Applying dialectical behavior therapy to chronic pain: A case study

1 Introduction

Although progress has been made, there are still numerous patients who suffer persistent, unrelenting musculoskeletal pain. It is estimated that from 12 to 25% of the population suffers longterm neck or back pain (Crombie et al., 1999;Swedish Council on Technology in Health Care, 2006), with a recent European study showing 19% of adults suffering and over 60% of those having work reductions as a result (Breivik et al., 2006). Rehabilitation and pain services for chronic suffers have improved over the past two decades, but recent reviews suggest that only a few receive proper pain management and of those only about half of the patients recover sufficiently for a return-to-work (Swedish Council on Technology in Health Care, 2006;Breivik et al., 2006;Burton et al., 2004). Moreover, of the successful cases most still experience considerable problems and as many as half relapse (Linton, 2005). A particular problem is how to manage patients who continue to suffer and are work disabled despite having received modern rehabilitation services. This is particularly difficult because it is not known why these patients do not respond fully to treatment.

Emotional regulation may be one important factor in the development of persistent pain problems. It is well established that emotional factors such as fear, anxiety, and depressed mood are associated with the development of chronic pain (Shaw et al., 2006). Indeed, as the problem develops these emotional factors seem to become prominent. Depression, for example, is found co-morbidly in more than half of those suffering chronic pain (Bair et al., 2003). Fear, avoidance, and anxiety problems are also common as is sleep disturbances (Leeuw et al., 2007;Linton and MacDonald, 2008). All of these problems may be related to problems of emotional regulation. To be sure, regulating such emotions might be conceptualized as a central process that maintains many of the apparently “dysfunctional” behaviors such as avoidance.

Dialectical behavior therapy (DBT) is a particular type of cognitive-behavioral therapy that was developed to deal with emotional regulation, originally for patients diagnosed with borderline personality disorders (Linehan, 1993;Marra, 2004). The dialectic approach focuses on accepting patients and their behavior without judgment but at the same time supporting them in the dialect of accepting what cannot be changed while working to change what can be improved. Emotional regulation is enhanced by the use of emotional skills training where patients learn to identify and express emotions as well as to analyze their own reactions in various situations. Validation is also used and involves understanding the patient and their situation and communicating this to the patient. The dialectic approach underscores that opposites may exist at the same time, e.g. that one may view a piece of art as both beautiful and ugly or one may experience a negative emotion, but still move on. The dialectic is used to enhance behavioral flexibility and acceptance of feelings. Exposure techniques may be used to test such opposites and bring the patient into contact with the prevailing contingencies of reinforcement. For example, attempting to do an activity that has been avoided for years because it is feared it will provoke pain, may be done to help the patient experience that another result may actually occur. Thus, while the patient may, for example, try to avoid feeling depressed, DBT strives to restore balance between the feeling and the reaction. DBT has been demonstrated to be useful with a variety of difficult problems such as self-harm in borderline and with high conflict couples (Fruzzetti, 2006).

DBT would seem to be applicable to more severe cases of persistent pain since these cases often involve a combination of highly emotional states (depression, fearful, anxious, victimized), avoidance of negative affect, and intrusive thoughts (worry, rumination) (Leeuw et al., 2007). Indeed, these may be the factors driving the pain and disability problem. The purpose of this controlled case study was to examine the application of DBT to a patient suffering a complex persistent pain, depression, and disability syndrome.

2 Methods

2.1 Participant

The client (C) is a 52-year-old woman who lives with her partner. She has two adult children who live on their own. C has worked within healthcare but has not worked at all during the past 1.5 years because of back and neck pain. Furthermore, C has not worked at her regular job in healthcare for over 10 years and has an extensive history during this time of sick leave because of the pain problem. This is despite numerous treatment regimes including several physical therapy programs, treatment at an anesthesiology-based pain service, a rehabilitation program, and care at the primary care level. The National Insurance Authority has also been facilitating the case for several years in hope of achieving some sort of return-to-work, but this had not been successful. In addition to the pain problem, C had a nonmalignant brain tumor removed about 13 years ago. C was concerned that the brain tumor had resulted in certain problems such as some perceptual difficulties, being tired, learning problems, and a lack of concentration, even though a neuropsychological evaluation found few abnormalities. She was no longer under treatment for the tumor nor did she suffer any pain from it.

2.2 Description of the problem

Back and neck pain were the sources of C’s sick leave, and was the primary symptom that C sought help for. The pain was continual and C reported that it averaged between 5 and 8 on a 0–10-point scale during any given week. However, she reported great variation with some “good” days and some “bad” days. She experienced a relationship between being too active physically and more subsequent pain. Indeed, C said that she viewed the situation as a real balance between wanting to do activities and limiting these since they always lead to more pain.

During the assessment interview C also reported that she suppressed her feelings and was having substantial problems regulating her emotions. Specifically, she said that she felt very bad when she considered her image of herself before becoming ill and her current picture of herself. She reported being “afraid” of looking at what she was like before and what she was like now; she reported great difficulty accepting any limitations from the pain or tumor. Consequently, a goal developed with C was to better accept her situation and deal with her feelings.

Assessment showed that C scored 28 on the Pain Catastrophizing Scale (PCS) (Sullivan et al., 1995) indicating a relatively high level; 35 on the Tampa Scale of Kinesiophobia (TSK) (Kori et al., 1990) also suggesting a high level of fear and avoidance of activities; and, 45 on the Chronic Pain Acceptance Questionnaire (CPAS) (McCracken et al., 2004) suggesting a relatively low level of acceptance. On the Beck Depression Inventory (BDI) (Beck et al., 1979), C scored 26 indicating a moderately severe intensity. On the Insomnia Severity Index (ISI) (Bastien et al., 2001) C had 21 indicating poor experienced sleep. C was screened for the risk of self-harm or suicide and monitored throughout the treatment, but with no detected risk.

3 Results

Results over the 16 sessions of treatment and at the three-month follow-up are reported on the objective measures. C’s self-report is also included to illustrate the findings.

3.1 Pain

As seen in Fig. 1 C reported considerable pain at the baseline daily assessments employing a 0–10 scale (0 = no pain). However, as therapy progressed this level decreased dramatically and was virtually at a zero level for some weeks. This drop occurred from around day 65 to 81 and is associated with C successfully completing key behavioral experiments. C said that she felt much better with regard to the pain. Although some increase was noted during the follow-up, C said she could now accept the pain and was not “bothered” by it. She attributed the improvements to acceptance and, in part, to simply being in a good period.

Fig. 1

Pain ratings during assessment, treatment and at follow-ups.

3.4 Catastrophizing and fear

C had high scores on the PCS and TSK at the start of therapy. She reported significant decreases in these: PCS; pre = 28, post = 14; TSK; pre = 35, post = 23 (both are within nonclinical “normal” range). Indeed, C began to participate in a host of activities that although she found challenging were still possible without necessarily having more pain.

Fig. 2

Pain ratings during assessment, treatment and at follow-ups.

4 Discussion

This case involved a DBT-based therapy for a woman complaining of persistent pain problem over a very long period of time and with multiple problems including depression and difficulties regulating emotions. The intervention was based on techniques developed in DBT that were adapted for the pain area. The patient made considerable progress, according to her own verbal reports as well as diary ratings and standardized measures, despite having had persistent problems for many years. Indeed, at the end of therapy she reported reaching her main goals and being satisfied with her pain level, emotional regulation, and sleep. While C still reported some pain, emotional discomfort and sleeping problems, she was able to function at a much more satisfying level. Consequently, this case study provides impetus for further research into whether DBT techniques might be of value for difficult chronic pain cases.

It is difficult to know what part of the therapy was the key to success. The DBT approach includes several aspects that may not be part of a traditional rehabilitation or pain management treatment. Here an understanding of the problem was underscored via the techniques of validation and we worked specifically with the emotional aspects of the problem. Not all patients may be aware of this connection or as willing to work with these. Still, the emotional regulation appeared to be a key to C’s success, since exposure to negative effect was followed by marked improvement. We also focused on positive emotions (providing a balance between opposites that DBT emphasizes) through savoring. The behavioral experiments instructed C to attempt new behaviors leading toward her own goals. These also appeared to be important as they expanded C’s behavioral repertoire and, in everyday language, allowed her to learn that these activities were not dangerous, but actually were rewarding. This seemed to be related to the fact that C began to seek employment on her own as she became more confident. This is interesting since the authorities had attempted to “find her an appropriate job” for more than two years.

A crucial question raised in this case study is the role of exposure and how it is administered (Asmundson et al., 2004). Having a patient conduct exposure via behavioral experiments by themselves in their home environment might be thought to lead to problems that would undermine the exposure. In fact, an important aspect of in vivo exposure is making sure that the patient is actually “fully” exposed and does not mediate the exposure with safety behaviors. On the other hand, patients may have cognitive safety behaviors during therapist lead in vivo exposure that nevertheless affects outcome. Consequently, a possible advantage of the exposure used in this case study is that the patient was definitely engaged in the exposure and conducted it in a real setting and with actual pertaining contingencies of reinforcement. This might be an effective way of eliminating some safety behaviors and also an excellent way of providing positive reinforcement when the desired behavior has been achieved (i.e. direct, positive reinforcement from the actual goal behavior). Consequently, this type of exposure may be an alternative that suits some patients better than usual therapist-led, in vivo exposure, although research will be needed to answer this question.

5 Conclusions

This patient had a complex problem with multiple symptoms and was helped by a DBT-based behavior therapy. Although this is only one case which says little about the internal and external validity of the intervention, the observed results nevertheless warrant further investigation of the value of a DBT oriented intervention and provides some promise for complex chronic pain cases.