitive Behavioral Therapy, there a lot of things as relaxation training, cognitive restructuring, pleasant activities, behavioral activation. There is graded exposure and there’s graded activity training. There’s so much in the cognitive model. Then the third wave comes in and you have acceptance and commitment therapy and mindfulness-based cognitive therapy. You have mindfulness-based stress reduction. What starts to separate the CBT from the mindfulness-based informed type of therapies?
It depends on who you talk to what answer you would get. I have had discussions with folks who have designed and implemented the ACT model. Sometimes we set it up as an opposition or a competition. We’re not the Democrats and the Republicans. We shouldn’t get into that kind of thing like, “You’re doing it wrong and I’m doing it right.” I’ve always had this stance of, “Isn’t that interesting that you’re using this technique to get at what we think the bottom of it is, but maybe we don’t know what the bottom of it is?” For example, is the key mechanism changing somebody’s acceptance or is the key mechanism changing somebody’s level of pain catastrophizing or is it both? There’s research that suggests that it’s both. When we do mindfulness-based stress reduction, ACT therapy or CBT, what’s interesting is we see any of those change people’s acceptance and their psychological flexibility, which are supposedly key mechanisms for ACT but not key mechanisms for CBT.
When we do ACT or mindfulness, what we see is those treatment approaches change people’s level of catastrophizing. That’s not supposed to be changing their thoughts, but it does because these things naturally fall into place. All of them also change people’s sense of self-efficacy and that’s such a key component. Most of the patients who come to me feel completely out of control with their life. They feel completely passive and dependent on a biomedical system. They feel like it’s constantly kicking them out the door like, “You’re a drug seeker now that we have an opioid epidemic. I prescribed you Oxicon for years, but now you are a drug seeker. We don’t want anything to do with you.” They feel out of control. They feel desperate and they feel like their life is over. If you can with any of these techniques, give them a little nugget that helps them start to feel self-efficacious again, to start to feel like, “I can do that. I can.” Then maybe in doing that, it makes a difference in how their life is going to be.
We need to capitalize on that. Theoretically, in the ACT model and in the mindfulness-based model, the emphasis is more on not necessarily changing the thing but changing the relationship to the thing. I do have a little difficulty throwing the welcome mat out for the pain. I must admit that makes me nervous when I don’t tell my patients to throw the welcome mat out for the pain. Change our relationship to the thing rather than changing the thing. Perhaps in Cognitive Behavioral Therapy, we’re changing the thing, not necessarily the pain. We are changing our behaviors, our thoughts and our emotions. We’re working with our behaviors, our thoughts and our emotions, which in some regards, both of those techniques do end up changing our perception of pain.
No one accepts pain, whether it’s someone who has pain. I’ve never met a physical therapist who accepts pain. I’ve never met a psychologist who accepts pain. There is a willingness that does need to happen so people can say, “I’m going to sign up for the CBT course. I’m going to take the NBSR course or take the yoga class,” or whatever it is. To roll back about what this ACT versus CBT, that sometimes comes up to let the psychologists and the mental health professionals off the hook. We have this in physical therapy too where it’s like the explain pain versus the pain neuroscience education, which one is better? When you look at all these types of treatments, eventually in a lot of ways you can boil it down to they all had similar mechanisms and in some ways, all roads lead to Rome. Each of us in clinical practice has that success story of one patient who stands out in your mind who everything worked right. There was a total transformation, metamorphosis. Tell me who that patient is for you in your career.
It’s interesting as you started to ask me that question, it was a pivotal moment in the therapeutic process. Was everything working right up to that point? No. She was pretty passive and a very depressed group member. I had a patient in our clinical trial who came into the group treatment very angry. He was one of the angriest people who were willing to come into the treatment program. The only reason he was willing to come in was that his primary provider who happened to be a chiropractor, he had an excellent relationship with her. He would do anything she said that he should do and she said, “That would be helpful for you to be in this program,” so he was willing to try it. He sat there very angry for the first several weeks. He talked about how the medical system had screwed him, how he had lost his job when he became less able. That means he lost his insurance. That means once he lost his insurance, he wasn’t getting the same kind of medical treatment. He had a surgery that he didn’t need for carpal tunnel syndrome when supposedly the issue was in his cervical spine and on and on. He felt like they made him addicted to opiates and then remove the opiates.
To see the transformation over time, to see him start to listen and uncross his arms and to start to say, “Sometimes I take the medicine, not because I’m in pain but because I’m afraid I’m going to be in pain. I can probably stop that. Sometimes I take medicine for because I’m pissed off at my wife, not because I’m in pain. Last week, I went and did a relaxation thing and then we had a good talk. Then I didn’t need the pain medicine.” It starts to dawn on them a little bit at a time and they start to incorporate this into their life. By the time he finished treatment, he wanted to be a spokesman for us. Patient-Centered Outcomes Research Institute did an interview with him and they put it on their website for a while too. He was our spokesman. He told us after the treatment that he thought that his chiropractor was sending him for electroconvulsive shock therapy of his brain. He thought that’s what we were going to do to his brain. He was willing to try it because of the strength of the relationship with his practitioner. He was relieved that we didn’t do that but he said, “What you did is as powerful as maybe giving me a shock therapy.” I have several of them but that one really sticks out in my mind.
It’s wonderful when people embody the work and they’re so motivated that they want to go help other people. We need more pilgrims of pain relief. It’s great that all of us clinicians are doing this, but when you look at the biblical amount of people who have chronic pain, there’s only so much we can do that the greater public is eventually going to be the force that helps others. We look into the research around prosocial behavior. It starts to tie in well with the chronic pain epidemic. We love helping people. We love more success stories but every once in a while, there’s that person who doesn’t do well, they slip through the cracks. You work in an interdisciplinary care like many of us do. Sometimes something in the chain of events doesn’t work well, doesn’t happen and doesn’t serve them. Maybe it’s one patient or maybe it’s a broader question I can ask you. Where are we failing people that we need to look at and say, “Even with our research and our degrees and all the things we have, we’re still not hitting this particular area or this particular person, this particular demographic that we need to address more?
We’re failing people by continuing to give them fragmented treatment. Our healthcare system is a paid per intervention system. If you have insurance, your insurance company will likely pay for up to five spinal fusions and the surgical cost alone is over $110,000. Then you’re pushed out the door after your surgery and you’re not given any help in how to cope with the postsurgical healing pain except for maybe a big bottle of Oxycodone. We’re only, “So and so is treating the headache. So and so is treating the low back pain but they’re not talking to each other.” We’re not interdisciplinary. We were more interdisciplinary in the 1980s when there were inpatient, interdisciplinary pain programs that were paid by insurance. They’re not paying for anymore.
Many physicians say, “This Cognitive Behavioral Therapy is a great stuff. I hear it, I buy it but I can’t find the CBT therapist anywhere. Where are they?” They’re not being paid. We don’t pay for these “ancillary treatments.” You’re not going to get a lot of people who are going to be doing this just out of the goodness of their heart. Physicians wouldn’t do it just out of the goodness of the heart. They have to make a living as well. We have these silos of treatment and approaches and we’re not working together. That’s where we’re failing our patients and we’re still letting them, asking them to function in this fragmented care system that isn’t a healthcare system. It’s an illness care system at best and we don’t do a good job with that either.
It’s always interesting to me when I look at chronic pain, people say, “How do you fix this problem? You’ve done these podcasts, you’ve talked to all these people. You’ve worked in chronic pain for years.” I always say, “The cure for chronic pain lies in the therapies. The allied health therapies are often the things that are not covered or if they are covered, they’re covered poorly.” I tell people all the time when I first started practicing in 1996, we had unlimited physical therapy visits for patients and there are drawbacks to that as well. The national average is about six visits for physical therapy and that’s not enough. It’s not enough to work on the physical aspects of things. As PT start to psychologically inform their care, it’s not enough to start to integrate the other things that need to be happening in physical therapy to integrate care or to help support what’s happening in psychotherapy. It’s an interesting time we’re living in and to see where this all starts to evolve, how it evolves and what’s going to be the big needle movers for people.
Not only are we reducing coverage for the allied health care, even if you had unlimited physical therapy visits. If the physical therapist and the primary care doctor aren’t talking and not working together, we’re still doing the silo thing that’s a travesty.
I talk about that silo mentality in the opening of my book. It’s the one thing that disappoints me. I get people who write in about, “You talked about the brain and pain. It was life-changing. You talked about nutrition. It was a life-changing exercise,” but no one ever mentions that silo in healthcare. I wonder why it’s not talked about more. I think because it’s one of the last glass ceilings we have to break down. It makes medical systems look at everything that they have set up needs to be reconstructed. That can be scary. It’s a big medical system because it involves a lot of change. Change is difficult especially for practitioners as well. Change is tough.
Change is difficult especially if it’s threatening, it might change the financial status quo, which it will. That’s not working this way.
Beverly, it’s been exciting and exhilarating to talk to you. I have both your books. If people want an excellent book on Cognitive Behavioral Therapy for chronic pain, Beverly’s book in the second edition is called Cognitive Therapy for Chronic Pain. It’s a step-by-step guide by Beverly E. Thorn. You can find it on Amazon. It’s a great book. The first edition was more from a cognitive model, the second edition, goes deeper into the cognitive model but also leaves in a little bit of mindfulness of what is super important. Tell us what else you have going on and where people can learn more about you.
I’ve been focusing my research for the past years on the simplification of Cognitive Behavioral Therapy, drilling down and making it meaningful for everybody, people with low literacy, low education. Also for people who are sick and can’t concentrate as much. We’ve finished a large behavioral trial looking at the efficacy of the simplified Cognitive Behavioral approach. Whereas the book you mentioned is not necessarily simplified. The second edition was quite informed by our efforts to simplify. It’s simpler than the first. What we’ve done is we’ve made a workbook for people who are working in a group or an individual setting with people who need a more simplified approach. It’s called Literacy-Adapted Cognitive-Behavioral Therapy workbook. It’s freely available on my website, which is a PMT.UA.Edu/publications.
For a therapist who wants multiple copies because they’re going to be giving out copies to their clients, we have a contract with BookBaby, which is one of those published-on-demand sites and you can order bound copies of it. I’ve waived my royalty so if you give them half price, you have to use a little half price coupon. You can download a copy for free. I would love for you to do that and experiment with it and see if it works for you. What we’re starting to have happened is that other research universities are starting to use this approach and to see if it works in their hands. We had someone from Johns Hopkins University say that they’ve been using the approach very successfully. We’ll see if that research bears out. What we have to do is just because it worked in my lab, in my hands with my approach, we have to replicate that in other labs with other people doing the same thing to make sure that it is something that can be very useful for people with low SES or for people who have limited cognitive function with cognitive illness.
As your research expands, you will find that because it’s a great work that you’ve spent a lot of years honing and perfecting. I want to thank Beverly for being on the show. This has been an excellent interview for anyone who’s interested in the cognitive and mindfulness approach to healing from chronic pain. Make sure you share with your colleagues or friends and family. Share it on Facebook, on Twitter and on LinkedIn. Those are the three places where people love to read this information. I want to thank everyone for joining us. As always, it’s a pleasure. I’m giving you the latest on pain care and pain science. Make sure you hop on over to DrJoeTatta.com/podcast. On the right-hand side of the page, you’ll see a little box where you can enter your name and email address. In that way, you can join the email list and I’ll send you the latest podcast to your inbox each and every week. It’s been a pleasure and I’ll see you here in our next episode.
- Dr. Beverly Thorn
- Cognitive Therapy for Chronic Pain
About Dr. Beverly E. Thorn, PhD
Beverly E. Thorn, PhD, is Professor Emerita of Psychology at the University of Alabama. She is the recipient of the 2018 Wilbert E. Fordyce Clinical Investigator Award from the American Pain Society. Her research has focused on investigating the important components of cognitive-behavioral therapy (CBT) for chronic pain. Since retiring in 2016, she has remained actively involved in making more comprehensive and interdisciplinary treatment available to everyone with chronic pain.
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