Hybrid emotion-focused exposure treatment for chronic pain

Michael K. Nicholas

doi:10.1016/j.sjpain.2014.05.005

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Hybrid emotion-focused exposure treatment for chronic pain

Michael K. Nicholas

Published/Copyright: July 1, 2014

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From the journal Scandinavian Journal of Pain Volume 5 Issue 3

The effectiveness of exposure-based treatments for people with disabling chronic pain is well-established and often impressive, but patients do not respond equally well, many drop out, and a proportion relapse once treatment is completed. It may just be there are limits to how much treatments for this population can achieve; after all, once pain becomes chronic there are no real cures and the known natural history of chronic pain is that it is likely to wax and wane over many years. But naturally, researchers and clinicians (and their patients) will always seek better outcomes.

While exposure-based treatments in the pain field have typically been based on the idea that people are avoiding movements expected to be painful, in this issue of the Scandinavian Journal of Pain Linton and Fruzetti [1] take up a perspective proposed by Lumley et al. [2] and argue that many chronic pain patients may also have learnt to avoid a variety of personally relevant, emotional stimuli, associated with the behaviour, as well as pain. In this sense, restricting the exposure treatment to movements alone may not be enough, especially if the patients engage in safety behaviours, like cognitive avoidance [3], that may undermine any benefits for behavioural exposure. Recent experimental evidence supporting this position was reported by Volders et al. [4].

One way of resolving the problem of patients presenting with evidence of both behavioural and emotional avoidance might be to address both domains of avoidance simultaneously. Tang et al. [5] recently described a hybrid version of cognitive behavioural therapy for patients reporting both insomnia and chronic pain, especially for patients in whom similar psychological mechanisms (e.g. catastrophic worry) seemed to be contributing to both problems. This work builds on the transdiagnostic perspective enunciated by Harvey et al. [6] and more recently by Linton [7]. Linton and Fruzetti [1] also utilize the transdiagnostic perspective in their study, but in this case they developed a hybrid treatment comprising behavioural exposure and emotion regulation. The behavioural exposure was consistent with the well-known methods previously described by Linton et al. [8] and others (e.g. de Jong et al. [9]).

The emotion regulation methods, however, were derived from dialectical behaviour therapy (DBT). DBT was originally described by Linehan et al. [10] as a version of cognitive behaviour therapy for chronically suicidal patients. The methods were subsequently adapted for patients with other difficult to treat conditions, including substance abuse and borderline personality disorders. In a previous paper Linton [7] described DBT for chronic pain as involving non-judgmental acceptance of patients and their behaviour while also supporting them in accepting what cannot be changed but working to change what can be improved. It is expected that emotional regulation can be enhanced by skills training that involves patients learning to identify and express emotions as well as by analyzing their own reactions in various situations and working towards their desired goals.

Linton and Fruzetti’s [1] study employed a single-subject design, with each of the six participants serving as his/her own control. Consistent with the premise underlying the hybrid treatment approach, the participants all had troubling chronic low back pain and high levels of catastrophic worry (pain catastrophizing scale scores > 25), as well, 5/6 had high fear of movement scale scores (>40). The treatments were conducted by three therapists (one experienced clinical psychologist and two clinical psychology trainees in their final term of training) on an individual basis in 9–12 sessions over 6–9 weeks. Evaluations were conducted at pretreatment, posttreatment and 5 months later. The measures evaluated pain catastrophizing, pain intensity, acceptance, negative affect (depression and anxiety), and function. Improvements were found for all participants on measures of catastrophizing, acceptance, and negative affect, at both post treatment and follow up. But for 5/6 participants improvements were also reported on pain intensity and function and these were thought to be clinically significant in magnitude. Importantly, in the follow-up period maintenance of gains was generally achieved across the participants.

This study has a number of strengths: it was carefully done and well-described, it used recommended single-case design methodology, and it confirms the findings of two earlier studies using a similar approach - a case report by Linton [7] and another by Lumley et al. [2] on patients diagnosed with fibromyalgia. The results are also consistent with another based on the same transdiagnostic approach with chronic pain patients by Tang et al. [5]. These outcomes provide important support for the potential value for the use of integrated hybrid models of treatment. By employing a single-case design methodology the researchers have avoided the usual pitfalls of group-based randomized controlled trials where patients are lumped together and it is difficult to identify response patterns at the individual level. Of course, the single-case design also means that it is not possible to generalize the findings to other pain patient populations, but that is not the purpose of these designs.

The main weakness of the study was that in some respects the participants were not representative of the sorts of patients typically referred to chronic pain services. This is probably due to the source of the participants (newspaper advertisements). Specifically, only one participant reported usual pain above 5/10, the rest were in the 3–5/10 range. Depression and anxiety scores also indicated that only two of the six participants were above the cut-off for clinical levels of either. Thus, it is not possible to generalize the results of this study to chronic pain patient populations broadly. Nevertheless, this issue should not detract from the merits of the study which provide a sound basis for further investigation of the hybrid treatment model. The next steps should include trials with more disabled and distressed patients, as well as those on significant amounts of medication.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2014.05.008.

References

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Published Online: 2014-07-01

Published in Print: 2014-07-01

Articles in the same Issue

https://doi.org/10.1016/j.sjpain.2014.05.005