ON Chiropractic Fall 2014 | Page 10

FEATURE STORY / CBT AND CHIROPRACTIC – PART 2 P erhaps the patient has recently been in a motor vehicle accident and is fearful of the pain they associate with the range of motion exercises you have recommended. You hear them using phrases like: “I will never be free of pain” and “I just need to learn to live with this.” Through a series of motivational interviews you come to understand their discouragement and hesitance and you adopt an approach of graded movement exposure to interrupt the cycle of fear the patient is experiencing. As they improve and gain confidence, you find the patient “ techniques into your treatment plans. A good first step is to understand the connection between physical and mental health. It is especially helpful to understand the important connection between psychological impairments, such as mood disorders, and recovery from an injury or chronic pain. Dr. Michael Cheng, a psychologist with the Altum Health/University Health Network, is providing training to practitioners working with the Interprofessional Spine Assessment and Education Clinics (ISAEC). He believes that the place to start is with the patient. If those automatic thoughts are not examined and corrected, they can continue to contribute to persistent angry mood and behaviours." rushing out of your clinic after treatment to meet their running group. The difference in these two stories is that the chiropractor was able to draw on additional training, in this case CBT, to aid their patient’s recovery at a time when the greatest barrier to success in treatment was psychosocial. The purpose of this second installment in our series on “CBT and Chiropractic” is to demonstrate a variety of ways to become better informed about psychosocial barriers to recovery and how you might incorporate some version of CBT into your practice. Getting Better Informed T here is a great deal to learn about the incorporation of psychological interviewing and treatment 10 FALL 2014 A logical progression through a treatment plan does not always materialize, prompting questions about the care the patient is receiving. But often, the lack of progression may be the result of psychological barriers the patient is experiencing internally and perhaps not sharing with their chiropractor. “Patients may have all kinds of beliefs, coping deficits and behavioural responses which may make sense in situations involving acute pain but which become problematic in cases involving prolonged pain,” Dr. Cheng said. A common example cited by Dr. Cheng is when patients believe that rest and activity avoidance are the best prescription for their recovery. In fact, as chiropractors know, this is generally detrimental to recovery. This is where psychological therapeutic techniques like CBT can play a role in patient recovery. CBT begins with the assertion that maladaptive beliefs and behaviours play an important role in the maintenance or exacerbation of mood, anxiety and somatic problems. A CBT practitioner will work with the patient to try to bring these thought patterns and behaviours to the surface so the practitioner can determine whether the patient’s reactions to situations are accurate. Dr. Cheng references the example of a driver who becomes very angry after being cut off in traffic. “While the situation itself is unpleasant, a person with problems with anger might have additional automatic thoughts about the situation including catastrophization (“he could have killed me!”), personalization (“he’s a bleeping so-and-so!”), or fairness (“I can’t let him get away with that!”),” Dr. Cheng explains. “If those automatic thoughts are not examined and corrected, they can continue to contribute to persistent angry mood and behaviours.” A challenge for patients with established patterns of maladaption is that they see the very behaviours that they need to change as the things that are helping them get through the day. This may even be true in the short term. Automatic beliefs and behaviours can be comforting, both psychologically and physically. Imagine the experience of an MVA patient who is fearful of movement and exercise. You prescribe a series of daily exercises. Because of previous poor experiences or due to cultural expectations, they automatically believe they cannot do the exercises or that it will cause unbearable pain. As a result, they do not engage in the recommended exercises and instead maintain a maladaptive pattern. An oft-cited resource for clinicians working with such patients is a quick, easy read called Mind Over Mood: Change How You Feel By Changing How You Think.