In Part One of this two-part piece focused on CBT for Chronic Pain and Opioid Use, I discussed my past personal reservations about working with clients of this type and the strategies I used to counteract my own related automatic negative thoughts. In this post, I’d like to share the story of a particularly remarkable client who benefited from CBT techniques and the way she helped to shape my own ideas about what’s possible.
Maria was a 43-year-old single woman who had been dealing with chronic pain for 10 years following an accident on the job in a manufacturing plant. She used opioids to cope with the pain and experienced common side effects from her dependency, including taking extra medications to compensate for her increased tolerance and confusion, problems with memory, and constipation. Caught up in the throes of opioid dependence, she did not realize that she also experienced hyperesthesia, or increased sensitivity to pain, due to the opioids. A vicious cycle ensued whereby, when she had pain, she took more opioid medications to deal with the pain--and the opioids caused her to feel more pain--and that led her to take more opioids.
In an attempt to reduce those side effects and her dependency on the opioids, Maria's physician initiated a tapering process. Maria feared that she would have even more pain without the medications. So she did what many people do. She started taking other medications on her own and drinking more alcohol.
Increased medication and drinking took Maria in a predictable direction. She grew dependent on more drugs. Eventually she was arrested for DWI. Her troubles were magnified, and she was lost. She was addicted to multiple drugs, recently arrested, out of work, had no income, and lived with a man whom she found repulsive because he let her live with him for free.
Maria and her physician decided that she would be better off without opioids. In the interest of managing her pain, they considered the possibility of getting a spinal cord stimulator implant. She was referred to a neurosurgeon for consultation about the implant. The consultation went well, so the neurosurgeon referred her for a psychological evaluation to determine whether she would be a good candidate for a spinal cord stimulator. This was the point that I first met her.
During my assessment with Maria I asked her what it was that was important to her and how she wanted her life to be. She quickly cited freedom as the thing that was most important to her in her life. She wanted to be free from pain; she wanted to be free from drugs; she wanted to be free from the courts; she wanted to be free from the repulsive man that she lived with; and, she wanted to be free to work and live the life she wanted. I asked her if she could imagine herself two years in the future being free of all her constraints. She was eager to imagine herself free and enjoying life. She said the very idea was exciting and something for which she was willing to work. A short time later, Maria underwent the procedure to receive the implant.
Maria was fortunate in that she received great relief with the implant, allowing her to begin her journey toward the freedom she most valued. We established a plan. The first step was eliminating her use of opioid medications and alcohol. This was made somewhat easier because of the relief she received from the implant and non-steroidal medications. Nevertheless, there were many other issues that needed to be addressed. She still had the immeasurable stress due to her arrest, no income, and an unacceptable living situation. Most restraining was the fact that she still believed she had no worth and despite her excitement about her aspirations, Maria did not believe she deserved them. It was important that we kept her values and aspirations in the forefront. The road to freedom would not be easy.
The medications she had taken had not only affected her physically, they muted her emotions. Without them, her emotions raged, and she had no idea how to manage them. We turned first to relaxation techniques to help manage stress and change her belief that she had no control. While relaxation helped manage her stress and gave her evidence that she did have some control, it did not remove all the stress and anxiety from her life. So I introduced Maria to some Mindfulness exercises to help her accept that a certain level of stress is just part of life.
Maria’s beliefs that she had no worth, no control, and did not deserve good things were a major challenge for her. Her lack of worth and lack of control grew over time due to her inability to function normally after her accident. Her long-held belief that she was undeserving originated in her abusive childhood and proved to be the greatest hurdle for her to overcome. We used guided discovery to collect evidence that supported her belief and evidence from her life that did not support her belief. After evaluating all the evidence, she was able to produce an alternative belief that she was a good person and deserved as much from life as anyone else. This was a true turning point for her. More than anything, her new belief that she was deserving freed her to pursue her aspirations.
From that point forward, Maria put all her energy into attacking her challenges. She continued using relaxation and mindfulness. She used coping cards and activity schedules, completed all court requirements stemming from her arrest, got a part-time job that gave her enough money to get an apartment with a friend. It was incredible that over the year in which I worked Maria she was able to move from the depths of hopelessness to coming into my office with a smile and the belief that she was as deserving to have good things in her life as does anyone else.
What did working with Maria do for me? Well, it gave me an enormous amount of evidence to evaluate my old beliefs that pain cases are too hard and whatever I do won’t help or make a difference anyway. In some ways, I think I was helped by Maria’s treatment as much as she was!
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. The 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/opioid use clients, improve their level of functioning, and increase their overall quality of life.