Cognitive Behavioral Therapy for Chronic Pain Therapist Manual Jennifer L. Murphy, Ph.D. & John D. McKellar, Ph.D. • Susan D. Raffa, Ph.D. • Michael E. Clark, Ph.D. Robert D. Kerns, Ph.D. • Bradley E. Karlin, Ph.D. The image on the cover shows a network of the nerve cells which carry sensory information from the external world to the spinal cord and brain. The image was captured at the Bosch Institute Advanced Microscopy Facility, University of Sydney and is used with permission from: Dr. Michael Lovelace and Professor Tailoi Chan-Ling, Retinal and Developmental Neurobiology Laboratory, Discipline of Anatomy and Histology, University of Sydney; Professor Patricia Armati and Dr. Roberta Chow, Brain and Mind Science Research Institute and Nerve Research Foundation, University of Sydney. Cognitive Behavioral Therapy for Chronic Pain Among Veterans Therapist Manual Suggested Citation: Murphy, J.L., McKellar, J.D., Raffa, S.D., Clark, M.E., Kerns, R.D., & Karlin, B.E. Cognitive behavioral therapy for chronic pain among veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. Table of Contents Title Page .............................................................................................................................................................................................2 Table of Figures ...................................................................................................................................................................................6 Acknowledgements ..............................................................................................................................................................................7 Preface ..................................................................................................................................................................................................8 Part 1: Background, Theory, and Case Conceptualization .........................................................9 Introduction ........................................................................................................................................................................................10 What is Cognitive Behavioral Therapy for Chronic Pain? .........................................................................................................10 Organization of Manual ..............................................................................................................................................................10 Chronic Pain: Foundational Information ........................................................................................................................................... 11 Definitions ................................................................................................................................................................................... 11 Types and Locations of Pain .......................................................................................................................................................12 Treatment Options for Chronic Pain ...........................................................................................................................................15 History, Components, and Support ....................................................................................................................................................20 Chronic Pain: A Historical Overview .........................................................................................................................................20 CBT-CP: Theoretical Components .............................................................................................................................................20 CBT-CP Intervention ..................................................................................................................................................................25 Case Conceptualization ......................................................................................................................................................................29 Case Examples ............................................................................................................................................................................29 Case Considerations ....................................................................................................................................................................30 Therapist Considerations ...................................................................................................................................................................31 Chronic Pain Experience ............................................................................................................................................................31 Special Topics .............................................................................................................................................................................31 Part 2: Cognitive Behavioral Treatment for Chronic Pain .........................................................37 Structure of Treatment .......................................................................................................................................................................38 Content of Treatment: CBT-CP Protocol ...........................................................................................................................................44 Session 1: Interview and Assessment .........................................................................................................................................44 Session 2: Treatment Orientation ................................................................................................................................................47 Session 3: Assessment Feedback and Goal Setting ....................................................................................................................51 Session 4: Exercise and Pacing ...................................................................................................................................................55 Session 5: Relaxation Training ...................................................................................................................................................62 Session 6: Pleasant Activities 1 ..................................................................................................................................................67 Session 7: Pleasant Activities 2 ..................................................................................................................................................71 Session 8: Cognitive Coping 1 ...................................................................................................................................................73 Session 9: Cognitive Coping 2 ...................................................................................................................................................76 Session 10: Sleep ........................................................................................................................................................................78 Session 11: Discharge Planning ..................................................................................................................................................82 Session 12: Booster Session .......................................................................................................................................................86 Conclusions .................................................................................................................................................................88 References ...................................................................................................................................................................89 Appendix ......................................................................................................................................................................95 Therapist Manual 5 Table of Figures Figure 1 Medications for Pain ............................................................................................................................................................16 Figure 2 Cognitive Behavioral Conceptualization .............................................................................................................................21 Figure 3 Biopsychosocial Model .......................................................................................................................................................22 Figure 4 Chronic Pain Cycle ..............................................................................................................................................................25 Figure 5 CBT-CP Model ....................................................................................................................................................................25 Figure 6 CBT-CP Session Structure ...................................................................................................................................................41 Figure 7 Timing for Administration of Assessment Measures...........................................................................................................46