Dialectical behavioural therapy for complex chronic pain conditions

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The use of behavioural methods in the management of chronic pain and especially with low back pain has been used since the seventies (Fordyce, 1976). In the eighties, behavioural methods started to change from basic behavioural therapies (BT) into more sophisticated cognitive behavioural treatments (CBT) (Beck et al., 1979). Because of this evolution in method, behavioural methods became much more common. The practice of the therapy, once limited to relatively few therapists, received a much wider acceptance by more health care professionals. Subsequently CBT techniques have been used in a variety of other conditions, notably in the management of depression, with amiable results (DeRubeis et al., 1999).

The expansion in the use of the method as well as its maturation, has not halted. Although the basic principles of CBT stand as the pillars of the method, various other therapy techniques and philosophical ideas have, with varying success, been integrated into new versions of CBT, for instance Mindfulness based Cognitive Behavioural Therapy (MBCBT) (Segal et al., 2001).

The experimentation with new CBT methods, if successful, may lead to accepted alternatives to, or even change the content of traditional CBT practice. However, when such new paths are taken, this can be quite demanding for the therapist as the success of the new methods depends on the therapist's knowledge of traditional CBT as well as the novel aspects of CBT methods that he is trying to adopt into his practice.

Steven Linton has an exceptional knowledge of traditional CBT, and he has extensive experience in managing low back pain (LBP). In this issue of the Scandinavian Journal of Pain, Linton (2010) presents a case study where CBT with a dialectical approach is applied to manage the complex pain condition of a patient with chronic LBP.

Linton (2010) explains his approach as follows: “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 that it will provoke pain, may be done to help the patient experience that another result may actually occur”.

This is a n=1 feasibility study with impressively successful results: At the end of therapy, after four months, the patient was satisfied with her pain level, emotional regulation, and sleep. The patient reported some pain, emotional discomfort, and sleeping problems, but she was able to function at a much more satisfying level.

One may wonder how much unspecific context sensitive therapeutic effects play a role in the present patient's outcome. However, it is not difficult to agree with Steven Linton's conclusions that this case study shows that dialectical behaviour therapy may be feasible especially for people suffering persistent pain with problems in addition to pain, such as depression. The positive findings of this case study certainly warrant further studies. The application of these techniques to larger groups of patients with complex chronic pain conditions will hopefully establish the validity of the results of this interesting feasibility study.

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References 

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