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.