Brief Cognitive Behavioral Therapy for Chronic Pain: Therapist Manual

Gregory P. Beeler, Ph.D., M.A.,

Jennifer L. Murphy, Ph.D.,

Paul R. King, Ph.D., &

Katherine M. Dollar, Ph.D.

U.S. Department of Veterans Affairs

VA Western New York Healthcare System

Buffalo, NY 14215

November 1, 2016

Veterans Health Administration

Washington, DC 20420

Gregory P. Beehler, Ph.D. , M.A.

Jennifer L. Murphy, Ph.D.

Paul R. King, Ph.D.

Katherine M. Dollar, Ph.D., ABPP

Brief Cognitive Behavioral Therapy for

Chronic Pain: Therapist Manual

Version 2.0

BRIEF CBT-CP IS FOR USE BY QUALIFIED CLINCIANS ONLY. THIS

PROTOCOL SHOULD BE REVIEWED IN ITS ENTIRETY BEFORE

BEING APPLIED TO PATIENT CARE.

THIS MANUAL AND RELATED MATERIALS SHOULD NOT BE

USED FOR RESEARCH WITHOUT PRIOR PERMISSION.

FOR ADDITIONAL INFORMATION

AND UPDATES PLEASE CONTACT:

Gregory P. Beehler, Ph.D., M.A.

Associate Director for Research

VA Center for Integrated Healthcare

VA Western New York Healthcare System

3495 Bailey Avenue

Buffalo, NY 14215

Phone: 716-862-7934

Email: [email protected]

Homepage: www.mirecc.va.gov/cih-visn2/

Suggested citation: Beehler, G. P., Murphy, J. L., King, P. R., & Dollar, K. M. (2021). Brief Cognitive

Behavioral Therapy for Chronic Pain: Therapist Manual, Ver 2.0. Washington, DC: U.S. Department

of Veterans Affairs.

iii

ACKNOWLEDGEMENTS

Support for developing this treatment manual was provided by the Department of Veterans

Affairs (VA) Center for Integrated Healthcare (CIH). Use of the facilities and resources were

provided by the VA Western New York Healthcare System at Buffalo and James A. Haley VA

Medical Center (Tampa, FL). The information provided in this document does not represent the

views of the Department of Veterans Affairs or the United States Government.

We wish to expressly thank 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. and Bradley E. Karlin, Ph.D., the authors of

the original Cognitive Behavioral Therapy for Chronic Pain among Veterans: Therapist Manual,

who laid the foundation for this adaptation.

We also thank Drs. Thomas Farrington and Denise Mercurio-Riley who assisted in reviewing and

providing feedback in the development of this manual.

Most importantly, we wish to offer sincere thanks to the dedicated clinicians and Veterans who

inspired us to adapt this intervention.

PREFACE

BACKGROUND

This manual includes information regarding the development of Brief Cognitive Behavioral

Therapy for Chronic Pain (Brief CBT-CP). The project is being led by contributors from CIH and

James A. Haley Veterans’ Hospital and developed for use by behavioral health providers who: a)

identify the need for a brief, focused intervention for chronic pain, or b) are not working in a

setting that can accommodate a full-length CBT-CP protocol. Incorporation of a Brief CBT-CP

treatment may be most appropriate for (but not limited to) providers working in the following

settings: Primary Care-Mental Health Integration (PCMHI), home-based primary care (HBPC),

outpatient/specialty mental health, or individuals working in consultation-liaison roles with

medical clinics (e.g., oncology, endocrinology, etc.). Individuals who are experienced in

delivering specialty pain interventions may also find benefit in this protocol, particularly if

briefer alternatives are needed based on setting-specific demands or patient preferences.

ORGANIZATION OF THE MANUAL

This manual is organized into multiple chapters. The initial chapters provide a rationale for

developing the brief intervention and an overview of foundational material about chronic pain.

The structure and components of Brief CBT-CP are summarized, and key contextual and clinical

considerations for addressing chronic pain are reviewed. Two case examples illustrate

indications for Brief CBT-CP. An approach to addressing measurement-based care with Brief

CBT-CP is described in depth as well as a chapter regarding how to engage new patients in

treatment.

Next, each treatment module is presented. The protocol requires that modules one and six are

stable anchors to begin and end the protocol. However, modules two through five can be

presented in any order, depending on the preference of the patient and clinical judgment of the

therapist. An important feature of each chapter is the inclusion of Therapist Guides. Each

module guide provides an overview of each appointment, including the key elements and

general recommended structure. They provide suggested language to introduce topics and key

talking points with patients. Module Outlines are one-page summaries of required steps to be

conducted in each appointment. These can be referenced in real time during your

appointments to keep you on track during your 30-minute appointment. Patient handouts are

an integral part of this treatment and in the first appendix for easy printing or duplication.

Several additional appendices include detailed information about pain conditions, specialty

pain treatments, and relevant mobile apps that can be used as an adjunct to Brief CBT-CP.

TABLE OF CONTENTS

1. RATIONALE FOR DEVELOPMENT OF BRIEF CBT-CP……………………………………………..1

2. FACTORS TO CONSIDER WHEN SELECTING BRIEF CBT-CP……………………………………4

3. INTRODUCTION TO CHRONIC PAIN……………………………………………………………………7

4. CLINICAL CONSIDERATIONS WHEN WORKING WITH PATIENTS WITH CHRONIC

PAIN…………………………………………………………………………………………………………………..14

5. AN OVERVIEW OF BRIEF CBT-CP MODULE STRUCTURE…………………………………….18

6. MEASUREMENT-BASED CARE (MBC) WITH THE PEG………………………………………..21

7. THE HOOK: OFFERING PATIENTS BRIEF CBT-CP………………………………………………..27

● BRIEF CBT-CP PROTOCOL AND THERAPIST GUIDE ●

MODULE 1: EDUCATION AND GOAL IDENTIFICATION………………………………………….35

MODULE 2: ACTIVITIES AND PACING…………………………………………………………………..47

MODULE 3: RELAXATION TRAINING……………………………………………………………………59

MODULE 4: COGNITIVE COPING 1……………………………………………………………………….71

MODULE 5: COGNITIVE COPING 2……………………………………………………………………….80

MODULE 6: THE PAIN ACTION PLAN……………………………………………………………………88

REFERENCES……………………………………………………………………………………………………….98

APPENDIX 1: PATIENT HANDOUTS BY MODULE…………………………………………………101

APPENDIX 2: PAIN CONDITIONS………………………………………………………………………..142

APPENDIX 3: TREATMENT OPTIONS FOR CHRONIC PAIN……………………………………148

APPENDIX 4: MOBILE APPS FOR PAIN AND RELATED CONCERNS…………………...….156

APPENDIX 5: GUIDED IMAGERY SCRIPT……………………………………………………………..159

1. RATIONALE FOR DEVELOPMENT OF BRIEF CBT-CP

The full course of CBT-CP treatment typically requires eleven 50-minute sessions delivered by

therapists with specialty training in behavioral medicine or those providers specially trained as

part of the VA’s EBP program. This approach of treating chronic pain as a specialty mental

health intervention is time and resource intensive. Because of the widespread occurrence of

chronic pain among the Veteran population, there is increased interest among VA providers to

be able to offer briefer versions that can be used in more flexible formats in a wider variety of

settings. Thus, this manual serves the goal of making CBT-CP more widely available in a

briefer format. Our hope is that by offering Brief CBT-CP, the overarching goal of improving

Veteran outcomes through chronic pain self-management will be met more effectively.

1.1. EVIDENCE THAT BRIEF TREATMENTS MAY WORK FOR CHRONIC PAIN

Research on briefer psychological treatments for addressing chronic pain are growing. There

are multiple factors and corresponding lines of research that underlie the development of Brief

CBT-CP. First, because chronic pain is a common condition, multiple types of interventions are

necessary to treat pain in a sufficiently patient-centered way across diverse settings and

populations. A brief treatment may be especially well suited for addressing pain early in the

trajectory of care with the goal of preventing functional disability and distress. Second, prior

research suggests that briefer versions of CBT-CP offered in primary care and various other non-

mental health settings are effective (Ahles et al., 2006; Buszewicz et al., 2006; S.K. Dobscha et

al., 2009; Lamb et al., 2010; Martinson, Craner, & Clinton-Lont, 2020; Moore, Von Korff,

Cherkin, Saunders, & Lorig, 2000; Smith & Torrance, 2011; Von Korff et al., 1998; Wetherell et

al., 2011). Since first developing Brief CBT-CP in 2017, subsequent evaluation has indicated that,

on average, participating in Brief CBT-CP is associated with clinically significantly improvement

in a composite measure of pain intensity and pain-related functional impairment (Beehler et al.,

2019). Additionally, patients report high levels of satisfaction and acceptability of Brief CBT-CP

(Beehler et al., in press). Third, providing psychological treatment in primary care is especially

important given that over half of patients in primary care report chronic pain (Kerns, Otis,

Rosenberg, & Reid, 2003). Primary care providers find pain management especially challenging

(Matthias et al., 2010) and, according to Dobscha and colleagues, have reported dissatisfaction

with their ability to provide optimal pain relief for their patients (2008). Fourth, chronic pain

commonly co-occurs with mental health conditions such as depression, anxiety, and PTSD.

Thus, mental health providers may be especially well-suited for addressing chronic pain and

associated distress given the common CBT-based model of intervention. Finally, local

availability of pain resources and interventions may vary considerably across clinics. Thus, Brief

CBT-CP provides an additional, more accessible alternative.

1.2. BRIEF CBT-CP: ADAPTED FROM THE VA EBP

Brief CBT-CP as described in this manual has been adapted from the full-length VA treatment

(Murphy et al.). The authors of Brief CBT-CP, who are subject matter experts in the areas of

chronic pain management and integrated care, developed the protocol with several factors in

mind. Research indicates that CBT-CP is an effective treatment for chronic pain, but dismantling

studies do not provide sufficient guidance to suggest which specific components of CBT are

responsible for effective treatment outcomes. Thus, Brief CBT-CP includes an adapted version

of each key CBT-CP element: psychoeducation/goal setting; behavioral skills: activities,

pacing, and relaxation training; cognitive coping; and relapse prevention. Brief CBT-CP mirrors

the full-length CBT-CP currently disseminated throughout the VA as part of the EBP initiative

(Stewart et al., 2015).

1.3. BRIEF CBT-CP EMPHASIZES PATIENT-REPORTED OUTCOMES

A key component of this protocol is the use of patient-reported outcome measures

throughout the intervention. Use of brief validated measures to capture patient-reported

outcomes (e.g., routine assessment of pain intensity, distress, functional interference, and

others) at each module are strongly recommended in order to inform both patient and provider

about patient response to treatment. Previous research has indicated that routine outcome

monitoring is important for identifying patients who are not responding to treatment, with

continued monitoring useful for capturing patients’ response to treatment modifications

(Carlier et al., 2012; Scott & Lewis, 2014). Routine outcome monitoring will also aid the provider

in identifying patients who need a “step up” to a higher level of care. Specific instruction in

conducting measurement-based care as part of Brief CBT-CP is provided in a later chapter.

1.4. BRIEF CBT-CP IS DESIGNED FOR A DIFFERENT SETTING AND PURPOSE

Although Brief CBT-CP is not designed exclusively for primary care settings, efforts were made

to adapt CBT-CP to the PCMHI service delivery platform that has relatively unique features,

such as sessions of 30 minutes or less, highly focused brief assessments, an emphasis on

improving functional outcomes, and an emphasis on early detection and prevention.

Brief CBT-CP is designed to introduce patient self-management, improve pain self-efficacy,

reduce functional limitations, and potentially reduce self-report ratings of pain and negative

impacts of pain. Brief CBT-CP may be a used in a variety of ways depending on the clinical

context, provider, and patient. For example, a PCMHI provider may wish to use Brief CBT-CP for

patients with distress and functional limitations that stem from chronic pain. Specialty mental

health providers, behavioral medicine providers, or those in consultation-liaison roles may wish

to use Brief CBT-CP alone or as an adjunct to other medical or psychological therapies. Similarly,

even a pain specialist who usually provides full-length CBT-CP may wish to use the brief version

to meet the needs of patients who prefer or need a shorter treatment.

After a course of Brief CBT-CP, there are several potential options for disposition of the patient.

For some, no additional treatment will be necessary. Other patients may benefit from

occasional follow-up or booster sessions over the subsequent months to help with fine-tuning

the application of skills developed in Brief CBT-CP. Some patients may choose to continue with

their routine mental health treatment focused on depression, anxiety, or other psychiatric

concerns. Other patients may ultimately benefit from continuing on with a full course of CBT-CP

or additional pain-related psychosocial and rehabilitative interventions.

2. FACTORS TO CONSIDER WHEN SELECTING BRIEF CBT-CP

2.1. BEFORE BEGINNING BRIEF CBT-CP

Selection of this protocol assumes that providers have identified that brief intervention for

pain-related issues is clinically indicated. Because detailed training in the foundational and

functional elements of CBT clinical skills are beyond the scope of this manual, we recommend

that providers who wish to implement Brief CBT-CP have completed prior training in the basic

principles of CBT.

NOTE: Brief CBT-CP assumes that the patient has completed at least one appointment with a

mental health provider who has conducted an initial assessment appropriate to the practice

setting (e.g., functional assessment and mental health screenings typical of the PCMHI

setting; psychosocial history for a specialty mental health clinic).

2.2. ADDING BRIEF CBT-CP TO YOUR CURRENT PRACTICE: PROVIDER AND

SETTING FACTORS

Adopting a patient-centered stance is essential for conducting CBT-CP, including this brief

version. Following the biopsychosocial model, a patient-centered approach is required so that

the therapist can use patient-identified goals to direct the course of care. Patients are likely to

have a variety of concerns that are impacted by their experience of chronic pain. Thus, it is

essential to elicit from them their primary concerns. In this way, patient-centeredness is not

only a general approach to engaging the patient, it is critical for ensuring Brief CBT-CP is being

applied in a way that will be most useful.

This protocol has been designed to meet the needs of generalist mental health providers. It is

therefore important to consider that, at times, additional support from specialists may be

necessary. We advise that you identify your clinic or facility’s behavioral medicine or chronic

pain specialist(s) who can provide additional clinical support to you or act as an additional

referral source should your patient wish to engage in longer-term treatment or require a

higher level of care. It may also be helpful to coordinate care with the patient’s prescriber who

will play a key role in medical management of pain. The prescriber may find it valuable to know

that the patient is working toward better self-management.

2.3. DETERMINING WHO MIGHT BENEFIT FROM BRIEF CBT-CP

Brief CBT-CP will not be suitable for all patients, so clinical judgment must be used when

determining who might be best served by Brief CBT-CP. Patients who are particularly likely to

benefit from Brief CBT-CP include those with one or more of the following characteristics:

• Mild to moderate functional impairment and distress

• No severe mental health disorder or substance use disorder impacting overall function

or suggesting imminent safety risk

• Patient receptiveness to non-pharmacological self-management approaches for pain

Note: The above characteristics are comprised of suggestions only and should not be

interpreted as a list of inclusion criteria.

Finally, we provide two prototypical examples of patients who are appropriate for Brief CBT-CP

below:

2.4. BRIEF CBT-CP CASE EXAMPLE 1: PCMHI SETTING

Jeff is a 26-year-old White Veteran who recently enrolled in VA primary care services after

separating from active service in the Marine Corps six months ago. Routine mental health

screening by his primary care provider resulted in a referral to PCMHI staff for concerns related

to mood. Further evaluation by the clinic’s psychologist uncovered that chronic low back pain

stemming from his combat deployment is a significant contributor to his feeling irritable, and

that over-the-counter analgesics have offered limited pain relief. Jeff noted that his back pain,

rated as a five on the Numeric Rating Scale, has increasingly interfered with his sleep, ability to

sit through college classes, and interactions with his young son. He has become increasingly

concerned that pain will impact his long-term goal of operating his own business. He is

frustrated by what he describes as a near constant dull ache over the past two years, and

wonders if it will improve. Considering Jeff’s endorsement of moderate chronic pain and its

interference with daily activities, the clinic psychologist discusses both mood and pain

management options with Jeff and his primary care provider. Though Jeff has never attempted

cognitive behavioral self-management of his pain symptoms, he appeared eager to learn more

about managing pain, particularly through implementation of techniques that he can use on his

own. Further, he wishes to receive the bulk of his medical and mental health care in his primary

care clinic. Therefore, Jeff and his treatment team agree to incorporate Brief CBT-CP into their

collaborative approach to care.

2.5. BRIEF CBT-CP CASE EXAMPLE 2: BEHAVIORAL MEDICINE SETTING

Paulette is a 65-year-old African American Navy Veteran who is finishing treatment for colon

cancer. Her level of fatigue has increased as she completes her course of chemotherapy, which

has contributed to decreased mood and limited engagement in hobbies and social activities.

She has a relatively new post-surgical abdominal pain following her initial cancer surgery six

months ago. Additionally, she was diagnosed with moderate arthritis of the right knee over 10

years ago which has become more bothersome in the last several months. The infusion clinic

nurse identified that Paulette’s Numeric Rating Scale for pain is a seven, suggesting clinically

significant pain in need of additional intervention. Upon further discussion with the infusion

nurse, Paulette also reported increased frustration with her multiple sources of pain that are

clearly interfering with daily routines. The infusion nurse informs the oncologist who suggests a

new course of NSAIDs with the option of as-needed hydrocodone for more significant pain

flare-ups. Paulette agrees to try the NSAIDs, but is disinclined to use opioids due to concerns

over side effects. The oncologist also requests a referral from the behavioral medicine

consultant who contacts Paulette during her last chemotherapy treatment the following week.

Paulette reports that her pain is slightly better using the new medication but continues to be

disruptive. She also reports moderate depressive symptoms on the PHQ-9. Paulette does not

use any non-prescription drugs, but reports that she has been consuming more alcohol recently

in the evenings to help with sleep. As Paulette has been reporting to the VA frequently over the

last nine months since first diagnosed with cancer, she is eager to finish her treatment but does

not want to engage in extended sessions of psychotherapy. She is, however, willing to try the 6-

week course of Brief CBT-CP to help with pain management.

3. INTRODUCTION TO CHRONIC PAIN

3.1. WHAT IS PAIN?

According to the International Association for the Study of Pain (IASP), pain is defined as an

unpleasant sensory and emotional experience associated with actual or potential tissue

damage, or described in terms of such damage (IASP, 1994). This definition stresses that pain is

both a subjective physical experience (i.e., unpleasant bodily sensations) and emotional

experience (i.e., distress related to bodily sensations).

3.2. THE DIFFERENCE BETWEEN ACUTE AND CHRONIC PAIN

Pain can be either acute or chronic in nature (Institute of Medicine, 2011) as described below:

Acute pain has a short duration and is typically characterized by an identifiable injury or

disease. Some acute pain is expected to occur in response to health events, such as childbirth

or following surgery. Acute pain usually subsides over time as the body heals, and often

responds to standard medical treatments.

Chronic pain is an ongoing or recurrent pain lasting beyond the usual course of acute illness or

injury. Chronic pain typically lasts more than three to six months and adversely affects the

individual’s well-being. There may not be a clear underlying physiological cause to chronic pain.

Table 1. COMMON SOURCES OF PAIN

Common Sources of Pain

Acute

Chronic

Infection

Migraine/headache

Dental conditions

Arthritis

Burns

Fibromyalgia

Trauma

Irritable Bowel Syndrome

Surgery, other procedures

Trauma

Childbirth

Shingles

Musculoskeletal disorders (e.g., low

back pain)

Note: A detailed listing of additional pain conditions is located in the appendices.

Although it is important to adequately treat both acute and chronic pain, this manual focuses

only on the treatment of chronic pain. Psychosocial treatment of chronic pain is especially

important because of the well-established connection between chronic pain and diminished

quality of life, functional limitations, and psychological distress.

3.3. ADDRESSING CHRONIC PAIN IN THE VA: THE STEPPED CARE MODEL FOR

PAIN MANAGEMENT

There is a wide array of treatments for individuals with chronic pain. As shown in Figure 1, the

VA has adopted a stepped care model for pain. Stepped care is designed to adjust the intensity

of intervention based on patient presentation and response to care. The foundational step of

the VA model reflects the importance of routine self-care, from weight management to being

engaged in a safe and supportive social and physical environment. Step 1 includes care from

Patient Aligned Care Teams, or PACTs, who manage the majority of patients with chronic pain.

In the event that additional intervention is needed beyond services offered in PACTs, the

second step of this model includes referral to chronic pain specialists. The third step of care is

reserved for the most complex patients who require treatments such as coordinated

interdisciplinary programs. At all levels, stepped care for chronic pain stresses the importance

of a biopsychosocial perspective which considers not only traditional biomedical factors

(underlying pathology, pharmacological treatment, brief advice administered by a medical

provider) but also the psychological, behavioral, and social factors that impact Veterans with

chronic pain. Furthermore, stepped care at all levels endorses team-based approaches to care

with an increasing emphasis on patient self-management approaches.

Although the VA stepped care model suggests certain services for each step, the actual

availability of these services may vary by location. For example, Step 1 includes support from

the PCMHI provider in variety of ways, including Brief CBT-CP. PCMHI providers at a given

facility may or may not be prepared to provide support specifically for chronic pain

management. However, most are likely able to assist patients in adjusting to their pain

condition or by addressing comorbid mental health conditions. Alternatively, some PCMHI

providers will have behavioral medicine backgrounds that will allow them to take a more

diverse role in chronic pain management. This manual is well-suited to PCMHI providers who

are either new to chronic pain management or who desire to implement a brief treatment for

pain adapted from an evidence-based protocol.

Figure 1. VA's Stepped Care Model for Pain Management

3.4. UNDERSTANDING CHRONIC PAIN

Chronic pain is a complex phenomenon. As such, there are a number of conceptual models that

have been developed to explain the etiology and nature of pain. Currently, the biopsychosocial

model (Engel, 1977) is the most widely accepted approach to understanding chronic pain. The

biopsychosocial model (see Figure 2 below) suggests that the experience of pain is

multifactorial, with a wide array of physical, psychological, social, and other environmental

factors that may play a role in perpetuating pain.

For example, the biopsychosocial model suggests that in addition to the physiological basis of

their pain, an individual’s thoughts, behaviors, and social relationships are all important

contributors. Importantly, this model suggests that there are multiple points of intervention for

addressing chronic pain, from medical treatments, to psychological interventions, to

modifications in one’s social environment.

Figure 2. The Biopsychosocial Model

3.5. TREATING CHRONIC PAIN

Chronic pain can be treated through a wide array of modalities. Some of the most common

biomedical approaches are summarized in Table 2, with additional details and descriptions of

these approaches available in the appendices. Although treatments that address the

physiological contributors to pain are important to pain management, individual responses to

these treatments may vary considerably. Often, patients and providers will need to work

together to identify the best approaches for optimal pain care.

In addition to these biomedical-based treatments that address the physical domain, applying

self-management and relevant psychological and physical therapies are essential since all

dimensions of the biopsychosocial model must be addressed.

Table 2: BIOMEDICAL MODALITIES FOR TREATING CHRONIC PAIN

3.6. COGNITIVE BEHAVIORAL THERAPY FOR CHRONIC PAIN (CBT-CP)

There are several evidence-based psychological therapies that have been shown to improve

outcomes for patients with chronic pain. Among these, Cognitive Behavioral Therapy (CBT) is a

widely researched, time-limited psychotherapeutic approach applied to numerous mental and

behavioral conditions. CBT involves a structured approach that focuses on the relationships

among cognitions (or thoughts), emotions (or feelings), and behaviors. Treatments based on

cognitive behavioral theory have been successfully applied to the management of chronic pain,

either delivered alone or as a component of an integrated, multimodal, and interdisciplinary

pain management program. Evidence suggests that CBT-CP improves functioning and quality of

life for a variety of chronic pain conditions (Williams, Fisher, Hearn, & Eccleston, 2020).

CBT-CP is an approach rooted in the development of a strong therapeutic relationship that

encourages clients to adopt an active, problem-solving approach to cope with the many

challenges associated with chronic pain (Burns et al., 2015). Currently, the VA has endorsed

CBT-CP and developed a full-length treatment currently available as part of the Evidence-Based

Psychotherapy program (Murphy et al.). Use this link to download the manual.

Biomedical Modalities for Treating Chronic Pain

Pain-relieving medications (i.e., analgesics)

• Non-opioid analgesics

• Opioid analgesics

• Topical analgesics

• Muscle relaxants

• Adjuvant analgesics

• Headache-specific analgesics

Invasive medical treatments

• Epidural steroid injections

• Nerve blocks

Non-invasive treatments

• Physical therapy

• Cold/heat

• TENS

• Complementary and Integrative Treatments

The value of CBT-CP is its focus on improving patient self-management to positively impact

the chronic pain cycle shown below. The pain cycle (see Figure 3) illustrates how the

experience of pain can lead to maladaptive changes in behavior that ultimately lead to

increased distress, decreased activity, and a chronic course of pain. The experience of pain

often leads to decreased activity out of fear of increased pain associated with movement.

Limiting one’s otherwise beneficial activities can lead to physical deconditioning and

disengagement from pleasurable or otherwise meaningful activities and life events. The

persistence of chronic pain and disengagement from valued activities can lead to increased

emotional distress, negative thinking, and decreased motivation that result in further

disengagement. The resulting state of disability is reinforced by ongoing maladaptive coping.

Figure 3. The Chronic Pain Cycle

CBT-CP can provide patients with both a new perspective and new coping skills to increase

self-efficacy and break the cycle of chronic pain. The goal of CBT-CP is to identify and modify

maladaptive cognitions and behaviors that perpetuate pain-related distress and dysfunction.

CBT-CP is based on cognitive behavioral theory which focuses on the impact of cognitive

processes on affective states and resulting behaviors (Beck, 1995). The suffering associated

with chronic pain often leads to a maladaptive disengagement from people, places, and events.

Like all CBT approaches, CBT-CP draws from both behavioral theory and cognitive theory.

Behavioral theory is based on the premise that distressed individuals get a very low rate of

positive reinforcement from their environment. Because they experience few benefits of

engaging in activities (and engaging in certain activities may lead to more pain), they tend to

disengage. As they disengage from activities and people, they become more distressed and

enter a cycle of inactivity and spiraling depression. A key target of behavioral intervention is

behavioral activation (i.e., helping people to re-engage in pleasurable events or find new

activities).

In the case of chronic pain, certain physical movements or activities can lead to increased pain.

Pain may also be interpreted as a warning sign that certain movements or activities are unsafe

and result in harm or damage. It is not difficult to see why people with chronic pain stop

participating in certain events. Thus, we must find new ways of engaging in favorite activities

that will be less likely to produce pain. Ways of addressing physical inactivity, such as pacing,

are a key behavioral component of CBT-CP.

According to cognitive theory, the way we perceive, think about, or interpret an event impacts

our emotional experiences. Therefore, monitoring and understanding our thoughts is essential

to facilitating change. Automatic thoughts are those that occur immediately in response to an

event/situation, but often go unnoticed. Sometimes automatic thoughts occur in relation to

internal events, such as increased pain. If the automatic thought is unhelpful or maladaptive,

we may experience an unpleasant reaction at the emotional, physiological, and/or behavioral

level.

A particularly common type of these automatic negative thoughts around pain is known as

catastrophizing. Catastrophizing is a distorted thought process of imagining or assuming that

pain will lead to the worst or most intolerable outcome, such as “My pain will never go away”

or “My pain will ruin my life.” Treating the cognitive components of chronic pain includes

teaching patients to self-monitor and ultimately modify their maladaptive negative cognitions

in favor of more balanced thinking.

3.7. SUMMARY

The key operational components of CBT-CP involve breaking the chronic pain cycle by:

• Increasing engagement in healthy and pleasurable activities

• Enhancing positive pain coping skills, such as pacing and relaxation activities

• Correcting faulty assumptions and thoughts about pain

• Improving self-efficacy regarding management of pain symptoms

4. CLINICAL CONSIDERATIONS WHEN WORKING WITH PATIENTS WITH

CHRONIC PAIN

4.1. INTRODUCTION

Veterans who have chronic pain present with various levels of functional impairment and all

have their own pain story. In addition to the physical strain of managing chronic pain each day,

their suffering may have significant emotional and social dimensions as well. Often times,

Veterans with pain have seen numerous healthcare providers regarding their condition and

may feel frustrated with not receiving answers that they find satisfying regarding the etiology

or treatment of their pain. Perhaps most importantly, those with chronic pain may feel as if

they have not been “heard” adequately by providers. Various patient reactions can be driven

by the perception that insufficient time, attention, or care has been paid by healthcare

professionals when they are suffering each day.

As with all therapies, using CBT for the management of chronic pain requires the development

of a strong rapport. While Veterans may resist being introduced to another provider, especially

one in the mental health field, creating an environment where the Veteran is heard and

believed fully is a key to success. It is not the role of the therapist to determine the veracity of

the physiology of the pain complaint - pain is a subjective experience that is affected by

various factors. The functional impacts experienced by the Veteran should be the focus of

treatment, with clear education and direction offered as ways to positively alter the pain

experience.

While there are many challenges that may arise when treating Veterans with chronic pain,

some common topics that may impede therapeutic progress (with ideas for how to address

these complex issues) are reviewed in this section.

4.2. LOSS, GRIEF, AND ACCEPTANCE

Those with chronic pain may display certain responses to their condition and it can be

beneficial to help them identify and understand what they are feeling. For many, adjusting to

pain-related losses is one of the biggest barriers to treatment progress. Loss of identity,

confidence, well-being, and relationship/vocational roles are frequently recurring issues. Since

it is challenging to cope with and accept that the “old me” is gone, it is important to normalize

this response when working with patients since they have experienced a difficult and

unexpected shift.

It may be useful for both patient and therapist to conceptualize the advent and experience of

chronic pain as a significant loss. Kubler-Ross’ well-known and non-linear five stages of grieving

(Kubler-Ross, 1972) can be applied to better process the emotional process. The denial stage

may involve being “stuck” in the biomedical model with cognitions such as, “there must be

something to fix this.” Anger is common throughout the chronic pain experience. Individuals

may feel frustrated with the perception that doctors are not helping them or loved ones do

not understand. They may also feel anger about the perceived injustice of their situation -

dealing with pain every day that is not their fault, not being able to do what they want, finding

little relief in treatments. Those reactions may be even more extreme in those that are

younger since it feels particularly unfair. Bargaining and “if only” thoughts as well as feelings of

depression around the reality of living with pain are often present.

Acceptance, the final “stage,” does not imply that it is “okay” to have chronic pain or that the

person is “fine with it.” Patients may react negatively to the word “acceptance” and it is

important to differentiate an active acceptance versus a passive giving up. Quite the opposite,

actively accepting that life has changed and may be very different than what was previously

hoped for or planned is critical in moving forward. There is no suggestion in these stages that

one should “get over it” but instead be able to eventually ask themselves, “now what?”

Acceptance is a process and it takes time. While there is no right way to grieve the losses that

accompany life with a chronic medical condition, it may be helpful to encourage patients to

concentrate on living the life they have instead of focusing on the one that used to be. These

are difficult concepts to discuss, but being open about them helps individuals feel better

understood, less alone in their experience, and better able to take steps toward self-

management. Life can still be meaningful and fulfilling even when someone has pain, even if it

looks different than what was originally imagined.

Use of measures, such as the Chronic Pain Acceptance Questionnaire (McCraken, Vowles, &

Eccleston, 2004), may provide helpful information regarding where someone is in the grieving

process as well as evidence of positive progress during treatment.

4.3. MEDICATION MANAGEMENT

When treating individuals with chronic pain, issues frequently arise around medications and

medical procedures. Some Veterans may be highly focused on obtaining a particular

medication or treatment or they may be frustrated by pills being “pushed” on them without

alternatives offered. Regardless, because medications are typically a first line treatment for

pain, they are often an integrated part of daily life.

One frequent medication-related issue that arises in the context of treating individuals with

chronic pain involves the use of opioid analgesics. Opioids have increasingly been prescribed to

treat chronic pain in recent years, but an increased risk of adverse events (including accidental

overdose) has led to heightened regulation around their use. A lack of evidence supporting

long-term opioid therapy as well as side effects such as sedation, constipation, and the

possible need for tolerance-related dose escalation are all areas of concern. Veterans who

have had opioids decreased or discontinued may be opposed to these changes, upset, and

angry. When this is the case, medications may become a focus area by the patient, leaving

clinicians feeling a sense of helplessness and desire to “resolve” the issue.

Not specific to opioids is the more general belief by Veterans that "there must be something"

that can reduce their pain. This manifests in many forms, from a medication that they have

seen advertised on television to a firmly held conviction that they “need” surgery because a

physician mentioned it many years ago. Regardless of the details, this supports a belief that

pain is unidimensional and that a medically driven “fix” exists.

Educating patients about the biopsychosocial approach to pain and the many factors that can

impact the pain experience can be helpful. Allowing Veterans to vent about their medical

frustrations may be necessary, but allowing sessions to be derailed by these tangents is

problematic. Clinicians should acknowledge patient frustrations, encourage them to speak to a

prescriber, and then redirect the focus back to the skills that can be addressed in this

treatment. While therapists sometimes feel as if they are being insensitive or unsupportive by

providing such clear redirection, it is most therapeutic for patients to focus on what they can

change and control versus external factors.

4.4. OPIOID USE DISORDER

Opioid Use Disorder (OUD) is a DSM-5 diagnosis signifying a problematic pattern of opioid use

associated with impairment and distress. In addition, at least two of a group of other

symptoms must be present, including taking more or using more for than intended, ongoing or

repeated attempts to control use, related physical or psychological problems, and spending

excessive time in opioid-related activities. Due to the nature of opioid analgesics, developing

physiological dependence over time as one does with nicotine is expected and does not

indicate problematic use by patients. However, once opioids become a focus of attention with

various related adverse consequences, patients should be evaluated for OUD.

Some Veterans on opioids may struggle with suggested changes in their medication regimen.

They may resent feeling labeled as “drug seeking” when they request increased doses to feel

better, often a result of tolerance. They may be angered with suggestions to decrease or

discontinue opioids for risk mitigation when they are pleased with opioids’ effects, even if

those do not include significant pain reduction. Furthermore, since opioids were typically

initiated by a prescriber, they may feel “punished” with alterations in dosing schedules. In

these cases, it is again important to acknowledge and normalize Veterans’ feelings. The focus

should then return to the message that pain is multidimensional and must be addressed from

various approaches. While medication may provide limited relief, the skills being reviewed in

Brief CBT-CP can help improve overall quality of life. When Veterans are fixated on idealizing

medications, it may be useful to return to the facts that have been gathered from them

regarding their less than ideal level of functioning. Finally, it may be helpful to remind patients

that they are in control of using the skills in this treatment - they do not need to rely on a

provider and can self-manage their symptoms.

4.5. SLEEP

Sleep problems are among the most common complaints voiced by individuals with chronic

pain and the relationship between sleep and pain is complex. The presence of pain may make

falling and staying asleep more difficult, and disturbed. Insufficient sleep may increase next

day pain. Sleep conditions such as insomnia are linked with inflammatory processes, which

may also impact the bidirectional relationship between sleep and pain. It is not unusual for

poor sleep to be identified as the most frustrating issue for those with chronic pain due to its

negative physical and emotional effects. Therefore, it is important to discuss sleep and

evaluate the needs of the Veteran related to this topic.

While basic education around sleep hygiene may be conveyed and incorporated into

treatment, as it often would be in the primary care setting, it is important to determine if

triage is necessary. For example, if sleep disordered breathing may be present and has not

been assessed, a consult for a formal sleep study is likely in order, particularly as the

prevalence of sleep apnea is significant in the chronic pain population. If sleep issues are

severe enough to meet the diagnostic criteria for insomnia, a referral for local Cognitive

Behavioral Therapy for Insomnia (CBT-I) treatment is indicated. Use of the Insomnia Severity

Index (ISI) may be helpful in differentiating whether a consult for more intensive sleep

intervention is appropriate. Completion of CBT-I prior to engaging in CBT-CP may increase

successful outcomes, but determining the preferred order should be evaluated and

determined individually with the patient’s preferences in mind.

4.6. WORKING WITH RESISTANCE

Those with chronic pain may be resistant to psychological interventions for pain for a variety of

reasons. One strategy that may be beneficial when encountering resistance is the use of

Motivational Interviewing (MI) techniques which are highly patient-centered. MI can be used

to facilitate Veterans’ motivation to make positive health behavior changes. Because it

assumes that individuals are ambivalent about change, it seeks to help them uncover their

own internal motivation. Using open-ended questions so that they can share about pain

openly, affirming their strengths, reflecting empathically, and summarizing their perspective

and the next logical steps may help minimize resistance to treatment.

As always, it is important to remember that Veterans with chronic pain are hurting, often

emotionally as well as physically. Although they may exhibit defensive attitudes initially,

acknowledging the difficulty of their situation, including potential lack of compassion by

providers, can help establish a more open and trusting working alliance.

5. AN OVERVIEW OF BRIEF CBT-CP MODULE STRUCTURE

5.1. TREATMENT MODULES

Brief CBT-CP assumes that a standard initial PCMHI session following the 30-minute schedule

has been completed prior to starting Module 1. Brief CBT-CP consists of six modules. The brief

protocol requires that modules one and six are stable anchors to begin and end the protocol.

However, modules two through five can be presented in any order, depending on the

preference of the patient or best clinical judgment of the therapist. If there is no alternative

order preference identified, the modules should be delivered as listed in Table 3.

Table 3: BRIEF CBT-CP MODULES

Because CBT-CP is based on a model of intervention that emphasizes education and skill

development, educational handouts have been developed for use within the modules and to be

applied during homework modules. Patient handouts are an integral component of this

protocol and included in the appendices.

5.2. MODULE STRUCTURE

The structure of the Brief CBT-CP protocol is similar across modules and includes:

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Introduce the new material and answer questions

5. Discuss new home practice opportunity

6. Module wrap-up

Brief CBT-CP Modules

Module

Content

Education and Goal Identification: Pain education and development of treatment

goals

Activities and Pacing: Importance of engagement in activities using a thoughtful

approach

Relaxation Training: Relaxation benefits and techniques

Cognitive Coping 1: Recognize unhelpful thoughts that negatively impact the pain

experience

Cognitive Coping 2: Modify thoughts that are unhelpful when managing pain

The Pain Action Plan: Plan for independent implementation of CBT-CP skills and

identify additional follow-up needs

5.2.1. Introduce the module and confirming the agenda (1-2 minutes)

Offering a brief introduction to the module helps orient the Veteran to the topics that will be

covered while also providing the opportunity to ask Veterans if they have anything to add to or

modify about the topic. This allows the Veteran to influence the agenda and emphasizes the

collaborative nature of Brief CBT-CP. Because the Brief CBT-CP protocol is highly structured and

works under time-limited modules, it is important to acknowledge that events may occur that

warrant discussion and that may result in adjusting content covered in a specific module.

5.2.2. Ask about mood, complete the PEG, and discuss findings (3-4 minutes)

In addition to briefly and informally asking about current mood, completion of patient-reported

outcome measures is an essential component of this protocol. The next chapter of this manual

provides detailed instruction in how to engage in measurement-based care using the PEG (Krebs

et al., 2009). Briefly, the PEG is a well-validated three-item measure that assesses pain intensity

(P), interference in enjoyment of life (E), and interference with general activity (G). Because the

PEG is so brief, it should be administered at each session as part of measurement-based care.

Additional measures can be added at the discretion of the provider.

5.2.3. Review material from the previous module, including home practice (3-5 minutes)

Providing a brief review of material covered in the prior module can create continuity between

modules and allow the Veteran to raise questions as needed. Taking a moment to discuss

potential questions reinforces the collaborative nature of the intervention and reduces the

chance of important messages being misconstrued. Review of home practice is an essential

component of Brief CBT-CP and serves to build competency in the use of adaptive pain coping

strategies. It should also enhance Veterans’ sense of self-efficacy to manage their chronic pain

condition by implementing acquired skills in the “real world”.

5.2.4. Introduce the new material and answer questions (12-15 minutes)

The majority of time in each module should be spent introducing and discussing the new

material for the module. Provide a clear rationale to the Veteran for each topic. To ensure

understanding, elicit reactions from the Veteran to material covered. Through discussion that

involves active listening, cuing, and reinforcing learning in a supportive and collaborative

environment, the Veteran is able to acquire adaptive pain management skills.

5.2.5. Discuss new home practice opportunity (2-3 minutes)

After a new topic has been reviewed in the module, it is important for the Veteran to be able to

practice building and implementing the skill independently. Discuss helpful areas for home

practice with the patient. It is important that the Veteran understands the potential benefits of

engaging in the coping technique and how it is related to better managing the effects of chronic

pain. Practice should be discussed collaboratively to ensure that it is manageable for the

Veteran.

5.2.6. Module wrap-up (1-2 minutes)

Each module should include a concise summary of key points that emphasizes the value of

outside practice. This wrap-up also signals the end of the module and allows for the patient to

ask any remaining questions about content addressed or next steps.

6. MEASUREMENT-BASED CARE (MBC) WITH THE PEG

6.1. WHY MBC?

Limiting excessive use of assessment tools in the context of everyday integrated care practice is

critical given time constraints; however, outcomes measurement is essential. Measurement

allows the clinician to better understand the Veteran’s experience of pain and the functional

domains that are impacted. Measurement also allows assessment of progress throughout

treatment and information generated can indicate when a change in practice is indicated. MBC

refers to the use of screening and ongoing symptom monitoring to guide treatment selection

and treatment modifications to improve outcomes for chronic health conditions (Morris, Toups,

& Trivedi, 2012). The aims of MBC are to rapidly and precisely diagnose conditions and to

evaluate patients’ response to intervention in order to improve treatment planning between

providers and patients (Harding, Rush, Arbuckle, Trivedi, & Pincus, 2011). Furthermore, it offers

patients a mechanism by which to track their progress and identify quantifiable goals for

treatment. The information from MBC can facilitate shared decision-making which includes

exploring options with the patient, weighing pros and cons of potential choices, and making

informed decisions in line with patient preference. MBC typically guides treatment for common

medical conditions in primary care, such as hypertension and diabetes, and has demonstrated

effectiveness in improving patient outcomes for these and other disorders (Klonoff et al., 2011;

Pickering et al., 2005). Similarly, routine monitoring of patient outcomes for mental health

conditions is associated with improvement in provider documentation of diagnosis, more rapid

treatment modifications, improved communication between patients and providers, and

improvement in patient mental health symptoms (Carlier et al., 2012). The VA strongly

endorses MBC for mental and behavioral health concerns and has been promoting the use of

MBC across mental health treatment settings since 2016 as part of a national initiative.

6.2 ADMINISTERING THE PEG

For Brief CBT-CP, the PEG (Krebs, et al., 2009) should be administered at every session, as

indicated in the module structure outline. The PEG includes three items. One item of the PEG

assesses pain intensity, and two items assess pain-related interference (i.e., enjoyment of life

and general activity). The PEG usually takes just a few minutes for patients to complete. The

measure can be completed on paper by the patient or administered verbally by the provider.

Scores should, however, be entered into the progress note for documentation. (Note that the

PEG is not included in this manual but is available as a supplemental .pdf document.) As a

helpful point of reference, research with primary care samples has estimated an average PEG

score of 6.1 (SD = 2.2) in this population, indicating a moderate level of overall pain and pain-

related interference (Krebs, et al. 2009).

6.3 CASE EXAMPLE: USING THE PEG IN EVERYDAY PRACTICE

A case example will be used to illustrate how to administer the PEG as part of Brief CBT-CP. Jeff

is a 26-year-old White Veteran who recently enrolled in VA primary care services after

separating from active service in the Marine Corps one year ago. Routine mental health

screening by his PACT provider and subsequent referral to PCMHI staff determined that chronic

low back pain stemming from his combat deployment is a significant contributor to his

irritability and depressed mood. Jeff’s back pain was rated as a 7 out of 10 on the Numeric

Rating Scale. He reports that pain negatively impacts his sleep, ability to sit through college

classes, and interactions with his young son. He is concerned that pain will impact his long-term

goal of operating his own business.

6.3.1. Establishing a baseline PEG and communicating findings

At Jeff’s first session of Brief CBT-CP with his PCMHI provider, his PEG scores were as follows:

Item

Score

Pain Intensity

Interference with life enjoyment

Interference with general activity

To determine Jeff’s baseline PEG score, simply compute an average score using the following

formula: (Item 1 + Item 2 + Item 3)/3 = average score. For convenience during clinical use, round

decimal points to the nearest whole number. This procedure is illustrated below:

To compute an average PEG score

Formula

(Item 1 + Item 2 + Item 3)/3

Example

(7 + 6 + 7)/3 = 6.6 = 7, if rounding

In this case, Jeff’s score is a 7 out of a possible 10, with 10 indicating the greatest severity. A

general guideline for interpreting 0-10 pain scales like the PEG is listed here:

PEG score

ranges

Qualitative description of level of

pain/interference

1-3

Mild

4-6

Moderate

7-10

Severe

In this case, Jeff was reporting severe overall pain and pain-related interference. Keep in mind

that scores of ≥4 indicate pain/interference that could benefit from intervention. Optionally,

consider reviewing the three PEG items separately, especially if they vary greatly (e.g., Pain

intensity = 8, Interference (life enjoyment) = 2, Interference (general activity) = 3). This

variability in items should be discussed to explore with the patient why there is a difference

between intensity and interference.

Part of establishing a useful baseline for Jeff is to utilize the score to enhance communication

with both the patient and the PCP. Scores at baseline (or any point in time) can convey current

status:

“Jeff, your score of seven on the PEG is in the severe range. This

score, along with the information you provided during our

discussion, indicates that you could benefit from starting Brief CBT-

CP…”

A discussion that incorporates patient-reported outcomes can also help fuel motivation to

engage in treatment:

“Over the next several weeks, we will use the PEG again to

monitor any changes in your pain ratings. These scores will help us

plan our next steps together. We will aim to have your score go

down over time as you apply new skills as part of Brief CBT-CP…”

This discussion can set a norm of using measurement as part of shared decision-making

between the patient and provider, while maintaining the focus of care on pain management and

restoring functioning.

In addition to discussing scores with the patient, conveying PEG scores to the primary care

provider (PCP) is also important. This type of communication not only improves flow of

information between providers, but ideally prompts the PCP to reinforce your plan for using

Brief CBT-CP when he or she interacts with the patient (e.g., motivating the patient to re-engage

in balanced, structured physical activity to avoid de-conditioning). The PCP may also consider

adjusting his/her own treatment plan (e.g., medication changes, adding adjunctive services such

as referral to physical therapy) depending on the information you convey.

6.3.2. Assessing for change over time

As mentioned previously, a primary reason for engaging in measurement at each session is to

be able to assess for meaningful changes in scores over the course of treatment. Stability of or

changes in scores are important for assessing response to treatment and can suggest times

when modification to a treatment plan is necessary. Assessing for change between two time

points is simple and can be computed quickly as follows:

To compute change in PEG scores

Formula

(Average PEG score at time 1 – Average PEG score at time 2)

Average PEG score at time 1

Multiplying the resulting figure by 100 will provide an estimate of percentage change in scores.

As a general rule, a 30% change (improvement) in pain-related scores, including the PEG, is

considered clinically significant in response to a course of treatment. Although a 30% decrease

is ideal, other meaningful patterns are also important to consider given the relatively short time

frame inherent to integrated care settings.

In Brief CBT-CP, less dramatic but potentially meaningful changes have been identified in our

pilot work (Beehler et al., 2019). Previously, as part of a clinical demonstration project, we

found, on average, a statistically significant 1-point decrease in PEG scores between session 1

and session 3. Although additional research is needed to replicate these findings under the

conditions of a rigorous randomized controlled trial, initial support for Brief CBT-CP is

encouraging.

Assessing for change can be done at any time frame, including when comparing the first and

third required modules. For example, note Jeff’s PEG scores below:

Module

PEG score

Module 1 (Education and Goal Setting)

Module 2 (Activities & Pacing):

Module 3 (Relaxation)

(7-6)/7 = 0.14 * 100 = 14% improvement

During this relatively short time frame common in PCMHI, these measures suggest no dramatic

changes, but a decreasing trend. This trend is encouraging in that there are no large

fluctuations in PEG scores that would suggest worsening of symptoms. If Jeff were to continue

on this course with additional Brief CBT-CP modules, the following pattern may emerge:

Module

PEG

score

Module 1 (Education and Goal Setting)

Module 2 (Activities & Pacing):

Module 3 (Relaxation)

Module 4 (Cognitive 1)

Module 5 (Cognitive 2)

Module 6 (Pain Action Plan)

(7-5)/7 = 0.29 * 100 = 29% improvement

In this case, additional improvement in PEG scores was realized by continuing with the

remaining Brief CBT-CP modules. Having reached a 29% decrease in PEG scores suggests a clear,

clinically significant improvement in outcome.

Of course, this is only one example of what you might find with the PEG. Below we discuss how

to address three different situations (i.e., beneficial change, no change, or worsening of

symptoms) over time. It is important to then discuss these changes with both the patient and

PCP in determining next steps.

6.4 USING THE PEG TO IMPROVE SHARED DECISION-MAKING

Discussing PEG scores, including changes in scores over time, can facilitate shared decision-

making in which the provider (or providers) work collaboratively with the patient to determine

the best course of treatment. Although a full description of the nature of shared decision-

making is beyond the scope of this chapter, there are a few general principles that should be

considered. According to Elwyn and colleagues (2012; 2017), shared decision-making is a

process that includes three general areas: 1) working as a team to identify choices in light of

patient goals; 2) discussing alternatives, such as the advantages and disadvantages of each

option; and 3) making an informed decision that aligns with patient preference. PEG scores can

help initiate the process of decision-making when the data indicate that change (or lack of

change) in symptoms is evident during or at the conclusion of treatment. Outlined below are

some general guidelines for using PEG scores to generate options for treatment decisions.

When PEG scores show sufficiently meaningful improvement over time, first confirm if the

patient concurs with this assessment. If the patient’s experience of pain or disability does not

appear to be reflected by the PEG scores, additional assessment may be necessary to

determine why there is a discrepancy. However, if the patient feels that sufficient improvement

has been achieved and treatment goals have been met, no additional treatment may be

necessary. Explore with the patient what an end to Brief CBT-CP means in terms of follow-up

options.

“One of the options for us to consider includes wrapping up your

treatment at this time. Based on the improvement we’ve seen in

your PEG scores and the fact that you’re meeting your main goal

of getting through your classes at college, you’re likely in a good

position to begin applying these skills on your own. If we decide to

end for now, my door remains open should you need to reconnect

with me, or another provider, regarding your pain or any other

concern that impacts your wellness...”

For many patients, knowing that they can return to PCMHI as-needed is sufficient. Other

patients may prefer to address additional concerns with you or another provider outside of

PCMHI now that their pain-related interference is under control.

In situations where PEG scores suggest that no meaningful change is evident, again confirm if

this finding is consistent with the patient’s experience. Additional discussion may be necessary

if the patient’s verbal report of response to treatment differs from PEG scores. If the patient

agrees that insufficient progress is being made, first discuss potential treatment barriers and

other factors that could have impacted patient adherence (e.g., not engaging in home practice,

change in patient goals for treatment). If the patient has had a difficult time with treatment

receipt (i.e., learning CBT skills) or enactment (i.e., using CBT skills outside of session), consider

if revisiting prior modules would be valuable for enhancing skills development.

“Let’s talk a little bit amore about what might be getting in the

way of moving forward. It sounds like it’s been a challenge to find

the time to apply the strategies we’ve discussed in session. One

option for us to consider is spend a moment to find times during

the day that might be best to apply one or more skills…”

Also consider if optional modules of Brief CBT-CP are appropriate. If additional discussion

suggests that Brief CBT-CP was not effective despite adequate patient adherence and interest,

consider stepping up the level of care for the patient to include referral to a pain specialty

provider or behavioral medicine expert.

When PEG scores suggest the patient is getting significantly worse over time, be certain to

confirm if this trajectory is consistent with the patient’s experience. Discrepancies should be

explored with the patient to determine why declines in PEG scores may not be reflective of the

patient‘s experience. Depending on the extent of the decline, first consider issues related to

patient safety and well-being. Additional suicide risk assessment should be conducted with

appropriate follow-up action taken as needed. Further assessment should be focused on

determining the cause of increased pain and disability, which may be transient (e.g., temporary

but repeated pain flare-ups due to overexertion) or stable (e.g., significant re-injury, new

medical or mental health diagnoses, negative life event/psychosocial factors).

“As you know, your PEG scores show that your pain and its

negative impact has become more significant since we first started

working together. I’d like to take a minute and talk with you a bit

more about what might be contributing to this situation from your

perspective. I’d also like to ask some questions about your safety

and well-being given how down you’ve been feeling. We might

want to consider adding some additional help alongside Brief CBT-

CP. Alternatively, we might consider whether or not services with

another provider who can offer more intensive support might be a

good option…”

Such factors likely suggest that stepping up to a higher level of care (e.g., referral to the

specialty pain clinic) or adding additional services (e.g., psychiatry) to the current course of

treatment may be indicated.

7. THE HOOK: OFFERING PATIENTS BRIEF CBT-CP

7.1. INTRODUCTION

The goal of offering an orientation to Brief CBT-CP is to provide the Veteran with a roadmap for

what can be expected during treatment and to establish clear expectations for both the

therapist and the Veteran. Brief CBT-CP can be introduced to patients any time chronic pain

management surfaces as a key concern for the patient’s wellbeing, provided that safety-related

concerns (e.g., lethality, significant neurocognitive disorder, psychosis) are absent or otherwise

addressed. Regardless of when Brief CBT-CP is introduced, it is helpful to provide a persuasive

but honest portrayal of the nature of the intervention and its potential to benefit the patient

The Therapist Guide that follows was designed to illustrate how to engage in a conversation

with the patient that can be addressed in 10 minutes or less as part of a brief, 30-minute

standard initial appointment or intake (Figure 4). We strongly recommend using this guide to

enhance motivation for treatment engagement. Of course, conversations about Brief CBT-CP

may need to be modified based on the level of patient receptivity.

The 5-A’s module

structure for initial

PCMHI appointments

(Figure 4) provides an

excellent approach for

how to introduce and

educate patients about

Brief CBT-CP. In short,

after conducting a

routine assessment of

patient functioning and

summarizing your

understanding of the

patient’s concerns (that

include the need for

chronic pain

management), the

remaining time can be

used to introduce the

patient to Brief CBT-CP,

answer questions, and

address potential barriers to full participation. If your treatment setting allows for

appointments of longer than 30 minutes, then the remaining time can be devoted to beginning

the first module of Brief CBT-CP.

Figure 4. Phases of a 30-Minute Appointment

If the patient ultimately decides not to engage in Brief CBT-CP, it is valuable to consider other

options that may be available. Some patients simply need more time to consider their

treatment options. For this kind of situation, we include a two-page patient handout entitled

Before You Go: Additional Information about Chronic Pain Treatment Options. This handout

includes the following: a quick summary of Brief CBT-CP; a short relaxation exercise; links to

freely available mobile apps that can address health and wellness topics; space for the provider

to summarize next steps regarding chronic pain management, such as referrals to other clinical

services; and a space for the provider’s contact information.

Offering Patients Brief CBT-CP:

Therapist Guide

Although adopting an empathic stance is not unique to CBT, it is nonetheless important when

working with patients experiencing chronic pain. Often, patients will be referred to you for

treatment when their pain is most distressing or when biomedical treatments have been

insufficient. Empathy is especially useful for building rapport and trust.

What is Brief CBT-CP?

• Brief CBT-CP targets thoughts, emotions, and behaviors in order to improve pain-related

functioning.

• Brief CBT-CP promotes the adoption of self-managed tools by patients so that they can

take an active role in effectively addressing chronic pain and its negative effects.

• Use the Brief Cognitive Behavioral Therapy for Chronic Pain handout to illustrate the

CBT-CP model.

Scripting includes:

1. “Living with chronic pain can be very challenging. It can negatively impact how we live

our lives, including our ability to participate in activities and important relationships with

others. Individuals with chronic pain often struggle to find ways to manage their pain

and feel that they lack the know-how to move forward with their lives.”

2. “Brief cognitive behavioral therapy, or CBT, for chronic pain is designed to help us

respond to chronic pain in a way that will help us live a more fulfilling life. Patients learn

new pain management skills that can keep us connected to the people and daily routines

that we value.”

3. “An important piece of Brief CBT for chronic pain is the teamwork between the patient

and therapist. My goal is to work closely with you in a way that you find supportive and

empowering.”

4. “This intervention is designed to be brief so it’s not a long-term commitment. Of course,

if we decide that additional support will be beneficial, then I will help connect you to

additional services.”

What does Brief CBT-CP Include?

• The treatment structure of Brief CBT-CP includes six appointments that last about 30

minutes each.

• Topics covered reflect the key components of full-length CBT for pain:

• Pain education and goal setting

• Activities and pacing

• Relaxation training

• Cognitive coping (covered in two sessions)

• The Pain Action Plan

• Treatment is structured, but decision making is collaborative between patient and

therapist.

Scripting includes:

1. “Brief CBT for chronic pain includes six modules of 30 minutes each. We will cover a new

pain management skill each week based on your preference. This means that we will

work closely and stay focused to make the most of our time together.”

2. “Our first module will provide some important background information about chronic

pain itself and setting new goals for moving forward. Then we will decide together about

the order of our remaining topics. We will choose from the following: activity planning

and pacing, which will help us avoid a common pitfall of overexerting ourselves and

causing a pain flare up; relaxation training which will cover several ways to reduce

tension in our bodies and feeling distressed; and cognitive coping, which helps us

address unhelpful thought patterns -we learn to feel better by changing the way we

think about pain and ourselves. Our final module will focus on reviewing the skills we

learned and developing a plan for how best to use those skills.”

3. “At the end of each module, we will talk about ways you can begin to practice each skill.

Practice is very important as we want these new approaches to become good habits. We

will find a way to make practice doable even during a busy day.”

What are the Advantages of Brief CBT-CP?

• There are number of advantages to applying Brief CBT-CP, both practical and research-

supported. Based on what you know about the patient, it’s helpful to emphasize the

match between patient needs/goals and what Brief CBT-CP can offer.

Scripting includes:

1. “CBT for pain has been studied by researchers for many years. Overall, these studies

show that patients experience less distress and disability after using what they learn in

CBT. Some patients even report that their pain intensity has decreased.”

2. “CBT for pain is safe for almost anyone. There are no known negative side effects and

the focus is educational and skill-building.”

3. “The brief version of CBT for pain that we will use is less than three hours of treatment

time and is spread out over several weeks. This minimizes the amount of travel and time

you spend in treatment.”

What are the Limitations of Brief CBT-CP?

• Discussing the limitations of Brief CBT-CP can be helpful in setting realistic expectations

about what treatment can and cannot accomplish.

Scripting includes:

1. “Brief CBT-CP can be very helpful, and it requires that we work together as a team to

help manage your pain more effectively. Part of your treatment will include assessing

your pain and distress using one or more brief, easy to complete surveys. These will help

us determine what is going right in treatment and other areas that may need more

focus.”

2. “Brief CBT for pain is primarily about helping with pain management. This does not

mean eliminating your pain but responding to your pain in a more helpful way so that it

feels less overwhelming.”

3. “Sometimes during treatment we will need to talk about some difficult experiences you

have had in relation to pain so that you are able to respond in beneficial ways in the

future. Over the course of treatment, the goal will be to use the skills we learn to address

distressing pain-related experiences.”

Before You Go: Additional Information about

Chronic Pain Treatment Options

Today we discussed some of the challenges of living with chronic pain. We also discussed some

options available to help manage chronic pain. One option that may be a good fit for you is

Brief Cognitive Behavioral Therapy for Chronic Pain, or Brief CBT-CP. Some key information

about Brief CBT-CP is summarized here, in case you would like to begin this treatment at a

future time:

1. Brief CBT-CP can help decrease distress and disability from pain and is safe for almost

anyone.

2. Brief CBT-CP includes six, one-to-one meetings of about 30 minutes each. Treatment can

be spread out over 6 to 12 weeks.

3. A new pain management skill is covered each week based on the order you prefer. Key

topics and skills include:

• Activity pacing, which helps with avoiding a common pitfall of overexertion that

causes a pain flare-up.

• Relaxation training, which will help to reduce tension in your body and manage

distress.

• Cognitive coping, which will help with managing unhelpful thought patterns.

• Developing an action plan, which will help you move forward with meeting

important personal goals based on new pain management skills.

Here’s a quick deep breathing exercise to consider that can help manage the stress that comes

with living with chronic pain:

1. Find a safe, quiet place to sit or lie in a comfortable position for at least five minutes.

Use soothing music to block out distracting noises, if necessary.

2. Breathe in deeply, but comfortably, taking a moment to focus your thoughts on your

breathing.

3. Count to yourself “one” at your next inhale, and exhale at your own pace. Continue to

count (e.g., “two”…, “three”…, “four”…) each time you inhale until you get to ten.

4. Take a moment to notice your breathing as it slows and develops a new rhythm. If

disruptive thoughts enter your mind, re-focus on counting each inhalation.

5. Count in sets of ten breaths for as long as you feel comfortable. Practicing two to three

times a day for short periods can be helpful when first learning this skill.

Visit the VA mobile app store (https://mobile.va.gov/appstore) to download free apps to help

with stress management and healthy lifestyles. These are a few examples of the health topics

these apps address:

• Chronic pain

• Sleep

• Weight loss

• Smoking cessation

• Stress management

• Coping with depression, anxiety, PTSD, and other mental health concerns

We discussed several options that can help you with better pain management and overall

wellness. Here is a summary of next steps to follow:

Provider: Include helpful information below on referrals to other services initiated today.

1._______________________________________________________________________

2._______________________________________________________________________

3._______________________________________________________________________

Living with chronic pain can be very challenging. It can negatively impact how we live our lives,

including our ability to participate in activities and important relationships with others.

Treatment options are available that can lead to new ways of coping with pain to maintain

connections to the people and daily routines that we value. My goal is to work with you in a

way that you find supportive and empowering.

If you would like more information about your treatment options for chronic pain or related

concerns, please contact me at the number below:

Provider/Clinic name: ____________________________________________________________

Phone number:_________________________________________________________________

Additional information: __________________________________________________________

BRIEF CBT-CP PROTOCOL AND THERAPIST

GUIDES

1. BRIEF CBT-CP MODULE ONE: EDUCATION AND GOAL IDENTIFICATION

In the context of primary care and other settings, the first contact with the Veteran is typically

used for the collection of information and to determine an appropriate treatment plan. At the

point of engaging in Brief CBT-CP, it is assumed that the initial functional and symptoms

assessment have been completed and that the Veteran has pain-related concerns that can be

best served in primary care.

1.1. Module Agenda

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Introduce the new material and answer questions

5. Discuss new home practice opportunity

6. Module wrap-up

1.2. Module Materials

• PEG self-report measure

• Patient handouts (see appendix):

o Factors That Impact Pain

o The Chronic Pain Cycle

o Brief Cognitive Behavioral Therapy for Chronic Pain

o SMART Goal Setting

1.3. Module Content for the Provider

1. Chronic Pain Education

Understanding the difference between acute and chronic pain is the beginning of effective

management of persistent pain. While acute pain is a symptom and requires adjustments in

behavior so that appropriate healing can take place, chronic pain is an ongoing condition that

no longer signifies that damage or harm is actively occurring. Even though these two different

types may feel exactly the same, the meaning has changed. While withdrawing from what

causes pain is adaptive in acute pain as it allows the healing process to occur, that response is

maladaptive in chronic pain. Even in the case of conditions such as arthritis where there is a

gradual degeneration occurring, pain is not a sign of an acute injury and there are no

expectations of resolution or healing. Thus, it must be addressed in the same way.

Because of these differences, chronic pain must be managed as a chronic condition in much of

the same way as other disorders such as diabetes or heart disease. The biomedical model,

which works well with problems that resolve such as a broken arm, does not work well with

chronic pain. Since chronic pain has not responded adequately to treatment and resolution is

no longer expected, a different model for understanding it must be applied: the biopsychosocial

model.

Figure 5. Acute and Chronic Pain

Figure 6. Biomedical and Biopsychosocial Approaches to Pain

Acute Pain

Lasts less than 3 months

Responds to medical treatment and

diminishes with healing

Has an identified cause; body's

response to injury

Is a symptom

Chronic Pain

Lasts more than 3 months

Persists despite treatment

May develop after incident; cause

may or may not be known

Is a condition

Biomedical Model

Focuses on purely biological factors of

illness/disease

Is a symptom; assumed that resolution or

cure is possible

Works well with acute pain

Biopsychosocial Model

Focuses on biological, psychological, and

social factors of pain that interact

Is a condition; assumed that management

is key since resolution is not possible

Is necessary for chronic pain

2. Effects of Pain

Chronic pain affects many different areas of life. The interaction between biological/physical

(pain and medical issues), psychological (cognition, affect/emotion, behavior), and social

influences helps to explain the variability between individuals and their reports of pain. Figure 7

shows the overlap between these areas.

Figure 7. The Biopsychosocial Model

Use the Factors That Impact Pain Handout to review some of most important biological,

psychological/behavioral, and social variables that may influence chronic pain. Discuss with

Veterans how pain has impacted their lives from all aspects:

• Biological or medical factors (e.g., pain condition, comorbidities)

• Psychological factors (e.g., negative mood, lowered self-esteem, activity engagement)

• Social factors (e.g., relationships, employment)

Explain that since chronic pain is a complex problem, it must be approached in a

comprehensive way. While some factors such as previous injuries cannot be changed,

emphasize that many of the factors that impact pain can be adapted with the assistance of Brief

CBT-CP. This treatment helps Veterans change the way that they react to pain so that it has less

of a detrimental impact on their lives.

Now that the various areas of life that pain affects have been identified, use the Chronic Pain

Cycle handout (see Figure 8) to discuss the process and stages that may occur over time for

Biological

Factors

Social

Factors

Psychological

Factors

those with chronic pain. As the figure illustrates, the onset of chronic pain often leads to a

decrease in activities, which leads to physical deconditioning. Dealing with constant pain may

also lead to negative thoughts (i.e., “I can’t do anything when I have pain like this”) and

emotions such as frustration and depression. These factors contribute to increased avoidance

of family and friends and anything that involves movement since it hurts to move. This

combination means more distress and disability, leading to increased pain. Many Veterans will

be able to recognize this pattern in their own lives.

Figure 8. Chronic Pain Cycle

3. Goal Identification

The general objectives of Brief CBT-CP are to improve quality of life through the steps listed in

Table 5:

Table 5. OBJECTIVES OF BRIEF CBT-CP

Reducing the negative effects of pain on daily life by engaging in more activities, improving

mood, and increasing coping skills should be highlighted. While decreased pain intensity may

occur, try to help Veterans shift their preoccupation away from pain and towards functioning.

The hope is to make life more fulfilling so that pain feels less overwhelming.

The identification of individualized, Veteran-centric goals is critical for tailoring modules and for

helping the patient increase motivation for treatment engagement. Developing personally

meaningful treatment objectives that are achievable provides a framework to guide therapy. It

can be introduced to the Veteran with a simple statement such as:

• Let’s get you back to doing more of what is important to you.

It is sometimes difficult for individuals to produce specific goals on their own, so it can be

helpful to ask questions to guide the discussion, such as:

• What is something specific that you would like to see change in your life in the weeks to

come?

• What would you like to be able to do (better, more of, etc.)?

• If this treatment were successful, how would that look in your day-to-day life?

• Are there relationships that you would like to improve?

In order to assist in goal setting, the SMART model will be used to develop individualized goals

that are outlined in Table 6.

Reducing the negative impact of pain on daily life

Improving physical and emotional functioning

Increasing effective coping skills for managing pain

Reducing pain intensity

Table 6. INDIVIDUALIZED SMART GOALS

Specific

Identifies a specific action or event that will take place.

Measurable

Should be quantifiable (countable) so progress can be tracked.

Achievable

Should be attainable and realistic given resources.

Relevant

Should be personally meaningful.

Time-Bound

State the time period for accomplishing the goal.

Adapted from Doran, 1981

The SMART Goal Setting worksheet should be used with the Veteran in session. This worksheet

includes both short-term goals that can be accomplished over the course of the Brief CBT-CP

treatment timeline, as well as long-term goals that may span over the next year but are

important in serving as a motivator. While engaging in Brief CBT-CP requires time and effort,

these goals should help illuminate why the long-term benefits outweigh the short-term

investment.

Once individualized treatment goals are established, they should be monitored on an ongoing

basis for positive reinforcement and to adjust goals and treatment as indicated. It is

recommended that both the Veteran and therapist have a copy of the goals sheet available

throughout the course of treatment so that it can be referred to regularly.

4. Home Practice

Ask Veterans to continue to contemplate both short- and long-term goals. Stress the

importance of following the SMART formula reviewed during the session. Remind Veterans that

the general Brief CBT-CP objectives will be the framework for all modules, while the

individualized objectives will help motivate Veterans to engage in activities that will improve

the quality of their life and reduce the negative consequences of pain. The SMART Goal Setting

worksheet should be completed at home prior to the next module.

Brief CBT-CP Module 1 Therapist Guide:

Education and Goal Identification

Note to provider: Scripted statements are provided below as suggestions, rather than rules, of

how to introduce topics to patients. Scripting can be especially helpful for those providers

who are new to the content of Brief CBT-CP. Feel free to modify the scripting as needed as you

become more comfortable with core elements of each module.

1. Introduce the module and confirm the agenda

Scripting includes:

1. “Today we will begin brief cognitive behavioral therapy for chronic pain. This treatment

will help you develop new skills to use at home between modules and in the future. One

of the first things we will do at each appointment is work together to establish an

agenda for our time together. I have found that having this agenda helps to ensure that

we both get to talk about the items that we would like to discuss.”

2. “First, I would like you to complete a brief pain measure, and I will also check in on your

mood. Next, we will discuss some background on chronic pain itself and develop a plan

for how we will address some of your goals related to pain management. How does that

sound to you? Are there other things relevant to our pain work that you want to be sure

to cover today?”

Note to provider: If the patient is inclined to add items to the agenda that are not related to

pain management, the first effort on behalf of the therapist may be to link the topic back to

pain. For example, a statement such as the following may be helpful to refocus the patient:

“That sounds like it was stressful. Did you notice that your pain worsened during that time?”

2. Ask about mood, complete the PEG, and discuss findings

Scripting includes:

1. “First off, how are you feeling today and how has your mood been?”

2. “Next, I would like you to complete these three quick questions today. These items will

help us track your progress over the course of treatment. They can also help us identify if

we need to provide additional help along the way. After you complete the measure, we’ll

review the results.”

Note to provider: Informally checking on mood will give you a sense of how the patient is

currently coping while also providing the patient with the opportunity to express any

significant distress that might need immediate attention. Do not hesitate to further assess

for significant safety concerns, such as suicidal ideation, when indicated and by using

standard local procedures for your clinic. Assuming no safety concerns are present, briefly

review the PEG scores with patient as described in the chapter on measurement-based care.

3. Review material from the previous module

Although this is the first module of Brief CBT-CP, it is a good time to check in with patients

about any final questions or concerns they have about this treatment before getting started.

Scripting includes:

1. “Before we get started on new material, do you have any questions?”

4. Introduce the new material and answer questions

4.1. Chronic pain education

Scripting includes:

1. “To get started, I want to talk a bit about what makes chronic pain different from acute

pain, or pain that goes away after an injury heals.”

• Compare and contrast chronic pain with acute pain.

• Explain why these pains may feel the same but must be treated differently.

4.2. Effects of pain

• Use the Factors that Impact Pain handout to explain the 1) biopsychosocial model and

2) review the variety of factors that can negatively or positively impact chronic pain

Scripting includes:

1. “Chronic pain impacts many areas of our lives. You can see in this diagram that the

chronic pain you experience can be impacted by the interaction of biological or medical

factors, psychological factors, or social factors.“

2. “These factors can impact our chronic pain in either a negative way, a beneficial way, or

both and vary from person to person. They can turn up the volume on pain or turn down

the volume. What factors impact you the most?”

Key Point: Asking patients about what factors impact them the most will help you to identify

potential treatment targets (e.g., for SMART goal development).

Key Point: Emphasize that Brief CBT-CP is designed to help patients manage the impact of

chronic pain across these three domains.

• Use The Chronic Pain Cycle handout to explain how chronic pain may negatively impact

life over time.

Scripting includes:

1. “Chronic pain can take a toll on our behaviors, thoughts, and feelings. It’s shown here

how pain may lead us to stop participating in activities that we enjoy which leads to

negative thoughts and feelings. As our mood gets worse, we might withdraw from

routine activities and even our relationships. The less engaged we are in life, the more

distress we may feel. And without enough physical activity, we might become

deconditioned or disabled, making our pain worse.”

Key Point: Review the costs of inactivity noted on the handout.

Note to provider: Be aware that some patients may not be avoiding or under-engaging in

activities, but may be dealing with negative ramifications of pain nonetheless. Some

individuals may also be overactive, which can exacerbate their pain. The primary goal, in this

regard, is to achieve balance in activities. The module regarding Activities and Pacing will

address this concern in greater detail.

Key Point: Brief CBT-CP can help break the chronic pain cycle.

4.3 Goal Identification

• Use the Brief Cognitive Behavioral Therapy for Chronic Pain handout to provide an

overview of the objectives of Brief CBT-CP

Scripting includes:

1. “Brief CBT for chronic pain will provide you with several new strategies to help you

manage your chronic pain. Overall, these tools are designed to help reduce the negative

impact of pain on daily life, improve your physical and emotional functioning, and

increase effective coping skills. This treatment may also reduce your pain over time.”

• Use the SMART Goal Setting handout to identify Veteran-specific goals for change.

Identify at least one short-term goal and supporting rationale during this appointment

(with additional goals completed as home practice.)

2. “It’s important that we make sure that Brief CBT for chronic pain is addressing the areas

of your life that you find important. So, let’s get you back to doing more of what is

important to you. The first step will be to identify some short-term goals and then some

long-term goals. We’ll use the SMART goals format you see here.”

Key Point: Be certain that goals identified are relevant to chronic pain management.

Key Point: Goals should include as many of the SMART elements as possible.

Key Point: It is sometimes difficult for individuals to produce specific goals on their own, so it

can be helpful to ask questions to guide the discussion, such as:

1. “What is something specific that you would like to see change in your life in the

weeks to come?”

2. “What would you like to be able to do (better, more of, etc.)?”

3. “If this treatment were successful, how would that look in your day-to-day life?”

4. “Are there relationships that you would like to improve?”

5. Discuss new home practice opportunity

5.1. Clearly specified goals

Emphasize the value of identifying clearly specified goals (using SMART elements) for ensuring

that Brief CBT-CP will address areas of concern for the patient.

5.2. Short and long-term goals

Any short- or long-term goals not identified during this appointment should be completed by

the patient as home practice.

Scripting includes:

1. “Today we’ve identified a few SMART goals that will guide our future appointments.

Since we have already determined that you have a number of strengths, such as (X) and

(Y), I am confident that you will be able to complete the remaining short-term (and/or

long-term) goals at home. By completing this at home and bringing them with you to our

next appointment, we will be able to review them together and move more quickly into

learning new skills for chronic pain management.“

6. Module wrap-up

6.1. Summary of key points

This module includes considerable educational information about chronic pain and ends with

identifying patient goals for treatment. The following scripting can provide a concise summary

of key points and emphasizes again the value of goal setting and home practice.

Scripting includes:

1. “Today we discussed the difference between acute and chronic pain, including why

chronic pain is best treated from a biopsychosocial perspective. This approach

emphasizes treating pain from several angles, including developing new coping skills. We

identified some of the areas in your life that have been negatively impacted by pain and

discussed how we must avoid getting caught in the chronic pain cycle. To help us become

more active and break this cycle, we began to identify some short- and long-term goals

that will guide the rest of our appointments together. Completing the SMART goals sheet

before the next module will ensure that the remainder of our appointments are geared

towards your top priorities.”

Brief CBT-CP Module 1 Outline: Education and Goal Identification

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

• Although this is the first module of Brief CBT-CP, it is a good time to check in with

patients about any final questions or concerns they have about this treatment before

getting started.

4. Introduce new material and answer questions

4.1. Chronic pain education

• Compare and contrast chronic pain with acute pain.

• Explain why these pains may feel the same but must be treated differently.

4.2. Effects of pain

• Use Factors that Impact Pain handout to explain the 1) biopsychosocial model and

2) factors that impact pain.

• Use The Chronic Pain Cycle handout to explain how chronic pain may negatively

impact life over time.

4.3. Goal identification

• Use the Brief Cognitive Behavioral Therapy for Chronic Pain handout to provide an

overview of the objective of Brief CBT-CP.

• Use the SMART Goal Setting handout to identify Veteran-specific goals for change.

Identify at least one short-term goal and supporting rationale within this in-session

(with additional goals completed as home practice.)

5. Discuss new home practice opportunity

• Emphasize the value of identifying clearly specified goals (using SMART elements) for

ensuring that Brief CBT-CP will address areas of concern for the patient.

• Any short- or long-term goals not identified during this appointment should be

completed by the patient as outside practice.

6. Session wrap-up

• Provide a concise summary of key points and emphasize the value of home practice.

2. BRIEF CBT-CP MODULE TWO: ACTIVITIES AND PACING

This module focuses on the importance of engaging in activities and how to safely do so

through the use of time-based pacing. Unlike many other mental health interventions,

behavioral activation and guidance on how to properly pace activities is particularly important

with managing chronic pain so it is typically introduced early in the intervention.

2.1. Module Agenda

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Introduce the new material and answer questions

5. Discuss new home practice opportunity

6. Module wrap-up

2.2. Module Materials

• PEG self-report measure

• Patient handouts (see appendix):

o The Chronic Pain Cycle

o Pleasant Activities List

o Pleasant Activities Schedule

o Pacing Activities

2.3 Module Content for the Provider

1. Hurt versus Harm

Often, one of the greatest challenges for those with chronic pain is the belief that they no

longer can engage in life fully or do the things that they want to do. Veterans with chronic pain

may believe that activity will lead to increased pain while also causing physical damage. This

belief, while typically true in acute pain, is inaccurate in chronic pain and may lead to

maladaptive responses such as avoidance. By avoiding activity, chronic pain worsens over time.

Inactivity leads to issues such as decreased flexibility and stamina, increased weakness and

fatigue, and even spasms from tight muscles. The problems related to deconditioning often

lead to increased risk of injury and weight gain (adding strain to the body) as well as feelings of

sadness, frustration, or boredom, which only encourage more general withdrawal from people

and places.

The avoidance response has been termed kinesiophobia (Miller, Kori, & Todd, 1991), or fear of

movement, and may develop to varying degrees in those with chronic pain. Unfortunately, it

creates a self-fulfilling cycle – not moving only makes patients’ next attempts to engage in

activity more difficult and painful, reinforcing this fear. For Veterans who have lower levels of

kinesiophobia and are more active, the manner in which they approach situations (e.g.,

overdoing) may also have detriments, such as new injuries. Flare-ups (relatively brief increases

in pain intensity) are a central concern of those with chronic pain. They do not want to induce a

flare-up with movement and are concerned with how to manage flare-ups when they occur.

Lack of movement, avoidance, or approaching activities without thoughtful planning makes the

occurrence of flare-ups more likely. Another common response is avoiding an area that hurts by

favoring another area. If a patient has pain in the right knee, they may begin compensating by

adding additional pressure to their left side when ambulating. In these cases, the initial area of

pain become deconditioned, and the area that is now absorbing additional stress may begin to

develop new pain.

Use The Chronic Pain Cycle handout, introduced in module one, to discuss the negative

consequences that often result from responding in a maladaptive manner to pain.

Figure 10. Chronic Pain Cycle

2. Pleasant Activities

For those with chronic pain, decreasing fear and engaging in activity is a key to improved

functioning but can be challenging. One way to increase re-engagement and decrease

kinesiophobia is to participate in pleasant activities. Many with pain may have stopped

participating in hobbies, spending time with others, or engaging in physical outings. For those

that do engage in activities more regularly, they may have given up some of their favorite

hobbies or be less comfortable when around friends and family. Many may feel that they

physically cannot do the things they want, are “no fun” to be with because of pain, or are

worried about experiencing a pain flare-up that might interfere with plans. The benefits of

engaging in pleasant activities are included in Figure 11.

Figure 11. Pleasant Activities

Identifying pleasurable activities for those with chronic pain may be challenging for several

reasons. Pain-related negative mood such as depression and irritability may lessen the ability to

identify such activities or diminish the motivation to engage in them. Psychosocial challenges,

such as limited resources, may be a barrier. Chronic pain and poor sleep may leave patients

feeling too tired or fatigued to participate in activities. Primarily, however, Veterans may

mention things that they would like to do but “can’t” because of pain limitations. Use the

Pleasant Activities List and Pleasant Activities Schedule to explore options. This discussion will

likely generate a forum for examining creative alternatives for previously enjoyed hobbies. For

example, if Veterans report that they used to enjoy bowling but are now unable to, inquire

about their willingness to teach bowling to children or adolescents or to play an adapted

version of bowling through a gaming system.

3. Time-Based Pacing

Some people are prone to “pushing through” pain in the name of accomplishing a task and will

not stop until it is complete, while others may be preoccupied with fears about harming

themselves and avoid activity altogether. Often, those with chronic pain use a “good pain day”

when they are feeling better to try and complete one or more rigorous activities that have

fallen by the wayside. For example, they clean the garage or mow the grass without excessive

pain – but wake up the next day feeling like they cannot move and thus are “laid up” for several

days in a row. This cycle of overactivity, increased pain, and increased rest seen in Figure 12

often happens on a recurring basis. This boom-bust pattern can lead to various negative

consequences such as pain flare-ups, increased stress and anxiety, decreased efficiency,

lowered self-esteem, and avoidance of any activity.

Positive distraction from pain

Improved mood and self-esteem

Increased socialization

Enhanced attention and concentration skills

Enhanced sense of purpose and direction

Figure 12. Overactivity Cycle

Overdoing or not planning activities carefully beforehand can lead to flare-ups lasting from

minutes to weeks. Minimizing the occurrence of flare-ups as well as knowing how to manage

them when they do occur is a critical component of successful Brief CBT-CP.

Engaging in a moderate, safe level of activity on a regular basis is how to avoid this maladaptive

cycle. Using the skill of pacing, where time is the guide for activity engagement, can be a helpful

strategy. It allows Veterans to consistently and thoughtfully engage in activities without causing

detrimental consequences. Pacing is often about balancing activities and planning ahead, or

working “smarter not harder.” Breaking tasks into “chunks” such as painting a room for 45

minutes per day over four days instead of for three hours on a single day is one example of

pacing. Alternating between standing to do dishes for ten minutes and sitting to fold laundry

for five minutes may be a way to avoid standing longer than is comfortable, avoiding a flare-up,

but also engaging in an “active rest” period where something is still being accomplished. Being

more thoughtful about activity allows Veterans to get more done on a more consistent basis,

which also encourages mood improvements brought about by accomplishment. Without

pacing, the cycle of being sedentary or over-active with pain flare-ups can be very discouraging.

During this module, use the Pacing Activities worksheet to explore how to pace an activity with

the Veteran. Use examples to illustrate how pacing can enable Veterans to consistently carry

out activities while minimizing the likelihood of increased pain. It is the middle ground between

doing nothing and overexertion that enables Veterans with chronic pain to engage in

reasonable amounts of activity and improve quality of life. It is important to remember to take

a break before an exacerbation occurs, and not wait until the pain is increasing. Asking a

Overactivity

Increased PainIncreased Rest

Veteran how long they can engage in an activity before they begin to experience an increase in

discomfort should be the guide.

Once the concept of pacing has been reviewed, it is important to discuss in this module how

Veterans will apply it to their own lives. Ask the Veteran to choose an activity where they can

use pacing over the next week, such as washing the dishes or doing yard work. With the

worksheet and sample provided, use the steps to develop a plan for incorporating the activity

into the week. Pacing is a primary means to avoid flare-ups which should be emphasized. While

pacing may be a difficult concept to implement, highlight its critical role in effective pain

management and the need for practice.

Brief CBT-CP Module 2 Therapist Guide:

Activities and Pacing

Note to provider: Scripted statements are provided below as suggestions, rather than rules, of

how to introduce topics to patients. Scripting can be especially helpful for those providers

who are new to the content of Brief CB-CP. Feel free to modify the scripting as needed as you

become more comfortable with core elements of each module.

1. Introduce the module and confirm the agenda

Scripting includes:

1. “Today we will discuss how to safely engage in activities through pacing. This topic is

important because it helps us to keep active but avoid “overdoing it.” As you may have

experienced, over activity can often lead to pain flare-ups that can last for days. It’s also

very important for individuals with pain to stick with enjoyable or pleasant activities, or

find new ones, because this helps lower our level of distress and makes life more

fulfilling.”

2. “First, I will ask you to complete our usual measure about your pain and functioning so

we can continue to track your progress. Next, I would like to do some follow-up from our

last module, then move into our new topic about activity pacing. How does that sound to

you? Are there other things relevant to our pain work that you want to be sure to cover

today?”

Note to provider: If the patient is inclined to add items to the agenda that are not related to

pain management, the first effort on behalf of the therapist may be to link the topic back to

pain. For example, a statement such as the following may be helpful to refocus the patient:

“That sounds like it was stressful. Did you notice that your pain worsened during that time?”

2. Ask about mood, complete the PEG, and discuss findings

Scripting includes:

1. “First off, how are you feeling today and how has your mood been?”

2. “I would like you to complete this brief measure, the PEG, again today to help with

tracking your progress. After you complete it, we’ll review the results.”

Note to provider: After the patient completes the measure, briefly review the score of the PEG

with patient in comparison to prior scores to identify any areas of significant concern/distress.

3. Review material from the previous module

Note to provider: The key purpose of reviewing prior module’s content is to 1) answer

questions/concerns about the topics and skills addressed, and 2) follow-up on home practice

for addressing skill acquisition and clarifying content.

Scripting includes:

1. “Before we get started on new material, do you have any questions about what we

covered last time?”

2. “Last time we discussed <previous topic> which included some home practice for you to

complete. Do you have your practice work from last time?”

Note to provider: It is not uncommon for patients to have not completed their home practice.

It is therefore important to briefly explore barriers to completion and re-state the importance

of home practice for developing and strengthening CBT skill development.

4. Introduce the new material and answer questions

4.1. Hurt versus harm

Use The Chronic Pain Cycle handout introduced in Module 1 to explain that acute and chronic

pain may feel the same but must be addressed differently

Scripting includes:

1. “It is important to remember that the pain we experience with our chronic pain condition

does not indicate that we are harming ourselves. Rather, this pain is like an annoying

alarm we can’t trust: unpleasant but not an indication of damage. Similarly, like leaving

bread in the toaster too long, smoke may set off the smoke detector. Even though the

alarm is going off and some action on our part is required, it’s not an emergency.

There’s no need to call the fire department.”

2. “Individuals with chronic pain often stop participating in certain activities out of fear

that they will experience a pain flare-up. Although we probably can’t avoid all flare-ups,

finding a balance between activity and rest is important when managing chronic pain.”

3. “As you can see in the chronic pain cycle, when we experience pain, we often decrease

our activity too much. This leads to lack of strength and flexibility, as well as an increase

in distress. As we feel worse, we might withdraw from even more activities. This cycle

can be broken by finding a balance in safe activities and rest.”

4. “Chronic pain can take a toll on our behaviors, thoughts, and feelings. It’s shown here in

the chronic pain cycle how pain often leads us to stop participating in activities that we

enjoy which leads to negative thoughts and feelings. As our mood gets worse, we might

withdraw from routine activities and even our relationships. The less engaged we are in

life, the more distress we may feel. And without enough physical activity, we might

become deconditioned or disabled, making our pain worse.”

Key Point: Review the costs of inactivity noted on The Chronic Pain Cycle handout.

Key Point: Brief CBT-CP can help break the chronic pain cycle.

Key Point: Managing chronic requires balance between safe, appropriate activity and rest to

avoid both inactivity that leads to deconditioning and overuse that typically results in pain flare-

ups.

4.2. Pleasant activities

Use the Pleasant Activities List and Pleasant Activities Schedule to help identify enjoyable or

meaningful activities, particularly if the patient has a difficult time generating ideas without

assistance. Explain that pleasant activities take many shapes and forms, including those that

require varying levels of physical activity, from walking to playing board games.

Start by asking the Veteran to identify activities on their own but use the Pleasant Activities List

if they have a difficult time or need to expand their list of potential activities. When several

activities are identified, record them on the Pleasant Activities Schedule as instructed in the

handout.

Scripting includes:

1. “One of the best ways to avoid inactivity is to get reconnected with your hobbies or

social activities. Pleasant activities are very helpful because they can distract us from

pain, improve our mood, give us a chance to socialize, and even help give us a sense of

purpose.”

2. “Often individuals stop certain activities because they no longer seem possible when

living with chronic pain. While this is true in some cases, other times we can modify the

activity itself, or how we participate. What pleasant activities or hobbies would you like

to go back to?

3. “It’s clear that chronic pain has had a negative impact on your activities lately.

Sometimes it’s nice to also explore some new options for the first time. Is there anything

on this list of Pleasant Activities that we might talk about further?”

Key Point: If the patient is highly committed to an activity that is no longer feasible, engage in a

conversation about what they found enjoyable about the activity (e.g., did they enjoy running

because of being outside, a running group, etc.) and go from there. The “essence” of that

activity that they enjoyed might be found in other more feasible activities. Alternatively, help

them find ways to remain active in a similar activity in a new capacity.

4. “It sounds like one of the parts about your jogging group that you loved was the

opportunity to meet with friends on a weekly basis. Even though you are no longer able

to jog with them for the full time, how might you continue to see your friends?”

5. “It’s clear that you really enjoyed the teamwork aspect of playing basketball. Is there a

way to keep helping the team, even if you don’t play as frequently?”

Key Point: It is often helpful to identify a range of activities, including those that may require

fewer resources (e.g., activities inside the home), can be completed alone (e.g., gardening), with

friends (e.g., lunch at a favorite restaurant), those where physical activity is the main focus (e.g.,

playing sports), and those that are important because they are personally meaningful (e.g.,

volunteering for a charitable organization.)

4.3. Time-based pacing

Use the Pacing Activities worksheet to describe the goals of planning activities and to illustrate

the process of planning activity and rest.

Scripting includes:

1. “The goal of activity planning, or pacing, is to take a larger job and break it into smaller

pieces to make it more manageable. For example, an individual might plan to paint a

room in their house. Trying to paint the room in one day may be too strenuous whereas

making progress each day for several days may help avoid overexertion that can cause a

pain flare-up.”

2. “Balance applies to everyday activities as well. For example, take a break from standing

every 10 minutes while doing the dishes. During a 5-minute break, you can remain active

with other tasks that don’t require standing, like folding laundry or paying your bills on-

line.”

3. “Whatever the activity, the main goal of pacing is to engage in routine moderate

activity. Using a bit of planning to guide our activities helps us avoid situations where we

‘push through’ the pain throughout the day, which often leads to several days of being

‘laid up’ due to a pain flare-up.”

4. “This worksheet will help us break down a larger activity into pieces to ensure that we

are finding a balance between activity and rest. It may seem unusual at first to make an

activity longer than you are used to, but it will help to avoid unnecessary pain in the long

run.”

5. “Pacing helps us stay balanced because it reminds us to start being active as well as to

stop or take breaks. Relying on a pre-determined schedule means we do not need to rely

only on our internal signals about the need for movement and rest.”

Key Point: To find the optimal balance of activity and rest, it’s important to estimate the degree

of active time and rest time ahead of time. The active v. rest time will vary depending on the

task. These time estimates can be adjusted as needed.

Key Point: Be sure to identify at least one activity to illustrate pacing, with attention to including

a pleasurable or personally meaningful activity (e.g., playing games with grandchildren) in

addition to others (e.g., washing dishes).

6. “Let’s use the worksheet to sketch out how to apply principles of pacing using active and

rest time. What activity should we focus on first?”

5. Discuss new home practice opportunity

With at least one activity identified, patients should record their engagement in pacing cycles,

noting both their active time and rest time. Additional activities can be identified by the patient

as part of outside practice.

Scripting includes:

1. “Today we’ve discussed the importance of pacing to keep active while reducing the

likelihood or overexertion. We’ve identified (one, two, three, etc.) activities and

estimated the amount of rest and active time for each. The next step will be for you to

record the number of cycles you complete for each activity. By completing this at home

and bringing them with you to our next appointment, we will be able to review the sheet

together, identify any areas of concern, and move into learning the next skills.“

6. Module wrap-up

This module included information about a key chronic pain management skill: time-based

activity pacing. The following scripting can provide a concise summary of key points and

emphasizes again the value of pacing and at-home practice.

Scripting includes:

1. “Today we discussed how chronic pain is like an unreliable alarm rather than an

indication that we are doing harm. Our topic emphasized finding balance between

activities that are pleasurable and helpful to us and avoiding overexertion that can bring

on a pain flare-up. Planning ahead and pacing out our activities is an important

approach to finding that balance and avoiding the risks of too little or too much activity.

Try out the pacing schedule we identified for your activities we discussed and record your

progress on the handout for discussion at our next module.

Brief CBT-CP Module 2 Outline: Activities and Pacing

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

• Reviewing the prior module’s content to 1) answer questions/concerns about the topics

and skills addressed, and 2) follow-up on outside practice or homework. Briefly explore

barriers to completion of outside practice and possible solutions (as necessary).

4. Introduce new material and answer questions

4.1. Hurt versus harm

• Use the Chronic Pain Cycle handout to explain that acute and chronic pain may feel

the same but must be addressed differently, and that chronic pain is like a “broken

alarm”.

• Use the Chronic Pain Cycle handout to explain how chronic pain negatively impacts

life over time unless we find a balance between activity and rest.

4.2. Pleasant activities

• Use the Pleasant Activities List to help identify enjoyable or meaningful activities,

particularly if the patient has a difficult time generating ideas without assistance.

• Explain that pleasant activities take many shapes and forms, including those that

require varying levels of physical activity, from walking to playing board games.

• Schedule identified activities on the Pleasant Activities Schedule handout.

4.3. Time-based pacing

• Use the Pacing Activities worksheet to describe the goals of planning activities and

to illustrate the process of planning activity and rest.

5. Discuss new home practice opportunity

• With at least one activity identified, patients should record their engagement in pacing

cycles, noting both their active time and rest time. Additional activities can be identified

by the patient as part of home practice.

6. Session wrap-up

• Provide a concise summary of key points and emphasize the value of home practice.

3. BRIEF CBT-CP MODULE THREE: RELAXATION TRAINING

This module introduces Veterans to the pain management benefits of relaxation and then

reviews two specific techniques: diaphragmatic or deep breathing and progressive muscle

relaxation. Since these interventions are used in the management of various mental health and

medical conditions, many providers may already be familiar with them. Emphasize that

practicing these techniques regularly between modules is critical to mastery and effective

application.

3.1. Module Agenda

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Introduce the new material and answer questions

5. Discuss new home practice opportunity

6. Module wrap-up

3.2. Module Materials

• PEG self-report measure

• Patient handouts (see appendix):

o Relaxation Benefits and Tips Handout

o Deep Breathing Training

o Progressive Muscle Relaxation

o Relaxation Practice Record

3.3. Module Content for the Provider

1. Relaxation Rationale

Relaxation techniques are fundamental skills for managing chronic pain. However, the notion of

relaxation in the service of pain management is an unfamiliar concept to most individuals with

chronic pain. The rationale behind the use of relaxation techniques for pain management can

be explained most easily by focusing on chronic pain as a chronic stressor, both physically and

psychologically.

When patients experience chronic pain, their bodies react with a “fight or flight” response. This

stress response, controlled by the sympathetic nervous system, is critical to survival when

individuals face a dangerous or threatening situation. While in acute pain the response is

adaptive, with chronic pain the response is ‘stuck on’ and creates additional wear and tear on

the body. Since the body is chronically stressed due to persistent pain, it does not have the

chance to recuperate (Benson & Klipper, 1975).

Veterans may hold certain areas of their bodies rigidly to brace or protect against pain. They

may tense their necks or shoulders in anticipation of or in response to pain. These types of

reactions, while perfectly natural, only increase tension levels and pain intensity, but are often

done unconsciously. In addition, coping with the chronicity of the pain condition, not feeling

understood by others, reduced involvement in enjoyable activities, and negative thoughts may

also increase the stress related to pain. Since stress and pain have a bidirectional relationship –

pain influences stress and stress influences pain – gaining greater control over the response to

stress can help to better manage pain.

The good news is that the opposite physiological process, known as the relaxation response,

slows down and stops the fight or flight reaction. This parasympathetic nervous system has the

effect of reversing physiological arousal and bringing the body back to a calm state. Human

beings are capable of developing control over this relaxation response and engaging it as a

means of managing physical and emotional stress. With practice, the skill of using relaxation

techniques to return the body to a relaxed state can be developed, thereby closing the pain

gate and reducing the intensity of pain. We are retraining the body and mind to respond in a

more adaptive way to stress and tension.

2. Implementation

As with any new skill, practice of relaxation techniques should be performed daily to gain

mastery. It can be helpful to offer an analogy such as learning to play the guitar. While at first it

may be difficult and uncomfortable with little noticeable improvement, regular practice helps a

person become a skilled musician over time. In fact, fingers may begin to play certain songs on

“autopilot” as the body develops a memory for the movements. This is the case with practicing

and learning relaxation as well. Over time, relaxation exercises become easier to implement,

require less thought, result in greater benefit. Daily practice is required to develop these skills.

Some hints that may be helpful are included in Figure 13.

Figure 13. Hints for Adding Relaxation Strategies to Daily Routines

Use the handout on Relaxation Benefits and Tips in this module which further outlines the

advantages to developing the skill of relaxation and ways to implement it successfully.

Pair relaxation with a daily activity such as having a meal or making coffee/tea.

Use a relaxation "app" on a smart phone (See Appendix for examples).

Select a phrase or mantra that serves as a cue such as "calm, peace, or positivity."

3. Techniques

While there are various relaxation techniques that are effective, all involve a unique mental

state of passive attention to a stimulus that decreases the inner dialogue and the sympathetic

nervous system arousal. They combine a focusing tool (e.g., breath, area of body, image) with a

quiet and accepting disregard of everyday thoughts when they occur in order to return to the

focus of attention. Steps to help achieve this mental state are illustrated in Figure 14.

Two relaxation techniques will be introduced and demonstrated in this module. A brief review

of deep breathing, the foundation of all options, will be followed by an overview of brief

progressive muscle relaxation. Information regarding guided imagery, another common

relaxation technique, is included in the appendix for those who would prefer this approach.

Guided imagery can be used as a substitute for brief progressive muscle relaxation or as an

additional relaxation skill.

Figure 14. Steps to Being Prepared for Relaxation Training and Practice

1. Sit in a comfortable chair or on a mat. (If you get in bed you may fall

asleep so it is not recommended, unless you are using the technique to

aid in sleep initiation).

2. Lower the lights.

3. Take off your shoes and loosen tight clothes.

4. Close your eyes. (If you want to keep your eyes open, then focus them

on one spot).

5. Turn off your phone, TV, and radio.

6. Put pets in another room.

7. Let others in the house know you need some time alone to focus on

your health.

Deep Breathing

The first relaxation technique is diaphragmatic breathing, often called “deep breathing”, and it

is the foundation for all other relaxation techniques. It uses deep breathing to contract the

diaphragm by expanding the chest cavity and allowing more room for the lungs to fill with air.

This serves the purposes of slowing breathing, increasing oxygen intake, and even increasing

energy.

Diaphragmatic breathing is a brief and portable strategy that can be done anywhere, at any

time, and usually without others becoming aware that it is being done. It involves normal

breathing, but uses breaths that are intentionally smoother, slower, and deeper than the

breaths usually taken throughout the day. It is one of the easiest, most effective ways to

decrease tension in the body.

The steps for teaching this exercise are detailed here. The clinician can help model effective

technique by engaging in the exercise along with the Veteran.

Steps for Deep Breathing

1. Establish good posture.

2. Explain chest/shallow versus belly/deep breathing.

3. Have Veteran place one hand on chest and one hand on abdomen.

4. Determine if the Veteran is “chest breathing” or “belly breathing.”

5. Close eyes completely or look downward and fix gaze on one spot.

6. Observe the hands and ensure they are free of tension.

7. Have the Veteran keep one hand on chest and one hand on abdomen and keep eyes

closed or fixed on one spot.

8. Have the Veteran inhale slowly through the nose (if possible), causing the abdomen to

expand, extending inhale to three to five seconds in duration.

9. Instruct the Veteran to exhale slowly and completely through mouth, extending exhale

to three to five seconds in duration.

10. Continue this exercise for three to five minutes.

During the exercise, the clinician may wish to coach the Veteran with statements such as: “Feel

your body become more and more relaxed with each exhalation,” or “Each time you exhale,

think of the word relax,” or “Breathe in feelings of relaxation and breathe out any tension.”

Refer to Figure 15 and to the Deep Breathing Training handout for a sample script of this

exercise.

Figure 15. Mini-Breathing

Brief Progressive Muscle Relaxation

The second technique is progressive muscle relaxation (PMR). This exercise is focused on

systematically tensing and relaxing specific muscle groups. The underlying explanation for the

utility of this technique is that a muscle group cannot be both tense and relaxed at the same

time. By deliberately tensing the muscles and then relaxing them, patients can learn to observe

the difference between these two sensations; the body can then learn to notice tension in

muscles and to automatically release that tension.

Gentle contraction (i.e., mild to moderate tension) of each muscle group is required, not severe

tension. Tensing the muscle should not hurt, but it may feel unfamiliar and thus slightly

uncomfortable on the first practice of PMR. Muscle groups that are particularly tense may be

repeated, if desired.

MINI BREATHING EXERCISE

One idea is to try and use mini-sessions of deep breathing during the day. Incorporating brief

sessions of breathing will help with frequent practice. Because this exercise is so portable

and easy, it can help any time you are “on the go.”

For example, when you are standing in a line at the store, you may find yourself becoming

increasingly tense or impatient. Instead of focusing on that:

1. Take a deep breath in. As you breathe out, imagine the tension and negativity leaving

your body.

2. On your next breath, imagine breathing in feelings of calm and relaxation.

3. Count to six taking a slow, deep breath. Breathe out slowly, again to a count of six.

Before you know it, you will feel less tense and more in control. What are some other

situations where you might be able to do a mini-session during the day?

For Veterans who fear that contracting a particular muscle will increase pain in that location,

encourage them to approach that area gently. If there is a spasm or any undesirable effect,

Veterans can visualize the muscle and imagine tensing that area when they get to that part of

the body. Veterans should continue to contract the other muscles as the PMR exercise

continues.

Given the time limitations of primary Care, it is recommended to provide an overview of the

concept behind PMR and demonstrate this approach with one area/muscle group during the

module, such as wrist and arm. Demonstrate other muscle groups if time allows.

Major Muscle Groups

Please also refer to the handout entitled Progressive Muscle Relaxation for a sample script of

this exercise. The following are the muscle groups to be tensed and relaxed:

• Lower arms/upper arms

• Lower legs

• Upper legs/buttocks/lower back

• Abdomen

• Chest

• Neck/shoulders/upper back

• Mouth/jaw/throat

• Eyes/upper forehead/scalp

Steps for Brief Progressive Muscle Relaxation

1. Start with relaxed, deep breathing.

2. Systematically tense and relax each major muscle group.

3. Tension should last 5-10 seconds then relax for 10-20 seconds.

4. Spend additional time on muscles that are difficult to relax.

5. Mentally scan the body in systematic order of muscle groups, looking for remaining

tension.

6. Allow Veteran to relax any residual tension.

4. Practice

Encourage Veterans to practice relaxation techniques at least once per day over the next week,

more if possible. In addition, ask them to use the Relaxation Practice Record to track practice

and progress. Ask the Veteran to write down a tension rating before starting the exercise and

then return to the record afterward to self-assess and rate tension again – clarify that they are

rating tension not pain intensity. Remind patients that as the skill develops, the techniques will

become easier and benefits will increase.

Brief CBT-CP Module 3 Therapist Guide:

Relaxation Training

Note to provider: Scripted statements are provided below as suggestions, rather than rules, of

how to introduce topics to patients. Scripting can be especially helpful for those providers

who are new to the content of Brief CBT-CP. Feel free to modify the scripting as needed as you

become more comfortable with core elements of each module.

1. Introduce the module and confirm the agenda

Scripting includes:

1. “As I mentioned last time, today we will review the benefits of relaxation training in

managing chronic pain, and practice two specific relaxation techniques: deep (or

diaphragmatic) breathing and progressive muscle relaxation. Going over these

techniques during our appointment today is important because this will help you learn

the basics. However, practicing these techniques on your own at home is critical to

mastering the techniques, and promoting your ability to apply them in an effective

manner.

2. “First, I will ask you to complete our usual measure about your pain and functioning so

we can continue to track your progress. Next, I would like to do some follow-up from our

last module, then move into our new topic about relaxation. How does that sound to

you? Are there other things relevant to our pain work that you want to be sure to cover

today?”

Note to provider: If the patient is inclined to add items to the agenda that are not related to

pain management, the first effort on behalf of the therapist may be to link the topic back to

pain. For example, a statement such as the following may be helpful to refocus the patient:

“That sounds like it was stressful. Did you notice that your pain worsened during that time?”

2. Ask about mood, complete the PEG, and discuss findings

Scripting includes:

1. “First off, how are you feeling today and how has your mood been?”

2. “I would like you to complete this brief measure, the PEG, again today to help with

tracking your progress. After you complete it, we’ll review the results.”

Note to provider: After the patient completes the measure, briefly review the score of the PEG

with patient in comparison to prior scores to identify any areas of significant concern/distress.

3. Review material from the previous module

Note to provider: The key purpose of reviewing prior module’s content is to 1) answer

questions/concerns about the topics and skills addressed, and 2) follow-up on home practice

for addressing skill acquisition and clarifying content.

Scripting includes:

1. “Before we get started on new material, do you have any questions about what we

covered last time?”

2. “Last time we discussed <previous topic> which included some outside practice for you to

complete. Do you have your practice work from last time?”

Note to provider: It’s not uncommon for patients to have not completed their home practice.

It is therefore important to briefly explore barriers to completion and re-state the importance

of home practice for developing and strengthening CBT skill development.

4. Introduce the new material and answer questions

4.1. Relaxation training education

Scripting includes:

1. “I’d like to provide a little bit of background on why relaxation techniques are valuable

tools to manage chronic pain.”

Discuss that chronic pain is a stressor for both the body and mind that triggers and

subsequently maintains the fight or flight response.

Explain that relaxation skills are more than just resting or enjoying a hobby. Relaxation training

is specifically designed to counteract the fight or flight response by reducing both bodily and

psychological tension/stress.

1. “These skills can be good for your health for a variety of reasons, including that

relaxation can help improve your mood, energy level, sleep, blood pressure, as well as

pain. Though there are many different types of relaxation skills, they each have common

features, and importantly, all require practice.”

Use the Relaxation: Benefits and Tips handout to 1) explain the benefits of relaxation training,

and 2) provide an overview of basic tips to enhance relaxation skill practice.

4.2. Provide a brief overview of two types of relaxation training:

4.2.1. Deep breathing:

Scripting includes:

1. “Deep breathing is the foundation for all other relaxation techniques. Very deep breaths

expand the chest cavity, contract the diaphragm, and make more room for your lungs to

fill with air. This helps to slow your rate of breathing and increase oxygen intake, among

other things. It is a brief, easy to learn, and portable strategy, but is also one of the most

effective ways of quickly decreasing tension in your body.”

Use the Deep Breathing Training handout to guide the patient through in-vivo practice of the

scripted exercise.

4.2.2. Progressive muscle relaxation:

Scripting includes:

1. “Progressive muscle relaxation involves purposely tensing and relaxing specific muscle

groups, one at a time. Naturally, a muscle cannot be both tensed and relaxed at the

same time. By intentionally focusing on these alternating tensed and relaxed states, you

can train yourself to notice when you are tense, and then help to alleviate it.”

Using the Progressive Muscle Relaxation handout, provide a verbal overview of the exercise.

Demonstrate tensing and relaxation of at least one muscle group (e.g., lower arms/wrists) and

confirm that the patient understands the general technique. Demonstrate on additional muscle

groups if time allows, but it is unlikely that you can complete the full in-vivo exercise in session

due to time constraints.

Note to provider: If you or the patient believes that guided imagery should be used instead of

Progressive Muscle Relaxation, this information is available in the appendices. Guided

imagery may be considered a viable alternative to deep breathing in particular if there are

risks or limitations associated with breathing retraining (e.g., patients with COPD or other

pulmonary dysfunction).

Key Point: Emphasize that relaxation training is used to retrain the body and mind to respond

differently to stressors so that it becomes automatic and more helpful.

Key Point: When using progressive muscle relaxation, Veterans may approach a currently

painful area gently to avoid a flare-up. Alternatively, they may skip an area or use visualization

to imagine tension and relaxation.

Key Point: Reinforce the importance of at-home practice, and practicality of mini-sessions brief

of practice throughout the day (e.g., mini-breathing exercise).

5. Discuss new home practice opportunity

Scripting includes:

1. “Earlier I mentioned that practicing these skills is important. But it is also important to

track progress in using these skills. One way we can do that is by rating our overall level

of tension before starting the exercise, and then again when we are through.”

Review Relaxation Practice Record handout and encourage patient to practice and track

progress using the form provided.

6. Module wrap-up

Scripting includes:

1. “Today we discussed the value of training our bodies and minds to relax. Relaxation skills

can be used to directly address the stress of living with chronic pain. The techniques we

reviewed are ones that you can use daily to help with feeling less tense and more in

control of your pain. These skills work best when we apply them routinely, so I’d

recommend practicing at least once per day over the next week (more if possible).”

Brief CBT-CP Module 3 Outline: Relaxation Training

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review previous module

• Reviewing the prior module’s content to 1) answer questions/concerns about the topics

and skills addressed, and 2) follow-up on outside practice or homework. Briefly explore

barriers to completion of outside practice and possible solutions (as necessary).

4. Introduce the new material and answer questions

4.1. Relaxation training education

• Discuss that chronic pain is a stressor for both the body and mind that triggers and

subsequently maintains the fight or flight response.

• Explain that relaxation skills are more than just resting or enjoying a hobby, but are

designed to counteract the fight or flight response

• Use the Relaxation: Benefits and Tips handout to 1) explain the benefits of

relaxation training, and 2) provide an overview of basic tips to enhance relaxation

skill practice.

4.2 Deep breathing

• Use the script in the Deep Breathing Training handout to guide the patient through

an in-vivo exercise.

4.3 Progressive Muscle Relaxation

• Use the Progressive Muscle Relaxation handout to provide an overview of the

technique and demonstrate tension and relaxation of one (or more) muscle groups.

5. Discuss new home practice opportunity

• Review the Relaxation Practice Record handout and encourage patient to practice and

track progress using the form provided.

6. Session wrap-up

• Provide a concise summary of key points and emphasize the value of home practice.

4. BRIEF CBT-CP MODULE FOUR: COGNITIVE COPING 1

This is the first of two modules that target the cognitive component of the Brief CBT-CP model

by helping Veterans to 1) recognize thoughts that are unhelpful, and 2) develop skills for coping

with those thoughts. By understanding the dynamic interplay between thoughts and pain and

recognizing common maladaptive cognitions, Veterans will be better equipped to manage their

chronic pain and the difficult emotional reactions that often accompany it.

This module will focus on identifying unhelpful thoughts while the second coping module

focuses on challenging those unhelpful thoughts. Cognitive Coping 1 should be addressed

before moving to Cognitive Coping 2. Although these have been divided into two modules, if

you find your patient masters this content quickly, it may be feasible to address both modules

in a single appointment.

4.1. Module Agenda

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Introduce the new material and answer questions

5. Discuss new home practice opportunity

6. Module wrap-up

4.2. Module Materials

• PEG self-report measure

• Patient handouts (see appendix):

o Brief Cognitive Behavioral Therapy for Chronic Pain

o Pain Thoughts

o Catching ANTs

4.3. Module Content for the Provider

1. Relationship Between Thoughts and Pain

For those with chronic pain, the impact of their thoughts on how they experience pain can be

powerful. If pain fails to disappear or improve significantly over time, Veterans’ thoughts may

become increasingly negative and exert a greater influence on pain. Research shows that

negative thoughts are directly associated with pain perception (Lawrence, Hoeft, Sheau, &

Mackey, 2011). Often, these thoughts are automatic and outside of a person’s awareness but

may still impact emotions and behaviors.

Return to the Brief Cognitive Behavioral Therapy for Chronic Pain handout to review the

relationships between thoughts, pain, mood, and behaviors. Veterans will often recognize that

with increased stress or negative emotions, they also notice an increase in pain intensity.

Explain to Veterans that all human beings have automatic thoughts that may be helpful or

unhelpful. The presence of pain, however, sets the stage for an increase in negative thinking

since uncomfortable stimuli is always present. It may be important to tell Veterans that this is

not suggesting that their thoughts have caused their pain; some patients may be sensitive to

this notion as they may feel they have been accused of exaggerating pain in the past.

Assure them that while their pain is real, it is also accurate that unhelpful thoughts can

negatively impact their pain experience in direct and indirect ways; conversely, having more

adaptive thoughts can have a positive impact and turn down the volume of their pain

experience.

Figure 16. Interactions among Chronic Pain, Thoughts, Emotions, and Behaviors

2. Pain Thoughts

Another method for discussing unhelpful thinking patterns and their potentially automatic

nature is through a discussion of common maladaptive cognitions, or pain thoughts, that many

people have. In this module, these will be introduced to Veterans using the Pain Thoughts

handout. While it is not necessary to review this entire list with Veterans, applying the

appropriate labels to the examples on the handout as well as those provided by patients may

be helpful.

It is important to make note of one cognitive distortion in particular: catastrophizing.

Catastrophizing, or believing the worst, is particularly salient in the treatment of pain as it has

consistently been associated with important pain-related outcomes. Catastrophizing is

characterized by the tendency to magnify the threat value of pain and to feel helpless in the

context of pain.

3. Recognizing Unhelpful Thoughts

Once Veterans have explored the role of unhelpful cognitions in the Brief CBT-CP model, they

must now begin the process of increasing their awareness of the frequency of maladaptive

thoughts associated with pain or negative mood. Use the Catching Automatic Negative

Thoughts (ANTs) Worksheet to facilitate this process. Clarify to Veterans that since many of

these thoughts happen without conscious awareness, this initial process requires some effort.

Explain that the first step in improving thoughts is to increase recognition of those that are not

helpful. Use time in this module to generate an example of a pain-related thought that the

patient has had recently that did not serve them in a positive way. If the Veteran is unable to

identify one, use an example that has arisen in previous modules. At this point in treatment, it

is likely that the Veteran has expressed various pain thoughts, so it is recommended to take

note of a few over the course of treatment. Identify how the thought impacted their mood as

well as their experience of pain. The focus should not be on whether there is a grain of truth in

the thought but rather on whether it is helpful – does it serve the Veteran? Does it make their

experience better or worse? Turn up the volume or turn down the volume? Indicate whether

the thought has been helpful or harmful to their pain experience on the Catching ANTs

Worksheet.

Note that the next module, Cognitive Coping 2, will address finding alternative ways to respond

to negative stimuli by challenging these thoughts and using coping statements.

4. Practice

Encourage Veterans to review the Pain Thoughts handout on their own to facilitate the

understanding and identification of their own unhelpful thoughts, stressing the importance of

completing as many examples as possible on the Catching ANTs worksheet. Circling whether

the thought had a helpful/positive or unhelpful/negative effect on their pain and/or mood will

help to connect the important role of thoughts in pain management.

Brief CBT-CP Module 4 Therapist Guide:

Cognitive Coping 1

Note to provider: Scripted statements are provided below as suggestions, rather than rules, of

how to introduce topics to patients. Scripting can be especially helpful for those providers

who are new to the content of Brief CBT-CP. Feel free to modify the scripting as needed as you

become more comfortable with core elements of each module.

1. Introduce the module and confirm the agenda

Scripting includes:

1. “Today we will focus on the relationships between our thoughts and how we experience

pain. We will discuss how some thoughts can be helpful, while others can make things

worse. We will also start to apply strategies to identify negative thoughts so that we can

learn to cope with them better.”

2. “First, I will ask you to complete our usual measure about your pain and functioning so

we can continue to track your progress. Next, I would like to do some follow-up from our

last module, then move into our new topic about pain-related thoughts. How does that

sound to you? Are there other things relevant to our pain work that you want to be sure

to cover today?”

Note to provider: If the patient is inclined to add items to the agenda that are not related to

pain management, the first effort on behalf of the therapist may be to link the topic back to

pain. For example, a statement such as the following may be helpful to refocus the patient:

“That sounds like it was stressful. Did you notice that your pain worsened during that time?”

2. Ask about mood, complete the PEG, and discuss findings

Scripting includes:

1. “First off, how are you feeling today and how has your mood been?”

2. “I would like you to complete this brief measure, the PEG, again today to help with

tracking your progress. After you complete it, we’ll review the results.”

Note to provider: After the patient completes the measure, briefly review the score of the PEG

with patient in comparison to prior scores to identify any areas of significant concern/distress.

3. Review material from the previous module

Note to provider: The key purpose of reviewing prior module’s content is to 1) answer

questions/concerns about the topics and skills addressed, and 2) follow-up on home practice

for addressing skill acquisition and clarifying content.

Scripting includes:

1. “Before we get started on new material, do you have any questions about what we

covered last time?”

2. “Last time we discussed <previous topic> which included some outside practice for you to

complete. Do you have your practice work from last time?”

Note to provider: It’s not uncommon for patients to have not completed their home practice.

It is therefore important to briefly explore barriers to completion and re-state the importance

of home practice for developing and strengthening CBT skill development.

4. Introduce the new material and answer questions

4.1. Relationship between thoughts and pain

Use the Brief Cognitive Behavioral Therapy for Chronic Pain handout to discuss the

relationships between thoughts and pain. (Some patients may also benefit from reviewing The

Chronic Pain Cycle handout to discuss the role of unhelpful thoughts in perpetuating the

chronic pain.)

Key Point: Explain that all people have automatic thoughts that may be helpful or unhelpful.

Scripting includes:

1. “Everyone has thoughts that can be either helpful or unhelpful. Sometimes, we don’t

even realize that our thoughts are related to how we are feeling and acting. As you can

see in this diagram, our thoughts, including negative beliefs, are linked to how we feel,

our behaviors, and even how we experience pain. These thoughts are called automatic,

meaning that they usually happen quickly and we often experience them as being out of

our control. However, with practice we can identify these thoughts and replace them

with alternative thoughts that can be more positive or helpful.”

Key Point: It may be important to tell Veterans that this is not suggesting that their thoughts

have caused their pain or that “pain is in their head.”

Key Point: Assure them that while their pain is real, it is also accurate that unhealthy thoughts

can negatively impact their pain experience in direct and indirect ways; conversely, having more

adaptive thoughts can have a positive impact and turn down the volume of their pain

experience.

Scripting includes:

1. “Your thoughts have not caused your pain and your pain is very real. When we

experience pain for a long time, we may be more likely to have negative pain-related

thoughts. Although our thoughts do not cause the pain, they can influence how we cope

with pain. The more skilled we are at creating helpful, balanced thoughts, the better we

are at coping with pain. Then we have more control over whether our thoughts turn up

or turn down the volume of our pain experience.”

4.2. Pain thoughts

Use the Pain Thoughts handout to review 1) common pain thoughts, 2) examples of unhelpful

thoughts, and 3) examples of helpful alternative thoughts

Scripting includes:

1. “There are some common types of thoughts that people with chronic pain report. This

worksheet provides examples of some common pain thoughts that are unhelpful and

others that are helpful. Although most people experience these pain thoughts as

automatic, with practice you can become aware of them. Once you are aware of them,

you can start to replace them with thoughts that are more helpful.”

Key Point: It is important to make note of one cognitive distortion in particular: catastrophizing.

Catastrophizing, or believing the worst, is particularly relevant in the treatment of pain as it has

consistently been associated with important pain-related outcomes.

Note to provider: Pick at least three examples to review with the Veteran, one of which

should be catastrophizing, to review both the unhelpful and alternative helpful thought.

Attempt to elicit from the Veteran if there are certain types of unhelpful thoughts that they

experience more than others as these are likely targets for cognitive restructuring.

4.3. Recognizing unhelpful thoughts

Use the Catching ANTs handout to help the Veteran learn to 1) identify (catch) negative

thoughts, 2) determine if the thought is helpful or harmful, and 3) challenge automatic negative

thoughts

Key Point: Clarify to Veterans that since many of these thoughts happen without conscious

awareness, this initial process requires some effort.

Scripting includes:

1. “Now that we have explored the relationship between negative thoughts and pain, the

next step is to learn how to identify some of the specific unhelpful thoughts you might

have. At first, this can be difficult to do and takes some practice to do it well. Remember

that these thoughts often occur quickly and outside of our awareness, making them hard

to identify. The first step is learning to accurately recognize and identify your thoughts.

Let’s look at this example and then we’ll create one that is specifically for you.”

Key Point: Review the example and use time in module to generate an example of a pain-related

unhelpful thought that the patient has had recently. If the Veteran is unable to identify one, use

an example that has arisen in previous modules.

Key Point: Using the Catching ANTS handout, identify how the thought impacted their mood as

well as their experience of pain.

Scripting includes:

1. “Can you think of a recent time when you had an unhelpful pain-related thought? What

was happening? What was the thought? Was that thought helpful or harmful?”

Key Point: Work with the patient to identify several unhelpful thoughts and clarify the impact on

mood or behavior. This skill is essential before moving on to the next module (Cognitive Coping

2) which will introduce ways to challenge negative cognitions and to use coping self-statements.

5. Discuss new home practice opportunity

Encourage Veterans to review the Pain Thoughts handout on their own to facilitate the

understanding and identification of their own unhelpful thoughts.

Scripting includes:

1. “We have talked about a number of new concepts today. There are a few things that I

am going to ask you to review on your own and practice before you come back. This is

critical to mastering the skills and getting the most benefit from our time together. First,

I would like you to take some time on your own to review the Pain Thoughts Handout. As

you review, think about each type of thought and ask yourself if you have these types of

thoughts or similar ones.”

Stress the importance of completing as many examples as possible on the Catching ANTs

worksheet as possible, including circling whether the thought had a helpful/positive or

unhelpful/negative influence.

Scripting includes:

1. “Second, I would like you to work on part of the Catching ANTs Worksheet. It would be

great if you could “catch” at least one unhelpful thought a day. The earlier we can catch

those unhelpful thoughts, the less potentially negative impact they have on our life. Just

like we did today, write down the situation, and the thought, and determine if it is

helpful or harmful. You do not need to complete the final column ‘Challenge it!’ as we

will review your examples at the next appointment.

6. Module wrap-up

This appointment includes information about how thoughts influence the experience of pain.

The goal of the appointment is for the patient to understand this relationship and be able to

identify and challenge negative pain-related cognitions. The following scripting can provide a

concise summary of key concepts.

Scripting includes:

1. “Today we focused on how our thoughts influence our experience of pain. We identified

how negative thoughts can make us feel worse while more balanced thoughts can be

helpful. We worked to “catch” specific negative thoughts, rated if they were helpful or

harmful, and started working to create more accurate and adaptive thoughts. This is the

first step to learning to cope with these unhelpful thoughts.”

2. “Next time, we will learn about how to modify these thoughts to make them more

balanced and helpful in our everyday lives. Although these skills can be difficult at first to

learn and apply, many people find them extremely helpful as they practice the skills.

Practicing these skills before our next appointment will help to improve your ability to

use positive thinking in your everyday life.”

Brief CBT-CP Module 4 Outline: Cognitive Coping 1

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review previous module

• Review the prior module’s content to 1) answer questions/concerns about the topics

and skills addressed, and 2) follow-up on outside practice or homework. Briefly explore

barriers to completion of outside practice and possible solutions (as necessary).

4. Introduce the new material and answer questions

4.1. Relationship between thoughts and pain

• Use the Brief Cognitive Behavioral Therapy for Chronic Pain handout to discuss the

relationships between thoughts and pain.

4.2. Pain thoughts

• Use the Pain Thoughts handout to review 1) common pain thoughts, 2) examples of

unhelpful thoughts, and 3) examples of helpful thoughts.

• Pick at least three examples to review with the Veteran, one of which should be

catastrophizing, to review both the unhelpful and alternative helpful thought.

4.3. Recognizing unhelpful thoughts

• Use the Catching ANTs handout to help the Veteran learn to 1) identify (catch)

negative thoughts, 2) determine if the thought is helpful or harmful, and 3)

challenge automatic negative thoughts.

5. Discuss new home practice opportunity

• Encourage Veterans to review the Pain Thoughts handout on their own to facilitate the

understanding and identification of their own unhelpful thoughts.

• Stress the importance of completing as many examples as possible on the Catching

ANTs worksheet as possible, including circling whether the thought had a

helpful/positive or unhelpful/negative influence.

6. Session wrap-up

• Provide a concise summary of key points and emphasize the value of home practice.

5. BRIEF CBT-CP MODULE 5: COGNITIVE COPING 2

This is the second of two modules that target the cognitive component of Brief CBT-CP. This

module focuses on modifying unhelpful thoughts identified in the previous module and during

the patient’s home practice. Cognitive Coping 2 is briefer in terms of its content to

accommodate sufficient review from Cognitive Coping 1 as well as in-session practice regarding

the key skill of challenging unhelpful thoughts. Taken together, the goal of these two modules is

to prepare patients to identify, evaluate, and modify unhelpful thoughts related to chronic pain.

5.1 Module Agenda

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Introduce the new material and answer questions

5. Discuss new home practice opportunity

6. Module wrap-up

5.2 Module Materials

• PEG self-report measure

• Patient handouts (see appendix):

o Brief Cognitive Behavioral Therapy for Chronic Pain (as needed)

o Pain Thoughts (as needed)

o Catching ANTs

o Coping Statements

5.3 Module Content for the Provider

1. Review of Progress - Pain Thoughts

Depending on the degree of skill or comfort the patient demonstrates with identifying

unhelpful thoughts, it may be useful to briefly review the content from the prior module. One

method for discussing unhelpful thinking patterns is by reviewing the Catching ANTS worksheet

in comparison to the Pain Thoughts handout. This process can help patients to identify if they

tend to experience certain types of negative thinking more often than others, such as a

preponderance of “should statements” or emotional reasoning. Even if no specific pattern

emerges, this is a good opportunity to link the patient’s thoughts to the variety of unhelpful

thoughts about pain that can occur. While it is not necessary to review their entire list, it can be

helpful to discuss with Veterans which of the thoughts they found most frequent and/or

distressing versus less so. This process can illustrate how thoughts can impact our mood and

behavior in different ways (i.e., helpful, neutral, unhelpful).

2. Recognizing and Challenging Unhelpful Thoughts

Using the examples listed by the patient on Catching ANTS worksheet, introduce the concept of

challenging unhelpful thoughts. Review one of the examples in detail, including how the

thought impacted their mood as well as their experience of pain. Recall that the focus should

not be on whether there is a grain of truth in the thought but rather on whether it is helpful –

does it serve the Veteran? Does it make their experience better or worse? Turn up the volume

or turn down the volume?

Once the Veteran understands and can identify unhelpful pain-related cognitions, work with

them on alternative ways to respond to negative stimuli. The objective is not to create an

unrealistic picture of situations but a more accurate and balanced perspective. If possible,

propose a statement that reflects the role of the Veteran that increases self-efficacy. Review

the full example on the Catching ANTS worksheet and determine if patients understand the

process and rationale. It may be helpful to remind them that this is not suggesting that

thoughts cause their pain, but rather that we may be able to decrease the negative impact of

pain by making small changes to how we interpret situations.

3. Coping Statements

Another technique that can be helpful in managing pain flare-ups or negative mood is to use

positive coping statements. The ideal coping statement helps patients remain calm during

stressful situations. Coping statements provide “go-to” phrases that can replace unhealthy

thoughts or help Veterans cope with specific difficult situations, especially ones that may be

unanticipated. A key element to the success of coping statements involves finding phrases that

strongly resonate with the individual Veteran. While these could be pain-specific, they might

also be quotations, verses (e.g., song, scripture), or a phrase that a friend has delivered – the

key is personal relevance and easy access.

The Coping Statements handout helps Veterans choose statements that may be effective for

them. Patients may have their own phrases or statements that they have used in the past and

have served them well. Encourage them to add such statements to the list provided. One

advantage of formulating effective coping statements is that they can be portable and kept

handy for use at any time. They can be written on a small piece of paper and kept in a wallet or

placed into a smartphone that is carried routinely.

4. Practice

Encourage Veterans to complete the process of challenging unhelpful thoughts using the

remaining examples on the Catching ANTs worksheet. Patients should make adaptations to

unhealthy thoughts by creating a more balanced and accurate cognition. Finally, ask the

Veteran to identify several statements that they find calming and reassuring which can be used

before the next module.

Brief CBT-CP Module 5 Therapist Guide:

Cognitive Coping 2

Note to provider: Scripted statements are provided below as suggestions, rather than rules, of

how to introduce topics to patients. Scripting can be especially helpful for those providers

who are new to the content of Brief CBT-CP. Feel free to modify the scripting as needed as you

become more comfortable with core elements of each module.

1. Introduce the module and confirm the agenda

Scripting includes:

1. “Today we will continue to focus on the relations between our thoughts and how we

experience pain. Last time, we discussed how some thoughts can be helpful, while others

can make things worse. Today, we will review strategies to identify unhelpful thoughts

but also find ways to challenge and cope with these negative thoughts.

2. “First, I will ask you to complete our usual measure about your pain and functioning so

we can continue to track your progress. Next, I would like to do some follow-up from our

last module, then move into our topic about pain-related thoughts. How does that sound

to you? Are there other things relevant to our pain work that you want to be sure to

cover today?”

Note to provider: If the patient is inclined to add items to the agenda that are not related to

pain management, the first effort on behalf of the therapist may be to link the topic back to

pain. For example, a statement such as the following may be helpful to refocus the patient:

“That sounds like it was stressful. Did you notice that your pain worsened during that time?”

2. Ask about mood, complete the PEG, and discuss findings

Scripting includes:

1. “First off, how are you feeling today and how has your mood been?”

2. “I would like you to complete this brief measure, the PEG, again today to help with

tracking your progress. After you complete it, we’ll review the results.”

Note to provider: After the patient completes the measure, briefly review the score of the PEG

with patient in comparison to prior scores to identify any areas of significant concern/distress.

3. Review material from the previous module

Note to provider: The key purpose of reviewing prior module’s content is to 1) answer

questions/concerns about the topics and skills addressed, and 2) follow-up on home practice

for addressing skill acquisition and clarifying content.

Scripting includes:

1. “Before we get started on new material, do you have any questions about what we

covered last time?”

2. “Last time we discussed <previous topic> which included some outside practice for you to

complete. Do you have your practice work from last time?”

Note to provider: It’s not uncommon for patients to have not completed their home practice.

It is therefore important to briefly explore barriers to completion and re-state the importance

of home practice for developing and strengthening CBT skill development.

4. Introduce the new material and answer questions

4.1. Pain thoughts

It may be useful to first briefly review the concepts presented in the previous module with the

help of the Pain Thoughts handout. Key areas to review (as needed) include 1) common pain

thoughts, 2) examples of unhelpful thoughts, and 3) examples of helpful thoughts. This is also a

good time to compare the patient’s responses to the Catching ANTS worksheet to the

prototypes in the Pain Thoughts handout.

Scripting includes:

1. “As we discussed last time, there are some common types of thoughts that people with

chronic pain report. This worksheet provides examples of some common pain thoughts

that are unhelpful and others that are helpful. Let’s compare your examples to those

from the Pain Thoughts handout. Looking at your examples, which thoughts have

impacted you the most?”

Key point: The amount of review and discussion about the prior module’s content will vary

depending on the needs of the patient. When the patient can identify unhelpful thoughts,

introduce the new content below about challenging these thoughts.

4.2. Recognizing and challenging unhelpful thoughts

Use the Catching ANTs handout to begin the process of challenging or modifying unhelpful

thoughts.

Scripting includes:

1. “The next step is to learn how to challenge some of the specific unhelpful thoughts you

might have. At first, this can be difficult to do, and it takes some practice to do it well.

Which of the examples you provided should we start with? Let’s work to see if we can

come up with a more positive or balanced thought. What might you have thought that

would be more positive or helpful in that situation?”

Key Point: Work with the patient to challenge the cognition. If possible, propose a statement

that reflects the role of the Veteran and increases self-efficacy. Review the full thought record

and determine if patients understand the process and rationale.

4.3. Coping statements

Use the Coping Statements handout to help the Veteran 1) become familiar with positive

coping statements and 2) chose statements that may be effective for them.

Scripting includes:

1. “Another technique that can be helpful in coping with pain or managing negative mood

is to use positive coping statements. Coping statements help you remain calm during

stressful situations. Coping statements are your “go-to” phrases that can replace

unhealthy thoughts or help you cope with specific difficult situations. For example, telling

yourself that, I’m going to focus on what I can do, not what I can’t do, is an example of a

powerful coping statement.”

Key Point: A key element to the success of coping statements involves finding phrases that

strongly resonate with the individual Veteran. Patients may have their own phrases or

statements that they have used in the past and have served them well. Encourage them to add

such statements to the list provided.

Key Point: For patients who struggle after repeated trials of challenging unhelpful thoughts,

developing coping statements can provide an alternative approach to coping with negative

thoughts.

5. Discuss new home practice opportunity

Scripting includes:

1. “We’ve covered some important material today. There are a few things that I am going

to ask you to review on your own and practice before you come back. This is critical to

mastering the skills and getting the most benefit from our time together. I would like you

to continue to work on the Catching ANTs Worksheet. It would be great if you could

“catch” at least one unhelpful thought a day. Just like we did today, write down the

situation, and the thought, and determine if it is helpful or harmful. Then, take a few

moments and challenge it. Work to identify a more positive and helpful thought that

would turn down the volume on pain. We will review this at our next appointment.”

Stress the importance of completing as many examples as possible on the Catching ANTs

worksheet as possible, including circling whether the thought had a helpful/positive or

unhelpful/negative influence and creation of a more balanced and accurate cognition.

Finally, ask the Veteran to identify several statements that they find calming and reassuring

which can be used before the next module.

Scripting includes:

1. “Finally, I’d like to ask you to review the list of coping statements and identify any that

you find calming or helpful. I would also like you to think about other statements that

you may find beneficial. These could be parts of songs or poems, or even encouraging

words from a close friend. Basically, these can be any statements that help to calm or

soothe you, if you are feeling anxious or upset.”

6. Module wrap-up

Several cognitive strategies are reviewed in this module. The goal of the cognitive coping

modules is for the patient to understand the relationship between thoughts and pain, be able

to identify and challenge negative pain-related cognitions, create more helpful thoughts, and

work to identify additional coping statements.

Scripting includes:

1. “Our last two appointments have focused on how our thoughts influence our experience

of pain. We identified how negative thoughts can make us feel worse while more

balanced thoughts can be helpful. We worked to “catch” specific negative thoughts,

rated if they were helpful or harmful, and started working to create more accurate and

adaptive thoughts. We also reviewed common helpful coping statements and worked to

identify some statements that are meaningful to you. Although these skills can be

difficult at first to learn and apply, many people find them extremely helpful as they

practice the skills. Practicing these skills before our next appointment will help to

improve your ability to use positive thinking in your everyday life.

Brief CBT-CP Module 5 Outline: Cognitive Coping 2

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review Previous Module

• Review the prior module’s content to 1) answer questions/concerns about the topics

and skills addressed, and 2) follow-up on outside practice or homework. Briefly explore

barriers to completion of outside practice and possible solutions (as necessary).

4. Introduce the new material and answer questions

4.1. Pain thoughts

• Briefly review the concepts presented in the previous module with the help of the

Pain Thoughts handout.

• Key areas to review, as needed, include 1) common pain thoughts, 2) examples of

unhelpful thoughts, and 3) examples of helpful thoughts.

4.2. Recognizing and challenging unhelpful thoughts

• Use the Catching ANTs handout to begin the process of challenging or modifying

unhelpful thoughts.

4.3. Coping statements

• Use Coping Statements handout to help the Veteran 1) become familiar with

positive coping statements, and 2) chose statements that may be effective for them.

5. Discuss new home practice opportunity

• Stress the importance of completing as many examples as possible on the Catching

ANTs worksheet, including circling whether the thought had a helpful/positive or

unhelpful/negative influence and creation of a more balanced and accurate cognition.

• Ask the Veteran to identify several coping statements that they find calming and

reassuring which can be used before the next module.

6. Session wrap-up

• Provide a concise summary of key points and emphasize the value of home practice.

6. BRIEF CBT-CP MODULE 6: THE PAIN ACTION PLAN

This is the final module that focuses on relapse prevention. While functioning, mood, and pain

intensity have likely improved, chronic pain remains a part of daily life and pain flare-ups are

expected in the future. This module focuses on developing a plan for implementing the skills

from prior modules. This appointment should also include making appropriate referrals as

indicated should additional treatment be warranted.

6.1 Module Agenda

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review material from the previous module, including home practice

4. Review all progress/obstacles to date and develop a plan for future pain management

5. Discuss new home practice opportunity

6. Module wrap-up

6.2 Module Materials

• PEG self-report measure

• Patient handouts (see appendix):

• Anticipating Obstacles: Plan for Coping

• Weekly Activities Schedule

• SMART Goal Setting

6.3 Module Content for the Provider

1. Review of Progress

Begin the module by reminding Veterans of where they were when they entered treatment and

how much progress they have made. Be specific in the feedback provided, as patients may have

lost sight of their gains. Obtain feedback from Veterans about areas where they feel they have

made the most progress and what has worked best for them.

Asking questions, such as the following, may facilitate discussion and help Veterans identify

their own progress:

• Have you become more active?

• Has your mood improved?

• Do you feel like your life is more fulfilling, even though you still have pain?

• Have you noticed a difference in your pain intensity?

• What about how you react to your pain?

• Have others commented on positive changes they have seen in you?

Before examining the things that may get in the way of pain management in the future, it is

important to reflect on what the Veteran has already accomplished as a means of motivation.

2. Anticipating Obstacles

The best way to prevent a relapse to previous poor functioning is to be prepared for pain

exacerbations and difficult days. Planning ahead will make it easier to cope during challenging

times. Discuss anticipated obstacles that are likely to arise in the future as well as how those

issues will be addressed.

Use the Anticipating Obstacles: Plan for Coping worksheet to identify Veterans’ triggers for

pain increases.

Common triggers are:

• Emotional stress

• Weather changes

• Lack of sleep

• Sitting or standing “too long”

When completing the handout, encourage Veterans to be as specific as possible. For example,

instead of listing “stress”, define it further by listing the source of stress such as, “kids fighting

with each other.” Similarly, if there is a particular kind of weather that increases pain, identify

“weather under 50 degrees.” Find out how many minutes of sitting or standing is “too long.” If

the patient is unable to think of potential barriers, suggest barriers identified in prior sessions

related to coping with pain or even completing the home practice assignments. While

identifying triggers may be challenging, increasing attention to any emotional and physical signs

that may indicate an imminent flare-up can be beneficial.

Once personal triggers are identified, determine the best approaches for coping. This process is

an opportunity to review all the ways to manage pain that have been explored over the last five

modules. Engage in a discussion about all of the Brief CBT-CP techniques, from the role of

pacing, to relaxation exercise, to monitoring and modifying pain-related thoughts. Reviewing

options for managing each specific stressor can help make the exercise more realistic and

facilitate implementation.

3. Action Planning

Now Veterans are ready to develop a specific daily plan. Having a clear schedule helps patients

feel more prepared for several reasons. First, it can assist in mitigating difficult situations and

minimizing the triggers previously discussed. Second, it shows Veterans how to incorporate

various positive coping techniques into their everyday lives. Third, creating a plan promotes a

structured and purposeful approach to daily life, something that is valuable for everyone.

Working through a plan will help reveal how all of the pieces fit together and increase

confidence moving forward.

Using the Weekly Activities Schedule collaborate with Veterans to develop a schedule of

activities for a typical week in their words. If they prefer to use their electronic device for the

schedule, then defer to their preference. Ask about specific behaviors that they want to avoid

and use these to develop items for the schedule that will combat maladaptive habits. For

example, if someone wants to avoid isolating from others, perhaps “Meeting my friend John for

coffee” can be scheduled for every Tuesday morning, and encourage Veteran to include where

they will meet. Noting specific distractions to help keep the Veterans’ minds occupied such as

“garden (if nice weather)/puzzles (if bad weather)” or “play catch with my dog” will help create

a concrete plan for the future. It is important that the schedule is realistic, since setting

unreasonable plans will only make self-disappointment more likely if goals are not achieved.

Rewarding oneself for engaging in all scheduled activities for one week may be another

incentive to stay the course.

In all settings, but especially in primary care, it is critical to identify future needs and place

referrals as indicated. For example, if the work thus far with Brief CBT-CP has been helpful but

there is still significant progress to be made, perhaps a consult to pain psychology or a

behavioral medicine specialist for continued services (such as group or individual treatment)

may be in order. If the Veteran has increased activities and would be aided by participation in a

rehabilitation modality, such as physical or aquatic therapy, these options should be discussed.

Similarly, if in the course of treatment other more general mental health needs have emerged,

consider connecting the patient to additional mental health services, such as psychiatry or a

therapist in the mental health clinic.

4. Goals

The final task in session is to explore goals for the future. There may be accomplishments made

in recent weeks that can be expanded or new ideas that the Veteran now feels comfortable

considering. For example, if the patient has largely overcome a fear of movement, they may

want to incorporate bicycling or another adapted sport into their routine. If negative cognitions

have kept Veterans from considering dating, they may now feel confident enough to begin

exploring ways to meet others. Discuss what the individual Veteran is motivated to accomplish

in the future and tailor goals to meet specific interests and needs.

5. Practice

Provide positive feedback about all that has been accomplished so that Veterans leave feeling

supported and confident. Assure them that even if obstacles or setbacks are encountered, they

now have foundational tools necessary to manage their chronic pain.

Brief CBT-CP Module 6 Therapist Guide:

The Pain Action Plan

Note to provider: Scripted statements are provided below as suggestions, rather than rules, of

how to introduce topics to patients. Scripting can be especially helpful for those providers

who are new to the content of Brief CBT-CP. Feel free to modify the scripting as needed as you

become more comfortable with core elements of each module.

1. Introduce the module and confirm the agenda

Scripting includes:

1. “Today is our final appointment for addressing chronic pain as part of Brief CBT for

chronic pain. Today we will review the progress we’ve made over the last several

modules and think about next steps. It’s important that we take some time to look back

on what we’ve learned to both consider the progress we’ve made as well as plan for how

to continue to use the skills learned in the future.

3. “First, I will ask you to complete our usual measure about your pain and functioning so

we can continue to track your progress. Next, I would like to do some follow-up from our

last module, then move into our final topic about planning for the future. How does that

sound to you? Are there other things relevant to our pain work that you want to be sure

to cover today?”

Note to provider: If the patient is inclined to add items to the agenda that are not related to

pain management, the first effort on behalf of the therapist may be to link the topic back to

pain. For example, a statement such as the following may be helpful to refocus the patient:

“That sounds like it was stressful. Did you notice that your pain worsened during that time?”

2. Ask about mood, complete the PEG, and discuss findings

Scripting includes:

1. “First off, how are you feeling today and how has your mood been?”

2. “I would like you to complete this brief measure, the PEG, again today to help with

tracking your progress. After you complete it, we’ll review the results.”

Note to provider: After the patient completes the measures, review the score of the PEG with

patient in comparison to baseline to identify any areas of significant concern/distress. As this

is the final module of this treatment protocol, it is also an excellent time to compare current

ratings to baseline ratings to draw some summary conclusions about progress made or areas

to address in next steps.

3. Review material from the previous module

Note to provider: The key purpose of reviewing prior module’s content is to 1) answer

questions/concerns about the topics and skills addressed, and 2) follow-up on home practice

for addressing skill acquisition and clarifying content.

Scripting includes:

3. “Before we get started on new material, do you have any questions about what we

covered last time?”

4. “Last time we discussed <previous topic> which included some outside practice for you to

complete. Do you have your practice work from last time?”

Note to provider: It’s not uncommon for patients to have not completed their home practice.

It is therefore important to briefly explore barriers to completion and re-state the importance

of home practice for developing and strengthening CBT skill development.

4. Introduce the new material and answer questions

4.1. Review of progress

It is important to first emphasize substantive gains in functioning or mood that have occurred

during the course of treatment. Identifying improvement (or stabilization) is accomplished in

part by reviewing the change in patient measures, particularly from baseline to current status.

If the patient is unable to spontaneously identify areas of improvement, asking open-ended

questions may help guide them through likely areas that have improved.

Scripting includes:

1. “I’d like to start by identifying either symptoms or larger areas of life that might have

improved during the course of this treatment. Thinking back to when we first started

Brief CBT for chronic pain, what changes have you seen in your life related to chronic

pain?”

2. “One way to help identify areas of change is to take another look at the information you

reported in the measures we completed at the beginning of each module. When we

compare your score on the PEG, it looks like there’s a trend for improved functioning in

everyday activities over the course of this treatment. Have you noticed that you’ve been

more active or better able to engage in routines? How has that impacted other areas of

your life?”

3. “Tell me about ways that you have become more active.”

4. “Have you noticed any difference in your pain intensity or frequency? How has it

changed? Do you respond to pain differently now?

5. “Have others commented on positive changes they’ve seen in you?”

Key Point: Identify progress first (and before addressing barriers to progress) to bolster

motivation and acknowledge the results of the patient’s efforts to use CBT skills.

4.2. Anticipating obstacles

Having identified areas of growth or improvement, there are likely still areas that may need

attention in the future should they arise again. Use the Anticipating Obstacles worksheet to

identify triggers for pain and appropriate responses.

Explain that now is good time to plan for how skills learned in this treatment can be applied in

the future when triggers for pain are present.

Scripting includes:

1. “One of the best ways to help maintain our progress (or continue to move toward

achieving our goals) is to take a moment to think about likely situations or other triggers

that might bring on a difficult pain episode. By thinking of these triggers now, we might

be able to avoid some difficult situations or match the coping skills that we’ve learned to

the area of concern. Planning ahead may help us feel more confident in our ability to

manage pain the future.”

2. “Sometimes it’s difficult to identify very specific triggers for pain. As a rule of thumb,

consider times when your emotions, thoughts, or physical sensations may be hinting that

a pain flare-up is close. Do you recall our last conversation when you found that ______

was a trigger for your pain? Of the skills that we’ve talk about in our modules, which was

the most effective?”

Key Point: As a chronic condition, pain will need to be managed well into the future. Planning

ahead provides the opportunity for the patient to identify the most likely predictors of future

pain episodes and matching the CBT skill to that situation that they have found to be most

effective.

4.3. Action planning

Use the Weekly Activities Schedule to schedule important activities over a typical week. This

process helps minimize the impact of triggers, ensures meaningful goals/activities are attended

to, and adds structure and beneficial routines to otherwise unstructured time.

Scripting includes:

1. “There are several benefits to developing this typical weekly schedule. For one, adding

structure to our weeks can help with pacing, making sure we avoid inactivity or

overactivity. By planning ahead, we are most likely to make sure that the activities or

routines that are most important to us are really part of our day. This is also a great way

to find time in the week to practice some prevention, such as using relaxation skills, to

keep our stress and muscle tension levels down.”

2. “Let’s be sure to be as realistic as possible as we develop this plan. We can include

obligations as well as pleasurable events. For example, we can include both your hours

required at your part-time job, as well as the time you want to spend with your social

club.”

In addition to completing the Weekly Activities Schedule, the final module is a time to make a

determination if additional services are warranted. If the patient is requesting additional

services, consider if these are best addressed by you or another provider. The options are

potentially many depending on the needs of the patient and resources available in your clinic

and health care system. Some patients may require additional psychosocial interventions for

pain management in settings, such as pain clinics, that allow for longer treatment protocols.

Other patients may benefit from additional services such as physical therapy, nutrition

counseling, or specialty mental health.

Key Point: Weekly activity planning is an important final step of this treatment. Scheduling

ensures that patient-identified goals and preferences are clearly included in future activities and

routines.

Key Point: Concluding Brief CBT-CP is a highly personalized process in which additional referrals

(e.g., more intensive pain management services, mental health, or other rehabilitation-focused

services) should be considered based on patient need and local resources.

4.4. Future goals

Following weekly activity scheduling, it is valuable to briefly consider future long-term goals

that are potentially feasible now that CBT skills have been introduced. Although the weekly

scheduling will address a number of routine activities, discussing long-term goals once again

can offer an opportunity to further enhance motivation for the patient to engage in additional

realistic goals to achieve. Use the SMART Goal Setting handout to write down the short and

long-term goals identified. The patient’s short-term goals might have changed from the

beginning of treatment, which could indicate progress that can be emphasized. Provide

encouragement for continuing long term goals after treatment ends.

Scripting includes:

1. “Now that we’ve taken a look at what your typical weekly schedule will look like, it’s also

a good time to consider future goals. You’ve made progress in your pain management,

so what other goals for the future should we discuss briefly? Let’s write them down using

the SMART Goal Setting handout. For example, early on in our modules we discussed

that you had to quit the softball league because of your chronic pain. Now that you’ve

made progress in addressing activity pacing and identifying triggers for flare-ups, maybe

there’s a way to return to playing softball or helping out with coaching.”

5. Discuss new home practice opportunity

Although it is very helpful to acknowledge the patient’s progress throughout the course of

treatment, it is especially important to provide positive feedback about small and large gains.

This time is also good for reminding patients that they can continue to master their skills with

additional practice, even when faced with setbacks.

The patient should complete (and continue to modify as needed) the Anticipating Obstacles:

Plan for Coping and the Weekly Activities Schedule for application in the future.

Scripting includes:

1. “Today we’ve discussed the importance of continued practice of the skills discussed over

the course of our time together. We’ve identified the techniques that have worked best

for you (or identified those in need of additional practice) as well as a plan for how to use

those skills into the future. Be sure to keep the materials provided in these modules

readily available as they can be an ongoing resource well into the future. I recommend

that you come back to the worksheets we completed today to update and revise your

goals as you move forward (or complete any unaddressed worksheet items at home).

Returning to these worksheets from time-to-time can be a good ‘tune-up’ or reminder of

how to practice these skills.”

6. Module wrap-up

This module emphasized progress made and the need for continued application of these skills

into the future. It allowed time to arrange for any additional pain (or related) services that

could not be addressed by Brief CBT-CP. This is also the perfect time to add any additional

personal messages to the patient that acknowledges the value of their efforts, end of the

focused therapeutic interaction, as well as options (pending how services are delivered at your

site) for re-engaging with you as necessary.

Scripting includes:

1. “As the final module of Brief CBT-CP, we review the progress you’ve made over the

course of treatment. We started a few new worksheets that will be important for you to

complete outside of this module because they will act as a guide for putting the skills

into practice on daily basis. We also identified that it would be helpful to try a course of

physical therapy to promote physical fitness. We’ve arranged for that service through

your primary care provider. Finally, this is an opportunity for me to express my

appreciation for the opportunity to work with you over this course of treatment as well

as the service you have provided to our country.”

Brief CBT-CP Module 6 Outline: The Pain Action Plan

1. Introduce the module and confirm the agenda

2. Ask about mood, complete the PEG, and discuss findings

3. Review previous module

• Review the prior module’s content to 1) answer questions/concerns about the topics

and skills addressed, and 2) follow-up on outside practice or homework. Briefly explore

barriers to completion of outside practice and possible solutions (as necessary).

4. Introduce the new material and answer questions

4.1. Review of progress

• First emphasize substantive gains in functioning or mood that have occurred during

the course of treatment. Review the change in the PEG, particularly from baseline to

current status.

4.2. Anticipating obstacles

• Use the Anticipating Obstacles: Plan for Coping to identify triggers for pain and

appropriate responses.

• Explain that now is good time to plan for how skills learned in this treatment can be

applied in the future when triggers for pain are present.

4.3. Action planning

• Use the Weekly Activities worksheet to schedule important activities over a typical

week.

• This module is a time to make a determination if additional services (from you or

another provider) are warranted.

4.4. Future goals

• Briefly consider future short and long-term goals using the SMART Goal Setting

handout to write down the short and long-term goals identified.

5. Discuss new home practice opportunity

• The patient should complete (and continue to modify as needed) the Anticipating

Obstacles: Plan for Coping and the Weekly Activities worksheet.

6. Session wrap-up

• In addition to providing a general summary, add an additional personal message to the

patient that acknowledges the value of their efforts, end of the focused therapeutic

interaction, as well as options for re-engaging with you as necessary in the future

(pending how services are delivered at your site).

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Appendix 1:

Patient Handouts

102

Module 1 Patient Handouts:

Education and Goal Identification

103

Brief Cognitive Behavioral Therapy for Chronic Pain

This treatment focuses on how you think, feel, and behave in relation to your pain. As

shown in the picture below, these things are all related:

For example, chronic pain could lead to:

• Thoughts like, “I’m never going to feel better”

• Avoiding activities, even ones that you enjoy

• Feeling sad, angry, or worried

The goal of this treatment is to help you address these common reactions to chronic

pain so that you feel more confident in your ability to do things you enjoy and live a

full and meaningful life despite having pain.

Behaviors:

Not spending

time with friends

or family

Emotions:

Sadness,

Anger, Worry

Chronic

Pain

Thoughts:

Assuming the

worst or

focusing on pain

Treatment Goals

• Learn new strategies to cope with pain

• Improve your physical and emotional functioning

• Decrease how often you experience flare-ups as well as how

much they impact you

• Reduce the intensity of your pain

104

The Chronic Pain Cycle

Many people with chronic pain fear that movement will increase pain or cause physical damage/injury. This fear often

leads a decrease in activities which then leads to physical deconditioning (e.g., less strength and stamina, weight gain).

Dealing with constant pain may also lead to negative thoughts and

emotions such as frustration and depression. All of these factors

contribute to increased avoidance of people and activities.

THE COSTS OF INACTIVITY

While this cycle is understandable for those

with chronic pain, it is not helpful! In fact,

getting stuck in this cycle actually makes things

worse over time:

• More pain

• Poor physical fitness

• Less time with family and friends

• Depressed mood or increased irritability

• Lower self-esteem

• Increased strain on relationships

• Decreased quality of life

105

Factors That Impact Pain

Below are just a few examples of factors

that may impact your pain:

Factors That May Increase Pain

Factors That May Decrease Pain

Physical Factors

Illness or new injuries

Seeking medical treatments

Muscle tension

Using relaxation techniques

Thoughts

Expecting the worst

Balancing positive and negative thinking

Focusing on pain

Distracting yourself

Emotions

Depression or anger

Appropriate emotional expression, seeking

social support, engaging in pleasant

activities

Chronic pain is impacted by many factors. The interactions among these factors (shown

below) influence how you feel overall:

1. Biological factors

• Pain, medical issues

2. Psychological factors

• Emotions, attention, thoughts

3. Social factors

• Relationships, job, hobbies

The good news is that while some factors may increase your pain, others may decrease it.

You can decide how to manage many of these factors.

Biological

Factors

Social

Factors

Psychological

Factors

106

Factors That May Increase Pain

Factors That May Decrease Pain

Stress/worry/anxiety

Exercising safely and using relaxation

techniques

Behaviors

Too much (or too little) activity

Pacing yourself

Lack of involvement in hobbies

Doing more of what you enjoy

Social Interactions

Social isolation

Spending time with family and/or friends

Lack of (or too much) support from others

Volunteering/staying involved with

community

What are some things that have helped make your experience with

pain better?

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

What are some things that have made your experience with pain

worse?

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

107

SMART Goal Setting

A SMART goal uses the following guidelines:

Adapted from Doran, 1981

SMART Goal Versus Non-SMART Goal

Non-SMART Goal:

I want to get into physical shape.

SMART Goal:

I want to be more active by walking twice a week for 30

minutes for the next three months so that I can keep up with my

grandchildren when I see them during the holidays.

Non-SMART Goal:

I want to be more social.

SMART Goal:

I want to go watch a movie and eat dinner with my friends

once a week for the next three months so I spend less time alone while I

manage my chronic pain.

Specific

Measurable

Attainable

Relevant

Time-bound

Should identify a specific action or event that will take

place. In other words, “What specifically do I want to

do?”

Should be able to track progress. In other words,

“How will I know I have met my goal?”

Should be attainable and realistic. In other words, “Is

this really something that I can do?”

Should be personally meaningful and really matter.

In other words, “How important is this to me?”

Should state the time period for accomplishing the

goal. In other words, “By when do I want to achieve

this goal?”

108

Short-term goals can be accomplished over the course of this treatment (about 3

months). For each goal, consider if it fits the SMART criteria listed above. These should

be personally meaningful goals that motivate you to complete the program and improve

your pain management skills. Once goals are identified, track them on a weekly basis to

ensure that progress is occurring. If it is not, make adjustments as needed.

Short-Term Goals

In the space below, write down SMART goals you would like to achieve in the next three

months.

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

Accomplishing short-term goals keeps us motivated to achieve long-term goals. Long-

term goals are those for the next 6–12 months (or even longer). They will not be

accomplished fully during this program, but you can continue to work towards them

using the skills you have developed.

Long-Term Goals

In the space below, write down SMART goals you would like to achieve in the next 6 –12

months.

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

109

Module 2 Patient Handouts:

Activities and Pacing

110

The Chronic Pain Cycle

Many people with chronic pain fear that movement will increase pain or cause physical damage/injury. This fear often

leads a decrease in activities which then leads to physical deconditioning (e.g., less strength and stamina, weight gain).

Dealing with constant pain may also lead to negative thoughts and emotions such as frustration and depression. All of

these factors contribute to increased avoidance of people and activities.

THE COSTS OF INACTIVITY

While this cycle is understandable for those

with chronic pain, it is not helpful! In fact,

getting stuck in this cycle actually makes things

worse over time:

• More pain

• Poor physical fitness

• Less time with family and friends

• Depressed mood or increased irritability

• Lower self-esteem

• Increased strain on relationships

• Decreased quality of life

111

Pleasant Activities List

Try different activities to distract yourself from pain and improve your mood.

Which of the following are activities that have helped you feel better in the past

or are some new things that you would like to try? Check off any that apply!

Adapted with permission from K.M. Phillips, Ph.D.

□ Repair or fix something

□ Start or finish a project

□ Go to the pool or beach

□ Plan something nice for others

□ Go for a drive

□ Decorate or re-arrange your home

□ Knit or sew

□ Sing or play an instrument

□ Do hobbies (e.g., building models)

□ Visit with family or friends

□ Enjoy a hot bath or shower

□ Chat with your neighbor

□ Write or journal

□ Play games or do puzzles

□ Go shopping

□ Meditate or pray

□ Other activities/ideas?

_____________________________

□ Go fishing

□ Text, email, or call friends/family

□ Get your hair cut or nails done

□ Take a walk, exercise, or stretch

□ Do yard work or gardening

□ Read a book or magazine

□ Watch or participate in sports

□ Go to the park

□ Organize

□ Woodwork

□ Surf the internet

□ Look into classes you’d like to take

□ Plan a trip

□ Draw or paint

□ Walk your dog/play with your pet

□ Listen to music

□ Watch a movie or your favorite

show

□ Take or edit pictures

112

Pleasant Activities Schedule

List some activities that you enjoy doing:

1. ______________________________________________________________________

2. ______________________________________________________________________

3. ______________________________________________________________________

4. ______________________________________________________________________

Choose at least two pleasant activities that can be scheduled over the course

of the week and write them on your personalized pleasant activity schedule on the

next page.

Place an “X” to schedule your pleasant activity (example shown below).

Activity

Sun

Mon

Tues

Wed

Thu

Fri

Sat

Gardening

Circle the “X” when completed (example shown below).

Activity

Sun

Mon

Tues

Wed

Thu

Fri

Sat

Gardening

113

Pleasant Activities Schedule, continued

Now schedule your own pleasant activities. The example from above is shown in

the shaded area.

Activity

Sun

Mon

Tues

Wed

Thu

Fri

Sat

Gardening

Remember to not overdo it when engaging in activities! This is an important

concept that will be discussed in more detail later.

114

Pacing Activities

Some people with chronic pain may be fearful about harming themselves and avoid

activity altogether. Others are prone to pushing through pain on a “good pain day” to

accomplish a strenuous task and will not stop until it is complete. The next day, they

wake up with a pain flare-up and must rest for a day or more to recover!

The example above describes the Overactivity Cycle. If the Overactivity Cycle happens

on a recurring basis, it can lead to negative consequences such as increased stress and

anxiety, decreased efficiency, lowered self-esteem, and avoidance of any activity.

Engaging in a moderate, safe level of activity on a regular basis helps you avoid this cycle

of being underactive or overactive. Using the skill of pacing, where time is the guide for

activity engagement, can be a helpful strategy. Pacing is about balancing activities,

planning ahead, and working “smarter not harder.”

How to Pace

1. Estimate how long you can safely do one of your regular activities (e.g., yardwork,

dishes) without causing a severe pain flare-up.

2. Set the length of time you’ve chosen minus one minute as your "active" goal time

for the activity.

3. Approximate the amount of "resting" time you will need in order to safely

resume activity or continue your day.

Overactivity

Increased

Pain

Increased

Rest

115

Pacing Activities, continued

Remember

You might discover that the amount of time you can stay active may need adjusting

after you practice pacing for the first time. It is important to stick with the time-based

pacing goals, even if you are having a “good” or “bad” pain day. Sticking to the pacing

schedule prevents you from getting stuck in the overactivity or inactivity cycle.

Spread out activities during the week and be reasonable with the schedule so you can

succeed.

Use the table on the next page to record how you pace activities this week. Use the

sample below as your guide where each period of activity and rest equals one cycle.

Examples

In the first example, one cycle of pacing was completed on Day 1 (working for 10

minutes and resting for 15 minutes). Two cycles of pacing were completed on Day 2

(working for 10 minutes and resting for 15 minutes).

Activity 1: Gardening

Active Goal

(Minutes)

Rest Goal

(Minutes)

Number of Cycles

Day 1

Day 2

Activity 2: Washing dishes

Active Goal

(Minutes)

Rest Goal

(Minutes)

Number

of Cycles

Day 1

Day 2

116

Pacing Activities, continued

Schedule Your Own Activity 1: _________________________________

Active Goal

(Minutes)

Rest Goal

(Minutes)

Number

of Cycles

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Schedule Your Own Activity 2: _________________________________

Active Goal

(Minutes)

Rest Goal

(Minutes)

Number

of Cycles

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

117

Module 3 Patient Handouts:

Relaxation Training

118

Relaxation: Benefits & Tips

The goal of relaxation is to reduce the effects of stress on your health. Since chronic pain

produces chronic stress on the body, it is important to regularly practice relaxation

techniques that can help your mind and body recover. Relaxation is more than resting or

enjoying a hobby – it involves using specific strategies to reduce tension.

Benefits of Relaxation

Relaxation is important for good health. When you are relaxed, your muscles are loose,

your heart rate is normal, and your breathing is slow and deep. Learning how to relax

can help especially when you feel pain. Relaxation prompts your body to release

chemicals that reduce pain and produce a sense of well-being.

Relaxation won't cure pain or other chronic symptoms, but skills that relax the body and

the mind may help decrease muscle tension, prevent muscle spasms, and relieve the

stress that can aggravate pain and other symptoms.

Taking time to relax and refuel your energy provides benefits such as:

• Improved mood

• Increased energy and productivity

• Improved concentration and focus

• Improved sense of control over stress and daily demands

• Improved nighttime sleep

• Increased self-confidence

• Greater ability to handle problems

• Decreased anxiety and other negative emotions such as anger and frustration

• Increased blood flow to muscles and reduced muscle tension

• Lower blood pressure, breathing rate, and heart rate

• Decreased pain, such as headaches and back pain

Relaxation Practice Tips

Relaxation is a skill that requires practice. You may not feel the benefits immediately, so

don't give up! Remain patient and motivated and you’ll reduce the negative impacts of

stress. And remember: If relaxation feels foreign or unnatural, that likely means you are

a person who needs it most!

119

Establish a routine

1. Set aside time to practice relaxation at least once or twice a day. Pairing

relaxation with a regular activity may help you remember to practice (for

example, take ten relaxed breaths before bed or whenever you sit down to eat).

2. Practice at various times throughout the day until relaxation becomes natural

and you can use it readily when you feel stressed. You may want to leave

"reminders" for yourself to relax (for example, sticky notes on the bathroom

mirror, kitchen cabinets, or car dashboard with the words "relax" or "breathe").

Be comfortable

1. Practice on a comfortable chair, sofa, mat, or bed. Dim the lights.

2. Loosen tight clothing and remove shoes, belt, glasses or contact lenses, if you

like.

Concentrate

1. Eliminate disruptions. Turn off the TV, radio, or telephone.

2. Practice in a quiet, calm environment.

3. Close your eyes to reduce distractions and improve concentration. If you prefer,

keep your eyes open and focus on one spot.

4. Move your body as little as possible, changing positions only for comfort. Don't

worry if you have some distracting thoughts—it happens to everyone. Just notice

that your thoughts have wandered and then gently, without judgment, return

your attention to your breath.

Relax

1. Begin and end relaxation practices with relaxed breathing techniques.

2. Use a relaxation CD if it helps. Gradually, learn to relax without a CD so that you

can use relaxation techniques anywhere.

120

3. Let relaxation proceed naturally and spread throughout your body. Do not try to

resist.

Be patient

1. Give yourself time to learn relaxation skills. Practice is required for these

techniques to become automatic.

2. Try not to become upset if you have trouble concentrating. A wandering mind is

normal and expected. Keep bringing your attention back to your breath.

3. Don't worry about how well you are practicing.

4. After a few weeks, select a word, such as "calm," "relax," “peace," or “patience”

that you can say during relaxation practices. Eventually, simply saying that word

may help you relax.

Incorporate relaxation into daily life

1. Over time, move relaxation practices from planned, quiet settings to "real life."

The goal is to be able to calm yourself when necessary, no matter where you are.

2. Use relaxation whenever you notice yourself feeling stressed or anxious, such as

waiting in line, at a doctor’s appointment, or during a difficult meeting.

121

Deep Breathing Training

1. Start by becoming aware of your breathing. Place one hand on your abdomen at the

waistline just over the bellybutton and the other hand on the center of your chest.

Without trying to change anything, simply notice how you are breathing. Notice where

you are breathing from, whether your shoulders are rising and falling, whether your chest

is rising and falling, or perhaps whether your belly is rising and falling. Notice how your

hands move as you breathe. Pay attention to whether one hand is moving more than the

other. (PAUSE 5 seconds)

2. Now notice the rate of your breathing. Pay attention to whether you are breathing rapidly

or slowly. Your breathing may be deep or shallow. (PAUSE 5 seconds)

3. Now as you slowly inhale, imagine the air flowing deeper into your belly. Feel your belly

fill with air as your lower hand rises. Pause briefly at the top of your breath, and then

follow your breath out as you completely exhale. Slowly take a breath in…two, three,

four, and slowly exhale…two, three, four. Let any tension melt away as you relax more

deeply with each breath. (PAUSE 5 seconds)

4. Notice the feeling of cool fresh air entering through your nose, through your nasal

passage, to the back of your throat, and descends deep into your lungs. Notice what

happens as you are inhaling… and then exhaling... Feel the temperature of each breath

cool as you inhale, and warm as you exhale. Count your breaths as you breathe in and

out. (PAUSE 10 seconds)

5. Notice your breath becoming smooth and slow. Feel your belly and ribcage expand

outward with each breath. Feel yourself become more relaxed with each exhale. Allow

your shoulders to become heavier with each exhale. (PAUSE 15 seconds)

6. Continue breathing slowly and gently. (PAUSE 15 seconds)

7. Again, slowly take a breath in…two, three, four, and slowly exhale…two, three, four. Feel

yourself become more and more relaxed with each exhale. (PAUSE 15 seconds)

8. Continue breathing slowly and gently. (PAUSE 15 seconds)

9. Now, as I count from five to one, feel yourself become more alert. Five…bringing your

attention to this room. Four…feeling calm and relaxed. Three…start to wiggle your fingers

and toes. Two…slowly start to move and stretch your muscles. One…open your eyes,

feeling refreshed.

122

Progressive Muscle Relaxation

Noticing the difference between tensed and relaxed muscles is important. This skill

reduces anxiety by promoting relaxation and helps you to recognize when your body is

tense. In order to master this skill, you will be asked to tense certain muscle groups as

hard as you can without hurting yourself. After 5 seconds of holding the tension, you

will be instructed to relax your muscles and release the tension.

1. Tense your lower arms by making fists with your hands and pulling your fists up

by bending your wrists. Focus on the tension. (PAUSE 5 seconds)

2. Now release the tension. Let your hands and lower arms relax onto the chair or

bed beside you. Feel the release from tension as you relax the muscles fully.

(PAUSE 10 seconds)

3. Create tension in the upper arms by pulling the arms back and in toward your

sides. Feel the tension in the back of the arms and radiating towards the

shoulders and into the back. Focus on the tension and hold. (PAUSE 5 seconds)

4. Now, release the arms and let them relax – almost feeling heavy at your sides.

Notice the difference between the previous tension and the new feelings of

relaxation. Your arms might feel heavy, warm, and relaxed. (PAUSE 10 seconds)

5. Now bring your attention to your lower legs. Build tension by extending your legs

in front of you and pointing your toes toward your upper body. Feel the tension

as it spreads through your feet, ankles, shins, and calves. Hold this tension.

(PAUSE 5 seconds)

6. Release all of the tension in your lower legs. Let your legs relax onto the chair or

bed. Feel the difference in these muscles as they relax. Feel the release from

tension, the sense of comfort, the heaviness of relaxation. (PAUSE 10 seconds)

Continue working through the various muscle groups, alternating between tension and

release. Remember to feel the tightness when holding the tension, and to notice the

difference between tension and relaxation upon release.

7. Upper legs and buttocks: Tense by pressing knees together and lifting legs

slightly off the bed or chair. (PAUSE 5 seconds). Release tension by letting legs

sink into chair or bed. (PAUSE 10 seconds)

123

8. Abdomen: Tense by pulling your abdomen in towards your spine. (PAUSE 5

seconds). Release tension by relaxing your abdomen to its normal position.

(PAUSE 10 seconds)

9. Chest: Build tension in your chest by taking in a deep breath and holding it.

(PAUSE 3-5 seconds). Release tension by slowly letting the air escape, and

resume normal breathing, letting air flow in and out smoothly and easily. (PAUSE

10 seconds)

10. Neck and shoulders: Create tension by pulling your shoulder blades back and up

towards your ears. (PAUSE 5 seconds). Release tension by letting your shoulders

drop down, sinking further and further until they are completely relaxed. (PAUSE

10 seconds)

11. Mouth, jaw, and throat: Create tension by clenching your teeth and turning the

corners of your mouth back into a forced smile. (PAUSE 5 seconds). Release the

tension by letting your jaw drop down and relaxing the muscles around your

throat and jaw. (PAUSE 10 seconds)

12. Eyes and lower forehead: Build tension by squeezing your eyes tightly shut and

pulling your eyebrows down. (PAUSE 5 seconds). Now release all the tension in

your eyes and lower forehead. (PAUSE 10 seconds)

13. Upper forehead and scalp: Build tension by raising your eyebrows as high as

possible. Feel the wrinkling and pulling across the forehead and top of the head.

(PAUSE 5 seconds). Now release all the tension in your forehead, letting the

eyebrows gently rest down. (PAUSE 10 seconds)

Now, you will work towards a state of relaxation.

14. Your whole body is feeling relaxed and calm. Scan your body for any last bits of

tension and if you notice any, let that tension go. Enjoy the feelings of relaxation.

(PAUSE 5 seconds)

15. As I count from one to five, feel yourself become more and more relaxed.

One…let all tension leave your body. Two…sink further and further into

relaxation. Three…feel more and more relaxed. Four…feel very relaxed.

Five…deeply relaxed. (PAUSE 30 seconds)

124

16. As you spend a few minutes in this relaxed state, think about your breathing. Feel

the cool air as you breathe in and the warm air as you breathe out. Your

breathing is smooth and regular. Every time you breathe out, think to yourself

"relax, relax, relax." You are feeling comfortable and relaxed. (PAUSE 1-3

seconds)

17. Now, as I count from five to one, feel yourself become more alert. Five…bringing

your attention to this room. Four…feeling calm and relaxed. Three…start to

wiggle your fingers and toes. Two…slowly start to move and stretch your muscles.

One…open your eyes, feeling refreshed and rejuvenated.

125

Relaxation Practice Record

Use the record below to chart your relaxation practice over time.

• Before you begin your practice, use the scale below to rate your level of tension.

• After you complete the practice, use the same scale again to rate your level of

tension.

• Noting any differences will help you figure out if the exercises are helping you

relax.

But remember, these exercises take practice and it might take several tries before

you start to see results!

Date

How long did you

practice?

(minutes)

Level of tension

before practice

(0-10)

Level of tension

after practice

(0-10)

What did I notice?

Extremely

Tense

Slightly

Tense

Slightly

Relaxed

Very

Relaxed

Totally

Relaxed

126

Module 4 Patient Handouts:

Cognitive Coping 1

127

Brief Cognitive Behavioral Therapy for Chronic Pain

This treatment focuses on how you think, feel, and behave in relation to your pain. As

shown in the picture below, these things are all related:

For example, chronic pain could lead to:

• Thoughts like, “I’m never going to feel better”

• Avoiding activities, even ones that you enjoy

• Feeling sad, angry, or worried

The goal of this treatment is to help you address these common reactions to chronic

pain so that you feel more confident in your ability to do things you enjoy and live a

full and meaningful life despite having pain.

Behaviors:

Not spending

time with friends

or family

Emotions:

Sadness,

Anger, Worry

Chronic

Pain

Thoughts:

Assuming the

worst or

focusing on pain

Treatment Goals

• Learn new strategies to cope with pain

• Improve your physical and emotional functioning

• Decrease how often you experience flare-ups as well as how

much they impact you

• Reduce the intensity of your pain

128

PAIN THOUGHTS:

Identifying and Replacing Thoughts That Are Not Helpful

Thinking about how much pain you are in does not help you cope with the pain. As pain

increases, thoughts may become more negative; as thoughts become more negative,

pain often increases further. Negative thoughts can lead to:

• Worsening mood

• Avoiding activities

• Isolating/avoiding others

Although pain thoughts can be automatic, with practice you can become more aware

when you have them. Then you can replace unhelpful thoughts with ones that are

helpful. Here are some examples of unhelpful pain thoughts and some coping

statements that you can use to replace them:

Common Pain Thoughts

Types of

Unhelpful Thoughts

Examples of

Unhelpful Thoughts

Examples of

Helpful Thoughts

Catastrophizing

Believing something is the

worst it could possibly be.

When my pain is bad, I can’t

do anything.

Even when my pain is bad,

there are still some things I

can do.

Should Statements

Thinking in terms of how

things should, must, or

ought to be.

My doctor should be able to

cure my pain.

There is no cure for chronic

pain, but I can use skills to

cope with my pain.

All or None Thinking

Seeing things as “either or”

or “right or wrong” instead

of in terms of degrees.

I can only be happy if I am

pain free.

Even if I am in pain, I can

still be happy. There is

always something that I

can do to have a better

quality of life.

129

Types of

Unhelpful Thoughts

Examples of

Unhelpful Thoughts

Examples of

Helpful Thoughts

Overgeneralization

Viewing one or two bad

events as an endless pattern

of defeat.

I tried doing exercises for my

back pain before and it didn’t

help. So, it isn’t going to help

now.

Although physical therapy

didn’t help much before,

maybe this time it will help.

I might as well try.

Jumping to Conclusions

Drawing negative

conclusions of events that

are not based on fact.

When I move my back hurts,

so it must be bad for me to

move.

Hurt does not equal harm.

Emotional Reasoning

Believing how you feel

reflects how things really

are.

I feel useless, so I am useless.

Even though I can’t do all

the things I used to do, it

doesn’t mean I can’t do

anything.

Disqualifying the Positive

Focusing on only the bad

and discounting the good.

So what if I am doing more, I

am still in pain.

Doing more is important

for me to live the life I want

to live.

Used with permission from KM. Phillips, Ph.D.

130

CATCHING ANTs: How to Catch, Check, & Challenge Automatic Negative Thoughts

When we feel upset or angry, most often we also have negative thoughts. These thoughts may happen automatically and

increase your pain and negative mood. You can feel better physically and emotionally by “catching” ANTs when they

occur, noticing how they make you feel, and challenging them with more balanced thoughts. Using the chart below,

record at least one ANT each day. Evaluate the thought and generate a new helpful one.

Day/Situation

Catch It!

Identify ANT

Check It!

Effect on your

pain/mood

Challenge It!

Positive/balanced coping

statement

Tuesday/Cleaning

garage and pain

flares

This pain is killing me. I can’t

do anything anymore.

Helpful or Unhelpful

I am hurting right now because I

overdid it, but I know that I will feel

better soon. Then I will pace myself

to get the job done.

Helpful or Unhelpful

Adapted with permission from S. Palyo, Ph.D. & J. McQuaid, Ph.D.

131

Module 5 Patient Handouts:

Cognitive Coping 2

132

Brief Cognitive Behavioral Therapy for Chronic Pain

This treatment focuses on how you think, feel, and behave in relation to your pain. As

shown in the picture below, these things are all related:

For example, chronic pain could lead to:

• Thoughts like, “I’m never going to feel better”

• Avoiding activities, even ones that you enjoy

• Feeling sad, angry, or worried

The goal of this treatment is to help you address these common reactions to chronic

pain so that you feel more confident in your ability to do things you enjoy and live a

full and meaningful life despite having pain.

Behaviors:

Not spending

time with friends

or family

Emotions:

Sadness,

Anger, Worry

Chronic

Pain

Thoughts:

Assuming the

worst or

focusing on pain

Treatment Goals

• Learn new strategies to cope with pain

• Improve your physical and emotional functioning

• Decrease how often you experience flare-ups as well as how

much they impact you

• Reduce the intensity of your pain

133

PAIN THOUGHTS:

Identifying and Replacing Thoughts That Are Not Helpful

Thinking about how much pain you are in does not help you cope with the pain. As pain

increases, thoughts may become more negative; as thoughts become more negative,

pain often increases further. Negative thoughts can lead to:

• Worsening mood

• Avoiding activities

• Isolating/avoiding others

Although pain thoughts can be automatic, with practice you can become more aware

when you have them. Then you can replace unhelpful thoughts with ones that are

helpful. Here are some examples of unhelpful pain thoughts and some coping

statements that you can use to replace them:

Common Pain Thoughts

Types of

Unhelpful Thoughts

Examples of

Unhelpful Thoughts

Examples of

Helpful Thoughts

Catastrophizing

Believing something is the

worst it could possibly be.

When my pain is bad, I can’t

do anything.

Even when my pain is bad,

there are still some things I

can do.

Should Statements

Thinking in terms of how

things should, must, or

ought to be.

My doctor should be able to

cure my pain.

There is no cure for chronic

pain, but I can use skills to

cope with my pain.

All or None Thinking

Seeing things as “either or”

or “right or wrong” instead

of in terms of degrees.

I can only be happy if I am

pain free.

Even if I am in pain, I can

still be happy. There is

always something that I

can do to have a better

quality of life.

134

Types of

Unhelpful Thoughts

Examples of

Unhelpful Thoughts

Examples of

Helpful Thoughts

Overgeneralization

Viewing one or two bad

events as an endless pattern

of defeat.

I tried doing exercises for my

back pain before and it didn’t

help. So, it isn’t going to help

now.

Although physical therapy

didn’t help much before,

maybe this time it will help.

I might as well try.

Jumping to Conclusions

Drawing negative

conclusions of events that

are not based on fact.

When I move my back hurts,

so it must be bad for me to

move.

Hurt does not equal harm.

Emotional Reasoning

Believing how you feel

reflects how things really

are.

I feel useless, so I am useless.

Even though I can’t do all

the things I used to do, it

doesn’t mean I can’t do

anything.

Disqualifying the Positive

Focusing on only the bad

and discounting the good.

So what if I am doing more, I

am still in pain.

Doing more is important

for me to live the life I want

to live.

Used with permission from KM. Phillips, Ph.D.

135

CATCHING ANTs: How to Catch, Check, & Challenge Automatic Negative Thoughts

When we feel upset or angry, most often we also have negative thoughts. These thoughts may happen automatically and

increase your pain and negative mood. You can feel better physically and emotionally by “catching” ANTs when they

occur, noticing how they make you feel, and challenging them with more balanced thoughts. Using the chart below,

record at least one ANT each day. Evaluate the thought and generate a new helpful one.

Day/Situation

Catch It!

Identify ANT

Check It!

Effect on your

pain/mood

Challenge It!

Positive/balanced coping

statement

Tuesday/Cleaning

garage and pain

flares

This pain is killing me. I can’t

do anything anymore.

Helpful or Unhelpful

I am hurting right now because I

overdid it, but I know that I will feel

better soon. Then I will pace myself

to get the job done.

Helpful or Unhelpful

Adapted with permission from S. Palyo, Ph.D. & J. McQuaid, Ph.D.

136

Coping Statements

Here are some statements that can be used to replace unhelpful thoughts. Put an “X”

next to the ones that you think may be helpful for you. What things have you told

yourself in the past to get through a pain flare or difficult situation? Add your helpful

statements to the list.

Coping Statement Checklist

The pain flare passes in a while.

I can handle this. I just have to make it through this moment.

I’ve gotten through it before and I can get through it again.

I don’t have to suffer. I have skills I can use to cope.

What would I tell a friend who was in pain?

How can I set a good example for my kids about coping with

life’s challenges?

How would someone I admire cope with this?

I just have to focus on something else.

There may be no cure, but I can still live my life.

I’m going to focus on what I can do, not what I can’t do.

Adapted with permission from K.M. Phillips, Ph.D.

Remember: It’s easy to think of positive statements when you’re feeling okay. But, if

you are in a bad mood or having a pain flare, it’s more difficult. Keep a list of these or

other helpful statements in a place where you can easily find them when you need them

most (e.g., in your wallet, on your refrigerator, in your phone).

137

Module 6 Patient Handouts:

The Pain Action Plan

138

Anticipating Obstacles: Plan for Coping

People have many challenging situations in their lives and it is expected that certain

obstacles will arise. A difficult day may involve life stressors and increased pain

symptoms. The best time to plan for how you will cope with and manage your pain

during one of these days is now.

Below, identify the specific things in your life that may be triggers for pain flare-ups, as

well as how you may cope with challenges using the skills that you have learned.

Potential Obstacles/Triggers/Stressors: (Example: Kids fighting, Cold weather)

1. ______________________________ 2. ______________________________

3. ______________________________ 4. ______________________________

5. ______________________________ 6. ______________________________

Ways to Cope: (Example: Walking, Deep breathing, Pleasant activity)

1. ______________________________ 2. ______________________________

3. ______________________________ 4. ______________________________

5. ______________________________ 6. ______________________________

Remember:

BE PREPARED! Consider all the tools you have learned and do not undersell yourself or

let automatic negative thoughts (ANTs) sabotage you. Contact friends, family, and VA

providers who are there to provide support as needed.

139

Weekly Activities Schedule

Use the schedule provided to plan your activities for the upcoming week. Be as

specific as possible and include items such as doing the dishes as well as the pain

management strategies you will employ regularly such as using relaxation techniques.

Be realistic in your planning so that you are able to follow the schedule.

Time

Sun

Mon

Tues

Wed

Thurs

Fri

Sat

7:00 a.m.

8:00

9:00

10:00

11:00

12:00 p.m.

1:00

2:00

3:00

4:00

5:00

Evening

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SMART Goal Setting

A SMART goal uses the following guidelines:

Adapted from Doran, 1981

SMART Goal Versus Non-SMART Goal

Non-SMART Goal:

I want to get into physical shape.

SMART Goal:

I want to be more active by walking twice a week for 30

minutes for the next three months so that I can keep up with my

grandchildren when I see them during the holidays.

Non-SMART Goal:

I want to be more social.

SMART Goal:

I want to go watch a movie and eat dinner with my friends

once a week for the next three months so I spend less time alone while I

manage my chronic pain.

Specific

Measurable

Attainable

Relevant

Time-bound

Should identify a specific action or event that will take

place. In other words, “What specifically do I want to

do?”

Should be able to track progress. In other words,

“How will I know I have met my goal?”

Should be attainable and realistic given resources. In

other words, “Is this really something that I can do?”

Should be personally meaningful and really matter.

In other words, “How important is this to me?”

Should state the time period for accomplishing the

goal. In other words, “By when do I want to achieve

this goal?”

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Short-term goals can be accomplished over the near future, or about 3 months from

now. For each goal, consider if it fits the SMART criteria listed above. These should be

personally meaningful goals that motivate you to complete the program and improve

your pain management skills. Once goals are identified, track them on a weekly basis to

ensure that progress is occurring. If it is not, make adjustments as needed.

Short-Term Goals

In the space below, write down SMART goals you would like to achieve in the next three

months.

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

Accomplishing short-term goals keeps us motivated to achieve long-term goals. Long-

term goals are those for the next 6–12 months (or even longer). They will not be

accomplished fully during this program, but you can continue to work towards them

using the skills you have developed.

Long-Term Goals

In the space below, write down SMART goals you would like to achieve in the next 6–12

months.

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

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Appendix 2:

Pain Conditions

143

PAIN CONDITIONS

From 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.

Low Back Pain. Low back pain (LBP or lumbago) is the most common form of pain and the

most fiscally costly worldwide in terms of medical visits and loss of work productivity (Deyo &

Weinstein, 2001). Most people with acute LBP recover in a matter of weeks, but for about

10% the pain will become chronic (Costa et al., 2012). Many individuals who experience

chronic LBP report high levels of fear of movement and consequently are prone to

deconditioning of the muscles leading to greater disability. LBP may be due to factors such as

herniated discs, degenerative disc disease, spinal stenosis, or arthritis, but the vast majority of

back pain is due to muscle strain (Deyo & Weinstein, 2001).

Middle and Upper Back Pain. Middle and upper back pain is less common than LBP because

the bones in these areas do not move as often. As in the lower area of the back, pain is most

often related to muscle sprain or overuse, herniated discs, or arthritic processes.

Neck Pain. Neck pain (i.e., cervicalgia) is a common issue with about 65% of the population

experiencing it at some point in their lives. It is generally caused by activities that strain the

neck such as poor posture or sleeping, muscle tightness, or whiplash from a motor vehicle

accident. Neck pain may also be associated with headache pain.

Osteoarthritis. Osteoarthritis (OA) is the most common form of arthritis (Prieto-Alhambra &

Judge, 2013) and occurs when cartilage that cushions the ends of bones and joints

deteriorates. Because of this, OA is often referred to as the “wear and tear” disease and is

common among Veterans given engagement in military and non-military occupations that

often involve physical labor (Morgenroth, Gellhorn, & Suri, 2012). The most common areas of

the body affected include hands, feet, neck, low back, knees, and hips.

Rheumatoid Arthritis. Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder

that primarily affects the joints. White blood cells accumulate in the joints causing swelling

and pain. Progression of the disease can lead to destruction of cartilage, ligaments, and

tendons. RA typically impacts functional status to a greater degree than OA and is twice as

prevalent in women than men.

Tendonitis/Bursitis. Tendonitis and bursitis involve inflammation of one of the tendons and

bursae, respectively. Tendons are thick cords that join muscles to bones and inflammation

causes pain and tenderness in the joints. Tendonitis is commonly associated with sports

involving repetitive motion, such as swimming or throwing a ball, but can result from any

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repetitive movement involving the joints. Bursae are fluid-filled sacs found in joints that

surround areas where tendons, skin, and muscle tissues meet. Bursae provide essential

lubrication to the hips, knees, elbows, and heels. Damage can cause pain, swelling, and

redness.

Pelvic Floor Disorders. Pelvic floor disorders occur when the area that supports the pelvic

organs becomes weak or damaged. These may result in urinary or fecal incontinence, as well

as persistent pain in the pelvic walls. Some of the common causes are endometriosis, pelvic

floor tension myalgia, pelvic inflammatory disease, fibroids, surgeries, and irritable bowel

syndrome. Pelvic pain is much more common among women, with one in seven experiencing

some form of this chronic condition.

Gout. Gout is a type of arthritis that is characterized by inflammation, tenderness, and

stiffness in joints. The disorder is more common in men than women and often affects the big

toe. Symptoms are episodic and flare-ups are typically associated with increased levels of uric

acid. Uric acid levels are influenced by genetic factors but also by diet and lifestyle (Gheita, El-

Fishwawy, Nasrallah, & Hussein, 2012).

Peripheral Neuropathic Pain. Peripheral neuropathy typically affects the hands and feet. It

involves microvascular lesions in small blood vessels and its development is often associated

with high blood sugar secondary to diabetes. Pain is commonly, but not universally,

associated with peripheral neuropathy. Pain quality is often described as numb and tingling,

pins and needles, electric, or burning, as opposed to being characterized as “pain.”

Radicular Pain. Radicular pain is most commonly associated with LBP or neck pain, referred to

as lumbar radiculopathy and cervical radiculopathy, respectively. It radiates along a nerve due

to inflammation or irritation of the nerve root and extends from the spinal cord to areas such

as the buttocks and down the legs in the case of back pain, or down the arms in the case of

neck pain. The sudden appearance of radicular pain, new muscular weakness, or the

identification of radicular pain that is not noted by medical providers is cause for immediate

medical evaluation (Gilron, Watson, Cahill, & Moulin, 2006). Radicular pain is typically

described as burning, shooting, or shock-like (Atlas et al., 1996).

Phantom Limb Pain. A phantom limb is the sensation that an amputated or missing limb is

still attached to the body. Between 60 and 80% of individuals with an amputation experience

phantom limb sensations and the majority of these sensations are painful (Sherman,

Sherman, & Parker, 1984). In addition, pain at the site of the amputation, or stump, caused by

nerve damage in the stump region is also common. Pain is variable from a dull ache to

shooting and severe.

145

Fibromyalgia. Fibromyalgia (FM) is a disorder of unknown etiology associated with

widespread pain, sleep disturbance, fatigue, and psychological distress among other

symptoms. FM pain typically includes tender “trigger” points found in soft tissue of the back

of the neck, shoulders, low back, hips, shins, and knees, and the pain is often described as a

deep aching or burning. FM is about 7 times more common in women than men (Haviland,

Banta, & Prezekop, 2011) and individuals with FM are 3 times more likely to have a comorbid

diagnosis of major depression than individuals without FM.

Complex Regional Pain Syndrome. Complex regional pain syndrome (CRPS), previously

known as reflex sympathetic dystrophy syndrome, or RSD, is a poorly understood pain

condition that often starts after a minor injury or complication, usually to a hand, arm, foot,

or leg, and often spreads. Type 1, the form most commonly seen, has no demonstrable nerve

lesions, while there is nerve damage in Type 2. Pain is described as severe and changes in the

appearance and texture of the skin are often noticeable.

Types of Headaches

The most common types of headaches are listed below. It is important to remember,

however, that patients may have more than one kind of headache (e.g., tension-type

headaches a few times per week and migraines a few times per month). In addition, in the

same way that other pain locations may be difficult to classify, Veterans may present with

mixed symptoms that do not fall neatly into one category.

Tension-type. Tension-type headaches (TTH) are by far the most common type,

accounting for over half of all headaches (ICHD, 2nd edition, 2004). The primary sensation

associated with TTH is the feeling of a tight band wrapped around one’s head. These

range in intensity from mild to moderate and also range in frequency from episodic to

chronic. Criterion for chronic TTH is met when an individual experiences headaches for 15

days a month for at least 6 months (ICHD, 2nd edition, 2004).

Migraine. Migraine headaches occur in about 10% of the population at some point in their

lifetime (Rasmussen, Jensen, Schroll, & Olesen, 1991). They are classified as either with or

without aura, defined by symptoms such as sensory or motor disturbance that precede or

accompany the headache. Migraine headaches tend to be recurrent and are associated

with a number of autonomic nervous system symptoms. The typical migraine headache is

unilateral and pulsing in nature, lasts from 2 to 72 hours, may be associated with nausea,

vomiting, sensitivity to light and sound, and aggravated by physical activity. Migraines are

2 to 3 times more common in women than men (ICHD, 2nd edition, 2004).

Cluster. Cluster headaches involve severe unilateral pain that is orbital, supraorbital, or

temporal, lasting 15 to 180 minutes, and occurring in frequency from every other day to

up to 8 times per day (ICHD, 2nd edition, 2004). Painful episodes may be accompanied by

tearing, nasal congestion, sweating, a drooping eyelid, or a contracted pupil. These all

occur on the affected side of the face. The intense pain of cluster headaches is due to

146

dilation of blood vessels creating pressure on the trigeminal nerve. However, the

underlying cause of the dilation is not understood. This type of headache is much less

common, affecting .1% of the population, and is 3 to 4 times more common in men than

women (ICHD, 2nd edition, 2004).

Post-traumatic. Headaches associated with head trauma (e.g., mild to severe traumatic

brain injury) is common immediately following an injury, with a prevalence up to 90%. Up

to 44% of patients report continued headaches 6 months following an injury (Nicholson &

Martelli, 2004). The three most common presentation patterns are tension-type, migraine

type, or cervicogenic (Gironda et al., 2009). Exposure to blasts and concussions while

deployed make this type of headache more common among Veterans and military Service

members.

Medication Overuse. Medication overuse headaches, previously known as rebound

headaches, are a secondary cause of chronic daily headaches due to the overuse of acute

headache analgesics. Overuse is defined by treatment days per month and depends on

the drug. Overuse is often motivated by the desire to treat headaches or a fear of future

headaches, but regardless can make headaches refractory to preventative medications

(Silberstein, Lipton, & Saper, 2007).

REFERENCES

Atlas, S. J., Deyo, R. A., Patrick, D. L., Convery, K., Keller, R. B., & Singer, D. E. (1996). The

Quebec Task Force classification for spinal disorders and the severity, treatment, and

outcomes of sciatica and lumbar spinal stenosis. Spine, 21(24), 2885-2892. doi:

10.1097/00007632-199612150-00020

Costa, L. C. M, Maher, C. G., Hancock, M. J., McAuley, J. H., Herbert, R. D., & Costa, L. O. P.

(2012). The prognosis of acute and persistent low-back pain: A meta-analysis. Canadian

Medical Association Journal, 184(11), 613-624. doi: 10.1503/cmaj.111271

Deyo, R. A., & Weinstein, J. N. (2001). Low back pain. New England Journal of Medicine,

344(5), 363-370. doi: 10.1056/NEJM200102013440508

Gheita, T. A., El-Fishawy, H. S., Nasrallah, M. M., & Hussein, H. (2012). Insulin resistance and

metabolic syndrome in primary gout: Relation to punched-out erosions. Internal Journal

of Rheumatic Diseases, 15(6), 521-525. doi: 10.1111/1756-185X.12007

Gilron, I., Watson, C. P., Cahill, C. M., & Moulin, D. E. (2006). Neuropathic pain: A practical

guide for the clinician. Canadian Medical Association Journal, 175(3), 265-275.

doi:10.1503/cmaj.060146

Gironda, R. J., Clark, M. E., Ruff, R. L., Chait, S., Craine, M., Walker, R., & Scholten, J. (2009).

Traumatic brain injury, polytrauma, and pain: Challenges and treatment strategies for

the polytrauma rehabilitation. Rehabilitation Psychology, 54(3), 247-258. doi:

10.1037/a0016906

Haviland, M. G., Banta, J. E., & Przekop, P. (2011). Fibromyalgia: Prevalence, course, and co-

morbidities in hospitalized patients in the United States, 1999-2007. Clinical and

Experimental Rheumatology, 29(6 Suppl 69), 79-87.

147

International Headache Society Classification Subcommittee. (2004). International

classification of headache disorders, 2nd edition. Cephalalgia, 24(Suppl 1), 1–160.

Morgenroth, D. C., Gellhorn, A. C., & Suri, P. (2012). Osteoarthritis in the disabled

population: A mechanical perspective. Osteoarthritis, 4(5 Suppl), 20-27.

http://dx.doi.org/10.1016/j.pmrj.2012.01.003

Nicholson, K., & Martelli, M. F. (2004). The problem of pain. The Journal of Head Trauma

Rehabilitation, 19(1), 2-9. doi: 10.1097/00001199-200401000-00002

Prieto-Alhambra, D., Judge, A., Javaid, M. K., Cooper, C., Diez-Perez, A., & Arden, N. K. (2013).

Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis:

Influences of age, gender and osteoarthritis affecting other joints. Annals of the

Rheumatic Diseases, 73(9), 1659-1664. doi: 10.1136/annrheumdis-2013-203355

Rasmussen, B. K., Jensen, R., Schroll, M., & Olesen, J. (1991). Epidemiology of headache in a

general population: A prevalence study. Journal of Clinical Epidemiology, 44(11), 1147-

1157. doi: 10.1016/0895-4356(91)90147-2

Sherman, R. A., Sherman, C. J., & Parker, L. (1984). Chronic phantom and stump pain among

American Veterans: Results of a survey. Pain, 18(1), 83-95. doi:10.1016/0304-

3959(84)90128-3

Silberstein S. D., Lipton R. B., & Saper J. R. (2007). Chronic daily headache including

transformed migraine, chronic tension-type headache, and medication overuse headache.

In: Silberstein, S. D., Lipton, R. B., & Dodick, D. W. (Eds). Wolff’s Headache and Other

Head Pain. New York, NY: Oxford University Press.

148

Appendix 3:

Treatment Options for Chronic

Pain

149

TREATMENT OPTIONS FOR CHRONIC PAIN

From 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.

The intent of this section is to familiarize non-medical providers with common treatment modalities

by providing basic information that does not include data on efficacy.

Analgesic Medications

The following section is an introduction to analgesic, or pain relieving, medications. It is not meant to

guide prescription of medications but instead to help providers understand the likely uses of

medications taken by Veterans with chronic pain. A table of medications including both generic and

brand names is also included below.

Non-Opioid Analgesics. Aspirin and other related compounds constitute a class of drugs known

as nonsteroidal anti-inflammatory drugs (NSAIDS). This class of medication produces three

desirable effects including anti-inflammatory, analgesic, and antipyretic (fever reducing).

Commonly used medications in this category include aspirin, ibuprofen, naproxen, etodolac,

meloxicam, and piroxicam. The most common adverse effects of NSAIDs are gastrointestinal and

renal (kidney). Acetaminophen is also a non-opioid analgesic but is not an NSAID because, though

possessing pain relieving and antipyretic properties, it lacks an anti-inflammatory component.

Opioid Analgesics. Opioid analgesics (or narcotics) refer to compounds that act by binding to

opioid receptors in the brain. Though often used interchangeably, the term opiate refers only to

the naturally occurring resin found in opium poppy while opioids also include synthetically

produced substances and thus is the preferred general term.

This class of medications can either be short- or long-acting. Commonly used opioids include

morphine, hydrocodone, oxycodone, codeine, methadone, and hydromorphone. The analgesic

effects of opioids are due to decreased perception of pain, decreased reaction to pain, and

increased pain tolerance. The most commonly cited side effects of opioids (in order of frequency

reported) include nausea, constipation, drowsiness, dizziness, and vomiting (Eisenberg, McNicol,

& Carr, 2006). Opioids may be associated with risk of misuse (Comptom & Volkow, 2006) and

physiological dependence.

Measuring the risk to benefit ratio of opioid therapy for patients with chronic pain is complicated

and prescribing providers are encouraged to follow the 2010 VA/Department of Defense (DoD)

Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain Of note,

concurrently prescribing opioids and sedatives/hypnotics (e.g., benzodiazepines) should be done

with extreme caution based on increasing evidence of risk of accidental overdose-related deaths

(Jones, Mack, & Paulozzi, 2013).

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Tramadol. Tramadol does not fit neatly into a single category because it is dual acting. It

interferes with the transmission of pain signals like an opioid, but it also releases norepinephrine

and serotonin like an antidepressant. It is used for moderate to severe chronic pain and the most

common side effects are dizziness, sedation, constipation, nausea, and headaches. Because it is

not a pure opioid, risk of physiological dependence is lower but is still present.

Topical Analgesics. Topical analgesics are applied to the skin for delivery of medication to

targeted pain areas. They block the generation and transmission of nerve signals to the brain

through a local numbing effect. Topical products are available in various creams, gels, lotions,

patches, and plasters. Since they are applied to a localized area externally, topical agents afford a

lower risk for systemic adverse events and side effects. They are frequently used in the VA and

the most commonly prescribed topicals are capsaicin, lidocaine, diclofenac, and menthol-

methylsalycylate.

Muscle Relaxants. Muscle relaxants (or spasmolytics, antispasmodics) are most commonly

prescribed for LBP, neck pain, fibromyalgia, and tension headaches in situations where muscular

contractions appear to be a prominent component of pain.

Muscle relaxants used most commonly in VA include cyclobenzaprine, tizanidine, baclofen, and

methocarbamol. Muscle relaxants work by inhibiting the central nervous system, which

contributes to the commonly reported side effect of sedation and the recommendation against

driving or operating heavy machinery. Other common side effects include dizziness, headache,

nausea, irritability, and nervousness. Muscle relaxants also pose a risk of physiological

dependence.

Adjuvant Analgesics. Adjuvant analgesics, or co-analgesics, are medications that were originally

developed and marketed for uses other than analgesia and are also used in pain management.

The two most common classes of medications that fall into this category are certain types of

antidepressants and anticonvulsants. Antidepressants commonly used for analgesic purposes

include duloxetine, venlafaxine, and nortriptyline. Common side effects of antidepressants

include nausea, vomiting, insomnia, decreased sex drive, and constipation. Anticonvulsants,

primarily used to relieve neuropathic pain, include gabapentin, pregabalin, topiramate, and

lamotrigine. Common side effects of anticonvulsant medications include dizziness, fatigue, weight

gain, and drowsiness.

Headache Analgesics. Analgesics used to treat headaches vary widely and do not fall into a single

class. Migraine medications are generally categorized by nature of their action into those that are

preventative (e.g., propranolol, topiramate or Topamax), abortive (e.g., sumatriptan or Maxalt),

and rescue (butalbital/acetaminophen/caffeine or Fioricet). Of note, medication overuse

headaches, or rebound headaches, may occur when excessive analgesics are taken for headache

relief, leading to chronic daily headaches of a different type.

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Examples of Common Analgesics, By Class

Opioid Analgesics

oxycodone

Oxycontin

oxycodone + acetaminophen

Percocet

oxymorphone

Opana

Opioid and Antidepressant

tramadol

Ultram

Muscle Relaxants

baclofen

cyclobenzaprine

Flexeril

methocarbamol

Robaxin

tizanidine

Zanaflex

Topical Analgesics

capsaicin cream/patch

diclofenac gel

Voltaren

lidocaine

gel/cream/ointment/

patch

Lidoderm

menthol-methylsalicylate cream

Adjuvant Analgesics:

Anticonvulsants

carbamazepine

Tegretol

gabapentin

Neurontin

pregablin

Lyrica

topiramate

Topamax

lamotrigine

Lamictal

Adjuvant Analgesics:

Antidepressants

amitriptyline

Elavil

duloxetine

Cymbalta

nortriptyline

Pamelor

venlafaxine

Effexor

Headache Analgesics

butalbital + acetaminophen + caffeine

Fioricet

rizatriptan

Maxalt

sumatriptan

Imitrex

zolmitriptan

Zomig

INVASIVE MEDICAL TREATMENT OPTIONS FOR CHRONIC PAIN

Epidural Steroid Injections. Epidural Steroid Injections (ESIs) are used for back pain complaints

associated with conditions such as spinal stenosis or spinal disc herniation. ESIs include a

combination of corticosteroids and local anesthesia that is injected into the epidural space around

152

the spinal cord and nerves. The injection may be guided by fluoroscopy or x-ray. The effects of the

injection last from one week to six months.

Nerve Blocks. Nerve blocks (aka, regional nerve blockade) are used for pain in the neck, back, feet or

even the head. Nerve blocks may include local anesthetic and epinephrine, with corticosteroids,

and/or opioids that are injected directly into the nerve group associated with reported pain. Nerve

blocks can be used to treat painful conditions, to determine sources of pain, or to judge the benefits

of more permanent treatments such as surgery.

Trigger Point Injections. Trigger point injections (TPI) are used to relieve muscles where knots form

when muscles do not relax. TPI is used in many muscle groups ranging from arms, legs, low back, and

neck and is most often associated with treatment of fibromyalgia and tension headache. The

injection contains a local anesthetic that may include a corticosteroid.

Facet Injections. Facet injections are used for those with chronic neck or back pain caused by

inflamed facet joints, which are located between each set of vertebrae in the spine from the neck to

the tailbone. A mixture of local anesthetic and corticosteroid medication is injected into the facet

joint to reduce swelling and inflammation around the facet joint space.

Radiofrequency Ablation. Radiofrequency ablation (RFA) is used to treat severe chronic low back

pain. Radiofrequency waves produce high heat on specifically identified nerves surrounding the facet

joints in the lumbar spine, ablating the nerves and destroying their ability to transmit pain signals.

RFA is an outpatient procedure using local anesthesia. While the procedure may provide pain relief,

in most patients the nerves regenerate.

OnabotulinnumtoxinA (Brand name: Botox). Botox injections are typically used for relief of frequent

migraine headaches. Botox received approval from the FDA as a treatment for chronic migraines in

2010.

Spinal Cord Stimulator. The most common use of spinal cord stimulators (SCS) is with patients

diagnosed with failed back syndrome (see definition under Surgery below). A SCS includes electrodes

implanted in the epidural space, an electrical pulse generator implanted in the lower abdominal area

of gluteal region, connecting wires to the generator, and a generator remote control.

Intrathecal Pump. An intrathecal pump is an implantable device that delivers pain medication

directly to the spinal fluid. Common medications used in pumps include baclofen or morphine. The

pumps deliver medications at higher dosages than possible with oral medications.

Surgery. Surgery may be offered for various pain locations such as back, neck, knee, shoulder, or

ankle. Surgery for chronic pain is usually considered only after conservative treatments have failed or

if seen as medically necessary. Individuals who have undergone one or more unsuccessful back

surgeries may receive the diagnosis or label of “failed back syndrome” or “failed back surgery

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syndrome.” Causes for failure of surgery vary, but the results can lead to frustration and distrust of

medical providers, increased depression, and increased perceptions of disability (Onesti, 2004).

NON-INVASIVE TREATMENT OPTIONS FOR CHRONIC PAIN

Physical Therapy. Reduction in bodily movement that can be related to fear of pain or re-injury is

common in chronic pain and often leads to physical deconditioning and, subsequently, increased

pain. Physical therapy is an integral part of chronic pain interventions as it helps restore physical

functioning and re-engagement in rewarding life activities. Physical therapy involves a range of

activities including stretching exercises, strengthening exercises, and use of graded exercise

techniques such as therapeutic pools or stationary bikes, in addition to a range of palliative therapies

such as spinal manipulation and ultrasound, among others.

Cold/Heat. Application of cold and heat are often used for the management of chronic pain. Cold and

heat may decrease sensitivity to pain and provide competing sensory central nervous system input

that can reduce pain sensations.

Transcutaneous Electrical Nerve Stimulation (TENS). TENS units stimulate nerves by introducing a

mild electrical current. The electric current is not strong enough to cause muscle contraction, but

instead is thought to interfere with the transmission of pain signals to the brain. Electrodes are

placed on the skin and a battery-powered unit is carried or worn on the person. No surgical

procedures are involved in the use of a TENS unit.

Chiropractic. These interventions primarily focus on spinal adjustment or adjustment to other joint

areas. Spinal or other joint manipulations involve a dynamic thrust that causes an audible release and

attempts to increase range of motion.

Chiropractic care may also involve soft tissue therapy, strength training, dry needling, functional

electrical stimulation, traction, or nutritional recommendations.

Acupuncture. Acupuncture involves the insertion of needles into acupuncture points in the skin in an

effort to relieve pain. Acupuncture produces physiologic effects that are relevant to analgesia;

however, the mechanism for how acupuncture affects chronic pain remains unclear (Vickers, et al.,

2012).

Yoga/Tai Chi. Yoga and Tai Chi may provide a source of graded physical exercise combined with

relaxation to improve chronic pain.

Biofeedback. Biofeedback involves increasing awareness of physiological functions or processes such

as muscle tone, skin conduction, heart rate, or brainwaves. Awareness of different physiological

processes is gained through use of a variety of types of monitoring devices specific to the process

being monitored, such as an electromyography (EMG) to measure muscle activity or

electrodermograph to register skin conductance or resistance.

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Information on a specific process is gathered, amplified, and displayed (fed back) to the patient who

then uses the visual or auditory feedback to gain control over the targeted behavior. Biofeedback has

been used to treat a variety of chronic pain disorders but is most often used in the management of

headaches.

Relaxation Training. Relaxation training, which may be done in the context of biofeedback, focuses

on identifying tension within the body and applying systematic techniques for decreasing that

tension. The most common techniques include diaphragmatic (or deep) breathing, progressive

muscle relaxation, and visualization.

SELECTED PSYCHOLOGICAL APPROACHES

Operant Behavioral Therapy. The operant-behavioral formulation of chronic pain by Fordyce (1976)

marked a significant development in the understanding and treatment of chronic pain by introducing

the concept of pain behaviors. These refer to forms of communication that are observable

expressions of pain and suffering such as moaning, clenching, grimacing, sighing, or limping. The

model suggests that reinforcement of such behaviors, often by those in one’s social environment,

could lead to maintenance of subjective reports of pain and increased self-perceptions of disability.

Cognitive Behavioral Therapy (CBT). CBT helps individuals resolve their problems concerning

maladaptive emotions, behaviors, and cognitions through a goal-oriented, systematic process. While

it was originally used for treatment of those with depression and anxiety disorders, it has been

implemented with a variety of other conditions from insomnia to substance abuse.

Acceptance and Commitment Therapy (ACT). Acceptance and Commitment Therapy, (ACT: Hayes et

al., 1999) is an acceptance- and mindfulness-based intervention that teaches patients to observe and

accept thoughts and feelings without judgment and without trying to change them. It focuses on

identifying core values and behaving in accordance with those values. As applied to chronic pain, ACT

emphasizes that while the physical sensation may be painful, the patient’s struggle with pain is what

causes suffering and emotional distress (Dahl & Lundgren, 2006). The aim of therapy, therefore, is to

develop greater psychological flexibility in the presence of thoughts, feelings, and behaviors

associated with pain.

Hypnotherapy. Hypnotherapy utilizes suggestive statements made by a therapist to alter the

patient’s attention and focus away from pain. Deep breathing is often used as a behavioral cue in an

effort to alter the subjective experience of pain. However, there is significant variation in specific

techniques.

Mindfulness. Mindfulness meditation is another approach combining elements of relaxation and

hypnotherapy, which seeks to increase focused attention and facilitate relaxation. Based in

Theravada Buddhism, it seeks to increase intentional self-regulation to what is occurring in the

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present without attaching negative associations. As applied to pain management, a primary goal is to

separate the pain sensation from unhelpful thoughts.

APPENDIX 3 REFERENCES

Compton, W. M., & Volkow, N. D. (2006). Major increases in opioid analgesic abuse in the United

States: Concerns and strategies. Drug and Alcohol Dependence, 81(2), 103-107.

http://dx.doi.org/10.1016/j.drugalcdep.2005.05.009

Dahl, J. C., & Lundgren, T. L. (2006). Living beyond your pain: Using Acceptance and Commitment

Therapy to ease chronic pain. Oakland, CA: New Harbinger.

Eisenberg, E., McNicol, E., & Carr, D. B. (2006). Opioids for neuropathic pain. Cochrane Database of

Systematic Reviews, Issue 3. Art. No.: CD006146. doi:10.1002/14651858.CD006146

Fordyce, W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis, MO: Mosby.

Hayes, S. C., Strosahl, K. D, & Wilson, K. G. (1999). Acceptance and commitment therapy: An

experiential approach to behavior change. New York, NY: Guilford Press.

Jones, C. M., Mack, K. A., & Paulozzi, L. J. (2013). Pharmaceutical overdose deaths, United States,

2010. Journal of the American Medical Association, 309(7), 657-659.

doi:10.1001/jama.2013.272

Onesti, S. T. (2004). Failed back syndrome. The Neurologist, 10(5), 259-264.

doi:10.1097/01.nrl.0000138733.09406.39

Vickers, A. J., Cronin, A. M., Maschino, A. C., Lewith, G., MacPherson, H., Foster, N.E., … & Linde, K.

(2012). Acupuncture for chronic pain: Individual patient data meta-analysis. Archives of Internal

Medicine, 172(19), 1444-1453. doi:10.1001/archinternmed.2012.3654

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Appendix 4:

Mobile Apps for Pain and

Related Health Concerns

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MOBILE APPS FOR PAIN AND RELATED CONCERNS

Below you will find several examples of mobile apps that can assist you with management of

important health topics, including chronic pain. They can be used with (or without) Brief

Cognitive Behavioral Therapy for Chronic Pain to help address wellness goals. All of the apps

below are available at the VA AppStore (https://mobile.va.gov/appstore) where there is a full

listing of additional free mobile apps:

Topic

App Image

Description

Pain

Management

Pain Coach is a mobile application for Veterans that

offers helpful tools to track and manage pain. You

can reference educational information about pain;

track your pain using a daily pain diary and a

monthly check-in; monitor your progress managing

your pain and see tables and graph of changes in

your pain level over time and; and use techniques

and tools to manage pain.

Self-care (Annie

App for Veterans)

Annie is a VA service that sends automated text

messages to Veterans to help them stay focused on

their self-care. This might include health related

notifications, reminders, or motivational messages.

Annie also empowers Veterans to play an active role

in their care, by prompting them to provide health

data such as weight or blood pressure. Anyone with

a phone that can send and received text messages

can use Annie.

Insomnia/Sleep

CBT-i Coach is for people who are engaged in

Cognitive Behavioral Therapy for Insomnia with a

health provider, or who have experienced

symptoms

of insomnia and would like to improve their sleep

habits.

Smoking/Tobacco

Cessation

Stay Quit Coach is intended to serve as a source of readily

available

support and information for adults who are

already in treatment to quit

smoking and to help them stay

quit after treatment ends.

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Topic

App Image

Description

Weight

Management

MOVE! Coach provides self-managed weight management

allowing Veterans to monitor, track, and receive tailored

feedback regarding their progress with weight and exercise

goals while controlling relapse triggers and forming coping

plans.

PTSD

PTSD Coach is designed for Veterans and military Service

Members who have, or may have, Post-traumatic Stress

Disorder (PTSD). This app provides users with education

about PTSD, information about professional care, a self-

assessment for PTSD, opportunities to find support, and

tools that can help users manage the stressors of daily life.

PTSD

CPT Coach is for Veterans, Service members, and others

with PTSD who are participating in Cognitive Processing

Therapy (CPT) with a professional mental healthcare

provider. This app contains support materials for a

complete course.

PTSD

ACT Coach is designed for Veterans and military Service

Members in Acceptance and Commitment Therapy (ACT)

with a professional mental healthcare provider and

provides additional assistance with unpleasant thoughts,

feelings, and impulses without avoiding them or being

controlled by them.

Emotional

Distress

Mindfulness Coach is for people who may be experiencing

emotional distress, and for those wanting to maintain

healthy coping practices. The app can be used on its own

by those who would like mindfulness tools, or to enhance

face-to-face care with a healthcare professional. It is not

recommended for PTSD. Available for iOS only.

TBI

Concussion Coach is designed for Veterans, Service

Members, and other individuals who experience physical,

cognitive, and emotional symptoms that may be related to

mild to moderate traumatic brain injury. App provides a

self-assessment and information on managing TBI.

Available for iOS only.

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Appendix 5:

Guided Imagery Script

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GUIDED IMAGERY SCRIPT

This technique is designed to train the Veteran to create mental images that foster a relaxed

state. The Veteran should choose a location to mentally visit during the exercise; the only “rule”

is that the Veteran must pick a place that is peaceful and calm, with positive associations.

Encourage a focus on detailed images that take the Veteran away from stressful thoughts and

bodily tension.

The key to developing a deeply immersive experience where the Veteran completely engages in

the imagery exercise is to give full attention to all the specific details of the scene. It is crucial to

involve all five senses; to consider specifically what would be seen, heard, smelled, felt, and

tasted in this location. Provide examples such as smelling fresh-baked cookies in the air, feeling

warm sand in the hand, or hearing the crush of leaves underfoot.

Once the mental scene and the details of the patient’s relaxing place are gathered, guide

Veterans through the steps below. A sample for the therapist is presented below. Please refer

to the Guided Imagery Handout for a sample script of this exercise.

OVERVIEW OF STEPS FOR ANY GUIDED IMAGERY

1. Begin with comfortable posture and relaxed breath with eyes closed or gaze fixed.

2. Imagine the “entryway” into the location (e.g., path, door, staircase, lake dock).

3. Enter the relaxing place (focus on five senses).

4. Spend 5-10 minutes in the relaxing scene.

5. Have the Veteran “leave” the location through the same “entryway.”

SCRIPTING FOR INTRODUCING GUIDED IMAGERY TO THE PATIENT

“Guided imagery is designed to help us create mental images that promote a state of

relaxation. Essentially, guided imagery involves creating a detailed, imaginal location to

mentally visit and attune your thoughts and senses to. For some people, this might involve

things like smelling fresh-baked cookies, listening to birdsongs, or imagining the sensation of

walking through warm sand. But no two people will create the same mental scene. The image

or images that you select are up to you; the only rule is that you must create a calm and

peaceful scene.”

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GUIDED IMAGERY EXERCISE

1. Imagine yourself walking slowly down a path toward your special place. This path can be

inside or outside. The path is comforting and peaceful. As you walk down this path,

imagine all of your stresses, worries, and tension are leaving you. Enjoy this journey to

your special place.

2. As you walk down this path, notice the ground beneath you…how it feels as you walk.

Notice the sounds…the comfortable temperature of the air. Take a breath in, feeling all

your tension leave you as you exhale. Notice any fragrance that may be here. Notice the

view around you. Reach out and touch something around you. Feel its textures.

3. You feel calm and safe. All your worries and anxieties being left behind as you move

toward your special place… (PAUSE 30 sec).

4. Walk down this path until you arrive at your own special place…and when you have

reached this special place, go ahead and enter… (PAUSE 10 sec).

5. You have arrived at this relaxing and peaceful place. Notice the ground underneath

you… whether it is hard or soft. Notice how the ground feels below your feet. Listen to

the sounds in this place, both close and distant. Smell the air, the fragrances. Notice the

temperature of the air around you.

6. Look above you… Notice the colors and sights above you. Look out into the distance… as

far as you can see… Take in all of the sights, fragrances, and sounds around you.

7. Reach out and touch something in this place… Notice its texture and how it feels against

your skin. Notice the different objects around you… their shapes, textures, and colors.

Notice the light and shade of this place and how it reflects off of these objects.

8. There is a comfortable place for you to sit or lie here as you take in all the smells,

sounds, sights, and textures… As you sit or lie in this place, away from it all, you feel

calm and secure, refreshed and renewed, strong and at peace. As you enjoy this place

for a few minutes, you know that you can come here whenever you please, and that this

place will always be waiting for you… (PAUSE 3-5 min).

9. Now it's time to come back… leave by the same way you came, enjoying the path… and

as you return on this path, you start to also notice the room in which you are sitting…

start to wiggle your fingers and toes… and when you are ready, slowly open your eyes

and stretch your muscles.

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United States Department of Veterans Affairs