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Man receiving physical therapy for pain.

By Allen R. Miller, PhD, MBA

Many therapists tell me that they don’t want to work with clients who have chronic pain, particularly clients who rely on opioids to manage their pain. They cite the complexities of understanding the cases, the attitudes of the clients, and poor outcomes as reasons to avoid working with these cases when there is an abundance of other “easier” cases with which to work.

To be completely transparent, I once had my own automatic thoughts about working with chronic pain cases. Incomplete and inaccurate information supported my negative thoughts about what it meant to work with these cases. It was only because of the great need and the absence of other willing therapists that I was cornered into taking my first case. That was a long time ago, and I have learned a lot since.

Man receiving physical therapy for pain.

First, I learned to stop thinking about these clients as chronic pain and opioid use cases and started to think about them as people. People with chronic pain have hopes, dreams, values and aspirations just like everybody else. Unfortunately, many of them have lost sight of their life goals because their pain has literally crippled them. The use of opioids to manage pain adds confusion, depression, and fear to their realities. People with chronic pain often feel cheated out of the vision they had for their lives and feel hopeless that they will ever be able to have value or enjoy life. That is what makes working with them so complex.

As I got to know my clients better, I found that their real-life experiences affected their ability to function. When they could no longer work, play with their children, or do their share of household duties, their beliefs about themselves changed.

Fortunately, I had strong ally in alleviating their desperation and despair—the fundamentals of cognitive behavior therapy (CBT). The humanistic side of CBT informed me that I needed to understand, show empathy for and work together with my clients. That meant I had to set aside my own negative beliefs (e.g., “These cases are too hard” and “I can’t help them anyway.”) I decided to use a little CBT on myself by challenging those negative beliefs. I took on some cases as experiments to see how things would go. The reactions of my clients and their successes served as corrective information for my negative beliefs.

As I got to know my clients better, I found that their real-life experiences affected their ability to function. When they could no longer work, play with their children, or do their share of household duties, their beliefs about themselves changed. They developed the core belief that they were worthless. They thought “things will never get better,” and they lost hope. It would have been tempting to delve into their misery with them.

Today, I know to help them look beyond their current circumstances and reacquaint themselves with their values and aspirations. After they gain a clear view of what they value, we work together to develop needed coping strategies and new skills to deal with current challenges that interfere with their abilities to progress toward their goals. I avoid the trap of telling them what they “must do” and simultaneously help them to get what they want.

Traditional CBT interventions work to help with many challenges that people with pain and opioid use encounter. Cognitive conceptualization, cognitive restructuring, problem solving, activity scheduling, behavioral activation, relaxation and mindfulness techniques, and communication skills all play a role in helping clients cope.

In Part Two of this series, I will discuss the case of a remarkable former client, showing what treatment can look like and how it can help.


If you want even more insights on this topic, Dr. Allen Miller will be leading a workshop at Beck Institute in Philadelphia from February 24-25 and August 31 – September 1 on CBT for Chronic Pain and Opioid Use. This workshop is designed for health and mental health professionals who want to learn how to use CBT techniques to work more effectively with complicated pain and opioid use clients, improve their level of functioning, and increase their overall quality of life.

CBT for Chronic Pain and Opioid Use

February 24 - 25 and August 31 - September 1