Explaining Pain/Cognitive Restructuring: Have we been barking up the wrong tree?

I do wonder what the response might be to the title of this blog? Physiotherapy within pain management is still very much in the midst of an explaining pain / CBT evolution, but I do wonder if we have disregarded what our peers in other professions have been questioning with respect to their own methods?

Last month I blogged about whether ‘ACT was anything to get excited about?’ I feel I gave my position on it and why I felt it was. I touched on the topic of psychologically informed practice and decided to focus a bit more on this topic for this blog.

A quote from my previous blog provided a reflection on the current trend physiotherapy is adopting – psychologically informed practice (PIP).

‘Currently, physiotherapy is embracing the CBT approach of cognitive restructuring, a process by which clients evaluate, challenge and construct alternative thoughts with supporting evidence (Hayes, 2019; Thorn, 2017).’

It is explaining pain and cognitive restructuring that I want to focus on a bit more because I do wonder if we are barking up the wrong tree by adopting these psychological approaches into physiotherapy. You may also recall the “wee side note” from my previous blog where I rant on about being conflicted with the need to justify psychologically informed practice (PIP) within physiotherapy.  This is particularly difficult to reconcile when much of the evidence base in PIP is drawn from traditional psychological approaches that have failed to make an impact on pain outcomes.

What is Explaining Pain?

Simply, explaining pain (EP) refers to a range of educational interventions that aim to change someone’s understanding of what pain actually is, what function it serves and what biological processes are thought to underpin it (Moseley & Butler, 2015). One of the key components of EP, drawn from educational psychology, is something called conceptual change. The premise behind EP is to ‘challenge existing knowledge and knowledge structures, rather than simply ‘learning new information’, and refining learning strategies that engage new and potentially challenging concepts.’ In their 2015 paper Moseley and Butler argue the differences between CBT and EP and the almost frustrating outcome that has resulted in a misrepresentation of EP suggesting that “pain is all in the head.” An unfortunate conundrum and somewhat unfair when pain is something we (humans experience) and that a central tenet of EP is that pain is an output of the brain. Whilst the authors suggest that EP has been misrepresented, it begs the question had they inadvertently shot themselves in the foot?

What is Cognitive Restructuring?

Cognitive restructuring (CR) is a common approach from within Cognitive Behavioural Therapy. The general tenet behind CR involves the therapist and patient working collaboratively to identify irrational or maladaptive thoughts (flawed ways of thinking) and challenging their truth using strategies such as challenging the validity of the thought or changing negative thought into more positive thoughts. For example, some sceptics characterize the process of challenging dysfunctional thoughts as engaging patients in an attempt to “master” and “control” their thoughts. Furthermore, the suggest that cognitive restructuring aims to “teach clients to become better suppressors and avoiders of their unwanted thoughts”, thereby arming them with a potentially unworkable strategy to avoid experiencing negative emotions (Deacon, Fawzy, Lickel, & Wolitzky-Taylor, 2011).

According to Hayes (2019), cognitive restructuring has failed to make any real change as it is essentially deemed to be “fixing” flawed thinking and Longmore & Worrell, (2007) conclude that ‘despite CBT being claimed to work through modifying dysfunctional cognitions and realigning thinking with reality, there is little empirical support for cognitive mediation and a paucity of evidence that cognitive interventions forming the core procedural aspects of CBT are differentially effective in reducing distress.’ What I understand this to mean is that the research evidence does not support the notion that thoughts that we have after a given stimulus can be identified and changed, which concurrently can impact our response.

What this tells me is that proponents of change within psychology have been challenging CBT approaches such as CR for quite some time (Hayes, Strosahl, & Wilson, 1999).

So what?

I was hoping you might ask. EP and CR attempt to reconcile a person’s thinking about what is happening in their body, to try and update a person’s sensemaking. Beliefs and memory are driven by context. Context can be built from memory, experiences, current state, future states etc. I don’t know about you but I’ve tried long and hard to reconceptualise the fear and worries that sit within my imposter syndrome. Ironically, the more I try to reconceptualise the more I feel like an imposter!

I’m not saying don’t do explain pain because at some level it’s helpful that people get an understanding of how pain works and the premise behind hurt not equalling harm. I do often wonder how useful explaining pain is. It’s not for everyone. What I am saying is perhaps we don’t need to lean so much on explaining pain to gain traction with people. I’m sure those of you reading this will have seen the frustrated looks on people’s faces when we launch into another session of explaining pain, particularly if they’ve heard it all before.

Ok, so what? Well, perhaps the answer goes back to Fordyce’s proposition of ‘For behaviour change, information is like wet noodles to a brick’. That we learn best from our own experiences. Perhaps we don’t need to change thoughts or update sense-making to challenge those thoughts. That this approach leads to thought suppression and people fusing more strongly with those thoughts (Longmore & Worrell, 2007). Perhaps, if we held the thoughts more lightly and reduced our fusion with the thoughts and focussed more on actions or behaviour. Perhaps, using expectancy violation as a mechanism to disprove a person’s hypothesis about what they expect to happen or feel. Perhaps, using individual experience and clinical reasoning rather than overly relying on an evidence base to provide us with the “truth”.

What does this mean for physiotherapy adopting EP/CBT approaches?

Certainly, there is merit to these approaches because we are working with people not primarily tissue. We are also working with behaviour, and so it makes sense to be more cognizant of psychological and behavioural approaches in practice. That’s not to say the profession has never done it, listening, talking, educating, and goal setting can all be classed as psychological. Maybe one way to think about it is should physiotherapy be appraising the psychological research rather than just adopting traditional psychological approaches, and only after having done this identify what is appropriate or workable within the remit of physiotherapy.

At a professional level, if we scratch away the surface of what lies beneath physiotherapy, we reveal that the profession feels isolated because it lacks a true direction and definition of its purpose. That a new methodology to understand the complexity of physiotherapy is required (Nicholls, 2018).

Thanks for having a read

TNP

References

Deacon, B. J., Fawzy, T. I., Lickel, J. J., & Wolitzky-Taylor, K. B. (2011). Cognitive defusion versus cognitive restructuring in the treatment of negative self-referential thoughts: An investigation of process and outcome. Journal of Cognitive Psychotherapy, 25(3), 218–232. https://doi.org/10.1891/0889-8391.25.3.218

Hayes, S. C. (2019). A Liberated Mind: How to Pivot Towards What Matters Most. New York: Avery.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and Commitment Therapy: An Experiential Approach to Behaviour Change. New York: The Guilford Press.

Longmore, R. J., & Worrell, M. (2007, March). Do we need to challenge thoughts in cognitive behavior therapy? Clinical Psychology Review. https://doi.org/10.1016/j.cpr.2006.08.001

Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. The Journal of Pain, 16(9), 807–813. https://doi.org/10.1016/j.jpain.2015.05.005

Nicholls, D. A. (2018). New materialism and physiotherapy. In Manipulating practices: A critical physiotherapy reader. Cappelen Damm Akademisk.

Thorn, B. E. (2017). Cognitive Therapy for Chronic Pain (2nd Editio). New York: The Guilford Press.