Pain Reporter: Crossing the Big Pond to Discuss "Behaviour" Therapy for Chronic Back Pain

A recent Daily Dose brought to our attention the results of a pilot study which suggested that contextual cognitive behavioral therapy, or CCBT, may ease psychological stress in chronic back pain patients, making their physiological treatment more effective. To learn more about CCBT and the study, the Pain Reporter crossed the Big Pond to talk to Tamar Pincus, a Professor in the Department of Psychology at the University of London, Royal Holloway, Egham, in Surrey.

Q: What steered you and your team to this research? How did you identify the interventional theory involved in back pain?

A: We were frustrated with the results that were published at that point from psychological intervention in people with low back pain (LBP). Despite the fact that there is growing and robust evidence that certain psychological factors can be obstacles to recovery and to coping with back pain, interventions show only moderate success at improving outcomes. The strongest predictors for poor outcomes, such as disability, include depression, fear about moving, and worry about the consequences of back pain. When we examined the published studies closely, we found that many of them did not really deliver psychology very well. Many trials chose to deliver psychology by healthcare professionals who were unskilled, or trained just for the trial. In many cases there was no theory or clear rationale behind the psychological interventions that were offered. We felt that there was a need to test an optimised intervention, which was carefully selected to match the factors that form obstacles to recovery, that was theory-driven, and that was delivered well, by a skilled professional, in sufficient dose.

We chose CCBT because it attempts to increase people’s ability to manage to live life to the full in the face of difficult challenges that may not be changeable. This applies to many people with LBP who have exhausted their options to ‘cure’ the problem. We also liked the principle that once the new skills were acquired, it would be easy for people to generalise them to all areas of life, rather than focusing just on back pain. The idea of having a holistic approach in which body and mind were considered as a whole unit was also appealing. In addition, there was plenty of evidence suggesting that the intervention was promising, but no definitive trials had been published.

Q: What is your next step getting the CCBT message out there to patients and physicians?

A: As it happens, the philosophy and concepts around CCBT have been embraced by patients and practitioners, and I am regularly approached by groups around the world asking for seminars and workshops to introduce the intervention. Practitioners are particularly keen to train in a method that allows them to engage with patients in this way. But I remain cautious and point out that we still do not know if this approach is more effective than other approaches, or whom it is particularly appropriate (or inappropriate) to treat with CBT.

Q: Do you foresee CCBT regularly being taught in medical schools? Hospitals?

A: Considering the enthusiasm for CCBT that I have witnessed, I would be surprised if CCBT and its closely related interventions—acceptance and commitment therapy (ACT) and mindfulness—were not included in the syllabus within the next 5 years.

Q: Is it difficult to get students to think outside the “medication” box?

A: Some people simply ‘get it’ and others really struggle. Interestingly, it isn’t the discipline or profession that defines who will embrace and become skilled in this approach, but rather the psychological flexibility of the people themselves. By this I mean that practitioners who are more strongly ‘married’ to one approach, hold strong biomedical ideas about pain, and are resistant to change themselves find it more difficult to guide patients towards a flexible approach.

Q: What do you think about the general state of pain management in your country today? How does it differ from that of the United States?

A: Pain management in the UK is generally good, but it is constrained by resources. We have a National Health Service, which means that the majority of people are treated free, funded by the state. Psychologists are relatively expensive, which is why other professionals are turning to training in delivering psychological interventions to patients. Unfortunately all too often training is insufficient—often less than a week—and in the face of complex problems and distressed patients, practitioners revert to their own tried and tested sets of skills or deliver suboptimal psychology. I believe the situation is similar in the USA. And despite this, we should be grateful that psychology is recognised as an important aspect of pain management at all. In the majority of developing countries there is no psychological input at all.

Q: What changes are you seeing in the study of health psychology? What are your students most interested in?

A: Health psychology is growing fast and really coming into its own, with the adaptation of strong scientific methodology, including a much stronger emphasis on large scale trials, excellent guidelines for the development and testing of measures to assess psychological factors and experimental methodologies such as brain imaging. Students are strongly drawn to new technology and love the idea of ‘mapping’ psychological processes to brain activation, but they need to realise the best way to really understand a person’s experience of pain remains asking them about it.

Q: What lead you to study psychology? And why health psychology?

A: Like many scientists I stumbled into the study of health psychology through a series of unforeseen turns! I certainly did not set out to study it when I first went to University to study music. Once I started studying pain, though, I realised what a fascinating area it was, and never looked back.

Q: When you’re not working, how do you like to spend your free time?

A: I raise 2 children, and play in a jazz band. I try to exercise, and be out doors as much as possible…not easy on our little grey island! I honestly never think of my time as split between work and free time. I’m simply active until I’m ready for bed, and then I read.

Q: What is a dream project you hope to work on?

A: Too many to mention, but I would love to bring together my knowledge of health psychology and music.



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