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CBT Pain Management

Behavioral Health Treatment for Injured Workers with Chronic Pain

 L. Stuart Cody, MHS, LMHC, SAP, MCAP, ICADC, CEAP, CRC
Joshua Shannon, PhD, LMHC, SAP, LCAP, ICADC, CEAP, CRC

 

Chronic pain remains a significant cost burden in workers’ compensation cases. This article addresses several relevant questions to consider when introducing the use of behavioral health treatment with injured workers.

Recently, the Stay-at -Work / Return-to-Work Policy Collaborative established by the US Department of Labor published a resource compendium for musculoskeletal disorders and pain management (August 2017). The pain management strategy considered to have the greatest potential involves the biopsychosocial model. Evidence suggests the integration of medical, behavioral health and physical rehabilitation into a comprehensive treatment strategy results in effective clinical care and may be the most cost-effective long-term treatment option.

Some initial questions to consider include:

  • What are some of the behavioral health therapies?
  • What duration might behavioral health providers target in the treatment plan?
  • What should you look for in choosing behavioral health providers to work with injured workers?

 

PROMISING BEHAVIORAL HEALTH THERAPUETIC APPROACHES

Cognitive behavioral therapy (CBT) is the most studied, however, Eye Movement Desensitization and Reprocessing (EMDR) and Solution Focused Brief Therapy (SFBT) have solid research foundations and are showing significant treatment effects.

CBT is the most common psychosocial approach to treating pain and leads to improvements in disability & psychological distress. Research, however, shows there is little direct impact on pain intensity. CBT aims to reduce subjective distress & strengthen adaptive cognitions through:

  • detailed descriptions of the event
  • direct challenging of beliefs
  • extended exposure
  • homework.

 

EMDR is a cutting-edge therapy which was originally developed to treat trauma and is currently used to treat a wide variety of clinical issues to include chronic pain. EMDR postulates that when a person is overwhelmed (traumatized), their brain cannot process information as it does ordinarily with that moment becoming ‘frozen’ in time. With subsequent triggering, the trauma is re-experienced in a similar manner to its original intensity because the images, sounds, smells and feelings have not changed. EMDR reprocesses the pain and traumatic memories in real-time such that what happened is still remembered, but it is significantly less upsetting.

SFBT is attractive to many clients because of its tendency to be much shorter in duration than more traditional treatment approaches. Much of this treatment approach derives from substance use (addictions) work and fits well with the injured worker population. SFBT has become widely accepted because of its focus on strengths and solutions rather than deficits and problems, and because it provides a rational framework for doing therapy briefly.

In addition to addressing chronic pain and trauma, these approaches can further bridge return-to-work endeavors. All three frameworks make use of resource (strength) identification and development which correlates with much of the focus in vocational rehabilitation services.



DURATION CONSIDERATIONS

CBT traditionally requires the longest duration of services and the greatest amount of out of session effort (homework) by the injured worker. However, the Veterans’ Administration developed an evidence and competency based, targeted 12 session program for chronic pain. Results indicate significantly enhanced therapist skills and Veteran’s outcomes and can serve as a template to direct services with injured workers.

EMDR is an empirically validated psychotherapy which rapidly treats unprocessed memories of adverse experiences. Seven of ten randomized control studies found that EMDR therapy is more rapid when compared to CBT. Whereas the EMDR therapy occurred over 8 sessions and no homework, the traditional CBT treatment was vastly more complex and entailed 4 imaginal exposure sessions, 4 sessions of therapist-assisted in vivo exposure (physical presence at the trauma location) plus approximately 50 hours of combined imaginal exposure and in vivo exposure homework.

A systematic qualitative review of SFBT studies found strong evidence that it is an effective treatment and tended to use fewer sessions than alternative therapies.

While each case is considered unique and requires individualized assessment and treatment planning, an initial target of 10-20 sessions of behavioral health treatment for injured workers appears reasonable.

 

BEHAVIORAL HEALTH PROVIDER BACKGROUND & CHARACTERISTICS

Licensed mental health counselors, social workers, psychologists or psychiatrists have a documented baseline competency to render behavioral health services. With injured workers, particularly those with chronic pain, additional cross-trained therapists are advantageous. In addition to licensure, certification as an addiction professional (CAP, MCAP, and/or ICADC) and as a substance abuse professional (SAP) permits valuable screening and insights given the propensity of substance use / abuse with pain meds.

Experience in vocational rehabilitation and case management can be very helpful, permitting a more seamless integration of the return-to-work orientation throughout the therapy process along with an understanding of claims management needs.

In conclusion, behavioral health services have shown significant treatment effects, increased functioning, and may be the most cost-effective long-term treatment option with musculoskeletal pain. Utilizing cross-trained professionals along with empirically validated therapeutic approaches, treatment effects can be targeted within reasonable service durations.

Sources:

Stay -at-Work / Return-to-Work Policy Collaborative (August 2017). Improving Pain Management and Support for Workers with Musculoskeletal Disorders – Policies to Prevent Work Disability and Job Loss

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: US Department of Veterans Affairs.

Shapiro, F. (2014). The role of eye movement desensitization and reprocessing (EMDR) therapy in medicine: Addressing the psychological and physical stemming from adverse life experiences. The Permanente Journal, 18(1), 71-77.

Tesarz, J., Liesner, S., Gerhardt, A., Janke, S., Seidler, G.H., Eich, W. and Hartman, M. (2014). Effects of eye movement densitization and reprocessing (EMDR) treatment in chronic pain patients: A systematic review. Pain Medicine, 15, 247-263.

Grant, M.D. (2014). Eye movement desensitization and reprocessing treatment of chronic pain. Open Access Musculoskeletal Medicine, 2(2).

Tefft, A.J. & Jordan, I.O. (2016). Eye movement desensitization reprocessing as treatment for chronic pain syndromes: A literature review. Journal of American Psychiatric Nurses Association, 22(3), 192-214. 

Gingerich, W.J. & Peterson, L.T. (2012). Effectiveness of solution-focused brief therapy: A systematic qualitative review of controlled outcome studies. Research on Social Work Practice, 23(3), 266-283.

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