Leeds Institute of Health Sciences Is CBT what we do? Stephen Morley.

Leeds Institute of Health Sciences

Is CBT what we do?

Stephen Morley

I really don’t know …

`

I don’t know what you door

how it compares with a definition / description of CBT

So is CBT what we do ?

An email from Neil – 4 April 2008

I’m wrestling with the question: “What do we mean by CBT in the pain management field?”

“CBT” = “Cognitive Therapy” with a strong Beckian flavour I am not entirely comfortable with this

… reading … Dennis Turk’s chapters … he barely touches on the cognitive therapy tradition of Beck et al…. he’s drawing on broad-based cognitive social learning theory tradition… with which I am much more comfortable!

Email from Neil ….

… not sure that cognitive therapy as applied to depression, panic disorder etc can be simply borrowed and applied to chronic pain … an emphasis on the links between pain and emotion and risks psychopathologising chronic pain

… I prefer my chronic pain models to be much broader and biopsychosocial …

… Am I just getting old and out of step?

… I recognise that a full and considered reply is a big ask but I’d appreciate any pointers to CBT / pain and CBT literature that might help me to get my head round this.

A current usage of the term

“The term CBT varies widely and may include self instructions … relaxation or biofeedback, developing coping strategies, changing maladaptive beliefs about pain and goal setting … varying selection of these strategies … embedded in a more comprehensive pain management program that includes functional restoration, pharmacotherapy, and general medical management.”

Gatchel et al. Psychol Bull 2007; 133: p606

The evidence:What do people report they do?

Unpublished data from Morley et al, Pain 1999: 80 1-13

CBT treatment components across trials

Heterogeneity between studies

Is the model like a shotgun or supermarket

sweep?

General protocol in CBT

Principles

1. Collaborative and consultative engagement

2. Active practice of skills3. Education about chronic

pain and its treatment

Goals1. Improved physical fitness2. Reduced disability3. (Re) introduction to work4. Increase in effective

problem solving5. Increase in adaptive

problem solving6. Reduction in pain related

fear7. Reduction in pain related

depression

From: Morley & Eccleston, CBT for chronic pain in adults, In press

Howard’s 3 RsRemoraliseRemediateRehabilitate

Principles …

Do you use behavioural principles?

Analysis of antecedents, behaviours and consequences– Setting conditions– Discriminative stimuli – Identify reinforcers– Contingency management

Do you use key cognitive therapy elements?

Identify core non-functional beliefs e.g. ‘if I move I will harm myself’

Design individualised behavioural experiments to test belief – behaviour link

Issue 1: The influence of non-specific effects

It is difficult to know whether change is due to non-specific effects– designing plausible controls

Morley, Pain 2004: 109; 205-206. / Morley & Keefe, Pain 2007: 127: 197-198

• CBT superior to WLC• CBT Equivalent to other active treatments

Plausible rival hypotheses:1. Influence of expectation, therapist effects, group effects,

attention etc.2. Different treatments produce the same cognitive-

behavioural changes (common process or different processes)

Issue 2: Precision of the cognitive model

Getting more precise specifications of CBT-going beyond ‘some changes in coping will be associated with and precede some changes in outcomes’

Cognitive Outcome

■ ●

■ ●

■ ●

■ ●

Time to abandon ‘brute empiricism’

‘not all possible pain –related coping strategies and attributions were assessed’

Nielsen & Jensen, Pain 2004;109: 233-241.

Issue 3:Testing causal models

We need to test causal models

2 strategies– Cross lagged panel designs in trials and cohorts

Pre treatment End of treatment

Causal process ■ ■

Outcome ● ●

Pre treatment Mid-treatment End of treatment

Causal process ■ ■ ■

Outcome ● ● ●

Cognitive mediators of change

• Several studies of correlations support perceived control, catastrophizing – Issues: temporal priority, autocorrelation, treatment specific (rather

than just change), non-specificity for different outcomes

• Lag sequential regression analyses e.g.– Burns et al n < 90 (mid treatment to end of treatment)– Morley et al n = +500 (end treatment to 9/12 follow up)

• Control for treatment– Turner et al (2007) end of treatment to 1 year follow up– Individual mediator analysis: Perceived control, Self-efficacy,

catastrophising– Group mediator analysis: Self efficacy

Issue 3:Testing causal models

ExperimentalDefusion vs Distraction Defusion vs Thought Control

Masuda et al BRAT 2004; 42: 477-485

Issue 4:Disaggregating chronic pain

CBT for - – Chronic low back pain– Osteo arthritis – Rheumatoid arthritis– Fibromyalgia

• Diagnostic category e.g. the headache personality– Transdiagnostic psychological processes

• Psychological typology – MMPI, MPI, SF36– Structural models, description still need functional

account for interventions

• Functional models– Fear avoidance– More general avoidance formulation

Issue 4:Disaggregating chronic pain

INJURY/STRAIN

DISABILITY

DISUSEPASSIVE AVOIDANCEPAIN

After Vlaeyen & Morley, Pain 2004; 110:512-516.

Catastrophic misinterpretations

Enjoy ?

INJURY/STRAIN

PAIN OVERUSE ACTIVE

AVOIDANCE

Inflated Responsibility

Enough ?

So ... Do you do CBT?

1. Perfectly all the time2. Most of the time3. Could improve4. Need to re-think quite a bit5. Definitely no and I don’t care

1 2 3 4 5

Thank you …

and thanks

especially to Neil Berry

Plus the usual suspects …..

Chris Eccleston

Amanda Williams

Frank Keefe

Johan Vlaeyen