Addressing Psychological Barriers to Chronic Pain Management

Saturday, June 1, 2013

Anger, anxiety, depression, fear, resentment and other psychological factors can prevent individuals with chronic pain from optimally responding to rehabilitation. Physicians’ Diagnostics & Rehabilitation Clinics (PDR) recently established a program that helps patients identify and overcome the thoughts and feelings that prevent them from enjoying the full benefits of rehabilitative therapy.

PDR — a practice with two decades of experience treating individuals suffering from chronic neck and low back pain — now offers Cognitive Behavioral Coaching (CBC) as one component to a patient’s overall program. CBC includes a series of six group sessions in which a licensed clinical social worker leads participants in performing cognitive behavioral therapy (CBT). A type of psychotherapy that helps individuals modify thought processes that lead to or exacerbate detrimental actions or behaviors, CBT allows PDR staff to help patients fully address their pain.

“Throughout the years, we’ve designed a program that manages the physical component of neck and low back pain quite effectively and predictably,” says Todd Ginkel, D.C., Director of Clinical Development and CEO of PDR. “What became clear as time passed is that the  psychological side of pain is more variable and difficult to treat. We began to consider offering CBT as its efficacy became increasingly apparent in scientific literature. In August 2012, the practice debuted CBC, a one-month, six-group series that patients can attend no matter where they are in their rehabilitation processes.”

Identifying Psychosocial Hurdles

Available at no additional cost to PDR patients, CBC is a flexible program that patients can begin at any point during the series. Individuals do not have to attend the entire course; in fact, some patients may wish to select the classes with topics that are most interesting or relevant to them.

Every individual with neck or low back pain who enters PDR’s rehabilitation program completes the Keele STarT Back Screening Tool, an exam that identifies patients’ psychological limiting factors and categorizes patients based on the risk of psychological barriers hindering their physical rehabilitation. PDR physicians review patients’ Keele STarT Back results and recommend CBC if results indicate patients would benefit from the educational support groups.

Keele STarT Back preliminary results from initial sets of rehabilitation participants indicated 51% of patients were at low risk for what Ginkel calls “psychosocial involvement”; 29% were at medium risk, while 20% were at high risk.

“Forty-nine percent of patients were dealing not only with the physical components of their pain but psychological limiting factors, as well,” Ginkel says. “That’s a huge percentage of the patient population who, before CBC debuted, weren’t receiving treatment for a significant component of their pain. We have seen impressive numbers of high- and medium-risk individuals transition to low risk since CBC began.”

“There are physical and emotional components to pain. Cognitive behavioral therapy doesn’t imply the pain a patient feels is all in his or her mind. Pain will emotionally impact any psychologically stable person who lives with it for a long time. What emotions and fears can do, however, is amplify pain and affect how individuals experience it.”
 — Sarah Nevin, M.S.W., LICSW, clinical social worker at Physicians’ Diagnostics & Rehabilitation Clinics

Developing New Ways of Thinking

Sarah Nevin, M.S.W., LICSW, clinical social worker at PDR, facilitates the CBC groups. “The first two sessions focus on thinking, the middle two explore the relationship between thinking and behaviors, and the final two emphasize behaviors,” she says.

  • Class 1: Automatic Thoughts and Self-Talk — This session helps patients identify the first, often inaccurate or psychologically harmful, thoughts they have when they feel emotionally vulnerable. Nevin illustrates, saying, “If I’m planning to go to a movie with a friend who has back pain, and I cancel at the last minute, my friend’s first thought might be: ‘No one ever wants to spend time with me because all I do is talk about my back pain.’ This is damaging self-talk.” She also focuses on how and why patients interpret the statements or actions of others.
  • Class 2: Restructuring Your Thought Process — Nevin discusses ways participants can change their thoughts and interpretations in this class.
  • Class 3: Stress Management and Understanding Chronic Stress — This class focuses on developing strategies for coping with persistent pain, which can contribute to chronic stress.
  • Class 4: Increasing Ways to Close the Gates to Pain — Drawing on the gate control theory of pain, Nevin teaches patients to identify positive actions or thoughts that shift the mind away from fixating on physical and emotional pain.
  • Class 5: Increasing Positive Experiences and Emotions — “What can you do today that will make you feel 5%, 10% or 15% better?” is a question Nevin poses to participants in this session.
  • Class 6: Acceptance, Willingness and Being Effective — In this meeting, Nevin teaches patients to accept that chronic pain is part of their lives but needn’t define them.

“Our goal for CBC is to reduce patients’ psychological hurdles and give them hope that they can build on incremental successes in their overall programs of care,” Ginkel says. “I believe the use of CBT as a component of managing chronic spinal pain will become increasingly commonplace as more practices recognize its efficacy.”

For information about PDR and its five locations in the Twin Cities metro area, visit