Behavioral Medicine and Psychotherapy Approaches to Pain Rehabilitation

By Alvina Rosales, PhD
Co-Director of Pain Rehabilitation Program
Children’s Hospital Los Angeles
Los Angeles, California

and Alyson Herme, PhD
Staff Psychologist
Children’s Hospital Los Angeles
Los Angeles, California

Behavioral medicine approaches are vital to disrupting long, arduous downward spirals of chronic pain and functional disability experienced by patients in need of pain rehabilitation.  Behavioral medicine is a broad term used to describe interdisciplinary behavioral health techniques rooted in psychological, social, and biological science (e.g., biofeedback, shaping behavior and hypnosis). One of the unique features of Intensive Interdisciplinary Pain Treatment (IIPT) programs is the coordinated use of behavioral medicine techniques among interdisciplinary team members including psychologists, physicians, physical therapists, occupational therapists, nurses, social workers, and psychiatrists. Approaches focus on identifying and addressing cognitive-behavioral and emotional barriers to engaging in functional restoration treatments, such as physical therapy and occupational therapy.  Behavioral medicine approaches in IIPT are often led by psychologists with expertise in cognitive-behavioral therapy and behavioral science.

To understand the importance of behavioral medicine interventions in IIPT, it is necessary to describe unique challenges this patient population faces. By the time they start IIPT, patients have often experienced months, if not years, of debilitating chronic pain, have drastically increased medical utilization, have been evaluated by multiple providers, may have received multiple diagnoses, and tried various treatments with limited progress. Patients are often left feeling hopeless, engage in maladaptive coping strategies, experience pain catastrophizing and comorbid mental health conditions such as anxiety and depressed mood. Similarly, the family system is often socially, economically, and emotionally frayed and desperately focused on finding a clear etiology for pain and pain relief for their child. Patient and family tailoring of behavioral medicine approaches follows comprehensive interdisciplinary evaluation, where team members conceptualize patient’s experiences and identify salient biopsychosocial factors contributing to pain management and disability, including family system beliefs, values, and culture.

Behavioral medicine strategies are interwoven into IIPT, making it difficult to determine the extent to which they contribute to treatment success.  The most discernable and most studied approaches include cognitive behavioral therapy (CBT), biofeedback, hypnosis, distress tolerance, and relaxation training. See descriptions below.

Cognitive Behavioral Therapy (CBT) for Pain Medicine
Cognitive Behavioral Therapy (CBT) is one of the most effective treatments from chronic pain conditions (Fisher et al., 2018). It teaches patients how to change negative thoughts and maladaptive behaviors about pain into helpful thoughts and healthy actions.

Biofeedback
Biofeedback teaches children and adolescents useful relaxation and stress management techniques, while simultaneously receiving in the moment feedback that their coping skills are effective in helping them relax and manage stress. During biofeedback treatments, sensors are placed on one’s body (e.g., heart rate monitor on the ear) to measure physiological processes like breathing, heart rate, temperature, and skin conductance. This information is then projected onto a computer screen/tablet where patients are guided through computer exercises and games that teach them about the relationship between the mind and the body. Patients are then encouraged to continue to utilize these coping skills on a regular basis to help manage pain, stress, and anxiety.

Hypnosis
Hypnosis can be an effective intervention for managing pediatric chronic pain (Rogovik, A. L., & Goldman, R. D.; 2007). Hypnosis is a therapeutic technique in which clinicians provide suggestions to help youth improve coping with chronic pain. For example, hypnosis may allow youth with chronic pain to notice how they can increase a sensation of comfort or change the quality of physical sensations through dissociation (i.e. imagining a cool quality for burning sensation). 

Distress Tolerance and Relaxation Training
Distress tolerance is a skill adapted from Dialectical Behavior Therapy (DBT) in which patients are taught to cope with situations they perceive as overwhelming or unbearable, in this case activity associated with pain related distress (e.g. walking without assistive devices). Patients are taught to accept some degree of pain as unavoidable, while also taught to engage in adaptive coping strategies such as distraction and self-soothing behaviors (e.g. using senses).

Behavioral medicine is more embedded in IIPT program than the discreet use of the approaches listed above. Behavioral medicine becomes a common language among interdisciplinary providers. It validates past experiences, shifts focus to new learning and healthy coping, reinforces desired healthy behaviors, and encourages independent practice of behavioral pain management. For example, physical therapists may incorporate use of distraction techniques during exercises that have become feared or distressing to a patient and use positive reinforcement to shape behavior. Psychologists may help a patient break down thoughts and feelings experienced during physical therapy (PT) to help build patient’s and therapists’ understanding of avoidance behaviors. Psychologists and physical therapists may team up for a session to help patients practice adaptive thoughts/behaviors during PT. Behavioral medicine approaches are also embedded in program structure.

For example, IIPT programs often have a structured schedule that purposively models for patients and caregivers’ ways to imbed healthy coping, school time, and rehabilitation treatments into their daily lives.  Behavioral medicine techniques are used to teach parents to recognize adaptive and maladaptive responses to their child’s pain, and to shift focus from eliminating pain to increasing function and value-based living. Future research may elucidate to what extent collective use of behavioral medicine among interdisciplinary team members functions as a mechanism that promotes rehabilitation for youth with chronic pain participating in IIPT programs.

References & Resources

• Fisher, E., Law, E., Dudeney, J., Palermo, T. M., Stewart, G., & Eccleston, C. (2018). Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database of Systematic Reviews, (9).
• Law, E., Fisher, E., Eccleston, C., & Palermo, T. M. (2019). Psychological interventions for parents of children and adolescents with chronic illness. Cochrane Database of Systematic Reviews, (3).
• Palermo, T (2012), CBT for Chronic Pain in Children and Adolescents. USA, Oxford University Press.
• Rogovik, A. L., & Goldman, R. D. (2007). Hypnosis for treatment of pain in children. Canadian family physician Medecin de famille canadien, 53(5), 823–825.
• Simons, L. E., Kaczynski, K. J., Conroy, C., & Logan, D. E. (2012). Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response. The Journal of Pain, 13(12), 1151-1161.