Designing next-generation psychotherapy in pain

People are often surprised at how badly our treatments for chronic pain perform. Pharmacological, surgical, rehabilitative, and psychological treatments all underperform against our expectations, wishes and ideals (Eccleston and Crombez, 2017). The good news, however, is that there is fervent research activity in the pharmacological and surgical fields to identify novel therapeutic avenues. The same is true in psychology. Recently, Professor Christopher Eccleston from the Centre for Pain Research at The University of Bath in the UK, visited our Department of Medical Psychology and Sociology at the Ruhr University of Bochum, headed by Prof. Monika I. Hasenbring, to present his new book ‘Embodied: the psychology of physical sensation and hold a one-day workshop ‘Developing next-generation psychotherapy for chronic pain’. This is what happened.

1 What is it like to be in chronic pain?

We started by putting the patient at the forefront of our thoughts. Pain starts with interruption. Imagine someone constantly demanding your attention and threatening to hurt you. Chronic pain is like that. Patients with pain are repeatedly interrupted, urged to escape and avoid harm, feel attacked by pain, and by the threat of (further) harm – feelings of failure and helplessness often follow and can be stubborn to shift. Living with constant interruption that interferes with normal life, that imposes new priorities and goals, can eventually alter identity. Over time, what is at stake is the very idea of who one is (Vlaeyen, Morley, and Crombez, 2016), a challenge that permeates through all aspects of life. Feelings of shame, guilt, anger, and embarrassment are constant companions but are rarely addressed in research. Despite the population and individual burden of pain, not to mention the clinical and economic, pain is often met with social silence, a cultural denial of suffering. Sociologically, pain is a challenge to the moral and micro-political order. Finding social or psychological help, the right kind of help, is a major challenge.

2 What do we do, and do well?

Undoubtedly, there is excellence in pain therapy. We discussed what is working and what we can improve? First, action needs to be based on theory. The links between applied psychology and fundamental psychology are perhaps weaker than they have ever been. We see fundamental researchers unaware of how their findings are being used in practice, and outstanding clinical practice not shared or broadcast outside of the local centre.

We had a lively discussion about how to capture what is done well. It is a major research imperative. How far is it possible to manualise treatments in order to share good practice, do we understand how to write at the right level of description, and what skills to assume essential? Like surgery, psychosocial interventions are highly dependent upon the skill of the operator, including the ability to tailor intervention to what one finds, ‘once inside’. On the other hand, how far can one deviate from the researched ideal and maintain the active ingredient. Where is the sweet spot between manual and individual? Although patterns of responding are evident, patients are as diverse as the general population (Hasenbring et al, 2012, 2014). In clinical studies, of course, we often seek to control the heterogeneity in patients, providers, treatment, and settings, in order to isolate the active components of any safe and effective intervention. In practice, however, the task becomes one of applying those active components back to the whole population in all of its glorious variety. Marginal gains in head to head trials of a novel treatment versus the standard may be important to the inventors of the novel treatment, but probably only to them. Moving to what is common across treatments, what is scalable, what can be delivered outside of expert centres, will be important in the future. Accepting that the different biology of chronic pain conditions may drive different psychologies, that some people are drawn to abstract therapies and others desire the highly practical, and that pain management for some will be relational whilst for others personal, will help us move forward. In greater specificity may lie greater impact.

3 Tomorrow’s world

Tomorrow will bring methods and technologies that allow for a much greater focus on the individual and individual change. Already there is growing research interest on personalisation, on what is important to people in the context of their lives, for some people that will mean a focus on suffering more generally, for others on techniques for altering the experience of pain. To date, there has been a traditional focus on suffering and quality of life, with pain rarely targeted directly. However, some are suggesting that we should bring direct experience ‘back to the table’ for discussion.  Can we directly improve pain with psychological methods? Understanding the psychology of physical sensations, grounded in biology, was much discussed. Increasing the richness of understanding in the varieties of physical experience, reducing the fear and uncertainties about cause, experience, and progression of sensation, and bringing those fears safely into the open are worthy of further research attention (Eccleston, 2016).

As we emerge from this second communication revolution, and the possibilities provided by a measured and instrumented life become clear, there is opportunity to change the very basis of therapy. To date this field has been dominated by the potential of technology to put patients in contact with experts. There is now development in the question of reimagining behaviour change interventions with novel technology, asking not can we do as well as expert face to face therapy, but can we make it better, much better? If we start from here what would we invent? The digital traces we leave in the wake of our communication, commercial, social, physical, and professional lives can be used to predict behaviour, and can be used therapeutically to prevent pain and related disability (Eccleston, Tabor, and Keogh, in press). It is early days, but it is our job to reimagine and innovate.

Finally, we recognized that as we move toward individual experience and individual change, so our philosophy of science, and our methods for establishing treatment efficacy and relevance, will also need to change. There is a place for larger multi-centre collaborations to both improve theory and capture larger samples. New strategies to develop, evaluate, and optimize treatments are also needed, including experimental factorial designs (Collins et al., 2014), and single case methods (Morley, 2018).

Attempting to predict the future is foolish, but to not plan for change is irresponsible. Change is necessary if we are to harness the extraordinary achievements of those who have developed psychological treatments, and demonstrated their value (Kugelmann, 2016). Our task now is to explore how to make that value relevant to the lives of more people, how to do it at scale, how to modernize it for how people live now, and how to guarantee it remains intimately linked to its foundations in basic psychological science.

About the authors

Nina Kreddig

Nina is a psychologist and post-doc researcher at the Department of Medical Psychology and Medical Sociology at the Ruhr University Bochum in Germany. She is interested in cognitive bias research in chronic pain, the role of sex/gender in pain anxiety, and the development of diagnostic tools.

Monika I. Hasenbring

Monika is Professor of Medical Psychology and directs the Department of Medical Psychology and Sociology at the Ruhr University of Bochum. The main area of research in the department is on psychobiological pain processing in the development, maintenance and treatment of musculoskeletal pain. “Psychology in depth” and”Psychology meets Neuroscience” are two current areas of research which complement clinical studies on an experimental level. Monika also directs the Psychotherapy Outpatient Clinic, mainly for patients with chronic pain, including research and training in psychotherapy and is member of the National Guideline Committee on Low Back Pain.

Christopher Eccleston

Chris is Professor of Medical Psychology at the University of Bath, UK, where he also directs the Centre for Pain Research. He established the Bath Pain Management Unit in 1995 and directed it until 2011, developing intensive treatment programmes for both adult and adolescents with chronic pain. He is the coordinating editor of the pain, palliative and supportive care (PaPaS) Cochrane Review Group (http://papas.cochrane.org), and psychology section editor for PAIN, and is actively involved in the promotion of pain science. He is interested in how people make sense of physical experience, how action in pain and discomfort is shaped, and how rehabilitation in pain is informed by the social, cognitive, and emotional context. In 2016 he published: Embodied: the psychology of physical sensation with Oxford University Press (ISBN: 9780198727903. e-ISBN: 9780191814099) and this year will publish an edited volume (with Chris Wells and Bart Morlion): ‘European Pain Management’ also with Oxford University Press (ISBN: 9780198785750).

References

Collins LM, Dziak JJ, Kugler KC, Trail, JB (2014). Factorial experiments. Efficient tools for evaluation of intervention components. Am J Prev Med; 47:498-504 (doi: 10.1016/j.amepre.2014.06.021)

Eccleston, C. (2016) Embodied: the psychology of physical sensation. Oxford University Press, Oxford.   ISBN: 9780198727903. e-ISBN: 978-0191814099

Eccleston C and Crombez G. Advancing psychological therapies for chronic pain F1000Research 2017, 6(F1000 Faculty Rev):461 (doi: 10.12688/f1000research.10612.1)

Eccleston C, Tabor A, Keogh E. (in press). Using advanced technologies to improve access to treatment, to improve treatment, and to directly alter experience. In DC Turk & RJ Gatchel (eds) Psychological approaches to pain management (3rd Edition). Guilford Press, New York.

Kugelmann R. (2016). Constructing Pain: Historical, psychological, and critical perspectives. Routledge, London. ISBN: 978-1138841222.

Hasenbring MI, Hallner D, Klasen B, Streitlein-Bohme I, Willburger R, Rusche H. Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up. Pain 2012;153(1):211–7.

Hasenbring MI, Chehadi O, Titze C, Kreddig N. Fear and anxiety in the transition from acute to chronic pain: there is evidence for endurance besides avoidance. Pain Management, 2014; 4: 363-374. (doi.org/10.2217/pmt.14.36)

Morley S (2018) Single Case Methods in Clinical Psychology; a Practical Guide. Routledge, London.ISBN: 978-1138211506

Vlaeyen JWS, Morley S, Crombez G. The experimental analysis of the interruptive, interfering, and identity-distorting effects of chronic pain. Behaviour Research and Therapy, 86:23-34 (doi.org/10.1016/j.brat.2016.08.016)